1. Multifetal Gestation

2. singleton
septuplets ……
twin
triplets

3. Factors that Influence Twinning
Race
Heredity
Maternal Age and Parity
Nutritional Factors
Pituitary Gonadotropin
Infertility Therapy
Assisted Reproductive Technology (ART)

4. Complications Fetal Maternal malformations
placental vascular anastomosis (twin-twin transfusion syndrome, TTTS)
fetal-growth restriction
preterm delivery
perinatal mortality ……
Maternal
preeclampsia
postpartum hemorrhage
maternal death ……

5. Labor and delivery complications
preterm labor
uterine contractile dysfunction
abnormal presentation
umbilical cord prolapse
premature separation of the placenta
immediate postpartum hemorrhage

6. Etiology ova–dizygotic or fraternal twins
maturation and fertilization of two ova
monozygotic or identical twins

7. Genesis of Monozygotic Twins

8. "Vanishing Twin" one twin is lost or "vanishes"
maternal serum alpha-fetoprotein level ↑
amnionic fluid alpha-fetoprotein level ↑
amnionic fluid acetylcholinesterase assay +

9. Determination of Chorionicity
Sonographic Evaluation
Placental Examination
Infant Sex and Zygosity

10. Diagnosis History and Clinical Examination Sonography
Radiological Examination
Biochemical Tests

11. large uterus for gestational age
Multiple fetuses
Elevation of the uterus by a distended bladder
Inaccurate menstrual history
Hydramnios
Hydatidiform mole
Uterine leiomyomas
A closely attached adnexal mass
Fetal macrosomia (late in pregnancy)

12. Duration of Gestation

13. Unique Complications

15. Vascular Anastomoses between Fetuses

17. Antepartum Management of Twin Pregnancy
Delivery of markedly preterm neonates be prevented
Fetal-growth restriction be identified and afflicted fetuses be delivered before they become moribund
Fetal trauma during labor and delivery be avoided
Expert neonatal care be available

18. Recommendations for intrapartum management
An appropriately trained obstetrical attendant should remain with the mother throughout labor. Continuous external electronic monitoring is employed. If membranes are ruptured and the cervix dilated, then simultaneous evaluation of both the presenting fetus by internal electronic monitoring and the remaining sibling(s) by external monitors is typically used
Blood transfusion products are readily available
An intravenous infusion system capable of delivering fluid rapidly is established. In the absence of hemorrhage, lactated Ringer or an aqueous dextrose solution is infused at a rate of 60 to 125 mL/hr

19. Recommendations for intrapartum management
An obstetrician skilled in intrauterine identification of fetal parts and in intrauterine manipulation of a fetus should be present
A sonography machine is made readily available to help evaluate position and status of the remaining fetus(es) after delivery of the first
Experienced anesthesia personnel are immediately available in the event that intrauterine manipulation or cesarean delivery is necessary
For each fetus, two attendants, one of whom is skilled in resuscitation and care of newborns, are appropriately informed of the case and remain immediately available
The delivery area should provide adequate space for all team members to work effectively. Moreover, the site must be appropriately equipped to provide maternal and neonatal resuscitation

20. Presentation and Position
admission for delivery: cephalic-cephalic, cephalic-breech, and cephalic- transverse

21. Vaginal delivery
When
How
Evaluation

22. Internal podalic version

23. Cesarean Delivery
Complications
Secondary
Rare situation

24. 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

25. Diagnosis--sonographic suspedted
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.

26. Quintero staging system
Stage I–discordant amnionic fluid volumes as described above, but urine still visible sonographically within the donor twin's bladder
Stage II–criteria of stage I, but urine is not visible within the donor's bladder
Stage III–criteria of stage II and 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

27. Disorders of Amnionic Fluid Volume

28. The role of amnionic fluid
a physical space
promotes normal fetal lung development
avert compression of the umbilical cord

29. Permitting fetal movement and the development of the musculoskeletal system.
Swallowing of amniotic fluid enhances the growth and development of the gastrointestinal tract.
The ingestion of amniotic fluid provides some fetal nutrition and essential nutrients.
Amniotic fluid volume maintains amniotic fluid pressure thereby reducing the loss of lung liquid - an essential component to pulmonary development. (Nicolini, 1989).
Protects the fetus from external trauma.
Protects the umbilical cord from compression.
It's constant temperature helps to maintain the embryo's body temperature.
It's bacteristatic properties reduces the potential for infection.

30. Pathway Pathway ml/day to the fetus to amniotic fluid Fetal swallowing -
Oral secretions 25
Secretions from the respiratory tract
170
Fetal urination
Intramembranous flow across the placenta, umbilical cord and fetal
Transmembraneous flow from the amniotic cavity into the uterine circulation 10

31. Normal Amnionic Fluid Volume
1 L by 36 weeks, decreases thereafter to less than 200 mL at 42 weeks
Diminished fluid is termed oligohydramnios
more than 2 L of amnionic fluid is termed hydramnios or polyhydramnios

32. Measurement of Amnionic Fluid
amnionic fluid index, AFI
adding the vertical depths of the largest pocket in each of four equal uterine quadrants
hydramnios : ＞ 24 cm

34. Sonogram of a pocket of amniotic fluid in a patient with hydrops fetalis and polyhydramnios. Two small segments of umbilical cord (arrows) are seen traversing the measured pocket of amniotic fluid. The placenta (P), which appears normal to prominent in this case, is, in fact, abnormally thickened.

35. Hydramnios

36. Causes fetal malformations TTTS fetal pseudohypoaldosteronism
gastrointestinal anomalies
nonimmune hydrops
chromosomal abnormalities
central nervous system
TTTS
fetal pseudohypoaldosteronism
fetal Bartter or hyperprostaglandin E syndrome
fetal nephrogenic diabetes insipidus
placental chorioangioma
fetal sacrococcygeal teratoma
maternal substance abuse

37. Oligohydramnios

38. Associated Conditions
Fetal
Chromosomal abnormalities
Congenital anomalies
Growth restriction
Demise
Postterm pregnancy
Ruptured membranes

39. Associated Conditions
Placenta
Abruption
Twin-twin transfusion
Maternal
Uteroplacental insufficiency
Hypertension
Preeclampsia
Diabetes

40. Associated Conditions
Drugs
Prostaglandin synthase inhibitors
Angiotensin-converting enzymeinhibitors
Idiopathic

41. The End