Multiple pregnancies
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Transcript of Multiple pregnancies
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Multiple Pregnancies
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DEFINITION :
• Any pregnancy which two or more embryos or fetuses present in the uterus at same time.
• It is consider as a complication of pregnancy due to ;
The mean gestational age of delivery of twins is approximately 36w.
The perinatal mortality &morbidity increase.
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Terminology vs. number
• Singletons one fetus
• Twins tow fetuses.
• Triplets three fetuses.
• Quadruplets four fetuses.
• Quintuplets five fetuses.
• sextuplets six fetuses.
• Septuplets seven fetuses.
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Incidence & epidemiology
• The incidence of multiple pregnancy in US is approximately 3% (increase annually due to Assisted Reproductive Technology ART ).
• Monozygotic twins ( approx. 4 in 1000 births ). • Triplet pregnancies ( approx. 1 in 8000 births ). • Multiple gestation increase morbidity & mortality for
both the mother & the fetuses.• Hellin's Law: is the principle that one in about 89
natural pregnancies ends in the birth of twins, triplets once in 892 births, and quadruplets once in 893 births.
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Overview
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Definitions:
• ZYGOSITY: - Refers to the Type of Conception.-only determined by DNA testing.
• CHORIONICITY: - Type of Placentation/ Sharing the placenta.- prenatally by ultrasound.- postnatally by examining membranes.
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A- Dizygotic twins
•Most common represents 2/3 of cases.
•Fertilization of more than one egg by more than one sperm
•Non identical ,may be of different sex.
•Two chorion and two amnion.
•Placenta may be separate or fused.
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Cont.
• The incidence of dizygotic twins is higher in:
1. Certain families.
2. Race; African American.
3. Increases with maternal age, parity, weight and height.
4. Ovulation Induction.
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B- Monzygotic twins
• Constitutes 1/3 of twins
• These twins are multiple gestations resulting from cleavage of a single, fertilized ovum.
• The timing of cleavage determines the placentation of the pregnancy.
• Not affected by heredity.
• Not related to induction of ovulation
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B- Monzygotic twins
1. If separation occurs before the differentiation of the trophoblast, two chorions and two amnions (Di-Di) result.
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B- Monzygotic twins
• 2. After trophoblast differentiation and before amnion formation (days 3 to 8), separation leads to a single placenta, one chorion, and two amnions (Mo-Di).
Blastocyct
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B- Monzygotic twins
3.Division after amnion formation leads to a single placenta, one chorion, and one amnion (Mo-Mo) (days8 to 13).
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B- Monzygotic twins
• 4. Rarely, conjoined or “Siamese” twins (days 13to 15).
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Conjoined twins
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Which is more important – zygosity or chorionicity??
• Dichorionic twins can be either mono/dizygotic.
• Dichorionic twins develop as two distinct organs. – so no risk.
• Monochorionic twins have increased vascular anastomoses between the two circulation
– so high risk!!
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Diagnosis: • History:
-Family hx of dizygotic twins.-Use of fertility drugs.-sensation of excessive fetal movements.-Exaggerated symptoms of pregnancy (hyperemesis gravidarum ).
• Examination: -GPE ( weight gain, Pre-eclampsia signs ).-Abdominal examination (excessive uterine fundal growth, and auscultation of fetal heart rates in separate quadrants of the uterus are suggestive but not diagnostic).
• Sonographic examination ( diagnostic )
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Ultrasound differentiation of chorionicity
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Ultrasound differentiation of chorionicity
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Ultrasound differentiation of zygocity
US
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Complications
1. Maternal Complications.
2. Fetal Complications.
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1.Maternal Complications
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Cont.
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2.Fetal Complications
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2.Fetal Complications
• Prematurity :
Single most important cause of perinatalmortaility and morbidity.
Ensure delivery in a tertiary care centre.
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2.Fetal Complications
• IUGR:Can affect one or both fetuses.
Monochorionic > Dichorionic.
Up to30-32 Weeks twins grow with same velocity , after that reduction in abdominal circumference.
Poor growth – poor placentation , unequal placental sharing, fetal anomalies.
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2.Fetal Complications
• Single Fetal Demise
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Single Fetal Demise cont.
Monochorionic - 25% risk of twin death, 25% risk of neurological damage in surviving twin.
• Dilemma exists whether to deliver early or not
• Terminated as soon as other twin is capable of extra uterine survival
Dichorionic – no such risk
• Conservative management
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2.Fetal Complications
• Twin-Twin Transfusion Syndrome• The presence of unbalanced anastomosis in the placenta
(typically arterial-venous connections) leads to a syndrome in which one twin’s circulation perfuses the other Twin.
• Complications: Donor : anemic HF, hypovolemia, hypotension, anemia,
oligohydramnios, growth restriction. Recipient : hypervolemic HF , hypervolemia, hypertension,
polyhydramnios, thrombosis, hyperviscosity,cardiomegaly, polycythemia, hydrops fetalis.
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Twin-Twin Transfusion Syndrome Cont.
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Twin-Twin Transfusion Syndrome Cont.
• Management :
Repeated amniocentesis from ( recipient).
Intrauterine transfusion of the anemic (donor) twin is of no benefit in this condition.
Fetoscopy and laser ablation of communicating vessels.
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2.Fetal Complications
• Vanishing Twin & Abortion
Incidence of abortion more in multiple pregnancy
Spontaneous cessation of cardiac activity in a previously viable fetus of a multiple gestation. – VANISHING TWIN
When fetal death occur after the first trimester, results in a thin parchment – like body called FETUS PAPYRACEOUS
Diagnosis made after delivery
No effect on mother or the viable fetus.
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Vanishing Twin & Abortion
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2.Fetal Complications
• Congenital Anomalies
• Unique to twins – conjoined twins , Acardiac fetus
• Non specific but common in twins – CHD , Anencephaly
• Postural deformities – Talipes & Congenital dislocation of Hip
STRUCTURAL MALFORMATIONS
• Dizygotic – independent risk, but both will not be involved
• Monozygotic – same risk as that of singleton, both affected
• Down’s syndrome
CHROMOSOMAL ANOMALIES
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Congenital Anomalies Cont.Conjoined Twins
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Congenital Anomalies Cont.
• Acardiac Foetus
Very rare
Bizarre form of monochorionic twinning
One fetus is normal
The other twin is severely malformed – no heart , absent development of upper part of body
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Acardiac Foetus Cont.
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Management • Antepartum : Adequate nutrition.
-Adequacy of maternal diet is assessed due to the increased need for overall calories, iron, vitamins, and folate.-The Institute of Medicine (IOM) recommends women with twins gain a total of 16.0 to 20.5 kg during the pregnancy.
More frequent prenatal visits. Periodic U/S assessment “ every 3-4 weeks from23weeks’
gestation “ to monitor the growth and detection of discordant growth or TTTS.
Amniocentesis .
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Management Cont.
• Intrapartum
Delivery should be considered if:1. Fetal lung maturity is demonstrated2. If compromise of the remaining fetus develops.3. If evidence of disseminated intravascular coagulation in the mother is present
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Management Cont.
The route of delivery depends on:1. Presentation of the twins.2. Gestational age.3. Presence of maternal or fetal complications.4. Experience of obstetrician.5. Availability of anesthesia & neonatal intensive care.
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Management Cont.
• postpartum :
Active management of PPH:
By giving oxytocin in the 3nd stage of labor just after delivery of both fetuses and placentas.