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Twins pregnancy

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  1. 1. น.พ. ธีระ ทองสง ภาควิชาสูติศาสตร์และนรีเวชวิทยา คณะแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่
  2. 2. 2 sperms, 2 eggs Incidence : variable Fetal sex : same or different Membranes : dichorionic, diamnionic Placenta : one fused or two separate
  3. 3. Incidence : 1:250 pregnancies Fertilization : 1 sperm, 1 egg Fetal sex : same (except XO,XY) Placenta : one fused or separate (two separate : dichorionic) Division of zygote : depend on day of twinning
  4. 4. Twin-specific Complication (%) Type of Twinning Twins (%) Fetal Growth Restriction Preterm Delivery Placental Vascular Anastomosis Perinatal Mortality Dizygotic 80 25 40 0 10-12 Monozygotic 20 40 50 15-18 -Diamnion/dichorion 6-7 30 40 0 18-20 -Diamnion/monochorion 13-14 50 60 100 30-40 -Monoamnion/monochorion <1 40 60-70 80-90 58-60 Conjoined Twins 0.002 - 0.008 — 70-80 100 70-90
  5. 5. History : Weak : maternal family history, advanced maternal age, high parity, large maternal size Strong : recent clomiphene citrate or gonadotropins, Assisted reproductive techniques (ART) Clinical examination : size > date (2nd trimester) Ultrasound : separate gestational sac, 2 head or abdomen in the same plane
  6. 6. Chorionicity Dichorion : twin peak sign (lambda sign) thick dividing membrane (> 2 mm) separate placenta Monochorion : T sign Zygosity genetic testing sex
  7. 7. 3500 kcal/day Iron (60 mg/day) Folic acid (1 mg/day) Calcium (2000 mg/day) TWG 16 – 20 kg at term DM screening (as same as singleton)
  8. 8. Serial U/S in 2nd and 3rd trimester Monochorionic twins every 2 – 3 wks in 2nd trimester Dichorionic twin every 4 – 6 wks in 2nd trimester (or after 20 wks) Frequent scans if FGR or growth discordance
  9. 9. Antepartum testing in uncomplicated twin No benefit Indicated in IUGR Discordant growth Abnormal amniotic fluid volumes Monoamniotic twins Preeclampsia NSTs or BPPs 1 – 2 weekly
  10. 10. Bed rest Is often recommended for prevention of preterm labor RCTs of hospitalization or bed rest in twin  failed to prolong GA Home uterine monitoring Effectively detects contractions predictive of preterm labor There are no data that it improves neonatal outcome
  11. 11. Measurement of cervical length Routine U/S for cervical length : not recommended Fetal fibronectin Routine fFN test of asymptomatic women : not recommended Cerclage RCT of prophylactic cerclage in twin : no benefit Tocolytic drugs Routine tocolysis for asymptomatic women : not effective
  12. 12. 2 skilled OB attendants for labor and delivery Anesthesiologist available at delivery Neonatal care personnel Portable ultrasound scanner Reliable IV access CTG with dual monitoring capability Delivery bed with lithotomy stirrups Forceps or vacuum Oxytocin infusion Tocolytic agent for uterine relaxation Methergine, 15-methyl PGF2 alpha or both Immediate availability of blood Capabilities and staff for emergency C/S
  13. 13. Latent phase Active phase Epidural block Hypotonic uterine dysfunction Hypocontractility after delivery of first twin Postpartum hemorrhage
  14. 14. Vertex-Vertex Vertex-Nonvertex Nonvertex
  15. 15. Vaginal delivery Time interval between deliveries of twins Fetal distress Instrumental delivery (vacuum, forceps) Internal podalic version Cesarean section
  16. 16. Clamp umbilical cord of twin A PV, U/S A short period of uterine quiescence  external manipulation of twin B if necessary Oxytocin IV infusion to resume uterine contraction (if no contraction within 10 min) Amniotomy when the head engage
  17. 17. Mean interval 21 min (2/3 interval < 15 min) ACOG 1998  interval between delivery of twins is not critical in determining the outcome of 2nd twin Umbilical cord blood gas deteriorate with increasing time interval Maximum time limit of 30 min with documentation of reassuring FHR pattern
  18. 18. There is a clear, emergent OB indication EFW > 1500 gm Experienced operator Available anesthesia for effective Uterine relaxation Simultaneous preparation for emergency C/S
  19. 19. Vaginal delivery Breech extraction of 2nd twin (partial or total) External cephalic version of 2nd twin Cesarean delivery of 2nd twin Cesarean delivery of both twins
  20. 20. Vaginal breech delivery of 2nd twin increase risk of mortality C/S delivery is associated with the lowest rate of neonatal morbidity and mortality
  21. 21. Observational, non-RCT study : no increased risk of adverse neonatal outcome Only 1 RCT prospective Maternal fever (11.1% vs 40.7%) Postpartum hospitalization (4.9 vs 8 days) Neonatal hospitalization (8.0 vs 13.1 days) Success rate > 95%
  22. 22. Operator must be experienced in Vg breech delivery Should be avoided if EFW of Twin B > Twin A 500 gm EFW of Twin B < 1500 gm Emergency conditions Total breech extraction C/S
  23. 23. An alternative for fetuses not appropriate for vaginal breech delivery Literature review 5 series reviewed, 118 patients Successful Vg deliveries (58% vs 98% in breech extraction) Complications (10% vs 1% in breech extraction) Cord prolapse (5% vs 0.3% in breech extraction) More likely to undergo abdominal delivery than breech extraction
  24. 24. Comparison of BE of 2nd twin, ECV of 2nd twin, C/S of both Healthy newborn BE > ECV and C/S Ventilator requirement C/S > ECV> BE Length of stay C/S > ECV> BE Charges C/S > ECV> BE Vaginal breech extraction of nonvertex 2nd twin provides equivalent, if not superior, outcomes at a lower cost
  25. 25. Limited data to support C/S delivery Transverse Breech (EFW < 1500 or > 1500 gm) Interlocking of fetal heads Interference of 2nd twin on descent of 1st twin deflection of head Inadequately dilate of cervix ACOG recommends C/S delivery of a nonvertex presenting 1st twin
  26. 26. C/S does not eliminate the possibility of a technically difficult or traumatic birth Type of uterine incision should be based on Size and weight of twins Skill of the operator Degree of development of lower uterine segment
  27. 27. The worst of both worlds A tiring and often risky pregnancy A tiring labor A major abdominal operation Two lots of stitches Two new babies to care for
  28. 28. 9.5% Increase C/S rate, increase combined delivery 1/3 of vertex-nonvertex twin No one intentionally plans a combined delivery If – for whatever reason – safe vaginal delivery of twin B cannot be expected, no need to test one’s ability to handle cataclysmic situations
  29. 29. Premature twins Prior cesarean
  30. 30. Vertex-Vertex Vertex-Nonvertex Increase perinatal asphyxia and birth trauma in very low birth weight twin with vaginal breech delivery ACOG conclude that C/S of nonvertex 2nd twin EFW< 1500-2000 gm is an appropriate management option
  31. 31. Should not be an absolute contraindication to vaginal delivery of twins Success rate 30-75% Risk of uterine rupture is the same as VBAC in singleton
  32. 32. Twin A Vertex Twin B Vertex Twin A Vertex Twin B Nonvertex Twin A Nonvertex EFW > 1500 g EFW < 1500 g Twin B > 500 g larger than twin A Contraindication to Vg breech delivery Twin A; Vx Vg delivery Twin B; Br Vg delivery C/S both twinsIntrapartum ECV Success Unsuccess Vx Vg delivery of both twins Combined Vg-C/S delivery C/S of both twinsVg delivery of both twins