Komplikasi Gemelli

Komplikasi Gemelli
Vanishing twins
Main article: Vanishing twin
Researchers suspect that as many as 1 in 8 pregnancies start out as multiples, but only a
single fetus is brought to full term, because the other has died very early in the pregnancy
and not been detected or recorded. Early obstetric ultrasonography exams sometimes
reveal an "extra" fetus, which fails to develop and instead disintegrates and vanishes. This
is known as vanishing twin syndrome.
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Vanishing twin
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Vanishing twin
Classification & external resourcesICD-10 O31.2
ICD-9 651.33
A vanishing twin, also called twin embolisation syndrome, is the term for a fetus in a
multi-gestation pregnancy which dies in utero and is then partially or completely
reabsorbed by the mother. Occasionally, rather than being completely resorbed, the dead
fetus will undergo mechanical compression by its wombmate(s), resulting in a flattened,
parchment-like state known as fetus papyraceus. If the fetus is absorbed completely, there
are usually no further complications to the pregnancy. However, if it is not, and the event
occurs in the second or third trimester, serious complications may include premature
labor, infection due to the demise of the fetus, and hemorrhage. Even at the end of the
pregnancy, a low-lying fetus papyraceus may block the cervix and require a cesarean to
deliver the living twin.
According to some researchers, vanishing twins occur in up to one out of every eight
pregnancies and may not even be known in most cases. Since it is hypothesized that some
instances of vanished twins leave no detectable trace, it is impossible to say for certain
how frequent the phenomenon is.
The Vanishing Twin Syndrome has been cited by biotech company Acu-Gen as an ad hoc
hypothesis to explain false results of the company's Baby Gender Mentor test. According
to the company, on occasions where their pregnancy gender test has apparently given the
incorrect gender of the fetus, the apparent mistake can be explained by a fetus having
been present at the time of testing, but later being reabsorbed as a vanished twin.
It has been speculated that the children born in such a pregnancy may have some
memories of their vanishing twins, and may feel lonely because of this. There is no
scientific evidence to support this claim. Researchers of the paranormal, such as George
Noory's talkshow Coast to Coast, have discussed the alleged phenomenon.
A wombtwin is a term used since 2003 to describe an embryo or fetus that was a member
of a twin pair or triplet set and which died in the womb. The loss of a twin very early in
pregnancy has been called "vanishing twin" phenomenon since the 1980s when twin
pregnancies were made visible by means of ultrasound (sonograph) scanning. Two
developing gestational sacs are seen at the first ultrasound scan but only one is visible at
the second scan. The wombtwin dies owing to a poorly implanted placenta; a
developmental anomaly that may cause major organs to fail or be missing completely;
there may be a chromosome abnormality incompatible with life. Frequently the twin is a
blighted ovum, that never developed beyond the very earliest stages of embryogenesis.
[edit]
See also
Chimera (genetics)
Parasitic twin
[edit]
External links
Vanishing twin at eMedicine.com
Wombtwin survivors research and support
Vanishing twin occurrence in India
Articles about vanishing twin phenomenon
Photographic evidence of a vanished twin found on the placenta after delivery of the
surviving twin
LNC Newsletter - Vanishing Twin Syndrome and Fetus Papyraceus
A review in Human Reproduction Update
50 articles about vanishing twin phenomenon in PubMed
Article by Kramer with useful references
Categories: Pages needing expert attention | Obstetrics | Twins

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[edit]
Conjoined twins
Main article: Conjoined twin
Conjoined twins (or "Siamese twins") are monozygotic twins whose bodies are joined
together at birth. This occurs where the single zygote of identical twins fails to separate
completely, and the zygote starts to split after day 13 following fertilization. This
condition occurs in about 1 in 50,000 human pregnancies. Most conjoined twins are now
evaluated for surgery to attempt to separate them into separate functional bodies. The
degree of difficulty rises if a vital organ or structure is shared between twins, such as
brain, heart or liver.

Conjoined twins
From Wikipedia, the free encyclopedia
(Redirected from Conjoined twin)
Conjoined twins
Classification & external resourcesICD-10 Q89.4
ICD-9 759.4
A painting of Chang and Eng Bunker, circa 1836

"Siamese twins" redirects here. For other senses of that term, see Siamese twins
(disambiguation).
Conjoined twins are twins whose bodies are joined together at birth. This happens where
the zygote of identical twins fails to completely separate. Conjoined twins occur in an
estimated one in 200,000 births, with approximately half being stillborn. The overall
survival rate for conjoined twins is between 5% and 25%. Conjoined twins are more
likely to be female (70-75%).
Perhaps the most famous pair of conjoined twins were Chang and Eng Bunker (1811
1874), Chinese brothers born in Siam, now Thailand. They traveled with P.T. Barnum's
circus for many years and were billed as the Siamese Twins; due to their notoriety and the
rarity of the condition, today the term is frequently used as a synonym for conjoined
twins. Chang and Eng were joined by a band of cartilage at the chest (xiphopagus). In
modern times, they could have been separated easily.
Contents [hide]
1 Conjoined twins in history
2 Types of conjoined twins
3 Criticism of the term
4 See also
5 External links
[edit]
Conjoined twins in history The examples and perspective in this article or section may
not represent a worldwide view of the subject.
Please improve this article or discuss the issue on the talk page.
Conjoined twins. From the Nuremberg Chronicle (1493).
The earliest known case of conjoined twins dates from the year 945, when a pair of
conjoined twin brothers from Armenia were brought to Constantinople for medical
evaluation. The English twin sisters Mary and Eliza Chulkhurst, who were conjoined at
the back (pygopagus), lived from 1100 to 1134 and were perhaps the best-known early
example of conjoined twins. Other early conjoined twins to attain notoriety were the
"Scottish brothers", allegedly twins of the dicephalus type, essentially two heads sharing
the same body (14601488, although the dates vary); the pygopagus Helen and Judith of
Szony, Hungary (17011723), who enjoyed a brief career in music before being sent to
live in a convent; and Rita and Cristina Parodi of Sardinia, born in 1829. Rita and
Cristina were dicephalus tetrabrachius (one body with four arms) twins and although they
died at only eight months of age, they gained much attention as a curiosity when their
parents exhibited them in Paris.
Several sets of conjoined twins lived during the nineteenth century and made careers for
themselves in the performing arts, though none achieved quite the same level of fame and
fortune as Chang and Eng. Most notably, Millie and Christine McCoy (or McKoy),
pygopagus twins, were born into slavery in North Carolina in 1851. They were sold to a
showman, J.P. Smith, at birth, but were soon kidnapped by a rival showman. The
kidnapper fled to England but was thwarted when England banned slavery. Smith
traveled to England to collect the girls and brought with him their mother, Monimia, from
whom they had been separated. He and his wife provided the twins with an education and
taught them to speak five languages, play music, and sing. For the rest of the century the
twins enjoyed a successful career as "The Two-Headed Nightingale" and appeared with
the Barnum Circus. In 1912 they died of tuberculosis, 17 hours apart.
Giovanni and Giacomo Tocci, from Locana, Italy, were immortalized in Mark Twain's
short story "Those Extraordinary Twins" as fictitious twins Angelo and Luigi. The Toccis,
born in 1877, were dicephalus tetrabrachius twins, having one body with two legs, two
heads, and four arms. From birth they were forced by their parents to perform and never
learned to walk, as each twin controlled one leg (in modern times physical therapy allows
twins like the Toccis to learn to walk on their own). They are said to have disliked show
business. In 1886, after touring the United States, the twins returned to Europe with their
family, where they fell very ill. They are believed to have died around this time, though
some sources claim they survived until 1940, living in seclusion in Italy.
Conjoined twins who appeared in the public eye during the 20th and 21st centuries
include:
Rosa and Josepha Blazek of Bohemia (modern-day Czech Republic (18781922);
Lucio and Simplicio Godina of Samar, Philippines (19081936);
Daisy and Violet Hilton of Brighton, East Sussex, England (19081969);
Mary and Margaret Gibb of Holyoke, Massachusetts (19121967);
Yvonne and Yvette McCarther of Los Angeles, California (19491992);
Ladan and Laleh Bijani of Shiraz, Iran (Persia)
Ronnie and Donnie Galyon of Ohio (1951), currently the world's oldest living conjoined
twins.
Lori and Reba Schappell of Reading, Pennsylvania (1961), American entertainers.
Ganga and Jamuna Shreshta of Nepal, conjoined twins who separated in a landmark
surgery in Singapore in 2001.
Krista and Tatiana Simms born in Vancouver, British Columbia (2006), craniopagus
conjoined twins.
At Guntur, India the following pairs were successfully operated, Ram & Laxman 1992,
Anjali & Geetanjali 1993, Rekha & Surekha 1998 and Veena & Vani 2004.
[edit]
Types of conjoined twins
There are several different types of conjoined twin:

Thoracopagus: Bodies fused in the thorax. The heart is always involved in these cases;
when the heart is shared, prospects for a long life, either with or without separation
surgery, are poor (35-40% of cases).
Omphalopagus: Joined at the lower chest. The heart is not involved in these cases but the
twins often share a liver, digestive system, diaphragm and other organs (34% of cases).
Xiphopagous: bodies fused in the xiphoid cartilage, e.g., Chang and Eng
Pygopagus (iliopagus): Joined, usually back to back, to the buttocks (19% of conjoined
twins).
Cephalopagus: Heads fused, bodies separated. These twins generally cannot survive due
to severe malformations of the brain. Also known as janiceps (after the two-faced god
Janus) or syncephalus.
Cephalothoracopagus: Bodies fused in the head and thorax. These twins also generally
cannot survive. (Also known as epholothoracopagus or craniothoracopagus.)
Craniopagus: Skulls fused, but bodies separate (2%).
Craniopagus parasiticus': A second bodiless head attached to the head.
Dicephalus: Two heads, one body with two legs and two, three, or four arms (dibrachius,
tribrachius or tetrabrachius, respectively.) Abigail and Brittany Hensel, 16-year-old
conjoined twins from the United States, are of the dicephalus tribrachius type, with their
third arm having been removed while they were very young.
Ischiopagus: Anterior union of the lower half of the body, with spines conjoined at a 180
angle (6% of cases). Or with the spines separate but both the pelvises forming a single
big ring which includes two sacrums and two pubic symphyses.
Ischio-omphalopagus: The most well known type of conjoined twins. The Twins are
conjoined with spines in a Y-shape. They have four arms and usually two or three legs.
These cases can be challenging because the twins often share reproductive and excretory
systems.
Parapagus: lateral union of the lower half extending variable distances upward, with the
heart sometimes involved (5% of cases).
Diprosopus: One head, with two faces side by side.
In some cases, parts of the brain have been known to be shared between conjoined twins
joined at the head.
Occasionally one of the twins will fail to develop properly, effectively acting as a parasite
upon the normally developed twin: this condition is known as parasitic twinning or
asymmetric conjoined twins. One twin may absorb the other, which is known as inclusion
twinning.
Natural death of the twins can occur within hours or a few days.
[edit]
Criticism of the term
As elaborated upon by the Rotten Library, the use of "conjoined" to describe said
condition is in dispute:
..Unfortunately, the term is completely inaccurate, since "conjoined" means "to join or
become joined together, or to unite," which is exactly the opposite of what happens in
these cases. Siamese twins can't be "conjoined" because they were never separated in the
first place, which leaves us in a semantic quandary that can only be resolved by a swift
and totally arbitrary ruling... [1]
However, some scientists now believe that the old-fashioned conjoining theory may be
correct after all, with the egg fully separating at first and then the embryos fusing when
cells in each are attracted to cells of the same type in the other.[citation needed]
[edit]
See also
List of twins
Parasitic twin
Polycephaly
Brothers of the Head, a film about conjoined twins that have a rock band
[edit]
External links
Wikimedia Commons has media related to:

Conjoined twins
Conjoined twins - Geneva Foundation for Medical Education and Research
Types of conjoined twins
A social history of conjoined twins
The Lives and Loves of Daisy and Violet Hilton by Dean Jensen, Ten Speed Press, 2006.
Friends of Conjoined Twins News & Discussion Forum
The site of the medical Saudi team responsible for the numerous successful separation
surgeries
Fortean Times article on some recent and classic cases
Eng and Chang - The Original Siamese Twins; The University of North Carolina at
Chapel Hill, The North Carolina Collection Gallery
The Human Marvels: A Historical Reference Site run by J. Tithonus Pednaud,
Teratological Historian
"Siamese Twins" at the Rotten Library
http://www.msnbc.msn.com/id/14359862/
Ronnie and Donnie Galyon
Emedicine article: http://www.emedicine.com/ped/topic2936.htm
Categories: Limited geographic scope | Articles with unsourced statements | Conjoined

twins
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Chimerism
A chimera is an ordinary person or animal except that some of his or her parts actually
came from his or her twin or from the mother. A chimera may arise either from identical
twin fetuses (where it would be impossible to detect), or from dizygotic fetuses, which
can be identified by chromosomal comparisons from various parts of the body. The
number of cells derived from each fetus can vary from one part of the body to another,
and often leads to characteristic mosaicism skin colouration in human chimeras. A
chimera may be a hermaphrodite, composed of cells from a male twin and a female twin.

Chimera (genetics)
For other uses of the term chimera, see the chimera (disambiguation).
In zoology, a chimera is an animal which has two or more different populations of

genetically distinct cells that originated in different zygotes; if the different cells emerged
from the same zygote, it is called a mosaicism. It is either acquired through the infusion
of allogeneic hematopoietic cells during transplantation or transfusion or it is inherited. In
fraternal twins, chimerism occurs by means of blood-vessel anastomoses. Chimeras were
named after the mythological creature Chimera.
Chimeras are formed from four parent cells (two fertilized eggs or early embryos are
fused together) or three parent cells (a fertilized egg is fused with an unfertilized egg or a
fertilized egg is fused with an extra sperm). Each population of cells keeps its own
character and the resulting animal is a mosaic of mis-matched parts. An analogy is two
jigsaw puzzles cut using an identical cutter, but with different pictures. A single puzzle
can be made out of the mis-matched parts, but the completed puzzle will show parts of
both different pictures. The likelihood of a child being a chimera is increased if the child
is created via in vitro fertilization. Chimeras can often breed, but the fertility and type of
offspring depends on which cell line gave rise to the ovaries or testes.Contents [hide]
1 Tetragametic chimerism
2 Microchimerism
3 Parasitic chimerism in leftvents
4 Chimeras in research
5 In popular culture
6 See also
7 References
8 External links
[edit]
Tetragametic chimerism
Tetragametic chimerism is a less common cause of congenital chimerism. It occurs

through the fertilization of two ova by two sperm, followed by the fusion of the zygotes
and the development of an organism with intermingled cell lines. This happens at a very
early stage of development, such as that of the blastocyst. Such an organism is called a
tetragametic chimera as it is formed from four gametes two eggs and two sperm. Put
another way, the chimera is formed from the merger of two fraternal twins in a very early
(zygote or blastocyst) phase. As such, they can be male, female, or hermaphroditic.
As the organism develops, the resulting chimera can come to possess organs that have
different sets of chromosomes. For example, the chimera may have a liver composed of
cells with one set of chromosomes and have a kidney composed of cells with a second set
of chromosomes. This has occurred in humans, though it is considered 'extremely' rare.
Affected persons are identified by the finding of two populations of red cells or, if the
zygotes are of opposite sex, ambiguous genitalia and hermaphroditism alone or in
combination; such persons sometimes also have patchy skin, hair, or eye pigmentation
(heterochromia). If the blastocysts are of the same sex, it can only be detected through
DNA testing, although this is a rare procedure. Thus the phenomenon may be more
common than currently believed. If the blastocysts are of opposite sex, genitals of both
sexes are formed, either ovary and testis, or combined ovotestes, in one rare form of
intersexuality, a condition previously known as true hermaphroditism. As of 2003, there
were about 30-40 human cases in the literature, according to New Scientist.[1]
Natural chimeras are almost always not detected unless the offspring has abnormalities
such as male/female or hermaphrodite characteristics or skin discoloring. The most
noticeable are some male tortoiseshell cats or animals with ambiguous sex organs or
behavioural abnormalities such as confused gender behaviour (where female cells made
the brain but male cells made the genitals or vice versa). Recent studies of tortoiseshell
male cats and unusually coloured tortoiseshell-like cats suggest that natural chimerism is
far more common than previously realised and that it frequently goes undetected.
Chimerism can be detected in DNA testing. The Lydia Fairchild case, for example, was
brought to court after DNA testing showed that her children could not be hers, since DNA
did not match. The charge against her was dismissed when it became clear that Lydia was
a chimera, with the matching DNA being found in her cervical tissue. Another case was
that of Karen Keegan.[1]
The tetragametic state has important implications for organ or stem-cell transplantation.
Chimeras typically have immunologic tolerance to both cell lines. Thus, for a
tetragametic human, a wider array of relatives and other persons may be eligible to be
organ donors.
[edit]
Microchimerism
Microchimerism is the presence of a small number of cells, genetically distinct from

those of the host individual and an organ. The most common form is fetomaternal
microchimerism (or fetal chimerism) whereby cells from a fetus pass through into the
mother. Fetal cells have been documented to persist in maternal circulation for as long as
38 years[2]. Microchimerism had also been shown to exist after blood transfusion to
severely immunocompromised population of patients who suffered trauma.
[edit]
Parasitic chimerism in leftvents
Chimerism occurs naturally in adult leftvents and is in fact a natural and essential part of
their lifecycle. One or more males attach to a female as parasites (they must do so, as
they will never fully mature alone), eventually fusing into a single, hermaphroditic
individual with a shared circulatory system. Once fused to a female, the males will reach
sexual maturity, developing large testicles as their other organs atrophy.
[edit]
Chimeras in research
In biological research, chimeras are artificially produced by physically mixing cells from
two different organisms. Chimeras are not hybrids, which form from the fusion of
gametes from two species (such as a donkey and a horse) that form a single zygote that
will develop as much as it can (in this case into a live mule); in comparison, chimeras are
the physical mixing of cells from two independent zygotes: for example, one from the
donkey and one from the horse. "Chimera" is a broad term and is often applied to many
different types of mixing of cells from two different species.
Some chimeras can result in the eventual development of an adult animal composed of
cells from both donors, which may be of different species for example, in 1984 a
chimeric geep was produced by combining embryos from a goat and a sheep[3]. The
"geep" has been a very important contributor to answering fundamental questions about
development and the techniques used to create it may one day help save endangered
species. For example, if one tried to let a goat embryo gestate in a sheep the sheep's
immune system would reject the developing embryo and the goat would die; however, if
one used a geep that shared markers of immunity with both sheeps and goats, the goat
embryo may survive. It may be possible to extend this practice for the purpose of
preventing the extinction of some endangered animal species.
Such interspecies chimeras such as the "geep" are made in the laboratory and rarely with
the purpose of generating living hybrid animals. In addition to the famous geep, there are
rat/mouse chimeras and a rabbit/human chimera that cannot develop beyond a few days.
Intraspecies chimeras are created by transplanting embryonic cells from an animal with
one trait into an embryo of an animal with a different trait. This practice is common in
field of embryology and has been a very important contributor to our current
understanding of human and animal biology. For example, by mixing embryonic cells of
differently coloured or otherwise genetically distinct mice (of the same species),
researchers have been able to see how embryos form and which organs and tissues are
related (arise from the similar cell lineages).
Hybridomas are not true chimeras as described above because they do not result from the
mixture of two cell types but result from fusion of two species cells into a single cell and
artificial propagation of this cell in the laboratory. Hybridomas have been very important
tools in biomedical research for decades.
In August 2003, researchers at the Shanghai Second Medical University in China

reported that they had successfully fused human skin cells and dead rabbit eggs to create
the first human chimeric embryos. The embryos were allowed to develop for several days
in a laboratory setting, then destroyed to harvest the resulting stem cells. It is important to
realize that studies like these are being conducted in order to identify a cheap, ethical
source of human embryonic stem-cells to study, from which to develop the medical cures
of the future. Because of the high therapeutic potential of human embryonic stem cells
and the American moratorium on using discarded embryos from in vitro fertilization
clinics as well as other concerns about using human embryos directly for research,
scientists are trying to find ways to find alternative paths of research. However,
increasingly realizable projects using part-human, part-animal chimeras as living
factories for producing cells or organs not only for biopharmaceutical production (see
hybridomas) for xenotransplantation raise a host of ethical and safety issues.
During November 2006, UK researchers from Newcastle University and King's College
London applied to the Human Fertilisation and Embryology Authority for a three-year
licence to fuse human DNA with cow eggs. The proposal is to insert human DNA into a
cow's egg which has had its genetic material removed and then create an embryo by the
same technique that produced Dolly the Sheep. The resulting embryo would be 99.9%
human; the only bovine element would be DNA outside the nucleus of the cell. This
research was attempted in the United States several years before and failed to yield such
an embryo.
Chimeras should not be confused with mosaics, which are organisms with genetically
different cell types, but which again originate from a single zygote.
[edit]
In popular culture
In his book Free Culture[4] (published in 2004), Lawrence Lessig digresses briefly to
describe chimerism and suggest that it could, and had yet to, be well used as a television
plot device (particularly for police procedurals involving genetic fingerprinting). The
book was released on the Internet under the Creative Commons Attribution/Non-
Commercial License on March 25, 2004.
On May 20, 2004, the CSI: Crime Scene Investigation episode called Bloodlines (episode
number 423), aired in which the main plot line involved a man who was a Chimera.
Chimerism was diagnosed in a boy in the medical drama House, in the episode Cane and
Able, Season 3, episode 2, (aired September 12, 2006).
In an episode of The Office, Dwight Schrute says that he absorbed his twin brother while
in his mother's womb. He also says that he now "has the strength of a man and a baby".
In November 2006, on the ABC soap opera, "All My Children", it is revealed that testing
of Emma's DNA did not reveal a match with her mother, Annie, because Annie is a
chimera.
One of the subplots in Michael Crichton's 2006 novel Next deals with chimerism.
[edit]
See also
Chimera (plant)
Mosaic (genetics)
Chimaera (fish)
Parahumans
Chimerism in human intersexuality
Vanishing twin
Lydia Fairchild
[edit]
References
^ "The Twin Inside Me: Extraordinary People" Channel 5 TV, UK, 23:00 9 March 2006
^ Evans PC, Lambert N, Maloney S, Furst DE, Moore JM, Nelson JL (1999). "Long-term
fetal microchimerism in peripheral blood mononuclear cell subsets in healthy women and
women with scleroderma.". Blood 93 (6): 2033-2037.
^ "It's a Geep", Time, 1984-02-27. Retrieved on 2006-08-02.
^ Lessig, Lawrence (2004). Chapter 11: Chimera, Free Culture.
Yu N, Kruskall MS, Yunis JJ, Knoll JH, Uhl L, Alosco S, Ohashi M, Clavijo O, Husain Z,
Yunis EJ, Yunis JJ, Yunis EJ (2002). "Disputed maternity leading to identification of
tetragametic chimerism". N Engl J Med 346 (20): 1545-52. PMID 12015394.
Ainsworth, Claire (November 15]], [[2003). The Stranger Within. New Scientist
(subscription). (reprinted here)
House, MD, TV Series Season 3, Episode 2 "Cane & Able" (Originally aired: Tuesday
September 12, 2006 on FOX). TV.COM.
Weiss, Rick (August 14, 2003). Cloning yields human-rabbit hybrid embryo. The
Washington Post.
Weiss, Rick (February 13, 2005). U.S. Denies Patent for a too-human hybrid. The
Washington Post.
[edit]
External links
Mosaicism and Chimerism has a photo of a geep
Medterms.com: Chimera
"'Humanised' organs can be grown in animals" New Scientist December 2003
Hermaphrodites
An article about a chimeric mouse with 100% human brain cells.
Discovery Health - I Am My Own Twin [2]
Categories: Developmental biology | Zoology | Intersexuality

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Mosaic (genetics)
(Redirected from Mosaicism)
Some information in this article or section has not been verified and may not be reliable.
Please check for inaccuracies, and modify and cite sources as needed.
In medicine (genetics), a mosaic or mosaicism denotes the presence of two populations of

cells with different genotypes in one individual, who has developed from a single
fertilized egg. Mosaicism may result from a mutation during development which is
propagated to only a subset of the adult cells.
Although the two can have some common symptoms, mosaicism is distinctly different
from chimerism. In the latter, the two or more genotypes arise from more than one
zygote, while in mosaics, these genotypes arise from only a single cell.
Sometimes intersex conditions can be caused by mosaicism - where some cells in the
body have XX and others XY chromosomes.
The most common form of mosaicism found through prenatal diagnosis involves
trisomies. Although most forms of trisomy are due to problems in meiosis and affect all
cells of the organism, there are cases where the trisomy only occurs in a selection of the
cells. This is usually due to a nondisjunction event in an early mitosis. Generally this
leads to a milder phenotype than in non-mosaic patients with the same disorder.
An example of this is one of the milder forms of Klinefelter's syndrome, called 46/47
XY/XXY mosaic wherein some of the patient's cells contain XY chromosomes, and some
contain XXY chromosomes. The 46/47 annotation indicates that the XY cells have the
normal number of 46 total chromosomes, and the XXY cells have 47 total chromosomes.
A special type of mosaicism is gonadal mosaicism. This is when a part of the gonadal
cells of an organism have different genotype than the rest of the cells, usually because of
a mutation that occurred in an early stem cell that gave rise to all or part of the gonadal
tissue. If these cells have sustained a new mutation that causes a dominant heritable
disease, then it is possible for two healthy parents to have an offspring suffering from the
disease. Usually when this happens it is because of a new mutation in the zygote, but if
the parents have two or more offspring with the same disorder, then it is an indication of
gonadal mosaicsm.
[edit]
Use in experimental biology
Genetic mosaics can be extraordinarily useful in the study of biological systems, and can
be created intentionally in many model organisms in a variety of ways. They often allow
for the study of genes that are important for very early events in development, making it
otherwise difficult to obtain adult organisms in which later effects would be apparent.
Furthermore they can be used to determine the tissue or cell type in which a given gene is
required and to determine whether a gene is cell autonomous. That is whether the gene
acts solely within the cell that is expressing it or whether it affects neighboring cells
which do not themselves show a phenotype when carrying a mutation in the gene.
The earliest examples of this involved transplantation experiments (technically creating

chimeras) where cells from a blastula stage embryo from one genetic background are
aspirated out and injected into a blastula stage embryo of a different genetic background.
Genetic mosaics are a particularly powerful tool when used in the commonly studied fruit
fly, where they are created through mitotic recombination. Mosaics were originally
created by irradiating flies heterozygous for a particular allele with X-rays, inducing
double-strand DNA breaks which, when repaired, could result in a cell homozygous for
one of the two alleles. After further rounds of replication, this cell would result in a patch,
or "clone" of cells mutant for the allele being studied.
More recently the use of a transgene incorporated into the Drosophila genome has made
the system far more flexible. The Flip Recombinase (or FLP) is a gene from the
commonly studied yeast Saccharomyces cerevisiae which recognizes "Flip Recombinase
Target" sites, which are short sequences of DNA, and induces recombination between
them. FRT sites have been inserted transgenically near the centromere of each
chromosome arm of Drosophila melanogaster. The FLP gene can then be induced
selectively, commonly using either the heat shock promoter or the GAL4/UAS system.
The resulting clones can be identified either negatively or positively.
In negatively marked clones the fly is transheterozygous for a gene encoding a visible
marker (commonly the green fluorescent protein, GFP) and an allele of a gene to be
studied (both on chromosomes bearing FRT sites). After induction of FLP expression,
cells that undergo recombination will have progeny that are homozygous for either the
marker or the allele being studied. Therefore the cells that do not carry the marker (which
are dark) can be identified as carrying a mutation.
It is sometimes inconvenient to use negatively marked clones, especially when generating

very small patches of cells, where it is more difficult to see a dark spot on a bright
background than a bright spot on a dark background. It is possible to create positively
marked clones using the so called MARCM (pronounced mark-em) system, which stands
for "Mosaic Analysis with a Repressible Cell Marker" and was developed by Liqun Luo,
a professor at Stanford University. In this system the GAL4/UAS system is used to
globally express GFP. However the gene GAL80 is used to repress the action of GAL4,
preventing the expression of GFP. Instead of using GFP to mark the wild type
chromosome as above, GAL80 serves this purpose, so that when it is removed, GAL4 is
allowed to function, and GFP turns on. This results in the cells of interest being marked
brightly in a dark background. [1]
[edit]
References
Mosaicism and Chimerism
[2]
Categories: Wikipedia articles needing factual verification | Genetics

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Parasitic twins
Main article: Parasitic twin
Sometimes one twin fetus will fail to develop completely and continue to cause problems
for its surviving twin. One fetus acts as a parasite towards the other.
Sometimes the parasitic twin becomes an almost indistinguishable part of the other

Parasitic twin
A parasitic twin is the result of a situation related to the process that results in vanishing
twin and conjoined twins; two unique embryos begin developing in utero, but something
goes wrong. Parasitic twins are also known as asymmetrical conjoined twins or unequal
conjoined twins. Parasitic twins are a variation on conjoined twinsexcept one of the
twins stopped developing during gestation and is now vestigial to a healthy, otherwise
mostly fully-formed individual twin. The undeveloped twin is defined as parasitic, rather
than conjoined, because it is incompletely formed or wholly dependent on the body
functions of the complete fetus.
Conjoined-parasitic twins united at the head are described as craniopagus or

cephalopagus. Craniopagus occipitalis is the term for fusion in the occipital region;
craniopagus parietalis is when the fusion is in the parietal region; craniopagus parasiticus
is term for a parasitic head attached to the head of a more fully-developed fetus or
infant.Contents [hide]
1 Specific types of parasitic twin
1.1 Acardiac twin or TRAP sequence
2 See also
2.1 Fiction
3 References
4 External links
[edit]
Specific types of parasitic twin
[edit]
Acardiac twin or TRAP sequence
An acardiac twin, also called the TRAP sequence, is a parasitic twin that fails to develop
a head, arms and a heart. The resulting torso survives by leeching blood flow from the
surviving normal twin by means of an umbilical cord-like structure, much like a fetus in
fetu, except the acardiac twin is not enveloped inside the normal twin's body. Because it
is pumping blood for both itself and its acardiac twin, this causes extreme stress on the
normal fetus's heart. This twinning condition usually occurs very early in pregnancy.
Without intervention, the normal fetus is only expected to have a 20% chance of survival.
Fetal surgery to cut off the blood supply to the parasite can greatly increase the chance of
survival for the normal fetus, but carries some risk of miscarriage or other complications.
[edit]
See also
Teratoma, including fetus in fetu
[edit]
Fiction
Conjoined twin myslexia (a fictional condition featured in an episode of South Park)
Brothers of the Head, a novel (and now a film) involving conjoined twin brothers with a
parasitic triplet.
Jonas Venture Junior, A fictional parasitic twin (later separated) from the TV series The
Venture Bros.
[edit]
References
[edit]
External links
UCSF Fetal Treatment Center: Learn more about Acardiac Twin or TRAP Sequence
The Brown Fetal Treatment Program - Providence, Rhode Island
Images of Acardiac twin (note: contains graphic anatomical pathology images)
[[Category:Obstetrics]
Categories: Conjoined twins | Parasitic twin | Congenital disorders

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Partial Molar twins

Main article: Partial Molar twin
A very rare type of parasitic twinning is where a single viable twin is endangered when
the other zygote become cancerous, or molar. This means that the molar zygote's cellular
division continues unchecked, resulting in a cancerous growth that overtakes the viable
fetus. Typically, this results when one twin has either triploidy or complete paternal
uniparental disomy, resulting in little or no fetus and a cancerous, overgrown placenta,
resembling a bunch of grapes.
Polyploidy
(Redirected from Triploidy)
Polyploidy is the condition of some biological cells and organisms of containing more
than two homologous sets of chromosomes. Polyploid types are termed according to the
number of chromosome sets in the nucleus: triploid (three sets; 3x), tetraploid (four sets;
4x), pentaploid (five sets; 5x), hexaploid (six sets; 6x) and so on.
A haploid (n) only has one set of chromosomes. Haploidy may also occur as a normal
stage in an organism's life cycle as in ferns and fungi. In some instances not all the
chromosomes are duplicated and the condition is called aneuploidy. Where an organism
is normally diploid, some spontaneous aberrations may occur which are usually caused
by a hampered cell division.Contents [hide]
1 Examples
2 Polyploidy in humans
3 Polyploid crops
4 Terminology
4.1 Autopolyploidy
4.2 Allopolyploidy
4.3 Paleopolyploidy
5 See also
6 References
7 Further reading
8 External links
[edit]
Examples
Polyploidy occurs in some animals, such as goldfish, salmon, and salamanders, but is
especially common among ferns and flowering plants, including both wild and cultivated
species. Wheat, for example, after millennia of hybridization and modification by
humans, has strains that are diploid (two sets of chromosomes), tetraploid (four sets of
chromosomes) with the common name of durum or macaroni wheat, and hexaploid (six
sets of chromosomes) with the common name of bread wheat. Many agriculturally
important plants of the genus Brassica are also tetraploids; their relationship is described
by the Triangle of U.
Speciation via polyploidy: A diploid cell undergoes failed meiosis, producing diploid
gametes, which self-fertilize to produce a tetraploid zygote.
Examples in animals are more common in the lower forms such as flatworms, leeches,
and brine shrimp. Polyploid animals are often sterile, so they often reproduce by
parthenogenesis. Polyploid salamanders and lizards are also quite common and
parthenogenetic. While mammalian liver cells are polyploid, rare instances of polyploid
mammals are known, but most often result in prenatal death.
The only known exception to this rule is an octodontid rodent of Argentina's harsh desert
regions, known as the Red Viscacha-Rat (Tympanoctomys barrerae), discovered by
Milton Gallardo Narcisi, member of Universidad Austral de Chile. This rodent is not a
rat, but kin to guinea pigs and chinchillas. Its "new" diploid [2n] number is 102 and so its
cells are roughly twice normal size. Its closest living relation is Octomys mimax, the
Andean Viscacha-Rat of the same family, whose 2n=56. It is surmised that an Octomys-
like ancestor produced tetraploid (i.e., 4n=112) offspring that were, by virtue of their
doubled chromosomes, reproductively isolated from their parents; but that these likely
survived the ordinarily catastrophic effects of polyploidy in mammals by shedding (via
translocation or some similar mechanism) the "extra" set of sex chromosomes gained at
this doubling.
Polyploidy can be induced in cell culture by some chemicals: the best known is
colchicine, which can result in chromosome doubling, though its use may have other less
obvious consequences as well.
In plant breeding, the induction of polyploids is a common technique to overcome the

sterility of a hybrid species. Triticale is the hybrid of wheat (Triticum turgidum) and rye
(Secale cereale). It combines sought-after characteristics of the parents, but the initial
hybrids are sterile. After polyploidization, the hybrid becomes fertile and can thus be
further propagated to become triticale.
Salsify or "goatsbeard" is another example of polyploidy resulting in new species.
[edit]
Polyploidy in humans
Polyploidy occurs in humans in the form of triploidy (69,XXX ) and tetraploidy

(92,XXXX). Triploidy occurs in about 2-3% of all human pregnancies and ~15% of
miscarriages. The vast majority of triploid conceptions end as miscarriage and those that
do survive to term typically die shortly after birth. In some cases survival past birth may
occur longer if there is mixoploidy with both a diploid and a triploid cell population
present.
Triploidy may be the result of either digyny (the extra haploid set is from the mother) or
diandry (the extra haploid set is from the father). Diandry is almost always caused by the
fertilization of an egg by two sperm (dispermy). Digyny is most commonly caused by
either failure of one meiotic division during oogenesis leading to a diploid oocyte or
failure to extrude one polar body from the oocyte. Diandry appears to predominate
among early miscarriages while digyny predominates among triploidy that survives into
the fetal period. However, among early miscarriages, digyny is also more common in
those cases <8.5 weeks gestational age or those in which an embryo is present. There are
also two distinct phenotypes in triploid placentas and fetuses that are dependent on the
origin of the extra haploid set. In digyny there is typically an asymmetric poorly grown
fetus, with marked adrenal hypoplasia and a very small placenta. In diandry, the fetus
(when present) is typically normally grown or symmetrically growth restricted, with
normal adrenal glands and an abnormally large cystic placenta that is called a partial
hydatidiform mole. These parent-of-origin effects reflect the effects of genomic
imprinting.
Complete tetraploidy is more rarely diagnosed than triploidy, but is observed in 1-2% of
early miscarriages. However, some tetraploid cells are not uncommonly found in
chromosome analysis at prenatal diagnosis and these are generally considered harmless.
It is not clear whether these tetraploid cells simply tend to arise during in vitro cell
culture or whether they are also present in placental cells in vivo. There are, at any rate,
very few clinical reports of fetuses/infants diagnosed with tetraploidy mosaicism.
Mixoploidy is quite commonly observed in human preimplantation embryos and includes

haploid/diploid as well as diploid/tetraploid mixed cell populations. It is unknown
whether these embryos fail to implant and are therefore rarely detected in ongoing
pregnancies or if there is simply a selective process favoring the diploid cells.
[edit]
Polyploid crops
Polyploid plants in general are more robust and sturdy than diploids. In the breeding of
crops, those plants that are stronger and tougher are selected. Thus many crops have
unintentionally been bred to a higher level of ploidy:
Triploid crops: banana, apple, ginger
Tetraploid crops: durum or macaroni wheat, maize, cotton, potato, cabbage, leek,
tobacco, peanut, kinnow, Pelargonium
Hexaploid crops: chrysanthemum, bread wheat, triticale, oat
Octaploid crops: strawberry, dahlia, pansies, sugar cane
Some crops are found in a variety of ploidy. Apples, tulips and lilies are commonly found
as both diploid and as triploid. Daylilies (Hemerocallis) cultivars are available as either
diploid or tetraploid. Kinnows can be tetraploid, diploid, or triploid.
[edit]
Terminology
[edit]
Autopolyploidy
Autopolyploids are polyploids with chromosomes derived from a single species.

Autopolyploids can arise from a spontaneous, naturally-occurring genome doubling (for
example, the potato). Bananas and apples can be found as triploid autopolyploids.
[edit]
Allopolyploidy
Allopolyploids are polyploids with chromosomes derived from different species. Triticale
is an example of an allopolyploid, having six chromosome sets, four from wheat
(Triticum turgidum) and two from rye (Secale cereale). Cabbage is a very interesting
example of a fertile allotetraploid crop (see Triangle of U). Amphidiploid is another word
for an allopolyploid.
The giant tree Sequoia sempervirens or Coast Redwood has a hexaploid (6n) genome,
and is also thought to be autoallopolyploid (AAAABB).
[edit]
Paleopolyploidy
Ancient genome duplications probably characterize all life. Duplication events that
occurred long ago in the history of various evolutionary lineages can be difficult to detect
because of subsequent diploidization (such that a polyploid starts to behave
cytogenetically as a diploid over time) as mutations and gene translations gradually make
one copy of each chromosome unlike its other copy.
In many cases, these events can be inferred only through comparing sequenced genomes.
Examples of unexpected but recently confirmed ancient genome duplications include the
baker's yeast (Saccharomyces cerevisiae), mustard weed/thale cress (Arabidopsis
thaliana), rice (Oryza sativa), and an early evolutionary ancestor of the vertebrates (which
includes the human lineage) and another near the origin of the teleost fishes.
Angiosperms (flowering plants) may have paleopolyploidy in their ancestry. All
eukaryotes probably have experienced a polyploidy event at some point in their
evolutionary history.
[edit]
See also
Speciation
Polyploid complex
[edit]
References
Griffiths, A. J. et al. 2000. An introduction to genetic analysis, 7th ed. W. H. Freeman,
New York ISBN 0-7167-3520-2
[edit]
Further reading
Arabidopsis Genome Initiative (2000). Analysis of the genome sequence of the flowering
plant Arabidopsis thaliana. Nature 408: 796-815.
Eakin, G.S. & Behringer, R.R. (2003). Tetraploid development in the mouse.
Developmental Dynamics 228: 751-766.
Gregory, T.R. & Mable, B.K. (2005). Polyploidy in animals. In The Evolution of the
Genome (edited by T.R. Gregory). Elsevier, San Diego, pp. 427-517.
Jaillon, O. et al. (2004). Genome duplication in the teleost fish Tetraodon nigroviridis
reveals the early vertebrate proto-karyotype. Nature 431: 946-957.
Paterson, A.H., Bowers, J. E., Van de Peer, Y. & Vandepoele, K. (2005). Ancient
duplication of cereal genomes. New Phytologist 165: 658-661.
Raes, J., Vandepoele, K., Saeys, Y., Simillion, C. & Van de Peer, Y. (2003). Investigating
ancient duplication events in the Arabidopsis genome. Journal of Structural and
Functional Genomics 3: 117-129.
Simillion, C., Vandepoele, K., Van Montagu, M., Zabeau, M. & Van de Peer, Y. (2002).
The hidden duplication past of Arabidopsis thaliana. Proceedings of the National
Academy of Science of the USA 99: 13627-13632.
Taylor, J.S., Braasch, I., Frickey, T., Meyer, A. & Van de Peer, Y. (2003). Genome
duplication, a trait shared by 22,000 species of ray-finned fish. Genome Research 13:
382-390.
Tate, J.A., Soltis, D.E., & Soltis, P.S. (2005). Polyploidy in plants. In The Evolution of
the Genome (edited by T.R. Gregory). Elsevier, San Diego, pp.371-426.
Van de Peer, Y., Taylor, J.S. & Meyer, A. (2003). Are all fishes ancient polyploids?
Journal of Structural and Functional Genomics 3: 65-73.
Van de Peer, Y. (2004). Tetraodon genome confirms Takifugu findings: most fish are
ancient polyploids. Genome Biology 5(12):250.
Van de Peer, Y. and Meyer, A. (2005). Large-scale gene and ancient genome duplications.
In The Evolution of the Genome (edited by T.R. Gregory). Elsevier, San Diego, pp.329-
368
Wolfe, K.H. & Shields, D.C. (1997). Molecular evidence for an ancient duplication of the
entire yeast genome. Nature 387: 708-713.
Wolfe, K.H. (2001). Yesterday's polyploids and the mystery of diploidization. Nature
Reviews Genetics 2: 333-341.
[edit]
External links
Polyploidy on Kimball's Biology Pages
Animation of Inversion
vde
Evolution of chromosomes[hide]
Basic topics: Chromosome - Karyotype - Ploidy - Meiosis
Classification: Autosome - Sex chromosome
Evolution: Chromosomal inversion - Chromosomal translocation - PolyploidySpeciation

guide v d e
Basic concepts: species | chronospecies | speciation | cline
Modes of speciation: allopatric | peripatric | parapatric | sympatric | polyploidy
Auxiliary mechanisms: sexual selection | assortative mating | punctuated equilibrium
Intermediate stages: hybrid | Haldane's rule | ring species
Categories: Classical genetics | Speciation

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Trke

Uniparental disomy
Uniparental disomy (UPD) occurs when a person receives two copies of a chromosome,
or part of a chromosome, from one parent and no copies from the other parent. UPD can
occur as a random event during the formation of egg or sperm cells or may happen in
early fetal development. It can also occur during trisomic rescue
Most occurrences of UPD result in no phenotypical anomalies. However, if the UPD

causing event happens during meiosis I, the genotype may include identical copies of the
uniparental chromosome, leading to the manifestation of rare recessive disorders. UPD
should be suspected in a individual manifesting a recessive disorder, where only one
parent is a carrier. Uniparental inheritance of imprinted genes can also result in
phenotypical anomalies. Few imprinted genes have been identified, however uniparental
inheritance of an imprinted gene can result in the loss of gene function can lead to
delayed development, mental retardation, or other medical problems. The most well-
known conditions include Prader-Willi syndrome and Angelman syndrome. Both of these
disorders can be caused by UPD or other errors in imprinting involving genes on the long
arm of chromosome 15. Other conditions, such as Beckwith-Wiedemann syndrome, are
associated with abnormalities of imprinted genes on the short arm of chromosome 11.
Occasionally, all chromosomes will be inherited from one parent, due to either a sperm
fertilizing an empty egg and duplicating itself, or a diploid egg that is not fertilized. The
effect is similar to triploidy, with either a molar pregnancy with no embryo if only
paternal genes are present, or an embryo with no placenta if only maternal genes are
present. Neither condition ever results in a liveborn infant.
[edit]
External links
Uniparental disomy (University of British Columbia)
This article incorporates public domain text from The U.S. National Library of Medicine
Category: Genetics
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This page was last modified 21:07, 15 November 2006. All text is available under the
terms of the GNU Free Documentation License. (See Copyrights for details.)
Miscarried twin
Occasionally, a female will suffer a miscarriage early in pregnancy, yet the pregnancy
will continue; one twin was miscarried but the other was able to be carried to term. This
occurrence is similar to the vanishing twin syndrome.

Miscarriage
Miscarriage
Classification & external resourcesICD-10 O03.
ICD-9 634
MedlinePlus 001488
eMedicine topic list
Miscarriage or spontaneous abortion is the natural or spontaneous end of a pregnancy at a

stage where the embryo or the fetus is incapable of surviving, generally defined at a
gestation of prior to 20 weeks. Miscarriages are the most common complication of
pregnancy. The medical term "abortion" refers to any terminated pregnancy, deliberately
induced or spontaneous, although in common parlance it refers specifically to active
termination of pregnancy.Contents [hide]
1 Terminology
2 Prevalence
3 Detection
4 Forms and types
5 Recurrent miscarriage
6 Management
7 Pathology
8 Causes
8.1 First trimester
8.2 Second trimester
8.3 General risk factors
9 Psychological aspects
10 ICD10 codes
11 Notes
12 See also
13 External links
[edit]
Terminology
Very early miscarriages - those which occur before the sixth week LMP (since the
woman's Last Menstrual Period) are medically termed early pregnancy loss. Miscarriages
that occur after the sixth week LMP are medically termed clinical spontaneous abortion.
[1]
In medical contexts, the word "abortion" refers to any process by which a pregnancy ends
with the death and removal or expulsion of the fetus, regardless of whether it's
spontaneous or intentionally induced. Many women who have had miscarriages,
however, object to the term "abortion" in connection with their experience, as it is
generally associated with induced abortions. In recent years there has been discussion in
the medical community about avoiding the use of this term in favor of the less ambiguous
term "miscarriage."[2]
Labor resulting in live birth before the 37th week of pregnancy is termed "premature
birth," even if the infant dies shortly afterward. Although long-term survival has never
been reported for infants born from pregnancy shorter than 21 weeks, infants born as
early as the 16th week of pregnancy may cry and live a few minutes or hours.[3]
A fetus that dies while in the uterus after about the 20th week of pregnancy is termed a
"stillbirth". Premature births or stillbirths are not generally considered miscarriages,
though usage of the terms and causes of these events may overlap.
[edit]
Prevalence
Determining the prevalence of miscarriage is difficult. Many miscarriages happen very

early in the pregnancy, before a woman may know she is pregnant. Treatment of women
with miscarriage at home means medical statistics on miscarriage miss many cases.[4]
Prospective studies using very sensitive early pregnancy tests have found that 25% of
pregnancies are miscarried by the sixth week LMP (since the woman's Last Menstrual
Period).[5][6] The risk of miscarriage decreases sharply after the 8th week, i.e. when the
fetal stage begins.[7] Clinical miscarriages (those occurring after the sixth week LMP)
occur in 8% of pregnancies.[6]
The prevalence of miscarriage increases considerably with age of the parents.

Pregnancies from men younger than twenty-five years are 40% less likely to end in
miscarriage than pregnancies from men 25-29 years. Pregnancies from men older than
forty years are 60% more like to end in miscarriage than the 25-29 year age group.[8] The
increased risk of miscarriage in pregnancies from older men is mainly seen in the first
trimester.[9] In women, by the age of forty-five, 75% of pregnancies may end in
miscarriage.[10]
[edit]
Detection
The most common symptom of a miscarriage is bleeding;[11] bleeding during pregnancy

may be referred to as a threatened abortion. Of women who seek clinical treatment for
bleeding during pregnancy, about half will go on to have a miscarriage.[4] Symptoms
other than bleeding are not statistically related to miscarriage.[11]
Miscarriage may also be detected during an ultrasound exam, or through serial human
chorionic gonadotropin (HCG) testing. Women pregnant from ART methods, and women
with a history of miscarriage, may be monitored closely and so detect a miscarriage
sooner than women without such monitoring.
Several medical options exist for managing documented nonviable pregnancies that have
not been expelled naturally.
[edit]
Forms and types
A complete abortion is when all products of conception have been expelled. Products of
conception may include the trophoblast, chorionic villi, gestational sac, yolk sac, and
fetal pole (embryo); or later in pregnancy the fetus, umbilical cord, placenta, and caul.
An incomplete abortion occurs when tissue has been passed, but some remains in utero.
[12]
An empty sac is a condition where the gestational sac develops normally, while the
embryonal part of the pregnancy is either absent or stops growing very early. Other terms
for this condition are blighted ovum and anembryonic pregnancy.
A missed abortion is when the embryo or fetus has died, but a miscarriage has not yet
occurred. It is also referred to as delayed miscarriage.
Several management options exist for miscarriages which have not completed on their
own.
A septic abortion occurs when the tissue from a missed or incomplete abortion becomes
infected. The infection of the womb carries risk of spreading infection (septicaemia) and
is a grave risk to the life of the woman.
[edit]
Recurrent miscarriage
Main article: Habitual abortion
Recurrent pregnancy loss (RPL) or recurrent miscarriage (medically termed habitual
abortion) is the occurrence of 3 consecutive miscarriages. A large majority (85%) of
women who have had two miscarriages will conceive and carry normally afterwards, so
statistically the occurrence of three abortions at 0.34% is regarded as "habitual".[13]
There are various medical conditions associated with this problem (e.g. antiphospholipid
syndrome), some of which may be corrected with medication.
[edit]
Management
Blood loss during early pregnancy is the most common symptom of both miscarriage and
of ectopic pregnancy. Pain does not strongly correlate with miscarriage, but is a common
symptom of ectopic pregnancy.[11] In the case of concerning blood loss, pain, or both,
transvaginal ultrasound is performed. If a viable intrauterine pregnancy is not found with
ultrasound, serial HCG tests should be performed to rule out ectopic pregnancy, which
is a life-threatening situation.[14][15]
If the bleeding is light, making an appointment to see one's doctor is recommended. If

bleeding is heavy, there is considerable pain, or there is a fever, then emergency medical
attention should be sought.
No treatment is necessary for a diagnosis of complete abortion (as long as ectopic

pregnancy is ruled out). In cases of an incomplete abortion, empty sac, or missed abortion
there are three treatment options:
With no treatment (watchful waiting), most of these cases (65-80%) will pass naturally
within two to six weeks.[16] This path avoids the side effects and complications possible
from medications and surgery.[17]
Medical management usually consists of using misoprostol (a prostaglandin, brand name
Cytotec) to encourage completion of the miscarriage. About 95% of cases treated with
misoprostol will complete within a few days.[16]
Surgical treatment (most commonly dilation and curettage, or D&C) is the fastest way to
complete the miscarriage. It also shortens the duration and heaviness of bleeding, and is
the best treatment for physical pain associated with the miscarriage.[16] In cases of
repeated miscarriage or later-term pregnancy loss, D&C is also the best way to obtain
tissue samples for pathology examination.
[edit]
Pathology
When looking for gross or microscopic pathologic symptoms of miscarriage, one looks
for the products of conception. Microscopically, these include villi, trophoblast, fetal
parts, and background gestational changes in the endometrium. Genetic tests may also be
performed to look for abnormal chromosome arrangements.
[edit]
Causes
Miscarriages can occur for many reasons, not all of which can be identified.
[edit]
First trimester
Most miscarriages (more than three-quarters) occur during the first trimester.[18]
Chromosomal abnormalities are found in more than half of embryos miscarried in the
first 13 weeks. A pregnancy with a genetic problem has a 95% chance of ending in
miscarriage. Most chromosomal problems happen by chance, have nothing to do with the
parents, and are unlikely to recur.[19] Genetic problems are more likely to occur with
older parents; this may account for the higher miscarriage rates observed in older women.
[20]
Another cause of early miscarriage may be progesterone deficiency. Women diagnosed

with low progesterone levels in the second half of their menstrual cycle (luteal phase)
may be prescribed progesterone supplements, to be taken for the first trimester of
pregnancy.[19]
[edit]
Second trimester
Up to 15% of pregnancy losses in the second trimester may be due to uterine

malformation, growths in the uterus (fibroids), or cervical problems.[19] These
conditions may also contribute to premature birth.[18]
One study found that 19% of second trimester losses were caused by problems with the
umbilical cord. Problems with the placenta may also account for a significant number of
later-term miscarriages.[21]
[edit]
General risk factors
Pregnancies involving more than one fetus are at increased risk of miscarriage.[19]
Uncontrolled diabetes greatly increases the risk of miscarriage. Women with controlled
diabetes are not at higher risk of miscarriage. Because diabetes may develop during
pregnancy (gestational diabetes), an important part of prenatal care is to monitor for signs
of the disease. High blood pressure and certain illnesses (such as rubella and chlamydia)
increase the risk of miscarriage.[19]
Tobacco (cigarette) smokers have an increased risk of miscarriage.[22] An increase in

miscarriage is also associated with the husband being a cigarette smoker.[1] The husband
study observed a 4% increased risk for husbands who smoke less than 20 cigarettes/day,
and an 81% increased risk for husbands who smoke 20 or more cigarettes/day.
Severe cases of hypothyroidism increase the risk of miscarriage. The effect of milder
cases of hypothyroidism on miscarriage rates has not been established. Certain immune
conditions such as autoimmune diseases greatly increase the risk of miscarriage.[19]
Cocaine use increases miscarriage rates.[22]
Physical trauma, exposure to certain chemicals, obesity, high caffeine intake (> 300
mg/day), high levels of alcohol consumption, and use of NSAIDs have also been linked
to increased risk of miscarriage.[citation needed]
[edit]
Psychological aspects
Although a woman physically recovers from a miscarriage quickly, psychological

recovery for parents in general can take a long time. People differ a lot in this regard:
some are 'over it' after a few months, others take more than a year. Still others may feel
relief or other less negative emotions.
For those who do go through a process of grief, it is often as if the baby had been born
but died. How short a time the fetus lived in the womb may not matter for the feeling of
loss. From the moment pregnancy is discovered, the parents can start to bond with the
unborn child. When the child turns out not to be viable, dreams, fantasies and plans for
the future are disturbed roughly.
Besides the feeling of loss, a lack of understanding by others is often important. People
who have not experienced a miscarriage themselves may find it hard to empathise with
what has occurred and how upsetting it may be. This may lead to unrealistic expectations
of the parents' recovery. The pregnancy and miscarriage are hardly mentioned anymore in
conversation, often too because the subject is too painful. This can make the woman feel
particularly isolated.
Interaction with pregnant women and newborn children is often also painful for parents
who have experienced miscarriage. Sometimes this makes interaction with friends,
acquaintances and family very difficult.[23]
[edit]
ICD10 codesHabitual abortion
Incomplete abortion
Missed abortion
Threatened abortion
N96
O03.0-O06.4
O02.1
O20.0
[edit]
Notes
^ a b Venners S, Wang X, Chen C, Wang L, Chen D, Guang W, Huang A, Ryan L,
O'Connor J, Lasley B, Overstreet J, Wilcox A, Xu X (2004). "Paternal smoking and
pregnancy loss: a prospective study using a biomarker of pregnancy.". Am J Epidemiol
159 (10): 993-1001. PMID 15128612.
^ Hutchon, DJR & S. Cooper, 1998. Terminology for early pregnancy loss must be
changed. British Medical Journal 317(7165):1081
^ Patricia Lee June (November 2001). "A Pediatrician Looks at Babies Late in Pregnancy
and Late Term Abortion". Presbyterians Pro-Life. Retrieved on 2006-12-24.
^ a b Everett C (1997). "Incidence and outcome of bleeding before the 20th week of
pregnancy: prospective study from general practice.". BMJ 315 (7099): 32-4. PMID
9233324.
^ Wilcox AJ, Baird DD, Weinberg CR (1999). "Time of implantation of the conceptus
and loss of pregnancy.". New England Journal of Medicine 340 (23): 1796-1799. PMID
10362823.
^ a b Wang X, Chen C, Wang L, Chen D, Guang W, French J (2003). "Conception, early
pregnancy loss, and time to clinical pregnancy: a population-based prospective study.".
Fertil Steril 79 (3): 577-84. PMID 12620443.
^ Q&A: Miscarriage. (August 6 , 2002). BBC News. Retrieved January 17, 2007. Also
see Lennart Nilsson, A Child is Born 91 (1990)(At eight weeks, "the danger of a
miscarriage . . . diminishes sharply.")
^ Kleinhaus K, Perrin M, Friedlander Y, Paltiel O, Malaspina D, Harlap S (2006).
"Paternal age and spontaneous abortion". Obstet Gynecol 108 (2): 369-77. PMID
16880308.
^ Slama R, Bouyer J, Windham G, Fenster L, Werwatz A, Swan S (2005). "Influence of
paternal age on the risk of spontaneous abortion.". Am J Epidemiol 161 (9): 816-23.
PMID 15840613.
^ Nybo Andersen A, Wohlfahrt J, Christens P, Olsen J, Melbye M (2000). "Maternal age
and fetal loss: population based register linkage study". BMJ 320 (7251): 1708-12. PMID
10864550.
^ a b c Gracia C, Sammel M, Chittams J, Hummel A, Shaunik A, Barnhart K (2005).
"Risk factors for spontaneous abortion in early symptomatic first-trimester pregnancies".
Obstet Gynecol 106 (5 Pt 1): 993-9. PMID 16260517.
^ MedlinePlus (2004-10-25). Abortion - incomplete. Medical Encyclopedia. Retrieved on
2006-05-24.
^ Royal College of Obstetricians and Gynaecologists (May 2003). "The Investigation and
Treatment of Couple with Recurrent Miscarriage" (PDF). Guideline No 17. Retrieved on
2006-05-24.
^ Yip S, Sahota D, Cheung L, Lam P, Haines C, Chung T (2003). "Accuracy of clinical
diagnostic methods of threatened abortion". Gynecol Obstet Invest 56 (1): 38-42. PMID
12876423.
^ Condous G, Okaro E, Khalid A, Bourne T (2005). "Do we need to follow up complete
miscarriages with serum human chorionic gonadotrophin levels?". BJOG 112 (6): 827-9.
PMID 15924545.
^ a b c Kripke C (2006). "Expectant management vs. surgical treatment for miscarriage".
Am Fam Physician 74 (7): 1125-6. PMID 17039747. Retrieved on 2006-12-31.
^ Tang O, Ho P (2006). "The use of misoprostol for early pregnancy failure.". Curr Opin
Obstet Gynecol 18 (6): 581-6. PMID 17099326.
^ a b Rosenthal, M. Sara (1999). The Second Trimester. The Gynecological Sourcebook.
WebMD. Retrieved on 2006-12-18.
^ a b c d e f Miscarriage: Causes of Miscarriage. Physician's Desk Reference Family
Guide to Women's Health. HealthSquare.com (2006). Retrieved on 2006-12-18.
^ Pregnancy Over Age 30. MUSC Children's Hospital. Retrieved on 2006-12-18.
^ Peng H, Levitin-Smith M, Rochelson B, Kahn E. "Umbilical cord stricture and
overcoiling are common causes of fetal demise.". Pediatr Dev Pathol 9 (1): 14-9. PMID
16808633.
^ a b Ness R, Grisso J, Hirschinger N, Markovic N, Shaw L, Day N, Kline J (1999).
"Cocaine and tobacco use and the risk of spontaneous abortion.". N Engl J Med 340 (5):
333-9. PMID 9929522.
^ David Vernon (2005). Having a Great Birth in Australia.
[edit]
See also
Childbirth
Doula
Stillbirth
Premature birth
[edit]
External links
MedLine Plus: Spontaneous Abortion
Hormones predict miscarriage risk
Miscarriage Overview
Frequently asked questions about recurrent miscarriage/recurrent pregnancy loss
Causes & Symptoms of Recurrent Miscarriage
Categories: Articles with unsourced statements | Obstetrics | Forms of abortion

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Ting Vit
Section:
Twins and Multiples

Think you might be carrying twins? Feel a little overwhelmed? From signs and
symptoms to some valuable tips and advice on giving birth to twins, you can be truly
prepared for this incredible time in your life.
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Being pregnant with twins can be a very joyful experience. After all, you get to nurture
two babies, instead of just one! However, a twin pregnancy can also be quite a stressful,
particularly when there is an increased chance of certain pregnancy complications. In
particular, some twins develop a problem with their circulation, known as Twin-to-Twin
Transfusion Syndrome. This syndrome is very dangerous and can inhibit the development
of one twin while leading to a variety of health complications for both twins. When left
untreated, Twin-to-Twin Transfusion Syndrome (TTTS) is often fatal.
What is Twin-to-Twin Transfusion Syndrome?

TTTS is a pregnancy complication that affects identical twins. Specifically, TTTS affects
the placenta, preventing proper circulation of blood and nutrients between the two twins.
This can lead to severe developmental deficits and health complications.
TTTS only affects twins that have a monochorionic placenta. This occurs when twins
develop a shared placenta in the uterus, instead of two separate placentas. If a fertilized
egg takes longer than four days to split, only one placenta develops instead of two.
Typically, this placenta is able to balance nutrients and blood flow to both babies.
However, in 5% to 25% of twins with a monochorionic placenta, abnormal blood vessels

form inside of the placenta. As a result, blood flow becomes imbalanced and one baby
begins to act as a filter for the placental blood. Known as the donor twin, this twin pumps
blood for both himself and his twin, causing excessive heart strain and poor development.
Meanwhile, the recipient twin receives too much blood, and begins to develop too
quickly, producing a large amniotic sac.
How Common is Twin-to-Twin Transfusion Syndrome?

It was once thought that TTTS was a very rare illness, affecting only a minute percentage
of all twin pregnancies. New research on the subject, though, has shown that TTTS
actually affects more pregnancies than previously thought. It appears that about 1 in 1000
identical twin births are affected by TTTS. Both male and female identical twins are
affected at the same rate.
What Causes Twin-to-Twin Transfusion Syndrome?

The cause of TTTS remains elusive to researchers. It appears that anybody can develop
TTTS, regardless of genetic background or medical history. Scientists believe that the
position of the twins in the placenta may contribute to TTTS, particularly if one twin is
taking up a greater percentage of the placenta than the other. However, the exact cause of
the syndrome is still unknown.
Symptoms of Twin-To-Twin Transfusion Syndrome

TTTS can manifest at any time during pregnancy, from the first trimester right up until
labor and delivery. It most commonly occurs during the fourth and fifth months of
pregnancy. Both mother and babies will exhibit symptoms of TTTS. Symptoms in mom
include:
rapid weight gain (due to excess amniotic fluid around the recipient twin)
abdominal pain and tightness
premature contractions
Symptoms in the twin babies include:
monochorionic placenta
one small baby and one large baby
one small amniotic sac and one large amniotic sac
Complications of Twin-to-Twin Transfusion Syndrome

Unfortunately, TTTS is a very dangerous illness that can drastically affect the health of
your twins. Common complications of TTTS include:
heart failure in the donor twin (from pumping too much blood)
anemia in the donor twin
poor fetal development in the donor twin
excess amniotic fluid in the recipient twin, leading to premature rupture of the
membranes
preterm labor
brain damage, heart damage, or fetal death
Treatment of Twin-to-Twin Transfusion Syndrome

Treatment is essential if you are suffering from TTTS. Without treatment, between 80%
and 100% of babies die, either in utero or shortly after birth. Treatment can help to
resolve circulation problems between the twins allowing for healthy fetal growth.
Common treatment options include:
Amnioreduction: Amnioreduction is used to help remove some of the excess amniotic

fluid from around the recipient twin. This can help to reduce your discomfort and the risk
of preterm labor. Using a large needle, your health care provider can drain off some of the
excess amniotic fluid. This procedure usually takes about an hour and removes anywhere
between one and three liters of excess amniotic fluid. Afterwards, the donor twin has
more room to grow and develop.
Septostomy: A septostomy is usually performed along with an amnioreduction. A hole is

created in the amniotic membranes with a needle. Amniotic fluid is then allowed to re-
balance itself, allowing each twin to have the same amount of amniotic fluid.
Laser Treatment: Laser treatment aims to destroy the abnormal blood vessels in the
placenta that are responsible for the poor blood circulation between the two twins. A
scope is passed through the abdomen and into the recipient twins amniotic sac. A laser is
then passed through the scope and used to break the abnormal blood vessels. This laser
treatment often helps to normalize blood flow and sometimes works to completely
eliminate the TTTS.
Umbilical Cord Occlusion: Occasionally, TTTS causes one twin to become sick or to die
in utero. In this case, the other twin may still receive the blood from the sick twin and, as
a result, could also become sick. Umbilical cord occlusion uses a special instrument to tie
off the umbilical cord of the sick baby. This will cause the sick baby to die, but will save
the remaining twin.
Prognosis of Twin to Twin Transfusion Syndrome

Unfortunately, the prognosis of TTTS is not very good. If untreated, most twins die in
utero or shortly after birth. Even with treatment, it is not always possible to save twins
suffering from TTTS. Treatment generally increases survival rates by between 20% and
50%. However, many babies are born with physical or developmental disabilities even
with treatment.
If you are having twins, it is important to receive proper prenatal care in order to ensure
quick diagnosis of TTTS.
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Multiple pregnancies: complications
Carrying more than one baby can put an extra strain on your body's resources. We give
you the lowdown on the complications which can occur when you're pregnant with twins
or more.
When you're pregnant with multiple babies, many of the usual physical problems of
pregnancy can start sooner or be exaggerated. Nausea may be more bothersome because
of the higher level of circulating hormones. Heartburn, indigestion and the need to urinate
frequently are more likely as the enlarging uterus presses on other organs. Back pain is
common because of the extra load combined with the ligament-relaxing effects of
pregnancy hormones. Sleep problems, piles and varicose veins are all more likely to
develop.
More serious complications of pregnancy are also possible. Threatened miscarriage

occurs more often and, according to some studies, so does vaginal bleeding, perhaps
partly because one or both placentas are lying low in the uterus.
It is now known that in some cases a twin dies in the womb in the early weeks, leaving a
healthy survivor. An ultrasound at four to six weeks reveals two tiny pregnancy sacs but
by 12 weeks one of the sacs has been reabsorbed back into the body.
Until around 28 weeks, twins growth rate is usually normal. But then some babies do not
grow as fast as they should. Intrauterine growth retardation is carefully monitored by
ultrasound scans.
In a few multiple pregnancies, too much amniotic fluid builds up (polyhydramnios),

making life very uncomfortable for the mother. The fluid can be drawn off by
amniocentesis but a premature labour may follow or bed rest may be advised.
Pregnancy hypertension (high blood pressure) and pre-eclampsia are also more frequent,
and may mean that the babies need to be delivered early.
Premature labour is the main risk of twin pregnancy, probably caused by the uterus
overstretching. Four out of ten twin pregnancies (more with identical twins) go into
labour before 37 weeks. Going into hospital means that the condition of the babies can be
monitored but preventing a premature birth may not be possible.
A rare complication that can occur in identical twins when they share a chorion (the outer
membrane) is twin to twin transfusion syndrome (TTTS). Some blood from the placenta
passes from one twin to the other, potentially leaving one twin thin and undernourished
while the other grows at his expense. This can be extremely serious but many TTTS
babies are only mildly affected and born slightly different in size and colour. If this
happens to your babies, you can get advice and support from the UK Twin 2 Twin
Transfusion Syndrome Association.
Find out more about

pregnancy problems
pregnancy complications
premature labour
UK Twin 2 Twin Transfusion Association
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home :: multiples
Complications in a Multiples Pregnancy
Of all multiples, twins normally face the fewest medical problems and complications.
Each additional baby a woman carries at one time increases the possibility of developing
complications.
What are the most common complications associated with multiples?

Preterm Labor/Delivery
Low Birthweight
Intrauterine Growth Restriction (IUGR)
Preeclampsia
Gestational Diabetes
Placental Abruption
Fetal Demise/Loss
Cesarean
Preterm Labor/Delivery:
Preterm labor/delivery is defined as delivery before 37 completed weeks of pregnancy.

The length of gestation decreases with each additional baby. On average most single
pregnancies last 39 weeks, twin pregnancies 36 weeks, triplets 32 weeks, quadruplets 30
weeks, and quintuplets 29 weeks. Almost 60% of twins are delivered preterm, while 90%
of triplets are preterm. Higher order pregnancies are almost always preterm. Many times
premature labor is a result of preterm premature rupture of the membranes (PPROM).
PPROM is ROM (rupture of membranes) prior to the onset of labor in a patient who is at
less than 37 weeks of gestation.
Low Birth Weight:
Low birth weight is almost always related to preterm delivery. Low birth weight is less
than 5 pounds (2,500 grams). Babies born before 32 weeks and weighing less than 3 ?
pounds (1,500 grams) have an increased risk of developing complications as newborns as
well as having long-term problems such as mental retardation, cerebral palsy, vision loss,
and hearing loss.
Intrauterine Growth Restriction (IUGR):
Multiple gestations grow at approximately the same rate as a single pregnancy up to a

certain point. The growth rate of twin pregnancies begins to slow at 30 to 32 weeks.
Triplet pregnancies begin slowing at 27 to 28 weeks, while quadruplet pregnancies begin
slowing at 25 to 26 weeks. IUGR seems to occur because the placenta cannot handle any
more growth and because the babies are competing for nutrients. Your doctor will
monitor the growth of your babies by ultrasound and by measuring your abdomen.
Preeclampsia:
Preeclampsia, Pregnancy Induced Hypertension (PIH), Toxemia, and high blood pressure
are all synonymous terms. Twin pregnancies are twice as likely to be complicated by
preeclampsia as single pregnancies. Half of triplet pregnancies develop preeclampsia.
Frequent prenatal care increases the chance of detecting and treating preeclampsia.
Adequate prenatal care also decreases the chance of a serious problem resulting from
preeclampsia for both the babies and mother.
Gestational Diabetes:
The increased risk for gestational diabetes in a multiple pregnancy appears to be a result
of the two placentas increasing the resistance to insulin, increased placental size, and an
elevation in placental hormones. The occurrence of gestational diabetes in a multiple
pregnancy is still being tested at this time. In one study, an increased risk of gestational
diabetes did seem to be apparent, but the doctors involved recommended that further
testing be conducted.
Placental Abruption:
Placental abruption is three times more likely to occur in a multiple pregnancy. This may
be linked to the fact that there is an increased risk of developing preeclampsia. It most
often occurs in the third trimester, but the risk significantly increases once the first baby
has been delivered vaginally.
Fetal Demise or Loss:
Intrauterine fetal demise is extremely uncommon. Your healthcare provider will

determine whether it is best to expose the other baby(ies) to the fetus that has died or to
proceed with delivery. If the pregnancy is dichorionic (two chorions present), then
intervention may not be necessary. (The chorion is a membrane that forms the fetal
portion of the placenta. Fraternal twins always have two chorions while identical twins
can have one or two chorions.) If the pregnancy has a single chorion then fetal maturity
will be assessed to see if immediate delivery is achievable. In this situation it would be
necessary to evaluate the risks between having a premature baby to the risks of remaining
in utero.
Cesarean:
If you are pregnant with multiples it does not necessarily mean that you will have a
cesarean birth. The common recommendation for the delivery of triplets and higher order
multiples are a cesarean, but twins are commonly delivered vaginally. The vaginal
delivery of twins depends on the presentation of the babies. Twins can be delivered
vaginally when:
The gestation is greater than 32 weeks
Twin A (the baby closest to the cervix) is the largest
Twin A is head down
Twin B is head down, Breech, or sideways
Twin B is smaller than twin A
There is no evidence of fetal distress
There is no cephalopelvic disproportion (CPD)
Last Updated: 01/2005
For further information, call our helpline at 800-672-2296 to speak with a Reproductive
Educator.
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health care plan outlined by your health care professional. For specific medical advice,
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Complications in Twin and Multiple Birth Pregnancies

Pregnancy is a time filled with wonderful experiences and lots of great surprises. But you
may also find that you are a little nervous throughout your pregnancy, particularly when
it comes to those pregnancy complications. Though most women experience
complication-free pregnancies, there is always a risk that you could develop some type of
health concern throughout these nine months. In particular, women who are expecting
twins or multiples are at increased risk of experiencing pregnancy complications. So, if
you are expecting twins or multiples, be sure to become familiar with the signs and
symptoms of these complications.
Miscarriage
Miscarriage is a concern for all pregnant women, particularly in the first trimester.
Miscarriage occurs when a pregnancy is lost before the 20th week of pregnancy. It is
actually a fairly common occurrence, taking place in almost 20% of all pregnancies.
Unfortunately, the risk of miscarriage is even higher in twin and multiple pregnancies,
due to an increased chance of one baby having a chromosomal abnormality. Miscarriage
is usually accompanied by various symptoms, including abdominal cramping and
bleeding.
Miscarriage in multiple pregnancies often takes place in the form of "Vanishing Twin
Syndrome." This is a condition in which two fetuses are detected, but only one develops
throughout the pregnancy. For unknown reasons, this miscarried twin is reabsorbed into
the mothers body, but causes no outward symptoms of miscarriage.
Preterm Labor
Preterm labor is probably the most common complication found in twin and multiple
pregnancies. In fact, approximately 70% of twins, and close to 100% of higher order
multiples are born prematurely. Preterm labor occurs when contractions or dilation of the
cervix begin before the 38th week of pregnancy. It occurs fairly frequently in single
pregnancies and is often the result of infection, abnormal placenta, or maternal illness
(such as gestational diabetes). In multiple pregnancies, however, preterm labor is often
the result of overcrowding inside the uterus. The more babies you are expecting, the more
likely it is that you will experience a preterm labor.
Preterm labor doesnt usually occur that early in multiple pregnancies. Most twins or
triplets are born after the 28th week of pregnancy. However, if your multiples are born
before the 28th week, they may be at risk for serious complications, including birth
defects or breathing difficulties. Be sure to keep an eye out for the signs of preterm labor,
including early, sustained contractions, vaginal bleeding, or severe abdominal cramping.
Intrauterine Growth Retardation (IUGR)

Intrauterine growth retardation can occur in any pregnancy, although it is much more
common in women who are expecting twins or multiples, with as much as 50% of all
multiples experiencing some degree of IUGR. IUGR occurs when one (or more than one)
baby experiences difficulties with growth and development while in utero. Specifically,
IUGR is diagnosed when a baby is less than 10% of her expected weight for her fetal age.
IUGR can be caused by a number of factors, including infection and poor placental blood
circulation. However, in multiple pregnancies, it is most commonly caused by
overcrowding in the uterus. IUGR can be quite serious because it can lead to preterm
labor.
Twin-to-Twin Transfusion Syndrome (TTTS)

Twin-to-Twin Transfusion Syndrome is a serious complication associated with twin
pregnancies. Affecting identical twins that share a placenta, TTTS causes one twin to take
over the others blood supply in utero. This prevents one baby from receiving enough
nutrients and oxygen, while the other receives too many nutrients. As a result, one twin
becomes very large while the other remains small and undernourished.
TTTS only occurs in about 1 in every 1,000 pregnancies, yet it can be quite damaging
when it does occur. It can result in poor fetal development, heart failure, brain damage, or
even fetal death if left untreated. To ensure that you receive necessary treatment for
TTTS, be on the lookout for symptoms including rapid maternal weight gain, premature
contractions, and abdominal pain or tightness.
Preeclampsia
Preeclampsia is a relatively common complication in all types of pregnancies. It usually
occurs in the second trimester and is characterized by high blood pressure levels and
large amounts of protein in the urine. Women who are pregnant with twins or multiples
are at an increased risk of suffering from preeclampsia. In fact, between 10% and 20% of
all women experiencing multiple pregnancies will develop some form of preeclampsia.
When kept under control, preeclampsia does not pose any risk to you or your babies.
However, if left untreated, preeclampsia can lead to severe complications including
preterm labor and HELLP syndrome. Symptoms to watch out for include high blood
pressure, swelling of the face and hands, as well as fever or headaches.
Conjoined Twins
Conjoined twins are a very rare complication of multiple pregnancies, occurring in fewer
than 1 in 400,000 births. Conjoined twins form when your fertilized egg does not split
completely into two separate balls of cells. Instead, the two halves of the egg remain
attached at some point and the cells of each baby become mixed up. This causes the two
babies to grow into one another. There are many different types of conjoined twins,
classified according to where on the body they are attached.
Unfortunately, the majority of conjoined twins are stillborn or die within 24 hours of
birth. This is because many conjoined twins share vital organs with one another.
Conjoined twins that do survive are typically separated at birth, but this can be a very
risky and complicated surgery.
Preventing Complications in Twin and Multiple Pregnancies

The vast majority of multiple pregnancies are free of complications. However, it is still
important to be aware of the possible health risks that can take place. Though it is
impossible to prevent all pregnancy complications, there are some steps that you can take
to ensure that you and your babies remain healthy and happy during these nine months.
Attend all of your prenatal appointments.

Get confirmation of your multiple pregnancy as soon as possible.
Maintain a healthy pregnancy diet.
Stay well hydrated.
Be aware of the signs and symptoms associated with major pregnancy complications.
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home :: labor and birth

Premature Labor
Pregnancy is normally a time of happiness and anticipation, but it can also be a time of
unknowns. Many women have concerns about what is happening with their baby. Is
everything okay? Some women wonder about going into labor early. Premature labor
occurs in about 12% of all pregnancies. However, knowing the symptoms and avoiding
particular risk factors can lower a woman's chance of premature labor.
What is premature labor?
A normal pregnancy should last about 40 weeks. Occasionally, labor may begin
prematurely before the 37th week of pregnancy because uterine contractions cause the
cervix to open earlier than normal. When this happens, the baby is born premature and
can be at risk for health problems. Fortunately, due to research, technology and medicine,
the health of premature babies is improving.
What risk factors place me at a high risk for premature labor?
Certain factors may increase a woman's risk of having premature labor, although the
specific causes of premature labor are not known. However, having a specific risk factor
does not mean a woman is predetermined to have premature labor. A woman may have
premature labor for no apparent reason. If you have any of these risk factors, it's
important to know the symptoms of premature labor and what you should do if they
occur.
Women are at greatest risk for premature labor if:
They are pregnant with multiples
They have had a previous premature birth
They have certain uterine or cervical abnormalities
Medical risk factors include:
Recurring bladder and/or kidney infections
Urinary tract infections, vaginal infections, and sexually transmitted infections
Infection with fever (greater than 101 degrees F) during pregnancy
Unexplained vaginal bleeding after 20 weeks of pregnancy
Chronic illness such as high blood pressure, kidney disease or diabetes
Multiple first trimester abortions or one or more second trimester abortions
Underweight or overweight before pregnancy
Clotting Disorder (thrombophilia)
Being Pregnant with a single fetus after in vitro fertilization (IVF)
Short time between pregnancies (less than 6-9 months between birth and beginning of the
next pregnancy)
Lifestyle risks for premature labor include:
Little or no prenatal care
Smoking
Drinking alcohol
Using illegal drugs
Domestic violence, including physical, sexual or emotional abuse
Lack of social support
High levels of stress
Low income
Long working hours with long periods of standing
What are warning signs of premature labor?
It may be possible to prevent a premature birth by knowing the warning signs and calling
your health care provider if you suspect you are having premature labor. Warning signs
and symptoms of premature labor include:
A contraction every 10 minutes, or more frequently within one hour (five or more uterine
contractions in an hour)
Watery fluid leaking from your vagina (this could indicate that your bag of water is
broken)
Menstrual-like cramps felt in the lower abdomen that may come and go or be constant
Low, dull backache felt below the waistline that may come and go or be constant
Pelvic pressure that feels like your baby is pushing down
Abdominal cramps that may occur with or without diarrhea
Increase or change in vaginal discharge
What does a contraction feel like?
As the muscles of your uterus contract, you will feel your abdomen harden. As the
contraction goes away, your uterus becomes soft. Throughout pregnancy, the layers of
your uterus will tighten irregularly which are usually not painful. These are known as
Braxton-Hicks contractions and are usually irregular and do not open the cervix. If these
contractions become regular or more frequent (one every 10-12 minutes for at least an
hour) they may be premature labor contractions which can cause the cervix to open. It is
important to contact your health care provider immediately.
How can I check for contractions?
While lying down, use your fingertips to feel your uterus tighten and soften. This is called
palpation. During a contraction your abdomen will feel hard all over, not just in one
area. However, as your baby grows you may feel your abdomen become firmer in one
area and then become soft again.
What should I do if I think I am experiencing premature labor?
If you suspect you are having signs and symptoms of premature labor call your health
care provider immediately. This can be a scary time for you but there are some ways you
can help to prevent premature labor by becoming aware of the symptoms and following
these directions:
Empty your bladder
Lie down titled towards your left side; this may slow down or stop signs and symptoms
Avoid lying flat on your back; this may cause the contractions to increase
Drink several glasses of water because dehydration can cause contractions
Monitor contractions for one hour by counting the minutes that elapse from the beginning
of one contraction to the beginning of the next
If symptoms get worse, or don't go away after one hour, call your health care provider
again or go to the hospital. When you call your health care provider, be sure to mention
that you are worried about premature labor. The only sure way to know if you are in
premature labor is by examination of your cervix. If your cervix is opening up, premature
labor could be starting.
What is the treatment to prevent premature labor from starting or continuing?
Magnesium Sulfate is a medication given through an IV, which may cause nausea
temporarily. A large dose is given initially and then a smaller continuous dose is given for
12-24 hours or more.
Corticosteroid is a medication given 24 hours before birth to help accelerate the baby's
lung and brain maturity.
Oral medications are sometimes used to decrease the frequency of contractions, and may
make women feel better.
What impact does premature labor have on my pregnancy?
The longer your baby is in the womb, the better the chance he or she will be healthy.
Babies who are born prematurely are at higher risks for brain and other neurological
complications, as well as breathing and digestive problems. Some premature babies grow
up with a developmental delay, and/or have learning difficulties in school. The earlier in
pregnancy a baby is born, the more health problems are likely to develop.
Premature labor does not always result in premature delivery. Some women with
premature labor and early dilation of the cervix are sometimes put on bed rest until the
pregnancy progresses further.
Most babies born prior to 24 weeks have little chance of survival. Only about 50% will
survive and the other 50% may die or have permanent problems. However, babies born
after 32 weeks have a very high survival rate, and usually do not have long term
complications.
Babies born at hospitals with neonatal intensive care units (NICU) do best. If you deliver
at a hospital that does not have a NICU, you may be transferred to a nearby hospital.
Compiled using information from the following sources:
March of Dimes, http://www.marchofdimes.com/
eMedicine, http://www.emedicine.com/
Williams Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 36.
Educator.
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home :: Pregnancy Complications

Preeclampsia or Toxemia : Pregnancy Induced Hypertension (PIH)
Preeclampsia is a condition of high blood pressure during pregnancy. Your blood pressure
goes up, you retain water, and protein is found in your urine. It is also called toxemia or
pregnancy induced hypertension (PIH). The exact cause of preeclampsia is unknown.
Who is at risk for preeclampsia?
The following may increase the risk of developing preeclampsia:

A first-time mom
Women whose sisters and mothers had preeclampsia
Women carrying multiple babies; teenage mothers; and women older than age 40
Women who had high blood pressure or kidney disease prior to pregnancy
What are the symptoms of preeclampsia?
Mild preeclampsia: high blood pressure, water retention, and protein in the urine.
Severe preeclampsia: headaches, blurred vision, inability to tolerate bright light, fatigue,
nausea/vomiting, urinating small amounts, pain in the upper right abdomen, shortness of
breath, and tendency to bruise easily. Contact your doctor immediately if you experience
blurred vision, severe headaches, abdominal pain, and/or urinating very infrequently .
How do I know if I have preeclampsia?
At each prenatal checkup your healthcare provider will check your blood pressure, urine
levels, and may order blood tests which may show if you have preeclampsia.
Your physician may also perform other tests that include: checking kidney and blood-
clotting functions; ultrasound scan to check your baby's growth; and Doppler scan to
measure the efficiency of blood flow to the placenta.
How is preeclampsia treated?
Treatment depends on how close you are to your due date. If you are close to your due
date, and the baby is developed enough, your health care provider will probably want to
deliver your baby as soon as possible.
If you have mild preeclampsia and your baby has not reached full development, your
doctor will probably recommend you do the following:
Rest, lying on your left side to take the weight of the baby off your major blood vessels.
Increase prenatal checkups.
Consume less salt.
Drink 8 glasses of water a day.
If you have severe preeclampsia, your doctor may try to treat you with blood pressure
medication until you are far enough along to deliver safely.
How does preeclampsia affect my baby?
Preeclampsia can prevent the placenta from getting enough blood. If the placenta doesn't
get enough blood, your baby gets less oxygen and food. This can result in low birth
weight.
Most women still can deliver a healthy baby if preeclampsia is detected early and treated
with regular prenatal care.
How can I prevent preeclampsia:
Currently, there is no sure way to prevent preeclampsia. Some contributing factors to

high blood pressure can be controlled and some can't. Follow your doctor's instruction
about diet and exercise.
Use little or no added salt in your meals.
Drink 6-8 glasses of water a day.
Don't eat a lot of fried foods and junk food.
Get enough rest
Exercise regularly
Elevate your feet several times during the day.
Avoid drinking alcohol.
Avoid beverages containing caffeine.
Your doctor may suggest you take prescribed medicine and additional supplements.
Preeclampsia Foundation, http://www.preeclampsia.org/index.asp
Educator.
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Gestational Diabetes
All expecting mothers will be tested for gestational diabetes at some point during their
pregnancy. Expecting mothers who are over the age of 35, over weight, or have a family
history of diabetes may be tested earlier and more frequently.
What is gestational diabetes?
Gestational diabetes is a temporary form (in most cases) of diabetes in which the body
does not produce adequate amounts of insulin to deal with sugar during pregnancy. It
may also be called glucose intolerance or carbohydrate intolerance. Signs and symptoms
can include:
Sugar in urine (revealed in a test done in your doctors office)
Unusual thirst
Frequent urination
Fatigue
Nausea
Frequent infections of bladder, vagina and skin
Blurred vision
Who gets gestational diabetes, and why do I have to be tested?
Approximately 2-5% of all expecting mothers will develop gestational diabetes; this
number may increase to 7-9% in populations where mothers are more likely to have risk
factors. The screening for this disease usually will take place some time between your
24th and 28th week of pregnancy. Doctors test for gestational diabetes during this time
because the placenta is producing large amounts of hormones that may cause insulin
resistance. If the result comes back with elevated levels, further testing would be done to
confirm a diagnosis of gestational diabetes.
What should I expect during my test?
During your prenatal visit your doctor will give you a sweet liquid (sweet does not
necessarily mean good!) to drink one hour before your blood is drawn. It may cause you
to feel a bit nauseous. The results will indicate if you are producing enough insulin or not.
If I have gestational diabetes how will I be treated?
The biggest part of treating gestational diabetes is controlling your blood sugar levels.
There are things you and your doctor can do in order to control your levels and keep them
at a safe and normal amount:
Close monitoring of you and your baby
Self monitoring of blood glucose levels
Insulin therapy, if necessary
Diet and exercise management
It has been reported that women who develop gestational diabetes have a greater chance
of developing overt (Type II) diabetes later in life.
Is there anything I should be afraid of?
If gestational diabetes is diagnosed and treated effectively, there is little risk of

complications. If gestational diabetes is not treated, effects for mother and baby can
include:
Large birth weight
Premature delivery
Increased chance of cesarean delivery
Slightly increased risk of fetal and neonatal death
With proper care and treatment, women with gestational diabetes can have healthy
babies, and the diabetes should disappear after delivery.
It is important that you watch for any continuing signs that you may still be diabetic after
giving birth. These symptoms include:
Frequent urination
Persistent thirst
Increased sugar in blood or urine
Testing may be done a few months after the delivery to make sure your blood sugar levels
have returned back to normal.
Recommended Reading
You may find the following books helpful.
Your purchase supports the American Pregnancy Association


MedlinePlus [Internet]. Bethesda (MD): National Library of Medicine (US); [updated
2006 Feb 21]. Gestational Diabetes; [updated 2006 Feb 14; reviewed 2006 Jan 27; cited
2006 Feb 22]. Available from:
http://www.nlm.nih.gov/medlineplus/diabetesandpregnancy.html
Educator.

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Placental Abruption : Abruptio Placentae
Placental abruption is the separation of the placenta from the uterine lining. This
condition usually occurs in the third trimester but can occur any time after the 20th week
of pregnancy. Only about 1% of all pregnant women will experience placental abruption,
and most can be successfully treated depending on what type of separation occurs.
What are the signs & symptoms of placental abruption?
The signs and symptoms of placental abruption include one or more of the following:
Vaginal bleeding (although about 20% of cases will have no bleeding)
Uterine tenderness
Rapid contractions
Abdominal pain
Fetal heart rate abnormalities
Any vaginal bleeding in the third trimester should be reported to your health care
provider immediately. Other causes for vaginal bleeding could be placenta previa. Your
health care provider will know the proper diagnosis.
What actually happens in placental abruption?
The placenta is part of your baby's life support system. It transfers oxygen and nutrients
to your baby. When the placenta separates from your uterine lining before labor it can
interrupt the transportation of oxygen and nutrients to your baby.
Placental abruption can only truly be diagnosed after birth, when the placenta can be
examined. There are a few methods that are used to try to make this diagnosis during
pregnancy so that proper treatment can be applied. These include:
Ultrasound
Evaluation of patients symptoms (bleeding, pain)
Blood tests
Fetal monitoring
What is the treatment for placental abruption?
Treatment depends on the severity of the separation, location of the separation and the
age of the pregnancy. There can be a partial separation or a complete (also called a total)
separation that occurs. There can also be different degrees of each of these which will
impact the type of treatment recommended.
In the case of a partial separation, bed rest and close monitoring may be prescribed if the
pregnancy has not reached maturity. In some cases, transfusions and other emergency
treatment may be needed as well.
In a case with a total or complete separation, delivery is often the safest course of action.
If the fetus is stable, vaginal delivery may be an option. If the fetus is in distress or the
mom is experiencing severe bleeding, then a cesarean delivery would be necessary.
Unfortunately, there is no treatment that can stop the placenta from detaching and there is
no way to reattach it.
Any type of placental abruption can lead to premature birth and low birth weight. In
cases where severe placental abruption occurs, approximately 15% will end in fetal death.
What causes placental abruption?
The causes of placental abruption are not completely known. However, women are more
at risk for this condition if they:
Smoke
Use cocaine during pregnancy
Are over the age of 35
Have preeclampsia or hypertension
Are pregnant with twins or triplets
Have had a previous placental abruption
Experience trauma to the abdomen
Have abnormalities in the uterus
When should I call my health care provider?
You should call your health care provider immediately if you experience bleeding in your
third trimester. Only your health care provider can make a proper diagnosis for the cause
of late term bleeding. The outcome of a placental abruption diagnosis is improved with
fast and accurate treatment.
Compiled using information from the following source:
William's Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 35
Educator.

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What is Infertility

Placental Abruption : Abruptio Placentae
Placental abruption is the separation of the placenta from the uterine lining. This
condition usually occurs in the third trimester but can occur any time after the 20th week
of pregnancy. Only about 1% of all pregnant women will experience placental abruption,
and most can be successfully treated depending on what type of separation occurs.
What are the signs & symptoms of placental abruption?
The signs and symptoms of placental abruption include one or more of the following:
Vaginal bleeding (although about 20% of cases will have no bleeding)
Uterine tenderness
Rapid contractions
Abdominal pain
Fetal heart rate abnormalities
Any vaginal bleeding in the third trimester should be reported to your health care
provider immediately. Other causes for vaginal bleeding could be placenta previa. Your
health care provider will know the proper diagnosis.
What actually happens in placental abruption?
The placenta is part of your baby's life support system. It transfers oxygen and nutrients
to your baby. When the placenta separates from your uterine lining before labor it can
interrupt the transportation of oxygen and nutrients to your baby.
Placental abruption can only truly be diagnosed after birth, when the placenta can be
examined. There are a few methods that are used to try to make this diagnosis during
pregnancy so that proper treatment can be applied. These include:
Ultrasound
Evaluation of patients symptoms (bleeding, pain)
Blood tests
Fetal monitoring
What is the treatment for placental abruption?
Treatment depends on the severity of the separation, location of the separation and the
age of the pregnancy. There can be a partial separation or a complete (also called a total)
separation that occurs. There can also be different degrees of each of these which will
impact the type of treatment recommended.
In the case of a partial separation, bed rest and close monitoring may be prescribed if the
pregnancy has not reached maturity. In some cases, transfusions and other emergency
treatment may be needed as well.
In a case with a total or complete separation, delivery is often the safest course of action.
If the fetus is stable, vaginal delivery may be an option. If the fetus is in distress or the
mom is experiencing severe bleeding, then a cesarean delivery would be necessary.
Unfortunately, there is no treatment that can stop the placenta from detaching and there is
no way to reattach it.
Any type of placental abruption can lead to premature birth and low birth weight. In
cases where severe placental abruption occurs, approximately 15% will end in fetal death.
What causes placental abruption?
The causes of placental abruption are not completely known. However, women are more
at risk for this condition if they:
Smoke
Use cocaine during pregnancy
Are over the age of 35
Have preeclampsia or hypertension
Are pregnant with twins or triplets
Have had a previous placental abruption
Experience trauma to the abdomen
Have abnormalities in the uterus
When should I call my health care provider?
You should call your health care provider immediately if you experience bleeding in your
third trimester. Only your health care provider can make a proper diagnosis for the cause
of late term bleeding. The outcome of a placental abruption diagnosis is improved with
fast and accurate treatment.
Compiled using information from the following source:
William's Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 35
Educator.

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What is Infertility

Risks of a Cesarean Procedure
A cesarean birth happens through an incision in the abdominal wall and uterus rather than
through the vagina. There has been a gradual increase in cesarean births over the past 30
years. In November of 2005, the Centers for Disease Control and Prevention(CDC)
reported the national cesarean birth rate was the highest ever at 29.1%, which is over a
quarter of all deliveries. This means that over 1 in 4 women will experience a cesarean
delivery.
With any major surgical procedure, there are risks involved. It is important to know and
understand your risks before a cesarean procedure, so that you may feel equipped to talk
with your health care provider and make informed decisions.
Risks and Complications for the Mom:
Take into account that most of the following risks are associated with any type of
abdominal surgery.
Infection: Infection can occur at the incision site, in the uterus and in other pelvic organs
such as the bladder.
Hemorrhage or increased blood loss: There is more blood loss in a cesarean delivery than
with a vaginal delivery. This can lead to anemia or a blood transfusion (1 to 6 women per
100 require a blood transfusion1).
Injury to organs: Possible injury to organs such as the bowel or bladder (2 per 1002).
Adhesions: Scar tissue may form inside the pelvic region causing blockage and pain. This
can also lead to future pregnancy complication such as placenta previa or placental
abruption3.
Extended hospital stay: After a cesarean, the normal time in the hospital is 3-5 days after
giving birth if there are no complications.
Extended recovery time: The amount of time needed for recovery after a cesarean can
extend from weeks to months, having an impact on bonding time with your baby (1 in 14
report incisional pain six months or more after surgery4).
Reactions to medications: There can be a negative reaction to the anesthesia given during
a cesarean or reaction to pain mediation given after the procedure.
Risk of additional surgeries: Such as hysterectomy, bladder repair or another cesarean.
Maternal mortality: The maternal mortality rate for a cesarean is greater than with a
vaginal birth.
Emotional reactions: Women who have a cesarean report feeling negatively about their
birth experience and may have trouble with initial bonding with their baby5.
Risks and Complications for the Baby:
Premature birth: If gestational age was not calculated correctly, a baby delivered by
cesarean could be delivered too early and be low birth weight6.
Breathing problems: When delivered by cesarean, a baby is more likely to have breathing
and respiratory difficulties. Some studies show an increased need for assistance with
breathing and immediate care after a cesarean than with a vaginal delivery7.
Low APGAR scores: Low APGAR scores can be the result of anesthesia, fetal distress
before the delivery or lack of stimulation during delivery (vaginal birth provides natural
stimulation to the baby while in the birth canal). Babies born by cesarean are 50% more
likely to have lower APGAR scores than those born vaginally8.
Fetal injury: Very rarely, the baby may be nicked or cut during the incision (1 to 2 babies
per 100 will be cut during the surgery9).
If your health care provider has suggested a cesarean and you are in a non-emergency
situation, take the time to really discuss your options regarding the procedure.
Ask questions so that you can understand why a cesarean procedure has been
recommended
Ask for any alternatives that my be an option in your particular situation
Have your health care provider compare all the possible risks and complications for you
and your baby when having a cesarean and not having a cesarean
Get information regarding the normal procedures after a cesarean (i.e., when can you
hold your baby, can the newborn evaluation be done while the baby is on your chest, how
soon can you try to breastfeed, are you given medication that would make you drowsy
after the delivery)
What else you should know about Cesarean Birth:
Cesarean Procedure
Reasons for a Cesarean
Trying to avoid a Cesarean
Creating a Positive experience
Cesarean Aftercare
1 & 2Shearer El. Cesarean section: medical benefits and costs. Soc Sci Med 1993;37(10):
1223-31.
3Lydon-Rochelle M et al..First birth cesarean and placental abruption or previa at second

birth. Obstet Gynecol 2000;97 (5 Pt 1):765-9.
4 & 5Declerq ER , Sakala C, Corry MP. Listening to Mothers: Report of the First
National U.S .Survey of Womens Childbearing Experiences. New York: Maternity
Center Association, Oct 2002.
6ACOG. Evaluation of Cesarean Delivery. Washington, DC: ACOG, 2000.

7 & 8Annibale DJ et al. Comparative neonatal morbidity of abdominal and vaginal
deliveries after uncomplicated pregnancies. Arch Pediatr Adolesc Med 1995;149(8):862-
7.
9Van Ham MA, van Dongen PW, Mulder J. Maternal consequences of cesarean section.
A retrospective study of intraoperative and postoperative maternal complications of
cesarean during a 10-year period. Eur J Obstet Gynecol Reprod Biol 1997; 74 (1): 1-6.
Educator.

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Cesarean Procedure
A cesarean birth happens through an incision in the abdominal wall and uterus rather than
through the vagina. There has been a gradual increase in cesarean births over the past 30
years. In November of 2005, the Centers for Disease Control and Prevention (CDC)
reported the national cesarean birth rate was the highest ever at 29.1%, which is over a
quarter of all deliveries. This means that over 1 in 4 women will experience a cesarean
birth.
Your purchase supports the APA

What can I expect in a Cesarean procedure?
The normal cesarean procedure will take an average of 45 minutes to an hour. The baby is
usually delivered in the first 5-15 minutes and the remainder of time is used for closing
the incision.
Pre surgery:
Before surgery, you will be given some type of anesthetic (general, spinal, or epidural) if
you have not been given one earlier in your labor. General anesthetic is normally only
used for emergency cesareans because it is effective immediately and the mother is
sedated. The spinal and epidural anesthesia will numb the area from the abdomen to
below the waist (sometimes the legs can be numb also), so that nothing can be felt during
the procedure. You will probably receive a catheter to collect urine while your lower body
is numb.
Surgery:
The health care provider will make an incision in the abdomen wall first. In an
emergency cesarean this will most likely be a vertical incision (from the navel to the
pubic area) which will allow the health care provider to deliver the baby faster. The most
common incision is made horizontally (often called a bikini cut), just above the pubic
bone. The muscles in your stomach will not be cut; they will be pulled apart so that the
health care provider can get to the uterus.
An incision will then be made into the uterus, horizontally or vertically. The same type of
incision does not have to be made in both the abdomen and uterus. The classical incision
made vertically, is usually reserved for complicated situations such as placenta previa,
emergencies, or babies with abnormalities. A vaginal birth after cesarean (VBAC) is not
recommended for women with the classical incision. Another type of incision which is
rarely used is the lower segment vertical incision. This would only be used if there were
problems with the uterus that would not allow another type of incision to be made. The
most common incision made is the low transverse incision. This incision has fewer risks
and complications than the others and allows most women to attempt a VBAC in their
next pregnancy with little risk of uterine rupture.
The health care provider will suction the amniotic fluid out and then will deliver the baby.
Your babies head will be delivered first so that the mouth and nose can be cleaned out to
allow for its first breath. Once the whole body is delivered, the baby will be lifted up so
that you can meet your newborn. Most health care providers will then pass the baby on to
the nurse for evaluation. The last thing to be delivered will be your placenta (you may
feel some tugging) and then the surgical team will begin the close up process.
After the Surgery:
Once the surgery is over, you may begin to experience some nausea and trembling. This
can be caused by the anesthesia, the effects of your uterus contracting, or from an
adrenaline let down. This usually passes quickly and can be followed by some
drowsiness. If your baby is healthy, this is usually the time when the baby can rest on
your chest and you can begin breastfeeding and bonding. You and your baby will
continually be monitored for any complications.
When you are discharged from the hospital you will be advised on the proper post-
operative care for your incision and yourself.
What else you should know about Cesarean Birth:
Reasons for a Cesarean

Risks of a Cesarean
Trying to avoid a Cesarean
Creating a Positive experience
Cesarean Aftercare
William's Obstetrics Twenty-Second Ed. Cunningham, F. Gary, et al, Ch. 25.
Coalition for Improving Maternity Services (CIMS), www.motherfriendly.org
Centers for Disease Control and Prevention, www.cdc.gov
Educator.
University of Virginia Health System

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High-Risk Pregnancy
Multiple Pregnancy
What is multiple pregnancy?
Multiple pregnancy is a pregnancy with two or more fetuses. Names for these include the
following:
Twins - 2 fetuses
Triplets - 3 fetuses
Quadruplets - 4 fetuses
Quintuplets - 5 fetuses
Sextuplets - 6 fetuses
Septuplets - 7 fetuses
While multiples account for only a small percentage of all births (about 3 percent), the
multiple birth rate is rising. According to the National Center for Health Statistics, the
twin birth rate has risen 59 percent since 1980, and is currently 30.1 per 1,000 live births.
The birth rate for triplets and other higher order multiples has also risen a staggering 423
percent. However, since 1998, the birth rate for triplets and higher has slowed.
What causes multiple pregnancy?
There are many factors related to having a multiple pregnancy. Naturally occurring
factors include the following:
heredity
A family history of multiple pregnancy increases the chances of having twins.
older age
Women over 30 have a greater chance of multiple conception. Many women today are
delaying childbearing until later in life, and may have twins as a result.
high parity
Having one or more previous pregnancies, especially a multiple pregnancy, increases the
chances of having multiples.
race
African-American women are more likely to have twins than any other race. Asian and
Native Americans have the lowest twinning rates. Caucasian women, especially those
over age 35, have the highest rate of higher-order multiple births (triplets or more).
Other factors that have greatly increased the multiple birth rate in recent years include
reproductive technologies, including the following:
Ovulation-stimulating medications such as clomiphene citrate and follicle stimulating
hormone (FSH) help produce many eggs, which, if fertilized, can result in multiple
babies.
Assisted reproductive technologies such as in vitro fertilization (IVF) and other

techniques help couples conceive. These technologies often use ovulation-stimulating
medications to produce multiple eggs which are then fertilized and returned to the uterus
to develop.
How does multiple pregnancy occur?
Multiple pregnancy usually occurs when more than one egg is fertilized and implants in
the uterus. This is called fraternal twinning and can produce boys, girls, or a combination
of both. Fraternal multiples are simply siblings conceived at the same time. However, just
as siblings often look alike, fraternal multiples may look very similar. Fraternal multiples
each have a separate placenta and amniotic sac.
Sometimes, one egg is fertilized and then divides into two or more embryos. This is
called identical twinning and produces all boys, or all girls. Identical multiples are
genetically identical, and usually look so much alike that even parents have a hard time
telling them apart. However, these children have different personalities and are distinct
individuals. Identical multiples may have individual placentas and amniotic sacs, but
most share a placenta with separate sacs. Rarely, identical twins share one placenta and a
single amniotic sac.
Why is multiple pregnancy a concern?
Being pregnant with more than one baby is exciting and is often a happy event for many
couples. However, multiple pregnancy has increased risks for complications. The most
common complications include the following:
preterm labor and birth
About half of twins and nearly all higher-order multiples are premature (born before 37
weeks). The higher the number of fetuses in the pregnancy, the greater the risk for early
birth. Premature babies are born before their bodies and organ systems have completely
matured. These babies are often small, with low birthweights (less than 2,500 grams or
5.5 pounds), and they may need help breathing, eating, fighting infection, and staying
warm. Very premature babies, those born before 28 weeks, are especially vulnerable.
Many of their organs may not be ready for life outside the mother's uterus and may be too
immature to function well. Many multiple birth babies will need care in a neonatal
intensive care unit (NICU).
pregnancy-induced hypertension
Women with multiple fetuses are more than three times as likely to develop high blood
pressure of pregnancy. This condition often develops earlier and is more severe than
pregnancy with one baby. It can also increase the chance of placental abruption (early
detachment of the placenta).
anemia
Anemia is more than twice as common in multiple pregnancies as in a single birth.
birth defects
Multiple birth babies have about twice the risk of congenital (present at birth)
abnormalities including neural tube defects (such as spina bifida), gastrointestinal, and
heart abnormalities.
miscarriage
A phenomenon called the vanishing twin syndrome in which more than one fetus is
diagnosed, but vanishes (or is miscarried), usually in the first trimester, is more likely in
multiple pregnancies. This may or may not be accompanied by bleeding. The risk of
pregnancy loss is increased in later trimesters as well.
twin-to-twin transfusion syndrome

Twin-to-twin syndrome is a condition of the placenta that develops only with identical
twins that share a placenta. Blood vessels connect within the placenta and divert blood
from one fetus to the other. It occurs in about 15 percent of twins with a shared placenta.
abnormal amounts of amniotic fluid

Amniotic fluid abnormalities are more common in multiple pregnancies, especially for
twins that share a placenta.
cesarean delivery
Abnormal fetal positions increase the chances of cesarean birth.
postpartum hemorrhage
The large placental area and over-distended uterus place a mother at risk for bleeding
after delivery in many multiple pregnancies.
What is multifetal pregnancy reduction?
In recent years, a procedure called multifetal pregnancy reduction has been used for very
high numbers of fetuses, especially four or more. This procedure involves injecting one
or more fetuses with a lethal medication, causing fetal death. The objective of multifetal
reduction is that by reducing the number of fetuses in the pregnancy, the remaining
fetuses may have a better chance for health and survival. Consult your physician for
additional information.
What are the symptoms of multiple pregnancy?
The following are the most common symptoms of multiple pregnancy. However, each
woman may experience symptoms differently. Symptoms of multiple pregnancy may
include:
uterus is larger than expected for the dates in pregnancy
increased morning sickness
increased appetite
excessive weight gain, especially in early pregnancy
fetal movements felt in different parts of abdomen at same time
How is multiple pregnancy diagnosed?
Many women suspect they are pregnant with more than one baby, especially if they have
been pregnant before. Diagnosis of multiple fetuses may be made early in pregnancy,
especially if reproductive technologies have been used. In addition to a complete medical
history and physical examination, diagnosis may be made by:
pregnancy blood testing
Levels of human chorionic gonadotrophin (hCG) may be quite high with multiple
pregnancy.
alpha-fetoprotein
Levels of a protein released by the fetal liver and found in the mother's blood may be
high when more than one fetus is making the protein.
ultrasound - a diagnostic imaging technique which uses high-frequency sound waves and
a computer to create images of blood vessels, tissues, and organs. Ultrasounds are used to
view internal organs as they function, and to assess blood flow through various vessels -
with a vaginal transducer, especially in early pregnancy, or with an abdominal transducer
in later pregnancy.
Management of multiple pregnancy:
Specific management for multiple pregnancy will be determined by your physician based
on:
your pregnancy, overall health, and medical history
the number of fetuses
your tolerance for specific medications, procedures, or therapies
expectations for the course of the pregnancy
your opinion or preference
Management of multiple pregnancy may include the following:

increased nutrition
Mothers carrying two or more fetuses need more calories, protein, and other nutrients,
including iron. Higher weight gain is also recommended for multiple pregnancy. The
American College of Obstetricians and Gynecologists recommends women carrying
twins gain at least 35 to 45 pounds.
more frequent prenatal visits (to check for complications and to monitor nutrition and
weight gain)
referrals
Referral to a maternal-fetal medicine specialist, called a perinatologist, for special testing
or ultrasound evaluations, and to coordinate care of complications, may be necessary.
increased rest
Some women may also need bedrest - either at home or in the hospital depending on
pregnancy complications or the number of fetuses. Higher-order multiple pregnancies
often require bedrest beginning in the middle of the second trimester.
maternal and fetal testing

Testing may be needed to monitor the health of the fetuses, especially if there are
pregnancy complications.
tocolytic medications
Tocolytic medications may be given, if preterm labor occurs, to help slow or stop
contractions. These may be given orally, in an injection, or intravenously. Tocolytic
medications often used include terbutaline and magnesium sulfate.
corticosteroid medications
Corticosteroid medications may be given to help mature the lungs of the fetus. Lung
immaturity is a major problem of premature babies.
cervical cerclage
Cerclage (a procedure used to suture the cervical opening) is used for women with an
incompetent cervix. This is a condition in which the cervix is physically weak and unable
to stay closed during pregnancy. Some women with higher-order multiples may require
cerclage in early pregnancy.
How are multiple pregnancies delivered?
Delivery of multiples depends on many factors including the fetal positions, gestational
age, and health of mother and fetuses. Generally, in twins, if both fetuses are in the vertex
(head-down) position and there are no other complications, a vaginal delivery is possible.
If the first fetus is vertex, but the second is not, the first fetus may be delivered vaginally,
then the second is either turned to the vertex position or delivered breech (buttocks are
presented first). These procedures can increase the risk for problems such as prolapsed
cord (when the cord slips down through the cervical opening). Emergency cesarean birth
of the second fetus may be needed. Usually, if the first fetus is not vertex, both babies are
delivered by cesarean. Most triplets and other higher-order multiples are born by
cesarean.
Vaginal delivery may take place in an operating room because of the greater risks for
complications during birth and the need for cesarean delivery. Cesarean delivery is
usually needed for fetuses that are in abnormal positions, for certain medical conditions
of the mother, and for fetal distress.
Care of multiple birth babies:
Because many multiples are small and born early, they may be initially cared for in a
special care nursery called the neonatal intensive care unit (NICU). Once babies are able
to feed, grow, and stay warm, they can usually be discharged. Other babies, that are
healthy at birth, may need only a brief check in a special care nursery.
Breastfeeding multiples is certainly possible and many mothers of twins and even triplets
are successful in breastfeeding all of their babies. Lactation specialists can help mothers
of multiples learn techniques for breastfeeding their babies separately and together, and to
increase their milk supply. Mothers whose babies are unable to breastfeed because they
are sick or premature can pump their breast milk and store the milk for later feedings.
Families with more than one baby need help from family and friends. The first two
months are usually the most difficult as everyone learns to cope with frequent feedings,
lack of sleep, and little personal time. Having help for household chores and daily tasks
can allow the mother the time she needs to get to know her babies, for feedings, and for
rest and recovery from delivery.
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