MULTIPLE PREGNANCY DR ENIE AKHTAR BT NAWAWI
Aug 06, 2015
MULTIPLE PREGNANCY
DR ENIE AKHTAR BT NAWAWI
Why?
Heredity Older women High parity Race Ovulation induction IVF
How?
usually occurs when more than one egg is fertilized and implants in the uterus.
Sometimes, one egg is fertilized and then divides into two or more embryos. Identical multiples may have individual placentas and amniotic sacs, but most share a placenta with separate sacs. Rarely, identical twins share one placenta and a single amniotic sac.
Types:
Monozygotic– 3-5/1000 LB
Dyzygotic– 4-50/1000 LB
Zygosity- refers to type of conception
Chorionicity-refers to type of placenta
Seventy percent of twins are dizygotic, resulting from the fertilization of two ova, whereas 30% are monozygotic, arising from a single fertilized ovum .
Three placentation types can occur depending on the timing of the development of twins from fertilization. From earlier division to later, the three types of placentation are dichorionic-diamniotic, monochorionic-diamniotic, and monochorionic-monoamniotic.
Dizygotic twins are always dichorionic. Monozygotic twins are dichorionic in one-third of cases,
monochorionic-diamniotic in two-thirds of cases, and monochorionic pregnancies are seen in less than 1% of cases
Antenatal assessment-<20/52->20/52
Assessment of chorionicity(can be assessed accurately in 100% of cases when performed <13/52)
Opportunity to screen for chromosomal abnormality by NT
Maternal complication– PE and APH(PP or AP), preterm labour,anaemia,PPH
Fetal complication– IUGR(12-47%),single IUD(2.5-5%),monoamniotic
pregnancy, TRAP sequence,conjoined twin,TTTS
Determination of chorionicity-important in stratification of clinical risk,genetic counselling
and prenatal screening and diagnosis of structural and chromosomal abN
criterion monochorionicity dichorionicity
Placenta Single(42%) Separate(98%)
Fetal sex Concordant(40%) Discordant(100%)
Dividing membrane Absent-MCMA(100%)
No of layers 2 layers(94%) 4 layers(100%)
Thickness <2mm(39-82%) >2mm(95%)
Twin peak sign Nil(44%) Present(100%)
Use of all criteria 92% 97%
Twin peak sign/ lambda sign
Management
*The risks for women with multifetal pregnancies include preterm labor, premature rupture of membranes, gestational hypertension or preeclampsia, gestational diabetes, anemia, and thromboembolism.
Management
Delivery of more than one baby is also more complicated, with a greater risk of cesarean delivery and postpartum hemorrhage.
Because of the high rate of preterm delivery in multiple gestations, these babies are at greater risk for adverse neurologic outcomes, such as cerebral palsy, compared with a singleton pregnancy.
Additionally, fetuses in multiple gestations have a greater risk of chromosomal and structural abnormalities.
..single IUD
Influenced by chorionicity DC
– Seldom a risk factor for the healthy surviving co-twin
MC– Delivery soon may prevent sudden demise of the
co-twin but is unlikely to reduce the neurological morbidity of the survivor
..monoamniotic-suspect in single pl mass with same sex,normal amniotic volume,absence of dividing membrane on 2 exam and unrestricted FM
Cord entanglement MOD- el LSCS before term
TRAP(Twin reversed arterial perfusion)/acardiac-where fetal tissue part grow in tandem with the normal fetus and are perfused in the reversed direction with deO2 blood entering the single umbilical artery
Nly formed twin=pump twin Risk-cardiac failure or preterm delivery PNM 50% while the perfused fetus is never
viable Occur due to primary failure of cardiac
development early in embryogenesis from chromosomal abN
Dx- US-grossly malformed fetus with no FH
…TTTS-acute/chronic
Severe case- when deep A-V anastomoses are uncompensated by supreficial A-A and V-V anastomoses, with resultant net flow in one direction,causing associated hypovolemia in one twin and volume overload in the other.
Acute-dx-postnatal ie Hb difference Chronic-dx-discordant fetal size with severe poly
around larger twin and oligo ar the smaller stuck twin
Perinatal mortality and morbidity
6x higher-mainly due to immaturity Others-IUD, cerebral atrophy,cerebral palsy
INTRAPARTUM CARE
The increased incidence of fetal malpresentation,preterm labour,IUGR and placental abnormalities,together with the need for skilled obstetrical maneuvres,suggest thet appropriate intrapartum management is an important as intensive antenatal care to improve overall neonatal morbidity and mortality
Mode of delivery
Vaginal Caesarean
– Non-cephalic presentation of 1st twin– Placenta praevia– Antepartum death of 1st twin– Monoamniotic twin,IUGR,chronic TTTS
Combined (ie CS for the 2nd twin)
VD in twin pregnancy
Timing of delivery-38-40/52 Management of labour
– First stage IV line, partogram, continous CTG monitoring, ensure good contraction,
augmentation after discuss with specialist, adequate pain relief preferably epidural– Second stage
Inform Paeds Delivery of 2nd twin Palpate abdomen immediately-aim:longitudinal External version to either breech/cephalic according to the ease and the
proximity of the presenting part to the pelvic brim…breech extraction. If fail version-internal podalic version
Use of immediate augmentation using oxytocin Ensure no undiagnosed triplet before giving Syntometrine
….continue
– Third stage IM Syntometrine 1 ml after delivery of the second twin Deliver placenta by CCT IV oxytocin Examine the placenta for type of chorionicity and
completeness and document findings properly
Issues on twin delivery at second stage
The optimal delivery interval between twins in vaginal twin delivery
– It is reasonable to either: Expedite delivery by oxytocin infusion, stabilising amniotomy and if
indicated operative vaginal delivery Permit a longer delay between deliveries and continuous EFM. For
the non cephalic second twin, if breech extraction is considered, this should be done without delay
No clear time limit is required as long as continuous FHR monitoring of second twin can be achieved and reassuring in cephalic second twin. No hard and fast rule in regards to this but up to 30 minutes is acceptable.
Thank you