Ultrasound plays an indispensable role in managing multifetal gestations. It is crucial for determining chorionicity and zygosity early in the first trimester, as this predicts complications. Ultrasound can also assess nuchal translucency, screen for anomalies, monitor growth and detect complications like twin-twin transfusion syndrome that are more common in monochorionic twins. Serial ultrasound examinations are important for detailed evaluation of the placenta, umbilical cords, fetal growth and well-being in order to guide management and improve outcomes in these high risk pregnancies.
Nuchal translucency
It is a sonographic pre natal screening scan to detect cardiovascular abnormality in a fetus.
NT can also detect altered extra cellular matrix composition and limited lymphatic drainage
Nuchal translucency
It is a sonographic pre natal screening scan to detect cardiovascular abnormality in a fetus.
NT can also detect altered extra cellular matrix composition and limited lymphatic drainage
In this presentation we will discuss role of Doppler US in Infertility, fertilization and assisted fertilization.
we will discuss the favorable and unfavorable RI and PI.
We will discuss role of doppler us in various gynecological malignancies.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
tubal factor is almost 30% of all female infertility causes.Hence evaluation of tubes is usulally the first of the testings.
this presentation evaluates all the methods for evaluation of fallopian tubes
With the use of fertility enhancing medications, advance maternal age pregnancies and just the natural order od twinning, this pregnancy presentation has become more common among providers. Here we explore the etiology, presentation and management of twin pregnancies.
In this presentation we will discuss role of Doppler US in Infertility, fertilization and assisted fertilization.
we will discuss the favorable and unfavorable RI and PI.
We will discuss role of doppler us in various gynecological malignancies.
Fetal growth restriction (FGR), formerly called intrauterine growth restriction (IUGR), refers to a condition in which an unborn baby is smaller than it should be because it is not growing at a normal rate inside the womb.
Mild FGR usually doesn't cause long-term problems. In fact, most babies who have it catch up in height and weight by age 2. But severe FGR can seriously harm a baby before and after birth. The extent of the problems depends on the cause and how severe the growth restriction is. It also depends on what point in the pregnancy it starts.
tubal factor is almost 30% of all female infertility causes.Hence evaluation of tubes is usulally the first of the testings.
this presentation evaluates all the methods for evaluation of fallopian tubes
With the use of fertility enhancing medications, advance maternal age pregnancies and just the natural order od twinning, this pregnancy presentation has become more common among providers. Here we explore the etiology, presentation and management of twin pregnancies.
The incidence of multiple gestation continues to increase, and now accounting for more than 3% of all live births.
Twin pregnancies and higher-order multiple births comprise an increasing proportion of the total pregnancies in the developed world due to the expanded use of fertility treatments and older maternal age at childbirth.
Multiple gestation is associated with:
Increase in neonatal morbidity and mortality rates.
Increase in maternal complications at least two folds.
The number of triplet, quadruplet, and higher-order multiple births peaked in 1998 and has dropped slightly recently, most likely because of limits in the number of embryos transferred and because of the availability and acceptance of multifetal pregnancy reduction (MFPR) procedures.
Prematurity, monochorionicity, and growth restriction pose the main risks to fetuses and neonates in multiple gestations.
The mean duration of pregnancy is 35.3 weeks for twin gestations, 31.9 weeks for triplets, and 29.5 weeks for quadruplets.
Stillbirth rates increase from 6.8 /1000 for singletons to 16.1 for twins and to 21.5 for triplets, and infant mortality rates increase from 5 to 23.4 and to 51.2 /1000 births, respectively.
Infants of multiple gestations comprise almost one quarter of very-low-birth-weight infants.
The incidence of severe handicap among neonatal survivors of multiple gestation is also increased: 34.0 and 57.5 /1000 twin and triplet survivors, respectively, compared with 19.7 /1000 singleton survivors.
Maternal morbidity is significantly increased in mothers with multiple gestations and is apparently related to the number of fetuses.
Multiple gestations are associated with significantly higher risks for:
Hypertension
Placental abruption
Preterm labor (78%)
Preeclampsia (26%);
HELLP syndrome (9%) (hemolysis, elevated liver enzymes, low platelets)
Anemia (24%)
Preterm premature rupture of membranes (pPROM) (24%)
Gestational diabetes (14%)
Acute fatty liver (4%)
Chorioendometritis (16%)
Postpartum hemorrhage (9%)
Twins can be dizygotic (DZ), resulting from the fertilization of two separate ova during a single ovulatory cycle.
DZ twins have dichorionic-diamniotic (DCDA) placentas, although these may fuse during pregnancy.
Monozygotic (MZ), resulting from a single fertilized ovum that subsequently divides into two separate individuals.
In MZ twins, the timing of egg division determines placentation (تكون المشيمة):
Diamniotic, dichorionic (DCDA) placentation occurs with division prior to the morula stage (within 3 days post fertilization).
Diamniotic, monochorionic (MCDA) placentation occurs with division between 4-8 days postfertilization.
Monoamniotic, monochorionic (MCMA) placentation occurs with division between 8-12 days postfertilization.
Division at or after day 13 results in conjoined twins.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
ROLE OF ULTRASOUND IN MULTIFETAL GESTATION - WHAT AN OBSTETRICIAN SHOULD KNOW ?
1. ROLE OF ULTRASOUND IN
MULTIFETAL GESTATION
What an obstetrician should know
?
DR BHARTI PANT GAHTORI
1 YEAR CERTIFICATE COURSE IN FIRST TRIMESTER
SCREENING, ANOMALY SCANNING & FETAL
DOPPLER, FMF APOLLO HOSPITAL, NEW DELHI
Special interest: Highrisk obstetrics,Fetal
Doppler,placental study & Fetal Echo. Gynae-infertility
ultrasound & Dopplers
2. INTRODUCTION
The term multifetal gestation includes twins, triplets &
higher-order multiples.
Incidence of dizygotic twins has increased
dramatically over few decades -
Increased maternal age of conception
Increased use of ovulation induction(6-8%) agents
and gonadotropin in ART( 20-30%)
The incidence of monozygotic twins remains constant
throughout the world, at 1:250 pregnancies.
Perinatal mortality ~ 11% & morbidity rates are 5 - 7
times higher than singletons.
6 times more likely to give birth preterm & 13 times
more likely to give birth before 32 wks of gestation
4. KEY TERMS
• ZYGOSITY - It refers to the type of conception &
the genetic make up of the pregnancy :
Monozygotic or dizygotic. Zygosity can only be
determined by genetic analysis of both foetuses.
• CHORIONICITY – It refers to the membrane
complement of the pregnancy and denotes the type
of placentation. In monozygotic, it is determined by
the occurrence, and timing of the embryo split.
Chorionicity, can be determined by non-invasive
USG
• AMNIONICITY- The number of amnions (inner
membranes) that surround fetuses .Pregnancies
with 1 amnion (so that all fetuses share 1 amniotic
5. ZYGOSITY
MONOZYGOTIC
• 1 ova +1 sperm =1
zygote
• ~25% of all twins
• Same sex & genetic
makeup
• Near identical
• Single or double
placenta
• DNA microprobe - same
DIZYGOTIC
• 2 ova +2sperm =2
zygote
• ~ 75-80 % of all twins
• Same or different sex &
Different genetic
makeup
• Fraternal
• Double or fused
placenta
• DNA microprobe-
different
6. CHORIONICITY
DICHORIONIC TWIN
70% Dizygotic origin & 30%
monozygotic origin.
If monozygotic origin,
splitting occurs < 3 days
PC
There is complete
duplication of all cell lines
with formation of chorions,
amnions, yolk sacs, and
embryos
MONOCHORIONIC TWIN
100% monozygotic origin
Occurs when the split of the
developing structures
occurs > 3rd day PC. Three
variants-
Monochorionic diamniotic
twins: 4th - 8th days PC
Monoamniotic twins:
8th – 13th days PC
Conjoined twins: embryo
split after 13th day PC, split
is incomplete; some
structures are duplicated
and some are shared.
8. PATHOPHYSIOLOGY OF GENERAL
COMPLICATIONS INCREASING FETAL MORBIDITY
/MORTALITY
• Restraint in the capacity of uterus to
distend and permit adequate fetal growth,
thus creating risk for preterm labor.
• Doubling of the placental mass is
associated with obstetric complications of
preeclampsia & gestational diabetes. Risk
with singletons is 6.5%, twins is 12.7%, and
triplets is 20.0%
• Increased risk of abnormal placentation
and function leads to FGR that may also
add to the risk for preterm labor and birth
9. Why we want to diagnose multifetal
gestation & its chorionicity as early as
possible ??
Reason 2 = MC twins are associated with higher fetal risk (
30-50%) than DC twins(10-20%).Chorionicity is the most
important determinant of adverse fetal outcome in multifetal
gestation.
Reason 4 = The early the risk assessment & pick up of
various complications the easier it is to formulate individual
guidelines for screening, surveillance & management,
including the need of any interventional procedures as a part of
treatment.
Reason 3 = Ultrasound shows ~ 99% sensitivity in
assigning chorionicity at <14 wks, which reduces to 90% for
dichorionics & 77% for monochorionics at >14 wks, Early
pickup holds the key.
Reason1 : The higher the order of multiple gestation the
more severe & complicated pregnancy with higher chances of
maternal & fetal morbidity/mortality.
10. COMPLICATIONS SPECIFIC TO
MONOCHORIONICITY
• Increased risk of preterm labor & malformations than
Dichorionic & singletons .
• Deserve extra scrutiny due to conditions like
Monochorionic monoamniotic twin & conjoined twin.
There is a unique risk of
intra-placental vascular
connections causing
unequal distribution of
placental blood supply
between the fetal
circulations leading to
--twin-twin transfusion
syndrome (TTTS)
--twin reversed arterial
perfusion syndrome (TRAP)
&
An unequal placental mass
assignment due to the
unequal placement of the
vascular "equator" &
the intervening membrane
occurs. The fetus with a
smaller placental mass
becomes at high risk for.
-- discordant twin growth
-- selective fetal growth
restriction (sFGR), &
-- single fetal demise
11. MULTIFETAL
RELATED
UNIQUE TO
MONOCHORIONIC
MATERNAL
Prematurity X 6 TTTS , TRAP ,
TAPS
Preeclampsia x 3
Eclampsia x 4
Chromosomal &
structural anomalies
Monoamniotic &
conjoined twin
Diabetes/ HT
IUGR s-FGR & fetal
growth
discordance
APH & PPH X 2
Intrauterine fetal
demise
Co twin fetal demise Polyhydramnios
High order multiple Vasa previa &
velamentous cord
C - Section related
mortality
13. ULTRASOUND AS AN INDISPENSIBLE
TOOL
• An important tool in the armamentarium of
obstetrician & fetal medicine experts for managing
multifetal gestation.
• Ultrasound assessment of chorionicity is considered
the most crucial step. .
• It also helps in preterm & preeclampsia - risk
assessment & guides timely interventions.
• Predictive nature of ultrasound report eventually
safeguards us by default.
• All prenatal diagnostic, interventional & invasive
therapeutic procedures (fetoscopic laser photo-
coagulation & cord occlusion are lame without USG.
14. ULTRASOUND + DOPPLER AS A SCREENING TOOL
• Dating of pregnancy (determine GA)
• Determining chorionicity and amnionicity
• Twin labeling (assigning fetal location)
• Role of Nuchal Translucency as screening tool for
aneupoidy, early TTTS ,CHD etc
• Screening for structural abnormalities
• Screening of cervical length for preterm birth
• Detailed evaluation of placenta & mapping, umbilical
cord insertion site and its associated abnormalities.
• Doppler studies for screening high chances of
preeclampsia and fetal growth disturbances
15. ULTRASOUND + DOPPLER AS SURVEILLANCE
TOOL
• Diagnosis and serial surveillance of pregnancies
complicated by discordant fetal anomalies & single
intrauterine fetal demise.
• Fetal growth & amniotic fluid studies for screening,
diagnosis, monitoring & management of sFGR and
discordant growth.
• Ductus venosus in first trimester(assess CHD ,
TTTS)
• Doppler interrogation of the umbilical arteries (PI) ,
middle cerebral arteries (PI &PSV) & ductus
venosus (waveform) is used to diagnose & stage
TTTS and TAPS
monitor twins with growth discordance.
16. SPECIFICALLY IN
MONOCHORIONICS
Increased scrutiny needed for complications
associated with vascular anastomoses leading to
unequal sharing of placental blood supply & nutrients
- unique to this type of placentation .
• Ultrasound & doppler screening, diagnosis( staging)
monitoring & management of TTTS,TAPS & TRAP
sequence.
• Diagnosis , surveillance & management of
monochorionic
monoamniotic (MCMA) and conjoined twins.
• Ultrasound & Doppler Screening ,diagnosis, monitoring
&
management of sFGR, discordant growth & single fetal
demise.
17. STEP WISE APPROACH IN
ULTRASOUND ASSESSMENT OF
MULTIFETAL GESTATION
STEP 1. : How many are you
??STEP 2 : Dead or alive ??
STEP 3 : Where are you finally
located ??
18. STEP 4:What is your correct age ??
IDEAL GA ~ 11wks -
13wks
• If conceived naturally
,choose the larger of the
two CRLs to estimate GA
• In IVF pregnancy use
the oocyte retrieval date or
the embryonic age from
fertilization.
• If > 14wks choose the
larger head
circumference
Dating is done by
the CRL of the
bigger twin
Step 5: What is your type i.e
chorionicity & ??How to determine it
19. LESS THAN 10 WEEKS
USG findings that help in
determining chorionicity.
• the number of observable
gestational sacs
2 G sac = DCDA ,
1 G sac = MCDA)
• the number of yolk sacs
( Represent amnionicity)
2 yolk sac = diamniotic ,
1 yolk sac = monoamniotic)
• the number of visible
amniotic sacs within the
chorionic cavity
FIG 1- DCDA twins at 5wks3DAYs. Two round sonolucent sacs
with a brightly echogenic rim are clearly visible in the thick
decidua.
FIG 2- At 6wks a single chorionic sac is seen containing
two yolk sacs: S/O ? monochorionic twin pregnancy it is
not possible yet to diagnose amnionicity.
FIG 3- At 8wks MCDA twin pregnancy The two amnions
appear as thin echogenic membranes (arrows) close to
the two embryos, inside the chorionic cavity.
20. MORE THAN 10 WKS Step 1 – Check for number for
placental masses. Separate or
single ? If single rule out fused
dichorionic or monochorionic.
Step 2 - Identifying the lambda()
or (T) sign . The image CLEARLY
demonstrating the chorionicity should
be saved in the records for future
reference.
Step 3 - Carefully examine
dividing inter-twin membrane by
assessing its layers and
reflection.
Step 4 - Assess memb. thickness
at its placental insertion site.
Step 5 – During the same scan,
amnionicity should also be
determined and documented.
As yolk sac disappears ,
G-sac is no more
distinct & intertwin
membrane appears.
At this stage, a new set
of sonographic findings
will help determine
amnionicity/chorionicity.
These findings are
(1) placental number,
(2) chorionic peak sign
&
(3) membrane
characteristics
21. LAMBDA SIGN
CONFIRMS DICHORIONIC
FUSED PLACENTA
• Two placenta either
separate or fused = two
chorionic membrane
• Each fetus is surrounded by
an outer chorionic & inner
amnionic membrane which
get fused (CAAC) at one
point.
• The area from where these
chorionic layers emerge a
wedge gets created with
placental tissue in it referred
as the ‘lambda sign’. ().
22. TAU (T) SIGN
CONFIRMS
MONOCHORIONIC
PLACENTA
• Single placenta = single
chorionic layer
• This layer outlines fetal side
of placenta & entire
Gestational sac with fetuses
inside it
• Amniotic membrane
surrounds each fetus and
fuse (AA) in the middle to
form a thin separating layer
with no placental insertion
creating (T) sign.
23. INTERTWIN
MEMBRANE
•The membrane is imaged
perpendicularly to the
ultrasonic beam magnified
& measured .
•Cut off is 2mm.
•In DC twins It is formed
by four layers (amnion-
chorion-chorion-amnion). &
measures >2mm reflective
• In MC twins it has only
two layers (amnios-
amnios) measuring < 2mm
less reflective .
24. AFTER 14 WEEKS The reliability of using the
number of placental masses
becomes questionable in
late
gestation
Always take note of other
parameters pointing towards
placental sharing.
It is likely that using a
combination of ultrasound
features, rather than a
single
one, would be more
accurate.
If facing difficulty in
assessing
(Chorion and amnion
already fused)
Step 1 - Try to follow the
above 5 steps and try to
pick out maximum
information
Step 6 - Add gender
evaluation, its
discordance assures of
dizygosity (and therefore
dichorionicity) in later
pregnancy.
ONLY 80-90%
ACCURACY
It is safer to manage the
pregnancy as monochorionic
if chorionicity is in doubt.
25. Step 6 :How comfortable are you with
each other ??(Labeling)
• Accurate labeling is essential
when prenatal diagnostic
testing & therapy is required
• Antenatal labeling of twins
according to laterality or
vertical orientation is reliable.
(CERVIX is used in CVS)
• GOOD PRACTICE to
describe each twin as fully as
possible e.g. (twin 1 is female,
on maternal left ,cephalic & has
anterior placenta), to minimize
the chance of confusion
26. STEP 6- Any one of you at risk of
Aneuploidy??
• 2- 2.5 times Increased risk of trisomy
• Relevance of nuchal translucency (CHD,TTTS,
triplets)
• Sensitivity of combined screening ~ 83% with
more
FPR so chances of invasive testing.
• In DC twins – risk result assessed per fetus
• In MC twins – risk results assesses per
pregnancy
• Role of NIPT yet to confirmed
27. STEP 7: Are you prone to
malformations more than singletons
??
• Yes as MC twin 2-3 times > DC twin ~ singleton
• Apart from increased chances of cardiac , neural ,
GI
& abdominal anomalies There are 3 types of
congenital anomalies unique to twin pregnancies-
Midline structural defects- conjoined twins
Malformations resulting from vascular events
as a
consequence of placental anastomoses –
microcephaly ,hydrocephalus, intestinal atresia
Defects or deformities from intrauterine
crowding-
Anatomic survey at the time of nuchal
translucency screening can identify several major
anomalies such as
anencephaly/holoprosencephaly, abdominal wall
defects,cystic hygroma etc . Abnormal cardiac
axis along with reverse ductus venosus & tricuspid
regurgitation in turn, identifies significant
congenital heart disease
18-22 wks anomaly scan has its own value.
28. STEP 8 : Is your relationship with your
placenta cordial ??
• Check the cord insertion site ,there inter-distance
,placental location & any abnormalities
• Velamentous cord insertion increases the risk for
vasa previa and, in monochorionic twins, it is a
marker for unequal placental sharing and increased
risk for selective fetal growth restriction. Check for
cord entanglement .
• Check for placenta previa , circumvallate placenta
abruptio and intra placenta anastomoses.
29. • Serial ultrasonography is the most accurate method to
assess fetal growth in cases of multiple gestation.
• Intrauterine growth of twins is similar to that of singletons
until 30 to 32 weeks’ gestation, when the abdominal
circumference measurements of twins begin to lag behind
those of singletons.
• There is no separate chart to assess the growth curve for
multifetal gestation, singleton growth chart is followed..
• Negate all conditions like fetal abnormality , infections,
TTTS before specifically diagnosing lag in growth potential
as the main cause of growth restriction.
• FETAL DOPPLER IS THE DIFFERENTIATING AND
MONITORING TOOL OF SUCH CONDITION.
STEP 9 : How are you growing ?? I
hope you are well nourished ??
30. STEP 10 – Is my cervix strong enough
??
IN ASYMPTOMATIC WOMEN
•Cervical length screening in twin
pregnancies as a predictor of
spontaneous PTB from 18 weeks
of gestation. Cut off – 3cm
REPEATED MEASURES OF
CERVICAL LENGTH NOT
NEEDED.
IN SYMPTOMATIC WOMEN
•Cervical length measurement had
a low predictive accuracy for PTB
at <34 weeks of gestation but
cervical length – 2.5 cm asks for
hawk eye and start of
progesterone..
31. DOPPLER MEASUREMENTS
• In each scan along with fetal growth (HC, AC,FL), amniotic
fluid (deepest vertical pool), assessment
• Assess PI by Doppler (umbilical artery, middle cerebral
artery and ductus venosus) and in monochorionic twins
middle cerebral artery PSV to detect possible twin anemia–
polycythemia sequence (TAPS) or fetal anemia condition.
• Management depends on-
• sFGR & Growth discordance - EDF of Umbilical A. , MCA
PI and ductus venosus PI
• TTTS - EDF of Umbilical A. , MCA PI , ductus venosus PI &
umbilical vein PI of donor & recipient
• TAPS – Middle cerebral A. peak systolic velocity (PSV) of
both Donor & recipient .
• TRAP – Blood flow of the inter anastamosing vessel is done.
32. DICHORIONIC DIAMNIOTIC TWINS(DCDA)
RECAP
SUMMARY
DCDA pregnancies
account for the majority
(~76%) of all twin
pregnancies.
They account for all
dizygotic pregnancies and
(~20%) of monozygotic
pregnancies.
Pathophysiology
DIZYGOTIC.
MONOZYGOTIC(
splitting
~1-3 days post
fertilisation (morula)
ULTRASOUND FINDINGS
Presence of two distinct
gestational sacs with
each sac having embryo
& yolk sac with outer
chorion & inner amnion
surrounding each embryo
A thick inter-twin
membrane 2C+2 A
Thick membrane
between two sacs-
Lambda sign twin peak
sign
Discordant sex
33. DCDA TWIN
MONITORING
•Scans at 12, 20 weeks
and then every 4 weeks
until delivery.
•If there is discordance in
fetal size of >15%,
discordance in amniotic
fluid or any abnormal
Dopplers then review
every 1 week.
•If there is no
complication, consider
delivery at 37 weeks.
34. FETAL COMPLICATIONS IN DCDA
TWINS
Lowest rate of complications amongst twin
pregnancies though more than singleton .Such
recognized complications include:
1)Increased risk of preterm labor and perinatal risk of
prematurity
2) Increased risk of intrauterine growth restriction
(IUGR)
3) placenta-related problems
– increased risk of velamentous cord insertion
– increased risk of marginal cord insertion
– increased incidence of placenta previa spectrum
35. MONOCHORIONIC DIAMNIOTIC TWIN -RECAP
SUMMARY
• MONOZYGOTIC SUBTYPE
with a single chorionic sac (
later placenta) but have
two amniotic sacs and two yolk
sacs.
Epidemiology
• It accounts for the vast majority
(~70-75%) of monozygotic twin
pregnancies although only
~30% of all twin pregnancies.
The estimated incidence is at
~1:400 pregnancies .
Pathology
• An MCDA pregnancy results
from a separation of a single
zygote at ~4-8 days (blastocyst
ULTRASOUND FINDING
• Shows a twin pregnancy
with a single gestational
sac, 1 Chorion with 2
amnions and 2 separate
yolk sacs
• A thin inter-twin dividing
membrane - must be
identified
• T sign seen ( negative
lambda sign) suggestive of
single placenta
• Almost always two
separate yolk
sacs (differentiating from
36. MONITORING IN
MCDA TWINS
•Scans at 12 and 16
weeks and then every 2
weeks until delivery.
•Doppler blood flow
studies
- UA, UV, DV and MCA PI
& PSV baseline 20 weeks
•If there is discordance in
fetal size of >15%, in
amniotic fluid or any
abnormal Dopplers then
review every 1 week.
•If there is no
complication, consider
delivery at 36 weeks
37. COMPLICATIONS SPECIFIC TO
MONOCHORIONICITY
• Increased risk of preterm labor & malformations than
Dichorionic & singletons .
• Deserve extra scrutiny due to conditions like
Monochorionic monoamniotic twin & conjoined twin.
There is a unique risk of
intra-placental vascular
connections causing
unequal distribution of
placental blood supply
between the fetal
circulations leading to
--Twin-twin transfusion
syndrome (TTTS)
--Twin reversed arterial
perfusion syndrome (TRAP)
&
An unequal placental mass
assignment due to the
unequal placement of the
vascular "equator" &
the intervening membrane
occurs. The fetus with a
smaller placental mass
becomes at high risk for.
-- Discordant twin growth
-- Selective fetal growth
restriction (sFGR), &
-- Single fetal demise
38. COMPLICATION COMMON TO ALL
TWIN SUBTYPES
• PRETERM LABOR & DELIVERY
• FETAL GROWTH RESTRICTION &
GROWTH DISCORDANCE
• MALFORMATION IN ONE FETUS
• SINGLE FETUS DEMISE
39. PRETERM LABOUR
& DELIVERY
MANAGEMENT:
• If h/o preterm in the past ,
present pregnancy is MC with
chances of TTTS etc , or high
order multiple Start cervical
length assessment at 16 wks :
• In asymptomatic women, a
cervical length ≤20 mm at 20–24
weeks was the most accurate
predictor of preterm birth before
32 and before 34 weeks
• If cervical length 2.5 – 3cm
then start vaginal progesterone
200mg
& monitoring every 2-3 wks
• If cervical length less than 1.5
cm go for cerclage
INCIDENCE: 20%–75% in
multiple gestations.
3 fold increased morbidity
AETIOLOGY:
•Intrauterine infection,
•Cervical insufficiency
•Increased uterine
stretch/distension.
• Corticotrophin‐releasing
hormone (CRH) from the
larger placental mass
INVESTIGATION: Cervical
length assessment b/w
18-24wks
40. SELECTIVE FGR WITH GROWTH DISCORDANCE
10% of dichorionics twins & 10-15% of monochorionic twins.
Investigations:
Detailed ultrasound examination.
Ultrasound scans every 1 week to monitor growth, amniotic fluid
volume & pulsatility index in the umbilical A.,middle cerebral artery
& ductus venosus of both fetuses.
If in the presence of ≥25% estimated weight discordance between
the fetuses there is polyhydramnios in the sac of the bigger twin the
condition is sFGR with superimposed TTTS
No chances of recurrence seen.
No associated genetic or chromosomal ab. seen.
MANAGEMENT
Types I and II with TTTS: endoscopic laser ablation of communicating placental
vessels
Type I without TTTS: Expectant management with close monitoring .If Doppler
normal then elective cesarean section at 34-35 weeks. There is intact survival of
both twins in 95% of cases.
Type II without TTTS: there is a high risk of perinatal death and handicap for both
twins.
≥26 weeks: the best management is close monitoring and delivery if the ductus
venosus EDF becomes negative or reversed.
<26 weeks: the best management is endoscopic laser ablation of
communicating placental vessels. Survival of the big baby is 70% and of the
small baby depends of ductus venosus EDF: 40% if positive and 10% if negative or
reversed. Risk of neonatal cerebral lesions primarily depends on gestational age at
delivery and varies from 20% for birth at <26 weeks to 5% for birth at ≥32 weeks.
An alternative management is cord occlusion of the small fetus; the survival of
the large twin is 90%.
Type III: the two umbilical cords are adjacent to each other and the behaviour of the
pregnancy is similar to that of monoamniotic twins; development of TTTS is rare
and sudden unexpected death could occur in 20-30% of cases. Laser surgery may
be impossible and the best management is close monitoring and delivery on the
basis of ductus venosus EDF in the small fetus. If the ductus venosus EDF is
positive elective delivery should be by cesarean section at 32 weeks’ gestation.
41. MALFORMATION IN
ONE TWIN
Management options-
a) Expectant ( > risk for PTD)
b) Termination of entire
pregnancy
c) Selective termination of
anomalous fetus depends on
chorionicity
If diachorionic
i) Intracardiac KCL as early
till 20wks
If monochorionic ( cord
occlusion)
i) Interstitial laser ( <13wks)
ii) In later gestation – Bipolar
cord coagulation else
Radiofrequency cord
Management is influenced
by-
CHORIONICITY
then
a) The type of abnormality
–lethal , impending death
due to severe IUGR or non
lethal but problematic
b) Whether or not it is
concordant
c) The GA when
diagnosed
d) Expectation of the
patient
42. SINGLE FETAL
DEMISE Spontaneous death of one fetus
occurs in 1% of MC twins.
ETIOLOGY
Discordant infections, discordant
structural congenital anomalies and
discordant fetal growth.
Placental factors involved in
sIUFD include uneven placental
sharing, placental implantation
anomalies, and peripheral cord
insertion
Death of one twin is associated
with acute hemorrhage from the co-
twin into the fetoplacental unit of the
dead one. In the co-twin there is a
15% risk of death and ≥ 25% of the
survivors have severe neurological
injury. There is also a high risk (60-
70%) of preterm birth.
ULTRASOUND
MONITORING
This should include
assessment of fetal
Doppler, especially MCA-
PSV, in order to look for
signs of fetal anemia in
the surviving twin.
MRI after 3 weeks of fetal
death to assess changes
in the brain sec. to
hypotensionhypovolemi
a ischemia
MANAGEMENT
Management therefore depends on chorionicity and gestational age.
Dichorionic gestation:
<12 weeks: Usually no consequences, so no intervention needed.
>12 weeks: Immediate delivery has no benefit for the remaining fetus
and the often-quoted maternal risk has not been demonstrated.
There is 57% chances of preterm delivery before 34 wks in of surviving
twin
Monochorionic gestation:
<12 weeks: Associated with high risk of loss of other twin with no
intervention studied.
>12 weeks: Associated with about 10% risk of intrauterine death and
additional 25% risk of neurologic complications in other twin.. At the
time the demise is discovered, the greatest harm has most likely
already occurred in the remaining fetus, and there seems to be no
benefit in immediate delivery, especially if the surviving fetus(es) are
very preterm and otherwise healthy. In such cases, allowing the
pregnancy to continue may provide the most benefit. The
coagulopathy risk for the mother is minimal, probably <2%.
43. MONOAMNIOTIC TWINS 1% of all Monozygotic
twins.
One G sac ,one chorion
,one amnion , one yolksac &
two embryo.
They result from splitting(7-
13) days after fertilization.
ULTRASOUND FEATURES –
•· Single placenta & same sex
•· Close approximation of the
cord insertions (<5cm)
•· Entanglement of the cords;
•· Normal and identical
AFV around both fetuses;
•· Unrestricted fetal
movement;
•· Absence of a dividing
membrane demonstrated on
two studies 24 hrs apart
• two distinct arterial waveform
with different heart rates within
the same sampling gate
•· A single yolk sac may be a
DIFFERENTIAL DIAGNOSIS
• Conjoined twins
• TTTS stuck twin
• Twin demise
•One twin with Renal abnormality so oligo
• PPROM or intertwin membrane rupture due to
interventions
MONITORING & MANAGEMENT
•Scans at 12 and 16 weeks and then every 2 weeks until
delivery.
•Watch for cord entanglement ,single fetal demise,
malpresentation
•If there is discordance in fetal size of >15% or any
abnormal Dopplers then review every 1 week.
•If there is no complication, delivery by cesarean section at
32 weeks.
44. CONJOINED TWINS
Prevalence:
1% of monochorionic twins.
Results from incomplete splitting of
the embryonic mass after day 13 PC.
Associated abnormalities:
The incidence of chromosomal
abnormalities and genetic syndromes
is not increased.
Investigations:
Detailed ultrasound examination and
assessment by multidisciplinary team.
Management:
Pregnancy termination, stillbirth or
neonatal death in >90% of cases.
If the pregnancy continues, delivery
should be by cesarean section in a
expertise centre
Prognosis:
Very high risk of handicap in
survivors.
Recurrence:
No increased risk of recurrence.
ULTRASOUND DIAGNOSIS:
Fused twins in MCMA pregnancy.
Classified according to the site of
fusion .Most common type is
thoracopagus (75% of cases)
with fusion in the thorax and
abdomen and often conjoined
hearts, livers and intestines.
Other types include pygopagus
(fetuses fused at the rump),
ischiopagus (fetuses fused at the
lower half of the bodies with
spines conjoined end to end at
180o angle), craniophagus (fused
skulls and separate bodies),
omphalopagus (fused at the
lower abdomen, with shared liver
and intestines).
45. TWIN – TWIN TRANSFUSION
SYNDROME (TTTS)
Complicates 10-15% of
(MCDA) twin. If left untreated
60-70%mortality.
The syndrome is caused by
unbalanced blood flow from
the donor to the recipient
through placental
anastomoses. AV>AA
Investigations:
Detailed Ultrasound to rule
out anomaly ,then scans every
1 week to monitor growth,
cervical length, AFV and
pulsatility index in the umbilical
artery, middle cerebral artery
and ductus venosus of both
MANAGEMENT
Only Discordance in amniotic fluid (not fulfilling Oli/poly criteria & normal fetal
Doppler:
Overall survival: 95%. Progression to TTTS: 15%.
Ultrasound scans every 1-2 weeks to monitor evolution.
Stage 1:
Survival: overall 85%, at least one twin 90%. Progression to stages 2 to 4: 20%.
Ultrasound scans every 1 week to monitor evolution.
Endoscopic Laser Ablation of communicating placental vessels if progression to
stages 2-4 or increasing polyhydramnios and shortening of cervical length.
Stages 2-4:
<28 weeks: ELA of communicating placental vessels; all communicating vessels should
be ablated and the area between them should also be coagulated to achieve
dichorionization of the placenta. If facility not available then amnioreduction.
≥28 weeks: the best option is to deliver by cesarean section and the timing would
depend on the Doppler findings in the umbilical artery and ductus venosus of both
fetuses.
Stage 2: survival overall 75%, at least one twin 85%.
Stages 3 and 4: survival overall 60-70%, at least one twin 75-85%.
Neurodevelopmental impairment in survivors: 5-10%.
Follow-up after laser therapy: ultrasound scans and Doppler every 1 week until
resolution of the signs of TTTS and normalization of Doppler findings and every 2 weeks
thereafter with special attention for signs of brain damage, recurrence of TTTS and
development of TAPS.
46. TWIN ANEMIA –
POLYCYTHEMIA
SEQUENCE
Prevalence:
Spontaneous: 5% of MC twins.
Usually occurs >26 weeks'
gestation.
After laser ablation of
placental vessels: 2-10% of MC
twins..
Etiology :
TAPS occurs due to a slow
transfusion of blood from the
donor to the recipient through
few very small arterio-venous
vascular anastomoses leading
to highly discordant hemoglobin
levels
There is no substantial
difference between the twins in
either size or AFV
ULTRASOUND FINDINGS-
PLACENTA- anemic fetus looks
thick and hyperechogenic,
polycythemic fetus looks thin and
translucent.
The fetal (MCA PSV) in the
anemic fetus is increased (>1.5
multiples of median), whereas that
in the polycythemic fetus is
decreased (<1 multiples of the
normal median).
The anemic fetus may have a
dilated heart, tricuspid regurgitation
and ascites.
Investigations:Detailed ultrasound
examination, including echo (to
assess cardiac function) and
measurement of MCA PSV
(to predict degree of anemia and
polycythemia).
MANAGEMENT:
<26 weeks: Endoscopic laser ablation of communicating
placental vessels. Subsequently, scans every 1 week to
monitor fetal growth, brain anatomy and MCA-PSV. Fetal brain
MRI at ≥32 weeks’ gestation should be considered for the
diagnosis of neuronal migration disorders. If both babies are
developing normally vaginal delivery can be carried out at 37
weeks.
26-30 weeks: intrauterine blood transfusions to the anemic
twin and exchange transfusion with Hartmans’ solution for the
polycythemic twin. Doppler assessment every 2-3 days
because it may become necessary to undertake
interventions every 3-4 days. Delivery by cesarean section
at 30-32 weeks.
>30 weeks: delivery by cesarean section.
PROGNOSIS:
Neurodevelopmental delay in up to 20% of cases, which
47. TWIN REVERSE ARTERIAL
PERFUSION ( TRAP)
2-3% of monochorionic twins.
Pathogenesis:I
First, abnormal cardiac
embryogenesis occurs between
8 to 12 weeks in one of the two
twins .
Second, a specific abnormal
placental angioarchitecture.
The size of the acardiac mass
is prognostic value for the
survival of the pump twin.
About 50% of pump twins die
before or after birth from
congestive heart failure or
severe preterm birth, due to
polyhydramnios.
ULTRASOUND DIAGNOSIS :
MC twins with one normal fetus
(pump twin) and another with no
cardiac acitivity (rarely, a
rudimentary heart may show slow
pulsations) and variable degrees of
deficient development of the head
and upper limbs and hydrops
(recipient twin).
PATHOGNOMIC SIGNS: Color
Doppler demonstration of seemingly
paradoxical arterial blood flow
toward, rather than away from, the
acardiac twin; reversal of arterial
blood flow.
Echocardiography to assess
cardiac function in the pump
twin.
MANAGEMENT
Fetal therapy:
•Prenatal treatment is by occlusion of the blood flow to the acardiac twin. Several
methods have been used, including ablation of umbilical cord vessels by laser or
diathermy, coagulation of placental anastomoses by laser, or ablation of intrafetal
vessels by monopolar diathermy, laser, or radiofrequency.
•When these methods are used at 16-18 weeks’ gestation the survival rate of the
pump twin is about 80%.
The preferred management is ultrasound-guided laser coagulation or radiofrequency
of the umbilical cord vessels within the abdomen of the acardiac twin at 11-13 weeks.
The survival is 70-75%, which is less than the 80% achieved with intervention at 16-18
weeks.
However, delay in intervention between the diagnosis of TRAP sequence at 11-
13 weeks’ gestation until 16-18 weeks is associated with spontaneous cessation
of flow in the acardiac twin in 60% of cases and in about 50% of these there is
also death or brain damage in the pump twin.
Follow up:
Intrauterine intervention: scan in 1 week to confirm that the pump twin is alive and that
there is cessation of flow in the acardiac twin. Subsequently, standard follow-up.
No intrauterine intervention: scans every 2-3 weeks to monitor growth of the acardiac
twin, heart function of the pump twin and amniotic fluid volume.
Delivery:
Standard obstetric care and delivery.
Prognosis:
Depends on gestational age at birth.
48. INVASIVE TESTING IN TWINS
Pregnancy loss rate is 3–4%, risk of post 2nd trimester
miscarriage is ~1%.
In invasive testing, Both DC twins have to be sampled But in
monochorionics as per indication.
In DC twins, CVS is preferred for early diagnosis of
aneuploidy
and plan low risk first trimester selective termination.
For amniocentesis, both single and double uterine entry
techniques are described, Single entry not to be attempted
in
MCDA twins .
When MC twins have discordant anomaly, prior to invasive
testing ,explain the complexity of selective termination if
needed.
NIPT( Cell-free fetal DNA testing ) is used for aneuploidy
screening in singleton pregnancies with detection rates
(>99%
51. TRIPLETS & HIGHER
ORDER PREGNANCY
• Triplet pregnancies result
from various fertilization,
splitting, and development
scenarios that involve ova and
sperm. Triplets can be
A)Trizygotic triplets : When
three sperm fertilize three ova.
B)Dizygotic triplets : develop
from one set of monozygotic
cotriplets and a third cotriplet
derived from a different zygote.
C) Monozygotic triplets : Two
consecutive zygotic splittings
with a vanished fetus can also
result in monozygotic triplets.
•Triplets and higher-order
multiples accounted for 13.8
out of 10,000 pregnancies in
2010.They rose drastically
during mid eighties due to
ART
•Less than 7% of higher-
order multiples result from
spontaneous ovulation .
Zygosity in quadruplets and
higher order multiples also
varies.
52. MANAGEMENT
• NT is the only option to assess aneuploidy risk. There is
no
role of serum screening or NIPT in triplets & higher.
• In triplet pregnancies diagnosed during the first trimester
management options include continuing with the whole
pregnancy or embryo reduction (ER) to twins or singletons.
• Assessment of chorionicity is very important for planning
embryo reduction & further monitoring and management
especially those with monochorionic origin.
• A very detailed USG evaluation of malformations & growth
parameters as well as scrutiny for TTTS is needed after
16wks
• The triplet pregnancy if continued has all maternal & fetal
complications sameas twins but with more severity and
morbidity.
• Prophylactic Cerclage is not proposed , but tocolytics
53. SUMMARY
• Constitute 2-3 % of all pregnancies
• There are 70-80% dichorionic and 30% monochorionic
• All Dizygotic are dichorionic but all monozygotic are 30%
dichorionic , 69% monochorionic and 1% monoamniotic.
• High perinatal morbidity mortality with preterm risk.
• Early Determination of chorionicity is a must
• "THERE IS NO DIAGNOSIS AS SIMPLY TWINS.”
“The only diagnosis is a monochorionic or dichorionic twin
gestation. This should be written in capital red letters on the
front of the ANC file at 8 - 10 weeks".
• Monochorionic twins are marred by high adverse fetal
outcome due to placental anastomoses and unequal
nutrient sharing.
54. SUMMARY
• If difficulty in determining chorionicity, try TVS , else refer
to higher centre for confirmation, else manage as
monochorionic twins.
• Offer combined screening for aneuploidy risk assessment
.Else NT is reliable.
• Early dating , labeling & detection of anomalies
• Embryo reduction after 12 weeks (< 16 weeks)
• No role of NIPT No role of triple/quadruple marker
• More frequent monitoring in MC twins
• Look for complications in monochorionics.
• Use doppler to assess placenta and cord abnormalities.
• Monitor for maternal complications as well.
55. TAKE HOME MESSAGE
• Insist that chorionicity is reported in every scan. If
unable to decipher send to experts for the same. If
not possible manage as monochorionic twins
• First trimester chorionicity assessment -100%
accurate
Second trimester - 97%
lambda sign
membrane
thickness
position of
placenta
fetal sex
Third trimester - difficult
separate
56. WHEN TO REFFER
1st trimester diagnosis of monochorionicity with features of
its complications -
• Raised Nuchal translucency of one twin with discrepant
amniotic fluid ( s/o TTTS)
• Difference in CRL > 15%
• Single amnion with one yolk sac & entangled cord ( s/o MA
twin)
• Single amnion with crowded fetal parts ( s/o conjoined twin)
2nd trimester appearance of complicating features-
• Features of oli/poly,absent bladder &abn. dopplers s/o TTTS
• Single fetal death in the 2nd & 3rd trimester as associated
with adverse neurological outcomes, such as multicystic
encephalomalacia, occurs in ~ 18% of surviving twins & 12%
risk of co twin death.
• Growth discordance in (intertwin growth-discordance >18% )
• Higher order multiple gestation.