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Twin pregnancy....a journey.....
- 1. 40 year old primi, BMI of 32,conceived twins with donor oocytes: how to make her journey safe? Dr.Sameer Dikshit www.birthdefects.in
- 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 www.birthdefects.in
- 3. Journey map……. Pot holes… www.birthdefects.in
- 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. www.birthdefects.in
- 6. 40 year old Height 162 cm, weight 84 kg, BMI 32 G1 P0 Donor oocytes Twin Pregnancy History….. www.birthdefects.in
- 7. Early Pregnancy Mid Pregnancy Late Pregnancy First Trim Screening Abnormalities Clinical Chorionicity Growth Complications www.birthdefects.in
- 9. Early pregnancy scan First Trimester Screening www.birthdefects.in
- 11. Age 40 years Age 25 Prior risk 1:83 Prior risk 1:950-1001 The recipient The donor www.birthdefects.in
- 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.. www.birthdefects.in
- 14. { T sign { Lambda sign MC Twin DC Twin www.birthdefects.in
- 16. The posterior risk in the two twins is different, and is determined by NT of individual twin In Dichorionic Twins…. www.birthdefects.in
- 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… www.birthdefects.in
- 19. Let us add First Trimester Biochemistry…….. www.birthdefects.in
- 20. Biochemistry in Twins is less accurate than in Singletons Some advocate doing only NT www.birthdefects.in
- 21. The biochemistry risk is calculated taking into consideration, the age of the recipient into account www.birthdefects.in
- 22. SYSTEMATIC LABELING OF TWINS www.birthdefects.in
- 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 www.birthdefects.in
- 25. Not applicable in monochorionic twins or dichorionic twins with fused placenta Placenta changes position #1) Labeling of twins by position of placenta www.birthdefects.in
- 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 www.birthdefects.in
- 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 www.birthdefects.in
- 28. Up or Down Right or Left www.birthdefects.in
- 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) www.birthdefects.in
- 31. Fetus designated as Twin 2 delivered first in 5% of vaginal delivery Perinatal switch www.birthdefects.in
- 32. Necessity is the mother of invention…. www.birthdefects.in
- 33. VANISHING TWIN……. www.birthdefects.in
- 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 www.birthdefects.in
- 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 www.birthdefects.in
- 36. What happens to the survivor???? www.birthdefects.in
- 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 www.birthdefects.in
- 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….. www.birthdefects.in
- 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… www.birthdefects.in
- 40. Early Pregnancy Mid Pregnancy www.birthdefects.in
- 41. Ultrasound scanning Uterine Artery Doppler Cervical length assessment www.birthdefects.in
- 42. DC - High risk pregnancy MC DA - Very high risk pregnancy MC MA – Extremely high risk pregnancy www.birthdefects.in
- 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.” www.birthdefects.in
- 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… www.birthdefects.in
- 45. A challenge to trace the anatomic parts to the respective Twin Labeling of Twin Constantly moving inter-twin membrane adds to confusion www.birthdefects.in
- 46. Twin to twin transfusion syndrome Selective IUGR TRAP (Twin Death of one of Reversed Arterial the Twins Perfusion) www.birthdefects.in
- 47. Twin to Twin transfusion Syndrome www.birthdefects.in
- 48. Polyhydramnios and large bladder in recipient twin Oligohydramnios and absent bladder in donor twin “Stuck Twin” Folding of inter Twin membrane www.birthdefects.in
- 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.. www.birthdefects.in
- 50. GROWTH RESTRICTION www.birthdefects.in
- 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 www.birthdefects.in
- 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 www.birthdefects.in
- 53. Selective IUGR and Growth Discordance www.birthdefects.in
- 54. Selective IUGR >10th centile + <10th centile Discordant Growth >20% difference www.birthdefects.in
- 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 www.birthdefects.in
- 56. Death of one of the Twin www.birthdefects.in
- 57. There is risk of CNS damage to the survivor There is risk of perinatal mortality to the survivor Decision to deliver www.birthdefects.in
- 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 www.birthdefects.in
- 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 www.birthdefects.in
- 60. sIUGR is more common before sIUFD Fetal surveillance should not be less in dichorionic twins with sIUFD www.birthdefects.in
- 61. Would you still call them “weaker sex”….????? www.birthdefects.in
- 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 ) www.birthdefects.in
- 66. Treatment with micronized Progesterone did not prevent PT delivery in twins Micronized Progesterone is NOT harmful to mother or twins www.birthdefects.in
- 67. Uterine Artery Doppler www.birthdefects.in
- 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 www.birthdefects.in
- 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 www.birthdefects.in
- 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 www.birthdefects.in
- 73. Early Pregnancy Mid Pregnancy Late Pregnancy www.birthdefects.in
- 74. Late pregnancy complications in Twins www.birthdefects.in
- 75. Anemia-35.8% Hypertension-22.6% PPH-18.9% Hyperemesis-7.5% Polyhydramnios- 5.7% Gestational Diabetes in 5.7% www.birthdefects.in
- 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 www.birthdefects.in
- 78. GESTATIONAL DIABETES www.birthdefects.in
- 79. The presence of GDM in Twin pregnancy was associated with higher risk of Hypertensive complications Prematurity RDS Macrosomia www.birthdefects.in
- 81. PT delivery & LBW www.birthdefects.in
- 84. Wish there were spell check in daily life too….. www.birthdefects.in
- 85. OPTIMUM TIMING FOR DELIVERY www.birthdefects.in
- 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 www.birthdefects.in
- 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 www.birthdefects.in
- 88. ROUTE OF DELIVERY www.birthdefects.in
- 89. Both vertex twins Allow vaginal delivery First breech/ Second vertex Elective LSCS First vertex/ Second non vertex 84% LSCS www.birthdefects.in
- 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 www.birthdefects.in
- 93. ANTENATAL CORTICOSTEROIDS www.birthdefects.in
- 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? www.birthdefects.in
- 96. Mono chorionic Twins to decrease hypoxic episodes? Pre term Twins with first Vertex? www.birthdefects.in
- 97. NEONATAL COMPLICATIONS www.birthdefects.in
- 98. Low Birth weight Prematurity CNS complications Cerebral Palsy www.birthdefects.in
- 99. The only person awake is probably the next speaker…. www.birthdefects.in