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Multifetal pregnancy

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  • 1. TOPIC REVIEW :MULTIFETAL PREGNANCY จัดทำโดย Ext.สรวิศ บุญญฐี นำเสนอวันที่ กรกฎำคม 2555
  • 2. 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.
  • 3. Incidences
  • 4. Etiology
  • 5. Type of Zygosity Monozygotic Twins (30 %)  True Twins  1 Ovum + 1 Sperm -> differentiation from morula to embryo (2 wks) Dizygotic Twins (70 %)  FalseTwins  2 Ovums + 2 Sperms = Diamnion Dichorion  Different or subsequent cycle -> “Superfetation”  Same cycle -> “Superfecundation”
  • 6. Factors that Influence Twinning Race Heredity Maternal age and parity Nutritional factors Pituitary Gonadotropin Infertility Therapy Assisted Reproductive Technology (ART)
  • 7. Important of Determination of Zygosity Overview of the Incidence of Twin Pregnancy Zygosity and Corresponding Twin-Specific Complications Rates of Twin-Specific Complication in Percent Placental Fetal-Growth Preterm Perinatal Type of Twinning Twins Vascular Restriction Delivery Mortality AnastomosisDizygous 80 25 40 0 10–12Monozygous 20 40 50 15–18 Diamnionic/dichorionic 6–7 30 40 0 18–20 Diamnionic/monochorionic 13–14 50 60 100 30–40 Monoamnionic/monochorionic <1 40 60–70 80–90 58–60 0.002 toConjoined 0.008 — 70–80 100 70–90Source: Fetal biophysical profile scoring. In Fetal Medicine: Principles and Practices, 1995.Copyright © The McGraw-Hill Companies, Inc.
  • 8. Overview Summary
  • 9. Diagnosis and Investigation
  • 10. 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
  • 11. 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)
  • 12. Differential Diagnosis
  • 13. 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.
  • 14. 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
  • 15. Sonographic Evaluation (Chorionicity) Twin Peak Sign T sign Dichorion Monochorion
  • 16. 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
  • 17. 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.
  • 18. Complication
  • 19. Maternal Complication Anemia PIH Preterm Labor Preterm PROM Placenta Abruptio Prolapsed Vasa previa previa placentae cord Postpartum Postpartum Hemorrhage Infection
  • 20. Preterm Labor
  • 21. Fetal Complication Abnormal Twinning Vascular Anastomoses between Fetuses Discordant Twins Twin Demise
  • 22. Abnormal Twinning
  • 23. Conjoined Twin
  • 24. Acardiac or TRAP
  • 25. Fetal Complication (Cont.) Vascular Anastomoses between Fetuses  artery-to-venous (AV)  artery-to-artery (AA)  vein-to-vein (VV) Found with monochorionic placentas
  • 26. 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
  • 27. 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 + + + + +
  • 28. 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.
  • 29. 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
  • 30. Antepartum Assessment
  • 31. 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
  • 32. Intrapartum and Postpartum Assessment
  • 33. Presentation and Position
  • 34. 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
  • 35. Internal Podalic Version
  • 36. 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
  • 37. Thank you for your kind attentions.