Multiple pregnancy including MCDA and MCMA.pptx

Simultaneous development of two fetuses (twins) is the commonest
Although rare, development of three fetuses (triplets), four fetuses (quadruplets), five fetuses (quintuplets or six fetuses (sextuplets) may also occur.

1. DR.DEEPEKA.T.S.M.S(OBG)., MRCOG(U.K).,FELLOW IN REPRODUCTIVE MEDICINE SENIOR RESIDENT, DEPARTMENT OF OBSTETRICS AND GYNECOLOGY, SNIMS.

2. Multiple Pregnancy t h an on e f e tus sim u ltan e ou s ly the u te r us t h e n i t is c a ll e d mu l t i p le “ W hen more develops in pregnancy” D C Dutta’s , Textbook of Obstetrics 9th edition Simultaneous development of two fetuses (twins) is the commonest Although rare, development of three fetuses (triplets), four fetuses (quadruplets), five fetuses (quintuplets or six fetuses (sextuplets) may also occur.

3. Few terms .. ZYGOSITY Genetic make up of the twin pregnancy CHORIONISITY Placenta’s membrane status Determined by the timing of embryo division

4. Twins pregnancy Varieties: Dizygotic t w i n s: i s the commonest(two- third) and results from the fertilization of two ova. (Biovular) Monozygotic twin s (one-third) res u lts from the fertilization of single

5. Diagnosis of Zygosity can be made by Examining fetal genders (different genders = dizygotic) Placenta (mono chorionic = monozygotic and genetic testing Determination of Zygosity

6. Examination of placenta and membranes Dizygotic Twin Monozygotic twin Two placenta, either completely separated or more commonly fused at the margin appearing to be one. No anastomosis between the two fetal vessels. Placenta is single. Varying degrees of anastomosis between the two fetal vessels. Each fetus is surrounded by a n amnion and chorion Each fetus is surrounded by a separate amniotic sac with the chorionic layer common to both. Intervening membranes consist of 4 layers-amnion, chorion, chorion and amnion. Intervening membrane consists of two layers of amnion only.

7. Determination of Zygosity cont... ZYGOSITY Monozygotic twins Dizygotic twins Placenta One Two (separate or most often fused ) Communicating vessels Present Absent Intervening membrane and thickness Two( aminons) <2mm Four(2 aminons 2 chorions) >2mm Sex Always identical May differ DNA fingerprinting Same Different Reciprocal skin grafting Acceptance Rejection Follow up Usually identical Not-identical

8. Determination of CHORIONISITY in Mo n o z y got i c Pregnancy

9. Cont... I f the d i v i s i o n tak e s p l a c e wit h in 7 2 ho u rs a ft er fertilization the resulting embryos will have two separate placenta, chorions and amnions (D/D) If the division takes place between the 4 th and 8 th day after the formation of inner cell mass when chorion has already developed diamniotic monochorionic twins develop (D/M) If the division after 8 th day of fertilization, when the amniotic cavity has already formed, a monoamniotic monochorionic twins develop (M/M)

10. c on t d … On extreme rare occasions, division occurs after 2 weeks of the development of embryonic disc resulting in the formation of conjoined twins called-Siamese twins. Four types of fusion may occur Thoracopagus (commonest) Pyopagus (Posterior fusion) Craniopagus (cephalic) Ischiopagus (caudal)

11. THOR A CO P AG CRAN A G US P H ALO P AG RAC H Y P AG

12. INCIDENCE Highest in Nigeria ( 1 in 20) Lowest in far eastern countries (1 in 200) In India- 1 in 80 Hellin’s Law: Twins: 1:80 Triplets: 1:80^2 Quadruplets: 1:80^3 Quintuplets: 1:80^4 Conjoined twins: 1 : 60,000

13. Factors that Influence Twinning The causes of twin pregnancy is not known. Race: Highest amongst Negroes (once in every 20 births), lowest amongst Mongols and intermediate among Caucasians Heredity: Family history in mother. Maternal Age and Parity : T winning peaks at age 37 years Increasing parity: 5 th gravid onwards. Nutritional Factors : Taller, heavier women—twinning rate 25 to 30 % greater. Pituitary Gonadotropin Assisted Reproductive Technology

14. Terms Superfecundation is fertilisation of two ova produced in the same menstrual cycle by two spermatozoa deposited in two separate acts of coitus Superfetation is fertilisation of two ova produced in two different menstrual cycles by two separate spermatozoa. The development of one foetus over another foetus is possible theoretically until the decidual space is obliterated until 12 weeks of pregnancy.

15. Terms Cont... Foetus papyraceous or compressus is a state which occurs if one of the foetus dies early. The dead foetus is flattened, mummified and compressed between the membranes of the living foetus and the uterine wall. Usually discovered at delivery or earlier USG.

16. Terms cont.. Fetus acardius occurs only in monozygotic twins. Part of one foetus remains amorphous and becomes parasitic without a heart.

17. Terms cont... Vanishing twin serial USG imaging in multiple Pregnancy since early gestation has revealed occasional death of one foetus and continuation of pregnancy with the surviving one. The dead foetus ( If within 14 weeks) simply vanishes by reabsorption. The rate of disappearance could be to the extent of 40%.

18. D i agnos i s History Recent administration of ovulation inducing drugs esp. gonadotropins for infertility or pregnancy accomplished by ART are much stronger associates. Family history of twinning specially on maternal side.

19. Diagnosis cont… Symptoms Minor symptoms o f no rm a l pregn a n cy are o f ten exaggerated. Increased nausea and vomiting in early months Cardio-respiratory embarrassment Te n d ency o f s w e l l i n g i n the l e gs, varicose v e i n s and hemorrhoids is greater Unusual rate of uterine enlargement and excessive fetal movements

20. Diagnosis cont… 20 General examination Prevalence of anemia is more U nusua l w e i gh t ga i n , no t e x p l a i n e d by preeclampsia or obesity Evidence of preeclampsia is a association. co mmon

21. Diagnosis cont… Abdominal examination Inspection : Barrel shaped and the abdomen is unduly enlarged Palpation Height of uterus > period of amenorrhoea Girth of abdomen> normal average at term (100 cm) Fetal bulk disproportionately larger in relation to the size of the fetal head. Palpation of too many fetal parts Finding of two fetal heads or three fetal poles Auscultation Two distinct FHS at separate spots, difference in heart rates is at least 10 beats/minute.

22. Diagnosis cont… Investigations Sonography separate gestational sacs identified early Confirmation of diagnosis as early as 10th week of pregnancy Variability of fetuses, vanishing twin in second trimester Chorionicity ( twin peak sign/ lambda sign ) Pregnancy dating, Fetal anomalies Fetal growth monitoring, Presentation and lie of fetuses Twin transfusion, placenta localisation, Amniotic fluid volume

23. Twin peak sign for dizygotic twins

24. T sign for mono chorionic twins

25. Diagnosis cont… Biochemical Tests: Levels of hCG in plasma and in urine are higher Maternal serum alpha-fetoprotein level: Elevated Unconjugated oestriol: approximately double

26. Diagnosis cont… In women with a uterus that appears large for gestational age, the following possibilities are considered: Multiple fetuses Elevation of the uterus by a distended bladder Inaccurate menstrual history Hydramnios Hydatidiform mole Uterine leiomyomas A closely attached adnexal mass Fetal macrosomia (late in pregnancy) 26

27. Comp li cat i ons Maternal During pregnancy Nausea and vomiting Anaemia Pre-eclampsia (25%) Hydramnios (10%) Antepartum haemorrhage Malpresentation Preterm labour (50%) Mechanical distress

28. Complications cont… During labour Early rupture of membranes and cord prolapse Prolonged labour Increased operative interference Bleeding after the birth of first baby Postpartum haemorrhage

29. Complications cont… During puerperium Sub involution Infection Lactation failure Foetal Miscarri a ge Prematurity (80%) Growth problem (25%) Intrauterine death Asphyxia and still birth Foetal anomalies

30. Complications of mono chorionic twins Twin twin transfusion syndrome (TTS ) one twin appears to bleed into other through placental vascular anastomosis. Receptor twin becomes larger with hydramnios, polycythemic, hypertensive and hypervolemic Donor twin which become smaller with oligohydramnios, anemic, hypotensive and hypovolemic. Donor may appear stuck due to severe oligohydramnios. Difference of hemoglobin concentration between the twin usually exceeds 5 gm% and estimated fetal weight discrepancy is 25% or more.

31. Complications of monochorionic twins contd… TTTS contd.. Management A n tenatal dia g no sis: u l tr a s o un d w i th d o p p l e r flow study in the placental vascular bed. R epe ated amnio c e ntesis to c o nt r o l po l yhyd r amn io s i n recipient twin. – prevent preterm labour and placental abruption. Selective reduction of one twin is done when survival of both the fetuses is at risk. Smaller twin generally have got better outcome. Plethoric twin: risk of CCF and hydrops. Perinatal mortality: 70%.

32. Complications of monochorionic twins contd… Single fetal death Death of one twin (2-7%) is associated with poor outcome of the Co-twin (25%) specially in monochorionic placenta. The surviving twin runs the risk of cerebral palsy, microcephaly, renal cortical necrosis and DIC. This is due to thromboplastin liberated from the dead twin that crosses via placental anastomosis to the living twin.

33. Complications of monochorionic twins contd… Twin reversed arterial perfusion (TRAP): Characterized by an acardiac perfused twin having blood supply from a normal co-twin via large arterio-arterial anastomosis. Conjoint twin: Rare. Perinatal survival depends upon the type of joint. Ma j or cardiov a scul a r anasto m osis l ead s to h i g h mortality.

34. Fetal acardius

35. Complications of monochorionic twins contd… Monoamniocity: Monoc h o rio n o c twins l e a d s to h i g h peri n atal morta l ity due to cord problems. Prostaglandin synthase inhibitor used to reduce fetal urine output, creating borderline oligohydramnios and to reduce the excessive movements.

36. Antepartum Management of Twin Pregnancy To reduce perinatal mortality and morbidity rates in pregnancies complicated by twins, it is imperative that: Delivery of markedly preterm neonates be prevented Fetal-growth restriction be identified and afflicted fetuses be delivered before they become moribund Fetal trauma during labor and delivery be avoided, and Expert neonatal care be available.

37. Management contd… Diet: increa s ed r equi r e m ent of c a lori e s, prote i n, miner a l s , vitamins, and essential fatty acids. Caloric should be increased by another 300 kcal/day. Supplementation with 60 to 100 mg/day of iron and1 mg/day of folic acid. Bed Rest Antepartum Surveillance: sonographic examinations Tests of Fetal Well-Being Prevention of Preterm Delivery Hospitalization Use of corticosteroids to accelerate fetal lung maturation.

38. Management during labour First stage: A sk illed o bs tet r i c i an, pr ese n c e of ult r a s o u nd m a c hine and experienced anesthetist Bed rest to prevent early rupture of membrane. Limit use of analgesic drugs Careful monitoring Internal examination soon after the rupture of membranes An intravenous line with ringer’s solution Availability of one unit of compatible and cross matched blood Neonatologist:Present at the time of delivery.

39. Management during labour contd.. Delivery of the first baby : D e li v e ry: S a me gu i de l i n es a s i n no r m a l l abo u r w i th liberal episiotomy. Forceps delivery: if needed, should be done preferably under pudendal block anaesthesia. Do not give intravenous ergometrine with delivery of the anterior shoulder of the first baby. Clamp the cord at two places and cut it between. At least 8-10 cm of cord is left behind for administration of any drug or transfusion, if required. The baby should be labeled one.

40. Management during labour contd.. Conduction of labour after the delivery of the first baby: Steps of management: Step I: Ascertain lie, presentation, size and FHS of the second baby. Vaginal examination: To confirm the abdominal findings and to exclude cord prolapsed, if any to note the status of membrane.

41. Lie & Presentation

42. Management during labour contd... Lie longitudinal: Step I : Lo w rupture o f m e m branes, sy n t o c i n o n , i n te r n a l examination to exclude cord prolapse. Step I I: I f the uteri n e co n trac t i o n i s p o o r , 5 un i ts of oxytocin is added. Step II I : Is there i s still a de l a y , i n terfer e n ce i s to b e done.

43. Management during labour contd... 1. Vertex: Low down—forceps are applied. High up—CPD should be ruled out. Th e p o ssi b i l i ty o f h y d roceph a l i c hea d s h o u l d a l s o b e kept in mind and excluded by ultrasonography. If these are excluded, internal version followed by breech extraction is performed under general anesthesia. Ventouse: effective alternative. Breech: internal podalic version Lie transverse : Correct by external version or internal version to cephalic or podalic.

44. Management during labour contd... 45 Indication of urgent delivery of second baby : Severe vaginal bleeding, Cord prolapse Inadvertent use of IV ergometrine with the delivery of anterior shoulder of the first baby, First baby delivered under general anesthesia, Appearance of fetal distress.

45. Management during labour contd... Delay in the birth of second twin Birth of second twin should be completed within 45 minute of the first twin being born but with close monitoring can be extended if there are no signs of fetal compromise. The risk of delays: intrauterine hypoxia, birth asphyxia, sepsis

46. Management during labour contd... meth e rg i n IV w i th Management of third stage R o utine admi n i str ation o f 0.2mg delivery of anterior shoulder. Deliver placenta by CCT C o nt i n u e o x yto c i n d r i p for a t l e ast on e h o ur, fo l l o wi n g delivery of second baby. The patient is to be carefu l y watched for about 2 hours after delivery.

47. Indications of caesarean section t w i n s; Obstetric causes: Placenta previa Severe preeclampsia Previous caesarean section Cord prolapse of the first baby Abnormal uterine contractions Contracted pelvis For twins: Both fetuses or even first fetus with non- cephalic presentation, Twins with complications: IUGR, conjoint Monoamniotic twins, monochorionic twins with TTS

48. Management of difficult cases of twins Interlocking Commonest: Aftercoming head o f first baby getting locked with forecomi ng head of second ba by. Vaginal manip ulation to separate chins of the fetuses Decapitation o f first baby (dead), pushing up decapitated head, followed by delivery of second baby and lastly, delivery of decapitated head. Occasionally, two heads of both vertex get locked at the pelvic brim preventing engagement of either of the head. Disengagement of the higher head: Under general anesthesia, If fails, caesarean section is the alternative

49. Management of difficult cases of twins contd.. Conjoined twins Extremely rare. Often diagnosed during delivery Presence of a bridge of tissue between the fetuses on vaginal examination confirms the diagnosis. Antenatal diagnosis is important. Benefits are: reduces maternal trauma and morbidity, improves fetal survival, helps to plan method of delivery, allows time to organize pediatric surgical team.

50. Postnatal period Care of the babies Immediate care Maintenance of body temperature, Use of overhead heaters, P a rents g i ven the op p ortunity t o check t h e i d entity t a g and cuddle them. regarding d i f f e r e n t w i th adv a ntages, Breastfeeding Provide knowledge to mother pos i tions f o r bre a s t f e ed i ng , a l o ng attachment, positioning timing.

51. Postnatal period contd.. Nutrition Expressed breast milk is best (for small babies), they may need to be fed intravenously or by nasogastric tube or cup-fed, depending on their size and general condition. Careful monitoring of weight gain, regular capillary blood glucose estimations Rea s s u re h e r t hat l a c t ation re s p o n d s t o the d em an d s made by babies sucking at the breast. At feeding times, mother must be provided support and advised on positioning and fixing babies. Care of the mother Slow involution of uter u s, increa s ed ‘A f ter pain s ’ s o analgesia should be offered. High calorie diet. Teach extra support to handle twin babies

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