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Multiple pregnancies.pptx

  1. Multiple Gestation • Done by: Mays Khaled Najjar. • Supervised by: Dr. Hylda Al-Salibi & Dr. Anan Amr. • 2/01/2023 1
  2. Outlines Definition. Classification. Clinical features. Twins. Twins Complications for mother and baby. Management. 2 2/01/2023
  3. Definition • Is a pregnancy in which more than one fetus is present. the fetuses may arise from one or more zygotes and are usually separate but may rarely be conjoined. 2/01/2023 3
  4. Incidence: Multiples make up only about 3 in 100 births, but the multiple birth rate is rising Hellin’s Law is the principle that one in about 89 natural pregnancies ends in the birth of twins, triplets once in 892 births, and quadruplets once in 893 births-probability; namely n’lets once in 89n−1. 4 2/01/2023
  5. Classification 2/01/2023 5 Number of fetuses: Twins, triplets, quadruplets, etc. Number of fertilized eggs: Zygosity. Number of placentae: Chorionicity. Number of amniotic cavities: Amnionicity.
  6. 2/01/2023 6 Clinical features High levels of beta-HCG and MSAFP and hyperemesis gravidarum. Enlarged abdomen Abdominal palpation shows multiple small parts and multiple large poles. Fundal level is more than GA In auscultation, many fetal heart sounds (sometimes gallop rhythm). Abdominal or transvaginal U/S show many heads. During labor, the presenting part is small in relation to the size of the uterus.
  7. Twins 2/01/2023 7
  8. Types Dizygotic (70%) Monozygotic (30%). 2/01/2023 8
  9. 2/01/2023 9
  10. Dizygotic twins (non-identical/ Fraternal) 2/01/2023 10 Occur from ovulation and subsequent fertilization of two oocytes. This results in dichorionic diamniotic twins, where each fetus has its own placenta and amniotic cavity. Although they always have two functionally separate placentae (dichorionic),if the two ova implanted close to each other, the placentae can become anatomically fused together and appear to the naked eye as a single placental mass. They always have separated amniotic cavities (diamniotic) and the two cavities are separated by a thick three-layer membrane (fused amnion in the middle with chorion on either side). The fetuses can be either same- sex or different-sex pairings. (the similarity between them is like the similarity between any two members of the same family).
  11. Monozygotic (identical): Result from fertilization of a single ovum with subsequent division of the zygote. 2/01/2023 11
  12. Monozygotic types: Type Duration Dichorionic diamniotic. If the zygote splits shortly after fertilization (within 3 days after fertilization, morula stage), the twins will each have a separate placenta Monochorionic diamniotic (20%) division of the zygote occurs between days four and eight postfertilization (at blastocyst stage). The vast majority of monochorionic twins have two amniotic cavities (diamniotic) but the dividing membrane is thin, as it consists of a single layer of amnion alone. Monochorionic monoamniotic (1%) when division occurs between days 8 and 12 postfertilization (splitting of the embryonic disk). Conjugated twins when incomplete division of the fertilized ovum, occur after more than 13 days of fertilization (embryo stage). 2/01/2023 12
  13. Monozygotic 13 2/01/2023
  14. Risk factors 14 2/01/2023 Dizygotic twins Monozygotic twin Previous multiple pregnancies ( the strongest) No identifiable risk factors Race ( more in blacks than whites) Geography Family history from mother’s side only and with spontaneous multiple gestation only (IVF is not included). Assisted reproductive technologies like IVF. Risk of twinning is up to 10% with drugs like clomiphene citrate and up to 30% with human menopausal gonadotropin Increased maternal age, parity, height and weight due to higher levels of FSH
  16. Twins VS Triplets VS Quadruplets U/S 2/01/2023 16
  17. Complications 17 • Twin pregnancy is associated with higher rates of almost every potential complication of singleton pregnancy, with the exceptions of postterm pregnancy and macrosomia, and is also associated with some unique complications 2/01/2023
  18. Maternal Complications 2/01/2023 18 ANTEpartum Anemia ↑ 3x (iron & folate) Preeclampsia ↑ 3x Gestational diabetes ↑ 2x Thromboembolism ↑ 4x INTRApartum Preterm labor (50%) Malpresentation (50%) Cesarean delivery (50%) POSTpartum Hemorrhage ↑ 5x
  19. Management 2/01/2023 19 Stage Management Antepartum Give mother iron and folate supplementation to prevent anemia, monitor BP to detect preeclampsia, educate mother regarding preterm labor symptoms and signs, and perform serial ultrasound examinations looking for twin–twin transfusion (amniotic fluid discordance). Intrapartum Route of delivery is based on presentation in labor—vaginal delivery if both are cephalic presentation (50%); cesarean delivery if first twin in noncephalic presentation; route of delivery is controversial if first twin is cephalic, and second twin is noncephalic, but if they are stable and have the same way, vaginal delivery is indicated. Postpartum: Watch for postpartum hemorrhage from uterine atony owing to an overdistended uterus.
  20. When to deliver when CS is indicated? When? Case 37 to 38 weeks Dichorionic 36 weeks Monochorionic 35 weeks Uncomplicated Triplet 32 to 33 weeks Monochorionic Monoamniotic 28 weeks Quadruplet 2/01/2023 20
  21. Fetal complications: 2/01/2023 21 Still birth or neonatal death. Abortion. Single fetal death in twin pregnancy. Intra Uterine Growth Restriction (IUGR). Small for Gestational Age (SGA). Higher risk for congenital anomalies.
  22. Twin-twin transfusion 2/01/2023 22
  23. Twin–twin transfusion syndrome 23 • Develops in 15% of mono-di twins with 25% mortality rate. • Most common cause of oligohydramnios and polyhydramnios in twins. • The twins share a single placenta but do so unequally, because there is an anastomoses between the two fetal circulations that could be artery to artery, artery to vein (most severe), vein to vein. 2/01/2023
  24. Twin–twin transfusion syndrome 24 • The donor twin gets less blood supply, resulting in growth restriction, oligohydramnios, hypotension, anemia and even fetal death due to heart failure resulted from anemia. However, neonatal outcome is usually better. • The recipient twin gets more blood supply, resulting in excessive growth, hypertension, polyhydramnios, polycythemia and fetal death due to congestive heart failure due to overperfusion. • Diagnosis by doppler U/S showing anastomosis within the placenta. • Intrauterine fetal surgery is indicated to laser the vascular connections on the placental surface between the two fetuses. Neonatal course is often complicated. 2/01/2023
  25. Quintero staging: Stage Events Stage 1 Oligohydramnios and polyhydramnios sequence and the bladder of the donor twin is visible. Dopplers in both twins are normal. Stage 2 Oligohydramnios and polyhydramnios sequence, but the bladder of the donor is not visualized. Dopplers in both twins are normal. Stage 3 Oligohydramnios and polyhydramnios sequence, non-visualized bladder and abnormal Dopplers. There is absent/reversed end-diastolic velocity in the umbilical artery, reversed flow in a-wave of the DV or pulsatile flow in the umbilical vein in either fetus. Stage 4 One or both fetuses show signs of hydrops. Stage 5 One or both fetuses have died. 2/01/2023 25
  26. Umbilical cord entanglement • It is a classical complication of a monochorionic-monoamniotic twin pregnancy which can mean either one or more loops of the umbilical cord encircling any part of the fetal body or two umbilical cords becoming entangled with each other. 2/01/2023 26
  27. Locked Twin Syndrome • Locked twins usually occur when the after-coming head of the first breech fetus is locked with the head of the second cephalic fetus. Of the different etiological factors, the most important are the ageand parity of the mother and the size of the twins 2/01/2023 27
  28. References • Kenny, L. C., & Bickerstaff, H. (2016). Gynaecology by Ten teachers. CRC Press. • Sakala, E. P. (2020). Usmle Step 2 Ck lecture notes 2021 Obstetrics and Gynecology. Kaplan Medical. 2/01/2023 28
  29. Thank You! 2/01/2023 29