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

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  • 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.  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. Journey map…….Pot holes… www.birthdefects.in
  • 4. Scenic beauty…..www.birthdefects.in
  • 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.  40 year old  Height 162 cm, weight 84 kg, BMI 32  G1 P0  Donor oocytes  Twin Pregnancy History…..www.birthdefects.in
  • 7. Early Pregnancy Mid Pregnancy Late PregnancyFirst Trim Screening Abnormalities ClinicalChorionicity Growth Complicationswww.birthdefects.in
  • 8. Early Pregnancywww.birthdefects.in
  • 9.  Early pregnancy scan  First Trimester Screeningwww.birthdefects.in
  • 10. Agewww.birthdefects.in
  • 11. Age 40 years Age 25 Prior risk 1:83 Prior risk 1:950-1001 The recipient The donorwww.birthdefects.in
  • 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. CHORIONICITYwww.birthdefects.in
  • 14. { T sign { Lambda sign MC Twin DC Twinwww.birthdefects.in
  • 15. DICHORIONICTWINS www.birthdefects.in
  • 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. MONOCHORIONICwww.birthdefects.in
  • 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. Let us add First Trimester Biochemistry……..www.birthdefects.in
  • 20.  Biochemistry in Twins is less accurate than in Singletons  Some advocate doing only NTwww.birthdefects.in
  • 21.  The biochemistry risk is calculated taking into consideration, the age of the recipient into accountwww.birthdefects.in
  • 22. SYSTEMATIC LABELING OF TWINSwww.birthdefects.in
  • 23. Comedyof errorswww.birthdefects.in
  • 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.  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.  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.  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.  Up or Down  Right or Leftwww.birthdefects.in
  • 29. www.birthdefects.in
  • 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.  Fetus designated as Twin 2 delivered first in 5% of vaginal delivery Perinatal switchwww.birthdefects.in
  • 32. Necessity is the mother of invention….www.birthdefects.in
  • 33. VANISHING TWIN…….www.birthdefects.in
  • 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.  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. What happens to the survivor????www.birthdefects.in
  • 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.  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.  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. Early Pregnancy Mid Pregnancywww.birthdefects.in
  • 41.  Ultrasound scanning  Uterine Artery Doppler  Cervical length assessmentwww.birthdefects.in
  • 42.  DC - High risk pregnancy  MC DA - Very high risk pregnancy  MC MA – Extremely high risk pregnancywww.birthdefects.in
  • 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.  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.  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.  Twin to twin transfusion syndrome  Selective IUGR  TRAP (Twin  Death of one of Reversed Arterial the Twins Perfusion)www.birthdefects.in
  • 47. Twin to Twin transfusionSyndrome www.birthdefects.in
  • 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.  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. GROWTH RESTRICTIONwww.birthdefects.in
  • 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.  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. Selective IUGR and Growth Discordancewww.birthdefects.in
  • 54.  Selective IUGR  >10th centile + <10th centile  Discordant Growth >20% differencewww.birthdefects.in
  • 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. Death of one of the Twinwww.birthdefects.in
  • 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.  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.  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.  sIUGR is more common before sIUFD  Fetal surveillance should not be less in dichorionic twins with sIUFDwww.birthdefects.in
  • 61. Would you still call them “weaker sex”….?????www.birthdefects.in
  • 62. Cervical lengthwww.birthdefects.in
  • 63. www.birthdefects.in
  • 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. www.birthdefects.in
  • 66.  Treatment with micronized Progesterone did not prevent PT delivery in twins  Micronized Progesterone is NOT harmful to mother or twinswww.birthdefects.in
  • 67. Uterine Artery Dopplerwww.birthdefects.in
  • 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. www.birthdefects.in
  • 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.  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. www.birthdefects.in
  • 73. Early Pregnancy Mid Pregnancy Late Pregnancywww.birthdefects.in
  • 74. Late pregnancy complications in Twinswww.birthdefects.in
  • 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. PIH IN TWINSwww.birthdefects.in
  • 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. GESTATIONAL DIABETESwww.birthdefects.in
  • 79.  The presence of GDM in Twin pregnancy was associated with higher risk of  Hypertensive complications  Prematurity  RDS  Macrosomiawww.birthdefects.in
  • 80. www.birthdefects.in
  • 81. PT delivery & LBWwww.birthdefects.in
  • 82. www.birthdefects.in
  • 83. www.birthdefects.in
  • 84. Wish there were spell check in daily life too…..www.birthdefects.in
  • 85. OPTIMUM TIMING FOR DELIVERYwww.birthdefects.in
  • 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.  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. ROUTE OF DELIVERYwww.birthdefects.in
  • 89.  Both vertex twins  Allow vaginal delivery  First breech/ Second vertex  Elective LSCS  First vertex/ Second non vertex  84% LSCSwww.birthdefects.in
  • 90. ORDER OF BIRTHwww.birthdefects.in
  • 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. Controversies in Twinswww.birthdefects.in
  • 93. ANTENATAL CORTICOSTEROIDSwww.birthdefects.in
  • 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. ELECTIVE LSCSwww.birthdefects.in
  • 96.  Mono chorionic Twins to decrease hypoxic episodes?  Pre term Twins with first Vertex?www.birthdefects.in
  • 97. NEONATAL COMPLICATIONSwww.birthdefects.in
  • 98.  Low Birth weight  Prematurity  CNS complications  Cerebral Palsywww.birthdefects.in
  • 99. The only person awake is probably the next speaker….www.birthdefects.in
  • 100. Thank you……www.birthdefects.in

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