1. Obstetric & Gynecology Hospital of Fudan Universtity
Multiple pregnancy
Kang Yu
Obstetric & Gynecology Hospital of Fudan Universtity

2. Multiple Pregnancy Incidence
Twins：1:100
Triplets：1:10,000
Quadruplets：1:1,000,000
Quintuplets：1:100,000,000

3. Classification Dizygotic twins：2/3
influenced remarkably by race, heredity, maternal age, parity, and especially fertility treatment
Monozygotic twins：1/3
independent of race, heredity, age, and parity

4. Dizygotic twins Two ovum, two sperm Different gene：
appearance: different or alike
gender：same or different
Placenta：
two placenta
fuse to one placenta, twin peak, no communicated blood vessel

5. Monozygotic twin One ovum, one sperm same gene： appearance: same
gender：same

6. Classification of monozygotic twin
dichorionic diamniotic twins:
18～36%
monochorionic diamniotic
twins:
65%
monochorionic monoamniotic
twins:
<1%
4 to 8 days
Postfertilization
0 to 4 days
9 to 13 days
>13 days
Conjoined twins

7. Case One Shi ××, 26 years old
Chief complaint：gravida 1 para 0, 27 weeks of gestation, found dyspnea one week and prostration three days.
Present history：last menstrual period (LMP):12, June, estimated date of conception(EDC):19, March,2012. Urine chorionic gonadotrophin(HCG) was positive at thirty-seven days of gestation and the morning sickness was severe. One sac was found through altrasound in the first trimester. Regular prenatal examination was not perform. Twin pregnancy was found at 25 weeks of gestation. Dyspnea one week and prostration three days.
Physical examination：T:36.8°C, P 98 counts per minute，R 18 counts per minute，BP 100/65mmHg

8. Ultrasound results：
Fetus A: BPD(biparietal diameter)-HC(head circumference)-AC(abdominal circumference)-FL(femur length): mm, estimated weight 1454g, AFV(amniotic fluid volume):26cm, bladder was visible, no abnormal doppers.
Fetus B: BPD-HC-AC-FL: mm, estimated weight 832g, AFV:1cm, bladder was visible, no abnormal doppers.
AFI: , 461. no twin peak, amniotic separation was found.

9. Question 1:Diagnosis
Gravida 1 Para 0, 27 weeks of gestation, twin pregnancy
Monochorionic Diamniotic Twins(MC/DA)
TTTS(stage 1)

10. Twin-Twin Transfusion Syndrome (TTTS)
Blood is transfused from a donor twin to its recipient sibling
The donor becomes anemic and its growth may be restricted
The recipient becomes polycythemic and may develop circulatory overload manifest as hydrops
Donor twin is pale, and its recipient sibling is plethoric

11. TTTS
Anastomoses in monochorionic diamniotic placenta：arterio-arterial,venous –venous,arterio-venous
Only arterio-venous anastomoses will result to TTTS.

12. Quintero staging system
Stage I: polyhydramnios(>8cm) in recipient / aligodramnios(<2cm) in donor, but urine still visible sonographically within the donor twin's bladder
Stage II: urine is not visible within the donor's bladder
Stage III: abnormal Doppler studies of the umbilical artery, ductus venosus, or umbilical vein.
Stage IV: ascites or frank hydrops in either twin
Stage V: demise of either fetus
I 羊水过多/羊水过少，供血胎膀胱可见，
II 供血胎膀胱不可见，
III 供血胎膀胱不可见，且任何一个胎儿出现异常多普勒血流（脐动脉舒张末期峰缺如或逆向，静脉导管逆流或脐静脉搏动）
IV 出现胎儿水肿
V 胎儿死亡（一个或两个）

13. Question 2: Management
An amnioreduction of 6.2 L was performed in the recipient sac.
Tocolytics (magnesium sulfate）were administered.
Follow up: ultrasound weekly
Ten days later
Ultrasound surveillance：
anuria and virtually no amniotic fluid in the donor twin, polyuria and excess amniotic fluid in the recipient, and abnormal umbilical venous and ductus venosus flows in both twins.

14. Management Termination: Cesarean section
premature donor and recipient twin boys were delivered, weighing 895 and 1450 g, with haemoglobin levels of 16.4 and 22.9 g/dl
Both infants required mechanical ventilation and administration of surfactant due to respiratory distress syndrome. The donor twin developed acute renal failure and necrotising enterocolitis which required surgery. The recipient developed the polycythaemiae hyperviscosity syndrome which required a partial exchange transfusion. Both children are alive.
Check the placenta after delivery: one placenta, two layer of membrane partition that separated twin fetuses
, all associated with severe TTTS. In addition, in this case the neonatal criteria of TTTS were valid (a difference of >25% in birth weight, and >5 g/dl Hb).

15. Diagnosis TTTS (Prenatal)
monochorionicity
same-sex gender
hydramnios defined if the largest vertical pocket is > 8 cm in one twin and oligohydramnios defined if the largest vertical pocket is < 2 cm in the other twin
umbilical cord size discrepancy
cardiac dysfunction in the recipient twin with hydramnios
abnormal umbilical vessel or ductus venosus Doppler velocimetry
significant growth discordance
There have been dramatic changes in the criteria used to diagnose and classify varying severities of TTTS.
Classically, weight discordancy and hemoglobin differences in monochorionic twins were calculated,
however, it was soon appreciated that in many cases, these were later clinical findings.

16. Diagnosis (Postnatal)
Examination in placenta, chorionic membrane, amniotic membrane
Examination in neonate：
Discordance in hemoglobin: ≥5g/dl
Discordance in body weight : ≥15-20%
产后检查胎盘及羊膜囊间隔确定为单绒毛膜妊娠
双胎体重相差≥20％
血色素相差＞5g/dL
双胎之小胎儿贫血
性别相同
单绒毛膜胎盘有血管吻合支
体重相差≥20％
大胎儿羊水过多；小胎儿羊水过少，或固定胎（stuck twin）
Bruner and Rosemond, 1993

17. Pregnancy Complications
Kang Yu
Obstetric & Gynecology Hospital of Fudan Universtity

18. Pregnancy Complications
Heart Diseases
Hepatitis
Diabetes
Anemia …
Appendicitis
Cholecystitis
Intestinal obstruction

19. Heart diseases in pregnancy

20. Clinical significance of heart disease in pregnancy
Interaction between heart disease and pregnancy
Mother: heart failure; infective endocarditis; hypoxia and cyanosis; thrombenbolism
Baby: miscarriage, still birth, fetal growth restriction, fetal and newborn distress, preterm delivery
Increased caesarean section rate

21. Heart diseases in pregnancy
Can I have a baby?
What is the risk for me and my baby?
What should I do during the course of pregnancy?
By which way should I delivery my baby?
Any special thing to be paid attention to after birth?

22. Can I have a baby? NO YES Mild Cardiac function I～II
Severe
Cardiac function Ⅲ一Ⅳ
History of heart failure
Pulmonary hypertension
Right-to-left shunts
Severe arrythmia
Active rheumatic heart disease
Acute Myocarditis, endocarditis
>35y with long history of cardiac disease
YES
Mild
Cardiac function I～II
No history of heart failure
No complication

23. During Pregnancy
Determine whether or not the pregnancy should be continued
NO: induced abortion before 12 weeks
YES:
Intensive care during pregnancy
Early diagnosis and treatment of congestive heart failure

24. During pregnancy Heart failure ---- prevention
Limited physical activity
Control of body weight: increase <12Kg (<0.5Kg / month)
Limited salt intake: <4-5g/day
Prevent risk factors: infection, anemia, arrhythmia, hypertensive diseases
Dynamic observation of cardiac function

25. During Pregnancy Heart failure---early diagnosis
Development of dyspnea and palpitation on exertion
Heart rate >110 bpm; breath rate >20/min
Nocturnal cough
Persistent basilar rales

26. During pregnancy Treatment of heart failure Digoxin Diuretics
Vessel dilating agents
Termination of pregnancy:
C-S
Timing
Termination after heart failure is controlled
C-S when heart failure could not be controlled

27. Intrapartum management
Pattern of delivery
Cesarean section
Vaginal delivery
Heart function I-II
Very good obstetrical condition
Vaginal delivery---- prevent heart failure
First stage: intensive care and sedation
Second stage: shorten the course
Third stage: Add pressure on abdomen
prevent postpartum hemorrhage

28. Puerperium management
Intensive care during the first 3 days
Prevent infection
Breast feeding
Sterilization

29. Viral Hepatitis in Pregnancy

30. Viral Hepatitis in Pregnancy
Interaction between pregnancy and hepatitis
Diagnose, Differential diagnosis and treatment
Pathway of maternal – fetal infection and prevention

31. Impact of pregnancy on viral hepatitis
Heavier liver burden
Compromised defending ability of liver
More complicated and severe condition in pregnant patients

32. Impact of hepatitis on pregnancy
Early Pregnancy
Serious pregnancy reaction
Abortion
Malformation
Late pregnancy
Hypertension
Postpartum hemorrhage
Preterm delivery, fetal death, stillbirth

33. Impact of hepatitis on pregnancy
Maternal - fetal infection HBV
Intrauterine
Intrapartum—main route of transmission
Fetal swallowing in genital tract
Mother blood leaking into fetal circulation
Postpartum: breastfeeding, salivary

34. Differential diagnosis
Intrahepatic cholestasis of pregnancy （ICP）
Happen during late pregnancy
Pruritus
Jaundice
Cholic acid
fetal death

35. Differential diagnosis
Acute fatty liver of pregnancy
Late pregnancy, acute and severe hepatic disfunction, fat filled hepatic cell
HELLP syndrome
Hypertension, hemolysis, BPC, elevated liver enzyme
Hyperemesis gravidarum
Light liver dysfunction, negative virus marker
Drug induced hepatitis
History of drug intake

36. Management Rest Nutrition Protection of liver function
Prevent infection and further damage
Fluminant hepatitis

37. Management Delivery C-S is preferred
Vitamin K mg im several days before delivery
Prevent postpartum hemorrhage
Fulminant hepatitis: C-S 24 hours after active treatment

38. Management Pureperium Prevent from damaging liver function
Breast feeding: Stop if HBsAg, HBeAg, anti-HBc, HBV-DNA positive

39. Diabetes complicating pregnancy

40. Diabetes complicating pregnancy
Gestational diabetes mellitus (GDM) and overt diabetes complicating pregnancy
Diabetes  pregnancy
Screening and diagnosis
Management of women complicating diabetes during pregnancy

41. Gestational diabetes mellitus GDM >90%
Incidence: 2.9% ( %)
Type 1 is characterized by lack of insulin (a production problem)
Type 2 is characterized by plentiful insulin that is not able to do its job effectively (a function problem – i.e., lack of response, hence the term “insulin resistance”)
Gestational diabetes mellitus
GDM >90%

42. Impact of pregnancy on diabetes
Insulin resistance and insufficiency
Increased glucose demands---hypoglycemia
Insulin overdose after delivery

43. Maternal and fetal effects
Maternal effects
Hypertensive disorders （高血压）
Infection （感染）
Ketoacidosis （酮症酸中毒）
Spontaneous abortion （自发流产）
Polyhydramnios （羊水过多）
Dystocia （难产） and C-S owing to macrosomia （巨大儿）
Recurrent GDM （再次妊娠时复发）

45. Maternal and fetal effects
Macrosomia （巨大儿）
Fetal growth restriction
（胎儿宫内生长受限）
Spontaneous abortion & Preterm delivery （自发流产和早产）
Malformation （胎儿畸形）

46. Maternal and fetal effects
Neonatal effects
Respiratory distress （呼吸窘迫）
Hyperinsulinemia Pulmonary Surfactant  Delayed pulmonary maturation
Hypoglycemia （低血糖）

47. Diagnosis----GDM
History: family, previous pregnancy, present pregnancy
Screening: 50-g oral glucose challenge test （24-28 weeks）
Confirmed diagnosis
OGTT: 75/100-g oral glucose tolerance test

48. The 50 gr. GCT (Cutoff >140 mg/dl, 7.8mmol/L)
Sensitivity: 93.3%
Specificity: 38.2%
Positive Predictive Value: 78.6 %
Negative Predictive Value : 70.0 %

49. Method Criteria (mmol/L)
Diagnostic criteria for GDM---OGTT
Method Criteria (mmol/L)
FPG 1 hr. 2 hr. 3 hr.
WHO (75 g)
Diagnosed when 2 or more values are abnormal
FPG: Fasting plasma glucose

50. Diagnosis—Overt diabetes
polydipsia （多饮）, polyuria （多尿）, unexplained weight loss，ketoacidosis
Random plasma glucose >200 mg/dL(11.1 mmol/L);
fasting glucose>126mg/dL (7 mmol/L)

51. Management Purpose Maintain glucose level within normal range
Minimize fetal and maternal complication
Lower peripartum fetal and neonatal mortality

52. During pregnancy
Diet
To provide the necessary nutrients for the mother and fetus
To control glucose levels
To prevent starvation
30-35kcal/kg of ideal body weight
55% carbohydrate
20% protein
25% fat
3 meals and 3 snacks daily
Intensified monitoring
Fasting glucose < mmol/L
Postprandial glucose <6.7mmol/L

53. During pregnancy
Drug treatment:
Insulin only
Individualized

54. Assessment of mother Glucose / ketone monitoring （监测血糖/酮体）
Retinal photograph (眼底)
Renal function （肾功能）
Glycated Haemoglobin （糖化血红蛋白）

55. Assessment of fetal well-being
Daily fetal movement counting
NST
AFV or biophysical profiles

56. Delivery WHEN? after 38 completed weeks Before 38 weeks when
Fetal lung muturation
Before 38 weeks when
Unsatisfied glucose control
Maternal complication: infection, severe preeclampsia; vascular diesease
Fetal distress or FGR
Caution in the use of corticosteroids

57. Delivery HOW? Diabetes itself is not the indication for C-S
C-S when indicated: macrosomia, compromised placenta function, etc.
Stop subcutaneous insulin 3 hours before operation

58. Delivery Vaginal delivery Close monitoring
Glucose monitoring: >5.6mmol/L (100mg/dL)
Control the whole course within 12 hours

59. Postpartum Insulin dose decrease 1/2 -1/3 after delivery
Encourage follow up with health care provider to have
OGTT (6 weeks to 6 months 75 g OGTT)
weight management,
postpartum visit with a registered dietitian
Encourage breastfeeding
Monitoring occasionally with meter
Future pregnancy

60. Neonatal management Treated as preterm baby
25% glucose intake 30 minutes after delivery
Prevent complications

61. Thank you!