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Twins pregnancy

Prepared by:

Dr. Kasturi Malla

Senior Consultant Gynecologist & Obstetrician: Government of Nepal


Visiting Professor: CTGU
February 2009

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Occurrence:
• Incidence= 1%
– 1/3rd=monozygotic, Twins
– 2/3rd=dizygotic
• Monozygotics = 1
in 80n-1
– Hellin’s rule Monozygotic Dizygotic
– n= Number of
fetus
• Twins=1:80
• Triplet=1:802 M/M=5% M/D=3% D/D=3% D/D=60%
• Quadruplet=1:803
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Embryonic division

Time of Development event Amnion Chorion Placenta


division
0-72hrs Before morula stage 2 2 2(D/D)

4th - 8th day After inner cell mass 2 1 1(D/M)

2nd week After amniotc cavity 1 1 1(M/M)

After After embryonic disc 1 1 1(conjoined)


2weeks

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Zygosity

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Types
Dizygotic=2 ova fertilized Monozygotic=1 ova
fertilized then split
• 2 Placentae (may be • 1 placenta
fused)
• Sex may not be same • Same sex
• Blood group may not be • Same blood group
same
• Variable incidence • Constant incidence
(1:250)
• May not match HLA • Similar HLA antigen
antigen

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Conjoined twin

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Types of conjoined twins
1. Thoracopagus

2. Pyopagus

3. Craniopagus

4. Ischiopagus

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Clinical Features…

Increased
1. Wt.
2. CO
3. Plasma & blood vol
4. AFP
5. Tidal vol.
6. GFR

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Presentation:

• Vx.Vx.=60%
• Vx.Br.=20%
• Br.Vx.=10%
• Br.Br.=10%

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…Clinical Features…
1. H/O ovulation, Family history
2. Hyperemesis, larger abd. size, early
cardiorespiratory overload
3. Increased edema, varicocity, hemorrhoid
4. More anemia/edema
5. Early onset PET
6. Early delivery

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…Clinical Features
• P/A: • Abd.girth (at umbilicus)
1. Large size uterus, =
No.of inch
2. Increased abd.girth, =
No.of week
3. >2fetal pole,
• Fundal ht.(from syphysis)
4. Multiple fetal parts, =
No.of cm
5. FHS at 2 places. =
No.of week
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Test

1. All baseline tests of blood and urine

2. USG

3. X-ray 2heads, 2spines

4. Biochemical  hCG ,AFP, Estriol= 2x

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D/D

1. Big baby

2. Polyhydramnios

3. Pregnancy
+
Fibroid uterus/Ovarian tumor

4. Pregnancy + ascites

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Maternal complication…

1.Hyperemesis

2.Anemia

3.PET

4.Polyhydramnios

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…Maternal complication…
5.Mechanical distress

6.Twin-twin transfusion

7.Cord entanglement

8.Conjoint twin

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…Maternal complication…
9. Placenta previa/APH

10. Preterm labor

11. Malpresentation

12. Locked twins

13. Cord prolapse

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…Maternal complication
14. Surgical intervention+

15. PPH

16. Subinvolution

17. Puerperal sepsis

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Average gestational age at delivery:

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Fetal Complication
1. Abortion

2. Premature birth

3. Discordant growth

4. IUGR/SB/IUFD

5. Birth asphyxia

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Mortality factor…
Maternal

1. PPH

2. PET/ET

3. Anemia/Cardiac
failure

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…Mortality factor
Perinatal

1. Prematurity

2. Entangled cord

3. Placental abruption

4. Surgical
intervention

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Antenatal care…
1. + calori

2. +rest

3. Iron/Folic acid

4. + visit

5. + fetal scan

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…Antenatal care
1. Uterine relaxant- Salbutamol,
Retodrine For Premature
contraction

2. Corticosteroid-
Dexamethasone 24mg/Day in
2-3 divided doses  For fetal
maturity if <34wk

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Labor management…
Prerequisites:
• Place-Hosp.

• Skilled obstetrician

• Keep obstetric
forceps ready

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…Labor management
1. Episiotomy under local anesthesia

2. No ergometrine prior to the 2nd twin birth

3. Cord clamp nearer to the fetus=3-4” ,cut


in between 2 ligatures

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…Labor management

For vertex or after


coming head of
breech

Assisted or Forceps del.

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…Labor management
2nd transverse

1. External cephalic version


+
assisted/Forceps del.

Or

2. Internal podalic version


+
Breech del.

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Indication of CS…
Maternal
1. Placenta previa/APH

2. Cord prolapse

3. Severe PET/ET

4. Prev.CS

5. CPD

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…Indication of CS
Fetal
1. Conjoint twin
2. 1st transverse
3. Twin-twin shunt
4. IUGR
5. Monoamniotic twins
6. Locked twins
• At brim
• In vagina
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