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Multiple Pregnancy PDF
Multiple Pregnancy PDF
Supervised by:
Prof. Salah Roshdy
Done by:
Yasser Abdulmohsen Alresiny
426035045
OBJECTIVES:
Definition.
Incidence and epidemiology.
Clinical characteristics.
Classification.
Diagnosis.
Complications.
Abnormalities of the twinning process.
Management.
DEFINITION:
Any pregnancy which two or more embryos or
fetuses present in the uterus at same time.
It is consider as a complication of pregnancy due
to ;
The mean gestational age of delivery of twins is
approximately 36w.
The perinatal mortality &morbidity increase.
Terminology vs. number
Singletons one fetus
Twins tow fetuses.
Triplets three fetuses.
Quadruplets four fetuses.
Quintuplets five fetuses.
sextuplets six fetuses.
Septuplets seven fetuses.
Mean gestational age of delivery
Number of babies Weeks of Gestation
1 40 weeks
2 36 weeks
3 33 weeks
4 29 weeks
Incidence & epidemiology
The incidence of multiple pregnancy in US is
approximately 3% (increase annually due to ART ).
Monozygotic twins ( approx. 4 in 1000 births ).
Triplet pregnancies ( approx. 1 in 8000 births ).
Multiple gestation increase morbidity & mortality
for both the mother & the fetuses.
The perinatal mortality in the developed countries
Twins = 5 10 % births.
Triplets = 10 20 % births.
Clinical characteristics:
Multiple gestation should be suspected when ;
Uterine size is greater than expected for
gestational age.
Multiple FHRs are heard
Multiple fetal parts are felt.
hCG & serum alpha-fetoprotein levels are
elevated for gestational age.
If the pregnancy is a result of ART.
Diagnosis is confirmed by US .
DDx of uterus that is greater than
expected for gestational age:
1- Polyhydramnios.
2- Macrosomia.
3- Placental abruption.
4- Gestational trophoplastic disease.
5- Uterine fibroid.
6- Ovarian mass.
Classification
Dichorionic/Diamniotic
Dichorionic/Diamniotic Monochorionic/Monoamniotic
(8%( (1%)
Monochorionic/Diamniotic
(20%)
0 - 72 hr diamniotic,dichorionic 8 8.9%
By ;
Ultrasound : genders,numbar of placentas,
Blood groups.
HLA.
DNA analysis.
During pregnancy by US :
2
different same
same Blood
HLA & DNA group
analysis
different
Septum Placental type Twin type
1 2 3 4
Complications:
A - Maternal:
Antepartum
Anemia.
Miscarriage.
Preeclampsia ( 40% in twins & 60% in triplets ).
Polyhydramnios ( 5 8%).
PTL ( Twin account for 10% of all PTL & 25% of all preterm
perinatal deaths ).
Cervical incompetence.
Hyperemesis gravidarum.
Intrapartum
CS.
Postpartum
postpartum uterine atony. b/c of
post partum Hemorrhage. Over distended uterus
postpartum endometritis
Cont..
B - Fetal:
Malpresentation.
Umblical cord prolapse.
Placenta previa & abruptio placenta.
PROM & Prematurity.
IUGR .
Congenitial anomalies.
Increase perinatal morbidity & mortality
Causes of perinatal morbidity and
mortality in twins:
Respiratory distress syndrome
Birth trauma
Cerebral hemorrhage
Birth asphyxia
Birth anoxia
Congenital anomalies
Stillbirths
Prematurity
Abnormalities of the twinning process:
Conjoined Twins.
Interplacental Vascular Anastomosis.
Twin-Twin Transfusion Syndrome.
Fetal Malformations.
Umbilical Cord Abnormalities.
Discordant Twin Growth.
Locked twins ( delivered by CS ).
Single fetal death
Rupture of membrane in single sac
Locked twins
Conjoined Twins ;
Etiology : It result from cleavage of the embryo is
incomplete because it happen very late (after 13 days,
when the embryonic disc has completely formed).
Incidence : once in 70,000 deliveries.
Classification:
Thoracopagus (antreior) most common.
Pygopagus (posterior)
Craniopagus (cephalic)
Ischiopagus (caudal)
Delivery by C.S.
Thoracopagus Craniopagus
Interplacental Vascular Anastomoses:
It occurs almost exclusively in monochorionic
twins at a rate of 90% or more.
Type:
Arterial_artarial(most common).
Arterial_venous.
Venous_venous.
Complications:
Abortion.
Hydramnios.
Twin-twin transfusion syndrome (TTTS).
Fetal malformations.
Twin-Twin Transfusion Syndrome ;
Definition:
15% of monochorionic twins have domensturable
anastomosis.
The presence of unbalanced anastomosis in the placenta
(typically arterial-venous connections) leads to a syndrome in
which one twins circulation perfuses the other Twin.
Complication:
Donor : anemic HF, hypovolemia, hypotension, anemia,
oligohydramnios, growth restriction. ( do intrauterine blood
trans fusion).
Recipient : hypervolemic HF , hypervolemia, hypertension,
polyhydramnios, thrombosis, hyperviscosity,cardiomegaly,
polycythemia, hydrops fetalis. ( do repeated amnioreduction).
Both: risk of demise & PTL.
Management of TTTs ;
If not treated death occurs in 80-100% of cases.
If extreme prematurity prevents immediate delivery,
Several interventions can be considered in view of the
high mortality associated with expectant management.
Repeated amniocentesis from ( recipient) .
Intrauterine transfusion of the anemic (donor) twin
is of no benefit in this condition.
Indomethacin.
Fetoscopy and laser ablation of communicating
vessels.
Fetal Malformations:
Incidence:
Twice as common in twins & 4 times more common
in triplets than in singleton infants.
Monozygotic > Dizygotic.
Etiology:
Usually result from arterial-arterial anastomosis.
Common deformations in twins include limb
defects, plagiocephaly, facial asymmetry, and
torticollis.
Acardia and twin-reversed arterial perfusion
(TRAP) rare but unique to multiple pregnancy.
Amniocentesis:
If U/S shows abnormality.
Acardiac
Normal twin
(pump) twin
Umbilical Cord Abnormalities:
Absence of one umbilical artery occurs in about
3% to 4% of twins (30% of case absence of one
artery associated with other congenital
anomaliesrenal agenesis ).
Cord entanglement ( esp. in monochorionic
monoamniotic twins ).
Discordant Twin Growth:
Definition:
Discrepancy of more than 20% in the estimated fetal
weights.
Causes:
TTTS.
Chromosomal or structural anomalies.
Discordant viral infection.
Interplacental Vascular Anastomoses.
Specific indication C/S in Twins ;
1. monochorionic monoamniotic twins
2. Conjoined twins
3. Non vertex presentation of first twin
4. Locked twins
5. Twin-reversed arterial perfusion (TRAP)
6. Placentation in Higher-Order Multiples
7. Other obstrictic indication of C/S
Management:
Antepartum
Adequate nutrition.
Adequacy of maternal diet is assessed due to the increased
need for overall calories, iron, vitamins, and folate .
The Institute of Medicine (IOM) recommends women with
twins gain a total of 16.0 to 20.5 kg during the pregnancy.
More frequent prenatal visits.
Periodic U/S assessment every 3-4 weeks from23weeks
gestation to monitor the growth and detection of
discordant growth or TTTS.
Fetal surveillance:
Performance of NST is not indicated before 34 wks unless to
confirm IUGR or discordant growth.
( avoid CST )
Amniocentesis. ( If indicated )
In case of death of one fetus is managed based on the gestational
age and condition of the surviving fetus.