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Multifetal Pregnancy

Multifetal Pregnancy. Radha Venkatakrishnan Clinical Lecturer Warwick Medical School. Incidence : Monozygotic twins - 4/1000 births Dizygotic twins – 2/3rds, race, age, assisted conception Triplets – 1 in 7000 to 10,000 births Quadruplets – 1 in 600,000 births

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Multifetal Pregnancy

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  1. Multifetal Pregnancy Radha Venkatakrishnan Clinical Lecturer Warwick Medical School

  2. Incidence : • Monozygotic twins - 4/1000 births • Dizygotic twins – 2/3rds, race, age, assisted conception • Triplets – 1 in 7000 to 10,000 births • Quadruplets – 1 in 600,000 births • Almost every maternal and obstetric problem occurs • more frequently in multiple Pregnancy • Perinatal mortality rate in twins is 5 times higher and • in triplets 10 times higher than in singletons

  3. Zygosity and Chorionicity • Zygosity refers to the type of conception • Chorionicity denotes the type of placentation • Chorionicity rather than zygosity determines out • outcome

  4. Mechanism of dizygotic twinning

  5. Fertilization of 2 separate ova • Fertilization of a single ovum • Similar sex • Genetically identical

  6. Monochorionic twins 3-8 days later (60-70%) • Within 72 hours (18-32%)

  7. Monochorionic twins 8-12 days later (1-2%) 12-13 days later (0.5%)

  8. Multiple pregnancy Maternal responses Cardiac output, GFR and renal blood flow Plasma volume by 1/3 > singletons Red cell mass 300 ml > singletons Hematocrit and hemoglobin Iron stores in 40% of women with twins

  9. Diagnosis Patient profile: • Etiological factors: • positive past history and family history specially maternal, race, age • Assisted reproductive technology • Early pregnancy: • Hyperemesis, excessive weight gain • minor complications of pregnancy such as backache, edema, varicose veins, hemorrhoids, striae, etc

  10. Physical signs • General: • Pallor, weight gain, excessive pedal edema/ varicose veins • Pregnancy Induced Hypertension(PIH) and Pre-eclampsia (5-10times more) • Abdominal: • Size > Date especially in midpregnancy • Multiple fetal parts • Auscultation of FHS: • 2 different recordings by 2 observers and a difference > 10 bpm

  11. Differential diagnosis • Elevation of the uterus by a distended bladder • Inaccurate menstrual history • Hydramnios • Hydatidiform mole • Uterine fibroids • A closely attached adnexal mass • Fetal macrosomia (late in pregnancy)

  12. Ultrasonography • Detect multifetal gestation 99% before 26 weeks • Confirm fetal number [ 2 sacs or 2fetal heads in 2 perpendicular planes] • Diagnose type and presentation and position and relation to each other • Exclude congenital abnormalities/ conjoint twin

  13. Maternal complications • Symptoms – hyperemesis, aches and pains of pregnancy worsen • Hypertensive disease of pregnancy • Preterm delivery • Premature rupture of membranes • Polyhydramnios • Placenta praevia • Malpresentation • Delivery complications (operative delivery, placental abruption, cord accidents) • Postpartum hemorrhage, depression

  14. Fetal complications • Spontaneous early pregnancy loss • Prematurity • Intra-uterine growth restriction • Cerebral palsy - related to gestational age, 3 times in twins, > 10 times in triplets • Intrapartum trauma • Monochorionic twins – specific complications

  15. Antenatal care • Routine booking investigations • Folic acid supplementation • anemia – treat immediately • Support symptomatically • Serial growth scans : • Dichorionic :4 weekly from 24 weeks • Monochorionic : 2 weekly from 18 weeks • - Liquor volume • - Doppler study of umbilical artery

  16. Intrapartum management • Presence of skilled obstetrician, anesthetist and neonatologist available at delivery • Reliable intravenous access • Cardiotocograph with dual monitoring capability • Portable ultrasound scanner • Delivery bed with lithotomy stirrups • Obstetric forceps or vacuum apparatus • active management of third stage: Uterotonics • Immediate availability of blood • Facilities and staff for emergency cesarean section

  17. Monochorionic Monoamniotic twins • 3 - 12 x perinatal mortality • 10 x cerebral necroticlesions • 1% of monozygotic twins are monoamnionic • Perinatal mortality rate of 30-50%, largely relates to a risk of intrauterine death before 32 weeks • Cord entanglement

  18. Twin-Twin Transfusion Syndrome • Incidence : 4 - 20% of MC twins • It is characterised by an imbalance of blood flow • between the twins • 15 - 20% of perinatal deaths • Untreated, perinatal loss rates in the mid-trimester • (80 - 100%)

  19. Large volume amnioreduction

  20. Amniotic Septostomy

  21. Fetoscopic Laser Ablation

  22. Delivery by Caesarean sectionat 34 weeks

  23. Conjoined twins or Siamese twins • Anterior (thoracopagus) • Posterior (pygopagus) • Cephalic (craniopagus) • Caudal (ischiopagus)

  24. Single intrauterine demise • 2-6% of twins pregnancies • Up to 25% in MC twin pregnancy • Perinatal morbidity and mortality of the surviving • co-twin • - 19% perinatal death • - 24% having serious long term sequelae

  25. Treatment options • No optimal management • Prompt delivery -Iatrogenic prematurity risks • Conservative treatment -Subsequent handicaps • Intrauterine interventions

  26. High order multiples • Perinatal risk increases exponentially with increasing • number of fetuses • Multifetal pregnancy reduction (MFPR) at 10 to 12 • weeks should be recommended for quadruplets and • higher multiples • The situation with triplets is more controversial

  27. Thank You

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