MULTIPLE GESTATIONLEONARD EVAN MELLA0961050199NADIA VINKA LISDIANTI1061050189

IncidenceThe incidence of multiple gestations has risen significantly, primarily due to increased use of fertility drugs for ovulation induction, superovulation, and assisted reproductive technologies (ART), such as in vitro fertilization (IVF).

The perinatal mortality rate of twins is 34 times higherand for triplets much higher stillthan in singleton pregnancies.

Approximately two-thirds of twin pregnancies end in a singleton birth.

Factors That Influence TwinningRaceMaternal AgeParityHeredityPituitary gonadotropinInfertility therapy

Maternal RisksSpontaneous abortionPreterm birthAnemiaMaternal death

Fetal RisksVanishing twinCongenital malformationsLow birth weightTwin-twin transfusion syndromeFetal demise

Types of Twins

Most commonMonochorionic, DiamnioticA single placentaRareMonochorionic, MonoamnioticA single placentaDichorionic, DiamnioticSeparate or fusedplacentasMonochorionic, MonoamnioticFused placenta

Dichorionic, DiamnioticSeparate placenta

Dizygotic TwinsTwins of different sexes are always dizygotic (fraternal).More common among women who become pregnant soon after cessation of long-term oral contraception.

Clinical FindingsSymptoms Earlier and more pressure in the pelvisNausea, backache, varicosities, constipation, hemorrhoids, abdominal distention, difficulty in breathingA large pregnancyFetal activity is greater and more persistent

Clinical FindingsSigns Uterus larger than expected (>4 cm) for dates.Excessive maternal weight gain that is not explained by edema or obesity.Polyhydramnios, manifested by uterine size out of proportion to the calculated duration of gestation, is almost 10 times more common in multiple pregnancy.History of assisted reproduction.Elevated maternal serum fetoprotein (MSAFP) values.

Clinical FindingsSigns Outline or ballottement of more than 1 fetus.Multiplicity of small parts.Simultaneous recording of different fetal heart rates, each asynchronous with the mothers pulse and with each other and varying by at least 8 beats/min. (The fetal heart rate may be accelerated by pressure or displacement.)Palpation of 1 or more fetuses in the fundus after delivery of 1 infant.

Laboratory FindingsMaternal hematocrit and hemoglobin values an the red cell count usually are considerably reduced.Maternal hypochromic normocytic anemia.

Ultrasound FindingsDichorionicity:Fetuses of different gendersSeparate placentasA thick (>2 mm) dividing membraneA twin peak sign in which the membrane inserts into 2 fused placentasMonochorionicity:Absence of those findingsA dividing membrane that is so thin (< 2-mm thick) and magnification reveals only two layersA T sign

Ultrasound Findings

Eng Bunkers home in Surry County, NCReturn to Famous PeopleHomeUNIQUE FETAL COMPLICATIONS

Eng Bunkers home in Surry County, NCReturn to Famous PeopleHomeConjoined TwinsConjoined twins result from incomplete segmentation of a single fertilized ovum between the 13th and 14th days.If cleavage is further postponed, incomplete twinning (ie, 2 heads, 1 body) may occur.

Conjoined Twins

EXTERNAL PARASITIC TWINSA grossly defective fetus or merely fetal parts, attached externally to a relatively normal twin. Usually consists of externally attached supernumerary limbs, often with some viscera.A functional heart or brain is absent.

FETUS IN FETUEarly in development, one embryo may be enfolded within its twin. Normal development of this rare parasitic twin usually arrests in the first trimester. As a result, normal spatial arrangement of and presence of many organs is lost.

Vascular Anastomoses

Twin-Twin Transfusion SyndromeLocal shunting of blood occurs because of vascular anastomoses to each twin that are established early in embryonic life.Affects approximately 15% of monochorionic twin pregnancies.Does not occur in dichorionic twins.Interestingly, does not occur in monochorionic, monoamniotic twins.

Twin-Twin Transfusion Syndrome

Twin-Twin Transfusion SyndromeThe recipient twin:Plethoric, edematous, hypertensiveAscites and kernicterusThe heart, liver, and kidneys are enlargedFetal polyuria hydramniosThe donor twin:Small, pallid, dehydrated (from growth restriction, malnutrition, and hypovolemia)Oligohydramnios

Twin-Twin Transfusion Syndrome

Obstetrical ManagementSerial removal of amniotic fluid for polyhydramnios if > 20 weeks gestationCreate an opening in amnion between the two fetuses to allow fluid exchangeLaser ablation of placental vascular anastomoses (high complication rate)Selective reduction of donor twin if high risk of death for both twins

Large volume amnioreduction

Amniotic Septostomy

Fetoscopic Laser Ablation

Acardiac Twins (TRAP)A parasitic monozygotic fetus without a heart. It is thought to develop from reversed circulation, perfused by 1 arterialarterial and 1 venousvenous anastomosis.

Treatment

Labor and DeliveryAdmit the patient to the hospital if:First sign of suspected labor or preterm laborThere is leakage of amniotic fluidSignificant bleeding occurs>4 contractions per hour at

Labor and DeliveryIndications for primary caesarean section:If either twin show signs of persistent compromiseMalpresentationMonoamniotic twinsGross disparity in fetal sizePlacenta previa

Labor and DeliveryIntrapartum twin presentations:

Labor and DeliveryThe umbilical cord should be clamped promptlyPerform a vaginal examination immediately after delivery of twin ATag and label the cords (twin A and B)Locked twins can be avoided by caesarean delivery in all cases

Labor and DeliveryIncreased intravenous oxytocin, elevation, and massage of the fundus and an intravenous ergot or prostaglandin product (only after the last fetus is delivered) may be required.Manual extraction of the placenta may be necessary.Prophylactic rectal misoprostol in the operating room followed by oral misoprostol every 6 hours for 24 hours after delivery for all multiple gestations.

Laporan Kasus

Identitas (20 Juli 2014 pukul 21.00)Nama Pasien: Ny. MUmur: 35 tahunPendidikan: SMAPekerjaan: Pegawai SwastaAgama: IslamSuku : BetawiAlamat: Duren Sawit

Identitas

SubjektifKU: Mulas-mulasKT: -

Subjektif

Riwayat Penyakit SekarangPasien datang ke IGD RS UKI dengan keluhan perut terasa mulas pada bagian kanan sejak 1 minggu SMRS. Keluhan ini dirasakan terus-menerus dan semakin lama terasa semakin mules. Keluhan tidak berkurang dengan perubahan posisi. Keluar cairan bercampur darah dari vagina disangkal. Pasien selalu kontrol kehamilan di poli RS UKI. Kontrol terakhir 1 minggu yang lalu (12 Juli 2014) dan dinyatakan pasien hamil gemeli. Usia kehamilan saat ini 32 minggu.

Riwayat HaidHaid pertama: 9 tahunSiklus: tidak teraturLama: 7 hariBanyak: 4x ganti pembalut /100 ccHPHT: 5 Des 2013TP: 12 september 2014Sakit saat haid: disangkal

Riwayat PerkawinanStatus Pernikahan: menikah 1xLama perkawinan: 2 tahun

Riwayat Kehamilan Persalinan, nifas yang lalu: IniRiwayat Penyakit Dahulu: DisangkalRiwayat Penyakit Keluarga: DisangkalRiwayat Operasi: DisangkalMetode KB : Tidak menggunakan KB

Riwayat ANCWaktu hamil periksa di: RS UKI Oleh dr. Januar Simatupang Sp.OG, Keluhan, kelainan, dan masalah: -

Waktu ANCUsia KehamilanTempatMasalahPenatalaksanaan00-12 mg---1x13-28 mgRS UKIHamil gemeli-1x29 mg sekarangRS UKIHamil gemeli-

OBJEKTIFPemeriksaan Umum / Status GeneralisTinggi badan: 160 cmBerat Badan: 75 kgKeadaan Umum: BaikKesadaran: KomposmentisObjektif

Tanda Vital TD : 110/80 mmHgNadi : 84 x/menitSuhu : 36,2 0CPernapasan : 20 x/menit

Kepala: normocephaliMataKonjungtiva: tidak anemisSklera: tidak ikterikGigi : lengkap, karies (-)THT : dalam batas normal

Leher : KGB tidak teraba membesarPayudara : massa (-/-) retraksi (-/-) nyeri (-/-)Jantung : BJ I & II reguler, gallop (-) murmur (-)Paru-paru : I: pergerakan dinding dada simetris ka/kiP: VF simetris ka/kiP: sonor ka/kiA: BND vesikuler, Rh -/- Wh -/-

AbdomenI: Perut tampak membuncitA: BU sulit dinilai P: Defense muskular (+) hepar dan limpa sulit dinilaiP: nyeri ketok (-)

Ekstremitas :Superior: akral hangat, CRT < 2 , edema -/-Inferior: akral hangat, CRT < 2, edema +/+

Pemeriksaan Umum / Status GeneralisPemeriksaan Luar I : perut tampak membuncit, linea nigra (+) striae gravidarum (+)P : TFU 36 cmLeopold I :Teraba 2 bagian terbesar janin bulat, keras, melenting, kesan kepala janin gemeliLeopold II :Teraba bagian memanjang tidak terputus-putus pada sebelah kiri ibu punggung kiri janin gemeliLeopold III :Teraba bagian bawah janin, bulat, lunak, tidak melenting, kesan bokongLeopold IV:Bayi belum memasuki PAP

Auskultasi :DJJ :Frekuensi: 140 xIrama: tidak teratur

HIS Frekuensi: 2x / 10 menitLamanya : 60Kekuatan: kuatRelaksasi: ada, lamanya 5 menit

Pemeriksaan DalamInspekulo: tidak dilakukanVTVulva / vagina : tenang, rugae (+), tidak teraba massaPortioAxis : PosteriorKonsistensi : LunakPenipisan : 20 %Pembukaan : 1-2 cmKetuban : utuh

Denominator : belum dapat dinilaiCaput : belum dapat dinilaiMoulage : belum dapat dinilai

ASSESMENT DIAGNOSIS KERJAIbu: G1POAO hamil 32 minggu partus prematur iminensJanin : Janin Gemeli hidupAssesment

PROGNOSISKehamilan: dubia et malamPersalinan: dubia et malam

C. DAFTAR MASALAHJanin GemeliAssesment

PLANNINGRencana pemeriksaan untuk konfirmasi diagnosisObservasi keluhan utama, TTV, DJJ, HISPeriksa Lab H2TL, MP3, HbSAgRencana USGPlanning

Rencana pengobatan / penatalaksanaan khususBila berlanjut inpartu RSCDiet BiasaInfus RL MM:DexametasoneNifedipineTramal Supp 1x1

Planning

Informed ConsentMenjelaskan kepada pasien tentang kehamilan dan rencana persalinan yang dilakukanMotivasi lakstasi dan KBPlanning

THANK YOU

**The perinatal mortality rate of twins is 34 times higherand for triplets much higher stillthan in singleton pregnancies as a result of chromosomal abnormalities, prematurity, structural anomalies, hypoxia, and trauma.

Approximately two-thirds of twin pregnancies end in a singleton birth; the other embryo is lost from bleeding, is absorbed within the first 10 weeks of pregnancy, or is retained and becomes mummified (fetus papyraceous).

Excerpt From: Laufer, Neri. CURRENT Treatment & Diagnosis- Obsterics & Gynecology. iBooks. ****Twins. (A), The most common type of monozygotic twinning, with division of the inner cell mass of the blastocyst resulting in separate amnions but a single chorion and placenta; (B), a rare form of monozygotic twinning, with complete division of the embryonic disc resulting in two embryos in a single amniotic sac with a single placenta and chorionic sac; (C), monozygotic twinning with division occurring between the two-cell and morula stages to produce identical blastocysts, resulting in separate amniotic and chorionic sacs and either separate (shown) or fused placentas; (D,E), dizygotic twinning, with (D) or without (E) fusion of the placenta and chorion. More common among women who become pregnant soon after cessation of long-term oral contraception. This may be a reflection of high rebound gonadotropin secretion. Induction of ovulation in previously infertile patients has resulted in many multiple pregnancieseven the gestation of septuplets and octuplets.

*Maternal hematocrit and hemoglobin values an the red cell count usually are considerably reduced in direct relationship to the increased blood volume.Maternal hypochromic normocytic anemia because fetal demand for iron increases beyond the mothers ability to assimilate iron in the second trimester.

*Chorionicity can sometimes be identified in the first trimester with sonography. The twin peak sign is seen by examining the point of origin of the dividing membrane on the placental surface. The peak appears as a triangular projection of placental tissue extending a short distance between the layers of the dividing membrane.

A dividing membrane that is so thin it may not be seen until the second trimester. The membrane is generally less than 2-mm thick, and magnification reveals only two layers. The right-angle relationship between the membranes and placenta and no apparent extension of placenta between the dividing membranes is called the T sign.

***Thoracopagus:connected at the upper portion of the torso, share a heart, which makes it nearly impossible to separate them and save them both. Thoracopagus twins make up about 40 percent of all conjoined cases.

***Both amniocentesis and chorionic villus sampling can safely be performed in multiple gestations in experienced centers. Careful documentation of the location of the fetuses and the membrane separating the sacs is important in case there is discordance for aneuploidy. Selective termination of an aneuploid fetus can be performed via ultrasound-guided intracardiac injection of potassium chloride. The pregnancy can then continue carrying the normal twin only. Multifetal reduction may be performed to decrease the risk of serious perinatal morbidity and mortality associated with preterm delivery by reducing the number of fetuses from 3 or more to twins or even a singleton.*An ultrasound evaluation should be performed to ascertain the presentation of each fetus and its estimated fetal weight.*For cephaliccephalic presentations in labor (category 1 above), vaginal delivery of both twins may be chosen in the absence of standard indications for caesarean section delivery. Of course, if either twin develops fetal distress, caesarean section delivery should be performed. Category 2 twins, each >32 weeks and weighing more than 15002000 g, can usually be managed successfully by vaginal delivery of both. This is generally accomplished by total breech extraction of twin B immediately after the delivery of twin A if the patient has been consented for this procedure. External cephalic version of twin B has also been described. While external version was previously recommended for conversion of twin B from breech to cephalic, now most operators deliver vaginal second twins by complete breech extraction. When either twin A or both twins are noncephalic (category 3), primary caesarean section should be performed. This is also sometimes recommended in cases of noncephalic twin B where the estimated fetal weight is much greater than that of twin A.*The umbilical cord should be clamped promptly to prevent the second twin of a monozygotic twin pregnancy from exsanguinating into the first born.Perform a vaginal examination immediately after delivery of twin A to note the presentation and station of the second twin, the presence of a second sac, an occult cord prolapse, or cord entanglement.Tag and label the cords (twin A and B) so that they may be associated with the proper placenta or placentas.

*