Multiple Gestations Why is this important? Incidence and complications Role of ART/AMA How does this happen? Embryology How do I recognize it? Diagnosis How do I manage it? Reduction/termination Management of common complications

Why is this important?

Incidence and complications

Role of ART/AMA

How does this happen?

Embryology

How do I recognize it?

Diagnosis

How do I manage it?

Reduction/termination

Management of common complications

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

On average… Twins deliver @ 35+2wk Triplets deliver @ 32+1wk BUT The lowest mortality for: Twins = 38 wk Triplets = 35 wk

Morbidity Infants IUGR ~1/4 of twins ~1/2 of triplets PTD CP 4x higher for twins 17x higher for triplets TTTS Mothers 6x more likely to be hospitalized for 6Ps: Preeclampsia PTL PPROM Placental abruption Pyelonephritis PPH Also think about PE GDM Acute fatty liver Placenta previa Cervical incompetence

Infants

IUGR

~1/4 of twins

~1/2 of triplets

PTD

CP

4x higher for twins

17x higher for triplets

TTTS

Mothers

6x more likely to be hospitalized for 6Ps:

Preeclampsia

PTL

PPROM

Placental abruption

Pyelonephritis

PPH

Also think about

PE

GDM

Acute fatty liver

Placenta previa

Cervical incompetence

AMA, ART and ovum induction Triplets+ numbers have increased ~40% increase due to ART Leads to monochorionic twins also! Thought to be b/c of ZP manipulation and decreased movement through fallopian tube ~40% increase due to ovulation induction (only ~20% due to spontaneous conception) AMA worsens the outcomes through fertility treatments and comorbidities (HTN, DM, labor problems, C/S, etc.)

Triplets+ numbers have increased

~40% increase due to ART

Leads to monochorionic twins also!

Thought to be b/c of ZP manipulation and decreased movement through fallopian tube

~40% increase due to ovulation induction

(only ~20% due to spontaneous conception)

AMA worsens the outcomes through fertility treatments and comorbidities (HTN, DM, labor problems, C/S, etc.)

Etiology: Monozygotic 1/3 of twins Dichorionic/Diamniotic Mono/Di Mono/Mono Conjoined Morula Day 0-3 Blastocyst Day 4-8 Implanted blastocyst Day 8-13 Embryonic disc Day 13-15

1/3 of twins

Dichorionic/Diamniotic

Mono/Di

Mono/Mono

Conjoined

Etiology: Dizygotic Ultrasound image of "twin-peak" sign showing an extension of placental tissue into the intertwin membrane, confirming dichorionic twinning. 2/3 of all twins Diamniotic/dichorionic

Differential diagnosis for LGA uterus Multiple fetuses Distended bladder Inaccurate dating Hydramnios Hydatidiform mole Uterine myomas Adnexal mass Fetal macrosomia

Multiple fetuses

Distended bladder

Inaccurate dating

Hydramnios

Hydatidiform mole

Uterine myomas

Adnexal mass

Fetal macrosomia

Maternal Complications GDM hi hPL  insulin resistance Hyperemesis gravidarum hi hCG  morning sickness PIH/Preeclampsia Acute fatty liver of pregnancy Pulmonary embolism Pulmonary edema PPH Enlarged uterine size  more difficult to contract and apply sufficient pressure to close sinuses postpartum

GDM

hi hPL  insulin resistance

Hyperemesis gravidarum

hi hCG  morning sickness

PIH/Preeclampsia

Acute fatty liver of pregnancy

Pulmonary embolism

Pulmonary edema

PPH

Enlarged uterine size  more difficult to contract and apply sufficient pressure to close sinuses postpartum

Preterm Delivery Endovaginal US may predict PTD <25mm cervical length @ 24wk scan Digital exam estimating cervical length PPV 60-70% Fetal Fibronectin (FFN) HMW Gp found in fetal membranes, placental tissues, amniotic fluid “ r/o PTL” High NPV Low PPV (38-53% for twins, 16.7% for singletons) Tx: Tocolysis? No improvements in PT/LBW/infant mortality Increased risk of pulmonary edema Tx: Just be prepared for EARLY DELIVERY

Endovaginal US may predict PTD

<25mm cervical length @ 24wk scan

Digital exam estimating cervical length

PPV 60-70%

Fetal Fibronectin (FFN)

HMW Gp found in fetal membranes, placental tissues, amniotic fluid

“ r/o PTL”

High NPV

Low PPV (38-53% for twins, 16.7% for singletons)

Tx: Tocolysis?

No improvements in PT/LBW/infant mortality

Increased risk of pulmonary edema

Tx: Just be prepared for EARLY DELIVERY

Fetal complications: TTTS “ Poly-oli” hydramnios sequence from unequal vascular flow Small anemic twin Large plethoric polycythemic ( + hydrops) twin Apparent in 2 nd trimester  PROM, PTL, early mortality, heart failure

“ Poly-oli” hydramnios sequence from unequal vascular flow

Small anemic twin

Large plethoric polycythemic ( + hydrops) twin

Apparent in 2 nd trimester  PROM, PTL, early mortality, heart failure

Fetal Complications: IUGR Detected as early as week 22 Discordance = 15-25% difference in EFW (Big-Small)/Big Causes Structural/genetic fetal anomalies Discordant infection Unfavorable placental/umbilical cord insertion Placental damage TTTS Review all prenatal labs Perform a specialized US exam Test of fetal wellbeing

Detected as early as week 22

Discordance = 15-25% difference in EFW

(Big-Small)/Big

Causes

Structural/genetic fetal anomalies

Discordant infection

Unfavorable placental/umbilical cord insertion

Placental damage

TTTS

Review all prenatal labs

Perform a specialized US exam

Test of fetal wellbeing

Routine Antepartum Fetal Surveillance NST and fetal BPP are effective No current guidelines on GA for testing, # of times/week, necessity for testing normal dizygotic twins NST: 2x/week for DM and IUGR Monitored also for AMA, multiple gestation with discordant growth and HTN Serial sonogram to track growth

NST and fetal BPP are effective

No current guidelines on GA for testing, # of times/week, necessity for testing normal dizygotic twins

NST:

2x/week for DM and IUGR

Monitored also for AMA, multiple gestation with discordant growth and HTN

Serial sonogram to track growth

Reduction/Selective Termination Improves survival rates of remaining fetuses Ethical debates abound! Reduction Early intervention (10-13 wk GA) US-guided injection of KCl into heart/thorax Selective termination Later intervention

Improves survival rates of remaining fetuses

Ethical debates abound!

Reduction

Early intervention (10-13 wk GA)

US-guided injection of KCl into heart/thorax

Selective termination

Later intervention

When do you deliver twins?

References ACOG Practice Bulletin #56: Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy. American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics; Society for Maternal-Fetal Medicine; ACOG Joint Editorial Committee. Obstet Gynecol. 2004 Oct;104(4):869-83. PMID 15458915 Blueprints: OB/GYN 4 th ed. OB, GYN, Infertility: Handbook for Clinicians. 6 th ed. Williams obstetrics / Cunningham. 22nd ed. c2005.

ACOG Practice Bulletin #56: Multiple gestation: complicated twin, triplet, and high-order multifetal pregnancy.

American College of Obstetricians and Gynecologists Committee on Practice Bulletins-Obstetrics; Society for Maternal-Fetal Medicine; ACOG Joint Editorial Committee.

Obstet Gynecol. 2004 Oct;104(4):869-83. PMID 15458915

Blueprints: OB/GYN 4 th ed.

OB, GYN, Infertility: Handbook for Clinicians. 6 th ed.

Williams obstetrics / Cunningham. 22nd ed. c2005.

ACOG Bulletin Summary Tocolytics – use judiciously Atypical HELLP syndrome more common Ask about nausea/epigastric pain Be on the lookout for atypical 3 rd trimester s/sx Vigilant screening for GDM and PIH PTL  give steroids! Counsel about risks of ART

Tocolytics – use judiciously

Atypical HELLP syndrome more common

Ask about nausea/epigastric pain

Be on the lookout for atypical 3 rd trimester s/sx

Vigilant screening for GDM and PIH

PTL  give steroids!

Counsel about risks of ART