Multiple Pregnancy

1. www.totalpregnancycare.com

2. Multiple Pregnancy Dr ShantalaVadeyar MD, FRCOG, DM (UK) Advanced Obstetric Ultrasound (RCO/RCR) Subspecialist in Maternal-Fetal Medicine (RCOG) Consultant Obstetrics, Fetal & Maternal Medicine KokilabenDhirubhaiAmbani Hospital, Mumbai

3. Incidence • Increased with Assisted Reproduction • Clomiphene citrate / Letrozol/ HMG, hCG • Advanced Age • Race – Afro-carribeans • 1:80-100

7. Risks in Multiple Pregnancy

9. DC twins - lambda sign

10. MC twins - T sign

11. Chorionicity v/s Zygosity

16. Techniques for invasive testing

17. Loss rates: Amniocentesis in Twins

18. Chorionic Villous Sampling in Twins

19. Selective Fetocide / ER

20. Management: Antenatal Maternal and Fetal Surveillance

21. Ultrasound in Multiples • Diagnosis and Chorionicitydeterminaiton • Dating, Chromosomal & Structural Normality • Growth, Dopplers • Amniotic fluid assessment • Twin twin transfusion syndrome • Invasive procedures – amniocentesis, CVS • Cervical length and funnelling • Prediction of preterm labour • Timing of delivery – Dopplers, BPS in IUGR, etc

22. Complications in Twins:Based on Chorionicity

23. Delivery <34 wks 1.8% Iatrogenic 1/3rd Spontaneous 2/3rd Cervical cerclage or Progesterone • Previous affected pregnancy (15%) • Nulliparous / No previous PTD (85%) 25% reduction (4% of total) Early screening for Preterm delivery Prevalence of spontaneous early preterm birth

24. Twin Twin Transfusion Syndrome Anastomoses in TTTS • Monochorionic twins • Donor twin is small, growth restriction • Recepient twin is big • Oligo / polyhydramnios • Big bladder, heart enlarged in recepient • Oliguria, donor • Abnormal Dopplers

25. Prognosis - TTTS • Staging (Quintero) • Stage I • Recipient hydramnios • Donor bladder visible/present • Stage II • Recipient hydramnios • Donor bladder remains empty (“stuck twin”) • Stage III • Abnormal Doppler studies: • absent or reversed end-diastolic flow in Donor UA OR • abnormal venous Doppler pattern in Recipient UA (reverse flow in the ductus venosus or pulsatile umbilical venous flow) • Stage IV • Fetal hydrops means stage IV and the end • Stage V • Fetal death of one or both twins.

26. Treatment of TTTS by selective laser ablation of A-V Anastamoses Laser ablation Stuck ‘donor twin’ wrapped in membrane Feely floating ‘recipient twin’ In hydramnios

27. Electronic Fetal Heart Rate monitoring in labour

28. Epidural Analgesia(painless labour)

29. Timing and Mode of Delivery • Dichorionic twins – 38 weeks • Monochorionic twins – 36 wks • Vaginal delivery in uncomplicated DC or MC twins if cephalic, cephalic presentations • Precious pregnancy, abnormal presentations, complications like IUGR, preterm, maternal DM/HT usually delivered by LSCS • Increased risk of placenta praevia and APH, PPH

30. Complications • Post-partum haemorrhage • Bimanual massage • Uterotonics • Prophylactic Misoprostol PR • Syntocinon infusion • B Lynch Suture • Uterine Artery Ligation • Uterine Artery Embolisation • Hysterectomy

31. Profile • Total Pregnancy Care is an online guide for pregnancy, childbirth and motherhood related information. Women wanting to conceive, pregnant women, expecting parents, and new mothers can use this pregnancy portal for a healthy pregnancy, fulfilling childbirth and joyful motherhood. With pregnancy at its core, this portal covers various important aspects and especially addresses those matters that the Indian Woman always wanted to know but did not know whom to ask. • This website is compiled by Dr. Shantala, an Indian Obstetrician and Gynaecologist. She has over 20 years of extensive medical and diagnostics experience in areas commonly related to the Maternity and Pregnancy fields. She has studied and practiced in India as well as in the United Kingdom and thus brings about the fusion of best practices of the Oriental East and the Progressive West. • A mother of three children, she has complete understanding of the emotional, mental and physical needs of the New Age Pregnant Woman. Her patients appreciate her empathic approach and wholeheartedly express their gratitude for her generosity and care. Dr.Shantala is presently a full time Obstetrics and Gynaecology Consultant at the Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, a premier health care initiative of the Reliance ADA Group. Dr.Shantala has a clear vision to promote a holistic pregnancy approach and her mission is to provide comprehensive maternity care. This website, www.TotalPregnancyCare.com, is her first step towards this future.

32. Services Offered • Pre-pregnancy counseling • Genetic counseling • Antenatal care, Labour Delivery • Specialist Ultrasound scans • Viability scan • The First trimester scan / Nuchal translucency scans • Detailed anatomy / anomaly scans • Fetal Echocardiograph • 3D / 4D scans • Assessment of the High risk Fetus and Mother • Amniocentesis • Chorionic Villous sampling • Cordocentesis • Intra-uterine transfusions • Embryo Reduction / Selective fetocide • Second opinion scans

33. Topics covered • Pre-Conception • Working on getting pregnant or just starting to think about a family, this is the place for you • Pregnancy • From trying to conceive to the first trimester to labor, learn what to expect during your pregnancy and more • Labor Delivery • From that first contraction to the final push, here's what to expect during labor and delivery • Post-Pregnancy • Learn more about your diet and workouts, shopping, feeding and your child's health

34. Interactive Corner • Month by Month happenings • Articles • FAQs • Gestation Calendar

35. Society Memberships • British Maternal & Fetal Medicine Society • Fetal Medicine Centre • Kokilaben Dhirubhai Ambani Hospital & Medical Research Institute • Royal College of Obstetricians and Gynaecologists • International Society of Ultrasound in Obstetrics and Gynecology

36. Contact Us • Email: shantala@totalpregnancycare.com • Mobile: +91 9324304212 • KDAH Board line: +91 22 30999999

37. THANK YOU www.totalpregnancycare.com