Professional Documents
Culture Documents
Januadi
Endjun
Gatot Soebroto Army Central Hospital/ Medical Faculty, University of Indonesia ISUOG Meeting, Bali, 2009
MATERI
AJAR
INI
HANYA
UNTUK
DIPERGUNAKAN
DALAM
KEGIATAN
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
AGENDA
Denitions
Introduction
Etiology
of
twins
Diagnosis
of
twins
Vanishing
twins
Perinatal
loss
in
twins
Placentation
Complications
and
Abnormality
in
twins
pregnancy
Conclusion
Take
home
messages
References
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
DEFINITIONS
Monozygotic
twins
:
a
pregnancy
of
2
fetuses
derived
from the same zygote that divided between the day of fertilization and the 14th day. They can have phenotypic and genotypic dierences and can have either a dichorionic or a monochorionic placentation.
2
dierent
zygotes,
resulting
from
the
fertilization
of
2
oocytes
from
the
same
cycle.
They
always
have
a
dichorionic
placentation.
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
Matias A, Jeanty P, Toy EC. Sonography in multiple gestation. In: Sonography in Obstetrics & Gynecology, 7th Ed, 2011:337-375
JJE-20091119
DEFINITIONS
Chorionicity
:
type
of
placentation
in
cases
of
multiple
Matias A, Jeanty P, Toy EC. Sonography in multiple gestation. In: Sonography in Obstetrics & Gynecology, 7th Ed, 2011:337-375 HANYA UNTUK PENDIDIKAN DAN KESEHATAN
JJE-20091119
INTRODUCTION
Denition:
any
pregnancy
in
which
2
embryos
or
fetuses
occupy
the
uterus
simultaneously
Epidemic
of
twins:
ART,
delayed
childbearing,
and
ovulation
induction
USA
(2003):
67%
twins;
500%
triplets
and
high-order
The
most
profound
implication:
preterm
delivery
infant
death
Maryam
Tarsa
et
al.
Multifetal
gestation
and
malpresentation.
In:
Essentials
of
obstetrics
and
gynecology,
5th
Ed,
2010
Young
Mi
Lee
et
al.
Multiple
pregnancy.
In:
Management
of
High-Risk
Pregnancy.
An
Evidence-based
Approach,
2007,304-315
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
INTRODUCTION
3.2%
of
all
live
births
(US
2003)
(Natality
Data
Set,
CDC,
1997
2002)
14
25%
are
IUGR
and
25%
require
NICU
(Mauldin
J
et
al,
1998;
Ettner
SL
et
Cerebral
palsy:
4x
(gemelli),
17x
(triplet)
(Elliott
JP
et
al,
1992;
Grether
JK
et
al,
al,
1997) 1993)
IUFD:
4x
(ACOG,
2004)
The
likelihood
of
not
surviving
the
1st
year
of
life:
7x
(Luke
B
et
al,
1994;
Kiely
JL
et
al,
1992)
Twin-specic
problems:
TTTS,
MCMA,
conjoined
Maternal
complications:
preeclampsia,
DM:
2
-
3x
(Roach
VJ
et
al,
1998;
Sibai
BM
et
al,
2000)
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
ETIOLOGY
OF
TWINS
Depending
on
the
number
of
eggs
fertilized
at
conception
monozygotic or dizygotic
Monozygotic:
identical,
same
genetic
make
up,
the
rate
is
constant
throughout
the
world
(1/250
pregnancies),
type
of
placentation
(DCDA,
MCDA,
and
MCMA)
and
the
likelihood
of
complications.
ART:
monozygotic
twins:
alter
the
zona
pellucida
around
the
time
of
fertilization
or
delayed
blastocyst
implantation
Egan
JFX
et
al.
Ultrasound
evaluation
of
multiple
pregnancies.
In
Ultrasonography
in
obstetrics
and
gynecology.
Callen,
5th
Ed,2008;266-296)
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
http://www.studentconsult.com/common/showimage.cfm?mediaISBN=9781416059400&FigFile=S9781416059400-013-f001.jpg&size=fullsize
JJE-20091119
MONOCHORIONIC TWIN
TWINNING
RATE
Twinning
rate
(per
1000
pregnancies)
in
England
and
Wales,
19601990
for
all
twins
(diamond
markers),
dizygotic
twins
(square
markers)
and
monozygotic
twins
(triangle
markers;
adapted
from
Derom
et
al.
1995)
JJE-20091119
GROWTH RESTRICTION
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/gem-03.jpg
Frequency
Mortality
JJE-20091119
35% 13%
27% 11%
36% 32%
2% 44%
DIAGNOSIS
OF
TWINS
Anamnesis:
risk
factors
Physical
examination:
dicult
ULTRASOUND:
should
begin
with
a
complete
imaging
sweep
of
the
uterus
FIRST
TRIMESTER
ULTRASOUND:
number
of
GS
and
embryo,
location
of
placenta,
dividing
membrane,
AF,
YS,
and
FHR
determine
chorionicity
potential
complications
Egan
JFX
et
al.
Ultrasound
evaluation
of
multiple
pregnancies.
In
Ultrasonography
in
obstetrics
and
gynecology.
Callen,
5th
Ed,
2008;266-296)
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
SONOGRAPHY
IN
TWINS
Determination
of
the
number
of
fetuses,
amnionicity,
Detection
of
complication
such
as
:
Growth
discrepancy
Abnormal
vascular
anastomosis
Amniotic
uid
volume
imbalance
Fetal
malformations
Cord
entanglement
Matias A, Jeanty P, Toy EC. Sonography in multiple gestation. In: Sonography in Obstetrics & Gynecology, 7th Ed, 2011:337-375 HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
ULTRASOUND
IN
TWIN
There
is
good
evidence
that
the
diagnosis
of
ULTRASOUND
IN
TWIN
Fetal
growth
diers
slightly
in
twin
gestations
and
twin specic charts may be used to dene the normal growth rate. race specic charts.
SOGC, Management of twin pregnancy (Part 1), July, 2000 HANYA UNTUK PENDIDIKAN DAN KESEHATAN
ULTRASOUND
IN
TWIN
Patterns
of
fetal
growth
are
more
important
clinical
history,
together
with
all
the
genetic
and
environmental
factors
that
may
aect
fetal
growth.
(III
B)
SOGC,
Management
of
twin
pregnancy
(Part
1),
July,
2000
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
ULTRASOUND
IN
TWIN
The
diagnosis
of
discordance
has
been
based
on the following:
SOGC, Management of twin pregnancy (Part 1), July, 2000 HANYA UNTUK PENDIDIKAN DAN KESEHATAN
ST
TRIMESTER
ULTRASOUND
1
u Every
eort
should
be
made
to
determine
chorionicity
at
u The optimal time to determine chorionicity is 10-14 u While these recommendations apply to diagnosis of twin
pregnancy
with
regard
to
prenatal
diagnosis
and
counseling,
there
have
been
no
studies
relating
the
establishment
of
prenatal
chorionicity
to
pregnancy
outcome.
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
JJE-20091119
JJE-20091119
VANISHING
TWINS
EARLY
(<
8
weeks)
Delivery
<
32
W
NICU
>
28
days
Neurodevelopment
disorders
(> 22 weeks)
LATE
Pregnancy outcome
Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstetrics and gynecology. Callen, 5th Ed,2008;266-296) JJE-20091119 HANYA UNTUK PENDIDIKAN DAN KESEHATAN
>
5
x
=
32.9/1000
live-born
twins
(USA,
1999)
Survival
depends
on
chorionicity:
anomalies,
growth
problems
&
prematurity
Cumulative loss rate: 3% dichorionic & 15% monochorionic (Sabire et al, 1997) Losses are more likely to occur between 16 22 W
ultrasound
examination
every
1
2
W
to
screen
TTTS
Fetal
demise
of
one
twin,
cerebral
palsy
Maternal
complications:
preeclampsia,
GDM
Egan
JFX
et
al.
Ultrasound
evaluation
of
multiple
pregnancies.
In
Ultrasonography
in
obstetrics
and
gynecology.
Callen,
5th
Ed,2008;266-296)
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
TWINS
DISCORDANT
In
twins
discordant
for
abnormality,
the
option
The
procedure
should
be
performed
in
a
tertiary
Transportation
and
out-of-province
costs
should
SOGC,
Management
of
twin
pregnancy
(Part
1),
July,
2000
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
PLACENTATION
The
most
important
is
the
identication
of
chorionicity
placentation
(chorionicity
and
amnionicity)
and
are
very
important
in
predicting
twin
pregnancy
complications
Egan
JFX
et
al.
Ultrasound
evaluation
of
multiple
pregnancies.
In
Ultrasonography
in
obstetrics
and
gynecology.
Callen,
5th
Ed,2008;266-296)
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
PLACENTATION
Chorionicity
and
amnionicity
First,
second
and
third
trimester
Membrane
insertion,
twin-peak
sign
Membrane
thickness
Membrane
layers
Multiple
sonographic
markers
to
determine
JJE-20091119
2 1* 1*
2
2
1
or
partially
divided*
1 2* 2*
2 2 1
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/images/g05-04b.jpg
JJE-20091119
JJE-20091119
TRIPLETS
JJE-20091119
QUADRUPLET
JJE-20091119
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/conj-01.jpg
CONJOINED
TWINS
MC,
MA
twins
Embryo
divides
at
13
to
15
days
from
conception
The
two
fetal
poles
may
be
attached
at
varying
sites
(Early
ultrasound
nding:
bid
appearing
fetal
pole)
Visualizing
in
the
same
relative
position
in
all
views
Direct
opposition
of
the
twins
from
each
other
Extreme
extension
of
the
fetal
spine
Inseparable
skin
contour
must
be
persistent
Prognosis:
very
poor
Egan
JFX
et
al.
Ultrasound
evaluation
of
multiple
pregnancies.
In
Ultrasonography
in
obstetrics
and
gynecology.
Callen,
5th
Ed,2008;266-296)
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
CONJOINED TWINS
Adapted from: Romero, R., Pilu, G., Jeanty, P., Ghidini, A. and Hobbins, J.C.(1988). Prenatal Diagnosis of Congenital Anomalies, p 405. ( courtesy from Philippe Jeanty www.thefetus.net ) http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/conj-01.jpg JJE-20091119 HANYA UNTUK PENDIDIKAN DAN KESEHATAN
ECTOPARASITIC
TWINS
Ectoparasitic
twins
are
parts
of
twins
implanted
in
another
fetus.
In
this
case
what
appears
to
be
an
omphalocele
on
the
left
is
a
fetal
abdomen
with
lower
legs
on
the
extreme
left.
(Courtesy
Glynis
Sack,
MD,
www.TheFetus.net)
JJE-20091119
arteriovenous
anastomoses
are
deep
in
the
placenta
but
almost
always
proceed
through
the
cotyledonary
capillary
bed
(Benirschke
K,
Kim
CK.
Multiple
pregnancy.
N
Eng
J
Med
1973;288:127684)
across
the
placental
vascular
arteriovenous
communications
from
one
fetus,
the
donor,
to
the
other,
the
recipient,
twin-to-twin
transfusion
syndrome;
50%
of
these
casessevere
twin-to-twin
transfusion
syndrome
acute
polyhydramnios
in
the
second
trimester
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-nal.htm
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
I II III IV V
Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstetrics and gynecology. Callen, 5th Ed,2008;266-296)
JJE-20091119
TTTS
JJE-20091119
STUCK TWINS
JJE-20091119
one twin (the recipient) due to an umbilical arterio arterio anastomosis with the other (donor or pump) twin
(Van Allen MI, Smith DW, Shepard TH. Twin reversed arterial perfusion (TRAP) sequence: study of 14 twin pregnancies with acardius. Semin Perinatol 1983;7:28593)
JJE-20091119
failure or severe preterm delivery, the consequence of polyhydramnios (Van Allen MI et al, 1983; Moore TR, 1990) malformations. (Nicolaides KH et al, 2001)
All
perfused
twins
die
due
to
the
associated
multiple
Acardiac
twins:
hydrops,
heart
beat
+/-
(rudimentary
Hecher
et
al.
2009)
JJE-20091119
GENETIC
TESTING
All
women
carrying
twin
pregnancies
should
be
referred for counseling to a centre for the consideration of invasive testing at age 32.
decision must be taken by the parents since the risk of amniocentesis is uncertain in twin gestation. (II-3 C)
JJE-20091119
GENETIC
SCREENING
Biochemical
screening
for
aneuploidy
is
not
recommended
in twins.
identifying
twin
pregnancies
at
high
risk
of
aneuploidy.
This
requires
further
prospective
investigation.
(II-3
C)
SOGC,
Management
of
twin
pregnancy
(Part
1),
July,
2000
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
recommended.
(I
E)
There
is
insucient
evidence
to
support
prophylactic
activity
PROPHYLACTIC
TOCOLYSIS
There
is
moderate
evidence
against
prophylactic
tocolysis
in
the
management
of
multiple
gestation,
but
it
may
be
indicated
on
other
grounds.
(I;II-2
D)
SOGC,
Management
of
twin
pregnancy
(Part
1),
July,
2000
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
change by digital examination predicts preterm birth in twins. (II-2 A) available, the role of sonographic clinical cervical assessment in the prenatal period has not been determined. (C)
SOGC, Management of twin pregnancy (Part 1), July, 2000 JJE-20091119 HANYA UNTUK PENDIDIKAN DAN KESEHATAN
cervical
length
measurement
in
the
prevention
of
preterm
birth,
the
role
of
sonographic
clinical
cervical
assessment
in
the
prenatal
period
has
not
been
determined.
(C)
SOGC,
Management
of
twin
pregnancy
(Part
1),
July,
2000
JJE-20091119
JJE-20091119
JJE-20091119
(Heath et al 1998)
FETAL
FIBRONECTIN
There
is
good
evidence
that
the
presence
of
cervicovaginal
no
basis
for
incorporating
fetal
bronectin
screening
into
routine
prenatal
management
of
multiple
gestation.
(C)
SOGC,
Management
of
twin
pregnancy
(Part
1),
July,
2000
JJE-20091119
Dichorionic and DiamnioFc pregnancy at 9+2 weeks gestaFon, with a discrepancy of to embryos size
ULTRASOUND
MANAGEMENT
Performed
in
1st
trimester:
number,
amnionicity,
chorionicity,
and
NT
(10
14
W)
JJE-20091119
ULTRASOUND
MANAGEMENT
Dichorionic
or
monochorionic:
if
IUGR,
discordant
fetal
growth,
discordant
AFV
NST,
Biophysical
Prole,
Doppler
studies
Monoamniotic:
daily
NST
starting
from
24
26
W
(risk
of
sudden
IUFD
from
cord
entanglement)
variable
deceleration
delivery?
Young
Mi
Lee
et
al.
Multiple
pregnancy.
In:
Management
of
High-Risk
Pregnancy.
An
Evidence-based
Approach,
2007,304-315
JJE-20091119
Cumulative fetal loss rates in monochorionic (solid line) and dichorionic (dashed line) twin pregnancies, from 12 weeks of gestation20
Gestational age distribution at delivery of monochorionic (solid bars) and dichorionic (open bars) twin pregnancies. The proportion of pregnancies delivering very preterm (before 32 weeks) is considerably higher in monochorionic compared to dichorionic twins20
JJE-20091119
http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-nal.htm
CASE
REPORT
Mrs
I,
34
year,
G1P0A0
20
weeks,
dizygotic
twin
pregnancy
(28-03-2008)
Fetus:
gemelli,
breech-breech
presentation,
boy
and
girl,
no
major
anomaly
seen
Placenta:
normal,
two
placenta
at
right
and
left
side
of
the
uterus
Amniotic
uid:
normal,
amniotic
membrane
(+)
Biometry:
equal
to
19
weeks,
EFW
1:
332
gr
and
EFW
2:
338
gr
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
JJE-20091119
CASE
REPORT
Mrs
F,
33th
years
old,
G2P1A0:
DIZYGOTIC
TWINS
IVF
Two
embryo
fetal
variability
(2nd
fetus)
CS
at
36
W:
F
2480
grams,
AS
9/9;
B
2082
grams,
AS
9/9.
Two
placenta,
two
amnion
and
two
chorion.
The
placenta
for
the
2nd
baby
is
smaller
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
JJE-20091119
JJE-20091119
JJE-20091119
CONCLUSIONS
ART
and
delayed
childbearing
increase
multiple
pregnancy
High
perinatal
morbidity
and
mortality
rates
Early
diagnosis
and
serial
ultrasound
studies
are
disturbances
When
the
best
time
to
delivery?
Condent
diagnosis
of
zygosity
may
require
detailed
examination
of
the
placenta
after
delivery
JJE-20091119
HANYA
UNTUK
PENDIDIKAN
DAN
KESEHATAN
REFERENCES
Tarsa
M,
Moore
TR.
Multifetal
gestation
and
malpresentation.
In:
obstetrics and gynaecology. European practice in Gynecology and obstetrics. Edited by JW Wladimiro, SH Eik-Nes,2009,247-258 Risk Pregnancy. An Evidence-based Approach, 2007,304-315
JJE-20091119
THANK YOU
http://www.scribd.com/Judi%20Endjun