1. 40 year old primi, BMI of 32,conceived
twins with donor oocytes: how to make
her journey safe?
Dr.Sameer Dikshit
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2. Wadia Hospital
S L Raheja Fortis Irla Nursing Home
Hospital Belle Vue Nursing
BSES MG Global Home
Hospital Sanket Sonography
Boisar Fetal Medicine Centre
Centre
Fetal Medicine Consultant
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5. Found pinned on the nursing station of a 5
star hospital in Mumbai…….
The doctors complain
that the patients are
more courteous to
nurses than to them.
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6. 40 year old
Height 162 cm, weight 84 kg, BMI 32
G1 P0
Donor oocytes
Twin Pregnancy
History…..
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7. Early Pregnancy Mid Pregnancy Late Pregnancy
First Trim Screening Abnormalities Clinical
Chorionicity Growth Complications
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11. Age 40 years Age 25
Prior risk 1:83 Prior risk 1:950-1001
The recipient The donor
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12. The background risk is the risk at
the age of the “Donor” and NOT at
the age of the “Recipient”
In this case, prior risk is NOT 1:83,
but it is 1:1001
In case of donor oocytes..
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18. The posterior risk of the two
twins is the same, and it is
calculated by taking a mean of
the two NTs……..
In Monochorionic
Twins…
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19. Let us add First Trimester
Biochemistry……..
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20. Biochemistry in
Twins is less
accurate than in
Singletons
Some advocate
doing only NT
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21. The biochemistry risk is
calculated taking into
consideration, the age of the
recipient into account
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22. SYSTEMATIC
LABELING OF
TWINS
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24. Biometric measurements from serial
scans should be consistently allocated
to the same twin (Yo Yo phenomenon)
When doing invasive testing, the
“correct” twin has to be sampled
Necessary to communicate correctly
with the neonatologist, in case a twin
develops an abnormality postnatally
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25. Not applicable in monochorionic
twins or dichorionic twins with
fused placenta
Placenta changes position
#1) Labeling of twins by position of
placenta
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26. PNDT law
Not possible in same sex twins
Ultrasonographic identification of
fetal sex in early pregnancy may not
be conclusive
#2) Labeling of twins by fetal sex
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27. The laterality of the gestational sac relative to
the cervix remains the same because the base of
the inter twin membrane remains fixed
The rest of the inter twin membrane can move
about, allowing the twins to swap position
#3) Labeling by position of base of inter
twin membrane
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28. Up or Down
Right or Left
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30. Implicit that Twin 1 delivers before
Twin 2
Fetuses designated as Twin 2
delivered first in 25% of cases of
LSCS
Twin 1 (A) & Twin 2 (B)
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31. Fetus designated
as Twin 2
delivered first in
5% of vaginal
delivery
Perinatal switch
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34. When live twins are detected prior to 7 weeks,
only 71% resulted in birth of Twin neonates
This percentage increased to 84% when the
gestational age reached 7-9 weeks
The chance of taking home, twin neonates is
markedly reduced in the presence of
threatened abortion, with only 63% take home
baby rate
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35. There is significant relationship between
CRL discrepancy at 7 + 0 to 9 + 0 weeks
and the likelihood of single fetal demise
Discrepancy of 40% is associated with
vanishing twin
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37. IVF pregnancies with vanished co-
twin had a higher rate of SGA than
singletons from single gestation
and the risk of SGA increased with
increasing GA at the time of
vanishing
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38. Use of biochemical markers in cases of
vanishing twin is inaccurate and best avoided
The risk is calculated using ONLY NT
FIRST TRIMESTER SCREENING IN CASE OF
VANISHING TWIN…..
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39. Incidence of hyperemesis is higher in twin
pregnancy as compared to singleton pregnancy
After 11-14 weeks scan, rate of subsequent fetal
loss before 24 weeks is 1% in singletons, 2% in
DC twins and 10% in MC twins
Other possible complications…
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42. DC - High risk pregnancy
MC DA - Very high risk pregnancy
MC MA – Extremely high risk
pregnancy
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43. “Twin gestations should be followed routinely with
serial ultrasonographic follow-up for growth at
appropriate (currently, non evidence based) intervals,
irrespective of chorionicity. If growth discordance is
detected, surveillance should be intensified.”
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44. Obesity
Difficulty in scanning the twin farther from the
transducer
Double Movements
Difficulty in maneuvering of the transducer
Difficulties encountered in
screening for malformations…
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45. A challenge to trace
the anatomic parts
to the respective
Twin
Labeling of Twin
Constantly moving
inter-twin
membrane adds to
confusion
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46. Twin to twin
transfusion
syndrome Selective IUGR
TRAP (Twin Death of one of
Reversed Arterial the Twins
Perfusion)
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47. Twin to Twin transfusion
Syndrome
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48. Polyhydramnios
and large bladder in
recipient twin
Oligohydramnios
and absent bladder
in donor twin
“Stuck Twin”
Folding of inter
Twin membrane
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49. Increased NT in one or both the Twins
Abnormal DV waveform in one or both the
Twins
Inter-twin discrepancy in CRL is NOT
predictive of TTTS
Inter-twin membrane folding
Early markers for TTTS..
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51. In singleton pregnancies the incidence of IUGR
is 5%
In Dichorionic Twins it is 20%
In Monochorionic Twins it is 30%
In 2% of dichorionic and 8% of monochorionic
Twins BOTH the twins have IUGR
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52. In singleton pregnancies, the reasons for IUGR are
either abnormal placental function or genetic growth
potential
In Dichorionic twins, IUGR is due to unequal
genetic potential or disparity in placentation
In Monochorionic twins it is due to unequal splitting
or due to unequal sharing of blood flow
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55. Type I (Normal UA Doppler) Good Prognosis
Type II (absent or reversed end diastolic
velocity flow) High incidence (50-60%) of
perinatal mortality
Type III (intermittent ARDF or iARDF) due
to Feto-fetal transfusion. Risk to BOTH IUGR
(20%) and non IUGR (15%) twin
Prediction of adverse outcome- UA
waveform of sIUGR Twin
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57. There is risk of CNS damage to the survivor
There is risk of perinatal mortality to the
survivor
Decision to deliver
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58. Vascular communication between the two
twins
Surviving twin demonstrates severe multi
organ damage
Either due to thromboembolic episodes or due
to bleeding of survivor into the vasculature of
the dead twin
Monochorionic Twins
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59. The risk to the survivor is significantly less
However, isolated cases of vascular
communication have been reported in
dichorionic twins too
Case reports of neurological damage in
survivor of dichorionic twins
Dichorionic Twins
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60. sIUGR is more common before sIUFD
Fetal surveillance should not be less in
dichorionic twins with sIUFD
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61. Would you still call them “weaker
sex”….?????
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64. Cervical lengths obtained between 16
and 31 weeks correlate with the risk of
PT birth
Length <2.4 cm suggests high risk of
PT birth
Could not come to any conclusion
about treatment (cerclage,
progesterone, tocolytics, rest)
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66. Treatment with micronized
Progesterone did not prevent PT
delivery in twins
Micronized Progesterone is NOT
harmful to mother or twins
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68. Uterine Artery doppler has an overall
low sensitivity in predicting adverse
obstetric outcome
Suggested that there are additional patho
-mechanism causing PIH and IUGR in
twins that is unrelated to uteroplacental
insufficiency
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70. PI in twin pregnancies is consistently lower
than singleton pregnancies
There is no difference in MC and DC twin Ut A
characteristics
ABNORMAL Ut A findings in twins has a
HIGHER positive predictive value
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71. The patients with ABNORMAL Ut A values
represent those patients who are likely to have
worst outcome
Hence screening for Ut A abnormalities should
be carried out
The negative predictive value NORMAL Ut A
findings is LOWER
Thus even NORMAL Ut A cases can have PIH/
IUGR
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77. The incidence of PIH in Twin pregnancy 18%
compared to 5% in Singletons
The incidence of complications ( PT delivery,
LSCS, Abruptio Placenta, PPH) was higher in
PIH
The PIH is more likely to be severe
The adverse maternal outcome is also more
common
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79. The presence of GDM in Twin
pregnancy was associated with
higher risk of
Hypertensive complications
Prematurity
RDS
Macrosomia
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84. Wish there were spell check in daily life
too…..
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85. OPTIMUM
TIMING FOR
DELIVERY
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86. When the pregnancy is uncomplicated,
the twins continue to grow and mature
with the advancement of the gestational
age
In the absence of maternal complications,
it is advisable to deliver twins at 38
weeks
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87. Elective induction of labour v/s Expectant
management
No statistically significant difference between
two groups in the incidence of LSCS
No statistically significant difference between
two groups in the incidence of adverse
outcome
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89. Both vertex twins Allow vaginal delivery
First breech/ Second vertex Elective LSCS
First vertex/ Second non vertex 84% LSCS
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91. There was no association between birth order
and risk of perinatal mortality before 36 weeks
Second twin born at term were at increased risk
of perinatal death related to delivery
Vaginally delivered second twin had four fold
increase in risk of death
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94. What is the dose for Twins?
Should it be double to cover the two?
Do Twins mature earlier than Singletons?
If so, should you decrease the dose required?
In Triplets and higher order pregnancies,
steroids are associated with intra uterine
contractions and cervical changes….do these
happen in Twins too?
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