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Twin gestation
- 1. TWIN GESTATION (multifetal gestation) DR ANITA RAMESH Professor ,OBGY Viswabharathi medical college
- 2. Incidence of multifetal gestation • Global incidence of Multiple pregnancy is 4/1000 • Global incidence of twins is 32/1000 • Triplets & higher order increased till the year 1998 but now declined to 1.43/1000 • Why decline? Due to stringrent guidelines about the no of embryos to be transferred
- 4. Types of twins • MONOZYGOTIC TWINS: Maternal/Identical/Uniovular twins • DIZYGOTIC TWINS : Fraternal/non identical/binovular twins
- 6. What is the meaning of ? • MONOZYGOTIC TWINS? Arise from a single fertilized ovum A single fertilized ovum divides into 2 embryos • DIZYGOTIC TWINS? Arise from fertilization of 2 different ova by 2 different sperms 70% of twin pregnancies are dizygotic
- 7. Incidence of Mono/Dizygotic twins • DIZYGOTIC TWINS Incidence:Changes.2/3rd s of twin pregnancies 3/1000 Asians 7-10/1000 Caucasians 10-40/1000 Africans • MONOZYGOTIC TWINS • Incidence:Constant • 1/3rds of twin pregnancies 1:250 Best to have? Dichorionic Diamniotic It occurs in dizygotic twins OR monozygotic twins(35% of cases) which split within 72 hrs
- 8. Differences between monozygotic/dizygotic twins MONOZYGOTIC DIZYGOTIC PHENOTYPE Identical Non identical GENDER Identical Same or different GENOTYPE same Non identical INCIDENCE constant Changes according to race,parity & other factors Ethnic variation Absent Present Increase with ART Minimal Marked Adverse perinatal outcome High Low
- 9. Determination of chorionicity DICHORIONIC MONOCHORIONIC FIRST TRIMESTER GESTATIONAL SACS DIVIDIDING MEMBRANE 2 Thick(>2mms) One Thin(<2mms) SECOND TRIMESTER Placenta Fetal gender Two discordant One concordant TWIN PEAK SIGN present Absent T SIGN absent present DIVIDING MEMBRANE 3 OR 4 layers 2 LAYERS
- 14. • SIAMESE TWINS
- 16. Risk factors for dizygotic twin pregnancy • Increased FSH levels Multiparity(after 4th pregnancy) Advancing maternal age(30-35yrs) Race….black race Maternal obesity • Past H/O dizygotic twins • Maternal family h/o twins • Ovulation induction Clomiphene/gonadotropins • ART IVF
- 18. SUPERFETATION:very rare in humans So,patient gets pregnant when she is already pregnant… Seen in rodents/cattle They could have different paternity
- 19. What is it? Superfetation/Superfecundation Superfecundation Can one of u share the story behind it?
- 20. Types of placentation in monozygotic twins TYPES OF PLACENTATION TIMING OF CLEAVAGE FREQUENCY DIAMNIOTIC DICHORIONIC <72 hrs 25%-30% DIAMNIOTIC MONOCHORIONIC 4-7days 70%-75% MONOCHORIONIC MONOAMNIOTIC 8-12days 1%-2% CONJOINED TWINS >12 days rare
- 21. Types of Monozygotic twins
- 22. History suggestive of twin pregnancy • Advanced maternal age • High parity • H/o ovulation induction • ART • Family H/O twins • pastH/O twins • Symptoms First trimester…hyperemesis? Second trimester Overdistended uterus Pressure symptoms breathlessness,backache,GI sym,varicose veins,haemorrhoids
- 23. Physical examination in twin pregnancy • GENERAL EXAMINATION Anaemia Pedal oedema High BP Varicose veins • OBSTETRIC EXAMINATION Uterine size larger than dates Fundal height more than expected Multiple fetal parts 3 or 4 fetal poleA Polyhydramnios 2 fetal hearts Malpresentations
- 24. USG in twin pregnancy • Diagnosis of twins • Determination of chorionicity /amnionicity • Detection of fetal anomalies • Evaluation of fetal growth • Evaluation of fetal well being • Measurement of cervical length • Guiding procedures Selective termination Amniocentesis Amnioreduction Diagnosis of malpresentation Assistance in labour
- 25. Twin peak sign(lamda sign) T sign Dichorionic Diamniotic Monochorionic Diamniotic
- 26. Maternal adaptations to twin pregnancy • Uterus is larger • Increased HCG levels • Increased HPL • Increased cardiac volume by 20% more/cardiac output • More hemodilution leading to anaemia
- 27. Presentation in twins PRESENTATION • Both vertex • First vertex & 2nd breech • First breech & 2nd vertex • Both breech • First vertex & 2nd transverse • Both transverse..rare FREQUENCY 50% 30% 10% 10% Common lie: Longitudinal lie but mal presentations are common
- 28. Maternal complications in twin pregnancy(2to 3foldincreaseinpregnancy complications) • ANTENATAL • INTRAPARTUM • POSTPARTUM
- 29. ANTENATAL COMPLICATIONS FIRST TRIMESTER SECOND TRIMESTER THIRD TRIMESTER Hyperemesis PIH(3-4 fold increase) Preterm labour Spontaneous miscarriage GDM Polyhydramnios Anaemia APH (Abruption Placenta Previa) Pressure symptoms Respiratory difficulty GI symptoms Pedal oedema
- 30. INTRAPARTUM COMPLICATIONS FIRST STAGE SECOND STAGE THIRD STAGE Prolonged labour(not necessarily) Operative vaginal delivery (forceps,vaccum,a ssisted breech delivery,IPV) PPH(3-4 fold increase) malpresentations Ceasarean section thromboembolism Need for augmentation PROM Cord prolapse Abruption of placenta of second twin Lactational difficulties
- 31. Fetal complication in mono/dizygotic twins • Congenital anomalies • Fetal growth restriction • Growth discordancy • Prematurity(17% of all preterm births) • Cord prolapse • Abruption(one fetus pulling cord of another/Pre eclampsia)
- 32. OTHER COMPLICATIONS • SPECIAL SITUATIONS: • Vanishing twin • Single fetal demise • IUD of both the fetuses • Abruption(one fetus pulling cord of another)
- 33. Complications unique to monozygotic twins • Twin to twin transfusion syndrome(TTTS) • Twin reversed arterial perfusion sequence(TRAP) • TWIN ANAEMIA-POLYCYTHEMIA SEQUENCE(TAPS) • Monoamniotic twins…. Preterm labour LBW Congenital anomalies Cord entanglement Interlocking of twins • Conjoined twins(monoamniotic)
- 35. Interlocking of twins in monoaniotic twins
- 37. Monoamniotic twins • 1% of all monozygotic twins • Associated with severe complications • High perinatal mortality 20% • Close monitoring by USG/CTG • Delivery by caesaren section • Deliver at 32-34 weeks • Betamethasone prior to delivery
- 38. TTTS
- 39. WHAT CAN HAPPEN IN TTTS • Hb difference by 5gm/dl • Weight difference by 20% • Difference in AC by 15%
- 41. Sonographic criteria for TTTS • MONOCHORIONICITY • SAME GENDER • SIGNIFICANT GROWTH DISCORDANCE • DISCREPANCY IN …..AFI…POLY/OLIGO Size of umbilical cord • CARDIAC DYSFUNCTION IN RECEPIENT
- 42. Quintero staging system for TTTS
- 43. Therapeutic options for TTTS • Expectant management • Serial amnioreduction • Laser ablation of vasular anastomosis • Septostomy • Selective feticide
- 44. Laser coagulation of AV anastomosis in TTTS
- 45. TRAP(Acardiac twin)(TWINREVERSED ARTERIALPERFUSION) • RARE CONDITION • 1:3500 pregnancies • 1% of Monochorionic twins • Large placental arterial anastomosis Receipient(Acardiac twin) Acardiac twin lacks heart & other structures Receives deoxygenated blood from the PUMP TWIN Blood flow mainly to lower half of body Donor twin(PUMP TWIN) Cardiac failure High mortality • Treatment Expectant Laser ablation of communicating vessel
- 46. TRAP
- 47. USG picture in TRAP
- 48. TRAP
- 50. CONJOINT TWINS • Extremely rare • High mortality • Can be connected at any level • May share vital organs • Diagnosis is by USG • Management Termination If late in pregnancy…CAESAREAN section SURGICAL SEPARATION if possible
- 51. Types of conjoint twins(Siamese twins) • Cephalopagus • Thoracopagus • Pyopagus • Ischiopagus • Omphalopagus
- 53. THORACOPHAGUS
- 54. Goals of management in twin pregnancy • Early diagnosis • Determination of chorionicity • Detection of congenital anomalies • Monitoring of fetal growth • Identification of discordancy • Prevention of preterm labour • Early diagnosis of maternal complications(PIH,anaemia) • Decision regarding timing of delivery/mode of delivery • Advise regarding breastfeeding/contraception
- 55. Management of twin pregnancy in 1st trimester • USG at 6-8 weeks(no of fetuses,no of gestational sacs,no of yolk sacs,gestational age) • USG at 11-13 weeks(chorionicity,NT,Congenital anomalies) • Counselling Diet Weight gain Pregnancy outcome • Supplementation…Folic acid
- 56. Management of twins in 2nd trimester • 14-20 weeks caloric requirement…2500 & 300KCAL more Iron,Calcium Antenatal visits 2-3 weekly USG at 18 weeks(fetal anomalies,cervical length) • 20-28 weeks Monitor BP Oral OGTT at 24 weeks Repeat Hb USG at 24 weeks & 28 weeks 1)FETAL GROWTH 2)Discordancy 3)TTTS 4)Cervical length
- 57. Management of twin pregnancy in 3rd trimester • UNCOMPLICATED TWIN PREGNANCY Antenatal check?. 2 weekly ill 36weeks,later on weekly Monitor BP Restrict physical activity Watch for polyhydramnios/pressure symptoms Ascertain presentation of fetuses USG 2 weekly
- 58. Managementof pregnancyin 3rd trimester(complicatedtwins) • COMPLICATED TWIN PREGNANCY 1. Weekly ANC visits 2. Weekly USG Fetal growth Biophysical profile Doppler velocimetry Fetal presentation confirmed of 1st & 2nd twin
- 59. Timing of delivery?(DCDA/MCDA) • Spontaneous labour by 37-38 weeks • Still birth rate in twins at 39 weeks is equal to that at 42 weeks in singleton pregnancy So,uncomplicated DIAMNIOTIC DICHORIONIC twins are delivered by 38 weeks • MONOCHORIONIC DIAMNIOTIC TWINS ARE DELIVERED BY 36 WEEKS • Complicated twin pregnancies are delivered according to maternal/fetal condition
- 60. Mode of delivery FETAL PRESENTATION MODE OF DELIVERY Vertex-vertex(42%) vaginal Vertex-nonvertex(38%) vaginal Nonvertex-vertex(20%) Caesarean section ALL 1st NON VERTEX PRESENTATIONS /MONOAMNIOTIC TWINS ARE DELIVERED BY CEASAREAN SECTION PLACE OF DELIVERY: Hospital equipped with NICU
- 61. Indications for elective caesarean in twins • ABSOLUTE INDICATIONS 1)First twin in transverse lie/breech 2)Placenta previa 3)Cord prolpse 4)Contracted pelvis 5)Placenta previa 6)Monoamniotic twins 7)FGR with abnormal doppler studies 8)Conjoint twins • RELATIVE INDICATIONS 1)Severe pre eclampsia 2)Abnormal uterine action 3)Fetal distress
- 62. Preparations for twin delivery • Keep patient on oral fluids • Start IV infusion with large bore IV cannula • Delivery team should have obstetrician,assistant,paediatrician & anaesthetist • Ensure availability of cross matched blood • EFM • 2 delivery sets • Oxtocin & Misoprostol • USG in the labour room • Epidural analgesia is preferred
- 63. Delivery of first baby • DO not give methergin after delivery of first baby • Episiotomy to be given • Avoid delayed clamping of the cord • Keep the cord long 8-10 cms for drug administration or transfusion
- 64. What should be the time intervalbetween the deliveryof twins • Not more than 30 mins • Start oxtocin 5U if the contractions are not that strong
- 65. Management after delivery of 1st twin Delivery of 1st twin Second twin vertex Deliver as vertex Second twin breech Assisted breech Second twin transverse(external version) Successfu(deliver as vertex/breech)l Unsuccessful(do IPV/Breech extraction) Ascertain lie/presentation Monitor fetal heart of 2nd twin
- 66. Indicationsfor urgent deliveryof 2nd twin? • Severe intrapartum vaginal bleeding • Cord prolapse • Fetal distress METHOD OF URGENT DELIVERY OF 2ND TWIN? 1. If head is low….Apply forceps.If head high up…do internal version 2. If breech…breech extraction has to be done 3. If transverse lie….do internal version & breech extraction
- 67. Management of 3rd stage of labour • Add 10 u Oxytocin to infusion • Deliver placenta • Examine placenta • Examine intertwin membrane(2 layers/4 layers) • Keep the patient under obsrvation for 2 hours
- 68. SPECIAL SITUATIONS • VANISHING TWINS • DEATH OF ONE TWIN • INTERLOCKING OF TWINS • MULIFETAL PREGNANCY REDUCTION • SELECTIVE TERMINATION
- 71. SINGLE FETAL DEMISE • Common in MC twins • Occurs in 5% of twin pregnancies • Poor outcome of 2nd twin in 25% of case • ETIOLOGY 1. anomalies 2. infections 3. placental insufficiency 4. cord abnormalities 5. TTTS • PROBLEMS IN SURVIVING FETUS 1. Monochorionic twins(multicystic encephalomalacia/multiorgan damage..RENAL CORTICAL NECROSIS) • COMPLICATIONS: Death of surviving twin,Preterm labour/coagulopathy
- 72. Management of surviving twin MONOCHORIONIC TWINS • CLOSE MONITORING NST USG(BPP/Multicystic lesions in brain • STEROIDS IF<34 WEEKS • DELIVERY AFTER 34 WEEKS DICHORIONIC TWINS MONITOR BY BPP DELIVER AT TERM
- 73. Iterlocking of twins • Extremely rare • Aftercoming head of 1st twin interlocks with leading head of 2nd twin • Delivery by ceasrean section
- 74. Multifetal pregnancy reduction • Done in higher order pregnancies • Transabdominal approach • At 10-13 weeks • Should not be don in MC twins • USG to detect fetal anomalies mandatory • Select the fetus most accessible • 2-3 ml of potassium chloride into fetal thorax • Fetal death due to cardiac asystole
- 75. Selective termination in multifetal pregnancies • Congenital chromosomal abnormalities • Confirmed by USG/CVS/Amniocentesis • Performed in 2nd trimester • Transabdominal approach • Potassium chloride into selected fetus
- 76. Thank u for attending this virtual class