Published on March 26, 2014
Dr Manal Behery 2014
Defintion • When more than one fetus simultaneously develops in the UTERUS • 3 fetuses : triplets • 4 fetuses : quadruplets • 5 fetuses : quintuplets • 6 fetuses : sextuplets
HELLIN’S RULE Twins 1 in 80 Triplets 1 in 80^2 Quadruplets 1 in 80^3
Types of twins • • Monozygotic (1/3 rds) Dizygotic (2/3 rd) Results from fertilization Results from fertilization of a single ova of two ovum
Dizygotic amnion amnion 2 chorions Always dichorionic & diamnionic
Factors affecting dizygotic twinning Ethnic group Increasing maternal age
Increasing parity Family h/o twinning, esp maternal Ovulation induction ART
• Monozygotic twinning is independent of • race, • heredity, • age & • Parity. • INCIDANCE 1/25O
MONOZYGOTIC 4-7 days
THORACOPAGUS ISCHIOPAGUSCRANIOPAGUS RACHYPAGUSPYOPAGUSOMPHALOPAGUS
History Previous history of twinning; high parity Older maternal age > 37yrs History of ovulation induction or pregnancy following ART Family history of twinning
Clinically Symptoms • Exaggerated pregnancy symptoms. • Fetal activity is greater and more persistent in twinning than in singleton pregnancy.
Signs • (1) Uterus > dates of amenorrehea . • (2) Excessive maternal weight gain that is not explained by edema or obesity. • (3)palpation of 2 fetal heads/presence of three fetal poles. • 4) Simultaneous recording of different fetal heart rates, each asynchronous with the mother’s pulse and with each other and varying by at least 8 beats per minute.
Ultrasound Determination of Chorionicity • Number of sacs. [ before 10 weeks ] 2 sacs – dichorionic Single sac - monochorionic • Placenta • Sex • Intertwin membrane thicker and more echogenic in dichorionic . Ideal time for assessing of chorionicity is before 14 weeks
MONOCHORIONIC & DIAMNIONIC T sign
Importance of chorionicity ?????
Problems Specific to Monochorionic twins Nearly 100% of monochorionic twin placentas have vascular anatomizes 2 patterns of vascular anastomosis •twin-to-twin transfusion syndrome (TTTS) acardiac twinning or twin •reversed arterial perfusion (TRAPS)
Maternal Complication Antenatal : 1.Hyperemesis gravidarum 2.↑chances of abortion 3.hydramnios 4.PIH 5.Placenta previa, abruptio 6.Anemia 7.Exaggerated minor problems: pressure symptoms, etc
• Intrapartum complications 1.Prolonged labor (uterine inertia) 2.Malpresentation 3.Cord prolapse 4.Abruptio placenta for 2nd twin 5.Interlocking of twins 6.PPH
Fetal complications 1.Preterm delivery 2.IUGR 3.Congenital Abnormalities 4.Cord abnormalities : 1. Single umbilical artery 2. Velamentous insertion 3. Cord entanglement 4. Cord prolapse 5.Monochorionic twins : 1. Discordant growth 2. Twin to twin syndrome 3. Single fetal Demise
TTTS:Arterio venous anastomoses with net flow in one direction..
Donor(arterial side) recipient •Severe IUGR •poor renal perfusion •Anuria •severe oligohydramnios •Hypervolemia •Polyuria with polyhydramnios •CCF…..hydrops…death Serial amnio reduction,fetoscopic laser ablation of anastomosis
Ultrasound in TTS – Stuck Twin Sign
Vanishing twin Cessation of cardiac activity in a previously viable foetus Fetus papyraceous…
TRAP sequence PUMP TWIN ACARDIAC TWIN
APARNA P 2009 MBBS
1.Prenatal care More frequent antenatal visits. prophylactic iron 60-100mg and folic acid 1mg daily should be given. Nutritional advice-calorie req is 300kcal/day more than that recommended for uncomplicated pregnancy. Restriction of activity and increased rest at home. Prophylactic steroids – risk for preterm labour or IUGR.
2.Ultrasound scan At 9-11 wks : confirmation, chorionicity determination, assessment of gestational age and nuchal translucency. anomaly scan at 20 wks 4 weekly scans in 3rd trimester to assess fetal growth, diagnose complications like TTS
Nuchal Translucency Mid Trimester Amniocentesis is the gold standard
Delivery prereqists CTG with dual monitoring capability Forceps or vacuum Oxytocin infusion Tocolytic agent for uterine relaxation Methergin, 15-methyl PGF2 alpha Immediate availability of blood Access for emergency C/S
1.Place of delivery- Fully equipped hospital having intensive neonatal care unit. 2.Timing of delivery RCOG recommends elective termination of pregnancy at 37- 38 weeks Monochorionic pregnancy best delivered at 36-37 weeks
Mode of delivery Depend on presentation of 1st twin Both vertex / 1st twin vertex – vaginal delivery Indication for Elective LSCS -More than 2 fetuses -1st twin malpresentation, CPD -Scarred uterus -MCMA -Conjoint twin -IUGR in dichorionic twin -TTTS
Delivery of 1st twin twin Deliver the first baby vaginally Cord is divided in between 2 clamps to prevent acute intrapartum transfusion. No methergin is given at this point as it can cause entrapment and asphyxia of second twin.
Delivery Of Second Twin • Palpate abdomen immediately to ensure lie,presentation. • If required-ultrasound examination done. • Vaginal examination is also done to exclude cord prolapse. • Acceptable interval between deliveries – 30 mins
Longitudinal lie A.R.M + oxytocin if necessary…. If delay Vertex- Low down->forceps or ventose; High up->internal version Breech- breech extraction
2ND Twins Transverse lie External version- cephalic or IF FAILS Internal version under G.A
Internal podalic version To do or not to do ?? Experienced operator EFW > 1500 gm Adequate liquor Available anesthesia for • effective uterine relaxation Simultaneous preparation • for emergency C/S
Rapid Delivery BY emergancy CS Severe vaginal bleeding Cord prolapse in second twin Inadvertent use of IV ergometrine with delivery of anterior shoulders of first baby 2nd twin is transverse, version failed after delivery of 1st twin Fetal distress
Third Stage Cross matched blood should be readily available. Risk of atonic PPH is more. Oxytocin infusion & i/v ergometrine 0.25mg or methergine 0.2mg given following delivery of anterior shoulder of second baby. Prostaglandins-15 methyl PG F2alpha can also be used. Placenta examined for completeness, confirm chorionicity.
Selective fetal reduction-one fetus in a multiple gestation is abnormal Multifetal reduction-in higher order pregnancy Iatrogenic fetal death –us guided fetal heart puncture or inj kcl One member of monochorionic pair should never be selected Multifetal and selective pregnancy reduction
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