TOPIC REVIEW : MULTIFETAL PREGNANCY

จัดทำโดย Ext.สรวิศ บุญญฐี นำเสนอวันที่ กรกฎำคม 2555

Multifetal Pregnancy
 

The term used to describe pregnancy with more than one fetus. Almost every maternal and obstetric problem occurs more frequently in multiple pregnancy. Perinatal mortality rate in twins is 5 times higher, and in triplets 10 times higher than in singletons.

Incidences

Etiology .

Type of Zygosity  Monozygotic Twins (30 %)  True Twins  1 Ovum + 1 Sperm -> differentiation from morula to embryo (2 wks)  Dizygotic Twins (70 %)  False Twins  2 Ovums + 2 Sperms = Diamnion Dichorion  Different or subsequent cycle -> “Superfetation”  Same cycle -> “Superfecundation” .

.

Factors that Influence Twinning Race Heredity Maternal age and parity Nutritional factors Pituitary Gonadotropin Infertility Therapy Assisted Reproductive Technology (ART) .

Inc. In Fetal Medicine: Principles and Practices. 1995.002 to 0.008 — 70–80 100 70–90 Source: Fetal biophysical profile scoring.Important of Determination of Zygosity Overview of the Incidence of Twin Pregnancy Zygosity and Corresponding Twin-Specific Complications Rates of Twin-Specific Complication in Percent Placental Fetal-Growth Preterm Perinatal Type of Twinning Twins Vascular Restriction Delivery Mortality Anastomosis 80 25 40 0 10–12 Dizygous 20 40 50 15–18 Monozygous 6–7 30 40 0 18–20 Diamnionic/dichorionic 13–14 50 60 100 30–40 Diamnionic/monochorionic 40 60–70 80–90 58–60 Monoamnionic/monochorionic <1 Conjoined 0.Copyright © The McGraw-Hill Companies. .

Overview Summary .

Diagnosis and Investigation .

Diagnosis of Multiple Fetuses  History A maternal personal or family history of twins  Advanced maternal age  High parity  Large maternal size  Recent administration of either clomiphene citrate or gonadotropins or pregnancy accomplished by ART .

 Palpation of fetal  Two fetal heartbeats (Difference between 8-10 bpm) .Diagnosis of Multiple Fetuses  Physical Examination  Fundal height. average approximately 5 cm greater than expected for singletons of the same fetal age.

Differential Diagnosis .

 Higher-order multifetal gestations are more difficult to evaluate. . if performed for specific indications.Sonographic Evaluation  About gestational age 6 – 7 wks  separate gestational sacs can be identified early in twin pregnancy  Routine midgestation sonographic examinations  99 % of multifetal gestations before 26 weeks.

)  Chorionicity can sometimes be determined sonographically in the first trimester.  Two separate placentas and a thick–generally 2 mm or greater– dividing membrane -> presumed diagnosis of  Fetuses of opposite gender are almost always dizygotic.Sonographic Evaluation (Cont. thus dichorionic .

Sonographic Evaluation (Chorionicity) Twin Peak Sign Dichorion T sign Monochorion .

Placental Examination  One common amnionic sac.  If adjacent amnions are separated by chorion. but dizygosity is more common .  the fetuses are monozygotic.  the fetuses could be either dizygotic or monozygotic. or with juxtaposed amnions not separated by chorion arising between the fetuses.

more complicated techniques such as DNA fingerprinting can be used.  Same blood type in each fetus does not confirm monozygosity   For definitive diagnosis. blood typing of cord blood samples may be helpful. . Twins of opposite sex are almost always dizygotic.Zygosity  If the neonates are of the same sex. monozygotic twins may be discordant for phenotypic sex.  Different blood types confirm dizygosity.  Rarely.X) and her sibling is 46. This occurs if one twin is phenotypically female due to Turner syndrome (45.XY.

Complication .

Maternal Complication Anemia Placenta previa PIH Abruptio placentae Postpartum Hemorrhage Preterm Labor Preterm PROM Prolapsed cord Vasa previa Postpartum Infection .

Preterm Labor .

Fetal Complication Abnormal Twinning Vascular Anastomoses between Fetuses Discordant Twins Twin Demise .

Abnormal Twinning .

Conjoined Twin .

Acardiac or TRAP .

Fetal Complication (Cont.)  Vascular Anastomoses between Fetuses  artery-to-venous (AV)  artery-to-artery (AA)  vein-to-vein (VV)  Found with monochorionic placentas .

Twin-Twin Transfusion Syndrome (TTTS)  Blood is transfused from a donor twin to its recipient sibling  The donor becomes anemic and its growth may be restricted. Contratures Pulmonary hypoplasia and Heart failure  Recipient  PROM .  Donor (Stuck twin)  Growth Restriction.  The recipient becomes polycythemic and may develop circulatory overload manifest as hydrops.

Twin-Twin Transfusion Syndrome (TTTS)  Quintero staging : Divided into 5 stages Oligo and Polyhydramnios Absent Urine in Donor Bladder + + + + Abnormal Doppler Blood Flows + + + Hydrops Fetalis Fetal Demise Stage I II III IV V + + + + + + + + .

.Discordant Twins  Size inequality of twin fetuses  be a sign of pathological growth restriction in one fetus  calculated using the larger twin as the index   Usually develops late in the second and early third trimester and is often asymmetrical Earlier discordancy is usually symmetrical and indicates higher risk for fetal demise.

Twin Demise  Death of One Fetus Common in monochorion  Early demise "vanishing twin"   Not appear to increase the risk of death in the surviving fetus after the first trimester  Late demise Twin embolization syndrome  Triggers DIC in mother   Impending Death of One Fetus  Abnormal antepartum test results of fetal health in one twin fetus  Death of Both Twins .

Antepartum Assessment .

Antepartum Care  Early Diagnosis -> Identified complication  Preterm Labor. iron and folic acid supplementation Rest at home -> After 28 wks No SI in third trimester Ultrasound      For anomaly screeing Evaluate gestational age Position of fetus Placenta attachment Growth assessment -> Identify IUGR  Non stress test . Pregnancy induced hypertension     Good diet.

Intrapartum and Postpartum Assessment .

Presentation and Position .

Delivery  Vertex .Vertex  Suggest Vaginal Delivery  Vertex – Non vertex  First Choice : Vaginal Delivery (If have experiences doctor)  When was delivered first twin  Check the position of another twin  If delivery if unsuccessful -> Cesarean section  If fetal distress in second or other twins  First choice : Internal Podalic Version or Breech Extraction  Second choice : Cesarean section .

Internal Podalic Version .

Postpartum Care  Prevent postpartum hemorrhage such as uterine atony  Give oxytocin drug in the third stage of labor and postpartum stage  If hypovolemic shock due to excessive blood loss should replace fluid adequated  Prevent postpartum infection in:  Large amount of postpartum bleeding  Preterm or prolong premature rupture of membrane  Manual internal version  Manual placenta removal .

.Thank you for your kind attentions.