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Multiple pregnancy

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Twins pregnancy and delivery in Obstetrics

Twins pregnancy and delivery in Obstetrics


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  • 1. Multiple pregnancy Assist.prof. Andrii Berbets
  • 2. Multiple pregnancy Multiple pregnancy involves more than one embryo (fetus) in any one gestation. Two independent mechanisms may lead to multiple gestation: • segmentation of a single fertile ovum (identical, monovular, or monozygotic) • or fertilization of separate ova by different spermatozoa (fraternal or dizygotic)
  • 3. BENSON & PERNOLL’S HANDBOOK OF OBSTETRICS AND GYNECOLOGY
  • 4. Maternal complications • • • • • • anemia; urinary tract infection; preeclampsia-eclampsia, hydramnios, uterine inertia (overdistention); hemorrhage (before, during, and after delivery).
  • 5. Fetal complications • • • • • • • prematurity fetal growth retardation congenital anomalies (18% higher) abnormal presentations cord prolapse (5 times increased) collision of twins fetus-fetus tranfusion syndrome
  • 6. Clinical findings • A uterus larger than expected for the duration of pregnancy (4 cm than anticipated); • Excessive maternal weight gain not explained by eating or edema; • Hydramnios; • Iron deficiency anemia; • Maternal reports of increased fetal activity;
  • 7. Clinical findings • Uterus containing 3 large parts or multiple small parts; • Simultaneous auscultation or recording of two fetal hearts varying 8 beats per min and asychronous to the maternal heart • Ultrasound confirmation
  • 8. Two-vertex twins presentation
  • 9. One vertex and one breech presentation
  • 10. Locked twins
  • 11. Feto-fetal transfusion syndrome • This condition affects approximately 1 in 5 (20%) of all twins that share the same placental mass (monochorionic). • This is a highly pathological condition, which if untreated will lead to fetal or newborn death in excess of 95% of cases.
  • 12. Feto-fetal transfusion syndrome • The underlying abnormality is that the placenta contains vascular connections that connect the twins, in effect, making them connected together by a continuous blood supply.
  • 13. Feto-fetal transfusion syndrome • The vascular (blood supply) connection between twins within the placenta leads to a haemodynamic (blood flow) imbalance between the twins, with one, the recipient, having a relative high perfusion of blood and the other, the donor, being under perfused with blood.
  • 14. Feto-fetal transfusion syndrome
  • 15. Severity classification • Stage 1. There is a difference in the amounts of amniotic fluid surrounding the twins. The recipient often is complicated by polyhydramnios (excess amniotic fluid with a maximum pool depth of around 8cms) and the donor is complicated by oligohydramnios (reduced amniotic fluid with a maximum pool depth of around 2cms).
  • 16. Severity classification • Stage 2. In addition to the discrepancy of amniotic fluid volumes, there is a difference in size between the two babies (the recipient is often larger than the donor).
  • 17. Severity classification • Stage 3. There are haemodynamic differences between the twins. The recipient has evidence of abnormal blood flow and right-sided heart strain. The donor often demonstrates absent or reversed blood flow in the umbilical arterial (cord) circulation. • Stage 4. One twin shows signs of severe right-sided heart failure. • Stage 5. One of twin has already died.
  • 18. Feto-fetal transfusion syndrome
  • 19. Treatment Fetoscopy and placenta laser ablation
  • 20. Delivery • Cesarean section is recommended for monoamniotic twins because of the 10% delivery loss from cord entanglement. • Other standard indications for cesarean include: any birth number exceeding twins (e.g., triplets), or if the first twin is nonvertex. • The first twin may be delivered vaginally if it presents by the vertex.
  • 21. Delivery • A vaginal examination immediately after the first delivery is performed to identify a possible forelying or prolapsed cord
  • 22. Delivery • If 2nd fetus has continued as a vertex, a second vaginal delivery may be performed.
  • 23. Delivery If the second fetus is anything but vertex there are three alternatives. ● Bringing the head into the inlet by external guidance (version); if successful, allows labor to proceed for another vertex vaginal delivery. ● Perform cesarean section ● Complete a vaginal breech delivery
  • 24. Delivery • Rupture of the second sac (if present) is accomplished as late as possible to avoid prolapse of the cord.
  • 25. Thank You!