Multiple Pregnancy for TPC


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Multiple Pregnancy for TPC

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  2. 2. Multiple Pregnancy Dr Shantala Vadeyar MD, FRCOG, DM (UK) Advanced Obstetric Ultrasound (RCO/RCR) Subspecialist in Maternal-Fetal Medicine (RCOG)Consultant Obstetrics, Fetal & Maternal Medicine Kokilaben Dhirubhai Ambani Hospital, Mumbai
  3. 3. Incidence• Increased with Assisted Reproduction• Clomiphene citrate / Letrozol/ HMG, hCG• Advanced Age• Race – Afro-carribeans• 1:80-100
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  7. 7. Risks inMultiple Pregnancy
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  9. 9. DC twins - lambdasign
  10. 10. MC twins - T sign
  11. 11. Chorionicity v/s Zygosity
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  16. 16. Techniques for invasive testing
  17. 17. Loss rates: Amniocentesis in Twins
  18. 18. Chorionic Villous Sampling in Twins
  19. 19. Selective Fetocide / ER
  20. 20. Management: AntenatalMaternal and Fetal Surveillance
  21. 21. Ultrasound in Multiples• Diagnosis and Chorionicity determinaiton• Dating, Chromosomal & Structural Normality• Growth, Dopplers• Amniotic fluid assessment• Twin twin transfusion syndrome• Invasive procedures – amniocentesis, CVS• Cervical length and funnelling• Prediction of preterm labour• Timing of delivery – Dopplers, BPS in IUGR, etc
  22. 22. Complications in Twins: Based on Chorionicity EVENT DICHORIONIC MONOCHORIONIC Miscarriage (11-23 weeks) 2% 10% Perinatal Death (>23 weeks) 2% 4%Fetal Growth Restriction (one /both) 20% 30% Preterm delivery (<32 weeks) 5% 10% Major birth defects 1% 4%
  23. 23. Preterm deliveryEarly screening for Cervical cerclage or Progesterone 25% reduction (4% Prevalence of spontaneous early preterm birth of total) Delivery <34 wks Delivery <34 wks 1.8% 1.8% Iatrogenic Iatrogenic Spontaneous Spontaneous 1/3rd 1/3rd 2/3rd 2/3rd Previous affected pregnancy • Previous affected pregnancy (15% (15% Nulliparous / No previous PTD • Nulliparous / No previous PTD (85% (85%
  24. 24. Twin Twin Transfusion Syndrome• Monochorionic twins Anastomoses in TTTS• Donor twin is small, growth restriction• Recepient twin is big• Oligo / polyhydramnios• Big bladder, heart enlarged in recepient• Oliguria, donor• Abnormal Dopplers
  25. 25. Prognosis - TTTS• Staging (Quintero) – Stage I • Recipient hydramnios • Donor bladder visible/present – Stage II • Recipient hydramnios • Donor bladder remains empty (“stuck twin”) – Stage III • Abnormal Doppler studies: – absent or reversed end-diastolic flow in Donor UA OR – abnormal venous Doppler pattern in Recipient UA (reverse flow in the ductus venosus or pulsatile umbilical venous flow) – Stage IV • Fetal hydrops means stage IV and the end – Stage V • Fetal death of one or both twins.
  26. 26. Treatment of TTTS by selective laser ablation of A-V Anastamoses Laser ablationStuck ‘donor twin’wrapped in membraneFeely floating ‘recipient twin’In hydramnios
  27. 27. ElectronicFetal Heart Ratemonitoring in labour
  28. 28. Epidural Analgesia (painless labour)
  29. 29. Timing and Mode of Delivery• Dichorionic twins – 38 weeks• Monochorionic twins – 36 wks• Vaginal delivery in uncomplicated DC or MC twins if cephalic, cephalic presentations• Precious pregnancy, abnormal presentations, complications like IUGR, preterm, maternal DM/HT usually delivered by LSCS• Increased risk of placenta praevia and APH, PPH
  30. 30. Complications• Post-partum haemorrhage – Bimanual massage – Uterotonics – Prophylactic Misoprostol PR – Syntocinon infusion – B Lynch Suture – Uterine Artery Ligation – Uterine Artery Embolisation – Hysterectomy
  31. 31. Profile• Total Pregnancy Care is an online guide for pregnancy, childbirth and motherhood related information. Women wanting to conceive, pregnant women, expecting parents, and new mothers can use this pregnancy portal for a healthy pregnancy, fulfilling childbirth and joyful motherhood. With pregnancy at its core, this portal covers various important aspects and especially addresses those matters that the Indian Woman always wanted to know but did not know whom to ask.• This website is compiled by Dr. Shantala, an Indian Obstetrician and Gynaecologist. She has over 20 years of extensive medical and diagnostics experience in areas commonly related to the Maternity and Pregnancy fields. She has studied and practiced in India as well as in the United Kingdom and thus brings about the fusion of best practices of the Oriental East and the Progressive West.• A mother of three children, she has complete understanding of the emotional, mental and physical needs of the New Age Pregnant Woman. Her patients appreciate her empathic approach and wholeheartedly express their gratitude for her generosity and care. Dr.Shantala is presently a full time Obstetrics and Gynaecology Consultant at the Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, a premier health care initiative of the Reliance ADA Group. Dr.Shantala has a clear vision to promote a holistic pregnancy approach and her mission is to provide comprehensive maternity care. This website,, is her first step towards this future.
  32. 32. Services Offered• Pre-pregnancy counseling• Genetic counseling• Antenatal care, Labour Delivery• Specialist Ultrasound scans – Viability scan – The First trimester scan / Nuchal translucency scans – Detailed anatomy / anomaly scans – Fetal Echocardiograph – 3D / 4D scans• Assessment of the High risk Fetus and Mother• Amniocentesis• Chorionic Villous sampling• Cordocentesis• Intra-uterine transfusions• Embryo Reduction / Selective fetocide• Second opinion scans
  33. 33. Topics covered• Pre-Conception – Working on getting pregnant or just starting to think about a family, this is the place for you• Pregnancy – From trying to conceive to the first trimester to labor, learn what to expect during your pregnancy and more• Labor Delivery – From that first contraction to the final push, heres what to expect during labor and delivery• Post-Pregnancy – Learn more about your diet and workouts, shopping, feeding and your childs health
  34. 34. Interactive Corner• Month by Month happenings• Articles• FAQs• Gestation Calendar
  35. 35. Society Memberships• British Maternal & Fetal Medicine Society• Fetal Medicine Centre• Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute• Royal College of Obstetricians and Gynaecologists• International Society of Ultrasound in Obstetrics and Gynecology
  36. 36. Contact Us• Email:• Mobile: +91 9324304212• KDAH Board line: +91 22 30999999
  37. 37. THANK