Twin pregnancy....a journey.....

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Twin pregnancy....a journey.....

  1. 1. 40 year old primi, BMI of 32,conceived twins with donor oocytes: how to make her journey safe? Dr.Sameer Dikshitwww.birthdefects.in
  2. 2.  Wadia Hospital  S L Raheja Fortis  Irla Nursing Home Hospital  Belle Vue Nursing  BSES MG Global Home Hospital  Sanket Sonography  Boisar Fetal Medicine Centre Centre Fetal Medicine Consultantwww.birthdefects.in
  3. 3. Journey map…….Pot holes… www.birthdefects.in
  4. 4. Scenic beauty…..www.birthdefects.in
  5. 5. Found pinned on the nursing station of a 5star hospital in Mumbai……. The doctors complain that the patients are more courteous to nurses than to them. www.birthdefects.in
  6. 6.  40 year old  Height 162 cm, weight 84 kg, BMI 32  G1 P0  Donor oocytes  Twin Pregnancy History…..www.birthdefects.in
  7. 7. Early Pregnancy Mid Pregnancy Late PregnancyFirst Trim Screening Abnormalities ClinicalChorionicity Growth Complicationswww.birthdefects.in
  8. 8. Early Pregnancywww.birthdefects.in
  9. 9.  Early pregnancy scan  First Trimester Screeningwww.birthdefects.in
  10. 10. Agewww.birthdefects.in
  11. 11. Age 40 years Age 25 Prior risk 1:83 Prior risk 1:950-1001 The recipient The donorwww.birthdefects.in
  12. 12.  The background risk is the risk at the age of the “Donor” and NOT at the age of the “Recipient”  In this case, prior risk is NOT 1:83, but it is 1:1001 In case of donor oocytes..www.birthdefects.in
  13. 13. CHORIONICITYwww.birthdefects.in
  14. 14. { T sign { Lambda sign MC Twin DC Twinwww.birthdefects.in
  15. 15. DICHORIONICTWINS www.birthdefects.in
  16. 16.  The posterior risk in the two twins is different, and is determined by NT of individual twin In Dichorionic Twins….www.birthdefects.in
  17. 17. MONOCHORIONICwww.birthdefects.in
  18. 18.  The posterior risk of the two twins is the same, and it is calculated by taking a mean of the two NTs…….. In Monochorionic Twins…www.birthdefects.in
  19. 19. Let us add First Trimester Biochemistry……..www.birthdefects.in
  20. 20.  Biochemistry in Twins is less accurate than in Singletons  Some advocate doing only NTwww.birthdefects.in
  21. 21.  The biochemistry risk is calculated taking into consideration, the age of the recipient into accountwww.birthdefects.in
  22. 22. SYSTEMATIC LABELING OF TWINSwww.birthdefects.in
  23. 23. Comedyof errorswww.birthdefects.in
  24. 24.  Biometric measurements from serial scans should be consistently allocated to the same twin (Yo Yo phenomenon)  When doing invasive testing, the “correct” twin has to be sampled  Necessary to communicate correctly with the neonatologist, in case a twin develops an abnormality postnatallywww.birthdefects.in
  25. 25.  Not applicable in monochorionic twins or dichorionic twins with fused placenta  Placenta changes position #1) Labeling of twins by position of placentawww.birthdefects.in
  26. 26.  PNDT law  Not possible in same sex twins  Ultrasonographic identification of fetal sex in early pregnancy may not be conclusive #2) Labeling of twins by fetal sexwww.birthdefects.in
  27. 27.  The laterality of the gestational sac relative to the cervix remains the same because the base of the inter twin membrane remains fixed  The rest of the inter twin membrane can move about, allowing the twins to swap position #3) Labeling by position of base of inter twin membranewww.birthdefects.in
  28. 28.  Up or Down  Right or Leftwww.birthdefects.in
  29. 29. www.birthdefects.in
  30. 30.  Implicit that Twin 1 delivers before Twin 2  Fetuses designated as Twin 2 delivered first in 25% of cases of LSCS Twin 1 (A) & Twin 2 (B)www.birthdefects.in
  31. 31.  Fetus designated as Twin 2 delivered first in 5% of vaginal delivery Perinatal switchwww.birthdefects.in
  32. 32. Necessity is the mother of invention….www.birthdefects.in
  33. 33. VANISHING TWIN…….www.birthdefects.in
  34. 34.  When live twins are detected prior to 7 weeks, only 71% resulted in birth of Twin neonates  This percentage increased to 84% when the gestational age reached 7-9 weeks  The chance of taking home, twin neonates is markedly reduced in the presence of threatened abortion, with only 63% take home baby ratewww.birthdefects.in
  35. 35.  There is significant relationship between CRL discrepancy at 7 + 0 to 9 + 0 weeks and the likelihood of single fetal demise  Discrepancy of 40% is associated with vanishing twinwww.birthdefects.in
  36. 36. What happens to the survivor????www.birthdefects.in
  37. 37.  IVF pregnancies with vanished co- twin had a higher rate of SGA than singletons from single gestation and the risk of SGA increased with increasing GA at the time of vanishingwww.birthdefects.in
  38. 38.  Use of biochemical markers in cases of vanishing twin is inaccurate and best avoided  The risk is calculated using ONLY NT FIRST TRIMESTER SCREENING IN CASE OF VANISHING TWIN…..www.birthdefects.in
  39. 39.  Incidence of hyperemesis is higher in twin pregnancy as compared to singleton pregnancy  After 11-14 weeks scan, rate of subsequent fetal loss before 24 weeks is 1% in singletons, 2% in DC twins and 10% in MC twins Other possible complications…www.birthdefects.in
  40. 40. Early Pregnancy Mid Pregnancywww.birthdefects.in
  41. 41.  Ultrasound scanning  Uterine Artery Doppler  Cervical length assessmentwww.birthdefects.in
  42. 42.  DC - High risk pregnancy  MC DA - Very high risk pregnancy  MC MA – Extremely high risk pregnancywww.birthdefects.in
  43. 43.  “Twin gestations should be followed routinely with serial ultrasonographic follow-up for growth at appropriate (currently, non evidence based) intervals, irrespective of chorionicity. If growth discordance is detected, surveillance should be intensified.”www.birthdefects.in
  44. 44.  Obesity  Difficulty in scanning the twin farther from the transducer  Double Movements  Difficulty in maneuvering of the transducer Difficulties encountered in screening for malformations…www.birthdefects.in
  45. 45.  A challenge to trace the anatomic parts to the respective Twin  Labeling of Twin  Constantly moving inter-twin membrane adds to confusionwww.birthdefects.in
  46. 46.  Twin to twin transfusion syndrome  Selective IUGR  TRAP (Twin  Death of one of Reversed Arterial the Twins Perfusion)www.birthdefects.in
  47. 47. Twin to Twin transfusionSyndrome www.birthdefects.in
  48. 48.  Polyhydramnios and large bladder in recipient twin  Oligohydramnios and absent bladder in donor twin  “Stuck Twin”  Folding of inter Twin membranewww.birthdefects.in
  49. 49.  Increased NT in one or both the Twins  Abnormal DV waveform in one or both the Twins  Inter-twin discrepancy in CRL is NOT predictive of TTTS  Inter-twin membrane folding Early markers for TTTS..www.birthdefects.in
  50. 50. GROWTH RESTRICTIONwww.birthdefects.in
  51. 51.  In singleton pregnancies the incidence of IUGR is 5%  In Dichorionic Twins it is 20%  In Monochorionic Twins it is 30%  In 2% of dichorionic and 8% of monochorionic Twins BOTH the twins have IUGRwww.birthdefects.in
  52. 52.  In singleton pregnancies, the reasons for IUGR are either abnormal placental function or genetic growth potential  In Dichorionic twins, IUGR is due to unequal genetic potential or disparity in placentation  In Monochorionic twins it is due to unequal splitting or due to unequal sharing of blood flowwww.birthdefects.in
  53. 53. Selective IUGR and Growth Discordancewww.birthdefects.in
  54. 54.  Selective IUGR  >10th centile + <10th centile  Discordant Growth >20% differencewww.birthdefects.in
  55. 55.  Type I (Normal UA Doppler) Good Prognosis  Type II (absent or reversed end diastolic velocity flow) High incidence (50-60%) of perinatal mortality  Type III (intermittent ARDF or iARDF) due to Feto-fetal transfusion. Risk to BOTH IUGR (20%) and non IUGR (15%) twin Prediction of adverse outcome- UA waveform of sIUGR Twinwww.birthdefects.in
  56. 56. Death of one of the Twinwww.birthdefects.in
  57. 57.  There is risk of CNS damage to the survivor  There is risk of perinatal mortality to the survivor  Decision to deliverwww.birthdefects.in
  58. 58.  Vascular communication between the two twins  Surviving twin demonstrates severe multi organ damage  Either due to thromboembolic episodes or due to bleeding of survivor into the vasculature of the dead twin Monochorionic Twinswww.birthdefects.in
  59. 59.  The risk to the survivor is significantly less  However, isolated cases of vascular communication have been reported in dichorionic twins too  Case reports of neurological damage in survivor of dichorionic twins Dichorionic Twinswww.birthdefects.in
  60. 60.  sIUGR is more common before sIUFD  Fetal surveillance should not be less in dichorionic twins with sIUFDwww.birthdefects.in
  61. 61. Would you still call them “weaker sex”….?????www.birthdefects.in
  62. 62. Cervical lengthwww.birthdefects.in
  63. 63. www.birthdefects.in
  64. 64.  Cervical lengths obtained between 16 and 31 weeks correlate with the risk of PT birth  Length <2.4 cm suggests high risk of PT birth  Could not come to any conclusion about treatment (cerclage, progesterone, tocolytics, rest)www.birthdefects.in
  65. 65. www.birthdefects.in
  66. 66.  Treatment with micronized Progesterone did not prevent PT delivery in twins  Micronized Progesterone is NOT harmful to mother or twinswww.birthdefects.in
  67. 67. Uterine Artery Dopplerwww.birthdefects.in
  68. 68.  Uterine Artery doppler has an overall low sensitivity in predicting adverse obstetric outcome  Suggested that there are additional patho -mechanism causing PIH and IUGR in twins that is unrelated to uteroplacental insufficiencywww.birthdefects.in
  69. 69. www.birthdefects.in
  70. 70.  PI in twin pregnancies is consistently lower than singleton pregnancies  There is no difference in MC and DC twin Ut A characteristics  ABNORMAL Ut A findings in twins has a HIGHER positive predictive valuewww.birthdefects.in
  71. 71.  The patients with ABNORMAL Ut A values represent those patients who are likely to have worst outcome  Hence screening for Ut A abnormalities should be carried out  The negative predictive value NORMAL Ut A findings is LOWER  Thus even NORMAL Ut A cases can have PIH/ IUGRwww.birthdefects.in
  72. 72. www.birthdefects.in
  73. 73. Early Pregnancy Mid Pregnancy Late Pregnancywww.birthdefects.in
  74. 74. Late pregnancy complications in Twinswww.birthdefects.in
  75. 75.  Anemia-35.8%  Hypertension-22.6%  PPH-18.9%  Hyperemesis-7.5%  Polyhydramnios- 5.7%  Gestational Diabetes in 5.7%www.birthdefects.in
  76. 76. PIH IN TWINSwww.birthdefects.in
  77. 77.  The incidence of PIH in Twin pregnancy 18% compared to 5% in Singletons  The incidence of complications ( PT delivery, LSCS, Abruptio Placenta, PPH) was higher in PIH  The PIH is more likely to be severe  The adverse maternal outcome is also more commonwww.birthdefects.in
  78. 78. GESTATIONAL DIABETESwww.birthdefects.in
  79. 79.  The presence of GDM in Twin pregnancy was associated with higher risk of  Hypertensive complications  Prematurity  RDS  Macrosomiawww.birthdefects.in
  80. 80. www.birthdefects.in
  81. 81. PT delivery & LBWwww.birthdefects.in
  82. 82. www.birthdefects.in
  83. 83. www.birthdefects.in
  84. 84. Wish there were spell check in daily life too…..www.birthdefects.in
  85. 85. OPTIMUM TIMING FOR DELIVERYwww.birthdefects.in
  86. 86.  When the pregnancy is uncomplicated, the twins continue to grow and mature with the advancement of the gestational age  In the absence of maternal complications, it is advisable to deliver twins at 38 weekswww.birthdefects.in
  87. 87.  Elective induction of labour v/s Expectant management  No statistically significant difference between two groups in the incidence of LSCS  No statistically significant difference between two groups in the incidence of adverse outcomewww.birthdefects.in
  88. 88. ROUTE OF DELIVERYwww.birthdefects.in
  89. 89.  Both vertex twins  Allow vaginal delivery  First breech/ Second vertex  Elective LSCS  First vertex/ Second non vertex  84% LSCSwww.birthdefects.in
  90. 90. ORDER OF BIRTHwww.birthdefects.in
  91. 91.  There was no association between birth order and risk of perinatal mortality before 36 weeks  Second twin born at term were at increased risk of perinatal death related to delivery  Vaginally delivered second twin had four fold increase in risk of deathwww.birthdefects.in
  92. 92. Controversies in Twinswww.birthdefects.in
  93. 93. ANTENATAL CORTICOSTEROIDSwww.birthdefects.in
  94. 94.  What is the dose for Twins?  Should it be double to cover the two?  Do Twins mature earlier than Singletons?  If so, should you decrease the dose required?  In Triplets and higher order pregnancies, steroids are associated with intra uterine contractions and cervical changes….do these happen in Twins too?www.birthdefects.in
  95. 95. ELECTIVE LSCSwww.birthdefects.in
  96. 96.  Mono chorionic Twins to decrease hypoxic episodes?  Pre term Twins with first Vertex?www.birthdefects.in
  97. 97. NEONATAL COMPLICATIONSwww.birthdefects.in
  98. 98.  Low Birth weight  Prematurity  CNS complications  Cerebral Palsywww.birthdefects.in
  99. 99. The only person awake is probably the next speaker….www.birthdefects.in
  100. 100. Thank you……www.birthdefects.in

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