Multifetal Pregnancy The term used to describe pregnancy with more than one fetus. Almost every maternal and obstetric problem occurs more frequently in multiple pregnancy. Perinatal mortality rate in twins is 5 times higher, and in triplets 10 times higher than in singletons.
Diagnosis of Multiple Fetuses History A maternal personal or family history of twins Advanced maternal age High parity Large maternal size Recent administration of either clomiphene citrate or gonadotropins or pregnancy accomplished by ART
Diagnosis of Multiple Fetuses Physical Examination Fundal height, average approximately 5 cm greater than expected for singletons of the same fetal age. Palpation of fetal Two fetal heartbeats (Difference between 8-10 bpm)
Sonographic Evaluation About gestational age 6 – 7 wks separate gestational sacs can be identified early in twin pregnancy Routine midgestation sonographic examinations 99 % of multifetal gestations before 26 weeks, if performed for specific indications. Higher-order multifetal gestations are more difficult to evaluate.
Sonographic Evaluation (Cont.) Chorionicity can sometimes be determined sonographically in the first trimester. Two separate placentas and a thick–generally 2 mm or greater– dividing membrane -> presumed diagnosis of Fetuses of opposite gender are almost always dizygotic, thus dichorionic
Placental Examination One common amnionic sac, or with juxtaposed amnions not separated by chorion arising between the fetuses, the fetuses are monozygotic. If adjacent amnions are separated by chorion, the fetuses could be either dizygotic or monozygotic, but dizygosity is more common
Zygosity If the neonates are of the same sex, blood typing of cord blood samples may be helpful. Different blood types confirm dizygosity, Same blood type in each fetus does not confirm monozygosity For definitive diagnosis, more complicated techniques such as DNA fingerprinting can be used. Twins of opposite sex are almost always dizygotic. Rarely, monozygotic twins may be discordant for phenotypic sex. This occurs if one twin is phenotypically female due to Turner syndrome (45,X) and her sibling is 46,XY.
Fetal Complication (Cont.) Vascular Anastomoses between Fetuses artery-to-venous (AV) artery-to-artery (AA) vein-to-vein (VV) Found with monochorionic placentas
Twin-Twin Transfusion Syndrome (TTTS) Blood is transfused from a donor twin to its recipient sibling The donor becomes anemic and its growth may be restricted. The recipient becomes polycythemic and may develop circulatory overload manifest as hydrops. Donor (Stuck twin) GrowthRestriction, Contratures Pulmonary hypoplasia Recipient PROM and Heart failure
Twin-Twin Transfusion Syndrome (TTTS) Quintero staging : Divided into 5 stagesStage Oligo and Absent Abnormal Hydrops Fetal Polyhydramnios Urine Doppler Fetalis Demise in Donor Blood Bladder Flows I + - - - - II + + - - - III + + + - - IV + + + + - V + + + + +
Discordant Twins Size inequality of twin fetuses be a sign of pathological growth restriction in one fetus calculated using the larger twin as the index Usually develops late in the second and early third trimester and is often asymmetrical Earlier discordancy is usually symmetrical and indicates higher risk for fetal demise.
Twin Demise Death of One Fetus Common in monochorion Early demise "vanishing twin" Not appear to increase the risk of death in the surviving fetus after the first trimester Late demise Twin embolization syndrome Triggers DIC in mother Impending Death of One Fetus Abnormal antepartum test results of fetal health in one twin fetus Death of Both Twins
Antepartum Care Early Diagnosis -> Identified complication Preterm Labor, Pregnancy induced hypertension Good diet, iron and folic acid supplementation Rest at home -> After 28 wks No SI in third trimester Ultrasound For anomaly screeing Evaluate gestational age Position of fetus Placenta attachment Growth assessment -> Identify IUGR Non stress test
Delivery Vertex - Vertex Suggest Vaginal Delivery Vertex – Non vertex First Choice : Vaginal Delivery (If have experiences doctor) When was delivered first twin Check the position of another twin If delivery if unsuccessful -> Cesarean section If fetal distress in second or other twins First choice : Internal Podalic Version or Breech Extraction Second choice : Cesarean section
Postpartum Care Prevent postpartum hemorrhage such as uterine atony Give oxytocin drug in the third stage of labor and postpartum stage If hypovolemic shock due to excessive blood loss should replace fluid adequated Prevent postpartum infection in: Large amount of postpartum bleeding Preterm or prolong premature rupture of membrane Manual internal version Manual placenta removal