1. Size and date discrepancy of pregnancy
Facilitator: Pawin Puapornpong

2. Size < date Inaccurate menstrual period Fetal growth restriction
oligohydramnios

3. Size > date Elevation of the uterus by a distended bladder
Multifetal pregnancy
􀁺 Inaccurate menstrual history
􀁺 Hydramnios
􀁺 Hydatidiform mole
􀁺 Uterine myomas
􀁺 A closely attached adnexal mass
􀁺 Fetal macrosomia (late in pregnancy, DM)

4. Oligohydramnios Normally, 1 L by 36 wks. Only 100 to 200 mL (postterm)
Diminished volume : oligohydramnios
Amniotic fluid index ( AFI) < 5 cm.
Risk of cord compression, fetal distress

5. AFI

6. Early onset oligohydramnios
Obstruction of urinary tract or renal agenesis
Preterm delivery and neonatal death
Adhesions between amnion and fetal parts : deformities (amputation)
Pressure to fetus, muscle, skeletal deformities : clubfoot
Pulmonary hypoplasia 15%
Impaired lung growth and development

7. Oligohydramnios in late pregnancy
Variable deceleration
c/s for fetal distress
5-minute apgar score < 7
Amnioinfusion during labor, prevent cord compression

8. Hydramnios > 2 L AFI > 25 cm. CNS or GI malformation
Anencephaly and esophageal atresia
First half of pregnancy : transfer water and small molecules across amnion and fetal skin
Second trimester : fetus urinate, swallow and inspire amnionic fluid
Maternal diabetes : fetal hyperglycemia, osmotic diuresis, excess amnionic fluid

9. Symptoms
Overdistended uterus
Dyspnea
Edema : compression of venous system ( lower extremieties, vulva)
Diagnosis : uterine enlargement with difficulty in palpating fetal parts
Differential diagnosis : ascites or a large ovarian cyst by U/S

10. Pregnancy outcome Fetal malformation Preterm delivery
Umbilical cord prolapse
Placental abruption
Uterine dysfunction
PPH
Abnormal fetal presentation

11. Management
Minor degrees : no Px
Dyspnea or abdominal pain : hospitalization
Bed rest, diuretics and water-salt restriction : ineffective

12. Therapeutic amniocentesis : relieve maternal distress (only transient)
Membranes rupture : cord prolapse, placental abruption
Indomethacin : impair lung liquid production, enhances absorption, fetal urine production
potential for closure of fetal ductus arteriosus

13. Fetal growth restriction
3 to 10 % of infants
Small-for-gestational age (SGA) : intrauterine growth retardation
Avoid “retardation” : fetal growth restriction now preferred

14. definition SGA : below 10th percentile for their GA
Some are small because of constitutional factors, not pathologically growth restricted.
Others define by + 2 SD with normal limits
SGA < 3rd percentile , most of them are poor outcomes.

15. Mortality and morbidity
Fetal demise, birth asphyxia, meconium aspiration, neonatal hypoglycemia and hypothermia
Growth restriction due to congenital, viral, chromosomal or maternal constitutional factors remains small throughout life.
but due to placental insufficiency will often catch-up growth after birth.

16. Symmetrical VS asymmetrical fetal growth restriction

17. symmetrical
Early insult : chemical exposure, viral infection, aneuploidy : proportionate reduction in both head and body.

18. asymmetrical
Late insult : placental insufficiency from hypertension, diminished glucose transfer and hepatic storage
Fetal abdominal circumference (liver size) is reduced.
Shunting of oxygen and nutrients to the brain : normal brain and head growth.
Increase relative brain size compared with small liver.

19. Risk factors Congenital malformations Constitutional small mothers
Fetal infections
Rubella and CMV
Hepatitis A and B
Listeriosis, TB, syphilis
Congenital malformations
karyotype abnormalities : trisomy 18, 13
Not in trisomy 21, Turner and Klinefelter

20. Maternal medical complications
Chemical teratogens
Cigarette, alcohol, cocaine
Maternal medical complications
Chronic vascular disease
Preeclampsia
Renal disease
High altitude residence
Placental and cord abnormalities
Multiple fetuses

21. diagnosis Early confirmation of GA Maternal weight gain
Uterine fundal growth
Identification of risk factors
Serial sonography
Doppler velocimetry
NST
Biophysical profile

22. management Near term : prompt delivery
Remote from term : growth remains normal, expectant until maturity, interval U/S of 2 to 3 wks.
Labor : monitor for evidence of compromise, insufficient placental function aggravated by labor.
Newborn : meconium aspiration, hypothermia, hypoglycemia and polycythemia

23. Twin pregnancy

24. Definition (Multi-fetal Gestation)
-Twins (two babies)
-Monozygotic(Division of 1 ova fertilized by the same sperm)
-Dizygotic(Fertilization of 2 ova by 2 sperm)
-Triplets (three babies)
-Quadruplets (four babies)

25. Incidence Twins - 1 in 100 births Triplets are about 1 in 7,500 births
African Americans: 1 in 70
Caucasians: 1 in 88
Japanese: 1 in 150
Chinese: 1 in 300
Triplets are about 1 in 7,500 births
Quadruplets are about 1 in 65,000 births

26. Causes of Multiple Gestation
Spontaneously
In Vitro fertilization
Intrauterine insemination
Assisted Hatching
GIFT, ZIFT
Frozen Embryo Transfer, Blastocyte Embryo Transfer
Fertility Drugs
Clomiphene citrate (clomid, serrophene)
Gonadotropins

27. Monozygotic twin (33%) Dizygotic twins (66% ) Ova division:
Dichorionic – separate chorion (placenta)
Diamniotic – separate amnion (amniotic sac)
Monozygotic twin (33%)
Ova division:
< 72 hours: Dichorionic, diamniotic
4-8 days: Monchorionic, diamniotic
8-13 days: Monochorionic, monoamniotic
> 13 days: conjoined twins

28. Average age of gestation
Number of babies Weeks of Gestation
weeks
/2 weeks
weeks
½ weeks

29. Zygosity & Chorionicity
Zygosity refers to the type of
conception whereas chorionicity
denotes the type of placentation.
Two thirds of all twins are dizygotic.
Approximately 25% of monozygotic
twins are dichorionic.
Chorionicity rather than zygosity
determines outcome.

30. Diagnosis of multiple fetuses

31. History Patient profile:
Etiological factors; with positive past history and family history specially maternal (advanced maternal age, high parity, large maternal size) ART
Early pregnancy: Hyperemesis, abnormal bleeding

32. Mid-pregnancy:
Greater weight gain than expected
abdominal size > period of amenorrhea,
early PIH symptoms.
Late pregnancy:
Pressure symptoms (dyspnea,
dyspepsia)

33. Examination Abdominal: Size > Date especially in midpregnancy
exclude other causes.
Palpation: Multiple fetal parts
Auscultation of FHS:
2 different recordings by 2 observers
and a difference > 10 bpm

34. Ultrasonography Detect multifetal gestation 99% before 26 weeks.
Confirm fetal number [ 2 sacs or 2 fetal heads in 2 perpendicular
planes].
Confirm fetal lives
Diagnosis of vanishing twin syndrome.
Diagnose type

35. Complication

36. Conjoined twins or Siamese twins
*Anterior (thoracopagus)
*Posterior (pygopagus)
*Cephalic (craniopagus)
*Caudal (ischiopagus)

37. Discordant twins
Diagnosis 1. US anatomical. 2.Fetal weight difference. * wt. of the larger - wt.of smaller wt.of the larger twin >15-25% poor outcome *
Abd circumferences differ >20 mm.

38. Twin-Twin Transfusion Syndrome
Incidence : % of MC twins 􀁺 It is characterised by an imbalance of blood flow between the twins 􀁺 The former criterion of > 20% discordance is no longer used in the diagnosis

39. Twin-Twin Transfusion Syndrome
Monochorionicity.
Marked discordance in amniotic fluid
volume between the twins.
Discordance in size with the larger twin
in the polyhydramniotic sac.
Fetal anomalies are excluded.

40. Suggested treatment in TTTS
Serial amnioreduction
Amniotic septostomy
Laser ablation
Selective fetocide

41. Antenatal care protocol
First visit
Routine growth scan & AFI
􀁺 Chorionicity determination
􀁺 Placental localization
􀁺 Cord insertions
􀁺 Doppler study of UA/UV in each
􀁺 Inspection of chorionic plate for
anastomotic vessels

42. Subsequent visit
As the first visit
Prenatal diagnosis as indicated
No agreement on the ideal frequency
of ultrasound examinations in twins.
DC : 4 weekly from 24 weeks
MC : 2 weekly from 18 weeks
Note any change in anastomotic flow
patterns

43. Delivery bed with lithotomy stirrups
Obstetric forceps (Piper’s forceps if breech delivery planned) or vacuum apparatus
Premixed oxytocin infusion
Methergine, 15-methyl PGF2 , or both
Immediate availability of blood
Capabilities and staff for emergency cesarean section

44. Uterine overdistension causes hypotonic uterine dysfunction.
Increased risk of postpartum hemorrhage due to uterine atony.
multifetal gestation is not a contraindication to labor induction, but is a condition that warrants special attention.

45. Thank you for your attention