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medical

1. Multiple Gestations Prepared by : Samir nasser

2. Timing of cell divison The timing of cell division within the monozygotic twin determines the amnionicity and chorionicity of twins. Division of the ovum between days 0 and 3 : Dichorionic , diamniotic monozygotic twins. Division between 4 and 8 days: Monochorionic , diamniotic monozygotic twins. Division between 9 and 12 days : Monochorionic , monoamniotic monozygotic twins . Division after 13 days : Conjoined twins.

3. Dizygotic or Monozygotic What is the difference? Which one is more common? Dizygotic is more common

4. Diagnosis of Twinning Physical exam Ultrasound

5. Finding of Physical Exam Physical exam may show a uterine size/gestational age (GA) difference with size greater than expected from GA.

6. Differential Diagnoses The differential diagnoses for size/date discrepancy in pregnancy include: Twins Adnexal mass Distended Bladder Fetal Macrosmia Hydramnios Maternal obesity Uncertain LMP Molar pregnancy

7. Ultrasound In Multiple Gestations Ultrasound is used for the following: Confirm diagnosis Determine chorionicity Detect fetal anomalies Measure cervical length Evaluate for fetal growth Guide invasive procedures Confirm fetal well-being

8. Determining chorionicity Chorionicity can best be determined in the first or early second trimester by ultrasound (US). Why is it important to determine chorionicity ? Monochorionic twins should undergo US examination to look for fetal growth every 4 weeks , while dichorionic twins can be scanned every 6–8 weeks for growth. Growth restriction rates are higher among the monochorionic in comparison to the dichorionic twin gestation. Monochorionic twins may also be at risk for twin-twin transfusion syndrome

9. What Do You See

10. The fused chorionic and amniotic membranes lead to the “twin peak” sign in the middle of image in Di-Di twins

11. Mo-Mo Twins What is the mortality rate of the mono-mono twins? Reported as high as 40-60% Why? Secondary to cord accidents due to entanglement How are Mo- M o twins delivered? Mo-Mo and conjoined twins are almost always delivered via cesarean section

12. What is cord entanglement Umbilical cord entanglement is a feature 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.

13. TTTS

14. TTTS Polyhydramnios–oligohydramnios (poly– oli ) sequence or TTTS has been described for several centuries and results in a small, anemic twin and a large, plethoric, polycythemic , and occasionally hydropic twin.

15. The Etiology of TTTS The etiology of TTTS appears to be secondary to unequal flow within vascular communications between the twins in their shared placenta, leading to one twin becoming a donor and the other a recipient of this unequal blood flow . In particular , an abundance of unidirectional ateriovenous connections without adequate bidirectional arterio -arterial or veno -venous connections to rescue this shunting appears to predispose to a higher risk of TTTS

16. Dye injected placenta Is It Normal?

17. TTTS Pathophysiology TTTS can result in one fetus with hypervolemia, cardiomegaly, glomerulotubal hypertrophy, edema, and ascites , and the other with hypovolemia, growth restriction, and oligohydramnios . The syndrome can present at any gestational age; however, earlier diagnosis is associated with worse outcomes .

18. Management of TTTS Given the risk of this syndrome in Mo-Di twins, serial ultrasounds examining the amniotic fluid and fetal growth should be obtained every 2 weeks after diagnosis . TTTS has historically been managed with serial amnioreduction , which can reduce preterm contractions secondary to uterine distension and maternal symptoms, but only occasionally actually cures the fetal syndrome. Laser coagulation of the abnormal vascular connections is a more useful method to manage patients with severe TTTS . Pregnancy Termination should always be offered as an option due to potential risks

19. Amnioreduction

20. Laser Coagulation

21. Twin Anemia polycythemia Sequence TAPS