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Multiple Pregnancy - Diagnosis ,Clinical Features & Complications
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Multiple Pregnancy - Diagnosis ,Clinical Features & Complications

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  • 1. Hari Dev2008 MBBS
  • 2. MULTIPLE PREGNANCY• Presence of more than one fetus in the gravid uterus• 1% of all pregnancies• Hellin’s Rule – Twins : 1 in 80 – Triplets : 1 in 80 × 80 – Quadruplets : 1 in 80 × 80 × 80….• Gemellology : Study of twins
  • 3. • ZYGOSITY - Refers to the Type of Conception. - only determined by DNA testing• CHORIONICITY - Type of Placentation - prenatally by ultrasound - postnatally by examining membranes.
  • 4. 1. ZYGOSITYDizygotic TwinsMonozygotic Twins
  • 5. 1.DIZYGOTIC TWINS/ BINOVULAR75%Fertilisation of 2 ova by different spermatozoa.Each twin has its own placenta, chorion , amnion.Hence always dichorionic, diamniotic.Factors affecting - ethnic group - increasing maternal age - increasing parity - Family history of twinning - ovulation induction with clomiphene citrate/gonadotrophins resulting in multiple ovulation.
  • 6. DIZYGOTIC TWINS/ BINOVULAR
  • 7. 2.MONOZYGOTIC / BINOVULAR/ IDENTICAL25%Result from splitting of a single fertilized ovumAlways same sex and look alike. [ IDENTICAL ]Rate of monozygotic twinning is relatively constant , not affectedby any factors.True etiology unknown.Type of placentation is determined by the time of splitting
  • 8. MONOZYGOTIC TWINS
  • 9. MONOZYGOTIC / BINOVULAR/ IDENTICAL
  • 10. 2.CHORIONICITY• Type of Placentation• Postnatally- Examination of Membranes• Prenatally- By Ultrasound• Ideal time for assesment is before 14 weeks
  • 11. Which is more important –zygosity or chorionicity??
  • 12. CHORIONICITY………Why????• Dichorionic twins can be either mono/dizygotic.• Dichorionic twins develop as two distinct organs. – so no risk.
  • 13. CHORIONICITY………Why????• Monochorionic twins have increased vascular anastomoses between the two circulation – so high risk!!
  • 14. Ultrasound Determination of Chorionicity• Number of sacs. [ before 10 weeks ] 2 sacs – dichorionic Single sac - monochorionic• Placenta• Sex• Intertwin membrane thicker and more echogenic in dichorionic.
  • 15. • Twin peak / Lambda sign - characteristic of dichorionic pregnancies - chorionic tissue between 2 layers of intertwin membrane at the placental origin• T Sign – in monochorionic , no chorionic tissue• If no membrane is seen in between – monochorionic monoaniotic
  • 16. Ultrasound differentiation of chorionicity Criterion Monochorionic DichorionicPlacenta Single DoubleFetal Sex -------- DiscordanceMembrane <2 mm >2 mmNo: of layers in 2 layers 4 layersmembraneTwin peak sign Absent Present
  • 17. Maternal ComplicationsAntepartum Intrapartum1.Hyperemesis 1.Dysfunctional labour2.Hydramnios 2.Malpresentation3.Pre-eclampsia 3.Operative delivery4.Pressure symptoms 4.Postpartum hemorrhage5.Anaemia 5.Retained Placenta6.Antepartum 6.Premature separationhemorrhage of placenta
  • 18. Maternal Complications - Antepartum Hyperemesis – increased β- hCG Hydramnios – monoamniotic pregnancies, Twin transfusion syndrome, major cause of prematurity Pre- eclampsia – 3 times commoner compared to singleton Pressure symptoms Anaemia – increased plasma volume expansion , fetoplacental demand for iron increased. APH – Placenta praevia , Abruptio placenta.
  • 19. Fetal ComplicationsAntepartum Intrapartum1.Prematurity 1.PROM2.IUGR 2.Cord Prolapse3.Single fetal demise 3.Abruption in second twin4.Twin to Twin transfusion 4.Interlocking (rare)syndrome5.Vanishing Twin/abortion6.Cong.anomalies7.Conjoined twins
  • 20. FETAL COMPLICATIONS Perinatal mortality: 6 times Morbidity: 2- 3 times Mono chorionic - morbidity/mortality twice as that of dichorionic. - additional risk from TTS Monoamniotic twins - 50% mortality. Main cause of adverse outcome is 1. Prematurity 2. IUGR Cerebral palsy, neurodevelopmental impairment, lower IQ scores. Monochorionic twins: 1. TTTS 2 .Monoamniotic twinning 3. Conjoined twinning 4. Acardiac fetus
  • 21. 1. Prematurity• Single most important cause of perinatal mortality and morbidity.• Ensure delivery in a tertiary care centre.!!
  • 22. 2. IUGRCan affect one or both fetuses.Monochorionic > Dichorionic.UPTO 30-32 Weeks twins grow with same velocity , afterthat reduction in abdominal circumference.Poor growth – poor placentation , unequal placentalsharing, fetal anomalies.
  • 23. 3. SINGLE FETAL DEMISEDeath of one twin NEUROLOGICAL DAMAGE in surviving TWIN Sudden acute shift of blood from surviving twin to dead fetus
  • 24. 3. SINGLE FETAL DEMISEMonochorionic - 25% risk of twin death, 25% risk ofneurological damage in surviving twin.• Dilemma exists whether to deliver early or not• Terminated as soon as other twin is capable of extra uterine survivalDichorionic – no such risk• Conservative management
  • 25. 4.Monochorionic Monoamniotic twinningSeen in less than 1% of all twin pregnanciesLate intrauterine death due to cord entanglement.Best diagnosed in 1st trimester – absence of intervening membrane.Colour doppler – cord entaglementFetal loss – 50-70%Hence elective CS at 36 weeks.
  • 26. 5. Twin – twin Transfusion Syndrome [ TTS]Occurs in monochorionic placentation due toAV anastomoses with resultant flow in onedirection.
  • 27. 5. Twin – twin Transfusion Syndrome [ TTS]
  • 28. Ultrasound in TTS – STUCK TWIN SIGN
  • 29. • Management after delivery – Exchange transfusion• Chronic TTS – Serial amnio reduction – - Reduces preterm labour - Reduce hydrostatic pressure – - improves circulation and urine production.• Fetoscopic laser ablation of anastomoses
  • 30. • Acute TTS can occur in 3rd trimester or in labour – sudden death of one twin• Overall mortality is 70%• High incidence of CP and neurological abnormalities in survivors.
  • 31. 6. Vanishing Twin & Abortion Incidence of abortion more in multiple pregnancy Spontaneous cessation of cardiac activity in a previously viable fetus of a multiple gestation. – VANISHING TWIN When fetal death occur after the first trimester, results in a thin parchment – like body called FETUS PAPYRACEOUS Diagnosis made after delivery No effect on mother or the viable fetus.
  • 32. 7. Congenital AnomaliesSTRUCTURAL MALFORMATIONS• Unique to twins – conjoined twins , Acardiac fetus• Non specific but common in twins – CHD , Anencephaly• Postural deformities – Talipes & Congenital dislocation of HipCHROMOSOMAL ANOMALIES• Dizygotic – independent risk, but both will not be involved• Monozygotic – same risk as that of singleton, both affected• Down’s syndrome
  • 33. Nuchal Translucency Mid Trimester Amniocentesis is the gold standard
  • 34. Management of Anomalies SelectiveDICHORIONIC If one fetus is feticide usingPREGNANCY abnormal KCl
  • 35. Conjoined TwinsAlways monozygoticIncomplete division occuring after 13 days.Very rareThoraco pagus, craniopagus, omphalopagus, pyopagus, ischiopagus..Prenatal diagnosis important – for termination , for planning operationSevere cases detected early – TerminationSurgical separation only in some cases – sharing of brain and heart – unsuccessful operationCaesarean preferred
  • 36. THORACOPAGUS CRANIOPAGUS ISCHIOPAGUSOMPHALOPAGUS PYOPAGUS RACHYPAGUS
  • 37. Acardiac FoetusVery rareBizarre form of monochorionic twinningOne fetus is normalThe other twin is severely malformed – no heart , absentdevelopment of upper part of body
  • 38. MECHANISM PUMP TWIN ACARDIAC TWIN
  • 39. Twin Reversed Arterial Perfusion Sequence [ TRAP]•Pump twin – high output cardiac failure, hydrops, poly hydramnios and death •Overall perinatal mortality of pump twin is 50%
  • 40. ACARDIAC TWIN PUMP TWIN
  • 41. THANK YOU