Uterus Larger

than Date
Raihanah Akhbar
Shari ah Aida Husna
Muaz
Content
1. Causes or uterus lar er than date in pre nancy

2. Special emphasis on:

a. Polyhydramnios

b. Multiple pre nancy

3. Appropriate mana ement o specific conditions.

 Causes of uterus larger than date

Maternal Fetal

● Polyhydramnios ● Fetal macrosomia

● Multiple pre nancy ● Fetal mal ormations (e
● Wron dates hydrocephalus)
● Molar pre nancy
● Pelvic masses (e uterine
fibroids, ovarian cyst,
ovarian tumour)
Polyhydramnios
1. Physiolo y o amniotic fluids
2. Definition
3. Causes
4. Clinical Features
5. Physical Examination
6. Investi ations
7. Mana ement
 Physiology of amniotic fluid
● Initially secreted by the amnion.
● By 10th week :
○ Mainly transudate o the etal serum via the skin and umbilical
cord
● From 16th week :
○ Fetal skin becomes impermeable to water
○ Increase in amniotic fluid due to small imbalance between
production by the kidneys and lun s and removal by etal
swallowin .
● Problems with any o the structures in this pathway can lead to
either too much or too little fluid production.
 Function of amniotic fluid

01 Protect the etus

rom mechanical
02 Prevent adhesions
between etus and
injury amnion

Permit etal lun development

in which there is two-way

03 04
movement o fluid into the etal
Permit movement
bronchioles; absence o
o the etus while
amniotic fluid in the second
preventin limb
trimester is associated with
contracture.
pulmonary hypoplasia
 Normal volume of amniotic fluids
Amniotic fluid volume increases pro ressively. The reason or the late reduction
has not been explained.

POG (weeks) Volume (mL)

10 30

20 300

30 600

38 1000

40 800

42 350
 Measurement of amniotic fluid
● The amount o amniotic fluid in the uterus is a uide to etal
wellbein in the third trimester.
● Two approaches o measurement o amniotic fluid throu h
ultrasound :
○ Maximum vertical pool.
○ Amniotic fluid index.
 Maximum Vertical Pool

● It is per ormed by assessin the

maximum depth o the amniotic fluid
which is ree rom an umbilical cord
and etal parts.
● Value:
○ < 2 cm su est oli ohydramnios
○ < 8 cm su est polyhydramnios.
 Amniotic Fluid Index (AFI)
● Measured by dividin the uterus into our ultrasound quadrants.
● A vertical measurement is taken o the deepest pool o fluid that is ree
o umbilical cord in each quadrant and the results summated.
● The AFI alters throu hout estation, but in the third trimester it should
be between 10 and 25 cm
○ < 10 cm indicate a reduced volume
○ < 5 cm indicate oli ohydramnios
○ > 25 cm indicate polyhydramnios.
AFI :

6.97 + 4.06 + 4.95 + 3.76 = 19.74cm

Interpretation:

Normal AFI.
 Polyhydramnios
Polyhydramnios is the term iven to an excess o amniotic fluid (i.e. AFI >95th
centile or estation on ultrasound estimation).
 Causes of Polyhydramnios
Maternal Fetal
• Multiple estation (twin-to-twin

• Maternal disease trans usion syndrome)

‒ Diabetes. • Idiopathic

‒ Heart disease • Oesopha eal

‒ Pre-eclampsia atresia/tracheo-oesopha eal fistula

• Placental • Duodenal atresia

‒ Chorioan ioma • Neuromuscular etal condition

‒ Arterio-venous fistula (prevent swallowin )

• TORCH in ection • Anencephaly

• Trisomy 21, 13 and 18.
• Hydrop etalis
 Clinical Presentations
Sign and symptoms Examination

● Abdomen appear distended out

● Severe abdominal swellin and
o proportion to the woman’s
discom orts.
estation (increased SFH).
● Dyspnea
● Abdomen may be tense and
● Tachycardia
tender
● Vomitin
● Fetal poles will be hard to
● Severe abdominal pain
palpate
● Fetal heart beat is muffled
 Investigations
1. Ultrasound
2. Oral lucose tolerance test or mothers suspected with DM
3. CTG, Fetoscope or etal arrhythmias
4. Ultrasound Doppler : Assess blood flow velocity in the anterior cerebral
artery o etal or etal arrythmias (hi h cardiac output will increase etal
urination)
5. Fetal karyotypin : Trisomy 21, 13 and 18 (collection o chorionic villi, amniotic
fluid or etal blood)
6. Maternal blood roup antibodies : hydrops etalis
7. TORCH screenin (I G & I M titers, VDRL)
 Prenatal Ultrasound
1. Evaluate etal swallowin
‒ Decrease de lutition occurs in anencephaly, trisomy 18 & 21, muscular
dystrophy & skeletal dysplasia
2. Evaluate etal anatomy
‒ Assess or diaphra matic hernia, lun mass and absence o stomach bubble
(esopha eal atresia).
‒ Duodenal atresia : double-bubble si n or dilated duodenum.
3. Test or etal arrhythmias & mal ormation - that cause cardiac ailure & hydrops.
4. Abnormally lar e abdominal circum erence (AC) - ascites and hydrops etalis.
5. Macrosomic etus - poorly controlled maternal DM.
6. Assess the blood flow velocity in etal middle cerebral artery or etal anaemia.
 Complications
With polyhydramnios, risk o the ollowin complications is increased:

● Preterm contractions and possibly preterm labor

● Premature rupture o membranes, sometimes ollowed by placental abruption
● Fetal malposition
● Maternal respiratory compromise
● Umbilical cord prolapse
● Uterine atony
● Postpartum hemorrha e
● Fetal death (risk is increased even when polyhydramnios is idiopathic)

Risks tend to be proportional to the de ree o fluid accumulation and vary with the
cause.
 Managements

● Mana ement is directed to:

‒ Establish cause & determine etus pro nosis

‒ Relieve mother’s discom ort (i necessary, by amnioreduction)

‒ Assess risk o preterm labour due to uterine over-distension

➔ Amnioreduction/reductive amniocentesis
◆ May be per ormed in patient who are
affected by severe polyhydramnios.

◆ Can reduce risk o preterm labour,

premature rupture o membrane, cord
prolapse & placenta abruptio.

◆ I too much fluid is removed - placenta

abruptio may occur.

◆ Other risks: in ection, bleedin and trauma

to etus.
Assessment o preterm labour risk:
• Patient with polyhydramnios
‒ Hi h incidence o preterm labor secondary to overdistension o uterus.
• Schedule weekly or twice weekly perinatal visits & cervical examination
• Bedrest
‒ To reduce likelihood o preterm labor
• Cervical suture insertion
‒ Given when cervical len th < than 25 mm ollowin amniotic fluid draina e
prior to 24 weeks estation.
• Use o steroids
‒ To enhance etal lun maturity i preterm delivery is expected
• Serial ultrasono raphy - determine AFI & document etal rowth.

• I polyhydramnios is associated with etal hydrops secondary to etal

anemia:

❖ Direct intravascular trans usion o RBCs OR in usion into etal abdomen

‒ May improved etal hematocrit

‒ Allow prolon ation o pre nancy & improve survival o etus.

• I polyhydramnios due to maternal DM is suspected:

‒ Required ur ent investi ations as it o ten su est hi h maternal blood lucose levels.

‒ Polyhydramnios should correct itsel when mother's lycemic control is optimized.

 Multiple
pregnancy
1. Introduction
2. Epidemiolo y
3. Aetiolo y
4. History
5. Physical Examination
6. Investi ations
7. Mana ement
Introduction
A multiple pre nancy means you are havin more than one baby at
the same time

The hi h prevalence o multiple pre nancy is explained by

increasin use o assisted ertility.

There are amilial and enetic actors that contribute to the risk o
havin naturally occurrin twins, which are most commonly
nonidentical twins ( raternal; dizy otic) and occur due to multiple
ovulation; there ore, the chance o havin twins runs down the
maternal line.
Epidemiology
A study conducted in 2010 by Centre o Clinical Research, Malaysia
where 136,856 deliveries studied, there were 1395 twins, 29 triplets,
and 2 hi her order pre nancies, ivin a multiple pre nancy rate
o 10.4 per 1000 deliveries (1.04%).

The incidence o multiple pre nancy varies worldwide, with rates

varyin rom approximately 6 per 1,000 births in Japan to rates o
approximately 40 per 1,000 births in Ni eria

The majority (97–99%) o these were twin pre nancies with the
remainder bein predominantly triplet pre nancies
 Aetiology
It can be classified according to:
Number o etuses Twins, triplets, quadruplets, etc

Number o ertilized e Zy osity

Number o placenta Chorionicity

Number o amniotic cavities Amnionicity

 Twin pregnancy
Maybe dizy otic (70%) or monozy otic (30%)

Dizygotic (non-identical)
● Occur rom ovulation and subsequent ertilization o
two oocytes
● This results in dichorionic diamniotic twins, where
each etus has its own placenta and amniotic cavity.
● Althou h unctionally separated, placentae can
become anatomically used to ether, appear as a
sin le placental mass
● Always have separate amniotic cavities (diamniotic)
and the two cavities are separated by a thick
three-layer membrane ( used amnion in the middle
with chorion on either side)
● Can be same sex, or different.
Ultrasound appearance o dichorionic
(A) and monochorionic (B) twin
pre nancies at 12 weeks’ estation.

Note that there appears to be a sin le

placental mass but in the dichorionic
type there is an extension o placental
tissue into the base o the inter-twin
membrane, ormin the lambda si n.
 Twin pregnancy
Maybe dizy otic (70%) or monozy otic (30%)

Monozygotic (identical)
● Result rom ertilization o a sin le ovum
● Monochorionic diamniotic (20%) pre nancies occur
when division o the zy ote occurs between days our
and ei ht post ertilization
● Majority o monochorionic twins have two amniotic
cavities
● Monochorionic monoamniotic (1%) pre nancy occurs
when division occurs between days 8 and 12
post ertilization and finally conjoined twins occur
when division o the zy ote happens a ter day 13
Sono raphic ima e o the two
thin amniotic layers (arrows)
separatin the twins in a
monochorionic diamniotic twin
pair at 11 weeks
Kumar, Bid; Alfirevic, Zarko (2016). Fetal Medicine || Multiple pre nancy:
patholo y and epidemiolo y. , 10.1017/CBO9781107585843(23), 299–303.
doi:10.1017/CBO9781107585843.024
Diagnosing:
● History
● Physical Examination
● Investigation
 History
● Details
■ Maternal a e and parity
■ West A rica descent

● Current pre nancy history

■ Exa erated symptoms o pre nancy (e :wei ht
ain,nausea, vomitin , )
■ Hyperemesis ravidarum
■ Sensation o movement more than one etus
 History
● Gynaecolo ical history
■ Sub ertility - increase risk in onadotropin stimulation
■ Pre nancy attained throu h assisted reproductive
technolo y (ART)

● Dru history
■ Usa e o ovulation inducin dru s -e : clomiphene

● Family history
■ Familial history o twinnin especially on maternal side
 Physical Examination
General

● Pallor - prevalence o anemia is more than in

sin leton pre nancy

● Accelerated wei ht ain

● Sometimes may show hi h BP and proteinuria be ore

22 weeks o estation (early onset o pre-eclampsia)
 Abdominal examination
Inspection:
★ Check or abdominal scars: laparoscopy (treatment or sub ertility)
★ Over distended abdomen (barrel shaped abdomen)
Palpation:
★ Symphysio- undal hei ht more than the period o amenorrhea in
second trimester
★ Size o uterus more than the periods o estation comparison with
sin leton pre nancy
★ Abdominal irth at the level o umbilicus reater than the normal
abdominal irth at term
★ Palpation o multiple etal part (more than 2 etal poles)
★ Polyhydramnios
Auscultation:
★ Two etal heart sound can be heard and located at two separate
spot
 Pelvic Examination
Va inal examination
★ Vulva-Increase risk o vulva varicosities in multiple pre nancy
★ Cervix - Early si ns o labour: so tenin , effacement (as multiple
pre nancies increased risk o pre nancy complication)
 Investigation: Ultrasound
● The optimal time or dia nosis is in the first trimester or early second
trimester
● Evidence o more than one etus
● Differentiation between monochorionic and dichorionic twins durin early
pre nancy
○ Dichorionic twins: lambda si n
■ Both chorionic cavities are separated rom one another.
■ Separation o the chorionic and amniotic sacs resembles the
Greek symbol λ (lambda) on ultrasound.
○ Monochorionic twins: T-si n
■ One chorionic cavity is present and each twin has an individual
amniotic sac.
■ Separation o the amniotic sacs resembles the letter T on
ultrasound
Complications
 Preterm delivery (most common)
Due to occurrence o other adverse pre nancy complications such as
pre-eclampsia or FGR .
Overall, approximately 60% o twin pre nancies result in spontaneous birth be ore
37 weeks’ estation

For twins the timin or delivery depends on chorionicity and amnionicity:

● Dichorionic-diamniotic: 38 0/7 weeks–38 6/7 weeks

● Monochorionic-diamniotic: 34 0/7 weeks–37 6/7 weeks
● Monochorionic-monoamniotic: 32 0/7 weeks–34 0/7 weeks
Late miscarriage

In dichorionic pre nancy, the chance is 2%.

Perinatal mortality

● Overall perinatal mortality or monochorionic twins is estimated at 30 per 1,000

(compared with 3.8 per 1,000 amon dichorionic twins). Overall, mortality rate or
twins 5.5 times hi her than sin letons.
● Mainly due to extreme prematurity
● Stillbirth rate - 12 per 1000 in twin births and 31 per 1000 in triplets. Compared to
sin letons, 5 in 1000
● Early demise and subsequently ‘vanish’
● The death o one o a monochorionic twin pair may result in either death or
handicap o the co-twin because o acute hypotension secondary to placental
vascular anastomoses between the two circulations
Fetal growth restrictions

Whilst etal rowth in multiple pre nancy is thou ht to mirror that o

sin leton rowth in the first and second trimester, some studies describe
slower rowth in the third trimester

This is probably due to both abnormal placentation and increased

metabolic demands.

The chance o suboptimal etal rowth or monochorionic twins is almost

double that or dichorionic twins.
Fetal abnormality

Increased risk o structural abnormalities and this is thou ht to be

mainly due to abnormal cleava e in monozy otic twinnin .

In the majority o cases, only one etus is affected.

The risk o chromosomal abnormality is hi her because o

the additive effect, i.e., because the more etuses the more chance
there is an abnormality, e. ., in twins it is doubled and in triplets it is
tripled.
Complications unique to monochorionic twin
pregnancies
Twin-to-twin trans usion syndrome

When twins share a placenta, there will always be

vascular anastomoses between the circulations o the
twins.

I the connections are unbalanced with more AV

connections occurrin in one direction than the other,
alterations in the hydrostatic and osmotic orces occur,
resultin in the mani estations seen in TTTS

Fetoscopic laser photocoa ulation (FLP) o placental

anastomoses is the standard treatment o TTTS.
● Recipient twin
○ Polyhydramnios in diamniotic
pre nancies
○ Hypervolemia
● Donor twin
○ Oli ohydamnios in diamniotic
pre nancies
○ Growth retardation
○ Hypovolemia, dehydration
○ (stuck twin or cocooned
appearance)
○
Quintero sta in system o TTTS based on ultrasono raphic findin s

Halvorsen, C.P. (2013). Twin-twin trans usion syndrome (TTTS) :

outcomes with special re erence to cardiovascular unction.
 Twin Anaemia Polycythemia Sequence (TAPS)

Defined as the presence o anemia in the donor twin and polycythemia in the
recipient twin in monochorionic twin pre nancy, and is associated with an
increased risk o perinatal morbidity and mortality.

TAPS is a rarer chronic orm o TTTS in which a lar e inter-twin haemo lobin
difference occurs but the oli ohydramnios polyhydramnios sequence that is
observed with TTTS is not seen.

The small residual anastomoses

lead to the radual development o
anaemia in one twin and
polycythaemia in the other twin.
 Maternal Complications
1. Hypertensive disorders ( estational hypertension
and pre-eclampsia)
2. Gestational diabetes
3. Obstetrics cholestasis
4. Antepartum haemorrha e
5. Postpartum haemorrha e
6. Incidence & complications o operative delivery
7. Postpartum depression
Management

Can be divided into sta es;

● Antenatal
● Intrapartum
● Postpartum
● Hi her Multiples
 Antenatal Management
Initial Visit
● Ensure chorionicity durin
first scan (increase POG =
increasin difficulty)
● Counsellin re ardin
options or antenatal
screenin or etal
anomalies
● Explainin the risk o
premature delivery, optimal
timin or uncomplicated
delivery and potential
modes o delivery
Subsequent Visit
● Increase requency o visits
● Screenin or hypertension
and GDM
● Close monitorin (hi her
risk o developin APH and
thromboembolic disease
● Routine supplementation is
recommended (increase in
etoplacental demand or
iron and olic acid)
 Determination of Chorionicity
● Critical to ood mana ement
(poses different risk and
outcome)
● Done most reliably by
ultrasound in the late 1st
trimester
● Dichorionic on ultrasound
○ V shaped extension o
placental tissue into the
base o the inter twin
membrane (Lambda or Twin
peak SI n)
● Monochorionic on ultrasound
○ The inter twin membrane
joins the uterine wall in a T
shape
 Screening for fetal abnormalities
● Trisomy 21 screenin by usin the maternal serum biochemistry
● Alpha etoprotein (neural tube de ects)
● Nuchal translucency scan at 12 weeks o estation (down
syndrome or any chromosomal abnormalities)
● Amniocentesis and chorionic villus samplin can be per ormed
in twin pre nancies
● Screenin or etal structural anomalies is done usin the 2nd
trimester ultrasound
Monitoring Fetal Growth and Wellbeing
● Measurement o Symphisial ● In monochorionic twins;
Fundal Hei ht and maternal ○ Features o twin - twin
reportin o etal trans usion syndrome
movements are unreliable should be seek;
● Principally by ultrasound ○ Discordances between
● Each assessment should etal size
include; ○ Fetal activity
○ Fetal measurements ○ Bladder volumes
○ Fetal activity ○ Amniotic fluid volumes
○ Fetal lies ○ Cardiac size
○ Amniotic fluid volumes ● In any twin pre nancy, when
one or both etuses are
small, additional
in ormation about etal well
bein can be obtained rom
Doppler assessment o etal
circulation and CTG
 Threatened Preterm Labour
● Neither bed rest nor prophylactic● administration o tocolytics is
use ul or preventin preterm delivery
● Antenatal strate ies in those identified as hi h risk:
○ Maternal steroid therapy: enhance etal lun maturity
○ Supplementary education as to the si ns o preterm labour
○ Advance plannin re ardin intrapartum care
○ Screenin or GBS
○ Additional medical and midwi ery support
● Transva inal cervical ultrasound shows the most promisin as
predictor o very preterm delivery
● Once preterm labour is dia nosed, neonatal unit staff must be
promptly involved.
Algorithm
Summary
Intrapartum Management

● Complications in labour are

common with twin estation
○ Premature birth
○ Abnormal presentation
○ Prolapsed cord
○ Premature separation
o placenta
○ PPH
 General Management
● Antenatal education and a pre - a reed birth plan, continuous
etal heart monitorin
● Two or resuscitation trolleys, obstetricians, paediatrics are
available and the special care baby unit and anesthetist are
in ormed well in advance o the delivery.
● Anal esia, ideally in the orm o an early epidural, to allow or
internal podalic version (i needed) or twin 2
● A standard oxytocin solution or au mentation should be
prepared
● Portable ultrasound
 Fetal Wellbeing
● Fetal HR monitorin should be continuous throu hout
labor, ideally usin a specialized twin monitor - scalp
electrode.
● An abnormal etal Hr pattern in the 1st twin may be
assessed usin etal scalp samplin , as or sin leton
pre nancy.
● A non reassurin pattern in the 2nd twin will usually
necessitate delivery by Caesarean section
● The condition o the 2nd twin must be care ully monitored
a ter the delivery o the 1st twin as acute complications such
as cord prolapse and placental separation are well
reco nized.
Presentation
 Vaginal Delivery of Vertex - Vertex
● Criteria or va inal delivery
○ Vertex presentation
○ Separate membranes
○ No obstetrics contraindication
● An obstetrician should be present in anticipation o
complication with delivery o the 2nd twin
● No ur ency to deliver the 2nd twin within a set time period,
providin both mother and baby remain well.
● A ter the delivery o the 1st twin, abdominal palpation
should be per ormed to assess the lie o the 2nd twin
● I the lie is lon itudinal with a cephalic presentation, one
should wait until the head is descendin and then per orm
amniotomy with a contraction.
● I contractions do not ensue within 5 - 10 minutes a ter
delivery o the 1st twin, an oxytocin in usion should be
started.
 Delivery of Vertex - Non - Vertex
● I the 2nd twin is non vertex (in about 40% o twins), va inal
delivery can still be sa ely considered
● I the 2nd twin is a breech, the membrane can be ruptured
on the breech is fixed in the birth canal
● A total breech extraction may be per ormed i etal distress
occurs or i a ootlin breech is encountered
● Where the etus is transverse, external cephalic version can
be success ul in >70% o cases.
● Monitor closely etal HR and ultrasound used to confirm
final position o the baby.
● I external cephalic version is unsuccess ul, provided
presence o experienced operator, an internal podalic
version can be undertaken.
Internal Podalic Version
 Non - Vertex 1st Twin

● I the 1st twin is in non vertex, delivery by C- Section is hi hly

recommended
● Rare phenomenon o locked twins where the chin o the 1st
baby locks a ainst the chin o the cephalic twin which could
happen i opted or va inal delivery
 Requirements
● Lar e delivery room
● Operatin theatre and staff ready
● Anaesthetist present
● Senior obstetrician present
● At least 2 midwives present
● Twin resuscitaires
● Ventouse/ orceps to hand
● Blood rouped and saved IV
access
● Neonatolo ist present
● Pre mixed oxytocin in usion ready
 Postpartum Haemorrhage
● The risk o PPH is increased in twin pre nancy
● Thus, all multiple estation should have and IV line and blood
rouped and saved durin labour.
● Do not attempt to remove the placenta a ter delivery o the first
twin
● Active mana ement o 3rd sta e o labour
○ IV syntocinon should be administered with the delivery o
the anterior shoulder o the 2nd twin
○ Oxytocin drip can be continued or about 1 hour ollowin
delivery
○ Delivery o placenta must be controlled cord traction
○ In case o excess blood loss, blood trans usion may be
required.
 Higher Multiples
● A consequence o the widespread introduction o
assisted reproductive techniques
● Mostly triplets
● Associated with increased risk o miscarria e,
perinatal death and handicapped
● Median estational a e at birth is 33 weeks
● Lon term complications primarily a consequence o
extremely preterm delivery
● Althou h the demands on maternal physiolo y are
reater still, antenatal care is essentially no different
rom that or a twin estation
● Caesarean section advocated or delivery