Multiple pregnancies Flashcards
Types of twins pregnancy.
- Number of conceptions Zygosity
(monozygotic/dizygotic)
• 2. Number of placenta Chorionicity
(monochorionic/dichorionic)
Number of amniotic cavities Amnionicity
(monoamniotic/diamniotic)
2 type of zygotes
- (DIZYGOTIC/ FRATERNAL /BINOVULAR ) : Twins resulting from ovulation and subsequent fertilization of more than one oocyte.
- (MONOZYGOTIC/IDENTICAL/MONOVULAR): Splitting of one embryonic mass to form two or more genetically identical fetuses.
If the fetus share of the placenta what type of the zygotes
Monozygous
The characteristic of the dizygotic twins 5.
- 2/3rd of all
- May/may not be of the same sex
- Genetically similar to other siblings
- Always have separate placentae &
amniotic membranes (dichorionic
diamniotic …DCDA) - Incidence varies by factors like age,
parity& ethnicity, etc.
What’s the characteristic of the monozygotic twins? 5
- 1/3rd of all
- Same sex
- Genetically identical
- Sharing of placenta and amniotic cavity depend on the time of splitting
- Incidence is relatively fixed i.e. 1/250
How much placenta and amniotic in the di-chorionic?
2 placenta , 2 amniotic
How much placenta and amniotic in mono chorionic?
Single placenta
2 amniotic
1 amniotic
If monozygotic twins, splitting within three days, what’s the results?
DCDA
If monozygotic twins, splitting within 4 to 8 days, what’s the results?
MCDA
Monozygotic twins, splitting with the 9 to 12 days what’s the results?
MCMA
If monozygotic twins, splitting with that more than 12 days, what’s the result?
Conjoined twins.
The longer the time between fertilization & splitting, what’s the result?
more structures the fetuses will share.
How to determine chorionicity ?
By US in late 1st and early 2nd (10-14 weeks )
By the ultrasound, if you see triangular projection of the chorion projecting between the two layer of the inter-twin membrane, what’s the type of placenta mono or di ?
What’s the name of the sign ?
Dichorionic.
Lambda sign.
If you see by the ultrasound The intertwin membrane ends
abruptly at the edge in a T
configuration.
what does it mean?
What’s the name of the sign?
Monochorionic
T sign
What’s the factors affecting dizygotic twins?
- Race Nigeria > Japan
- Increases maternal age. :
<20 (( 6:1000 ))
>35 (( 22 :1000 ))
>45 (( 57 : 1000 )) - Assistant reproduction:
IUI 10-20%
IVF 20-30% - Parity > in multipara
- Heredity +ve maternal family history
- Nutritional status
- Conception after stopping OCP
Maternal Complications ?
- Hyperemesis gravidarum
- Pre-eclampsia
- Gestational diabetes
- Anemia (iron & folate)
5.Thromboembolic disease 6.Antepartum hemorrhage – placenta previa and placental abruption
7.Cholestasis of pregnancy - Malpresentations
9.Mechanical distress such as palpitation, dyspnea, varicosities, and
hemorrhoids - Preterm labor (50%)
twins –37 weeks, triplets –34 weeks, quadruplets –30 weeks • Pre-labour rupture of the membranes • Cord prolapse • Increased cesarean delivery (50%) • Postpartum hemorrhage
What are the 2 obstetrical complications that are never seen in
multiple pregnancy?
Postpartum
Macrosomia
Fetal Complications
- Spontaneous Miscarriages
- Congenital Anomalies
- Conjoined twins
- IUGR
- Twin-twin Transfusion Syndrome
- Twin Anemia Polycythemia Sequence
- Twin Reversed Arterial Perfusion Sequence
- Monoamniotic Twin Pregnancy
Spontaneous Miscarriages more in
monochorionic twins
Spontaneous Miscarriages
Types
➢VanishingTwinSyndrome/FetalResorption during first10weeks(anabortedfetus
absorbedcompletely,sonosigns/remainsvisibleinlaterscans)
➢Fetus Papyraceous/Compressus during early (12-20 weeks) 2nd trimester
(a dead flattened fetus compressed against the uterine wall by the second
alivetwin)
Fetus Papyraceous/Compressus
12-20wks
VanishingTwinSyndrome/FetalResorption
during first10weeks
Congenital Anomalies
What’s the classification?
Chromosomal like Down syndrome
• Structural : Neural tube defects – anencephaly, microcephaly, hydrocephaly, cardiac anomalies
etc
Because of over crowding of uterine space like talipes, hip dislocation etc) Unique to twins : acardiac twin, conjoined twins
Conjoined twins
What’s the treatment?
CS
What’s the complication of
Dichorionic Twins
preterm labor
What’s the complication of
Monochorionic Twins
immediate death or neurological deficit.
Twin-twin Transfusion Syndrome what’s the cause?
Monochorionic twin
vascular anastomoses exist between two fetal circulations • Vascular anastomoses, A-V, V-A, A-A, V-V. Mostly, these are balanced • In About 10-15% of monochorionic twins, an imbalance
Twin-twin Transfusion Syndrome Management
• Serial amnioreduction from the recipient sac
• Septostomy
• Selective feticide by umbilical cord occlusion
• Selective laser ablation of abnormal vascular connections
Diagnostic markers for TTTS
• Ø both fetuses of the same gender
• Ø polyhydramnios/oligohydramnios
• Look for the bladder size and liquor volume of each twin (Quintero Staging)
Management of labour
• First stage: 4
• Same as in singleton pregnancy but with more vigilance
• Avoid supine hypotension
• Blood to be cross-matched and ready
• Intrapartum fetal monitoring separately for both fetuses
Management of labour
SECOND STAGE– Delivery of the first baby
6
• As in singleton pregnancy
• maintain an IV line
• No oxytocic (AMTSL) after delivery of the first baby*
• Secure cord clamping
• Ensure labeling of 1st baby*
• 2 separate neonatal resuscitation teams
Management of labour
Second stage
Delivery of second twin
• FHS of second baby
• Lie and presentation of the second twin
• Wait for uterine contractions
• Oxytocin infusion to ensure adequate uterine contraction
Transverse lie - external cephalic version/internal podalic version
Breech presentation - breech extraction
Cephalic presentation – amniotomy once the head is in the pelvis
complete the delivery
Management of the labor third stage
-Continue oxytocin drip
-Carboprost250 gm/ Oxytocin 10 units IM
-Delivery of placenta following delivery of both twins, by controlled cord
traction (CCT) method
- Monitor for at least 2 hours
-Exam of placenta & membranes
Indications for c-section twins:👯
• Non cephalic presentation of first twin
• Monoamniotic twins
• Conjoined twins
• Locked twins
• Other obstetric conditions like placenta previa
• Second twin –closure of cervix (rarely)
Antenatal management twins
✓Aim is to early detection & management & prevention (where possible)
✓More frequent A/N visits
✓Advice regarding diet, rest, physical activity
✓Folic acid, iron & calcium supplements
✓Ultrasound:
✓ 1st trimester for dating, no of fetuses, viability & chorionicty
✓ 2nd trimester for congenital anomalies
✓ 3rd trimester for serial growth ✓Corticosteroids when preterm labor is suspected
INVESTIGATION
(ultrasound)
• 1st trimester-no of fetuses, viability, chorionicity, nuchal translucency
• 2nd trimester-congenital anomalies
• 3rd trimester- serial growth scan, fetal complications like TTTS etc.
Monoamniotic Twin Pregnancy how you can diagnosed
Ultrasound, no divide membrane
Monoamniotic Twin Pregnancy
What’s the management?
Frequent antenatal visits and ultrasound scans with Doppler
study
• Give corticosteroids
• CTG to detect bradycardia or deceleration.
• Delivery by caesarean section at 32 to 34 weeks.
