Multiple gestation


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  • Multiple gestation

    1. 1. +MultipleGestationPrepared by:Jumana HaiderN. H.
    2. 2. + Multiple pregnancies consists of ≥2 fetuses. Twins make up ~99% Pregnancies of ≥3 fetuses are referred to as “Higher Multiples”.
    3. 3. +Classification Number of fetuses: Twins, triplets, quadruplets, etc. Number of fertilized eggs: Zygosity Number of placentae: Chorionicity Number of amniotic cavities: Amnionicity
    4. 4. + Non-identical/fraternal twins are dizygotic Fertilization of 2 separate eggs. Either same- or different sex pairings. Always have 2 functionally separate placetae
    5. 5. + Identical twins are monozygotic Fertilization of a single egg Always same-sex pairings. Mono- or di- chorionic
    6. 6. + In dichorionic twins, the 2 separate placentae my anatomicallyfuse together and appear as a single placental mass.
    7. 7. +Key point Not all dichorionic pregnancies are dizygotic. All monochorionic pregnancies and monozygotic.
    8. 8. +Risk Factors Assisted reproduction techniques IVF Ovulation induction Increased maternal age High parity Black race Maternal family history
    9. 9. + Type of monozygotic twin depends on how long aftercontraception the splitting occurs.
    10. 10. +Physiological changes
    11. 11. +I. Maternal All the physiological changes will be exaggerated. There will be an increase in: Cardiac output Volume expansion Relative hemodilution Diaphragmatic splinting Weight gain Lordosis
    12. 12. +II. Fetal Monochorionic placentae have the unique ability to developvascular connections between the two fetal circulations. These anastomoses carry the potential for complications.
    13. 13. +Complications Relevant toTwin Pregnancy
    14. 14. + Miscarriages and severe preterm delivery Death of one fetus in a twin pregnancy Fetal Growth Restriction Fetal Abnormalities Chromosomal defects in twinning
    15. 15. +Complications Unique toMonochrionic Twinning
    16. 16. + Twin-to-twin transfusion syndrome (15%) Growth-restricted fetus (donor)  Hypovolaemic and oligouric oligohydramnios Recepient  hypervolaemic  polyuria polyhydramnios
    17. 17. + >90% TTTS complicated pregnancies end in miscarriage orvery preterm delivery. With treatment, one or both babies survive (~70% ofpregnancies).
    18. 18. +Complications Unique toMonoamniotic Twinning
    19. 19. + Increased cord accidents, mainly through their universal cordentanglement. This could be acute, fatal and unpredictable. Many clinicians support elective CS at 32-34 weeks.
    20. 20. +Differential diagnosis Polyhydramnios Uterine fibroids Urinary retention Ovarian masses
    21. 21. +Determination of choronicity In Monochorionic twins the inter twin membrane joins theuterine wall in a T shape.
    22. 22. + In dichorionic twins there is a V shape extension of placentaltissue into the base of the intertwin membrane (Lambda or twinpeak sign).
    23. 23. +Antenatal Management Screening for common conditions in twin pregnancy ,such ashypertension and gestational diabetes. Increase supplementation of iron and folic acid.
    24. 24. +Screening for fetal abnormalities Screening of trisomy 21 Procedures such as amniocentesis and chorionic villussampling can be done Screening for structural anomalies
    25. 25. +Monitoring fetal growth and wellbeing Measuring symphysis fundal height Presence of fetal movements Doppler investigations CTG
    26. 26. +Threatened preterm laborStart steroid therapyScreen for GBS and give antibiotictherapy if needed
    27. 27. +Intrapartum ManagementPreterm birthCord prolapseAbnormal presentationPost-partum hemorrhage
    28. 28. +Preparation:Start CTG for fetal monitoringKeep oxytocin ready in case of PPHGive appropriate analgesia
    29. 29. +Delivery Allow vaginal delivery of the first twin Palpate the abdomen to asses the lie of thesecond twin Then wait for the delivery of the second twinI. Vaginal delivery of vertex - vertex:
    30. 30. + If the second twin is breech, then externalcephalic version has to be done ,and then thedelivery can proceed successfullyII. Delivery of vertex non vertex:
    31. 31. + Cesarean section is done immediatelyIII. Non vertex first twin:
    32. 32. Questions?!