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Multiple Fetal Pregnancy

Multiple Fetal Pregnancy. Prepared by Dr. S. Rouholamin Assistant Professor. Content:. 1- Incidence and epidemiology. 2- Etiology of multiple fetus. 3- Types of twins:- a- Determination of zygosity. b- Risk of zygosity: * Risk of fetuses. * Maternal complications.

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Multiple Fetal Pregnancy

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  1. Multiple Fetal Pregnancy Prepared by Dr. S. Rouholamin Assistant Professor

  2. Content: 1- Incidence and epidemiology. 2- Etiology of multiple fetus. 3- Types of twins:- a- Determination of zygosity. b- Risk of zygosity: * Risk of fetuses. * Maternal complications. * Problem specific to monochorionic twins 4- Management of twins:- a- Antenatal.b- In labor.

  3. Incidence and epidemiology • Rate of twins and higher-order multiple births increase by infertility therapy. • Increase neonatal morbidity and mortality rates. • Increase maternal complication with multiple gestations at least two fold. • Frequency of twins:- a- Monozygotic: 1:250 (independent) b- Dizygatic: 1:90 white USA 1:20 African * Depend on race, hereditary, age, parity and fertility drugs.

  4. Incidence and epidemiology • Hereditary mother important than father. • Age  peak at 37 years of age. • Parity  increase more than six times.

  5. Ethiology of multiple fetuses • Dizygotic: It is a fertilization of two separate ovum. • Monozygotic = Identical twins: It is a single fertilized ovum that subsequently divides into two similar structures.

  6. Divisions • First 72 H  two embryos, diamniotic, dichorionic and two placenta or single fused placenta. • 4-8 days  two embryos, diamniotic, monochorionic. • About 8 days after fertilization  two embryos, monoamniotic and monochorionic. • Divisions  clearage is incomplete and conjoined twins result.

  7. Types of twins Determination of zygosity: (dizygotic twins are a genetic model).*Multiple pregnancy increase risk of perinatal mortality and morbidity.* Monochronic twins 20% of all twin pregnancy have the worse prognosis than their dichorionic.* Early ultra sound determine the chorionicity.* The effect of the zygosity on the out come is less clear.* the out come of dichorionic monozygotic seem to have the same out come of dizygotic twins. * zygosity refers to genetic work up of the pregnancy.* Chorionicity indicate the membrane composition of the pregnancy (the chorion and amnion)

  8. Diagnosis of Multiple Fetuses • History. • Clinical Examination. • Investigations.

  9. History • Family history. • Advanced age. • High parity. • Large maternal size. • Medication.

  10. Clinical Examination • Late in first trimester by Doppler  two fetal hearts. • Uterine palpation can feel two fetal heads or multiple fetal parts. • Uterine size is larger than expected for the gestational age determined from menstrual data.

  11. Deferential diagnosis for large for date • Multiple fetuses. • Inaccurate menstrual history. • Hydramnios. • Hydatidiform mole. • Elevation of the uterus by distended bladder. • Uterine myomas. • A closely attached adnexal mass. • Fetal macrosomia (late in pregnancy)

  12. Investigations • Ultrasonograghic examination  separated gestational sacs in early pregnancy. • Radiological • Biochemical tests:a-chorionic gonadotropin in plasma and in urine.b-alpha fetoprotein level (alone is not diagnostic).

  13. Risk of Multiple Fetal Pregnancy • Abortion: Increase spontaneous abortion more than three times. • Malformation: Congenital malformation > single • Low birth weight:a- growth restriction (estimated fetal weight less than 10th percentile for singleton gestation).b-preterm c-discordance (difference in estimated fetal weight of greater than 20%-25% between twin A and twin B). • Decrease duration of gestation:a- 57% of twins  at 35 weeks.b- 92% of triplets  at 32 weeks.c- all quadruplets  at 29–30 weeks

  14. Risk of Multiple Fetal Pregnancy • Preterm birth:a- It is the most common complication of multiple pregnancies effecting long term out come.b- prophylactic use of c- fetal fibronectin (at 24-28 weeks if high associated with increase risk of preterm before 32 weeks of gestation). Tocolytics Bed rest Cercolage

  15. Risk of Multiple Fetal Pregnancy • Prolonged pregnancy:a-twin pregnancy of 40 weeks or more should be considered post term.b- increase risk of stillbirth.c- conceder delivery of uncomplicated twins of 39 weeks of gestation. • Intrauterine fetal demise of one twin (late pregnancy), Vanishing twin (early pregnancy).

  16. Maternal Complication • Acute fatty liver. • Anemia. • Abnormal placentation. • Amniotic fluid volume abnormalities. • Preeclampsia. • Operative vaginal delivery and C-section. • Premature rupture of membrane. • Postpartum hemorrhage. • Umbilical cord prolapse.

  17. Problems Specific to Monochorionic twins Twin-Twin transfusion syndrome:-*15% of monochorionic develops.* Early onset often is associated with poor prognosis. * Twin-Twin transfusion can be acute or chronic.* The net effect of blood flow imbalance result:a- donor  small, hypoperfused, anemic.b- recipient  large, hyperperfused.

  18. Problems for Monoamnionicity Rare < 1% . • Mortality 20-50%. • Cord entanglement. • Perinatal mortality. • Preterm Delivery. • Growth restriction. • Congenital anomalies. • Conjoined twins  Siamese twins*Anterior (thoracopagus).* Posterior (pygopagus).* Cephalic (craniopagus).* Caudal (ischopagus).

  19. Problems for Monoamnionicity • Acardiac twins (Reversed-Arterial Perfusion TRAP).* rare 1:3500 births.* large A-A placental shunt between umbilical arteries in early embryogenesis, 75% monochorionic, diamniotic. 25% monochorionic monoamniotic.

  20. Management • Antenatal. • In Labor.

  21. Antenatal Management • Early diagnosis (mainly by ultra sound) • Adequate nutrition:-1-Caloric consumption increased by 300 Kcal per day.2- Iron 60-100 mg per day.3- Folic acid 1mg per day. • Frequent prenatal visit:-observe maternal and fetal complications1- Frequent ultra sound  fetal growth, congenital anomalies, amniotic fluid. 2- Doppler.3- BPP.

  22. In Labor Management • Trained obstetrical attendant. • Available blood. • Good access I.V live. • CTG monitoring. • Anesthetist  ER C-S • Pediatrician for each fetus. • Mode of delivery depend on presentation.

  23. Presentation • Cephalic - Cephalic 42% • Cephalic - Breech 27% • Cephalic - Transverse 18% • Breech - Breech 5% • Other 8% Management in First stage Second stage Third stage (PPH)

  24. In Labor Management • Ceph-ceph: NVD • Ceph –non ceph: contraversy. • Breech:cord prolaps,Head trappe,Locked twin:c/s. • Second twin: 10 min and no contraction. • Non fixed p.p :abdominal manipulation • Second twin:internal pudalic version. • Irregular FHR,VB,larger,Bx, Trans ,contract Cx: C/S .

  25. In Labor Management • Trained obstetrical attendant. • Available blood. • Good access I.V live. • CTG monitoring. • Anesthetist  ER C-S • Pediatrician for each fetus. • Mode of delivery depend on presentation.

  26. Thank You

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