Multiple Pregnancy
Multiple Pregnancy
Multiple Pregnancy
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OBJECTIVES:
Definition.
Incidence and epidemiology.
Clinical characteristics.
Classification.
Diagnosis.
Complications.
Abnormalities of the twinning process.
Management.
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.
Weeks of Gestation
40 weeks
36 weeks
33 weeks
29 weeks
Clinical characteristics:
Multiple gestation should be suspected when ;
Uterine size is greater than expected for
gestational age.
Multiple FHRs are heard
Multiple fetal parts are felt.
hCG & serum alpha-fetoprotein levels are
elevated for gestational age.
If the pregnancy is a result of ART.
Diagnosis is confirmed by US .
Classification
Monozygotic (<30%)
Dizygotic (>70%)
Dichorionic/Diamniotic
Dichorionic/Diamniotic
(8%(
Monochorionic/Monoamniotic
(1%)
Monochorionic/Diamniotic
(20%)
N.B. : Placentation in higher-order multiples ( triplets, quadruplets( follows the same
principles, except monochorionic & dichorionic may coexist.
Important notes:
1- Monozygotic twins having same sex & blood
group.
2- Process of formation of chorion is earlier than
formation of amnion.
3-Dizygotic twins must be dichorionic/diamniotic.
Cont
The incidence of dizygotic twins is higher in ;
1. Certain families .
2. Race ;African Americans .
3. Increases with maternal age, parity, weight and
height .
4. Ovulation induction.
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.
Constant incidence .
Not affected by heredity.
Not related to induction of ovulation.
Time of
cleavage
Nature of membranes
Perinatal
mortality
0 - 72 hr
diamniotic,dichorionic
8.9%
4 8 days
diamniotic,monochorionic
20
25%
9-12days
monoamniotic,monochorionic
50-60%
>13 days
Conjoined twin
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Diagnosis:
History:
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).
Ultrasound evaluation:
The diagnosis of multiple gestation requires a
sonographic examination demonstrating two
separate fetuses and heart activities.
The diagnosis can be made as early as 6 weeks of
gestation.
DETERMINATION OF ZYGOSITY:
Very important as most of the complications occur in
monochorionic monozygotic twins.
By ;
Ultrasound : genders,numbar of placentas,
Blood groups.
HLA.
DNA analysis.
During pregnancy by US :
Very accurate in the first trimester, two sacs,
presence of thick chorion between amniotic
membrane .
Less accurate in the second trimester the
chorion become thin and fuse with the amniotic
membrane .
Different sex indicates dizygotic twins.
Separate placentas indicates dizygotic twins
After birth ;
By examination of the MEMBRANE,
PLACENTA,SEX , BLOOD group .
Examination of the newborn DNA and HLA may
be needed in few cases.
DETERMINATION OF ZYGOSITY:
Findings
Zygosity
Freq.
Different genders
dizygotic
30%
dizygotic
27%
One placentas
monozygotic
23%
20%
US
dizygotic
twins
different
same
gender
different
Monozygotic
twins
Number of
placenta
same
same
HLA & DNA
analysis
different
Blood
group
Septum
Placental type
Twin type
1- None
Monochorionic/Monoamniotic
monozygotic
2- Amnion only
Monochorionic/Diamniotic
monozygotic
Dichorionic/ diamniotic
Dizygotic or monozygotic
4- No common septum
Dichorionic/ diamniotic
dizigotic
Complications:
A - Maternal:
Antepartum
Anemia.
Miscarriage.
Preeclampsia ( 40% in twins & 60% in triplets ).
Polyhydramnios ( 5 8%).
PTL ( Twin account for 10% of all PTL & 25% of all preterm
perinatal deaths ).
Cervical incompetence.
Hyperemesis gravidarum.
Intrapartum
CS.
Postpartum
b/c of
Over distended uterus
Cont..
B - Fetal:
Malpresentation.
Umblical cord prolapse.
Placenta previa & abruptio placenta.
PROM & Prematurity.
IUGR .
Congenitial anomalies.
Increase perinatal morbidity & mortality
Conjoined Twins.
Interplacental Vascular Anastomosis.
Twin-Twin Transfusion Syndrome.
Fetal Malformations.
Umbilical Cord Abnormalities.
Discordant Twin Growth.
Locked twins ( delivered by CS ).
Single fetal death
Rupture of membrane in single sac
Locked twins
Conjoined Twins ;
Etiology : It result from cleavage of the embryo is
incomplete because it happen very late (after 13 days,
when the embryonic disc has completely formed).
Delivery by C.S.
Thoracopagus
Craniopagus
Complications:
Abortion.
Hydramnios.
Twin-twin transfusion syndrome (TTTS).
Fetal malformations.
Complication:
Donor : anemic HF, hypovolemia, hypotension, anemia,
oligohydramnios, growth restriction. ( do intrauterine blood
trans fusion).
Recipient : hypervolemic HF , hypervolemia, hypertension,
polyhydramnios, thrombosis, hyperviscosity,cardiomegaly,
polycythemia, hydrops fetalis. ( do repeated amnioreduction).
Both: risk of demise & PTL.
Management of TTTs ;
If not treated death occurs in 80-100% of cases.
If extreme prematurity prevents immediate delivery,
Several interventions can be considered in view of the
high mortality associated with expectant management.
Fetal Malformations:
Incidence:
Twice as common in twins & 4 times more common
in triplets than in singleton infants.
Monozygotic > Dizygotic.
Etiology:
Usually result from arterial-arterial anastomosis.
Common deformations in twins include limb
defects, plagiocephaly, facial asymmetry, and
torticollis.
Acardia and twin-reversed arterial perfusion
(TRAP) rare but unique to multiple pregnancy.
Amniocentesis:
If U/S shows abnormality.
Normal
(pump) twin
Acardiac
twin
Causes:
TTTS.
Chromosomal or structural anomalies.
Discordant viral infection.
Interplacental Vascular Anastomoses.
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.
Amniocentesis. ( If indicated )
Cont..
Intrapartum
The route of delivery depends on:
Delivery:
Vertex/Vertex(43%):
Vaginal delivery. (Successful in 70-80%of cases).
Surveillance of twin B with real-time U/S.
Vertex/Nonvertex(38%):
Vaginal delivery ( better ) (in absence of discordant
growth).
Either external cephalic version or podalic version
with breech extraction may be attempted.
CS.
Cont.
postpartum
Active management of PPH:
By giving oxytocin in the 3nd stage of labor just
after delivery of both fetuses and placentas.
Summary:
1- Definition.
2- Incidence why Increased?
3- Types (2).
4- Diagnosis (History, examination & US).
5- Complication( Maternal, fetal & placentation
process).
6- Management (antepartum, intrapartum &
postpartum).
References
The Johns Hopkins manual of gyencology &
obestetrics.
Essentials of gyencology & obestetrics by
Hacker, Moore & Gambone.
Pictures: From internet.
Thank You