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MULTIPLE PREGNANCY

MULTIPLE PREGNANCY. Ghadeer Al-Shaikh , MD, FRCSC Assistant Professor & Consultant Obstetrics & Gynecology Urogynecology & Pelvic Reconstructive Surgery Department of Obstetrics & Gynecology College of Medicine King Saud University. MULTIPLE PREGNANCY.

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MULTIPLE PREGNANCY

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  1. MULTIPLE PREGNANCY Ghadeer Al-Shaikh, MD, FRCSC Assistant Professor & Consultant Obstetrics & Gynecology Urogynecology & Pelvic Reconstructive Surgery Department of Obstetrics & Gynecology College of Medicine King Saud University

  2. MULTIPLE PREGNANCY • Twin pregnancy represents 2 to 3% of all pregnancies. • The PNMR is 5 times that of singleton

  3. DIZYGOTIC TWINS • Most common represents 2/3 of cases. • Fertilization of more than one egg by more than one sperm. • Non identical ,may be of different sex. • Two chorion and two amnion. • Placenta may be separate or fused.

  4. Factors affecting it’s incidence • Induction of ovulation, 10% with clomide and 30% with gonadotrophins. • Increase maternal age ? Due to increase gonadotrophins production. • Increases with parity. • Heredity usually on maternal side. • Race; Nigeria 1:22 North America 1:90.

  5. MONOZYGOTIC TWINS • Constant incidence of 1:250 births. • Not affected by heredity. • Not related to induction of ovulation. • Constitutes 1/3 of twins.

  6. Results from division of fertilized egg: 0-72 H. Diamniotic dichorionic. 4-8 days Diamniotic monochor. 9-12 days Monoamnio.monochor. >12 days Conjoined twins.

  7. MONOZYGOTIC TWINS • 70% are diamniotic monochorionic. • 30% are diamniotic dichorionic.

  8. Determination of zygosity • Very important as most of the complications occur in monochorionic monozygotic twins.

  9. During pregnancy by USS • Very accurate in the first trimester, two sacs, presence of thick chorion between amniotic memb. • Less accurate in the second trimester the chorion become thin and fuse with the amniotic memb.

  10. Different sex indicates dizygotic twins. • Separate placentas indicates dizygotic twins

  11. Determination of zygozity After Birth • By examination of the MEMBRANE, PLACENTA,SEX , BLOOD group . • Examination of the newborn DNA and HLA may be needed in few cases.

  12. Complications of Multiple Gestation Maternal Fetal • Anemia • Hydramnios • Preeclampsia • Preterm labour • Postpartum hemorrhage • Cesarean delivery • Malpresentation • Placenta previa • Abruptio placentae • Premature rupture of the membranes • Prematurity • Umbilical cord prolapse • Intrauterine growth restriction • Congenital anomalies

  13. Specific Complications in Monochorionic Twins TWIN-TWIN transfusion. • Results from vascular anastomosesbetween twins vessels at the placenta. • Usually arterio (donor) venous (recipient). • Occurs in 10% of monochorionic twins.

  14. TWIN-TWIN transfusion • Chronic shunt occurs ,the donor bleeds into the recipient so one is pale with oligohydramnios while the other is polycythemic with hydramnios. • If not treated death occurs in 80-100% of cases.

  15. Possible methods of treatment: • Repeated amniocentesis from recipient. • Indomethacin. • Fetoscopy and laser ablation of communicating vessels.

  16. Other Complications in Monochorionic Twins: • Congenital malformation. Twice that of singleton. • Umbilical cord anomalies. In 3 – 4 %. • Conjoined twins. Rare 1:70000 deli varies. The majority arethoracopagus. • PNMR of monochorionic is 5 times that of dichorionic twins(120 VS 24/ 1000 births)

  17. Maternal Physiological Adaptation • Increase blood volume and cardiac output. • Increase demand for iron and folic acid. • Maternal respiratory difficulty. • Excess fluid retention and edema. • Increase attacks of supine hypotension.

  18. DIAGNOSIS OF MULTIPLE PREGNANCY • +ve family history mainly on maternal side. • +ve history of ovulation induction. • Exaggerated symptoms of pregnancy. • Marked edema of lower limb. • Discrepancy between date and uterine size. • Palpation of many fetal parts.

  19. Auscultation of two fetal heart beats at two different sites with a difference of 10 beats • USS Two sacs by 5 weeks by TV USS. Two embryos by 7 weeks by TV USS.

  20. Antenatal Care AIM • Prolongation of gestation age, increase fetal weight. • Improve PNM and morbidity. • Decrease incidence of maternal complications.

  21. Antenatal Care Follow Up • Every two weeks. • Iron and folic acid to avoid anemia. • Assess cervical length and competency.

  22. Antenatal Care Fetal Surveillance • Monthly USS from 24 weeks to assess fetal growth and weight. • A discordinate weight difference of >25% is abnormal (IUGR). • Weekly CTG from 36 weeks.

  23. Method Of Delivery Vertex- Vertex (50%) • Vaginal delivery. Vertex- Breech (20%) Vaginal delivery by senior obstetrician

  24. Method Of Delivery Breech- Vertex( 20%) • Safer to deliver by CS to avoid the rare interlocking twins( 1:1000 twins ). Breech-Breech( 10%) • Usually by CS.

  25. Method Of Delivery in Monochorionic Twins • C/S

  26. Perinatal Outcome • PNMR is 5 times that of singleton (30-50/1000 births). • RDS accounts for 50% 0f PNMR.2nd twin is more affected. • Birth trauma . 2ND twin is 4 times affected than 1st . • Incidence of SB is twice that of singleton.

  27. Perinatal Outcome • Congenital anomalies is responsible for 15% of PNMR. • Cerebral hemorrhage and birth asphyxia are responsible for 10% of PNMR. • Cerebral palsy is 4 times that of singleton . • 50% of twins babies are borne with low birth(<2500 gms.) from prematurity & IUGR.

  28. INTRAUTERINE DEATH OF ONE TWIN • Early in pregnancy usually no risk. • In 2nd or 3rd trimester: • Increase risk of DIC . • Increase risk of thrombosis in the a live one • The risk is much higher in monochorionic than in dichorionic twins

  29. The alive baby should be delivered by 32-34 weeks in monochorionic twins.

  30. HIGH RANK MULTIPLE GESTATION • Spontaneous triplets 1:8000 births. • Spontaneous quadruplets 1:700,000 births. • The main risk is sever prematurity . • CS is the usual and safe mode of delivary. • High PNMR of 50-100 / 1000 births

  31. Thank You!!!

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