Twins

TwinsTopic ConferenceLU VI Block 10Tindoc.Tugano.Urquiza.Uy.Velasco.Ventigan.Ventura.Verdolaga.VillanuevaM.VillanuevaR.Visperas.Yabut.Yambot.YapB.YapJ

1EV, 33 year old G2P1(0010), single2EV, 33 year old G2P1(0010), single3EV, 33 year old G2P1(0010), single4EV, 33 year old G2P1(0010), singleObstetric HistoryGDateAOGMode of Delivery120072 mos.Spontaneous Abortion22011Present pregnancy5History of present illness6Review of systems7EV, 33 year old G2P1(0010), single8Physical Exam9Physical Exam10BPP/Biometry/Doppler Studies11BPP/Biometry/Doppler Studies12EV, 33 year old G2P1(0010), single13Prevalence of spontaneous twinning1 in 80 live births (1 in 40 babies)10-20/1000 live births in US, Europe40/1000 in Africa6/1000 in Asia

14Etiology of multifetal gestationDizygotic fertilization of 2 ova15

Etiology of multifetal gestationMonozygotic division of single fertilized ovum16Factors that influence twinningRace6/1000 livebirths in AsiaE.g. 4.3/1000 in Japan, 11.3/1000 in India, 12.3/1000 in England, WalesHeredityMaternal history more importantMothers who themselves are twins gave birth to twins at a 1/58 live birthsMaternal Age and ParityTaller, heavier more nutritionally provided women, 25-30% inc in twinning ratePituitary GonadotropinInc dizygotic twinning rate w/in 1 mo. of stopping oral contraceptives, associated with sudden surge in gonadotropinAssisted Reproductive TechnologyResponsible for 17% of multiple births in the US17Maternal physiologyCardiovascularMore hyperdynamic circulation than singleton pregnancyCardiac output increases by 20% more in twin gestation than in singleton15% from stroke volume: due to increase in preload3.5% from heart rateGI and Hepatic ChangesPregnancy nausea and vomiting 50%Twice the risk for obstetric cholestasisTwin pregnancy independent risk factor for acute fatty liver, 9-25% of all cases seen in twin pregnanciesRenalNo significant difference from singletonIncreased GFR, leads to decreased BUN, Crea and increased urine protein18Maternal physiologyRespiratoryNo significant differenceIncrease use of accessory musclesExaggerated abdominal distentionLoss of abdominal toneHematologicRBC mass increases by 25% in both single and multifetal gestations Inc. in plasma volume is 10-20% greater in twin pregnancy vs singletonOther changes associated with singleton pregnancy occur in the same wayFall in Hct 1st-2nd trimesterGranulocytosis with increase in immature WBCsHypercoagulability due to changes in coagulation and fibrinolytic cascades

19ComplicationsAntepartum complicationspreterm laborgestational diabetesPreeclampsiapretermpremature rupture of the membranesintrauterine growth restrictionintrauterine fetal demiseTTTS80% in multiple gestations vs 25% in singleton pregnancies 20MATERnal complicationsPreterm Delivery57% of twin gestations are pretermNot all spontaneousHigher risk for male-male twinsAve. length of pregnancy 35 wks for twins vs 39 wks for singletonsGestational DMMay be increased in multifetal gestation though not universally confirmedTreated the same way in twin pregnancies21Maternal complicationsPregnancy HPN Gestational HPN - RR 2.04 (95% CI 1.60 - 2.59)Pre-eclampsia RR 2.62 (95% CI 2.03 - 3.38), w/ earlier onset, greater severityGestational HPN and preeclampsia also associated with higher preterm delivery ratesGestational HPN, 2mm in dichorionic twinsExtraembryonic coelimic space 2 in dichorionicYolk sacs 2 in dichorionicFetal sexesLambda/twin peak sign diagnostic of dichorionic twins; triangular chorionic tissue from fused dichorionic placenta extending into the intertwin membrane

28Labor management & deliveryThe cornerstone of antepartum care is prevention of preterm labor and deliveryMain cause of high perinatal mortality and complications in twinsLabor and Delivery ProblemsHypotonic uterine inertiaDue to overdistended uterusOxytocin just as effective as in single births, dosage, time to delivery, complications sameIntrapartum bleedingMore common in twins due to abruptio or vasa previa29Labor management & deliveryRoute of DeliveryVaginal delivery for mature vertex-vertex twins and 1500gVBAC: same risk of uterine rupture as in singleton pregnancy32Cesarean sectionBreech: CS ifLarge fetus, and the aftercoming head is larger than the birth canalSmall fetus the extremities and trunk may deliver through an inadequately effaced and dilated cervix, but the head may become trapped above the cervix The umbilical cord prolapses.

33In this study there was no significant differencein perinatal mortality and neontala mortality in both the CS group and planned vaginal group.

34