KEHAMILANKEHAMILAN= MULTIPLE PR= MULTIPLE PR

(GEME(GEME

O �O �

Dr. HOTMA PARTOGDr. HOTMA PARTOGSUB BAGIAN FETOMSUB BAGIAN FETOMSUB BAGIAN FETOMSUB BAGIAN FETOM

RS. PIRNGARS. PIRNGA

N KEMBARN KEMBARREGNANCIES =REGNANCIES =ELLI)ELLI)

��

GI PASARIBU SpOGGI PASARIBU SpOGMATERNAL FKMATERNAL FK--USUUSUMATERNAL FKMATERNAL FK--USUUSUADI MEDANADI MEDAN

PendahPendah• Two for the price of oneTwo for the price of one• High Complication Risk

mortalitas ↑ 50% 32-38 mmortalitas ↑ 50% 32 38 m• Pe↑ Malpresentasi:

kedua janin sungsang 4- kedua janin sungsang 4- Janin kembar I sungsan

L k d t i (j )- Locked twins (jarang)• Persalinan operatif & res

huluanhuluane” atau “instant family”e atau instant familyk→Morbiditas & minggu, 10% dibawahnyaminggu, 10% dibawahnya

41%41%ng 17%

siko persalinan preterm ↑

Definisi & KDefinisi & KKehamilan 2 janin atau lebihKehamilan 2 janin atau lebihKembar dizigotik (66%) Bin1. fertilisasi 2 ovum oleh 2 s2. Dikorionik: Amnion terpiKembar monozigotik (33%)

P b l h 1 f til- Pembelahan 1 ovum, fertilsperma yang sama

- Pembelahan <72 jam: Dik- Pembelahan <72 jam: Dik(96%)

- Pembelahan 4-8 hari: Mon(4%)

KlasifikasiKlasifikasihhnovular-fraternal twinsspermaisah) Mono ovular-identical twinsli i l hlisasi oleh sperma

orionik diamnotikorionik diamnotik

nokorionik diamniotik

Mono ovular-idenMono ovular idendiamniotik mon

ntical twins,ntical twins, nokorionik

- Pembelahan 8-13 hari: MonPembelahan 8 13 hari: Mon- Pembelahan >13 hari: Conjo

Fetus PapyraceousFetus Papyraceous- Salah satu janin kembar tida

Tak berbentuk mengkerut &- Tak berbentuk, mengkerut &Perbandingan Mono/DizigoFaktor resiko untuk kembarFaktor resiko untuk kembar

- tuaM lti it- Multiparitas

- Riwayat keluarga kehamilan

okorionik, Monoamniotikokorionik, Monoamniotikoined twins

ak berkembang& rata& rataotik 1:2r dizigotik:r dizigotik:

n kembar dizigotik

Fetus Papyraceous, salah satu ffetus yang tidak berkembang

Insi

1% dari kehamilan, 2/3 diziEtnik (1:50 Afrika, 1:80 Cau( ,Usia (2% > 35 thn) Paritas (2% setelah kehamil( %Metode konsepsi (20% induRiwayat keluargaRiwayat keluargaInsidensi menurut hukum Hkehamilane

iden

got & 1/3 monozigotusasia, 1:50 Asia), )

lan ke-4))uksi ovulasi)

Hellin adalah 1 dalam 80n-1

Etio

• Bangsa, hereditas, umur fraternal-twins

• Obat klomid & gonadotr• Fertilisasi in vitro & tran• Fertilisasi in vitro & tran

ologi

& paritas→ binovular

ropin hormon→ dizigotik nsfer embrio (IVF&ET)nsfer embrio (IVF&ET)

Patofis

Fertilisasi ovum&spermOvum yang telah dibuahi tOvum yang telah dibuahi tnidasi dan Pertumbuhan fe

Selama proses ini kem

siologi

ma di tuba falopii turun uterusturun uterus etus

mbar dapat terbentuk

Kehamilan berasal dari satu telur terjadi Akibat adanya kerja faktor penghambat (pada masa awal pertumbuhan embrio intp pmempengaruhi segmentasi selanjutnyapada berbagai tingkatan.

:(inhibiting factor)trauterin, ,

Tipe Pre

• Janin kembar I presentas• Kedua janin presentasi vKedua janin presentasi v• Salah satu janin vertex, l

K d j i i b• Kedua janin presentasi b

esentasi

si vertex 75%vertex 45%vertex 45%lainnya bokong 37%b k 10%bokong 10%

tipe-tipe ppresentasi

Distribusi dari letakembar (dalam

KEMBARDUA

KEM

KeKe

Kepala

SSungsang

Lintang

ak dan posisi janin %) antara lain:

MBAR PERTAMA

epala Sungsang Lintangepala Sungsang Lintang

39 13 0,6

26 9 0 626 9 0,6

8 4 0,6

Early Di

Anamnesa

GemGem

P ik kli iPemeriksaan klinis

iagnosis

Ultrasonografi

mellimelli

R di l iRadiologi

Diagnosis A

DIZYGOTICDIZYGOTIC

Awal Twins

MONOZYGOTICMONOZYGOTIC

Ultrasonografi kehamilan kembag f r pada usia kehamilan 38-40 harip

Diagnosa dini gagal →- P↑ PJT & persalinan prem- P↑ mortalitas & morbidita

P↑ komplikasi- P↑ komplikasi

Berdasarkan o

36-37 mgg +++

P’tbh j i 24 35P’tbhan janin 24-35 mgg

Kematian intra uteKematian intra ute

maturas perintal

observasi

Amnion <<<

l t t ++ plasenta matang++

erin ↑ 37-38 mggerin ↑ 37-38 mgg

iff i l i• Differential Diagn

Kehamilan lewat waktuPolihidramnionPolihidramnionTumor fibroid uterusKistaMola hidatiforma

inosis

u

Anemia AtoAnemia Ato

PPHK lik iKomplikasi

Retensio plasentaRetensio plasenta

Inersia uteri

onia uterionia uteriHidramnion

Abortusi t li maternal

Partus prematurPartus prematur

Pre-eklampsia

Solusioplasenta Malpresentasplasenta

KPD

Komplikasi f

BBLR

I fi i i l tInsufisiensi plasenta

si Plasenta Previa

PrematuritasPrematuritas

fetal

Kelainan kongenital

Prolapsus tali pusatProlapsus tali pusat

Komplikasi In

Plasenta

kebutuhan nutrisi>>

Kond

ntrapartum

Insufisiensi plasenta

Polihidramnion

disi lain

Prolapsus tali pusatProlapsus tali pusat

PPH K lik i P iPPH Komplikasi Peri

Solusio Plasenta Tran

Malpresentasi Malpresentasi

Lockedi t T iipartum Twins

nsfusion Syndrom

PenatalaA. Tindakan umum

- Diet & Pola makan yanB i & A f l t- Besi & Asam folat

- Aktivitas << & aktivita

B. Pem. Klinis setiap 2mgg - keadaan servik setelah - pengetahuan kehamila- pergerakan bayi setelah

aksanaan

ng baik

as +++

setelah 24 mgg24 mggggn pretermh 32 mgg

C USG setiap 4-6 mgg seC. USG setiap 4-6 mgg se- kemungkinan plasent

kem ngkinan gangg- kemungkinan ganggu- presentasi janin

D. Nonstress test setelah - keadaan janin- penekanan taki pusatp p

E. Konsultasi perinatologE. Konsultasi perinatolog

etelah dignosisetelah dignosista previaan pert mb han janinuan pertumbuhan janin

setelah 32mgg

t

gigi

Kembar discordant: janin resepiendonorabnormalitas arteriovenous tampaab o alitas a te iove ous ta padarah arteri kaya O2 donor bercam

nt lebih besar dari pada janin

ak pada permukaan plasenta, a pada pe u aa plase ta,mpur dengan darah resepient

PENANGANAN• KALAU ANAK I SUNGS

SEBAIKNYA S.CESAR.• KALAU ANAK I P KEPA• KALAU ANAK I P.KEPA

DENGAN P/ VAGINAL AV.EKSTRAKSI.

• SELAMA DJJ NORMAL UNTUK MEMPERCAPAKEDUA

• PENGAWASAN YANG KOUTCOME PERSALINA

N PERSALINANSANG ATAU LINTANG

ALA DIUPAYAKANALA DIUPAYAKAN ANAK KE DUA DENGAN

TIDAK ADA ALASAN AT KELAHIRAN ANAK

KETAT MENENTUKAN AN

anak pertama lintang atau memanjang (terjadi posisi s

sungsang dan anak kedua saling mengunci interlocking)

Panduan penanganan pPanduan penanganan pkehamilan

Janin pertamaSiapkan peralatan resusitasiP i f & i i tPasang infus & cairan intravPantau keadaan janin, djjPeriksa presentasi janinPeriksa presentasi janin- vertex → PSP, monitor pe- bokong → indikasi SCg- lintang → SCTinggalkan klem pada ujung

persalinan spontan padapersalinan spontan pada n kembar

i & perawatan bayivena

ersalinan

g maternal tali pusat

• Janin kedua atau berikiuJanin kedua atau berikiuSegera setelah bayi perta

P l i bd l- Palpasi abdomen → let- lakukan versi luar - Periksa djj

• Periksa dalamPeriksa dalam- Presentasi janin kedua

k h l k b- keutuhan selaput ketub- Prolapsus tali pusat

utnyautnyaama lahir:

k j itak janin

bban

Monoamniotic

• 2 to 5% loss every 2 wee

• 9% at 33 wks → 29% at

• 95% cord entanglement

twins mortality

eks from 15 to 32 weeks

t 36-38 wks

(prenatal diagnosis 28%)

Comparison of ratessingleton and musingleton and mu

Complications

ChorioamnionitisPremature rupture of membranesFetal asphyxiaFetal asphyxiaTwin-twin transfusionCongenital malformations

d iHydramniosAbruptio placentaePlacenta previapCompression of cordBirth injuryPrematurityPrematurityUmbilical cord knots

s of complications in ultiple gestationsultiple gestations

Rate for twins (increase)

4-fold4-fold5 fold5-fold1 of 9 monoamniotic twins3-fold

f i1 of 12 twins2-fold2-fold2-fold10-fold10 fold10-fold2-fold

Maternal morbidity and f d lof quadruplet pre

VARIABLE

Antepartum hospitalizationHyperemesis gravidarumHyperemesis gravidarum, total parenteraG t ti l di b t llit A1Gestational diabetes mellitus, A1Gestational diabetes mellitus, A2Anemia (Hct < 30%), no antepartum tranAnemia (Hct < 30%) antepartum transfuAnemia (Hct < 30%), antepartum transfuAntepartum bleedingPlacenta previaPreeclampsiaPreeclampsiaHELLP syndromePPROMPTLTwin-twin transfusion syndromeChorioamnionitis

obstetric complications egnancy (No. 22)

INCIDENCE (%)

1009.4

al nutrition required 3.118 818.83.1

nsfusion required 25.0usion required 15 6usion required 15.6

3.10.071.971.92.518.81003.16.3

I. Psychological SuCCouns

• All parents should be awaf t l th t d tifetal growth retardationabnormal placentation,malpresentation and premalpresentation and precommonly in multiple than i

• These aspects result in himortality and morbidity.

• Antenatal complications aremultiple pregnancy than inmultiple pregnancy than in

• From the first trimester oparents to cope with possparents to cope with possalso with the socio-econmultiple birth.

upport and Clinicalliseling

are that pathologies such asit l lin, congenital anomalies,

abruptio placentae, fetalterm delivery, occur moreterm delivery, occur morein singleton pregnancyigher maternal and perinatal

e three to five times higher insingleton pregnancysingleton pregnancy.

onwards is required to helpsible negative outcome andsible negative outcome andnomic problems related to

The most important:The most important:

EARLY DIAEARLY DIAWHY?WHY?

MULTIPLE MULTIPLE MULTIPLE MULTIPLE PREGNANCYPREGNANCY ==

•• COMPLICATIONS DURINGCOMPLICATIONS DURING•• SPECIFIC MALFORMATIOSPECIFIC MALFORMATIO•• SPECIFIC MALFORMATIOSPECIFIC MALFORMATIO•• HIGHER PERINATAL MORHIGHER PERINATAL MOR•• INTRAPARTAL COMPLICAINTRAPARTAL COMPLICA

AGNOSISAGNOSIS

HIGHHIGH--RISK RISK HIGHHIGH RISK RISK PREGNANCYPREGNANCY==

G PREGNANCYG PREGNANCYON SEQUENCESON SEQUENCESON SEQUENCESON SEQUENCESRBIDITIY AND MORTALITYRBIDITIY AND MORTALITYATIONSATIONS

DIAGNOSIS OFDIAGNOSIS OF MULTIFETAL PREGSIMULTANEOUS VSIMULTANEOUS VSIMULTANEOUS VSIMULTANEOUS V

two or more embtwo or more emb• two or more embtwo or more emb

••or or corresponding bocorresponding bop gp gor more fetusesor more fetuses

GNANCY:VISUALIZATIONVISUALIZATIONVISUALIZATIONVISUALIZATION

ryosryosryosryos

odyody partsparts of of twotwoyy pp

EARLY DIAGNOSIEARLY DIAGNOSIThe first visiThe first visi

22 GESTATIONAL SACSGESTATIONAL SACS22 GESTATIONAL SACSGESTATIONAL SACS22 YOLK SAC (YOLK SAC ( BCBC // BABA ))

DIZYGOTICDIZYGOTIC

IS OF TWINSIS OF TWINSible structures:ible structures:

11 GESTATIONAL SACGESTATIONAL SAC22 YOLK SACS (YOLK SACS ( MCMC // BABA )

YOLK SACSYOLK SACSfusedfusedfusedfused

separated

MONOZYGOTICMONOZYGOTIC

EARLY DIAGNOSEARLY DIAGNOS

EMBRYOSEMBRYOS AND AMNIOAND AMNIOMEMBRANESMEMBRANES

A firm diagnosiA firm diagnosithe number of embrthe number of embr

after 7th weafter 7th we

IS OF TWINSIS OF TWINS

OTICOTIC

is ofis ofryosryoseekeek !!

MONOCHOMONOCHOMONOCHOMONOCHOMONOAMNMONOAMNTWINSTWINSTWINSTWINS

ORIONICORIONICORIONICORIONICNIOTICNIOTIC

HIGHHIGH ORDER MULTIPORDER MULTIPHIGHHIGH--ORDER MULTIPORDER MULTIPPregnancy with threePregnancy with three

PLE PREGNANCYPLE PREGNANCYPLE PREGNANCYPLE PREGNANCYor more fetusesor more fetuses

three chorionicthree chorionic

three amnioticthree amnioticthree amnioticthree amniotic

2D multiplanar imaging2D multiplanar imaging

3D3D

• volume scanning• volume rendering• spatial reconstruction 3D3Dspatial reconstruction • plastic imaging

TRIPLETSTRIPLETS

reconstructionreconstructionreconstructionreconstruction

FRONTFRONT BACKBACK

HIGH ORDER PHIGH ORDER PHIGH ORDER PHIGH ORDER P

QUADRUP

PREPREGGNANCYNANCYPREPREGGNANCYNANCY

LETS

HIGH ORDER PHIGH ORDER PHIGH ORDER PHIGH ORDER PREREGGNANCYNANCYREREGGNANCYNANCY

HIGH ORDER PRHIGH ORDER PRHIGH ORDER PRHIGH ORDER PRSEPTUPLETSSEPTUPLETSSEPTUPLETSSEPTUPLETS

REREGGNANCYNANCYREREGGNANCYNANCY

HIGH ORDER PHIGH ORDER P

12 EMBRYOS12 EMBRYOS12 EMBRYOS12 EMBRYOS

REREGGNANCYNANCY

II. Correct DiCharacterizationCharacterization

• Multiple gestation should be susppredicted by menstrual history.p y y

• Approximately one fifth of multiplefour fifths are dichorionic.

• Type of placentation and chorion• Type of placentation and chorionclinical situations: 1) The differesyndrome (TTS) from a twin gegrowth retardation; 2) the mangrowth retardation; 2) the manmalformations, in which selectiveoption if the gestation is dichorionfetal death in a multiple gestationfetal death in a multiple gestation.

• The thickness of dividing membra~ 2 mm, in DC/DA the membrane

• The “lambda” sign is an indicator o

iagnosis andn of Chorionicityn of Chorionicityected when the uterus is larger than

e gestations are monochorionic and

icity is helpful in the following threeicity is helpful in the following threeentiation of twin to twin transfusionestation in which one fetus showsagement of twins with congenitalagement of twins with congenital

e feticide may be considered as annic and 3) the management of single

ne is in 85% of monochorionic twinsis ~ 4 mmof dichorionic pregnancy

II. Correct DiCharacterizationCharacterization

• The following criteria mThe following criteria mmonoamniotic twins:

1 no dividing amniotic mem1. no dividing amniotic mem2. only one placenta is see3 both fetuses are of the s3. both fetuses are of the s4. the fetuses must have a

surrounding themsurrounding them5. both fetuses must move

cavitycavity.

iagnosis andn of Chorionicityn of Chorionicity

must be fulfilled to diagnosemust be fulfilled to diagnose

mbrane is presentmbrane is presentensame sexsame sex adequate amniotic fluid

e freely within the uterine

Zigosity of spontane

Spontaneous tripletsTZ

26%

MZDZ 22%DZ

52%

adapted from

eus vs. ART triplets

ARTTZ

84%

Unknown3%

MZ1%

DZ12%

m Derom, 2000

ACCURATE PRENATAL DIAGNACCURATE PRENATAL DIAGNACCURATE PRENATAL DIAGNACCURATE PRENATAL DIAGNOF CHORIONICITY IS OF PREDOF CHORIONICITY IS OF PREDIMPORTANCE FOR THE CLINICIMPORTANCE FOR THE CLINICOFOF MULTIPLEMULTIPLE PREGNANCIESPREGNANCIESOF OF MULTIPLE MULTIPLE PREGNANCIESPREGNANCIES

NOSISNOSISNOSISNOSISDOMINANTDOMINANTCAL MANAGEMENT CAL MANAGEMENT

SSSS

EARLY DIAGNOSIS OEARLY DIAGNOSIS OEARLY DIAGNOSIS OEARLY DIAGNOSIS O

1st TRIMESTER1st TRIMESTER

NUMBER OF NUMBER OF GESTATIONALGESTATIONALGESTATIONAL GESTATIONAL SACSSACS

OF CHORIONICITYOF CHORIONICITYOF CHORIONICITYOF CHORIONICITY

EARLY DIAGNOSIS EARLY DIAGNOSIS G OS SG OS S

6 weeksNUMNUM

OR OR

NUMNUMNUMNUM

7 weeks7 weeks7 weeks7 weeks

OF AMNIONICITYOF AMNIONICITYO O CO O C

MBER OF YOLK SACSMBER OF YOLK SACS

MBER OF VISIB E AMNIONSMBER OF VISIB E AMNIONSMBER OF VISIBLE AMNIONSMBER OF VISIBLE AMNIONS

EARLY DIAGNOSIEARLY DIAGNOSI

ALAR

EARLY DIAGNOSIEARLY DIAGNOSIWhy is it i

ALARMONOCHMONOCH

ANDANDANDANDMONOAMNIMONOAMNI

FETAL FETAL COMPLICCOMPLIC

S OF AMNIONICITYS OF AMNIONICITY

RM !

S OF AMNIONICITYS OF AMNIONICITYimportant?

RM !HORIONICHORIONICD / ORD / ORD / ORD / ORIOTIC TWINSIOTIC TWINS

CATIONSCATIONS

PECULIAR COMPLPECULIAR COMPLTwin embolisation syndrTwin embolisation syndr

TwinTwin toto twin transfusiotwin transfusioTwinTwin--toto--twin transfusiotwin transfusio

Twin reversed arteriaTwin reversed arteriaTwin reversed arteriaTwin reversed arteria

Cord entanCord entan

ConjoineConjoine

LICATIONSLICATIONSrome ( vanishingrome ( vanishing--twin )twin )

on syndrome ( TTS )on syndrome ( TTS )on syndrome ( TTS )on syndrome ( TTS )

l perfusion ( TRAP )l perfusion ( TRAP )l perfusion ( TRAP )l perfusion ( TRAP )

nglementnglement

d twinsd twins

SECOND ANDSECOND ANDTHIRD TRIMESTETHIRD TRIMESTETHIRD TRIMESTETHIRD TRIMESTERRRR

NUMBER OF NUMBER OF PLACENTASPLACENTAS

DETERMINATION OF IN SECOND T

Sonographic counting of sSonographic counting of st th dt th dan accurate method oan accurate method o

chorionicity in the schorionicity in the s

PLACENTA 1

TWO SEPARATED PLACENTAS

PLACENTA 1

PLACENTAS

PLACENTA 2

THE CHORIONICITYTRIMESTERseparated placentas is separated placentas is f d t i i thf d t i i thof determining the of determining the

second trimester second trimester

BICHORIONICBIAMNIOTIC TWINS

MONOCHORIONICMONOCHORIONICBIAMNIOTIC TWINS

BICHORIONIC BIAMNIBICHORIONIC BIAMNIIOTIC TWINSIOTIC TWINS

LAMBDA SIGN

BIAMNIOTICBICHORIONIC

TWINS

MONOAMNIOTIC MONOCMONOAMNIOTIC MONOCCHORIONIC TWINSCHORIONIC TWINS

THE YY--SHAPESHAPESS

Y-SIGNTRICHORIONICTRICHORIONICTRICHORIONICTRICHORIONICTRIAMNIOTICTRIAMNIOTIC

TRIPLETSTRIPLETSTRIPLETSTRIPLETS

EDED JUNCTIONJU C O

“MERCEDES” SIGN“MERCEDES” SIGN

III. Close Evaluatio

Fetal Malformations and Prena

• The incidence of malformation in mthat in dizygotics.

• Chromosomal anomalies are no mor• Anomalies not unique to twins but b

because of mechanical factors arebecause of mechanical factors areand congenital dislocation of the hip

• Additional anomalies due to vascuit l ki d f t icongenital skin defects, microcep

multicystic encephalomalacia, hydroamputation.

n of Fetal Anatomyy

atal Genetic Diagnosisg

monozygotic twin pregnancies is twice

re common in twins than singletonsbelieved to be increased in frequency

positional defects (such as clubfootpositional defects (such as clubfoot) due to intrauterine crowding.lar consequences of fetal death areh l h d h l h lphaly, hydrancephaly, porencephaly,

ocephalus, intestinal atresia and limb

III Close EvaluatioIII. Close Evaluatio

Fetoplacental Markers in TwDown Syndrome

• Around one-third of twin pand their rate of Dowi d d t f dindependent of race and ma

• Dizygous twins are more cth i fas they arise from se

simultaneously shed ova thrisk than for a singleton prrisk than for a singleton prhave Down syndrome

n of Fetal Anatomyn of Fetal Anatomy

win Pregnancies Affected by

pregnancies are monozygouswn syndrome is relatively

t laternal age.ommon in older mothers and

t f tili ti f teparate fertilisation of twohere is double the age-relatedregnancy that either twin willregnancy that either twin will

EPIDEMIOLOGY OEPIDEMIOLOGY OANOMALIES

Anomaly rates for:

singletons 2singletons 2twins 5

Incidence of congenital anotwin than in singl

Monozygotic twins ha50% higher than dg

OF CONGENITALOF CONGENITALS IN TWINS

2 4 %2 - 4 %5 - 10 %omalies is 2 - 3 x higher in leton pregnancy.

ave an anomaly rate dizygotic twins.yg

CONJOINED (SIAMCONJOINED (SIAMINCIDENCE 1: 50 INCIDENCE 1: 50

ULTRASOUND CRITERIA ULTRASOUND CRITERIA

1) LACK OF SEPARATE VISOF FETUSES IN SPECIFICREGIONSREGIONS

2) FIXED POSITION OF THETOWARD EACH OTHER

3) MISSING SEPARATING M3) SS G S G

MESE) TWINSMESE) TWINS000 BIRTHS000 BIRTHS

FOR DIAGNOSIS:FOR DIAGNOSIS:

SUALISATION C ANATOMICAL

E TWIN

MEMBRANE

PATTERNS OF PHYSIPATTERNS OF PHYSIICAL JOININGICAL JOINING

SYMMETRICAL SYMMETRICAL COMPLETE FORMCOMPLETE FORMCOMPLETE FORMCOMPLETE FORM

Two fetuses shareTwo fetuses shareTwo fetuses shareTwo fetuses sharea certain amount of tissuea certain amount of tissue

Surgical separation is Surgical separation is possible in general.possible in general.

PATTERNS OF PHYPATTERNS OF PHYYSICAL JOININGYSICAL JOINING

SYMMETRICAL SYMMETRICAL INCOMPLETE FORMINCOMPLETE FORMINCOMPLETE FORMINCOMPLETE FORM

Surgical separation Surgical separation is usually impossibleis usually impossible

EARLY DIAGNOSIS OF CCONJOINED TWINS

Conjoined twins: Conjoined twins:

subtotal fusionsubtotal fusionwith partial separation with partial separation of fetal headsof fetal heads

OO

lack of separate vislack of separate visin thoracoin thoraco--abab

CONJOINED TWINSTWINS

THORACOTHORACOTHORACOTHORACO--OMPHALOPHAGUSOMPHALOPHAGUS

sualisation of fetuses sualisation of fetuses bdominal regionbdominal region

THOROMP

FIVEFIVE

COLOR DOPPLERCOLOR DOPPLERSINGLE SHARED UMBILICALSINGLE SHARED UMBILICALCORDCORDCOCO

RACO-HALOPHAGUS

E E -- VESSEL CORDVESSEL CORD

L L

VI. Avoidance ofComplip

Complications of multiple pregna• Abortion,,• Vanishing twin syndrome• Malformation

V i• Vasa previa• Growth discrepancy• Intra uterine growth restrictionIntra uterine growth restriction• Polyhydramnios• Preeclampsia• Preterm-premature rupture of• Preterm delivery• Gestational diabetes• Gestational diabetes• Intrauterine fetal death.

f Most Frequent cationsancies comprise:

n (IUGR)n (IUGR)

f membranes (P-PROM)

VANISHING TWINVANISHING TWINVANISHING TWINVANISHING TWIN

• single fetal demisesingle fetal demise•• highhigh--risk surviving twinrisk surviving twin•• intintrarauterine hematomasuterine hematomas•• intintrarauterine hematomasuterine hematomas•• better prognosis in dichoriobetter prognosis in dichorio•• thromboplastine ethromboplastine e•• thromboplastine ethromboplastine e

NNNN•• in in 20%20% of twinof twinss

oniconicembolisationembolisationembolisationembolisation

VANISHING TWIN

SUBCHORIONIC HAEMATOMA

VII. ConsiderationPathoPatho

Twin to Twin Transfusion S• Is associated with a high raIs associated with a high ra

survivors, substantial morb• Diagnostic criteria include: g

same sex with growth discoolygohydramnios of the gropolyhydramnios of the largpolyhydramnios of the larghemoglobin difference > 5m

• Antepartum management oAntepartum management ocontroversy, because no suproblems.

• The three types of vasculaand A-V, are generally presplacentae

n of Some Specific logieslogies

Syndrome (TTS)ate of mortality and amongate of mortality and, among bidity.

monochorionic pregnancy; p g y;ordance between twins; owth retarded fetus and er twin; an intertwiner twin; an intertwin mg/dl (after cordocentesis).of TTS is not withoutof TTS is not without uggested therapy is without

r anastomoses, A-A, V-V sent in monochorionic

MONOCHORONIC / BMONOCHORONIC / B“TWIN TO TWIN” “TWIN TO TWIN” TRANSFUSION SYNDTRANSFUSION SYND

MONOAMNIOTIC:MONOAMNIOTIC:UMBILICAL CORD ENUMBILICAL CORD ENUMBILICAL CORD ENUMBILICAL CORD ENACARDIAC TWIN ACARDIAC TWIN -- TRTRCONJOINED TWINSCONJOINED TWINSCONJOINED TWINSCONJOINED TWINS

IAMNIOTICIAMNIOTIC::

DROMEDROME TTTSTTTS

NTAGLEMENTNTAGLEMENTNTAGLEMENTNTAGLEMENTRAPRAP SEQUENCE SEQUENCE

TWIN TO TWIN TRANSFTWIN TO TWIN TRANSF••5% 5% -- 20% monochor20% monochor••arterioarterio venoveno

TWIN TO TWIN TRANSFTWIN TO TWIN TRANSF

••arterioarterio venoveno••discordant growthdiscordant growth

DONOR DONOR OLIGOHYDRAMNIOS POLIGOHYDRAMNIOS POLIGOHYDRAMNIOS POLIGOHYDRAMNIOS PIUGR IUGR MMMICROCARDIA CMICROCARDIA CMICROCARDIA CMICROCARDIA CANEMIA PANEMIA Pfetal loss 80%fetal loss 80%fetal loss 80%fetal loss 80%

USION SYNDROMEUSION SYNDROMEionic twinsionic twins

ousous anastomosesanastomoses

USION SYNDROMEUSION SYNDROME

ous ous anastomosesanastomoses

RECIPIENTRECIPIENTPOLYHYDRAMNIOSPOLYHYDRAMNIOSPOLYHYDRAMNIOSPOLYHYDRAMNIOSMACROSOMIA, HYDROPSMACROSOMIA, HYDROPSCARDIOMEGALIACARDIOMEGALIACARDIOMEGALIACARDIOMEGALIAPOLYCYTHAEMIAPOLYCYTHAEMIA

TWIN TO TWIN TRANSFUSTWIN TO TWIN TRANSFUS

SCALP EDEMASCALP EDEMA

RECIPIENT:RECIPIENT:F t l h dFetal hydrops

ASCITESASCITES

SION SYNDROMESION SYNDROME

TWIN TO TWIN TRANSFU

POLYHYDRAMRECIPIENT RECIPIENT

fixed twinfixed twinh d ih d ianhydramniosanhydramnios

collapsed acollapsed amembramembra

USION SYNDROME

NIOS OF TWIN TWIN

DONOR:St k t iStuck twin

mniotic mniotic aneane

TWIN TO TWIN TRANSFUUSION SYNDROME

TWIN TO TWIN TRANSFFUSION SYNDROME

TWIN TO TWIN TRANSFU

UMBILICAL VEIN UMBILICAL VEIN SONOGRAM SONOGRAM IN RECIPIENT TWININ RECIPIENT TWININ RECIPIENT TWININ RECIPIENT TWIN

PULSATIONS WITHPULSATIONS WITHREVERSEREVERSE-- FLOW ATFLOW ATREVERSEREVERSE-- FLOW AT FLOW AT THE END OF DIASTOLETHE END OF DIASTOLE

USION SYNDROMERecipient : Recipient : venous return patternvenous return pattern

DUCTUS VENOSUSDUCTUS VENOSUSSONOGRAMSONOGRAM

IN RECIPIENT TWININ RECIPIENT TWIN

REVERSAL OF FLOWREVERSAL OF FLOWDURING ATRIALDURING ATRIALDURING ATRIALDURING ATRIALCONTRACTIONCONTRACTION

TWIN TO TWIN TRANSFUTWIN TO TWIN TRANSFU

PlethoricPlethoricRECIPIENTRECIPIENT

AnaemicAnaemicAnaemicAnaemicDONORDONOR

Weight Weight HaemoHaemo

USION SYNDROMEUSION SYNDROME

t difference > 25%t difference > 25%globin difference >5%globin difference >5%

VASCULAR ANVASCULAR ANVASCULAR ANVASCULAR ANIN A TWIN IN A TWIN

superficialsuperficial

ARTERIOARTERIOARTERIOARTERIOARTERIO ARTERIO

VENOVENOVENO VENO

NASTOMOSES NASTOMOSES NASTOMOSES NASTOMOSES PLACENTA: PLACENTA:

VENOUSVENOUSdeepdeep

VENOUSVENOUSARTERIOUSARTERIOUSVENOUSVENOUSVENOUSVENOUS

SURFACE ANASTOMOSESSURFACE ANASTOMOSES

VISUALIZATION WITHVISUALIZATION WITHPOWER ANGIO MODEPOWER ANGIO MODE

VII. ConsiderationPathoPatho

Twin Reversed Arterial Perfu• The most extreme manifestaThe most extreme manifesta

syndrome, found in approximpregnancies is acardiac twinchorioangiopagus parasiticuschorioangiopagus parasiticus

• The underlying mechanism isnormal vascular perfusion annormal vascular perfusion anrecipient twin due to an umbianastomosis with the donor o

• At least 50% of donor twins dfailure or severe preterm delipolyhydramniospolyhydramnios.

• All perfused twins die due to malformations.

n of Some Specific logieslogiession (TRAP) Sequence

ation of twin to twin transfusionation of twin to twin transfusionmately 1% of monozygotic twin ning (acardius s)s).s thought to be disruption of nd development of thend development of the ilical arterial-to-arterial or pump twin.die due to congestive heart ivery, the consequence of

the associated multiple

TWIN REVTWIN REVTWIN REVTWIN REVARTERIAL PARTERIAL P

(TRA(TRAIN MONOCHORIONIC

( PUMP-TWIN ) ACTTHE SECOND TWIN (THE SECOND TWIN (

VIA LARGE A -A AND/O

1% of monozygotic1% of monozygoticIncidence 1 : 3Incidence 1 : 3Incidence 1 : 3Incidence 1 : 3

VERSEDVERSEDVERSED VERSED PERFUSIONPERFUSIONAP)AP)C TWINS ONE TWIN TIVELY PERFUSES( PERFUSED TWIN )( PERFUSED TWIN )

OR V - V ANASTOMOSES

twins are affected twins are affected 35 000 births35 000 births35 000 births35 000 births

PATHOGENESI

ARTERIAL SUPPLY INTO

PATHOGENESI

ARTERIAL SUPPLY INTOBY THE PUMP TWIN IS AOVERCOME THE BLOODCO TWIN SO AS TO PERCO-TWIN SO AS TO PERBY REVERSED FLOW (TIN THE UMBLICAL ARTECO-TWIN

IS

O PLACENTA

IS

O PLACENTA ABLE TO D PRESSURE OF THE

RFUSE THAT TWINRFUSE THAT TWINOWARD CO-TWIN)

ERIES OF THE

NORMALNORMAL( PUMP TWIN )( PUMP TWIN )

PERFUSED TWIN PERFUSED TWIN ACARDIUSACARDIUS

REVERSE FLOW NORMAL FLOWNORMAL FLOW

THE UMBILICAL VEIN OF THE PARETURNS THE BLOOD INTO THEBACK TO PUMP TWINBACK TO PUMP TWIN

TRAPBLOOD FLOWS FROM AN BLOOD FLOWS FROM AN UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE PUMP TWIN IN PUMP TWIN IN REVERSE DIRECTIONREVERSE DIRECTION VIA VIA ARTERIO ARTERIO -- ARTERIAL ARTERIAL ANASTOMOSES INTO ANASTOMOSES INTO UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE PERFUSED TWIN.PERFUSED TWIN.

ARASITIC FETUS E PLACENTA AND

PATHOGENESIS OF FETPATHOGENESIS OF FET

EARLY REVERSEEARLY REVERSE

REVERSE PASSIVEREVERSE PASSIVE

PERFUSION IN OPPPERFUSION IN OPPPERFUSION WITH DPERFUSION WITH D

INDUCTION OF DEVELINDUCTION OF DEVEL

REDUCTION ANOMAREDUCTION ANOMADEVELOPMENTAL ATROPDEVELOPMENTAL ATROPDEVELOPMENTAL ATROPDEVELOPMENTAL ATROP

TAL DYSMORPHIA:TAL DYSMORPHIA:

E OF CIRCULATIONE OF CIRCULATION

E PERFUSION OF TWINE PERFUSION OF TWIN

POSITE DIRECTION ANDPOSITE DIRECTION ANDDEOXIGENATED BLOODDEOXIGENATED BLOOD

LOPMENTAL DISORDERSLOPMENTAL DISORDERS

ALIES ( EXTREMITIES )ALIES ( EXTREMITIES )PHIES ( HEART AND BRAIN )PHIES ( HEART AND BRAIN )PHIES ( HEART AND BRAIN ) PHIES ( HEART AND BRAIN )

Ultrasound finding = earlyUltrasound finding = early the most bizzarre feta

PUMP - TWIN

normalmorphology

normalnormaldirection ofblood flow

ultrasound detectionultrasound detectional malformations

PERFUSED TWIN

acardius

reduction anomalies ofreduction anomalies of head and extremities

reversed blood flowreversed blood flow

COLORCOLORDOPPLERDOPPLER

REVERSEDREVERSEDPERFUSIONPERFUSIONPERFUSIONPERFUSION

TWINS MC / MA 15 TWINS MC / MA 15 kkTWINS MC / MA, 15 TWINS MC / MA, 15 wkswks

ULTRASONIC CRITERIULTRASONIC CRITERIU SO C CU SO C C

An amAn amits owits owits owits owcord cord monomonomonomonotwin ptwin p

A FOR ACARDIUSA FOR ACARDIUSO C USO C US

morphous mass with morphous mass with wn umbilicalwn umbilicalwn umbilical wn umbilical in monochorionicin monochorionic--

oamnioticoamnioticoamnioticoamnioticpregnancypregnancy

ACARDIAC ACACARDIAC - AC

No trunkNo trunkand headand head

No heart d b i

This acardiac twin

and brain

This acardiac twinlower ex

CEPHALICCEPHALIC

n consists mainly ofn consists mainly of xtremities

VII. ConsiderationPatho

Stuck TwinStuck Twin• Refers to the ultrasonog

monochorionic diamniooligohydramniotic sac fixethe uterine wall.

• This is frequently a manif• This is frequently a maniftransfusion syndrome (TT

• Management may incManagement may incumbilical cord ligation of oanastomosing placen

i t iamniocentesis.

n of Some Specific logies

graphic finding of one of aotic twin pair in aned in a location adjacent to

festation of the twin to twinfestation of the twin-to-twinTS).clude: selective feticide;clude: selective feticide;one twin; laser occlusion ofntal vessels; serial

CORD ENTAGLEMECORD ENTAGLEMEENTENT

COMPLICATION SPECIFIC FORMONOAMNIOTIC MONOCHORIONICTWINSTWINS

CORD ENTANGLEMCORD ENTANGLEMCORD ENTANGLEMCORD ENTANGLEM

MONOAMNIOTIC MONOAMNIOTIC TWINNINGTWINNING

THE CLOSE INSERTION OFTHE CLOSE INSERTION OFCORDS INTO PLACENTA ISCORDS INTO PLACENTA ISLARGELARGE--CALIBER ANASTOMCALIBER ANASTOMANDANDAND AND HIGH PREDISPOSITIONHIGH PREDISPOSITION

MENTMENTMENTMENT

F THE UMBILICAL F THE UMBILICAL S ASSOCIATED WITH:S ASSOCIATED WITH:MOSES MOSES

N FOR ENTANGLEMENTN FOR ENTANGLEMENT

CORD ENTANGLECORD ENTANGLECOLOR DOPPLERCOLOR DOPPLER

CORD ENTANGLECORD ENTANGLEMENTMENTPOWER DOPPLERPOWER DOPPLER

MENTMENT

TWINTWIN--TOTO--TWIN TTWIN TTWINTWIN--TOTO--TWIN TTWIN Tshould be should be considered wheconsidered whe

i di d ii di d i hhis diagnosed in is diagnosed in monochmonoch

Multiple gestations prMultiple gestations prMultiple gestations prMultiple gestations prdedecrease in fetal gcrease in fetal g

in direct relationshiin direct relationshiin direct relationshiin direct relationshiof fetusesof fetuses in in high orhigh or

TRANSFUSIONTRANSFUSIONTRANSFUSIONTRANSFUSIONen growth discordancy en growth discordancy h i i t tih i i t tihorionic gestationshorionic gestations

resent a significantresent a significantresent a significantresent a significantgrowth growth which is which is p to the numberp to the numberp to the number p to the number rder pregnanciesrder pregnancies

VIII Close MonitVIII. Close Monit

D l V l i tDoppler Velocimetry• Recent studies have a

usefulness of this techfetuses small for gestaIUGR, twins with TTS,discordant growth

toring of Fetusestoring of Fetuses

addressed the hnique in predicting twin ational age (SGA) or , and those with

VIII Close MonitVIII. Close Monit

C di t hCardiotocography• Is not always easy to

is possible to performfetus.

• The best methodrecording of FHR patteg p

toring of Fetusestoring of Fetuses

identify the twins and ittwo NSTs on the same

is the simultaneouserns on one tracing.g

SPONTANEOUS MOTSPONTANEOUS MOT

• COMPLEX BOD• HICCUPS• HAND-FACE COHAND FACE CO• MOUTH OPENIN• SWALLOWING

BREATHING MO• BREATHING MO• HEAD MOVEME• EXTREMITY MO• JUMPING• TWISTING• STRETCHINGSTRETCHING• YAWNING

TORIC ACTIVITYTORIC ACTIVITY

DY MOVEMENTS

ONTACTSONTACTSNG

OVEMENTSOVEMENTSENTSOVEMENTS

FETAL ACT

COMPLEXBODYBODY MOVEMENTS

NO INTERTWIN CONTACTS

TIVITY

FETAL ACT

NO INTERTWIN CONTACTS

EXTREMITY MOVEMENTSEXTREMITY MOVEMENTS

TIVITY

INTERINTER--TWIN CTWIN C

• FIRST REACH AND TOUCH• FIRST REACTION• “SLOW” OR “FAST” ARM, LEG, • MOUTH CONTACT• COMPLEX INTERACTIONSCOMPLEX INTERACTIONS

CONTACTSCONTACTS

HEAD OR BODY CONTACT

TRIPLET ACTIVITYTRIPLET ACTIVITY

HEAD TO BODYCONTACT

JUMPINGJUMPING

AND CONTACTSAND CONTACTS

The Ten Comin Multiple Pin Multiple P

I. Psychological Support and Cy g ppII. Correct Diagnosis and ChaIII. Close Evaluation of Fetal AIII. Close Evaluation of Fetal AIV. Management at Referral CV Individualization of CareV. Individualization of CareVI. Avoidance of Most FrequeVII Consideration of Some SpVII Consideration of Some SpVIII. Close Monitoring of FetusIX Planning of Time and ModIX. Planning of Time and ModX. Monitoring of the Mother D

mmandmentsPregnanciesPregnanciesClinical Counselinggracterization of Chorionicity

AnatomyAnatomyCenters

nt Complicationspecific Pathologiespecific Pathologiessese of Deliverye of Deliveryuring Postpartum

Ult d t fUlt d t fUltrasound assessment ofUltrasound assessment of

1 EARLY DIAGNOSIS OF MULT1 EARLY DIAGNOSIS OF MULT1. EARLY DIAGNOSIS OF MULT1. EARLY DIAGNOSIS OF MULT2. DIAGNOSIS OF CHORIONIC2. DIAGNOSIS OF CHORIONIC3 COMPLICATIONS IN MONOC3 COMPLICATIONS IN MONOC3. COMPLICATIONS IN MONOC3. COMPLICATIONS IN MONOC4. FETAL CONGENITAL ANOMA4. FETAL CONGENITAL ANOMA5 APPROPRIATE VERSUS DIS5 APPROPRIATE VERSUS DIS5. APPROPRIATE VERSUS DIS5. APPROPRIATE VERSUS DIS6. COLOR6. COLOR--DOPPLER OF MULTDOPPLER OF MULT7. PREDICTION OF PRETERM 7. PREDICTION OF PRETERM 8. INTRAPARTUM ULTRASONO8. INTRAPARTUM ULTRASONO

f lti l f lti l f multiple pregnancy:f multiple pregnancy:

TIPLE PREGNANCYTIPLE PREGNANCYTIPLE PREGNANCYTIPLE PREGNANCYITY AND AMNIONICITYITY AND AMNIONICITY

CHORIONIC TWINSCHORIONIC TWINSCHORIONIC TWINSCHORIONIC TWINSALIES ALIES

SCORDANT GROWTHSCORDANT GROWTHSCORDANT GROWTHSCORDANT GROWTHTIFETAL PREGNANCYTIFETAL PREGNANCYDELIVERYDELIVERYOGRAPHYOGRAPHY