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הריונות מרובי עוברים הריונות מרובי עוברים. General concerns:  Multiple gestations are HIGH RISK pregnancies.  The major problems are:  PRETERM.

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Presentation on theme: "הריונות מרובי עוברים הריונות מרובי עוברים. General concerns:  Multiple gestations are HIGH RISK pregnancies.  The major problems are:  PRETERM."— Presentation transcript:

1 הריונות מרובי עוברים הריונות מרובי עוברים

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4 General concerns:  Multiple gestations are HIGH RISK pregnancies.  The major problems are:  PRETERM BIRTH  LOW BIRTH WEIGHT General concerns: MMMMultiple gestations are HIGH RISK pregnancies. TTTThe major problems are: PPPPRETERM BIRTH LLLLOW BIRTH WEIGHT

5 Frequency Twins: 2% of all deliveries-Twins: 2% of all deliveries- 12% of NND. Monozygotic 1/250 (1/3 of twins)Monozygotic 1/250 (1/3 of twins) Tiplets: 1/80 2Tiplets: 1/80 2 Quadriplet: 1/80 3Quadriplet: 1/80 3 Twins: 2% of all deliveries-Twins: 2% of all deliveries- 12% of NND. Monozygotic 1/250 (1/3 of twins)Monozygotic 1/250 (1/3 of twins) Tiplets: 1/80 2Tiplets: 1/80 2 Quadriplet: 1/80 3Quadriplet: 1/80 3

6 Epidemiology:  In 1970’s multiple gestations  1% of births  In 1990’s multiple gestations > 2% due to:  75% - Assisted Reproductive Technologies (ART)  25% - older age childbearing Epidemiology:  In 1970’s multiple gestations  1% of births  In 1990’s multiple gestations > 2% due to:  75% - Assisted Reproductive Technologies (ART)  25% - older age childbearing

7 Multiple gestation Epidemiology:  Up to 10% of natural conceptions begin as twins  By early 1st trim. transvaginal sonography.  Up to 10% of natural conceptions begin as twins  By early 1st trim. transvaginal sonography. Bateman,1990; Boklage, wk (LMP) vanishing sac

8 Multiple gestation Epidemiology: "Natural" (1970’s) ART ( 1990's) "Natural" (1970’s) ART ( 1990's) Twins 1:80 births 1: 55 to 43 x 2 Triplets 1:6400 (1:80 2 ) 1: 3323 to 1341 x 6 Quadruplets 1:512,000 (1:80 3 ) x balanced by fetal reduction balanced by fetal reductionEpidemiology: "Natural" (1970’s) ART ( 1990's) "Natural" (1970’s) ART ( 1990's) Twins 1:80 births 1: 55 to 43 x 2 Triplets 1:6400 (1:80 2 ) 1: 3323 to 1341 x 6 Quadruplets 1:512,000 (1:80 3 ) x balanced by fetal reduction balanced by fetal reduction 5 +5 wk (LMP)

9 Multiple gestation Definitions: Dizygotic Twins (Fraternal): Dizygotic Twins (Fraternal):  66% U.S. twins  fertilization of 2 ova by 2 sperm Monozygotic Twins (Identical) Monozygotic Twins (Identical)  33% U.S twins  division of 1 ovum fertilized by same sperm by same spermDefinitions: Dizygotic Twins (Fraternal): Dizygotic Twins (Fraternal):  66% U.S. twins  fertilization of 2 ova by 2 sperm Monozygotic Twins (Identical) Monozygotic Twins (Identical)  33% U.S twins  division of 1 ovum fertilized by same sperm by same sperm unlike sex: 33% of twin pairs

10 Etiology Causes of twiningCauses of twining (race, heredity, age, parity, fertility agents, IVF) Genesis of monozygotic twinsGenesis of monozygotic twins Monoamniotic twinsMonoamniotic twins Causes of twining (race, heredity, age, parity, fertility agents, IVF) Genesis of monozygotic twins Monoamniotic twins

11 Multiple gestation Risk factors for dizygotic twins:  Age:  older mothers  Race:  1:20 in nigeria  1:80 whites  1:150 japanese  Parity:  higher  Family history Risk factors for dizygotic twins:  Age:  older mothers  Race:  1:20 in nigeria  1:80 whites  1:150 japanese  Parity:  higher  Family history

12 Multiple gestation Risk factors for dizygotic twins:  ART results:  35% of twins  77% of higher order multiples  Clomiphene citrate: 10-15%  Gonadotropins: 20-40%  IVF ~ number of embryos Risk factors for dizygotic twins:  ART results:  35% of twins  77% of higher order multiples  Clomiphene citrate: 10-15%  Gonadotropins: 20-40%  IVF ~ number of embryos

13 Multiple gestation Monozygotic twinning:  random event ~ 1:250 pregnancies.  not influenced by age, race  increased with ovulation induction (?)  sex ratio in pairs: female>male Monozygotic twinning:  random event ~ 1:250 pregnancies.  not influenced by age, race  increased with ovulation induction (?)  sex ratio in pairs: female>male

14 Multiple gestation Definitions: Superfecundation - twins fertilized by different fathers Superfecundation - twins fertilized by different fathers Superfetation - 2nd ovum fertilized at different month (in animals) Superfetation - 2nd ovum fertilized at different month (in animals) Heterotopic Multiple Gestation - intrauterine Heterotopic Multiple Gestation - intrauterine pregnancy coexisting with extauterine one (IVF) pregnancy coexisting with extauterine one (IVF)Definitions: Superfecundation - twins fertilized by different fathers Superfecundation - twins fertilized by different fathers Superfetation - 2nd ovum fertilized at different month (in animals) Superfetation - 2nd ovum fertilized at different month (in animals) Heterotopic Multiple Gestation - intrauterine Heterotopic Multiple Gestation - intrauterine pregnancy coexisting with extauterine one (IVF) pregnancy coexisting with extauterine one (IVF)

15 Multiple gestation Definitions: Dichorionic: separate chorions Dichorionic: separate chorions Diamniotic: separate amnions Diamniotic: separate amnions Monochorionic: common chorion Monochorionic: common chorion Monoamniotic: common amnion Monoamniotic: common amnionDefinitions: Dichorionic: separate chorions Dichorionic: separate chorions Diamniotic: separate amnions Diamniotic: separate amnions Monochorionic: common chorion Monochorionic: common chorion Monoamniotic: common amnion Monoamniotic: common amnion Dizygotic Twins: always Di-Di Dizygotic Twins: always Di-Di Monozygotic Twins: Di-Di; Di-Mo; Mo-Mo Monozygotic Twins: Di-Di; Di-Mo; Mo-Mo

16 Multiple gestation Chorionicity & amnionicity impact: MZ Twins FrequencyMortality Di-Di 30% 9% Mo-Di 68% 25% Mo-Mo 2% 60-50% Chorionicity & amnionicity impact: MZ Twins FrequencyMortality Di-Di 30% 9% Mo-Di 68% 25% Mo-Mo 2% 60-50%

17 Embryology of membranes Multiple gestation amnioticcavity exocoelomic cavity (primary yolk sac) Blastocyst implantation: day 6-7 (embryonic age) Blastocyst implantation: day 6-7 (embryonic age)

18 Embryology of membranes Multiple gestation Chorionic cavity: day 14 (embryonic age) Chorionic cavity: day 14 (embryonic age) chorionic cavity chorionic cavity (exraembryonic coelom) (exraembryonic coelom) secondary yolk sac

19 Embryology of membranes Multiple gestation Folding & amniotic cavity: day (embryonic age) Folding & amniotic cavity: day (embryonic age) cephalocaudalfolding lateral folding

20 embryo yolk sac chorioniccavity Embryology of membranes chorion decidua capsularis amnion - ? Multiple gestation 6 +2 wk (LMP)

21 Embryology of membranes Multiple gestation amnion 6 wk (LMP) 7 wk (LMP) 9 wk (LMP) 8 mm 21 mm

22 ZigosityZigosityDC/DAMC/DAMC/MACon--joinedFraternal ~1/3 identical ~2/3 identical 3%1/ Conception chorion amnion embryonic disc

23 Multiple gestation Monozygotic twinning: division <3 days: Di-Di division <3 days: Di-Di division 4-8 days: Mo-Di division 4-8 days: Mo-Di division 9-13 days: Mo-Mo division 9-13 days: Mo-Mo division >13 days: Conjoined twins division >13 days: Conjoined twins Monozygotic twinning: division <3 days: Di-Di division <3 days: Di-Di division 4-8 days: Mo-Di division 4-8 days: Mo-Di division 9-13 days: Mo-Mo division 9-13 days: Mo-Mo division >13 days: Conjoined twins division >13 days: Conjoined twins

24 Dichorionic – always diamniotic Monoamniotic – always monochorionic Multiple gestation Monozygotic twinning: implantationimplantation

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31 Diagnosis HistoryHistory Physical examinationPhysical examination X raysX rays UltrasoundUltrasound Biochemical testBiochemical test History Physical examination X rays Ultrasound Biochemical test

32 Multiple gestation Diagnosis:  Historically up to 2/3 not diagnosed until labor:  poor dates  late/poor prenatal care  absence of ultrasound screening Diagnosis:  Historically up to 2/3 not diagnosed until labor:  poor dates  late/poor prenatal care  absence of ultrasound screening

33 Multiple gestation Diagnosis:  Clinical Hints:  family history, late childbearing, black race  ART: clomiphene citrate, gonadotropins, IVF  Large for dates uterus: fundal height >3 cm  Elevated MSAFP > 2 MOM  More than one audible FHR (late finding) Diagnosis:  Clinical Hints:  family history, late childbearing, black race  ART: clomiphene citrate, gonadotropins, IVF  Large for dates uterus: fundal height >3 cm  Elevated MSAFP > 2 MOM  More than one audible FHR (late finding)

34 Multiple gestation Definitive diagnosis: UltrasoundUltrasound Multiple gestations outcome is improved withMultiple gestations outcome is improved with screening all pregnancies at weeks. screening all pregnancies at weeks. Definitive diagnosis: UltrasoundUltrasound Multiple gestations outcome is improved withMultiple gestations outcome is improved with screening all pregnancies at weeks. screening all pregnancies at weeks.

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36 Multiple gestation Differential Diagnosis:  Misdated pregnancy  Polyhydramnios  Uterine myomas  Ovarian cyst  Hydatiform mole Differential Diagnosis:  Misdated pregnancy  Polyhydramnios  Uterine myomas  Ovarian cyst  Hydatiform mole

37 Multiple gestation Determination of chorionicity & amnionicity: Early determination: 8-10 weeks is optimal Early determination: 8-10 weeks is optimal Determination of chorionicity & amnionicity: Early determination: 8-10 weeks is optimal Early determination: 8-10 weeks is optimal Di-Di Mo-Di Mo-Mo

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39 Multiple gestation Determination of chorionicity & amnionicity: Dichorionic-Diamniotic: late determination Dichorionic-Diamniotic: late determination  Unlike sex fetuses  "Lambda" or “Y” sign  Thick membrane (> 2mm) 3-4 layers  Two separate placentas Determination of chorionicity & amnionicity: Dichorionic-Diamniotic: late determination Dichorionic-Diamniotic: late determination  Unlike sex fetuses  "Lambda" or “Y” sign  Thick membrane (> 2mm) 3-4 layers  Two separate placentas Placentas may fuse (40%), but no vascular anastamosis occurs

40 Multiple gestation Determination of chorionicity & amnionicity:  Monochorionic-Diamniotic: late determination  Same sex fetuses  "T" sign  Thin membrane: 2 layers  Fused placenta Determination of chorionicity & amnionicity:  Monochorionic-Diamniotic: late determination  Same sex fetuses  "T" sign  Thin membrane: 2 layers  Fused placenta Interplacental vascular anastamosis > 20%

41 Multiple gestation Determination of chorionicity & amnionicity:  Monochorionic-Monoamnionic: late determination  Same sex fetuses  No membrane seen between fetuses  Adequate fluid with free movement of both fetuses  Single placenta Determination of chorionicity & amnionicity:  Monochorionic-Monoamnionic: late determination  Same sex fetuses  No membrane seen between fetuses  Adequate fluid with free movement of both fetuses  Single placenta Interplacental vascular anastamosis - almost always

42 Multiple gestation Maternal adaptation:  Weight gain ~ 15 kg (twin gestation)  Plasma volume  Cardiac output  Systemic vascular resistance  Venous engorgement Maternal adaptation:  Weight gain ~ 15 kg (twin gestation)  Plasma volume  Cardiac output  Systemic vascular resistance  Venous engorgement

43 Multiple gestation Maternal adaptation:  Tidal volume  Residual volume  Ventilation  Decreased GIT motility  Renal plasma flow  Uterine volume: 10 liters at term (x2 as singleton) (x2 as singleton) Maternal adaptation:  Tidal volume  Residual volume  Ventilation  Decreased GIT motility  Renal plasma flow  Uterine volume: 10 liters at term (x2 as singleton) (x2 as singleton)

44 Multiple gestation General management:  Nutrition  2700 kcal/day – twins  2400 kcal/day – singleton  2100 kcal/day – non pregnant  Elementary Iron mg/day  Folate 1 mg/day  protein gr/day  Reduce activity and increase rest (after 20 weeks) General management:  Nutrition  2700 kcal/day – twins  2400 kcal/day – singleton  2100 kcal/day – non pregnant  Elementary Iron mg/day  Folate 1 mg/day  protein gr/day  Reduce activity and increase rest (after 20 weeks)

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48 Multiple gestation General management : Clinic visits every 2 wks after 24 wks :Clinic visits every 2 wks after 24 wks :  Preterm labor Education  Fetal movement counts daily after 32 weeks General management : Clinic visits every 2 wks after 24 wks :Clinic visits every 2 wks after 24 wks :  Preterm labor Education  Fetal movement counts daily after 32 weeks

49 Obstetric ultrasound: every 2-4 weeks  Fetal growth assessment  Biophysical profile  Presentations  Placental site  Cervix length  Doppler study Obstetric ultrasound: every 2-4 weeks  Fetal growth assessment  Biophysical profile  Presentations  Placental site  Cervix length  Doppler study Multiple gestation weightweightweightweight (kg) singletons twins triplets

50 Non Stress Test:  Weekly after 34 weeks  More frequent and earlier if indicated  Assess fetal well-being Non Stress Test:  Weekly after 34 weeks  More frequent and earlier if indicated  Assess fetal well-being Multiple gestation

51 Complications

52 Complications:  Fetal:  Abortion / vanishing twin  Inevitable abortion X 2 as in singleton  50 % of early 1st trim. twin sacs are finally deliver as twins  80 % of early 1st trim. alive twins are finally deliver as twins  Congenital Anomalies: usual & unique Complications:  Fetal:  Abortion / vanishing twin  Inevitable abortion X 2 as in singleton  50 % of early 1st trim. twin sacs are finally deliver as twins  80 % of early 1st trim. alive twins are finally deliver as twins  Congenital Anomalies: usual & unique

53 Multiple gestation Complications:  Fetal:  Hydramnios / Oligohydramnios: TTTS  Discordant growth  Intrauterine growth retardation: IUGR ~ 70% of multiple gestations IUGR ~ 70% of multiple gestations More than 50% of twins < 2500 gr at birth More than 50% of twins < 2500 gr at birth  Intrauterine fetal death of one or more fetuses Complications:  Fetal:  Hydramnios / Oligohydramnios: TTTS  Discordant growth  Intrauterine growth retardation: IUGR ~ 70% of multiple gestations IUGR ~ 70% of multiple gestations More than 50% of twins < 2500 gr at birth More than 50% of twins < 2500 gr at birth  Intrauterine fetal death of one or more fetuses

54 Multiple gestation Complications:  Maternal:  Hyperemesis gravidarum  Anemia (40%)  GDM  Pregnancy induced hypertension: twins - 40% twins - 40% triplets - 60% triplets - 60%Complications:  Maternal:  Hyperemesis gravidarum  Anemia (40%)  GDM  Pregnancy induced hypertension: twins - 40% twins - 40% triplets - 60% triplets - 60%

55 Multiple gestation Complications:  Maternal-fetal:  Premature uterine contractions / labor twins: 10% of all preterm deliveries twins: 10% of all preterm deliveries twins: 25% of prenatal deaths twins: 25% of prenatal deaths worse < 32 weeks and birth weight < 1500gr worse < 32 weeks and birth weight < 1500gr  Premature rupture of membranes  Antepartum hemorrhage: abruptio placenta abruptio placenta placenta previa placenta previaComplications:  Maternal-fetal:  Premature uterine contractions / labor twins: 10% of all preterm deliveries twins: 10% of all preterm deliveries twins: 25% of prenatal deaths twins: 25% of prenatal deaths worse < 32 weeks and birth weight < 1500gr worse < 32 weeks and birth weight < 1500gr  Premature rupture of membranes  Antepartum hemorrhage: abruptio placenta abruptio placenta placenta previa placenta previa

56 Multiple gestation Labor: Intrapartum hemorrhage Intrapartum hemorrhage  abruptio placenta  placenta previa  uterine rupture Postpartum hemorrhage Postpartum hemorrhage  atonia uteri  placental residia  DIC  birth canal trauma  uterine rupture Labor: Intrapartum hemorrhage Intrapartum hemorrhage  abruptio placenta  placenta previa  uterine rupture Postpartum hemorrhage Postpartum hemorrhage  atonia uteri  placental residia  DIC  birth canal trauma  uterine rupture

57 Multiple gestation Labor: Malpresentation Malpresentation Cord accident: prolapse, entanglement Cord accident: prolapse, entanglement Prematurity associated morbidity and mortality Prematurity associated morbidity and mortality Birth trauma (interlocking, breech extraction) Birth trauma (interlocking, breech extraction) Instrumental delivery Instrumental delivery Cesarean delivery Cesarean deliveryLabor: Malpresentation Malpresentation Cord accident: prolapse, entanglement Cord accident: prolapse, entanglement Prematurity associated morbidity and mortality Prematurity associated morbidity and mortality Birth trauma (interlocking, breech extraction) Birth trauma (interlocking, breech extraction) Instrumental delivery Instrumental delivery Cesarean delivery Cesarean delivery

58 Multiple gestation Premature delivery:  Average length of gestation to delivery : Premature delivery:  Average length of gestation to delivery : No. fetuses weeks (LMP) ~33 3 ~33 4 ~29 4 ~29

59 Multiple gestation Premature delivery: Twins: X 12 as singletonsTwins: X 12 as singletons > 50% of twins deliver 50% of twins deliver < 37 weeks 91% of triplets deliver < 37 weeks91% of triplets deliver < 37 weeks Premature delivery: Twins: X 12 as singletonsTwins: X 12 as singletons > 50% of twins deliver 50% of twins deliver < 37 weeks 91% of triplets deliver < 37 weeks91% of triplets deliver < 37 weeks

60 Multiple gestation Premature delivery:  Liberal policy of tocolysis may be justified  The decision to administer tocolytics is influenced by:  gestational age  fetal well-being  subtle cervical changes  history of prior preterm delivery  Prophylactic tocolysis in multiple gestations is not indicated Premature delivery:  Liberal policy of tocolysis may be justified  The decision to administer tocolytics is influenced by:  gestational age  fetal well-being  subtle cervical changes  history of prior preterm delivery  Prophylactic tocolysis in multiple gestations is not indicated

61 Multiple gestation Premature delivery:  Contraindications for tocolytic use:  unexplained vaginal bleeding  fetal distress  chorioamnionitis  advanced cervical dilation. Premature delivery:  Contraindications for tocolytic use:  unexplained vaginal bleeding  fetal distress  chorioamnionitis  advanced cervical dilation.

62 Multiple gestation Premature delivery:  Special considerations for tocolysis in multiple gestations:  High intravascular volume and cardiac output.  Careful fluid balance using beta-mimetics:  increased risk for pulmonary edema  Fetal status may preclude use:  indomethacin with oligohydramnios Premature delivery:  Special considerations for tocolysis in multiple gestations:  High intravascular volume and cardiac output.  Careful fluid balance using beta-mimetics:  increased risk for pulmonary edema  Fetal status may preclude use:  indomethacin with oligohydramnios

63 Vascular anastomoses between fetuses Effects of anastomotic circulationEffects of anastomotic circulation Twin to twin transfusionTwin to twin transfusion Acardiac twinAcardiac twin Effects of anastomotic circulationEffects of anastomotic circulation Twin to twin transfusionTwin to twin transfusion Acardiac twinAcardiac twin

64 Multiple gestation Twin-to-twin transfusion syndrome (TTTS):  A-V, A-A, V-V shunting between placental vessels of the monochorionic twins of the monochorionic twins  10-20% of monochorionic: (Mo-Mo > Mo-Di)  80%-100% perinatal mortality if not treated (lethal in early, acute form) (lethal in early, acute form) Twin-to-twin transfusion syndrome (TTTS):  A-V, A-A, V-V shunting between placental vessels of the monochorionic twins of the monochorionic twins  10-20% of monochorionic: (Mo-Mo > Mo-Di)  80%-100% perinatal mortality if not treated (lethal in early, acute form) (lethal in early, acute form)

65 Multiple gestation Twin-to-twin transfusion syndrome (TTTS):  Ultrasound:  oligo/polyhydramnios - the first finding  stuck twin: severe oligohydramnios severe oligohydramnios fetus stucked close to the uterine wall fetus stucked close to the uterine wall  discordancy: >20-25% weight difference >20-25% weight difference >20mm abdominal circuference difference >20mm abdominal circuference difference Twin-to-twin transfusion syndrome (TTTS):  Ultrasound:  oligo/polyhydramnios - the first finding  stuck twin: severe oligohydramnios severe oligohydramnios fetus stucked close to the uterine wall fetus stucked close to the uterine wall  discordancy: >20-25% weight difference >20-25% weight difference >20mm abdominal circuference difference >20mm abdominal circuference difference

66 Multiple gestation Twin-to-twin transfusion syndrome (TTTS): Donor twin:Donor twin:  small & anemic  poor renal perfusion  small urinary bladder  oligohydramnios Twin-to-twin transfusion syndrome (TTTS): Donor twin:Donor twin:  small & anemic  poor renal perfusion  small urinary bladder  oligohydramnios

67 Multiple gestation Twin-to-twin transfusion syndrome (TTTS): Recipient twin:Recipient twin:  large & polycythemic (>5 gm% Hb difference)  large urinary bladder  hypertrophic heart  polyhydramnios  CHF, hydrops & death from circulatory overload  polyhydramnious can cause early labor Twin-to-twin transfusion syndrome (TTTS): Recipient twin:Recipient twin:  large & polycythemic (>5 gm% Hb difference)  large urinary bladder  hypertrophic heart  polyhydramnios  CHF, hydrops & death from circulatory overload  polyhydramnious can cause early labor

68 Twin-twin transfusion syndrome PrenatalPrenatal Donor : anemia, oligohydramnios, IUGR, Recipient :polycytemia, polyhydramnios, macrosomia PostnatalPostnatal Donor : swollen placenta, pale Recipient : red, congested, hypertrophy of placenta, injection studies:anastomoses. PrenatalPrenatal Donor : anemia, oligohydramnios, IUGR, Recipient :polycytemia, polyhydramnios, macrosomia PostnatalPostnatal Donor : swollen placenta, pale Recipient : red, congested, hypertrophy of placenta, injection studies:anastomoses.

69 Twin-to-twin transfusion: mechanism DonorRecipient Placental shunt Chronic blood lossChronic blood gain Hypervolemia Polyhydramnios Polycytemia Embolization Hypertension Cardiac failure Hypovolemia Anemia Hypoxia IUGR Decreased renal flow  Oligohydramnios

70 Twin transfusion with stuck twin Recipient twin with progressive polyhydramnios Donor twin with progressive oligohydramnios Stuck twin

71 Twin transfusion with stuck twin Recipient twin with progressive polyhydramnios Donor twin with progressive oligohydramnios Stuck twin

72 Twin transfusion with stuck twin Recipient twin with progressive polyhydramnios Donor twin with progressive oligohydramnios Stuck twin

73 Twin transfusion with stuck twin Recipient twin with progressive polyhydramnios Donor twin with progressive oligohydramnios Stuck twin

74 Twin transfusion with stuck twin Recipient twin with progressive polyhydramnios Donor twin with progressive oligohydramnios Stuck twin

75 Twin transfusion with stuck twin Recipient twin with progressive polyhydramnios Donor twin with progressive oligohydramnios Stuck twin

76 The “stuck twin”

77 The folding of the membrane Early stages of the stuck twin phenomenon: folding of the membrane

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80 Multiple gestation Twin-to-twin transfusion syndrome (TTTS):  Treatment:  Bed rest improves intrauterine blood flow  Laser coagulation of shunting vessels  Aggressive serial amniocentesis  Septostomy (?)  If treated - survival up to the 80%  To attain > 28 weeks seems to be critical Twin-to-twin transfusion syndrome (TTTS):  Treatment:  Bed rest improves intrauterine blood flow  Laser coagulation of shunting vessels  Aggressive serial amniocentesis  Septostomy (?)  If treated - survival up to the 80%  To attain > 28 weeks seems to be critical

81 Multiple gestation Discordant growth and IUGR: Discordance:Discordance:  100% x (  weights / larger twin weight) Discordance of 20-25%:Discordance of 20-25%:  single IUGR fetus > 50% Discordance > 25%:Discordance > 25%:  X 6 risk of IUFD ( compared to discordance < 25%) Discordant growth and IUGR: Discordance:Discordance:  100% x (  weights / larger twin weight) Discordance of 20-25%:Discordance of 20-25%:  single IUGR fetus > 50% Discordance > 25%:Discordance > 25%:  X 6 risk of IUFD ( compared to discordance < 25%)

82 Multiple gestation Discordant growth and IUGR: At > 30% discordancy in weight:At > 30% discordancy in weight:  fetal death (the smaller) : 25%  congenital anomalies: 38%  low Apgars < 7 at 5 min.: 33%  periventricular leukomalacia: 17% Discordant growth and IUGR: At > 30% discordancy in weight:At > 30% discordancy in weight:  fetal death (the smaller) : 25%  congenital anomalies: 38%  low Apgars < 7 at 5 min.: 33%  periventricular leukomalacia: 17%

83 Multiple gestation Discordant growth and IUGR:  Ultrasound diagnostic criteria:  >20mm abdominal circumferences difference  >25% fetal weight difference Discordant growth and IUGR:  Ultrasound diagnostic criteria:  >20mm abdominal circumferences difference  >25% fetal weight difference

84 Multiple gestation Discordant growth and IUGR:  Management considerations:  chorionicity:  Di-Di virtually rules out TTTS  gestational age:  late IUGR suggests extrinsic causes  weight percentiles:  Both twins with normal percentiles - less concern Discordant growth and IUGR:  Management considerations:  chorionicity:  Di-Di virtually rules out TTTS  gestational age:  late IUGR suggests extrinsic causes  weight percentiles:  Both twins with normal percentiles - less concern

85 Multiple gestation Discordant growth and IUGR:  Management considerations:  pattern of growth important:  < 10th percentile or oligohidramnios or pathologic umbilical artery Doppler – close antepartum testing  isolated discordance at <32 weeks and <2000 gr, does not support intervention in the absence of other signs of fetal jeopardy. Discordant growth and IUGR:  Management considerations:  pattern of growth important:  < 10th percentile or oligohidramnios or pathologic umbilical artery Doppler – close antepartum testing  isolated discordance at <32 weeks and <2000 gr, does not support intervention in the absence of other signs of fetal jeopardy.

86 Multiple gestation Single IUFD in 2nd and 3rd trimester:  Unlike the demise in early pregnancy, significant problems may occur depending upon the gestational age and chorionicity  Loss during the 2nd half of twin pregnancies: ~ 2-3%  X 3 as often in monochorionic as dichorionic  Fetus papyraceous - hylanized twin remnant Single IUFD in 2nd and 3rd trimester:  Unlike the demise in early pregnancy, significant problems may occur depending upon the gestational age and chorionicity  Loss during the 2nd half of twin pregnancies: ~ 2-3%  X 3 as often in monochorionic as dichorionic  Fetus papyraceous - hylanized twin remnant

87 Multiple gestation Single IUFD in 2nd and 3rd trimester:  Overall morbidity and mortality approximates %  IUFD of one fetus is associated with preterm delivery in the surviving fetus  Associated with prematurity, fetal distress and PET  Maternal coagulopathy (DIC) Single IUFD in 2nd and 3rd trimester:  Overall morbidity and mortality approximates %  IUFD of one fetus is associated with preterm delivery in the surviving fetus  Associated with prematurity, fetal distress and PET  Maternal coagulopathy (DIC)

88 Multiple gestation Single IUFD in 2nd and 3rd trimester:  Monochorionic IUFD:  worst prognosis with placental anastomoses:  death of one fetus causes severe hypotension in the surviving twin  embolisation(?)/DIC and organ damage in the surviving twin:  CNS: porencephaly, hydrocephalus, microcephalus  limb reduction  renal cortical necrosis  intestinal atresia  aplasia cutis Single IUFD in 2nd and 3rd trimester:  Monochorionic IUFD:  worst prognosis with placental anastomoses:  death of one fetus causes severe hypotension in the surviving twin  embolisation(?)/DIC and organ damage in the surviving twin:  CNS: porencephaly, hydrocephalus, microcephalus  limb reduction  renal cortical necrosis  intestinal atresia  aplasia cutis

89 Multiple gestation Single IUFD in 2nd and 3rd trimester:  Management depends upon:  chorionicity  cause of the demise  gestational age  Intensive fetal monitoring should be undertaken Single IUFD in 2nd and 3rd trimester:  Management depends upon:  chorionicity  cause of the demise  gestational age  Intensive fetal monitoring should be undertaken

90 Multiple gestation Single IUFD in 2nd and 3rd trimester:  Because of the potential for chronic damage, it is reasonable to deliver monochorionic gestations with lung maturity after 32 weeks  Timing of delivery for dizygotic twins with a single demise should be individualized Single IUFD in 2nd and 3rd trimester:  Because of the potential for chronic damage, it is reasonable to deliver monochorionic gestations with lung maturity after 32 weeks  Timing of delivery for dizygotic twins with a single demise should be individualized

91 Multiple gestation Presentations:  First twin presents vertex: 74%  Both twins vertex: 40%  First twin presents breech: 20%  Both twins breech: 10%  Other (transverse/oblique): 6% Presentations:  First twin presents vertex: 74%  Both twins vertex: 40%  First twin presents breech: 20%  Both twins breech: 10%  Other (transverse/oblique): 6%

92 Multiple gestation Cesarean delivery: Absolute indications: Absolute indications:  monoamniotic twins  conjoined twins  first twin - not vertex  triplets and higher order  other Cesarian section indications:  non progressive labor  fetal distress  placenta previa  uterine scar: corporeal, >1 past CSLT’s  absolute CPD, etc. Cesarean delivery: Absolute indications: Absolute indications:  monoamniotic twins  conjoined twins  first twin - not vertex  triplets and higher order  other Cesarian section indications:  non progressive labor  fetal distress  placenta previa  uterine scar: corporeal, >1 past CSLT’s  absolute CPD, etc.

93 Multiple gestation Cesarean delivery: Relative indications: Relative indications:  Second twin - not vertex: Mother not willing to undergo breech delivery Mother not willing to undergo breech delivery Fetus <1.5 kg (? 2 kg) Fetus <1.5 kg (? 2 kg)  one or both twins have non-reassuring fetal status  fetal discordancy: the first twin is the smaller member  single past low transverse cesarian delivery Cesarean delivery: Relative indications: Relative indications:  Second twin - not vertex: Mother not willing to undergo breech delivery Mother not willing to undergo breech delivery Fetus <1.5 kg (? 2 kg) Fetus <1.5 kg (? 2 kg)  one or both twins have non-reassuring fetal status  fetal discordancy: the first twin is the smaller member  single past low transverse cesarian delivery

94 Multiple gestation Vaginal delivery: (ACOG, 1998)  During labour - continuous cardiotocogram  All patients should have a ready IV access  Double set-up delivery room  First twin - vertex vaginal delivery Vaginal delivery: (ACOG, 1998)  During labour - continuous cardiotocogram  All patients should have a ready IV access  Double set-up delivery room  First twin - vertex vaginal delivery

95 Multiple gestation Vaginal delivery: (ACOG, 1998)  Second twin - vertex presentation:  vertex vaginal delivery  Second twin - non vertex presentation:  internal podalic version and breech extraction  external cephalic version: less successful  expectant management Vaginal delivery: (ACOG, 1998)  Second twin - vertex presentation:  vertex vaginal delivery  Second twin - non vertex presentation:  internal podalic version and breech extraction  external cephalic version: less successful  expectant management

96 Multiple gestation Vaginal delivery: (ACOG, 1998) Second twin considerations:Second twin considerations:  Delay > 20 min. may increase morbidity of the 2nd twin.  Delays >15 min. are associated with a 6 fold increase in Cesarean section. Vaginal delivery: (ACOG, 1998) Second twin considerations:Second twin considerations:  Delay > 20 min. may increase morbidity of the 2nd twin.  Delays >15 min. are associated with a 6 fold increase in Cesarean section. Morbidity and mortality are minimized with continuous CTG of twin B and the ability for immediate Cesarean section.

97 Multiple gestation Vaginal delivery: (ACOG, 1998) Second twin considerationsSecond twin considerations:  ~15% of vertex/nonvertex require a Caesarean section for the second twin: Failure of second twin delivery Failure of second twin delivery Second twin experiences fetal distress Second twin experiences fetal distress  prepare for double set-up delivery  placentas of multifetal pregnancies should be sent to pathology with each cord clearly labelled. Vaginal delivery: (ACOG, 1998) Second twin considerationsSecond twin considerations:  ~15% of vertex/nonvertex require a Caesarean section for the second twin: Failure of second twin delivery Failure of second twin delivery Second twin experiences fetal distress Second twin experiences fetal distress  prepare for double set-up delivery  placentas of multifetal pregnancies should be sent to pathology with each cord clearly labelled.

98 Multiple gestation Prenatal diagnosis:  Diagnosis of multiple gestation  Gestational age assessment  Determination of Amnion/Chorion Status  Survey for anomalies: NTT, Triple screen, TIFFA  Invasive procedures: CVS, Amniocentesis Prenatal diagnosis:  Diagnosis of multiple gestation  Gestational age assessment  Determination of Amnion/Chorion Status  Survey for anomalies: NTT, Triple screen, TIFFA  Invasive procedures: CVS, Amniocentesis

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100 Multiple gestation Problems with prenatal diagnosis: Increase in multiple gestations and Increase in multiple gestations and aneuploidy with older maternal age aneuploidy with older maternal age Increased background risk for anomalies Increased background risk for anomalies Correct determination of zygosity Correct determination of zygosity Difficulties with interpretation of triple screen Difficulties with interpretation of triple screen Problems with prenatal diagnosis: Increase in multiple gestations and Increase in multiple gestations and aneuploidy with older maternal age aneuploidy with older maternal age Increased background risk for anomalies Increased background risk for anomalies Correct determination of zygosity Correct determination of zygosity Difficulties with interpretation of triple screen Difficulties with interpretation of triple screen

101 Multiple gestation Problems with prenatal diagnosis: Ability to sample all fetuses (CVS, AC)Ability to sample all fetuses (CVS, AC) Increased loss of pregnancies before 28 weeksIncreased loss of pregnancies before 28 weeks Increased loss rate with CVS and amniocentesisIncreased loss rate with CVS and amniocentesis Problems with prenatal diagnosis: Ability to sample all fetuses (CVS, AC)Ability to sample all fetuses (CVS, AC) Increased loss of pregnancies before 28 weeksIncreased loss of pregnancies before 28 weeks Increased loss rate with CVS and amniocentesisIncreased loss rate with CVS and amniocentesis

102 Multiple gestation Congenital anomalies:  Incidence in twins: x2 as in singletons  major malformations: 2.3% vs. 1%  Monozygotic: x2 as in dizygotic  chromosomal anomalies:  each twin ~ singleton  conjoined twins – higher incidence  risk of Down syndrome in twins:  1:370 for women aged 33 (35 in singeltons) (35 in singeltons) Congenital anomalies:  Incidence in twins: x2 as in singletons  major malformations: 2.3% vs. 1%  Monozygotic: x2 as in dizygotic  chromosomal anomalies:  each twin ~ singleton  conjoined twins – higher incidence  risk of Down syndrome in twins:  1:370 for women aged 33 (35 in singeltons) (35 in singeltons)

103 Multiple gestation Congenital anomalies:  Unique to monozygotic twins:  conjoined twins  acardiac twin (TRAP syndrome)  fetus-in-fetu Congenital anomalies:  Unique to monozygotic twins:  conjoined twins  acardiac twin (TRAP syndrome)  fetus-in-fetu

104 Multiple gestation Congenital anomalies:  Twinning process associated anomalies:  anencephaly  holoprosencephaly  sirenomelia  extrophy of cloaca  renal agenesis  anal atresia  tracheoesophageal fistula  situs inversus defects Congenital anomalies:  Twinning process associated anomalies:  anencephaly  holoprosencephaly  sirenomelia  extrophy of cloaca  renal agenesis  anal atresia  tracheoesophageal fistula  situs inversus defects

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106 Multiple gestation Congenital anomalies:  Vascular disruption sequences secondary to one twin demise: secondary to one twin demise:  porencephaly  hydranencephaly  hydrocephalus  multicystic encephalomalacia  microcephalus  limb reduction  renal cortical necrosis  intestinal atresia  aplasia cutis Congenital anomalies:  Vascular disruption sequences secondary to one twin demise: secondary to one twin demise:  porencephaly  hydranencephaly  hydrocephalus  multicystic encephalomalacia  microcephalus  limb reduction  renal cortical necrosis  intestinal atresia  aplasia cutis

107 Multiple gestation Congenital anomalies:  Deformations due to crowding of fetuses:  congenital dislocation of hip  clubfoot Congenital anomalies:  Deformations due to crowding of fetuses:  congenital dislocation of hip  clubfoot

108 Multiple gestation Monoamniotic twins:  Cord entanglement  Twin to twin transfusion  Mortality - up to 60%  Ultrasound surveillance and delivery ~34 weeks Monoamniotic twins:  Cord entanglement  Twin to twin transfusion  Mortality - up to 60%  Ultrasound surveillance and delivery ~34 weeks

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110 cord cord entanglement

111 Multiple gestation Vanishing twin:  1st trim. spontaneous loss of one or more with higher order multiples fetus or more with higher order multiples fetus  50 % - if only "sacs" are counted  20 % - if alive embryos counted  Higher loss rate with advancing maternal age  Excellent prognosis for remaining fetus(es) Vanishing twin:  1st trim. spontaneous loss of one or more with higher order multiples fetus or more with higher order multiples fetus  50 % - if only "sacs" are counted  20 % - if alive embryos counted  Higher loss rate with advancing maternal age  Excellent prognosis for remaining fetus(es)

112 Multiple gestation Acardiac twin:  One of Mo-Mo twins grows despite of the absence of cardiac activity / presence of heart. the absence of cardiac activity / presence of heart.  Occurs at 1 : 30,000-40,000 pregnancies or slightly less than 1% of monozygous twins.  A normal ("pump") twin supplies perfusion to acardiac twin. to acardiac twin. "twin reverse arterial perfusion" (TRAP) "twin reverse arterial perfusion" (TRAP) Acardiac twin:  One of Mo-Mo twins grows despite of the absence of cardiac activity / presence of heart. the absence of cardiac activity / presence of heart.  Occurs at 1 : 30,000-40,000 pregnancies or slightly less than 1% of monozygous twins.  A normal ("pump") twin supplies perfusion to acardiac twin. to acardiac twin. "twin reverse arterial perfusion" (TRAP) "twin reverse arterial perfusion" (TRAP)

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114 Multiple gestation Acardiac twin:  Hydramnios is a common finding (40%), with a strong association with PTD and CHF in the pump twin.  Better prognosis if acardiac twin weight < 50% of the pump twin weight < 50% of the pump twin Acardiac twin:  Hydramnios is a common finding (40%), with a strong association with PTD and CHF in the pump twin.  Better prognosis if acardiac twin weight < 50% of the pump twin weight < 50% of the pump twin

115 Multiple gestation Acardiac twin:  Treatment:  Conservative: digoxin and indomethacin  Fetal surgery: endoscopic laser prior to 24 weeks and umbilical cord ligation thereafter  Invasive techniques may be avoided if acardiac fetal mass very small or flow to acardiac decreasing or absent. Acardiac twin:  Treatment:  Conservative: digoxin and indomethacin  Fetal surgery: endoscopic laser prior to 24 weeks and umbilical cord ligation thereafter  Invasive techniques may be avoided if acardiac fetal mass very small or flow to acardiac decreasing or absent.

116 Multiple gestation Conjoined twins:  Also called "Siamese" twins  Incomplete division of the embryonic disk at day after conception disk at day after conception  The incidence 1: ,000 births  High rate of congenital anomalies Conjoined twins:  Also called "Siamese" twins  Incomplete division of the embryonic disk at day after conception disk at day after conception  The incidence 1: ,000 births  High rate of congenital anomalies

117 Multiple gestation Conjoined twins:  Classification by the area of joining:  chest (thoracopagus)  head (craniopagus)  abdomen (omphalopagus)  coccyx and sacrum (ischiopagus)  body with two heads (dicephalus)  one head with two bodies (dipygus) Conjoined twins:  Classification by the area of joining:  chest (thoracopagus)  head (craniopagus)  abdomen (omphalopagus)  coccyx and sacrum (ischiopagus)  body with two heads (dicephalus)  one head with two bodies (dipygus)

118 Conjoined twins CraniopagusCraniopagus ThoracopagusThoracopagus IschiopagusIschiopagus CraniopagusCraniopagus ThoracopagusThoracopagus IschiopagusIschiopagus

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120 Multiple gestation Conjoined twins:  Survival in conjoint twins depends upon:  extent of attachment  place of attachment  presence of other anomalies Conjoined twins:  Survival in conjoint twins depends upon:  extent of attachment  place of attachment  presence of other anomalies

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123 Multiple gestation Prof. S. Degani June 2007


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