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Multiple Pregnancy Prof Uma Singh. Multiple Pregnancy/ Multifetalpregnancy The presence of more than one fetus in the gravid uterus is called multiple.

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Presentation on theme: "Multiple Pregnancy Prof Uma Singh. Multiple Pregnancy/ Multifetalpregnancy The presence of more than one fetus in the gravid uterus is called multiple."— Presentation transcript:

1 Multiple Pregnancy Prof Uma Singh

2 Multiple Pregnancy/ Multifetalpregnancy The presence of more than one fetus in the gravid uterus is called multiple pregnancy Two fetuses (twins) Three fetuses (triplets) Four fetuses (quadruplets) Five fetuses (quintuplets) Six fetuses (sextuplets)

3 INCIDENCE Hellin’s Law: Twins: 1:89 Triplets: 1:89 2 Quadruplets: 1:89 3 Quintuplets: 1:89 4 Conjoined twins: 1 : 60,000 Worldwide incidence of monozygotic - 1 in 250 Incidence of dizygotic varies & increasing

4 Demography Race: most common in Negroes Age: Increased maternal age Parity: more common in multipara Heredity - family history of multifetal gestation Nutritional status – well nourished women ART - ovulation induction with clomiphene citrate, gonadotrophins and IVF Conception after stopping OCP

5 Twins Varieties: 1. Dizygotic twins: commonest (Two-third) 2. Monozygotic twins (one-third) Genesis of Twins: Dizygotic twins (syn: Fraternal, binovular) - - fertilization of two ova by two sperms.

6 Monozygotic twins (syn: Identical, uniovular): Upto 3 days - diamniotic-dichorionic Between 4 th & 7 th day - diamniotic monochorionic - most common type Between 8 th & 12 th day- monoamniotic- monochorionic After 13 th day - conjoined / Siamese twins.

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8 Conjoined twins Ventral: 1) Omphalopagus 2) Thoracopagus 3) Cephalopagus 4) Caudal/ ischiopagus Lateral: 1) Parapagus Dorsal: 1)Craniopagus, 2)Pyopagus

9 Superfecundation Fertilization of two different ova released in the same cycle Superfetation Fertilization of two ova released in different cycles

10 Differences in zygocity Monozygotic 1 ova + 1 sperm Same sex Identical features Single or double placenta Same genetic features DNA microprobe -same Dizygotic 2 ova + 2 sperm Same or opposite sex Fraternal resemblance Double or s/t fused Different genetic features DNA microprobe - different

11 Differences in chorionicity with single placenta D / D ( fused placenta ) Monozygotic or dizygotic Thick dividing membrane > 2mm Twin peak / lambda sign M / D Monozygotic Thin dividing membrane 2mm or less T sign

12 Diagnosis HISTORY: I.History of ovulation inducing drugs specially gonadotrophins II.Family history of twinning (maternal side). SYMPTOMS: i.Hyperemesis gravidorum ii.Cardio-respiratory embarrassment - palpitation or shortness of breath iii.Tendency of swelling of the legs, iv. Varicose veins v. Hemorrhoids vi.Excessive abdominal enlargement vii.Excessive fetal movements.

13 GENERAL EXAMINATION: I.Prevalence of anaemia is more than in singleton pregnancy II.Unusual weight gain, not explained by pre-eclampsia or obesity III.Evidence of preeclampsia(25%)is a common association. ABDOMINALEXAMINATION: Inspection: The elongated shape of a normal pregnant uterus is changed to a more "barrel shape” and the abdomen is unduly enlarged.

14 Palpation: Fundal height more than the period of amenorrhoea girth more than normal Palpation of too many fetal parts Palpation of two fetal heads Palpation of three fetal poles Auscultation: Two distinct fetal heart sounds with Zone of silence 10 beat difference

15 D/D of increased fundal height Full bladder Wrong dates Hydramnios Macrosomia Fibroid with preg Ovarian tumor with preg Adenexal mass with preg Ascitis with preg Molar pregnancy

16 INVESTIGATIONS Sonography: In multi fetal pregnancy it is done to obtain the following information: i.Suspecting twins – 2 sacs with fetal poles and cardiac activity ii.Confirmation of diagnosis iii.Viability of fetuses, vanishing twin iv.Chorionicity – 6 to 9 wks ( single or double placenta, twin peak sign in d /d gestation or Tsign in m/d ) v.Pregnancy dating,

17 i.Fetal anomalies ii.Fetal growth monitoring (at every 3-4 weeks interval) for IUGR iii.Presentation and lie of the fetuses iv.Twin transfusion (Doppler studies) v.Placental localization vi.Amniotic fluid volume Sonography ( ctd )

18 Radiography Biochemical tests: raised but not diagnostic Maternal serum chorionic gonadotrophin, Alpha fetoprotein Unconjugated oestriol

19 Lie and Presentation Longitudinal lie (90%) 1.both vertex (40%) 2.Vertex + breech (28%) 3.breech + vertex ( 9%) 4.both breech ( 6%) Others vertex + transverse breech + transeverse both transeverse

20 Complications Maternal – Pregnancy – Labour – Puerperium Fetal MATERNAL: During pregnancy: - miscarriages – Hyperemesis gravidorum – Anaemia – Pre-eclampsia (25%) – Hydramnios ( 10 % )

21 GDM ( 2 – 3 times) Antepartum hemorrhage – placenta previa and placental abruption Cholestasis of pregnancy Malpresentations Preterm labour (50%) twins – 37 weeks, triplets – 34 weeks, quadruplets – 30 weeks Mechanical distress such as palpitation, dyspnoea, varicosities and haemorrhoids Obstructive uropathy

22 During Labour: Prelabour rupture of the membranes Cord prolapse Incoordinate uterine contractions Increased operative interference Placental abruption after delivery of 1 st baby Postpartum haemorrhage During puerperium: Subinvolution Infection Lactation failure

23 FETAL – more with monochorionic Spontaneous abortion Single fetal demise Vanishing twin – before 10 weeks Fetus papyraceous/compressus – 2 nd trim Complications in 2 nd twin (depend on chorionicity) – neurological, renal lesions - anaemia, DIC - hypotension and death

24 FETAL – more with monochorionic Low birth weight ( 90%) Prematurity – spontaneous or iatrogenic Fetal growth restriction - in 3 rd trimester, asymmetrical, in both fetus Discordant growth - Difference of >25% in weight, >5% in HC, >20mm in AC, abnormal doppler waveforms - Causes – unequal placental mass, lower segment implantation, genetic difference, TTTS, congenital anomaly in one

25 FETAL COMPLICATIONS (ctd) Congenital anomalies – conjoined twins, neural tube defects – anencephaly, hydrocephaly, microcephaly, cardiac anomalies, Downs syndrome, talipes, dislocation of hip TTTS -Twin to twin transfusion syndrome - cause – AV communication in placenta – blood from one twin goes to other – donor to recipient - donor – IUGR, oligohydramnios - recipient – overload, hydramnios, CHF, IUD

26 FETAL COMPLICATIONS (ctd) TRAP -Twin reversed arterial perfusion syndrome or Acardiac twin - absent heart in one fetus with arterio-arterial communication in placenta, donor twin also dies Cord entanglement and compression – more in monoamniotic twins Locked twins Asphyxia – cord complication, abruption Still birth – antepartum or intrapartum cause

27 Monoamniotic twins high perinatal morbidity, mortality. Causes : cord entanglement congenital anomaly preterm birth twin to twin transfusion syndrome

28 Antenatal Management Diet: additional 300 K cal per day, increased proteins, 60 to 100 mg of iron and 1 mg of folic acid extra Increased rest Frequent and regular antenatal visit Fetal surveillance by USG – every 4 weeks Hospitalisation not as routine Corticosteroids -only in threatened preterm labour, same dose Birth preparedness

29 Management During Labour Place of delivery: tertiary level hospital FIRST STAGE: blood to be cross matched and ready confined to bed, oral fluids or npo intrapartum fetal monitoring ensure preparedness SECOND STAGE – first baby - second baby

30 Management During Labour SECOND STAGE –delivery of first baby as in singleton pregnancy start an IV line no oxytocic after delivery of first baby secure cord clamping at 2 places before cutting ensure labeling of 1 st baby Delivery of second twin FHS of second baby lie and presentation of second twin wait for uterine contractions conduct delivery

31 Management During Labour Delivery of second twin – problems & interventions -inadequate contraction- augmentation – ARM, oxytocin -transverse lie – ECV, IPV -fetal distress, abruption, cord prolapse- expedite delivery – forceps, ventouse, breech extraction THIRD STAGE – AMTSL - continue oxytocin drip - carboprost 250µgm IM - monitor for 2 hours

32 Indications of caesarean Non cephalic presentation of first twin Monoamniotic twins Conjoined twins Locked twins Other obstetric conditions Second twin – incorrectible lie, closure of cervix

33 MCQs Text book of Obstetrics, Dr J B Sharma, 1 st edition ( 2012) page-473 to 483 Chapter - multiple pregnancy

34 1. Splitting of single fertilized ovum between 8 to 12 days results in a) conjoined twins b) monochorionic monoamniotic twin c) dichorionic diamniotic twin d) monochorionic diamniotic twin

35 Splitting of single fertilized ovum between 8 to 12 days results in a) conjoined twins b) monochorionic monoamniotic twin c) dichorionic diamniotic twin d) monochorionic diamniotic twin

36 2. Twin peak sign is a feature of a) conjoined twins b) monochorionic monoamniotic twins c) dichorionic diamniotic twins d) monochorionic diamniotic twins

37 Twin peak sign is a feature of a) conjoined twins b) monochorionic monoamniotic twins c) dichorionic diamniotic twins d) monochorionic diamniotic twins

38 3. Additional caloric requirement ( K cal per day) of a mother in a case of twin pregnancy is a) 300 b) 500 c) 800 d) 1000

39 Additional caloric requirement ( K cal per day) of a mother in a case of twin pregnancy is a) 300 b) 500 c) 800 d) 1000

40 4. Additional iron supplementation requirement ( mg per day) of a mother in a case of twin pregnancy is a) 30 b) 50 c) 100 d) 200

41 Additional iron supplementation requirement ( mg per day) of a mother in a case of twin pregnancy as compared to singleton pregnancy is a) 30 b) 50 c) 100 d) 200

42 5. Iron supplementation required by a mother having twin pregnancy is a) 30 b) 50 c) 100 d) 200

43 Iron supplementation required by a mother having twin pregnancy is a) 30 b) 50 c) 100 d) 200

44 6. Twin pregnancy is complicated by all of the following except a) placenta previa b) malpresentation c) hydramnios d) post term labour

45 Twin pregnancy is complicated by all of the following except a) placenta previa b) malpresentation c) hydramnios d) post term labour

46 7. Caesarean section is indicated in a) monoamniotic twin b) monochorionic twin c) dichorionic twin d) diamniotic twin

47 Caesarean section is indicated in a) monoamniotic twin b) monochorionic twin c) dichorionic twin d) diamniotic twin

48 8) 32year old G2P1 at 20 weeks pregnancy in USG shows twin pregnancy, single placental mass with dividing membrane having inverted T sign. The type of twinning is a) monochorionic monoamnionic b) monochorionic diamnionic c) dichorionic monoamnionic d) dichorionic diamnionic

49 8) 32year old G2P1 at 20 weeks pregnancy in USG shows twin pregnancy, single placental mass with dividing membrane having lambda sign. The type of twinning is a) monochorionic monoamnionic b) monochorionic diamnionic c) dichorionic monoamnionic d) dichorionic diamnionic

50 9) Monochorionic twin placenta has unidirectional deep arteriovenous communication with lack of superficial vascular anastomoses. The likely complication is a) twin to twin transfusion syndrome b) twin reversed arterial perfusion c) acute intertwin transfusion d) twin cord entanglement

51 9) Monochorionic twin placenta has unidirectional deep arteriovenous communication with lack of superficial vascular anastomoses. The likely complication is a) twin to twin transfusion syndrome b) twin reversed arterial perfusion c) acute intertwin transfusion d) twin cord entanglement

52 10) Most common variety of conjoined twins is a) craniopagus b) thoracopagus c) omphalopagus d) pyopagus

53 10) Most common variety of conjoined twins is a) craniopagus b) thoracopagus c) omphalopagus d) pyopagus


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