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Multiple Pregnancy

Multiple Pregnancy. Prof Uma Singh. Multiple Pregnancy/ Multifetalpregnancy. The presence of more than one fetus in the gravid uterus is called multiple pregnancy Two fetuses (twins) Three fetuses (triplets) Four fetuses (quadruplets) Five fetuses (quintuplets) Six fetuses (sextuplets).

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Multiple Pregnancy

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  1. Multiple Pregnancy Prof Uma Singh

  2. Multiple Pregnancy/ Multifetalpregnancy • The presence of more than one fetus in the gravid uterus is called multiple pregnancy • Two fetuses (twins) • Three fetuses (triplets) • Four fetuses (quadruplets) • Five fetuses (quintuplets) • Six fetuses (sextuplets)

  3. INCIDENCE Hellin’s Law: Twins: 1:89 Triplets: 1:892 Quadruplets: 1:893 Quintuplets: 1:894 Conjoinedtwins: 1 : 60,000 Worldwide incidence of monozygotic - 1 in 250 Incidence of dizygotic varies & increasing

  4. Demography • Race: most common in Negroes • Age: Increased maternal age • Parity: more common in multipara • Heredity - family history of multifetal gestation • Nutritional status – well nourished women • ART - ovulation induction with clomiphene citrate, gonadotrophins and IVF • Conception after stopping OCP

  5. Twins Varieties: • 1. Dizygotic twins: commonest (Two-third) • 2. Monozygotic twins (one-third) Genesis of Twins: • Dizygotic twins (syn: Fraternal, binovular) - - fertilization of two ova by two sperms.

  6. Monozygotic twins (syn: Identical, uniovular): • Upto 3 days - diamniotic-dichorionic • Between 4th & 7th day - diamnioticmonochorionic - most common type • Between 8th & 12th day-monoamniotic-monochorionic • After 13th day - conjoined / Siamese twins.

  7. Conjoined twins Ventral: 1) Omphalopagus 2) Thoracopagus 3) Cephalopagus 4) Caudal/ ischiopagus Lateral: 1) Parapagus Dorsal: 1)Craniopagus, 2)Pyopagus

  8. Superfecundation Fertilization of two different ova released in the same cycle Superfetation Fertilization of two ova released in different cycles

  9. Differences in zygocity Monozygotic Dizygotic 2 ova + 2 sperm Same or opposite sex Fraternal resemblance Double or s/t fused Different genetic features DNA microprobe - different • 1 ova + 1 sperm • Same sex • Identical features • Single or double placenta • Same genetic features • DNA microprobe -same

  10. Differences in chorionicity with single placenta D / D ( fused placenta ) M / D Monozygotic Thin dividing membrane 2mm or less T sign • Monozygotic or dizygotic • Thick dividing membrane > 2mm • Twin peak / lambda sign

  11. Diagnosis • HISTORY: • History of ovulation inducing drugs specially gonadotrophins • Family history of twinning (maternal side). • SYMPTOMS: • Hyperemesisgravidorum • Cardio-respiratory embarrassment - palpitation or shortness of breath • Tendency of swelling of the legs, • Varicose veins • Hemorrhoids • Excessive abdominal enlargement • Excessive fetal movements.

  12. GENERAL EXAMINATION: • Prevalence of anaemia is more than in singleton pregnancy • Unusual weight gain, not explained by pre-eclampsia or obesity • Evidence of preeclampsia(25%)is a common association. ABDOMINALEXAMINATION: Inspection: • The elongated shape of a normal pregnant uterus is changed to a more "barrel shape” and the abdomen is unduly enlarged.

  13. Palpation: Fundal height more than the period of amenorrhoea • girth more than normal • Palpation of too many fetal parts • Palpation of two fetal heads • Palpation of three fetal poles • Auscultation: Two distinct fetal heart sounds with Zone of silence 10 beat difference

  14. D/D of increased fundal height • Full bladder • Wrong dates • Hydramnios • Macrosomia • Fibroid with preg • Ovarian tumor with preg • Adenexal mass with preg • Ascitis with preg • Molar pregnancy

  15. INVESTIGATIONS • Sonography: In multi fetal pregnancy it is done to obtain the following information: • Suspecting twins – 2 sacs with fetal poles and cardiac activity • Confirmation of diagnosis • Viability of fetuses, vanishing twin • Chorionicity – 6 to 9 wks ( single or double placenta, twin peak sign in d /d gestation or Tsign in m/d ) • Pregnancy dating,

  16. Sonography ( ctd ) • Fetal anomalies • Fetal growth monitoring (at every 3-4 weeks interval) for IUGR • Presentation and lie of the fetuses • Twin transfusion (Doppler studies) • Placental localization • Amniotic fluid volume

  17. Radiography • Biochemical tests: raised but not diagnostic Maternal serum chorionic gonadotrophin, Alpha fetoprotein Unconjugated oestriol

  18. Lie and Presentation Longitudinal lie (90%) • both vertex (40%) • Vertex + breech (28%) • breech + vertex ( 9%) • both breech ( 6%) Others vertex + transverse breech + transeverse both transeverse

  19. Complications • Maternal • Pregnancy • Labour • Puerperium • Fetal • MATERNAL: During pregnancy: - miscarriages • Hyperemesis gravidorum • Anaemia • Pre-eclampsia (25%) • Hydramnios ( 10 % )

  20. GDM ( 2 – 3 times) • Antepartum hemorrhage – placenta previa and placental abruption • Cholestasis of pregnancy • Malpresentations • Preterm labour (50%) twins – 37 weeks, triplets – 34 weeks, quadruplets – 30 weeks • Mechanical distress such as palpitation, dyspnoea, varicosities and haemorrhoids • Obstructive uropathy

  21. During Labour: • Prelabour rupture of the membranes • Cord prolapse • Incoordinate uterine contractions • Increased operative interference • Placental abruption after delivery of 1st baby • Postpartum haemorrhage During puerperium: Subinvolution Infection Lactation failure

  22. FETAL – more with monochorionic • Spontaneous abortion • Single fetal demise Vanishing twin – before 10 weeks Fetus papyraceous/compressus – 2nd trim Complications in 2nd twin (depend on chorionicity) – neurological, renal lesions - anaemia, DIC - hypotension and death

  23. FETAL – more with monochorionic • Low birth weight ( 90%) Prematurity – spontaneous or iatrogenic Fetal growth restriction - in 3rd trimester, asymmetrical, in both fetus • Discordant growth - Difference of >25% in weight , >5% in HC, >20mm in AC, abnormal doppler waveforms - Causes – unequal placental mass, lower segment implantation, genetic difference, TTTS, congenital anomaly in one

  24. FETAL COMPLICATIONS (ctd) • Congenital anomalies – conjoined twins, neural tube defects – anencephaly, hydrocephaly, microcephaly, cardiac anomalies, Downs syndrome, talipes, dislocation of hip • TTTS -Twin to twin transfusion syndrome - cause – AV communication in placenta – blood from one twin goes to other – donor to recipient - donor – IUGR, oligohydramnios - recipient – overload, hydramnios, CHF, IUD

  25. FETAL COMPLICATIONS (ctd) • TRAP -Twin reversed arterial perfusion syndrome or Acardiac twin - absent heart in one fetus with arterio-arterial communication in placenta, donor twin also dies • Cord entanglement and compression – more in monoamniotic twins • Locked twins • Asphyxia – cord complication, abruption • Still birth – antepartum or intrapartum cause

  26. Monoamniotic twins high perinatal morbidity, mortality. Causes : cord entanglement congenital anomaly preterm birth twin to twin transfusion syndrome

  27. Antenatal Management • Diet: additional 300 K cal per day, increased proteins, 60 to 100 mg of iron and 1 mg of folic acid extra • Increased rest • Frequent and regular antenatal visit • Fetal surveillance by USG – every 4 weeks • Hospitalisation not as routine • Corticosteroids -onlyin threatened preterm labour , same dose • Birth preparedness

  28. Management During Labour • Place of delivery: tertiary level hospital • FIRST STAGE: blood to be cross matched and ready confined to bed, oral fluids or npo intrapartum fetal monitoring ensure preparedness • SECOND STAGE – first baby • - second baby

  29. Management During Labour • SECOND STAGE –delivery of first baby as in singleton pregnancy start an IV line no oxytocic after delivery of first baby secure cord clamping at 2 places before cutting ensure labeling of 1st baby • Delivery of second twin FHS of second baby lie and presentation of second twin wait for uterine contractions conduct delivery

  30. Management During Labour • Delivery of second twin – problems & interventions -inadequate contraction- augmentation – ARM, oxytocin -transverse lie – ECV, IPV -fetal distress, abruption, cord prolapse- expedite delivery – forceps, ventouse, breech extraction • THIRD STAGE – AMTSL - continue oxytocin drip - carboprost 250µgm IM - monitor for 2 hours

  31. Indications of caesarean • Non cephalic presentation of first twin • Monoamniotic twins • Conjoined twins • Locked twins • Other obstetric conditions • Second twin – incorrectible lie, closure of cervix

  32. MCQs • Text book of Obstetrics, Dr J B Sharma, 1st edition ( 2012) page-473 to 483 • Chapter - multiple pregnancy

  33. 1. Splitting of single fertilized ovum between 8 to 12 days results in a) conjoined twins b) monochorionic monoamniotic twin c) dichorionic diamniotic twin d) monochorionic diamniotic twin

  34. Splitting of single fertilized ovum between 8 to 12 days results in a) conjoined twins b) monochorionic monoamniotic twin c) dichorionic diamniotic twin d) monochorionic diamniotic twin

  35. 2. Twin peak sign is a feature of a) conjoined twins b) monochorionic monoamniotic twins c) dichorionic diamniotic twins d) monochorionic diamniotic twins

  36. Twin peak sign is a feature of a) conjoined twins b) monochorionic monoamniotic twins c) dichorionic diamniotic twins d) monochorionic diamniotic twins

  37. 3. Additional caloric requirement ( K cal per day) of a mother in a case of twin pregnancy is a) 300 b) 500 c) 800 d) 1000

  38. Additional caloric requirement ( K cal per day) of a mother in a case of twin pregnancy is a) 300 b) 500 c) 800 d) 1000

  39. 4. Additional iron supplementation requirement ( mg per day) of a mother in a case of twin pregnancy is a) 30 b) 50 c) 100 d) 200

  40. Additional iron supplementation requirement ( mg per day) of a mother in a case of twin pregnancy as compared to singleton pregnancy is a) 30 b) 50 c) 100 d) 200

  41. 5. Iron supplementation required by a mother having twin pregnancy is a) 30 b) 50 c) 100 d) 200

  42. Iron supplementation required by a mother having twin pregnancy is a) 30 b) 50 c) 100 d) 200

  43. 6. Twin pregnancy is complicated by all of the following except a) placenta previa b) malpresentation c) hydramnios d) post term labour

  44. Twin pregnancy is complicated by all of the following except a) placenta previa b) malpresentation c) hydramnios d) post term labour

  45. 7. Caesarean section is indicated in a) monoamniotic twin b) monochorionic twin c) dichorionic twin d) diamniotic twin

  46. Caesarean section is indicated in a) monoamniotic twin b) monochorionic twin c) dichorionic twin d) diamniotic twin

  47. 8) 32year old G2P1 at 20 weeks pregnancy in USG shows twin pregnancy, single placental mass with dividing membrane having inverted T sign. The type of twinning is a) monochorionic monoamnionic b) monochorionic diamnionic c) dichorionic monoamnionic d) dichorionic diamnionic

  48. 8) 32year old G2P1 at 20 weeks pregnancy in USG shows twin pregnancy, single placental mass with dividing membrane having lambda sign. The type of twinning is a) monochorionic monoamnionic b) monochorionic diamnionic c) dichorionic monoamnionic d) dichorionic diamnionic

  49. 9) Monochorionic twin placenta has unidirectional deep arteriovenous communication with lack of superficial vascular anastomoses. The likely complication is a) twin to twin transfusion syndrome b) twin reversed arterial perfusion c) acute intertwin transfusion d) twin cord entanglement

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