Multiple pregnancy by Dr taimur afridi
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Multiple Pregnancy
Muhammad Taimur AfridiRoll No : 08-127
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•Incidence :•Monozygotic twins - 4/1000 births•Dizygotic twins – 2/3rds, race, age, assisted conception•Triplets – 1 in 7000 to 10,000 births•Quadruplets – 1 in 600,000 births
• Almost every maternal and obstetric problem occursmore frequently in multiple Pregnancy
• Perinatal mortality rate in twins is 5 times higher andin triplets 10 times higher than in singletons
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•Zygosity refers to the type of conception
•Chorionicity denotes the type of placentation
•Chorionicity rather than zygosity determines outoutcome
Zygosity and Chorionicity
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Mechanism of dizygotic twinning
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Fertilization of a single ovum
Similar sex
Genetically identical
Fertilization of 2 separate
ova
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MONOCHORIONIC TWINS
•3-8 DAYS LATER (60-70%) Within 72 hours (18-32%)
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MONOCHORIONIC TWINS
•8-12 DAYS LATER (1-2%)
•12-13 DAYS LATER
(0.5%)
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Maternal responses
Cardiac output, GFR and renal blood flowPlasma volume by 1/3 > singletonsRed cell mass 300 ml > singletons
Hematocrit and hemoglobinIron stores in 40% of women with twins
Multiple pregnancy
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DIAGNOSIS
Patient profile:
Etiological factors:
positive past history and family history specially maternal, race, age
Assisted reproductive technology
Early pregnancy:
Hyperemesis, excessive weight gain
minor complications of pregnancy such as backache, edema, varicose veins, hemorrhoids, striae, etc
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PHYSICAL SIGNS
General:
Pallor, weight gain, excessive pedal edema/ varicose veins
Pregnancy Induced Hypertension(PIH) and Pre-eclampsia (5-10times more)
Abdominal:
Size > Date especially in midpregnancy
Multiple fetal parts
Auscultation of FHS:
2 different recordings by 2 observers and a difference > 10 bpm
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Differential diagnosis
• Elevation of the uterus by a distended
bladder
• Inaccurate menstrual history
• Hydramnios
• Hydatidiform mole
• Uterine fibroids
• A closely attached adnexal mass
• Fetal macrosomia (late in pregnancy)
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Ultrasonography
• Detect multifetal gestation 99% before
26 weeks
• Confirm fetal number [ 2 sacs or 2fetal
heads in 2 perpendicular planes]
• Diagnose type and presentation and
position and relation to each other
• Exclude congenital abnormalities/
conjoint twin
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MATERNAL
COMPLICATIONSSymptoms – hyperemesis, aches and pains
of pregnancy worsen
Hypertensive disease of pregnancy
Preterm delivery
Premature rupture of membranes
Polyhydramnios
Placenta praevia
Malpresentation
Delivery complications (operative delivery, placental abruption, cord accidents)
Postpartum hemorrhage, depression
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FETAL COMPLICATIONS
Spontaneous early pregnancy loss
Prematurity
Intra-uterine growth restriction
Cerebral palsy - related to gestational age, 3 times in twins, > 10 times in triplets
Intrapartum trauma
Monochorionic twins – specific complications
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Antenatal care
• Routine booking investigationsFolic acid supplementationanemia – treat immediatelySupport symptomatically
• Serial growth scans :
Dichorionic :4 weekly from 24 weeks
Monochorionic : 2 weekly from 18 weeks- Liquor volume- Doppler study of umbilical artery
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Intrapartum management
•Presence of skilled obstetrician, anesthetist and neonatologist available at delivery•Reliable intravenous access•Cardiotocograph with dual monitoring capability•Portable ultrasound scanner•Delivery bed with lithotomy stirrups•Obstetric forceps or vacuum apparatus• active management of third stage: Uterotonics•Immediate availability of blood•Facilities and staff for emergency cesarean section
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Monochorionic Monoamniotic twins
•3 - 12 x perinatal mortality•10 x cerebral necrotic lesions
•1% of monozygotic twins are monoamnionic
•Perinatal mortality rate of 30-50%, largely relates to a risk of intrauterine death before 32 weeks
•Cord entanglement
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Twin-Twin Transfusion Syndrome
•Incidence : 4 - 20% of MC twins
•It is characterised by an imbalance of blood flowbetween the twins
•15 - 20% of perinatal deaths
•Untreated, perinatal loss rates in the mid-trimester(80 - 100%)
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Large volume amnioreduction
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Amniotic Septostomy
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Fetoscopic Laser Ablation
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DELIVERY BY CAESAREAN SECTION
AT 34 WEEKS
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Conjoined twins or Siamese twins
•Anterior (thoracopagus)
•Posterior (pygopagus)
•Cephalic (craniopagus)
•Caudal (ischiopagus)
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Single intrauterine demise
•2-6% of twins pregnancies
•Up to 25% in MC twin pregnancy
• Perinatal morbidity and mortality of the surviving co-twin
- 19% perinatal death- 24% having serious long term sequelae
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Treatment options
•No optimal management
•Prompt delivery -Iatrogenic prematurity risks
•Conservative treatment -Subsequent handicaps
•Intrauterine interventions
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High order multiples
•Perinatal risk increases exponentially with increasing number of fetuses
•Multifetal pregnancy reduction (MFPR) at 10 to 12weeks should be recommended for quadruplets andhigher multiples
•The situation with triplets is more controversial
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