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Twins

Twins. Topic Conference LU VI Block 10 Tindoc.Tugano.Urquiza.Uy.Velasco.Ventigan.Ventura.Verdolaga . VillanuevaM.VillanuevaR.Visperas.Yabut.Yambot.YapB.YapJ. EV, 33 year old G2P1(0010), single. EV, 33 year old G2P1(0010), single. EV, 33 year old G2P1(0010), single.

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Twins

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  1. Twins Topic Conference LU VI Block 10 Tindoc.Tugano.Urquiza.Uy.Velasco.Ventigan.Ventura.Verdolaga. VillanuevaM.VillanuevaR.Visperas.Yabut.Yambot.YapB.YapJ

  2. EV, 33 year old G2P1(0010), single

  3. EV, 33 year old G2P1(0010), single

  4. EV, 33 year old G2P1(0010), single

  5. EV, 33 year old G2P1(0010), single

  6. History of present illness

  7. Review of systems

  8. EV, 33 year old G2P1(0010), single

  9. Physical Exam

  10. Physical Exam

  11. BPP/Biometry/Doppler Studies

  12. BPP/Biometry/Doppler Studies

  13. EV, 33 year old G2P1(0010), single

  14. Prevalence of spontaneous twinning • 1 in 80 live births (1 in 40 babies) • 10-20/1000 live births in US, Europe • 40/1000 in Africa • 6/1000 in Asia

  15. Etiology of multifetal gestation • Dizygotic – fertilization of 2 ova

  16. Etiology of multifetal gestation • Monozygotic – division of single fertilized ovum

  17. Factors that influence twinning • Race • 6/1000 livebirths in Asia • E.g. 4.3/1000 in Japan, 11.3/1000 in India, 12.3/1000 in England, Wales • Heredity • Maternal history more important • Mother’s who themselves are twins gave birth to twins at a 1/58 live births • Maternal Age and Parity • Taller, heavier more nutritionally provided women, 25-30% inc in twinning rate • Pituitary Gonadotropin • Inc dizygotic twinning rate w/in 1 mo. of stopping oral contraceptives, associated with sudden surge in gonadotropin • Assisted Reproductive Technology • Responsible for 17% of multiple births in the US

  18. Maternal physiology • Cardiovascular • More hyperdynamic circulation than singleton pregnancy • Cardiac output increases by 20% more in twin gestation than in singleton • 15% from stroke volume: due to increase in preload • 3.5% from heart rate • GI and Hepatic Changes • Pregnancy nausea and vomiting 50% • Twice the risk for obstetric cholestasis • Twin pregnancy independent risk factor for acute fatty liver, 9-25% of all cases seen in twin pregnancies • Renal • No significant difference from singleton • Increased GFR, leads to decreased BUN, Crea and increased urine protein

  19. Maternal physiology • Respiratory • No significant difference • Increase use of accessory muscles • Exaggerated abdominal distention • Loss of abdominal tone • Hematologic • RBC mass increases by 25% in both single and multifetal gestations • Inc. in plasma volume is 10-20% greater in twin pregnancy vs singleton • Other changes associated with singleton pregnancy occur in the same way • Fall in Hct 1st-2nd trimester • Granulocytosis with increase in immature WBCs • Hypercoagulability due to changes in coagulation and fibrinolytic cascades

  20. Complications • Antepartum complications • preterm labor • gestational diabetes • Preeclampsia • preterm premature rupture of the membranes • intrauterine growth restriction • intrauterine fetaldemise • TTTS • 80% in multiple gestations vs 25% in singleton pregnancies

  21. MATERnal complications • Preterm Delivery • 57% of twin gestations are preterm • Not all spontaneous • Higher risk for male-male twins • Ave. length of pregnancy 35 wks for twins vs 39 wks for singletons • Gestational DM • May be increased in multifetal gestation though not universally confirmed • Treated the same way in twin pregnancies

  22. Maternal complications • Pregnancy HPN • Gestational HPN - RR 2.04 (95% CI 1.60 - 2.59) • Pre-eclampsia – RR 2.62 (95% CI 2.03 - 3.38), w/ earlier onset, greater severity • Gestational HPN and preeclampsia also associated with higher preterm delivery rates • Gestational HPN, <37 wks 51.1% vs 5.9% singleton • Preeclampsia, <37 wks 66.7% vs 19.6% singleton • pPROM • Occurs in 7-10% of twin pregnancies • Typically occurs in the presenting sac • Management same as in singleton pregnancies

  23. Fetal complications • Fetal Growth Restriction • 10 times more likely in multiple gestations compared to singletons • Growth Discordance • >=20% difference in EFW • 5-15% of twins • Usu. birth weight difference of 15% for twins • 34% chance of growth restriction in at least one twin for monochorionic twins, 23% for dichorionic twins • Associated with 6 fold increase in risk for perinatal morbidity and mortality • Congenital anomalies • Studies suggest 2-3x increased risk in twins, with probably 10% of twins born w/ congenital anomalies

  24. Fetal Complications • Spontaneous Pregnancy Loss • Around 14% of twin gestations spontaneously convert to singleton pregnancies before the 1st trimester – “Vanishing twin” • Remaining fetus a 3x inc risk for abortion • Est. that only 1/8 individuals conceived as a twin is born a twin • Intrauterine Fetal Demise • Overall survival rate of both twins is 93.7% • Death of one or both fetus at 11-15 wks 5% vs 2% in singletons • Subsequent risk of miscarriage of surviving fetus 24% • Chorionicity important • Monochorionic twin – death of one fetus inc risk of death of the other of 25% • Dichorionic twin – 5-10% risk

  25. Fetal Complications • Twin-to-Twin Transfusion Syndrome (TTTS) • Almost exclusively confined to monochorionic twins, with 10-15% of these having a severe form • Around ¼ of all monochorionic twins have some features of the syndrome • Due to the presence of intertwinanastomosis: A-A, V-V, A-V • A-V and A-A occur in 70% of monochorionic twins • Classically due to A-V anastomoses carrying unidirectional blood flow from donor to recipient twin

  26. Fetal complications • TTTS • Donor twin may become anemic and growth restricted • Recipient twin may become polycythemic, w/ circulatory overload and heart failure • Diagnosed by UTZ at 15-22 wks. • Diagnosed by presence of monochorionic twins with one oligohydramnios twin, other polyhydramnios twin • Most commonly treated with aggressive amniodrainage and laser photocoagulation of anastomoses • Survival rate of at least one twin with laser therapy higher (66%) vsamniodrainage (57%) • Acute twin-to-twin transfusion • Antepartum complication in the interval of cord clamping of 1st twin and delivery of the 2nd twin • 2nd twin left alone with 2 placentas, where its blood may be pumped into - death

  27. DIAGnosis • Suggested by • Accelerated fundal growth • Multiple fetal parts • Auscultation of 2 FHTs • Sonography – the “sine qua non” of diagnosis • Chorionicity • Fetal viability/diagnosis of intrauterine death • Nuchal translucency thickness • Chromosomal abnormalities • Early TTTS diagnosis • Fetal structural abnormalities • IUGR, discordant growth • Fetal circulation • Placental localization, fetal position

  28. Diagnosis • Chorionicity • Important – highest rate of death in twins occurs before 24 wks, most often due to TTTS • Chorionicity easier to determine at early gestation • What to look for • Separate placentas – diagnostic but usu. difficult • Intertwin membrane – from 2 amnions, 2 chorions, >2mm in dichorionic twins • Extraembryoniccoelimic space – 2 in dichorionic • Yolk sacs – 2 in dichorionic • Fetal sexes • Lambda/twin peak sign – diagnostic of dichorionic twins; triangular chorionic tissue from fused dichorionic placenta extending into the intertwin membrane

  29. Labor management & delivery • The cornerstone of antepartum care is prevention of preterm labor and delivery • Main cause of high perinatal mortality and complications in twins • Labor and Delivery Problems • Hypotonic uterine inertia • Due to overdistended uterus • Oxytocin just as effective as in single births, dosage, time to delivery, complications same • Intrapartum bleeding • More common in twins due to abruptio or vasaprevia

  30. Labor management & delivery • Route of Delivery • Vaginal delivery for mature vertex-vertex twins and <1500g vertex-vertex twins – same outcome as CS • CS indications for singleton pregnancy still apply • If the 1st twin is transverse or breech, CS in favored • Avoid “locked-twins” complication • CS for non-vertex second twin • No improvement in fetal outcome • Inc. maternal febrile morbidity • Best delivered by assisted breech delivery or breech extraction

  31. Labor and Delivery • Presentation and Position • Most common combination is cephalic-cephalic, cephalic-breech, and cephalic-transverse • Presentations other than cephalic-cephalic are unstable

  32. Vaginal delivery • Cephalic-cephalic: spontaneous or forceps assisted • Cephalic-noncephalic: vaginal delivery of the noncephalic twin can be done if the weight > 1500g • VBAC: same risk of uterine rupture as in singleton pregnancy

  33. Cesarean section • Breech: CS if • Large fetus, and the aftercoming head is larger than the birth canal • Small fetus the extremities and trunk may deliver through an inadequately effaced and dilated cervix, but the head may become trapped above the cervix • The umbilical cord prolapses.

  34. In this study there was no significant differencein perinatal mortality and neontala mortality in both the CS group and planned vaginal group.

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