Multiple pregnancy file

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  • Note: isolated case reports publication bias: unsuccessful attempts are not published. Measures employed: antibiotics cerclage tocolysis + cerclage cerclage, antibiotics + tocolysis Clearly should be limited to dichorionic pregnancies only.
  • Multiple pregnancy file

    1. 1. Multiple pregnancy for MRCOG
    2. 2. Multiple birth UK 1995 <ul><li>No. (Rate/1000 mats) Ratio </li></ul><ul><li>Twins 9889 (13.6) 1 in 73 </li></ul><ul><li>Triplets 318 (0.4) 1 in 2282 </li></ul><ul><li>Quads 10 (0.0001) 1 in 72563 </li></ul><ul><li>Total 10217 (14) 1 in 71 </li></ul>
    3. 3. Importance of chorionicity? <ul><li>Chorionicity affects pregnancy risk: </li></ul><ul><ul><li>Fetal loss rates </li></ul></ul><ul><ul><li>Cerebral palsy rates </li></ul></ul><ul><li>Pregnancy risk assessment </li></ul><ul><ul><li>Twin-twin transfusion syndrome </li></ul></ul><ul><ul><li>Prenatal diagnosis </li></ul></ul><ul><ul><ul><li>Chromosome abnormality </li></ul></ul></ul><ul><ul><ul><li>Strucural abnormality </li></ul></ul></ul><ul><li>Further schedule of surveillance based on chorionicity (?=delivery mode) </li></ul>
    4. 4. Prevalence death & cerebral palsy Western Australia 1980-1989
    5. 5. Fetal and Perinatal Mortality Fetal Loss (<24 weeks) Perinatal Loss (>24 weeks) Sebire N et al. BrJOG 1997 12.1% 1.8% 2.8% 1.6% Monochorionic Dichorionic
    6. 6. Presumed zygosity & cerebral palsy ( Western Austailia 1956-1985) P=0.0026 Concordant Discordant Monozygotic 6 9 Dizygotic 0 21
    7. 7. Chorionicity versus zygocity 0-4 days 4-7 days 7-14 days Fused or unfused
    8. 9. Early ultrasound appearances <ul><li>Scans before 11 weeks common in AC pregnancies </li></ul><ul><li>Chorionicity: </li></ul><ul><ul><li>2 clear sacs dichorionic </li></ul></ul><ul><ul><li>?1sac monochorionic </li></ul></ul><ul><li>Amnionicity: </li></ul><ul><ul><li>Uncertain </li></ul></ul><ul><ul><li>Yolk sac number </li></ul></ul>Dichorionic twins (7 weeks)
    9. 10. Ultrasound diagnosis of chorionicity <ul><li> “ T” sign </li></ul><ul><li>MONOCHORIONIC </li></ul><ul><li> “ Lambda” sign </li></ul><ul><li>DICHORIONIC </li></ul>
    10. 11. Twin-twin transfusion syndrome <ul><li>25% MC twins will have evidence of TTS at 15-17 weeks </li></ul><ul><li>50%  severe TTS </li></ul><ul><li>Severe TTS 80-90% mortality </li></ul><ul><li>Death will occur in both babies </li></ul><ul><ul><li>Recipient </li></ul></ul><ul><ul><li>Donor </li></ul></ul>
    11. 13. Indicators of risk of TTTS <ul><li>11-13 week scan </li></ul><ul><ul><li>Discrepancy in CRL </li></ul></ul><ul><ul><li>Discrepancy in NT </li></ul></ul><ul><ul><ul><li>Donor small NT </li></ul></ul></ul><ul><ul><ul><li>Receipient raised NT </li></ul></ul></ul><ul><li>16 week scan </li></ul><ul><ul><li>Infolding of the membranes </li></ul></ul><ul><ul><li>Size discrepancy </li></ul></ul>
    12. 14. Diagnosis of chronic TTTS Monochorionic Stuck twin Polyhydramnios Growth discrepancy Doppler Hydrops PROGRESSIVE*
    13. 15. Serial Amniodrainage <ul><li>Multicentre Registry (Mari et al. 1998) </li></ul><ul><ul><li>579 cases </li></ul></ul><ul><ul><li>Survival 68% </li></ul></ul><ul><ul><li>Abnormal neonatal head sonograms - 25% </li></ul></ul><ul><li>Normalise amniotic fluid volume </li></ul><ul><li>Improves uterine blood flow </li></ul><ul><li>Prevents premature labour </li></ul>
    14. 16. Fetoscopic Laser Ablation Ville et al. 1998 BrJOG DiLia 1998 (TTTS website) Non-selective Laser Ablation 202 cases 59% Survival 4% neurological handicap rate
    15. 18. FLA vs Amniodrainage n=116, 17-25 weeks’ gestation n=43: Amniodrainage, Bonn; n=73: Laser ablation, Hamburg Hecher K et al. 1999 AmJOG Overall survival (NS) 61% 51% FLA Abnormal brain scan (p <0.03) 6% 18% FLA FLA Amnion Drainage Gestation at delivery (p <0.02) 33.7 30.7
    16. 19. TTS in the 3rd trimester? <ul><li>REMEMBER </li></ul><ul><li>Chronic type TTS </li></ul><ul><li>Acute “late onset” TTS </li></ul><ul><ul><li>Antenatal </li></ul></ul><ul><ul><li>Intrapartum </li></ul></ul><ul><ul><li>Delivery of twin 1 </li></ul></ul>
    17. 20. Mono-amniotic twins <ul><li>High mortality rates (upto 50%) </li></ul><ul><li>TTTS/Discordant growth unusual </li></ul><ul><li>Monitor amniotic fluid volume </li></ul><ul><li>Colour-flow doppler for cord entanglement </li></ul><ul><li>Monitoring of uncertain value </li></ul><ul><li>Delivery at 32-34 weeks? </li></ul>
    18. 21. Prenatal diagnosis in twins <ul><li>Screening </li></ul><ul><ul><li>Nuchal translucency </li></ul></ul><ul><ul><li>Serum screening </li></ul></ul><ul><li>Invasive diagnosis </li></ul><ul><ul><li>Chorionic villous sampling </li></ul></ul><ul><ul><li>Amniocentesis </li></ul></ul>
    19. 22. Screening for aneuploidy in twins <ul><li>Calculation of risks </li></ul><ul><ul><li>For each fetus </li></ul></ul><ul><ul><li>For the pregnancy </li></ul></ul><ul><li>NT screening </li></ul><ul><li>Biochemical screening </li></ul><ul><li>Risks of intervention </li></ul><ul><ul><li>Invasive procedure </li></ul></ul><ul><ul><li>Selective fetocide </li></ul></ul>
    20. 23. Single puncture amniocentesis Sebire et al 1996 Miscarriage risk 1-2% Selective fetocide 8%+ Sample one sac in MC Careful documentation
    21. 24. CVS in twins <ul><li>Single or double entry </li></ul><ul><ul><li>Experienced operator </li></ul></ul><ul><ul><li>Careful documentation </li></ul></ul><ul><li>Sample 1 placenta in MC twins </li></ul><ul><li>Miscarriage risk </li></ul><ul><ul><li>1-2% </li></ul></ul><ul><li>Risk of selective fetocide </li></ul><ul><ul><li>11-13 weeks 5% </li></ul></ul><ul><li>CVS for “high risk” </li></ul>
    22. 25. Twins and fetal abnormality <ul><li>Dichorionic </li></ul><ul><ul><li>Same risk doubled </li></ul></ul><ul><li>Monochorionic </li></ul><ul><ul><li>“ Teratogenic” stimulus </li></ul></ul><ul><ul><li>Increased risk midline abnormalities </li></ul></ul><ul><ul><li>Not always cordant </li></ul></ul><ul><li>Specific twin abnormalities </li></ul>
    23. 27. Conjoined twins
    24. 28. Acardiac twinning
    25. 29. Scanning schedule- normal <ul><li>Monochorionic </li></ul><ul><li>12 weeks </li></ul><ul><li>16 weeks </li></ul><ul><li>20 weeks </li></ul><ul><li>24 weeks </li></ul><ul><li>27 weeks </li></ul><ul><li>30 weeks </li></ul><ul><li>33 weeks </li></ul><ul><li>Delivery 36 weeks </li></ul><ul><li>Dichorionic </li></ul><ul><li>12 weeks </li></ul><ul><li>20 weeks </li></ul><ul><li>28 weeks </li></ul><ul><li>32 weeks </li></ul><ul><li>36 weeks </li></ul><ul><li>Delivery 38 weeks </li></ul>Increased surveillance if evidence of TTTS or growth abnormality
    26. 30. Low birthweight a Singleton b Twins c Triplets d quads 52% twins (n=5416) <2500g compared 6% singletons ( Regan 2001)
    27. 31. Delivery of pre-term twins 37
    28. 32. Elective delivery of twins Sairam et al 2002
    29. 33. Delivery mode? <ul><li>Chorionicity </li></ul><ul><ul><li>Monochorionic </li></ul></ul><ul><ul><li>Mononamniotic </li></ul></ul><ul><li>Presentation and lie </li></ul><ul><ul><li>Breech twin 1 </li></ul></ul><ul><li>Fetal/maternal complications </li></ul><ul><ul><li>Preterm labour </li></ul></ul><ul><ul><li>Growth restriction </li></ul></ul><ul><ul><li>Previous caesarean section </li></ul></ul><ul><ul><li>Elective delivery </li></ul></ul>Consider
    30. 34. Delivery monochorionic diamniotic? <ul><li>No evidence </li></ul><ul><li>Elective LSCS </li></ul><ul><ul><li>Allows early delivery (36-37 weeks) </li></ul></ul><ul><ul><li>Avoids late onset TTTS </li></ul></ul><ul><ul><li>Avoids “circulatory charge” T2 after T1 delivered </li></ul></ul><ul><ul><li>Small number of absolute total of twins </li></ul></ul><ul><li>Vaginal delivery </li></ul><ul><ul><li>No antenatal evidence TTTS </li></ul></ul><ul><ul><li>Favorable cervix (multips) </li></ul></ul><ul><ul><li>Limit delivery interval </li></ul></ul><ul><ul><li>Monitor T2 carefully </li></ul></ul>
    31. 35. Presentations of twins FIRST TWIN SECOND TWIN Percentage of presentation combinations in labour Cephalic Breech Other Cephalic 38.6 13.1 0.6 Breech 25.5 9.2 0.6 Other 8.0 3.9 0.5
    32. 36. Breech twin 1 <ul><li>Prevalent practice =LSCS </li></ul><ul><li>ACOG recommends LSCS </li></ul><ul><li>Reasons sited </li></ul><ul><ul><li>Interlocking twins (1 in 90) </li></ul></ul><ul><ul><li>Interference with decent of breech </li></ul></ul><ul><ul><li>Term breech study (irrelevant) </li></ul></ul><ul><ul><li>Lack of experience </li></ul></ul><ul><li>Vaginal delivery maybe safe in selected cases </li></ul><ul><ul><li>EFW1500-3500 </li></ul></ul><ul><ul><li>US no interlocked heads </li></ul></ul><ul><ul><li>No IUGR </li></ul></ul><ul><ul><li>Non-footling breech </li></ul></ul>
    33. 37. Weight difference in twins Audit data SHH 1998 N=45 Twin 1 is not usually bigger than twin 2
    34. 38. Evidence based medicine & twins? <ul><li>Observational and non-randomised comparative studies </li></ul><ul><li>Address controversy : </li></ul><ul><ul><li>mode of delivery of twin 2 </li></ul></ul><ul><ul><li>time interval between delivery of T1 andT2 </li></ul></ul><ul><ul><li>ECV vs breech extraction </li></ul></ul><ul><ul><li>Trial of scar in twin pregnancy </li></ul></ul><ul><li>Problem: </li></ul><ul><ul><li>retrospective studies </li></ul></ul><ul><ul><li>inappropriate measures of outcome </li></ul></ul><ul><ul><li>recommendations are often empirical </li></ul></ul>
    35. 39. Delivery of growth restricted twins <ul><li>30-50% IUGR </li></ul><ul><ul><li>Progressive </li></ul></ul><ul><ul><li>Beginning 32-34wks </li></ul></ul><ul><ul><li>Worse after 36wks </li></ul></ul><ul><li>Offer IOL at 38wks </li></ul><ul><ul><li>Earlier if severe IUGR </li></ul></ul><ul><li>Doppler assessment </li></ul><ul><li>Delivery mode </li></ul><ul><ul><li>EFW </li></ul></ul><ul><ul><li>Severe discordance (>20%) </li></ul></ul>
    36. 40. Vertex/vertex <ul><li>Literature supports vaginal delivery </li></ul><ul><li>5% cases T2 will become non-vertex after delivery T1 </li></ul><ul><li>Report 81% success </li></ul><ul><li>Differences of opinion </li></ul><ul><ul><li>?  Perinatal morbidity </li></ul></ul><ul><li>Concerns </li></ul><ul><ul><li>Head entrapment </li></ul></ul><ul><li>Overall evidence suggests vaginal delivery is as safe as LSCS </li></ul>Vertex/breech
    37. 41. VTX/Non-VTX >2000g <24 weeks ECV T2 Successful >24wks & <2000g Vaginal T1 *Vaginal breech T2 Vaginal T1&T2 *Vaginal breechT2 Probable vaginal T2 Vaginal T1 ECV T2 Unsuccessful Unsuccessful Successful LSCS LSCS Probable vaginal T2 *Suitable for vaginal breech
    38. 42. Recent evidence? <ul><li>Retrospective 92-97 </li></ul><ul><li>Scotland </li></ul><ul><li>All twin births >24 weeks </li></ul><ul><li>Excluding </li></ul><ul><ul><li>pre-labour IUD </li></ul></ul><ul><ul><li>Congenital abnormality </li></ul></ul><ul><li>PRETERM (vaginal) </li></ul><ul><li>1438 twin pairs <36/40 </li></ul><ul><ul><li>23 deaths T1 </li></ul></ul><ul><ul><li>23 deaths T2 </li></ul></ul><ul><ul><ul><li>Pulmonary & anoxia </li></ul></ul></ul><ul><li>TERM (vaginal) </li></ul><ul><li>2436 twin pairs >36/40 </li></ul><ul><ul><li>No deaths T1 </li></ul></ul><ul><ul><li>9 deaths T2 </li></ul></ul><ul><ul><ul><li>7 deaths due to anoxia </li></ul></ul></ul><ul><ul><ul><li>5 “mechanical” problems </li></ul></ul></ul><ul><li>TERM (elective LSCS) </li></ul><ul><li>454 twin pairs </li></ul><ul><ul><li>No deaths T1 or T2 </li></ul></ul>Conclusion Planned caesarean birth may prevent perinatal deaths BUT Chorionicity unknown (7 of 9 T2 deaths were concordant for sex ie. may be monochorionic) Smith et al 2002, BMJ
    39. 43. Twin vaginal birth after LSCS <ul><li>Controversial limited data about safety </li></ul><ul><li>Concern ?  risk of uterine rupture </li></ul><ul><ul><li>Over-distention </li></ul></ul><ul><ul><li>Intrauterine manipulations </li></ul></ul><ul><li>No evidence of risk </li></ul><ul><ul><li>3 studies no increased risk </li></ul></ul><ul><ul><li>Other caused of over-distention no  risk </li></ul></ul><ul><li>Trial of labour at maternal request </li></ul>
    40. 44. Analgesia <ul><li>Appropriate analgesia essential </li></ul><ul><li>Operative delivery may be required </li></ul><ul><li>Increased risk of GA </li></ul><ul><ul><li>Prophylactic antacids </li></ul></ul><ul><li>Anaesthetist available on LW </li></ul><ul><li>Epidural optimizes vaginal delivery (recommended) </li></ul><ul><li>Epidural not mandatory </li></ul><ul><ul><li>Nitrous oxide </li></ul></ul><ul><ul><li>Opiates </li></ul></ul>
    41. 45. Issues in monitoring twins <ul><li>“ High risk”  EFM </li></ul><ul><li>Continuous & simultaneous </li></ul><ul><li>External transducer T2 </li></ul><ul><li>FSE T1 after ROM </li></ul><ul><li>Ensure 2 heartbeats seen </li></ul><ul><li>Careful monitoring after delivery of T1 (ultrasound aids transducer positioning) </li></ul>
    42. 46. ‘ The Delivery’ - Twin 1 <ul><li>Encourage active pushing </li></ul><ul><li>Semi-recumbent position once T1 crowning </li></ul><ul><li>Episiotomy as necessary </li></ul><ul><li>Clamp & mark cord T1 </li></ul><ul><li>Ventouse or forceps </li></ul>
    43. 47. ‘ The Delivery’ - Twin 2 ECV versus Breech delivery versus Internal podalic version Palpate lie immediately after delivery T1
    44. 48. ‘ The Delivery’ - Twin 2 <ul><li>Start syntocinon infusion once T2 cephalic </li></ul><ul><li>Escalate dose at 5 minute intervals </li></ul><ul><li>Await contractions & PP to stabilized above pelvis </li></ul><ul><li>ARM </li></ul><ul><li>FSE if poor external CTG </li></ul><ul><li>Ventouse </li></ul><ul><li>Breech extraction </li></ul><ul><li>?Delivery interval </li></ul>
    45. 49. Combined vaginal-abdominal delivery Misfortune or mismanagement? <ul><li>Increasing incidence 1-15% LSCS T2 </li></ul><ul><li>Higher rate elLSCS in twins   LSCS for T2 </li></ul><ul><ul><li>Operator experience </li></ul></ul><ul><ul><li>Some management issues </li></ul></ul><ul><li>Justified </li></ul><ul><ul><li>Failed version in transverse lie </li></ul></ul><ul><ul><li>SROM-shoulder presentation </li></ul></ul><ul><ul><li>Cord prolapse (especially prems) </li></ul></ul><ul><ul><li>Large T2 </li></ul></ul><ul><ul><li>?Fetal distress with high presenting part </li></ul></ul>
    46. 50. Delayed delivery interval <ul><li>Caution: </li></ul><ul><ul><ul><li>isolated case reports </li></ul></ul></ul><ul><ul><ul><li>publication bias </li></ul></ul></ul><ul><li>Consideration: </li></ul><ul><ul><ul><li>gestation </li></ul></ul></ul><ul><ul><ul><li>chorionicity </li></ul></ul></ul><ul><ul><ul><li>maternal informed consent </li></ul></ul></ul>
    47. 51. Delayed delivery interval <ul><li>48 twin pregnancies </li></ul><ul><li>40/96 surviving infants (39=T2) </li></ul><ul><li>Interval 3 - 143 days </li></ul><ul><li>mean 44.8 days </li></ul><ul><li>No consensus on treatment strategy </li></ul>Obs & Gyn Survey 1999: 54,343-8
    48. 52. ‘ The delivery’ - third stage <ul><li>Active management </li></ul><ul><ul><li>Syntocinon 5 units (IV or IM) after delivery of second twin </li></ul></ul><ul><ul><li>Syntocinon infusion after delivery of placenta </li></ul></ul>
    49. 53. UK birth rate of Triplets
    50. 54. Higher multiples-?chorionicity <ul><li>Can be: </li></ul><ul><ul><li>Trichorionic </li></ul></ul><ul><ul><li>Dichorionic </li></ul></ul><ul><ul><ul><li>Triamniotic </li></ul></ul></ul><ul><ul><ul><li>Diamniotic </li></ul></ul></ul><ul><ul><li>Monochorionic </li></ul></ul><ul><ul><ul><li>Tri-amniotic </li></ul></ul></ul><ul><ul><ul><li>Monoamniotic (rare) </li></ul></ul></ul><ul><li>Scan early </li></ul><ul><li>Scan often </li></ul>

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