Transcript Ghadeer Al-Shaikh

Ghadeer Al-Shaikh, MD, FRCSC
Assistant Professor & Consultant
Obstetrics & Gynecology
Urogynecology & Pelvic Reconstructive Surgery
Department of Obstetrics & Gynecology
College of Medicine
King Saud University
MULTIPLE PREGNANCY
 Twin pregnancy represents 2 to 3% of all pregnancies.
 The PNMR is 5 times that of singleton
DIZYGOTIC TWINS
 Most common represents 2/3 of cases.
 Fertilization of more than one egg by more than one
sperm.
 Non identical ,may be of different sex.
 Two chorion and two amnion.
 Placenta may be separate or fused.
Factors affecting it’s incidence
 Induction of ovulation, 10% with clomide and 30%
with gonadotrophins.
 Increase maternal age ? Due to increase
gonadotrophins production.
 Increases with parity.
 Heredity usually on maternal side.
 Race; Nigeria 1:22 North America 1:90.
MONOZYGOTIC TWINS
 Constant incidence of 1:250 births.
 Not affected by heredity.
 Not related to induction of ovulation.
 Constitutes 1/3 of twins.
Results from division of
fertilized egg:
0-72 H.
4-8 days
9-12 days
>12 days
Diamniotic dichorionic.
Diamniotic monochor.
Monoamnio.monochor.
Conjoined twins.
MONOZYGOTIC TWINS
 70% are diamniotic monochorionic.
 30% are diamniotic dichorionic.
Determination of zygosity
 Very important as most of the complications occur in
monochorionic monozygotic twins.
During pregnancy by USS
 Very accurate in the first trimester, two sacs, presence
of thick chorion between amniotic memb.
 Less accurate in the second trimester the chorion
become thin and fuse with the amniotic memb.
 Different sex indicates dizygotic twins.
 Separate placentas indicates dizygotic twins
Determination of zygozity After Birth
 By examination of the MEMBRANE, PLACENTA,SEX ,
BLOOD group .
 Examination of the newborn DNA and HLA may be
needed in few cases.
Complications of Multiple Gestation
Maternal
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Anemia
Hydramnios
Preeclampsia
Preterm labour
Postpartum hemorrhage
Cesarean delivery
Fetal
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Malpresentation
Placenta previa
Abruptio placentae
Premature rupture of the
membranes
Prematurity
Umbilical cord prolapse
Intrauterine growth
restriction
Congenital anomalies
Specific Complications in
Monochorionic Twins
TWIN-TWIN transfusion.
 Results from vascular anastomoses between twins
vessels at the placenta.
 Usually arterio (donor) venous (recipient).
 Occurs in 10% of monochorionic twins.
TWIN-TWIN transfusion
 Chronic shunt occurs ,the donor bleeds into the
recipient so one is pale with oligohydramnios while the
other is polycythemic with hydramnios.
 If not treated death occurs in 80-100% of cases.
Possible methods of treatment:
 Repeated amniocentesis from recipient.
 Indomethacin.
 Fetoscopy and laser ablation of communicating
vessels.
Other Complications in Monochorionic Twins:
 Congenital malformation. Twice that of singleton.
 Umbilical cord anomalies. In 3 – 4 %.
 Conjoined twins. Rare 1:70000 deli varies. The
majority are thoracopagus.
 PNMR of monochorionic is 5 times that of
dichorionic twins(120 VS 24/ 1000 births)
Maternal Physiological Adaptation
 Increase blood volume and cardiac output.
 Increase demand for iron and folic acid.
 Maternal respiratory difficulty.
 Excess fluid retention and edema.
 Increase attacks of supine hypotension.
DIAGNOSIS OF MULTIPLE PREGNANCY
 +ve family history mainly on maternal side.
 +ve history of ovulation induction.
 Exaggerated symptoms of pregnancy.
 Marked edema of lower limb.
 Discrepancy between date and uterine size.
 Palpation of many fetal parts.
 Auscultation of two fetal heart beats at two different
sites with a difference of 10 beats
 USS
Two sacs by 5 weeks by TV USS.
Two embryos by 7 weeks by TV USS.
Antenatal Care
AIM
 Prolongation of gestation age, increase fetal weight.
 Improve PNM and morbidity.
 Decrease incidence of maternal complications.
Antenatal Care
Follow Up
 Every two weeks.
 Iron and folic acid to avoid anemia.
 Assess cervical length and competency.
Antenatal Care
Fetal Surveillance
 Monthly USS from 24 weeks to assess fetal growth and
weight.
 A discordinate weight difference of >25% is abnormal
(IUGR).
 Weekly CTG from 36 weeks.
Method Of Delivery
Vertex- Vertex (50%)
 Vaginal delivery.
Vertex- Breech (20%)
Vaginal delivery by senior obstetrician
Method Of Delivery
Breech- Vertex( 20%)
 Safer to deliver by CS to avoid the rare interlocking
twins( 1:1000 twins ).
Breech-Breech( 10%)
 Usually by CS.
Method Of Delivery in Monochorionic Twins
 C/S
Perinatal Outcome
 PNMR is 5 times that of singleton (30-50/1000 births).
 RDS accounts for 50% 0f PNMR.2nd twin is more
affected.
 Birth trauma . 2ND twin is 4 times affected than 1st .
 Incidence of SB is twice that of singleton.
Perinatal Outcome
 Congenital anomalies is responsible for 15% of PNMR.
 Cerebral hemorrhage and birth asphyxia are
responsible for 10% of PNMR.
 Cerebral palsy is 4 times that of singleton .
 50% of twins babies are borne with low birth(<2500
gms.) from prematurity & IUGR.
INTRAUTERINE DEATH OF ONE TWIN
 Early in pregnancy usually no risk.
 In 2nd or 3rd trimester:
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Increase risk of DIC .
 Increase risk of thrombosis in the a live one
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The risk is much higher in monochorionic than in
dichorionic twins
 The alive baby should be delivered by 32-34 weeks in
monochorionic twins.
HIGH RANK MULTIPLE GESTATION
 Spontaneous triplets 1:8000 births.
 Spontaneous quadruplets 1:700,000 births.
 The main risk is sever prematurity .
 CS is the usual and safe mode of delivary.
 High PNMR of 50-100 / 1000 births
Thank You!!!