MULTIPLE PREGNANCY

By: Dr Syuhadah

Mentor: Dr Hasniza

MULTIPLE PREGNANCY Definition: Any Pregnancy in which 2 or

more embryos or fetuses occupy the uterus simultaneously

Increased incidence (assisted reproductive technology)

Twins account for about 1% of pregnancies

Hellins law (80 n-1)- Twins → 1 in 80- Triplets → 1 in 802 - Quadruplets → 1 in 803

PREDISPOSING CONDITIONS ↑maternal age and parity Assisted reproduction

techniques - Ovulation induction agents (gonadotropins)- In-vitro fertilization (IVF)

Family history

GENESIS OF TWINMonozygotic VS Dizygotic

TYPES OF TWINS Monozygotic twins (identical)

Originate by fertilization of single ovum by single sperm.

The twinning may occur at different periods after fertilization and this influences the process of implantation and the formation of the fetal membranes.

TYPES/CLASSIFICATION OF TWINNING

Monozygotic/ identical/uniovular

(1 zygote divide into 2) ~33%

Dichorionic Diamniotic

(cleavage of embryonic

egg <3days )~30%

MONOchorionic Diamniotic

(4-8days)~69%

MONOchorionic

MONOamniotic(9-12days)

~1%

MONOZYGOTIC @ UNIOVULAR

DIZYGOTIC @ BINOVULAR Dizygotic twins

(non-identical )

Results from fertilisation of two ova by two sperms.

Dichorionic and diamniotic twins.

CLINICAL PRESENTATIONA. History Taking Family history of multiple

pregnancy Recent infertility treatment Excessive nausea and

vomiting Excessive lower limb

swelling and varicosities Excessive fetal movement

and abdomen overdistension

Extremely fatigue

CLINICAL PRESENTATIONB. Physical Examination Anaemia & oedema Raised BP Uterus larger than dates Polyhydramnios (> in monozygotic

twins) Multiple fetal parts & poles > 1 heart sound with different rates Abnormal weight gain

WAYS TO DETERMINE ZYGOSITY, CHORIONICITY Zygosity

Ultrasound- => Gender discordance = dizygotic DNA fingerprinting, from amniotic fluid

sample (amniocentesis), placental tissue (chorionic villi sampling) and fetal blood (cordocentesis)

Chorionicity Characteristic of membrane(US)-

A: Thick amnion-chorion septum, Twin-peak sign (lamda sign)~dichorionic

B: Thin amnion-chorion septum, The "T sign" ~monochorionic

Why so important to differentiate???

Prenatal diagnosis of chorionicity is important as monochorionic pregnancies have increased rates and severity of all types of obstetric complications when compared with dichorionic pregnancies.

COMPLICATIONS

Maternal • ↑ Sx of early pregnancy (↑HCG)• Miscarriage • Anaemia (↑ Fe,folate & B12 )• Polyhydramnios (uniovular twins)• PIH (↑3-5x)• APH (placenta praevia)• PPH (uterine atony d2 over

stretching)• GDM (↑diabetogenic placental

hormones)• Ineffective labour

(malpresentation)• Thromboembolic ds (↑pelvic vein

compression)

Fetal

• Single fetal death• Preterm labour (d2

overdistended uterus, polyH, intrauterine infection)

• IUGR (discordant growth)• Stillbirth• Congenital abnormality • Twin to twin transfusion

syndrome• Asphyxia (cord

entanglement)• Intrauterine death

TWIN-TO-TWIN TRANSFUSION SYNDROME (TTTS)

TTTS is found in MCMA as well as MCDA pregnancies.

TTTS is more common in MCDA pregnancies than MCMA pregnancies, possibly reflecting that there are more protective artery–artery anastomoses in the latter.

Rarely (in approximately 5% of cases), the transfusion may reverse during pregnancy, with the donor fetus demonstrating features of a recipient fetus and vice versa

Unequal placental sharing and peripheral, ‘velamentous’ cord insertions are common in TTTS

Affects 10-15% of monochorionic twin pregnancies.

Pathophysiology: Result of transfusion of blood from donor

to recipient twin through abnormal artery-to-vein anastomoses in the placenta

The donor suffers hypovolaemia and hypoxia → IUGR, smaller in size, oligohydramnios & high output cardiac failure

The recipient fetus exhibit hypervolemia → large size, polyhydramnios, cardiomegaly, CCF

More than 90% ends in miscarriage/severe preterm delivery

To monitor: US doppler 2 weekly

Management:I. Laser coagulation – occlude the vascular

anastomosis between twins (presenting prior to 26weeks of gestation)

II. Amnioreduction every 1 - 2/52, drain amniotic fluid from recipient sac

III. Septotomy (cord entanglement risk)

IV. Anticipate preterm delivery – corticosteroid (promote fetal lung maturity

SINGLE FETAL DEMISE Occur in monochorionic twin Fetal demise <14weeks-not increase risk

on the survivor twin Confers risk to survivor twin if fetal

demise after 14 weeks. Dt transfer of thromboplastin from dead

twin > produce thrombotic arterial occlusion > occlusions of ant & mid cerebral arteries > multicystic encephalomalacia & neurologic damage.

Induce consumptive coagulopathy in mother.

MANAGEMENT OF MULTIPLE PREGNANCY

Antenatal Intrapartum

ANTENATAL MANAGEMENT

• All women with a multiple pregnancy should be offered an ultrasound examination at 10–13weeks of gestation to assess:

I. viabilityII. chorionicityIII. major congenital malformationIV. nuchal translucency for designation of

risk of aneuploidy and twin-to-twin transfusion syndrome.

DICHORIONIC TWINS

1. Ultrasound at 10–13 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy

2. Structural anomaly scan at 20–22 weeks.3. Serial fetal growth scans e.g 24, 28, 32 and

then two- to four-weekly.4. BP monitoring and urinalysis at 20, 24, 28

and then two-weekly.5. 34–36 weeks: discussion of mode of delivery

and intrapartum care.6. Elective delivery at 37–38 completed weeks.7. Postnatal advice and support (hospital- and

community-based) to include breastfeeding and contraceptive advice

MONOCHORIONIC TWINS1. Ultrasound at 10–13 weeks: (a) viability; (b)

chorionicity; (c) NT: aneuploidy/TTTS2. Ultrasound surveillance for TTTS and discordant

growth: at 16 weeks and then two-weekly.3. Structural anomaly scan at 20–22 weeks (including

fetal ECHO).4. Fetal growth scans at two-weekly intervals until

delivery.5. BP monitoring and urinalysis at 20, 24, 28 and then

two-weekly.6. 32–34 weeks: discussion of mode of delivery and

intrapartum care.7. Elective delivery at 36–37 completed weeks (if

uncomplicated).8. Postnatal advice and support (hospital- and

community-based) to include breastfeeding and contraceptive advice.

ANTENATAL MANAGEMENT Dietary advice: adequate caloric intake to

meet increased demands, supplement of iron (60-80 mg /day), folic acid, calcium, vitamins

Monitor for infection, anaemia, PIH, preterm labour & malpresentation

Corticosteroid if strong possibility of preterm labour (for lung maturity)

CRITERIA FOR VAGINAL DELIVERY FULFILLED

1. Leading twin is cephalic

INTRAPARTUM MANAGEMENT OF TWINSCriteria for vaginal delivery fulfilled

Deliver the 1st twin

Clamp and cut the cord

Note lie of 2nd twin

Transverse lie Longitudinal lie

Attempt External Cephalic Version and vaginal delivery under GA

If unsuccessful C-section

Amniotomy with controlled oxytocin infusion if there is

uterine inertiaNote presentation

Vertex Breech

Vaginal delivery or optionally outlet forceps or

ventouse

Breech extraction or assisted breech

delivery

MANAGEMENT OF THIRD STAGE OF LABOUR

In PIH and cardiac disease: give oxytocin 10 unit i.m

Syntometrine 1 ml (5 unit oxytocin and 500 mcg ergometrine i.m) with delivery of anterior shoulder of 2nd baby

Placenta delivered with controlled cord traction In high risk of uterine atony and PPH, i.v

infusion 40 units oxytocin over 6 hours after delivery)

Episiotomy/perineal repair if needed

INDICATION OF CAESAREAN SECTIONi) ELECTIVE

1st baby non-cephalic especially shoulder

Conjoined twins Congenital abnormality

precluding safe vaginal delivery

IUGR in dichorionic twin Chronic TTTS Monoamniotic twin Placenta praevia Triplets or more Contracted pelvis Previous C-section Pre-eclampsia

ii) EMERGENCY Fetal distress Cord prolapse in 1st

baby Non-progress of

labour Collision of both

twins 2nd twin transverse,

version failed after 1st delivery of twin

THANK YOU….