Tinjauan Pustaka Multiple Gestation

5/20/2018 Tinjauan Pustaka Multiple Gestation

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MULTIPLE GESTATION

LEONARD EVAN MELLA 0961050199

NADIA VINKA LISDIANTI 1061050189


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Incidence

The incidence of multiple gestations has risensignificantly, primarily due to increased use of fertility

drugs for ovulation induction, superovulation, andassisted reproductive technologies (ART), such as invitro fertilization (IVF).

The perinatal mortality rate of twins is 34 timeshigherand for triplets much higher stillthan insingleton pregnancies.

Approximately two-thirds of twin pregnancies endin a singleton birth.


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Factors That InfluenceTwinning

Race Maternal Age

Parity

Heredity

Pituitary gonadotropin

Infertility therapy


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Maternal Risks

Spontaneous abortion

Preterm birth

Anemia

Maternal death


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Fetal Risks

Vanishing twin

Congenital malformations

Low birth weight

Twin-twin transfusion syndrome

Fetal demise


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Types of Twins

MultipleGestation

Dizygotic

Monozygotic

A single

fertilized ovum

divides into 2

separate

individuals

Produced

from

separately

fertilized ova.


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Most commonMonochorionic, Diamniotic

A single placenta

RareMonochorionic,Monoamniotic

A single placenta

Dichorionic, DiamnioticSeparate or fused

placentas

Monochorionic,MonoamnioticFused placenta

Dichorionic, DiamnioticSeparate placenta

MONOZYGOTIC

DIZYGOTIC


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Dizygotic Twins

Twins of different sexes are always dizygotic

(fraternal).

More common among women who becomepregnant soon after cessation of long-term oral

contraception.


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Clinical Findings

Symptoms

Earlier and more pressure in the pelvis

Nausea, backache, varicosities, constipation,hemorrhoids, abdominal distention, difficulty in

breathing

A large pregnancy

Fetal activity is greater and more persistent


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Clinical Findings

Signs

Uterus larger than expected (>4 cm) for dates.

Excessive maternal weight gain that is notexplained by edema or obesity.

Polyhydramnios, manifested by uterine size out of

proportion to the calculated duration of

gestation, is almost 10 times more common inmultiple pregnancy.

History of assisted reproduction.

Elevated maternal serum fetoprotein (MSAFP)

values.


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Clinical Findings

Signs

Outline or ballottement of more than 1 fetus.

Multiplicity of small parts.

Simultaneous recording of different fetal heart

rates, each asynchronous with the mothers pulse

and with each other and varying by at least 8

beats/min. (The fetal heart rate may beaccelerated by pressure or displacement.)

Palpation of 1 or more fetuses in the fundus after

delivery of 1 infant.


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Laboratory Findings

Maternal hematocrit and hemoglobin values an the

red cell count usually are considerably reduced.

Maternal hypochromic normocytic anemia.


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Ultrasound Findings

Dichorionicity:

Fetuses of different genders

Separate placentas

A thick (>2 mm) dividing membrane

A twin peak signin which the membrane inserts

into 2 fused placentas

Monochorionicity: Absence of those findings

A dividing membrane that is so thin (< 2-mm

thick) and magnification reveals only two layers

A T sign


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Ultrasound Findings


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UNIQUE FETALCOMPLICATIONS


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Conjoined Twins

Conjoined twins result from incomplete

segmentation of a single fertilized ovum between

the 13th and 14th days. If cleavage is further postponed, incomplete

twinning (ie, 2 heads, 1 body) may occur.


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Conjoined Twins


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EXTERNAL PARASITICTWINS

A grossly defective fetus or merely fetal parts,attached externally to a relatively normal twin.

Usually consists of externally attachedsupernumerary limbs, often with some viscera.

A functional heart or brain is absent.


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FETUS IN FETU

Early in development, one embryo may be

enfolded within its twin. Normal development of this rare parasitic twin

usually arrests in the first trimester. As a result,normal spatial arrangement of and presence of

many organs is lost.


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Vascular Anastomoses


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Twin-Twin TransfusionSyndrome

Local shunting of blood occurs because of vascular

anastomoses to each twin that are established early

in embryonic life. Affects approximately 15% of monochorionic twin

pregnancies.

Does not occur in dichorionic twins.


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The recipient twin:

Plethoric, edematous, hypertensive

Ascites and kernicterus The heart, liver, and kidneys are enlarged

Fetal polyuriahydramnios

The donor twin:

Small, pallid, dehydrated (from growth restriction,malnutrition, and hypovolemia)

Oligohydramnios


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Obstetrical Management

Serial removal of amniotic fluid for polyhydramnios if> 20 weeks gestation

Create an opening in amnion between the twofetuses to allow fluid exchange

Laser ablation of placental vascular anastomoses(high complication rate)

Selective reduction of donor twin if high risk of deathfor both twins


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Large volume amnioreduction


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Amniotic Septostomy


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Fetoscopic Laser Ablation


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Acardiac Twins (TRAP)

A parasitic monozygotic fetus without a heart. It is

thought to develop from reversed circulation,

perfused by 1 arterialarterial and 1 venousvenousanastomosis.


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Treatment

Ultrasound and/or maternal serum testingAmniocentesis and chorionic villus samplingPrenatalDiagnosis

Ultrasonography

Routine growth scans on twins every 4 weeks in the thirdsemester or more frequently if growth restriction isdetected

Iron and calcium supplementation, vitamin and folicacid administration, a high protein diet,supplementation with Mg, Zn, and essential fatty acids

Tocolytic drugs may be used

AntepartumManagement


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Labor and Delivery

Admit the patient to the hospital if:

First sign of suspected labor or preterm labor

There is leakage of amniotic fluid

Significant bleeding occurs

>4 contractions per hour at


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Labor and Delivery

Indications for primary caesarean section: If either twin show signs of persistent compromise

Malpresentation

Monoamniotic twins

Gross disparity in fetal size

Placenta previa


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Labor and Delivery

Intrapartum twin presentations:


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Labor and Delivery

The umbilical cord should be clamped promptly

Perform a vaginal examination immediately after

delivery of twin A Tag and label the cords (twin A and B)

Locked twins can be avoided by caesarean

delivery in all cases


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Labor and Delivery

Increased intravenous oxytocin, elevation, and

massage of the fundus and an intravenous ergot or

prostaglandin product (only after the last fetus isdelivered) may be required.

Manual extraction of the placenta may be

necessary.

Prophylactic rectal misoprostol in the operating

room followed by oral misoprostol every 6 hours for24 hours after delivery for all multiple gestations.


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Laporan Kasus


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I. Identitas(20 Juli 2014 pukul 21.00)

Nama Pasien : Ny. M

Umur : 35 tahun

Pendidikan : SMA

Pekerjaan : Pegawai Swasta

Agama : Islam

Suku : Betawi

Alamat : Duren Sawit

Identitas


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II. Subjektif

KU : Mulas-mulas

KT : -

Subjektif


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Riwayat Penyakit Sekarang

Pasien datang ke IGD RS UKI dengan keluhanperut terasa mulas pada bagian kanan sejak 1minggu SMRS. Keluhan ini dirasakan terus-menerus dan semakin lama terasa semakin

mules. Keluhan tidak berkurang denganperubahan posisi. Keluar cairan bercampurdarah dari vagina disangkal. Pasien selalu kontrolkehamilan di poli RS UKI. Kontrol terakhir 1 mingguyang lalu (12 Juli 2014) dan dinyatakan pasienhamil gemeli. Usia kehamilan saat ini 32 minggu.


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Riwayat Haid

Haid pertama : 9 tahun

Siklus : tidak teratur Lama : 7 hari

Banyak : 4x ganti pembalut /100 cc

HPHT : 5 Des 2013

TP : 12 september 2014

Sakit saat haid : disangkal

Riwayat Perkawinan Status Pernikahan : menikah 1x

Lama perkawinan : 2 tahun


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Riwayat Kehamilan Persalinan, nifas yang lalu: Ini

Riwayat Penyakit Dahulu : Disangkal

Riwayat Penyakit Keluarga : DisangkalRiwayat Operasi : Disangkal

Metode KB : Tidak menggunakan KB


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Riwayat ANC

Waktu hamil periksa di : RS UKI Oleh

dr. Januar Simatupang Sp.OG, Keluhan, kelainan, dan masalah : -

Waktu ANC Usia Kehamilan Tempat Masalah Penatalaksanaan

0 0-12 mg - - -

1x 13-28 mg RS UKIHamil

gemeli-

1x 29 mg sekarang RS UKIHamil

gemeli-


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III. OBJEKTIFA. Pemeriksaan Umum / Status Generalis

Tinggi badan : 160 cm

Berat Badan : 75 kg

Keadaan Umum : BaikKesadaran : Komposmentis

Objektif


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a. Tanda Vital

TD : 110/80 mmHg

Nadi : 84 x/menit

Suhu : 36,2 0C

Pernapasan : 20 x/menit

b. Kepala : normocephali

c. Matai. Konjungtiva : tidak anemis

ii. Sklera : tidak ikterik

iii. Gigi : lengkap, karies (-)iv. THT : dalam batas normal


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d. Leher : KGB tidak teraba membesar

e. Payudara : massa (-/-) retraksi (-/-) nyeri (-/-)

f. Jantung : BJ I & II reguler, gallop (-)murmur (-)

g. Paru-paru : I : pergerakan dinding dada simetris ka/ki

P : VF simetris ka/ki

P : sonor ka/ki

A : BND vesikuler, Rh -/- Wh -/-


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h. Abdomen

I : Perut tampak membuncit

A : BU sulit dinilai

P : Defense muskular (+) hepar dan limpa sulitdinilai

P : nyeri ketok (-)

i. Ekstremitas :

Superior : akral hangat, CRT < 2 , edema -/-

Inferior : akral hangat, CRT < 2, edema +/+


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B. Pemeriksaan Umum / Status Generalis

1. Pemeriksaan Luar

a. I : perut tampak membuncit, linea nigra (+) striaegravidarum (+)

b. P : TFU 36 cm Leopold I :

Teraba 2 bagian terbesar janin bulat, keras, melenting,

kesan kepala janin gemeli Leopold II :

Teraba bagian memanjang tidak terputus-putus padasebelah kiri ibu punggung kiri janin gemeli

Leopold III :

Teraba bagian bawah janin, bulat, lunak, tidak melenting,kesan bokong Leopold IV:

Bayi belum memasuki PAP


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c) Auskultasi : DJJ :

i. Frekuensi : 140 x

ii. Irama : tidak teratur

2. HIS

Frekuensi : 2x / 10 menit

Lamanya : 60

Kekuatan : kuat

Relaksasi : ada, lamanya 5 menit


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3. Pemeriksaan Dalam

a. Inspekulo : tidak dilakukanb. VT

Vulva / vagina : tenang, rugae (+), tidakteraba massa

Portio

Axis : Posterior

Konsistensi : Lunak

Penipisan : 20 %

Pembukaan : 1-2 cm Ketuban : utuh


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c. Denominator : belum dapat dinilai

d. Caput : belum dapat dinilai

e. Moulage : belum dapat dinilai


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IV. ASSESMENT

A. DIAGNOSIS KERJA

Ibu : G1POAO hamil 32 minggu partusprematur iminens

Janin : Janin Gemeli hidup

Assesment


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B. PROGNOSIS

Kehamilan : dubia et malam

Persalinan : dubia et malam

C. DAFTAR MASALAH Janin Gemeli

Assesment


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V. PLANNINGA. Rencana pemeriksaan untuk konfirmasi

diagnosis

Observasi keluhan utama, TTV, DJJ, HIS

Periksa Lab H2TL, MP3, HbSAg Rencana USG

Planning


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B. Rencana pengobatan / penatalaksanaankhusus

Bila berlanjut inpartu RSC

Diet Biasa

Infus RL

MM:

Dexametasone Nifedipine

Tramal Supp 1x1

Planning


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C. Informed Consent

Menjelaskan kepada pasien tentangkehamilan dan rencana persalinan yangdilakukan

Motivasi lakstasi dan KB

Planning


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THANK YOU

Tinjauan Pustaka Multiple Gestation

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