Multiple Gestations

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  • Multiple Gestations

    1. 1. Multiple Gestations <ul><li>Why is this important? </li></ul><ul><ul><li>Incidence and complications </li></ul></ul><ul><ul><li>Role of ART/AMA </li></ul></ul><ul><li>How does this happen? </li></ul><ul><ul><li>Embryology </li></ul></ul><ul><li>How do I recognize it? </li></ul><ul><ul><li>Diagnosis </li></ul></ul><ul><li>How do I manage it? </li></ul><ul><ul><li>Reduction/termination </li></ul></ul><ul><ul><li>Management of common complications </li></ul></ul>
    2. 2. Incidence is increasing! Inc 65% for twins Inc 500% for triplets+ Multifetal gestation = only 3% of total births, but >20% of complications like PTD, LBW, VLBW babies
    3. 3. On average… Twins deliver @ 35+2wk Triplets deliver @ 32+1wk BUT The lowest mortality for: Twins = 38 wk Triplets = 35 wk
    4. 4. Morbidity <ul><li>Infants </li></ul><ul><li>IUGR </li></ul><ul><ul><li>~1/4 of twins </li></ul></ul><ul><ul><li>~1/2 of triplets </li></ul></ul><ul><li>PTD </li></ul><ul><li>CP </li></ul><ul><ul><li>4x higher for twins </li></ul></ul><ul><ul><li>17x higher for triplets </li></ul></ul><ul><li>TTTS </li></ul><ul><li>Mothers </li></ul><ul><li>6x more likely to be hospitalized for 6Ps: </li></ul><ul><li>Preeclampsia </li></ul><ul><li>PTL </li></ul><ul><li>PPROM </li></ul><ul><li>Placental abruption </li></ul><ul><li>Pyelonephritis </li></ul><ul><li>PPH </li></ul><ul><li>Also think about </li></ul><ul><li>PE </li></ul><ul><li>GDM </li></ul><ul><li>Acute fatty liver </li></ul><ul><li>Placenta previa </li></ul><ul><li>Cervical incompetence </li></ul>
    5. 5. AMA, ART and ovum induction <ul><li>Triplets+ numbers have increased </li></ul><ul><li>~40% increase due to ART </li></ul><ul><ul><li>Leads to monochorionic twins also! </li></ul></ul><ul><ul><ul><li>Thought to be b/c of ZP manipulation and decreased movement through fallopian tube </li></ul></ul></ul><ul><li>~40% increase due to ovulation induction </li></ul><ul><li>(only ~20% due to spontaneous conception) </li></ul><ul><li>AMA worsens the outcomes through fertility treatments and comorbidities (HTN, DM, labor problems, C/S, etc.) </li></ul>
    6. 6. Etiology: Monozygotic <ul><li>1/3 of twins </li></ul><ul><li>Dichorionic/Diamniotic </li></ul><ul><li>Mono/Di </li></ul><ul><li>Mono/Mono </li></ul><ul><li>Conjoined </li></ul>Morula Day 0-3 Blastocyst Day 4-8 Implanted blastocyst Day 8-13 Embryonic disc Day 13-15
    7. 7. Etiology: Dizygotic Ultrasound image of &quot;twin-peak&quot; sign showing an extension of placental tissue into the intertwin membrane, confirming dichorionic twinning. 2/3 of all twins Diamniotic/dichorionic
    8. 8. Differential diagnosis for LGA uterus <ul><li>Multiple fetuses </li></ul><ul><li>Distended bladder </li></ul><ul><li>Inaccurate dating </li></ul><ul><li>Hydramnios </li></ul><ul><li>Hydatidiform mole </li></ul><ul><li>Uterine myomas </li></ul><ul><li>Adnexal mass </li></ul><ul><li>Fetal macrosomia </li></ul>
    9. 9. Maternal Complications <ul><li>GDM </li></ul><ul><ul><li>hi hPL  insulin resistance </li></ul></ul><ul><li>Hyperemesis gravidarum </li></ul><ul><ul><li>hi hCG  morning sickness </li></ul></ul><ul><li>PIH/Preeclampsia </li></ul><ul><li>Acute fatty liver of pregnancy </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Pulmonary edema </li></ul><ul><li>PPH </li></ul><ul><ul><li>Enlarged uterine size  more difficult to contract and apply sufficient pressure to close sinuses postpartum </li></ul></ul>
    10. 10. Preterm Delivery <ul><li>Endovaginal US may predict PTD </li></ul><ul><ul><li><25mm cervical length @ 24wk scan </li></ul></ul><ul><li>Digital exam estimating cervical length </li></ul><ul><ul><li>PPV 60-70% </li></ul></ul><ul><li>Fetal Fibronectin (FFN) </li></ul><ul><ul><li>HMW Gp found in fetal membranes, placental tissues, amniotic fluid </li></ul></ul><ul><ul><li>“ r/o PTL” </li></ul></ul><ul><ul><ul><li>High NPV </li></ul></ul></ul><ul><ul><ul><li>Low PPV (38-53% for twins, 16.7% for singletons) </li></ul></ul></ul><ul><li>Tx: Tocolysis? </li></ul><ul><ul><li>No improvements in PT/LBW/infant mortality </li></ul></ul><ul><ul><li>Increased risk of pulmonary edema </li></ul></ul><ul><li>Tx: Just be prepared for EARLY DELIVERY </li></ul>
    11. 11. Fetal complications: TTTS <ul><li>“ Poly-oli” hydramnios sequence from unequal vascular flow </li></ul><ul><li>Small anemic twin </li></ul><ul><li>Large plethoric polycythemic ( + hydrops) twin </li></ul><ul><li>Apparent in 2 nd trimester  PROM, PTL, early mortality, heart failure </li></ul>
    12. 12. Fetal Complications: IUGR <ul><li>Detected as early as week 22 </li></ul><ul><li>Discordance = 15-25% difference in EFW </li></ul><ul><ul><li>(Big-Small)/Big </li></ul></ul><ul><li>Causes </li></ul><ul><ul><li>Structural/genetic fetal anomalies </li></ul></ul><ul><ul><li>Discordant infection </li></ul></ul><ul><ul><li>Unfavorable placental/umbilical cord insertion </li></ul></ul><ul><ul><li>Placental damage </li></ul></ul><ul><ul><li>TTTS </li></ul></ul><ul><li>Review all prenatal labs </li></ul><ul><li>Perform a specialized US exam </li></ul><ul><li>Test of fetal wellbeing </li></ul>
    13. 13. Routine Antepartum Fetal Surveillance <ul><li>NST and fetal BPP are effective </li></ul><ul><ul><li>No current guidelines on GA for testing, # of times/week, necessity for testing normal dizygotic twins </li></ul></ul><ul><ul><li>NST: </li></ul></ul><ul><ul><ul><li>2x/week for DM and IUGR </li></ul></ul></ul><ul><ul><ul><li>Monitored also for AMA, multiple gestation with discordant growth and HTN </li></ul></ul></ul><ul><li>Serial sonogram to track growth </li></ul>
    14. 14. Reduction/Selective Termination <ul><li>Improves survival rates of remaining fetuses </li></ul><ul><li>Ethical debates abound! </li></ul><ul><li>Reduction </li></ul><ul><ul><li>Early intervention (10-13 wk GA) </li></ul></ul><ul><ul><li>US-guided injection of KCl into heart/thorax </li></ul></ul><ul><li>Selective termination </li></ul><ul><ul><li>Later intervention </li></ul></ul>
    15. 15. When do you deliver twins?
    16. 16. References <ul><li>ACOG Practice Bulletin #56: Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. </li></ul><ul><ul><li>American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics; Society for Maternal-Fetal Medicine; ACOG Joint Editorial Committee. </li></ul></ul><ul><ul><li>Obstet Gynecol. 2004 Oct;104(4):869-83. PMID 15458915 </li></ul></ul><ul><li>Blueprints: OB/GYN 4 th ed. </li></ul><ul><li>OB, GYN, Infertility: Handbook for Clinicians. 6 th ed. </li></ul><ul><li>Williams obstetrics / Cunningham. 22nd ed. c2005. </li></ul>
    17. 17. ACOG Bulletin Summary <ul><li>Tocolytics – use judiciously </li></ul><ul><li>Atypical HELLP syndrome more common </li></ul><ul><ul><li>Ask about nausea/epigastric pain </li></ul></ul><ul><ul><li>Be on the lookout for atypical 3 rd trimester s/sx </li></ul></ul><ul><li>Vigilant screening for GDM and PIH </li></ul><ul><li>PTL  give steroids! </li></ul><ul><li>Counsel about risks of ART </li></ul>

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