Multiple pregnancy

1. Multiple pregnancy Kang Yu Obstetric & Gynecology Hospital of Fudan Universtity 2013-10-15

2. Multiple Pregnancy Incidence • Twins：1:100 • Triplets：1:10,000 • Quadruplets：1:1,000,000 • Quintuplets：1:100,000,000

3. Classification • Dizygotic twins：2/3 • influenced remarkably by race, heredity, maternal age, parity, and especially fertility treatment • Monozygotic twins：1/3 • independent of race, heredity, age, and parity

4. Dizygotic twins • Two ovum, two sperm • Different gene： • appearance: different or alike • gender：same or different • Placenta： • two placenta • fuse to one placenta, twin peak, no communicated blood vessel

5. Monozygotic twin • One ovum, one sperm • same gene： • appearance: same • gender：same

6. Classification of monozygotic twin dichorionic diamniotic twins: 18～36% monochorionic diamniotic twins: 65% monochorionic monoamniotic twins: <1% 4 to 8 days Postfertilization 0 to 4 days 9 to 13 days >13 days Conjoined twins

7. Case One • Shi ××, 26 years old • Chief complaint：gravida 1 para 0, 27 weeks of gestation, found dyspnea one week and prostration three days. • Present history：last menstrual period (LMP):12, June, 2011. estimated date of conception(EDC):19, March,2012. Urine chorionic gonadotrophin(HCG) was positive at thirty-seven days of gestation and the morning sickness was severe. One sac was found through altrasound in the first trimester. Regular prenatal examination was not perform. Twin pregnancy was found at 25 weeks of gestation. Dyspnea one week and prostration three days. • Physical examination：T:36.8°C, P 98 counts per minute，R 18 counts per minute，BP 100/65mmHg

8. Ultrasound results： • Fetus A: BPD(biparietal diameter)-HC(head circumference)-AC(abdominal circumference)-FL(femur length): 75-268-256-52mm, estimated weight 1454g, AFV(amniotic fluid volume):26cm, bladder was visible, no abnormal doppers. • Fetus B: BPD-HC-AC-FL:65-236-206-44 mm, estimated weight 832g, AFV:1cm, bladder was visible, no abnormal doppers. • AFI: 127-98-102-134, 461. no twin peak, amniotic separation was found.

9. Question 1:Diagnosis • Gravida 1 Para 0, 27 weeks of gestation, twin pregnancy • Monochorionic Diamniotic Twins(MC/DA) • TTTS(stage 1)

10. Twin-Twin Transfusion Syndrome (TTTS) • Blood is transfused from a donor twin to its recipient sibling • The donor becomes anemic and its growth may be restricted • The recipient becomes polycythemic and may develop circulatory overload manifest as hydrops • Donor twin is pale, and its recipient sibling is plethoric

11. TTTS Anastomoses in monochorionic diamniotic placenta：arterio-arterial,venous –venous,arterio-venous Only arterio-venous anastomoses will result to TTTS.

12. Quintero staging system Stage I: polyhydramnios(>8cm) in recipient / aligodramnios(<2cm) in donor, but urine still visible sonographically within the donor twin's bladder Stage II: urine is not visible within the donor's bladder Stage III: abnormal Doppler studies of the umbilical artery, ductus venosus, or umbilical vein. Stage IV: ascites or frank hydrops in either twin Stage V: demise of either fetus

13. Question 2: Management • An amnioreduction of 6.2 L was performed in the recipient sac. • Tocolytics (magnesium sulfate）were administered. • Follow up: ultrasound weekly Ten days later • Ultrasound surveillance： • anuria and virtually no amniotic fluid in the donor twin, polyuria and excess amniotic fluid in the recipient, and abnormal umbilical venous and ductus venosus flows in both twins.

14. Management • Termination: Cesarean section • premature donor and recipient twin boys were delivered, weighing 895 and 1450 g, with haemoglobin levels of 16.4 and 22.9 g/dl • Both infants required mechanical ventilation and administration of surfactant due to respiratory distress syndrome. The donor twin developed acute renal failure and necrotising enterocolitis which required surgery. The recipient developed the polycythaemiae hyperviscosity syndrome which required a partial exchange transfusion. Both children are alive. • Check the placenta after delivery: one placenta, two layer of membrane partition that separated twin fetuses

15. DiagnosisTTTS (Prenatal) monochorionicity same-sex gender hydramnios defined if the largest vertical pocket is > 8 cm in one twin and oligohydramnios defined if the largest vertical pocket is < 2 cm in the other twin umbilical cord size discrepancy cardiac dysfunction in the recipient twin with hydramnios abnormal umbilical vessel or ductus venosus Doppler velocimetry significant growth discordance

16. Diagnosis (Postnatal) Examination in placenta, chorionic membrane, amniotic membrane Examination in neonate： Discordance in hemoglobin:≥5g/dl Discordance in body weight : ≥15-20%

17. Pregnancy Complications Kang Yu Obstetric & Gynecology Hospital of Fudan Universtity 2013-10-15

18. Pregnancy Complications • Heart Diseases • Hepatitis • Diabetes • Anemia • … • Appendicitis • Cholecystitis • Intestinal obstruction • …

19. Heart diseases in pregnancy

20. Clinical significance of heart disease in pregnancy • Interaction between heart disease and pregnancy • Mother: heart failure; infective endocarditis; hypoxia and cyanosis; thrombenbolism • Baby: miscarriage, still birth, fetal growth restriction, fetal and newborn distress, preterm delivery • Increased caesarean section rate

21. Can I have a baby? What is the risk for me and my baby? What should I do during the course of pregnancy? By which way should I delivery my baby? Any special thing to be paid attention to after birth? Heart diseases in pregnancy

22. Can I have a baby? • NO • Severe • Cardiac functionⅢ一Ⅳ • History of heart failure • Pulmonary hypertension • Right-to-left shunts • Severe arrythmia • Active rheumatic heart disease • Acute Myocarditis, endocarditis • >35y with long history of cardiac disease • YES • Mild • Cardiac function I～II • No history of heart failure • No complication

23. During Pregnancy Determine whether or not the pregnancy should be continued • NO: induced abortion before 12 weeks • YES: • Intensive care during pregnancy • Early diagnosis and treatment of congestive heart failure

24. During pregnancy • Heart failure ---- prevention • Limited physical activity • Control of body weight: increase <12Kg (<0.5Kg / month) • Limited salt intake: <4-5g/day • Prevent risk factors: infection, anemia, arrhythmia, hypertensive diseases • Dynamic observation of cardiac function

25. During Pregnancy • Heart failure---early diagnosis • Development of dyspnea and palpitation on exertion • Heart rate >110 bpm; breath rate >20/min • Nocturnal cough • Persistent basilar rales

26. During pregnancy • Treatment of heart failure • Digoxin • Diuretics • Vessel dilating agents • Termination of pregnancy: • C-S • Timing • Termination after heart failure is controlled • C-S when heart failure could not be controlled

27. Intrapartum management • Pattern of delivery • Cesarean section • Vaginal delivery • Heart function I-II • Very good obstetrical condition • Vaginal delivery---- prevent heart failure • First stage: intensive care and sedation • Second stage: shorten the course • Third stage: Add pressure on abdomen prevent postpartum hemorrhage

28. Puerperium management • Intensive care during the first 3 days • Prevent infection • Breast feeding • Sterilization

29. Viral Hepatitis in Pregnancy

30. Viral Hepatitis in Pregnancy • Interaction between pregnancy and hepatitis • Diagnose, Differential diagnosis and treatment • Pathway of maternal – fetal infection and prevention

31. Impact of pregnancy on viral hepatitis • Heavier liver burden • Compromised defending ability of liver • More complicated and severe condition in pregnant patients

32. Impact of hepatitis on pregnancy • Early Pregnancy • Serious pregnancy reaction • Abortion • Malformation • Late pregnancy • Hypertension • Postpartum hemorrhage • Preterm delivery, fetal death, stillbirth

33. Impact of hepatitis on pregnancy • Maternal - fetal infection HBV • Intrauterine • Intrapartum—main route of transmission • Fetal swallowing in genital tract • Mother blood leaking into fetal circulation • Postpartum: breastfeeding, salivary

34. Differential diagnosis • Intrahepatic cholestasis of pregnancy （ICP） • Happen during late pregnancy • Pruritus • Jaundice • Cholic acid • fetal death

35. Differential diagnosis • Acute fatty liver of pregnancy Late pregnancy, acute and severe hepatic disfunction, fat filled hepatic cell • HELLP syndrome Hypertension, hemolysis, BPC, elevated liver enzyme • Hyperemesis gravidarum Light liver dysfunction, negative virus marker • Drug induced hepatitis History of drug intake

36. Management • Rest • Nutrition • Protection of liver function • Prevent infection and further damage • Fluminant hepatitis

37. Management • Delivery • C-S is preferred • Vitamin K1 20-40mg im several days before delivery • Prevent postpartum hemorrhage • Fulminant hepatitis: C-S 24 hours after active treatment

38. Management • Pureperium • Prevent from damaging liver function • Breast feeding: Stop if HBsAg, HBeAg, anti-HBc, HBV-DNA positive

39. Diabetes complicating pregnancy

40. Diabetes complicating pregnancy • Gestational diabetes mellitus (GDM) and overt diabetes complicating pregnancy • Diabetes  pregnancy • Screening and diagnosis • Management of women complicating diabetes during pregnancy

41. Incidence: 2.9% (1.5-14.0%) Gestational diabetes mellitus GDM >90%

42. Impact of pregnancy on diabetes • Insulin resistance and insufficiency • Increased glucose demands---hypoglycemia • Insulin overdose after delivery

43. Maternal and fetal effects • Maternal effects • Hypertensive disorders （高血压） • Infection （感染） • Ketoacidosis （酮症酸中毒） • Spontaneous abortion （自发流产） • Polyhydramnios （羊水过多） • Dystocia （难产） and C-S owing to macrosomia （巨大儿） • Recurrent GDM （再次妊娠时复发）

45. Maternal and fetal effects • Fetal effects • Macrosomia （巨大儿） • Fetal growth restriction （胎儿宫内生长受限） • Spontaneous abortion & Preterm delivery （自发流产和早产） • Malformation （胎儿畸形）

46. Maternal and fetal effects • Neonatal effects • Respiratory distress（呼吸窘迫） • Hyperinsulinemia Pulmonary Surfactant  Delayed pulmonary maturation • Hypoglycemia（低血糖）

47. Diagnosis----GDM • History: family, previous pregnancy, present pregnancy • Screening: 50-g oral glucose challenge test （24-28 weeks） • Confirmed diagnosis • OGTT: 75/100-g oral glucose tolerance test

48. The 50 gr. GCT (Cutoff >140 mg/dl, 7.8mmol/L) • Sensitivity: 93.3% • Specificity: 38.2% • Positive Predictive Value: 78.6 % • Negative Predictive Value : 70.0 %

49. Diagnostic criteria for GDM---OGTT Method Criteria (mmol/L) FPG 1 hr. 2 hr. 3 hr. WHO (75 g) 5.6 10.3 8.6 6.7 Diagnosed when 2 or more values are abnormal FPG: Fasting plasma glucose

50. Diagnosis—Overt diabetes • polydipsia （多饮）, polyuria （多尿）, unexplained weight loss，ketoacidosis • Random plasma glucose >200 mg/dL(11.1 mmol/L); fasting glucose>126mg/dL (7 mmol/L)