Multiple pregnancy

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  • Pembelahan sebelum stadium morula dan diferensiasi trofoblas (pada hari ke III) menghasilkan 1 atau 2 plasenta, 2 chorion dan 2 amnion (sangat menyerupai kembar dizygotic dan meliputi hampir 1/3 kasus kembar monozygotic)Pembelahan setelah diferensiasi trofoblas tapi sebelum pembentukan amnion (hari ke IV – VIII) menghasilkan 1 plasenta dan 2 amnion (meliputi 2/3 kasus kembar monozygotic)Pembelahan setelah diferensiasi amnion ( hari ke VIII – XIII) menghasilkan 1 plasenta, 1 chorion dan 1 amnionPembelahan setelah hari ke 15 menyebabkan kembar tak sempurna, pembelahan pada hari ke XIII – XV menyebabkan kembar siam.
  • Multiple pregnancy

    1. 1. MULTIPLE PREGNANCY Dr Avinash kumar Moderator : Dr Manish Dr Shobhna
    2. 2. Introduction• More than one fetus develops simultaneously in the womb• Spontaneous twinning highest among blacks and East Indians• Account for 2.5% of births• Rate of monozygotic twin 3.5 /1000 live birth(constant)• Rate of dizygotic twin is variable• Influenced by several factors like ethinicity , maternal age, genetic tendency• Actual rate of twining is much higher because early fetal loss with vanishing twin is more common than recognised.• Hellin-Zelleny law: if twins frequency is 1/n ,then triplet at 1/n2 ,quadruplets at 1/n3 and so on.
    3. 3. Embryology• Zygote: sperm + oocyte• Embryo: prenatal period between 14 days to 9 week• Implantation occurs in form of blastocyst on 6 to 8 day• Fetus: prenatal period between 9 week to birth Primitive uteroplacental circulation: begins at the end of 2nd week• Placenta: chorion frondosum(fetal)+decidua basalis(maternal)• Placental borders :chorionic plate (fetal side) and desidual plate(maternal side)• Amnion: innermost avascular layer facing fetus
    4. 4. Cont……• Chorion begins to form at 3rd day after fertilization• Amnion begins to form between day 6 to 8
    5. 5. Cont.• Zygosity: determined by number ova fertilized• Multiple pregnancy can be multizygotic , monozygotic or combination of both• superfecundation: fertilization of an ovum after one ovum is already fertilized• Superfetation: fertilization and development of ovum when one fetus is in utero
    6. 6. classification1. Monozygotic or identical twin: develop from single fertilized egg after division of inner cell mass of blastocyst2. Dizygotic or fraternal twin: from two separately fertilized eggs.• Dizygotic represents 2/3rd cases and monozygotic are 1/3rd
    7. 7. Genesis of Monozygotic Twinning
    8. 8. Etiology• Increasing maternal age• Maternal parity• Nutritional factor• Family history• Infertility therapy• Assisted reproductive therapy• High pituitary gonadotropins
    9. 9. Clinical diagnosis• Uterine size more than expected age• Weight gain more than expected• Two fetal heart sound• Hyperemesis gravidarum
    10. 10. Diagnosis…• By USG as early as 5weeks by multiple gestational sac• At 6th week by cardiac activity• From 10th to 14th weeks by placentation• Lambda sign: internal dividing membrane or ridge at placental surface in dichorionic• Increased maternal AFP,hcg
    11. 11. Maternal complication• Preterm labour(57% in twin,76-90% in higher order multiple)• PROM• Operative delivery(66% in twins and 91%)• Postpartum endometritis• Anemia• Hypertensive diseases• HELLP syndrome• Acute fatty liver
    12. 12. Cont….• PIH (2.5 times)• Complication associated with tocolytic treatment• Gestation diabetes mellitus• Spontaneous abortion(vanishing twin)8%to36%• Incompetent cervix(up to 14%)
    13. 13. Fetal complication• Prematurity• Low birth weight• IUGR• Fetal growth discordance• Intra uterine fetal demise• Congenital malformations
    14. 14. Cont…..• Chromosomal anomalies• TTTS• Velamentous cord insertion and vasa previa• Perinatal mortality• Thromboembolic arterial occlusion• Necrotic limb• Small bowel atresia• Horse shoe kidney
    15. 15. Fetal growth discordance• Intrapair difference in birth weight >20% of larger twin`s weightClassification:Mild <15%Moderate15-30%Severe>30%Risk factors :TTTS,placental dysfunction,fetal infection,fetal structural and chromosomal abnomalities,antepartum bleeding,velamentous cord insertion
    16. 16. Velamentous cord insertion
    17. 17. Case reports…… Intrauterine Fetal Death of a Monochorionic Twin with Peripheral Pulmonary Infarcts: Potential Thromboembolic Events Following Death of Co-Twin Amy A. Lo, Ona M. Faye-Petersen, and Linda M. Ernst Pediatric and Developmental Pathology March/April 2012, Vol. 15, No. 2, pp. 142-145• Twin reversed arterial perfusion (TRAP) sequence in association with VACTERL association: a case report• Sharan Athwal*, Katherine Millard and Kokila Lakhoo Journal of Medical Case Reports 2010, 4:411
    18. 18. Management (antenatal)• Early diagnosis• Nutritional intervention• Prophylactic tocolytic• Steroid stimulation of fetal lung maturity• Therapeutic amniocentesis• Multifetal reduction• Bed rest beginning before 28 week
    19. 19. Management in labor and delivery• Best method of delivery depend on1. No of fetus2. Presentation of first fetus3. Gestational ageTwin presentationVertex-vertex:42.5%Vertex-nonvertex:38.4%Nonvertex:19.1%
    20. 20. Mode of delivery• Vertex-vertex=vaginal and interval should not be >20 min• Vertex –breech=vaginal by senior obstetrician• Breech-vertex=prefer CS to avoid interlocking(a rare complication 1/1000)• Breech-breech=CS
    21. 21. Twin to twin transfusion
    22. 22. TTTS…• Only in monochorionic gestation• Complicates 10-20% of such pregnancy• Pathophysiology :1. placental vascular anastomoses2. Unequal placental sharing3. Abnormal umbilical cord insertion• AV anastomoses with unidirectional flow leads to shunting of blood from one twin to other• AA connections are thought to be protective
    23. 23. DIAGNOSIS• Usually made between 17 and 26 weeks gestation• May occur as early as 13 weeks• Criteria:1. Monochorionicity2. Cord size discrepancy3. Significant growth discordance(>20%wt difference and Hb difference>5g/dl)4. Polyhydroamnios in recipient sac and oligohydramnios in donor sac5. Cardiac dysfunction in polyhydroamniotic twin ,abnormal umbilical artery and/or ductus venosus doppler velocimetry• Staging system for severity :quintero,CVPS,CHOP ,cincinnati staging system
    24. 24. Fetus papyraceous
    25. 25. Lithopedion(stone child)
    26. 26. Treatment modes of twin-to-twintransfusion syndromeConservative management and monitoring:• USG• Biophysical profile• Doppler blood flow velocimetry• Fetal echocardiography• Cardiotocography• Digoxin• Serial aminoreduction• Fetoscopic laser occlusion of placental vessels
    27. 27. Treatment cont….• Selective feticide:-Cord embolization-Nd:YAG laser technique-Fetoscopic cord ligation-Bipolar coagulationref: fanaroff and Martin’s neonatal-perinatal medicine 8th edition
    28. 28. TRAP sequence( ACARDIA)• Rare• 1% monoamniotic twin pregnancy• Twin reverse arterial perfusion is a type of vascular disruption syndrome occurs early in gestation• Large anastomoses between embryo may cause unequal arterial perfusion• Embryo which receives only low pressure blood flow through umbilical artery and preferentially perfuses lower extremity• Co-twin is well formed
    29. 29. Conjoined twin
    30. 30. Conjoined (siamese twin)• Result of late incomplete embryonic division• Only in monochorionic –monoamniotic twins• Incidence -1 in 50,000 to 100,000 births• Mostly female sex• Most common –thoracopagus• Serial USG required for fetal anatomy and management• Ex utero intrapartum treatment(EXIT):procedure for delivery of co-twin when one twin is not likely to survive

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