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Twin pregnancy-DR.DIVYA JAIN


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Twin pregnancy-DR.DIVYA JAIN

  1. 1. Twinpregnancy -DR.DIVYA JAIN
  2. 2. Terms • Zygosity refers to the type of conception – Two thirds of all twins are dizygotic. • Chorionicity denotes the type of placentation. *Chorionicity rather than zygosity determines outcome.
  3. 3. TWINS DIZYGOTIC 2/3 MONOZYGOTIC 1/3 Monochorionic monoamniotic <1% Monochorionic diamniotic -75% Dichorionic diamniotic -25% Dichorionic Diamniotic
  4. 4. SUSPICION OF TWIN PREGNANCY  History • h/o IVF, taking ovulation inducing drugs  Symptoms • Early pregnancy : excessive nausea, vomiting, Abnormal bleeding • Mid pregnancy : excessive weight gain, uterus larger than date • Late pregnancy : pressure symptoms – dyspnea, dyspepsia  Signs • Anemia, edema, high BP, abnormal weight gain • Uterus larger than date • Multiple fetal poles felt • 2 distinct FH heard
  5. 5. DIAGNOSIS Before 10 weeks sonographic findings to determine chorionicity depends upon number of • gestational sacs • yolk sacs.
  6. 6.  1. Number of Gestational Sacs  Each gestational sac forms its own placenta and chorion:  gestational sacs: DC twin  1 gestational sac with 2 identified heartbeats: MC twin  Number of Yolk Sacs  2 yolk sacs are seen in the extra-embryonal coeloma: diamniotic  1 yolk sac in most cases indicate monoamniotic twins
  7. 7. After 10 weeks These sonographic signs are no longer present: gestational sacs are no longer distinctly separable, and the inter-twin membrane is formed Diagnosis depends upon • Placental number • Chorionic peak sign • Membrane characteristics.
  8. 8.  Number of Distinct Placentas-  1placental mass: MC  2 distinct, separate placentas: DC Careful sonographic examination may help distinguish a single placenta from 2 placentas in abutment.  Presence or Absence of the Chorionic Peak (twin peak or lambda sign)- Projecting zone of tissue of similar echotexture to the placenta Triangular in cross-section and wider at the chorionic surface of the placenta, extending into, and tapering to a point within, the inter twin membrane. Most often identifies DC MC: absence of the twin peak sign.
  9. 9.  Inter-Twin Membrane Characteristics DC : 2 layers of amnion and 2 layers of chorion. Thicker > 2 mm MC: ≤ 2mm
  10. 10. If a membrane is not detected: careful evaluation to diagnose or exclude monochorionic monoamniotic twinning Possibilities: 1.Monoamniotic twinning 2.Twin with complete oligohydramnios (stuck twin) ABSENT MEMBRANE IN A MONOAMNIOTIC TWIN
  11. 11. LAMBDA SIGN
  13. 13. MATERNAL COMPLICATIONS Antepartum hyperemesis hydramnios
  14. 14. Pre eclampsia(3 fold times),eclampsia(6 fold times) Pressure symptoms Anaemia Antepartum hemorrhage- Placenta previa Abruption
  15. 15. Intrapartum complications Dysfunctional labour Malpresentations Increased chance for operative delivery Post partum hemorrhage Retained placenta
  16. 16. FOETAL COMPLICATIONS I. Prematurity
  17. 17. 2.DISCORDANT GROWTH • Fetal growth differs slightly in twin gestations and twin specific charts may be used to define the normal growth rate. Precision may also be obtained by using sex and race specific charts. • In clinical practice, however, these differences are small and singleton growth curves may be used. Patterns of fetal growth are more important than absolute measurements. Both must be interpreted in the light of the clinical history, together with all the genetic and environmental factors that may affect fetal growth. • The diagnosis of discordance has been based on the following: • • AC difference of 20 mm (sensitivity of 80%, specificity 85%, PPV= 62%) • • EFW based on bi-parietal diameter (BPD) and AC or AC and femur length (FL) > 20 percent (sensitivity 25-55%)
  18. 18. • Discordant fetal growth can be due to different genetic growth potentials, structural anomaly of one fetus, or an unfavourable placental implantation. • True discordance is an indicator for an increased risk of IUGR, morbidity, and mortality for the smaller twin. • A risk for aneuploidy, anomaly or viral syndrome affecting only one fetus must also be considered when discordant growth is identified.
  19. 19. • USG monitoring of growth within a twin pair is mainstay in management . • The indication for delivery should take into consideration of the fetal well-being, the gestational age and serial growth velocity MANAGEMENT
  20. 20. 3. Single fetal demise monochorionic Death of one twin Shift of blood Normal twin 25% risk of co-twin death /25% risk of neurological damage in surviving twin(FOETAL DEATH SYNDROME)
  21. 21. • 2-6% of twins pregnancies • Perinatal morbidity and mortality of the surviving co-twin 19% perinatal death 24% having serious longterm sequelae • Morbidity of surviving fetus depend on chorionicity and consequences of prematurity
  22. 22. 4. Cord entanglement • Cord entanglement occurs in over 70% of MCMA twins and is believed to be the major cause for sudden IUFD • Ultrasound diagnosis of cord entanglement and close fetal surveillance from 24 weeks onward, may help to improve perinatal outcome. • Because of the high perinatal mortality, prophylactic delivery by caesarean section at 32 to 34 weeks is recommended
  23. 23. 5. TWIN-TWIN TRANSFUSION SYNDROME • Features of TTTS are the result of hypoperfusion of the donor twin and hyperperfusion of the recipient twin. • Oligohydramnios develops in the amniotic sac of the donor twin. • Profound oligohydramnios can result in the stuck twin phenomenon in which the twin appears in a fixed position against the uterine wall. • Either twin can develop hydrops fetalis. • The donor twin can become hydropic because of anemia and high- output heart failure. • The recipient twin can become hydropic because of hypervolemia. • The recipient twin can also develop hypertension, hypertrophic cardiomegaly, disseminated intravascular coagulation, and hyperbilirubinemia after birth
  24. 24. Uss of TTS….STUCK TWIN
  25. 25. TREATMENT FOR TTTS • Amniotic septostomy • Laser ablation • Selective fetocide • Serial amnioreduction
  26. 26. Serial amnioreduction survival 64% overall, 74% of at least one twin
  27. 27. Laser ablation (55% overall survival—73% of at least one twin),
  28. 28. 6.Acardiac foetus Normal fetus/pump twin Minimal oxy. extracted by lower part of Acardiac fetus A-A anastamoses in placenta De oxygenated blood Umb .A Umb. A Fully de oxygenated Upper part of fetus ,no growthUmb.VV-V anastomoses in placenta Umb.V
  29. 29. 7. Vanishing twin Cessation of cardiac activity in a previously viable foetus Foetus papyraceous…
  30. 30. 8.Conjoint twins Always monozygotic Classification- Thoracopagus Craniopagus ischiophagus pyophagus omphalopagus
  31. 31. • Rare complication of monoamniotic twining, with an incidence of around 1: 55 000 pregnancies. • Accurate prenatal diagnosis is possible in the first trimester and allows better counseling of the parents regarding the management options.
  32. 32. Dichorionic twins • Ultrasound at 10–14 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy • Structural anomaly scan at 20–22 weeks. • Serial fetal growth scans e.g 24, 28, 32 and then two- to four- weekly. • 34–36 weeks: discussion of mode of delivery and intrapartum care. • Elective delivery at 37–38 completed weeks. Some by 40weeks • Postnatal advice and support (hospital- and community-based) to include breastfeeding and contraceptive advice Monochorionic twins • Ultrasound at 10–14 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy/TTTS • Ultrasound surveillance for TTTS and discordant growth: at 16 weeks and then two-weekly. • Structural anomaly scan at 20–22 weeks (including fetal ECHO). • Fetal growth scans at two-weekly intervals until delivery. • 32–34 weeks: discussion of mode of delivery and intrapartum care. • Elective delivery at 36–37 completed weeks (if uncomplicated). • Postnatal advice and support (hospital- and community-based) to include breastfeeding and contraceptive advice. ANTENATAL CARE
  33. 33. PRESENTATION • 40% of twins present as vertex/vertex, • 35% as vertex/non-vertex, • remaining 25% of twins present with the leading twin in a non-vertex presentation at birth .
  34. 34. MANAGMENT Basic Principles- • The presence of skilled obstetrics attendants for labor and delivery • Anesthesiologist available • Neonatal care personnel sufficient for resuscitation of the newborns • Reliable IV access • CTG
  35. 35. If the second twin is in non-vertex presentation, the other options include o Assisted vaginal breech delivery or breech extraction, o Internal podalic version following by breech extraction, o ECV followed by vaginal cephalic delivery,
  36. 36. Indications for Caesarean Section- Elective- • First twin non-cephalic • Conjoined twin • Monoamniotic twin • Placenta previa • Previous LSCS • IUGR in dichorionic twin • Congenital abnormality Emergency- • Fetal distress • Cord prolapse of 1st twin • Non progress of labor • 2nd twin transverse after delivery of 1st twin
  37. 37. MANAGEMENT DURING LABOUR 1st stage- • Good intrapartum care : blood, IV access, continuous FHS monitoring. • In case of inefficient uterine contractions, oxytocin augmentation can be used. • The criteria for diagnosing slow progress are the same as in singletons.
  38. 38. SECOND STAGE OF LABOUR • Following delivery of the first twin, ergometrine must NOT be given as it might facilitate the premature placental separation before the delivery of the second twin. • The cord of the first twin should be clamped and divided as usual. • After delivery of the 1st twin, the obstetrician should ascertain the lie and presentation of the 2nd twin. • Once a Cx presentation is confirmed, the decent of the fetal head is expected with re-establishment of uterine contractions. • Oxytocin infusion should be commenced if uterine contractions have failed to resume. • Fetal heart rate should be continuously monitored. • A twin-to-twin delivery interval of ≤ 30 minutes, after which delivery should be expedited, since the risks of both acidosis and second stage Caesarean section increase with the length of this interval
  39. 39. THIRD STAGE • increased risk of primary PPH. • After delivery of the shoulder of the 2nd twin, active management of the third stage should ensue. • Oxytocin infusion in addition is advised. • The placentas should be examined as a routine to confirm the chorionicity and amnionicity.