Pathology of Twinning Flashcards

1
Q

Dizygotic vs monozygotic twins

A
Dizygotic (“Fraternal”):
2 ova fertilized by 2 sperm
Not genetically identical
~70% of spontaneous twins
~95% of Assistive Reproductive Technology twins
Monozygotic (“Identical”)
1 ovum fertilized by 1 sperm, fertilized oocyte divides
Genetically identical
~30% of spontaneous twins
3-5/1000 births
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2
Q

When embryo divides and how that affects the growth of twins?

A

When splits:

1-3 days: Dichorionic, diamniotic twins (monozygotic or dizygotic) 20-30% of monozygotic twins

4-8 days: Monochorionic, diamniotic twins (monozygotic ONLY) 70% of monozygotic twins

9-12 days: Monochorionic, monoamniotic (monozygotic ONLY) 1% of monozygotic twins. More dangerous (umbilical cords can get wrapped around each other)

13-15 days: Conjoined twins, monochorionic, monoamniotic

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3
Q

How do we determine if twins are di or mono chorionic and amniotic?

A

Ultrasound

Dichorionic/Diamniotic: thick dividing membrane; “twin peak” or “lambda” sign

Monochorionic/Diamniotic: thin dividing membrane; “T” sign

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4
Q

What are the layers of the placenta starting from baby to uterine wall

A

Amnion, chorion, extravillous trophoblast, decidua capsularis

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5
Q

Amnion

A

single layer of flat, cuboidal or columnar epithelial cells derived from fetal ectoderm. Passively attached to chorion by amniotic fluid pressure.

Amniotic Fluid: Absorbs jolts, allows fetal movement, sustains amnion and is swallowed by fetus after 20 weeks GA; aids lung development

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6
Q

Chorion

A

tough fibrous layer that carries fetal blood vessels, often with atrophied villous remains (chorion frondosum).

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7
Q

Why Are Twin Rates Increasing?

A

20x higher incidence with fertility treatment

25% of Assistive Reproductive Technology (ART) pregnancies worldwide are twins

Only ~50% of twin pregnancies are conceived spontaneously

Also ↑ with maternal age independent of ART

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8
Q

Risks of Twin Pregnancies

A

Miscarriage

Hyperemesis (higher levels of hCG)

Increased risk of aneuploidy and anomalies (increased 3-5x in monozygotes)

Prenatal screening tests less sensitive and diagnostic
procedures more difficult

Maternal anemia

Gestational diabetes (? increased hPL)

Gestational hypertension/preeclampsia (increased 2x)

Intrauterine growth restriction

Preterm birth – $$$

Cesarean delivery

Postpartum hemorrhage

Higher perinatal mortality – 5-7x rate in singletons

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9
Q

Why does it matter what kinds of twins you have?

A

Affects the complication rate and mortality of the twins

monoamniotic/monochorionic are most dangerous

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10
Q

Twin-Twin Transfusion Syndrome

A

TTTS

Monochorionic-diamniotic twins that are MONOZYGOTIC by definition

15-20% of monochorionic-diamnionic twins have unbalanced flow through connected vessels

Recipient twin (larger) increases urine production to reduce blood volume: Large bladder on ultrasound abd polyhydramnios

Donor twin (smaller) reduces urine production to retain blood volume- Oligohydramnios

Classification based on ultrasound findings

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11
Q

Who is most at risk for TTTS and why?

A

monochorionic-diamnionic twins

More likely to have unbalanced arterio-venous connections

Dichorionic twins shouldn’t have any connecting vessels

Monoamniotic twins have so many vascular connections, they tend to balance out

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12
Q

Prognosis of TTTS

A

Untreated, TTTS prior to 24 weeks gestational age leads to mortality of one or both twins in 80-90% of cases

After death of one twin, other twin at increased risk for brain damage in 1/3 of cases

Severe TTTS prior to 16 weeks has dismal prognosis

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13
Q

What causes death of donor twin

A

Decreased blood volume

Lower urine output

oligohydramnios

Small placental volume; not enough nutrients

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14
Q

What causes death of recipient twin

A

Too much blood volume, strains baby heart

Too much urine production:
Polyhydramnios

Fetal hydrops

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15
Q

Treatment options for TTTS

A

Reduction amniocentesis
Microseptostomy
Laser Ablation

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16
Q

Microseptostomy

A

Creation of hole between the babies’ sacs

Fluid moves into donor twin to equalize

If hole gets larger, umbilical cords may become entangled

80% survival of at least one twin and 60% survival of both twins in one study

17
Q

Laser Ablation

A

Direct visualization of communicating vessels and ablation with laser

Higher complication rate (15-20%)

70-80% survival of at least one twin and 35% survival of both

If demise of one twin, lower rate of mortality for surviving twin (35% to 7%)

18
Q

Reduction amniocentesis

A

Removal of excess fluid from recipient twin sac using needle through mom’s abdomen

Up to 3L may be removed at one time

Repeated every few days to weekly

Usually early delivery (29-30 weeks)

Survival 18-83%