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MULTIPLE GESTATION

MULTIPLE GESTATION. Incidence. Spontaneous twins ~1 in 80 pregnancies Triplets ~1 in 8000 pregnancies Monozygotic twins- 3 to 5 per 1000 pregnancies with uniform frequency worldwide Dizygotic twins- variable incidence (4-50 per 1000 pregnancies) by locale, race, maternal age. Maternal Risks.

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MULTIPLE GESTATION

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  1. MULTIPLE GESTATION

  2. Incidence • Spontaneous twins ~1 in 80 pregnancies • Triplets ~1 in 8000 pregnancies • Monozygotic twins- 3 to 5 per 1000 pregnancies with uniform frequency worldwide • Dizygotic twins- variable incidence (4-50 per 1000 pregnancies) by locale, race, maternal age

  3. Maternal Risks • Hyperemesis • Anemia • PIH • Gestational diabetes • Postpartum hemorrhage • Placenta previa

  4. Fetal Risks • Congenital anomalies • Growth restriction of discordant twin • Twin-twin transfusion • Fetal demise (death of one fetus puts other at risk for DIC) • Premature delivery • 2nd twin: malpresentation, in utero hypoxia, hyaline membrane disease • Cerebral palsy

  5. Unique Risk of CP in Multiple Gestation • Single fetal demise • Zygosity and chorionicity (monochorionic) • Twin-twin transfusion • Growth restriction • Embryonic death • Mode and circumstances of delivery • Fetal inflammation

  6. Types of Twins Dizygotic (2/3): dichorionic (2 placentas) • if implant sites are near, placentas may fuse yet there are no vascular connections Monozygotic (1/3): dichorionic, monochorionic, diamniotic, monoamniotic • fused or separate placentas • at risk for twin-twin transfusion

  7. Most common Monochor, Diamnio Single placenta MONOZYGOTIC Rare Monochor,Monoamnio Single placenta Dichor, Diamnio Separate or fused placenta Monochor, Monoamnio Fused placenta Dichor, Diamnio Separate placenta DIZYGOTIC

  8. MONOZYGOTIC: Dichorionic, Diamniotic

  9. MONOZYGOTIC: Monochorionic, Diamniotic Highest risk of twin-twin transfusion

  10. MONOZYGOTIC : Monochorionic, Monoamniotic Risks: cord problems, high mortality rate

  11. Conjoined Twins • 1/200,000 births • Half born stillborn • More likely female ~75% • Thoracopagus most common Eng Bunker’s home in Surry County, NC Return to Famous People Home

  12. Twin-Twin Transfusion • Placental vascular anastomoses • Occurs in only 5-15% of monochorionic, diamniotic twins despite ~85% with vascular anastomoses • Does not occur in dichorionic twins • Interestingly, does not occur in monochorionic, monoamniotic twins

  13. Vascular Anastomoses

  14. Twin-Twin Transfusion • Dx: discordant growth by ultrasound • Amniotic sacs and umbilical cords • Single placenta Clinical Sxs: rapid uterine growth, changes in fetal movement, preterm labor, postnatal hemoglobin difference of >5 g/dl between the twins

  15. Twin-Twin Transfusion • Recipient twin: • Polycythemia • Hypervolemia • Polyhydramnios • CHF, hydrops • Hyperbilirubinemia • High birthweight • Donor twin: • Anemia • Hypovolemia • Oligohydramnios • Hypoglycemia • “stuck twin” fetus appears stuck due to amnion adhering to fetus • Decreased urine output • Lower birthweight

  16. Obstetrical Management • Serial removal of amniotic fluid for polyhydramnios if > 20 weeks gestation • Create an opening in amnion between the two fetuses to allow fluid exchange • Laser ablation of placental vascular anastomoses (high complication rate) • Selective reduction of donor twin if high risk of death for both twins

  17. Prognosis • Perinatal death rate is 9-11 times the rate for singletons • Monoamniotic twins have the highest mortality rate mostly because of cord entanglement • Monozygotic twins have a mortality and morbidity rate that is 2-3 times that of dizygotic twins

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