rps138 slide kehamilan kembar multiple pregnancies
DESCRIPTION
bhnTRANSCRIPT
KEHAMILANKEHAMILAN= MULTIPLE PR= MULTIPLE PR
(GEME(GEME
O �O �
Dr. HOTMA PARTOGDr. HOTMA PARTOGSUB BAGIAN FETOMSUB BAGIAN FETOMSUB BAGIAN FETOMSUB BAGIAN FETOM
RS. PIRNGARS. PIRNGA
N KEMBARN KEMBARREGNANCIES =REGNANCIES =ELLI)ELLI)
��
GI PASARIBU SpOGGI PASARIBU SpOGMATERNAL FKMATERNAL FK--USUUSUMATERNAL FKMATERNAL FK--USUUSUADI MEDANADI MEDAN
PendahPendah• Two for the price of oneTwo for the price of one• High Complication Risk
mortalitas ↑ 50% 32-38 mmortalitas ↑ 50% 32 38 m• Pe↑ Malpresentasi:
kedua janin sungsang 4- kedua janin sungsang 4- Janin kembar I sungsan
L k d t i (j )- Locked twins (jarang)• Persalinan operatif & res
huluanhuluane” atau “instant family”e atau instant familyk→Morbiditas & minggu, 10% dibawahnyaminggu, 10% dibawahnya
41%41%ng 17%
siko persalinan preterm ↑
Definisi & KDefinisi & KKehamilan 2 janin atau lebihKehamilan 2 janin atau lebihKembar dizigotik (66%) Bin1. fertilisasi 2 ovum oleh 2 s2. Dikorionik: Amnion terpiKembar monozigotik (33%)
P b l h 1 f til- Pembelahan 1 ovum, fertilsperma yang sama
- Pembelahan <72 jam: Dik- Pembelahan <72 jam: Dik(96%)
- Pembelahan 4-8 hari: Mon(4%)
KlasifikasiKlasifikasihhnovular-fraternal twinsspermaisah) Mono ovular-identical twinsli i l hlisasi oleh sperma
orionik diamnotikorionik diamnotik
nokorionik diamniotik
Mono ovular-idenMono ovular idendiamniotik mon
ntical twins,ntical twins, nokorionik
- Pembelahan 8-13 hari: MonPembelahan 8 13 hari: Mon- Pembelahan >13 hari: Conjo
Fetus PapyraceousFetus Papyraceous- Salah satu janin kembar tida
Tak berbentuk mengkerut &- Tak berbentuk, mengkerut &Perbandingan Mono/DizigoFaktor resiko untuk kembarFaktor resiko untuk kembar
- tuaM lti it- Multiparitas
- Riwayat keluarga kehamilan
okorionik, Monoamniotikokorionik, Monoamniotikoined twins
ak berkembang& rata& rataotik 1:2r dizigotik:r dizigotik:
n kembar dizigotik
Fetus Papyraceous, salah satu ffetus yang tidak berkembang
Insi
1% dari kehamilan, 2/3 diziEtnik (1:50 Afrika, 1:80 Cau( ,Usia (2% > 35 thn) Paritas (2% setelah kehamil( %Metode konsepsi (20% induRiwayat keluargaRiwayat keluargaInsidensi menurut hukum Hkehamilane
iden
got & 1/3 monozigotusasia, 1:50 Asia), )
lan ke-4))uksi ovulasi)
Hellin adalah 1 dalam 80n-1
Etio
• Bangsa, hereditas, umur fraternal-twins
• Obat klomid & gonadotr• Fertilisasi in vitro & tran• Fertilisasi in vitro & tran
ologi
& paritas→ binovular
ropin hormon→ dizigotik nsfer embrio (IVF&ET)nsfer embrio (IVF&ET)
Patofis
Fertilisasi ovum&spermOvum yang telah dibuahi tOvum yang telah dibuahi tnidasi dan Pertumbuhan fe
Selama proses ini kem
siologi
ma di tuba falopii turun uterusturun uterus etus
mbar dapat terbentuk
Kehamilan berasal dari satu telur terjadi Akibat adanya kerja faktor penghambat (pada masa awal pertumbuhan embrio intp pmempengaruhi segmentasi selanjutnyapada berbagai tingkatan.
:(inhibiting factor)trauterin, ,
Tipe Pre
• Janin kembar I presentas• Kedua janin presentasi vKedua janin presentasi v• Salah satu janin vertex, l
K d j i i b• Kedua janin presentasi b
esentasi
si vertex 75%vertex 45%vertex 45%lainnya bokong 37%b k 10%bokong 10%
tipe-tipe ppresentasi
Distribusi dari letakembar (dalam
KEMBARDUA
KEM
KeKe
Kepala
SSungsang
Lintang
ak dan posisi janin %) antara lain:
MBAR PERTAMA
epala Sungsang Lintangepala Sungsang Lintang
39 13 0,6
26 9 0 626 9 0,6
8 4 0,6
Early Di
Anamnesa
GemGem
P ik kli iPemeriksaan klinis
iagnosis
Ultrasonografi
mellimelli
R di l iRadiologi
Diagnosis A
DIZYGOTICDIZYGOTIC
Awal Twins
MONOZYGOTICMONOZYGOTIC
Ultrasonografi kehamilan kembag f r pada usia kehamilan 38-40 harip
Diagnosa dini gagal →- P↑ PJT & persalinan prem- P↑ mortalitas & morbidita
P↑ komplikasi- P↑ komplikasi
Berdasarkan o
36-37 mgg +++
P’tbh j i 24 35P’tbhan janin 24-35 mgg
Kematian intra uteKematian intra ute
maturas perintal
observasi
Amnion <<<
l t t ++ plasenta matang++
erin ↑ 37-38 mggerin ↑ 37-38 mgg
iff i l i• Differential Diagn
Kehamilan lewat waktuPolihidramnionPolihidramnionTumor fibroid uterusKistaMola hidatiforma
inosis
u
Anemia AtoAnemia Ato
PPHK lik iKomplikasi
Retensio plasentaRetensio plasenta
Inersia uteri
onia uterionia uteriHidramnion
Abortusi t li maternal
Partus prematurPartus prematur
Pre-eklampsia
Solusioplasenta Malpresentasplasenta
KPD
Komplikasi f
BBLR
I fi i i l tInsufisiensi plasenta
si Plasenta Previa
PrematuritasPrematuritas
fetal
Kelainan kongenital
Prolapsus tali pusatProlapsus tali pusat
Komplikasi In
Plasenta
kebutuhan nutrisi>>
Kond
ntrapartum
Insufisiensi plasenta
Polihidramnion
disi lain
Prolapsus tali pusatProlapsus tali pusat
PPH K lik i P iPPH Komplikasi Peri
Solusio Plasenta Tran
Malpresentasi Malpresentasi
Lockedi t T iipartum Twins
nsfusion Syndrom
PenatalaA. Tindakan umum
- Diet & Pola makan yanB i & A f l t- Besi & Asam folat
- Aktivitas << & aktivita
B. Pem. Klinis setiap 2mgg - keadaan servik setelah - pengetahuan kehamila- pergerakan bayi setelah
aksanaan
ng baik
as +++
setelah 24 mgg24 mggggn pretermh 32 mgg
C USG setiap 4-6 mgg seC. USG setiap 4-6 mgg se- kemungkinan plasent
kem ngkinan gangg- kemungkinan ganggu- presentasi janin
D. Nonstress test setelah - keadaan janin- penekanan taki pusatp p
E. Konsultasi perinatologE. Konsultasi perinatolog
etelah dignosisetelah dignosista previaan pert mb han janinuan pertumbuhan janin
setelah 32mgg
t
gigi
Kembar discordant: janin resepiendonorabnormalitas arteriovenous tampaab o alitas a te iove ous ta padarah arteri kaya O2 donor bercam
nt lebih besar dari pada janin
ak pada permukaan plasenta, a pada pe u aa plase ta,mpur dengan darah resepient
PENANGANAN• KALAU ANAK I SUNGS
SEBAIKNYA S.CESAR.• KALAU ANAK I P KEPA• KALAU ANAK I P.KEPA
DENGAN P/ VAGINAL AV.EKSTRAKSI.
• SELAMA DJJ NORMAL UNTUK MEMPERCAPAKEDUA
• PENGAWASAN YANG KOUTCOME PERSALINA
N PERSALINANSANG ATAU LINTANG
ALA DIUPAYAKANALA DIUPAYAKAN ANAK KE DUA DENGAN
TIDAK ADA ALASAN AT KELAHIRAN ANAK
KETAT MENENTUKAN AN
anak pertama lintang atau memanjang (terjadi posisi s
sungsang dan anak kedua saling mengunci interlocking)
Panduan penanganan pPanduan penanganan pkehamilan
Janin pertamaSiapkan peralatan resusitasiP i f & i i tPasang infus & cairan intravPantau keadaan janin, djjPeriksa presentasi janinPeriksa presentasi janin- vertex → PSP, monitor pe- bokong → indikasi SCg- lintang → SCTinggalkan klem pada ujung
persalinan spontan padapersalinan spontan pada n kembar
i & perawatan bayivena
ersalinan
g maternal tali pusat
• Janin kedua atau berikiuJanin kedua atau berikiuSegera setelah bayi perta
P l i bd l- Palpasi abdomen → let- lakukan versi luar - Periksa djj
• Periksa dalamPeriksa dalam- Presentasi janin kedua
k h l k b- keutuhan selaput ketub- Prolapsus tali pusat
utnyautnyaama lahir:
k j itak janin
bban
Monoamniotic
• 2 to 5% loss every 2 wee
• 9% at 33 wks → 29% at
• 95% cord entanglement
twins mortality
eks from 15 to 32 weeks
t 36-38 wks
(prenatal diagnosis 28%)
Comparison of ratessingleton and musingleton and mu
Complications
ChorioamnionitisPremature rupture of membranesFetal asphyxiaFetal asphyxiaTwin-twin transfusionCongenital malformations
d iHydramniosAbruptio placentaePlacenta previapCompression of cordBirth injuryPrematurityPrematurityUmbilical cord knots
s of complications in ultiple gestationsultiple gestations
Rate for twins (increase)
4-fold4-fold5 fold5-fold1 of 9 monoamniotic twins3-fold
f i1 of 12 twins2-fold2-fold2-fold10-fold10 fold10-fold2-fold
Maternal morbidity and f d lof quadruplet pre
VARIABLE
Antepartum hospitalizationHyperemesis gravidarumHyperemesis gravidarum, total parenteraG t ti l di b t llit A1Gestational diabetes mellitus, A1Gestational diabetes mellitus, A2Anemia (Hct < 30%), no antepartum tranAnemia (Hct < 30%) antepartum transfuAnemia (Hct < 30%), antepartum transfuAntepartum bleedingPlacenta previaPreeclampsiaPreeclampsiaHELLP syndromePPROMPTLTwin-twin transfusion syndromeChorioamnionitis
obstetric complications egnancy (No. 22)
INCIDENCE (%)
1009.4
al nutrition required 3.118 818.83.1
nsfusion required 25.0usion required 15 6usion required 15.6
3.10.071.971.92.518.81003.16.3
I. Psychological SuCCouns
• All parents should be awaf t l th t d tifetal growth retardationabnormal placentation,malpresentation and premalpresentation and precommonly in multiple than i
• These aspects result in himortality and morbidity.
• Antenatal complications aremultiple pregnancy than inmultiple pregnancy than in
• From the first trimester oparents to cope with possparents to cope with possalso with the socio-econmultiple birth.
upport and Clinicalliseling
are that pathologies such asit l lin, congenital anomalies,
abruptio placentae, fetalterm delivery, occur moreterm delivery, occur morein singleton pregnancyigher maternal and perinatal
e three to five times higher insingleton pregnancysingleton pregnancy.
onwards is required to helpsible negative outcome andsible negative outcome andnomic problems related to
The most important:The most important:
EARLY DIAEARLY DIAWHY?WHY?
MULTIPLE MULTIPLE MULTIPLE MULTIPLE PREGNANCYPREGNANCY ==
•• COMPLICATIONS DURINGCOMPLICATIONS DURING•• SPECIFIC MALFORMATIOSPECIFIC MALFORMATIO•• SPECIFIC MALFORMATIOSPECIFIC MALFORMATIO•• HIGHER PERINATAL MORHIGHER PERINATAL MOR•• INTRAPARTAL COMPLICAINTRAPARTAL COMPLICA
AGNOSISAGNOSIS
HIGHHIGH--RISK RISK HIGHHIGH RISK RISK PREGNANCYPREGNANCY==
G PREGNANCYG PREGNANCYON SEQUENCESON SEQUENCESON SEQUENCESON SEQUENCESRBIDITIY AND MORTALITYRBIDITIY AND MORTALITYATIONSATIONS
DIAGNOSIS OFDIAGNOSIS OF MULTIFETAL PREGSIMULTANEOUS VSIMULTANEOUS VSIMULTANEOUS VSIMULTANEOUS V
two or more embtwo or more emb• two or more embtwo or more emb
••or or corresponding bocorresponding bop gp gor more fetusesor more fetuses
GNANCY:VISUALIZATIONVISUALIZATIONVISUALIZATIONVISUALIZATION
ryosryosryosryos
odyody partsparts of of twotwoyy pp
EARLY DIAGNOSIEARLY DIAGNOSIThe first visiThe first visi
22 GESTATIONAL SACSGESTATIONAL SACS22 GESTATIONAL SACSGESTATIONAL SACS22 YOLK SAC (YOLK SAC ( BCBC // BABA ))
DIZYGOTICDIZYGOTIC
IS OF TWINSIS OF TWINSible structures:ible structures:
11 GESTATIONAL SACGESTATIONAL SAC22 YOLK SACS (YOLK SACS ( MCMC // BABA )
YOLK SACSYOLK SACSfusedfusedfusedfused
separated
MONOZYGOTICMONOZYGOTIC
EARLY DIAGNOSEARLY DIAGNOS
EMBRYOSEMBRYOS AND AMNIOAND AMNIOMEMBRANESMEMBRANES
A firm diagnosiA firm diagnosithe number of embrthe number of embr
after 7th weafter 7th we
IS OF TWINSIS OF TWINS
OTICOTIC
is ofis ofryosryoseekeek !!
MONOCHOMONOCHOMONOCHOMONOCHOMONOAMNMONOAMNTWINSTWINSTWINSTWINS
ORIONICORIONICORIONICORIONICNIOTICNIOTIC
HIGHHIGH ORDER MULTIPORDER MULTIPHIGHHIGH--ORDER MULTIPORDER MULTIPPregnancy with threePregnancy with three
PLE PREGNANCYPLE PREGNANCYPLE PREGNANCYPLE PREGNANCYor more fetusesor more fetuses
three chorionicthree chorionic
three amnioticthree amnioticthree amnioticthree amniotic
2D multiplanar imaging2D multiplanar imaging
3D3D
• volume scanning• volume rendering• spatial reconstruction 3D3Dspatial reconstruction • plastic imaging
TRIPLETSTRIPLETS
reconstructionreconstructionreconstructionreconstruction
FRONTFRONT BACKBACK
HIGH ORDER PHIGH ORDER PHIGH ORDER PHIGH ORDER P
QUADRUP
PREPREGGNANCYNANCYPREPREGGNANCYNANCY
LETS
HIGH ORDER PHIGH ORDER PHIGH ORDER PHIGH ORDER PREREGGNANCYNANCYREREGGNANCYNANCY
HIGH ORDER PRHIGH ORDER PRHIGH ORDER PRHIGH ORDER PRSEPTUPLETSSEPTUPLETSSEPTUPLETSSEPTUPLETS
REREGGNANCYNANCYREREGGNANCYNANCY
HIGH ORDER PHIGH ORDER P
12 EMBRYOS12 EMBRYOS12 EMBRYOS12 EMBRYOS
REREGGNANCYNANCY
II. Correct DiCharacterizationCharacterization
• Multiple gestation should be susppredicted by menstrual history.p y y
• Approximately one fifth of multiplefour fifths are dichorionic.
• Type of placentation and chorion• Type of placentation and chorionclinical situations: 1) The differesyndrome (TTS) from a twin gegrowth retardation; 2) the mangrowth retardation; 2) the manmalformations, in which selectiveoption if the gestation is dichorionfetal death in a multiple gestationfetal death in a multiple gestation.
• The thickness of dividing membra~ 2 mm, in DC/DA the membrane
• The “lambda” sign is an indicator o
iagnosis andn of Chorionicityn of Chorionicityected when the uterus is larger than
e gestations are monochorionic and
icity is helpful in the following threeicity is helpful in the following threeentiation of twin to twin transfusionestation in which one fetus showsagement of twins with congenitalagement of twins with congenital
e feticide may be considered as annic and 3) the management of single
ne is in 85% of monochorionic twinsis ~ 4 mmof dichorionic pregnancy
II. Correct DiCharacterizationCharacterization
• The following criteria mThe following criteria mmonoamniotic twins:
1 no dividing amniotic mem1. no dividing amniotic mem2. only one placenta is see3 both fetuses are of the s3. both fetuses are of the s4. the fetuses must have a
surrounding themsurrounding them5. both fetuses must move
cavitycavity.
iagnosis andn of Chorionicityn of Chorionicity
must be fulfilled to diagnosemust be fulfilled to diagnose
mbrane is presentmbrane is presentensame sexsame sex adequate amniotic fluid
e freely within the uterine
Zigosity of spontane
Spontaneous tripletsTZ
26%
MZDZ 22%DZ
52%
adapted from
eus vs. ART triplets
ARTTZ
84%
Unknown3%
MZ1%
DZ12%
m Derom, 2000
ACCURATE PRENATAL DIAGNACCURATE PRENATAL DIAGNACCURATE PRENATAL DIAGNACCURATE PRENATAL DIAGNOF CHORIONICITY IS OF PREDOF CHORIONICITY IS OF PREDIMPORTANCE FOR THE CLINICIMPORTANCE FOR THE CLINICOFOF MULTIPLEMULTIPLE PREGNANCIESPREGNANCIESOF OF MULTIPLE MULTIPLE PREGNANCIESPREGNANCIES
NOSISNOSISNOSISNOSISDOMINANTDOMINANTCAL MANAGEMENT CAL MANAGEMENT
SSSS
EARLY DIAGNOSIS OEARLY DIAGNOSIS OEARLY DIAGNOSIS OEARLY DIAGNOSIS O
1st TRIMESTER1st TRIMESTER
NUMBER OF NUMBER OF GESTATIONALGESTATIONALGESTATIONAL GESTATIONAL SACSSACS
OF CHORIONICITYOF CHORIONICITYOF CHORIONICITYOF CHORIONICITY
EARLY DIAGNOSIS EARLY DIAGNOSIS G OS SG OS S
6 weeksNUMNUM
OR OR
NUMNUMNUMNUM
7 weeks7 weeks7 weeks7 weeks
OF AMNIONICITYOF AMNIONICITYO O CO O C
MBER OF YOLK SACSMBER OF YOLK SACS
MBER OF VISIB E AMNIONSMBER OF VISIB E AMNIONSMBER OF VISIBLE AMNIONSMBER OF VISIBLE AMNIONS
EARLY DIAGNOSIEARLY DIAGNOSI
ALAR
EARLY DIAGNOSIEARLY DIAGNOSIWhy is it i
ALARMONOCHMONOCH
ANDANDANDANDMONOAMNIMONOAMNI
FETAL FETAL COMPLICCOMPLIC
S OF AMNIONICITYS OF AMNIONICITY
RM !
S OF AMNIONICITYS OF AMNIONICITYimportant?
RM !HORIONICHORIONICD / ORD / ORD / ORD / ORIOTIC TWINSIOTIC TWINS
CATIONSCATIONS
PECULIAR COMPLPECULIAR COMPLTwin embolisation syndrTwin embolisation syndr
TwinTwin toto twin transfusiotwin transfusioTwinTwin--toto--twin transfusiotwin transfusio
Twin reversed arteriaTwin reversed arteriaTwin reversed arteriaTwin reversed arteria
Cord entanCord entan
ConjoineConjoine
LICATIONSLICATIONSrome ( vanishingrome ( vanishing--twin )twin )
on syndrome ( TTS )on syndrome ( TTS )on syndrome ( TTS )on syndrome ( TTS )
l perfusion ( TRAP )l perfusion ( TRAP )l perfusion ( TRAP )l perfusion ( TRAP )
nglementnglement
d twinsd twins
SECOND ANDSECOND ANDTHIRD TRIMESTETHIRD TRIMESTETHIRD TRIMESTETHIRD TRIMESTERRRR
NUMBER OF NUMBER OF PLACENTASPLACENTAS
DETERMINATION OF IN SECOND T
Sonographic counting of sSonographic counting of st th dt th dan accurate method oan accurate method o
chorionicity in the schorionicity in the s
PLACENTA 1
TWO SEPARATED PLACENTAS
PLACENTA 1
PLACENTAS
PLACENTA 2
THE CHORIONICITYTRIMESTERseparated placentas is separated placentas is f d t i i thf d t i i thof determining the of determining the
second trimester second trimester
BICHORIONICBIAMNIOTIC TWINS
MONOCHORIONICMONOCHORIONICBIAMNIOTIC TWINS
BICHORIONIC BIAMNIBICHORIONIC BIAMNIIOTIC TWINSIOTIC TWINS
LAMBDA SIGN
BIAMNIOTICBICHORIONIC
TWINS
MONOAMNIOTIC MONOCMONOAMNIOTIC MONOCCHORIONIC TWINSCHORIONIC TWINS
THE YY--SHAPESHAPESS
Y-SIGNTRICHORIONICTRICHORIONICTRICHORIONICTRICHORIONICTRIAMNIOTICTRIAMNIOTIC
TRIPLETSTRIPLETSTRIPLETSTRIPLETS
EDED JUNCTIONJU C O
“MERCEDES” SIGN“MERCEDES” SIGN
III. Close Evaluatio
Fetal Malformations and Prena
• The incidence of malformation in mthat in dizygotics.
• Chromosomal anomalies are no mor• Anomalies not unique to twins but b
because of mechanical factors arebecause of mechanical factors areand congenital dislocation of the hip
• Additional anomalies due to vascuit l ki d f t icongenital skin defects, microcep
multicystic encephalomalacia, hydroamputation.
n of Fetal Anatomyy
atal Genetic Diagnosisg
monozygotic twin pregnancies is twice
re common in twins than singletonsbelieved to be increased in frequency
positional defects (such as clubfootpositional defects (such as clubfoot) due to intrauterine crowding.lar consequences of fetal death areh l h d h l h lphaly, hydrancephaly, porencephaly,
ocephalus, intestinal atresia and limb
III Close EvaluatioIII. Close Evaluatio
Fetoplacental Markers in TwDown Syndrome
• Around one-third of twin pand their rate of Dowi d d t f dindependent of race and ma
• Dizygous twins are more cth i fas they arise from se
simultaneously shed ova thrisk than for a singleton prrisk than for a singleton prhave Down syndrome
n of Fetal Anatomyn of Fetal Anatomy
win Pregnancies Affected by
pregnancies are monozygouswn syndrome is relatively
t laternal age.ommon in older mothers and
t f tili ti f teparate fertilisation of twohere is double the age-relatedregnancy that either twin willregnancy that either twin will
EPIDEMIOLOGY OEPIDEMIOLOGY OANOMALIES
Anomaly rates for:
singletons 2singletons 2twins 5
Incidence of congenital anotwin than in singl
Monozygotic twins ha50% higher than dg
OF CONGENITALOF CONGENITALS IN TWINS
2 4 %2 - 4 %5 - 10 %omalies is 2 - 3 x higher in leton pregnancy.
ave an anomaly rate dizygotic twins.yg
CONJOINED (SIAMCONJOINED (SIAMINCIDENCE 1: 50 INCIDENCE 1: 50
ULTRASOUND CRITERIA ULTRASOUND CRITERIA
1) LACK OF SEPARATE VISOF FETUSES IN SPECIFICREGIONSREGIONS
2) FIXED POSITION OF THETOWARD EACH OTHER
3) MISSING SEPARATING M3) SS G S G
MESE) TWINSMESE) TWINS000 BIRTHS000 BIRTHS
FOR DIAGNOSIS:FOR DIAGNOSIS:
SUALISATION C ANATOMICAL
E TWIN
MEMBRANE
PATTERNS OF PHYSIPATTERNS OF PHYSIICAL JOININGICAL JOINING
SYMMETRICAL SYMMETRICAL COMPLETE FORMCOMPLETE FORMCOMPLETE FORMCOMPLETE FORM
Two fetuses shareTwo fetuses shareTwo fetuses shareTwo fetuses sharea certain amount of tissuea certain amount of tissue
Surgical separation is Surgical separation is possible in general.possible in general.
PATTERNS OF PHYPATTERNS OF PHYYSICAL JOININGYSICAL JOINING
SYMMETRICAL SYMMETRICAL INCOMPLETE FORMINCOMPLETE FORMINCOMPLETE FORMINCOMPLETE FORM
Surgical separation Surgical separation is usually impossibleis usually impossible
EARLY DIAGNOSIS OF CCONJOINED TWINS
Conjoined twins: Conjoined twins:
subtotal fusionsubtotal fusionwith partial separation with partial separation of fetal headsof fetal heads
OO
lack of separate vislack of separate visin thoracoin thoraco--abab
CONJOINED TWINSTWINS
THORACOTHORACOTHORACOTHORACO--OMPHALOPHAGUSOMPHALOPHAGUS
sualisation of fetuses sualisation of fetuses bdominal regionbdominal region
THOROMP
FIVEFIVE
COLOR DOPPLERCOLOR DOPPLERSINGLE SHARED UMBILICALSINGLE SHARED UMBILICALCORDCORDCOCO
RACO-HALOPHAGUS
E E -- VESSEL CORDVESSEL CORD
L L
VI. Avoidance ofComplip
Complications of multiple pregna• Abortion,,• Vanishing twin syndrome• Malformation
V i• Vasa previa• Growth discrepancy• Intra uterine growth restrictionIntra uterine growth restriction• Polyhydramnios• Preeclampsia• Preterm-premature rupture of• Preterm delivery• Gestational diabetes• Gestational diabetes• Intrauterine fetal death.
f Most Frequent cationsancies comprise:
n (IUGR)n (IUGR)
f membranes (P-PROM)
VANISHING TWINVANISHING TWINVANISHING TWINVANISHING TWIN
• single fetal demisesingle fetal demise•• highhigh--risk surviving twinrisk surviving twin•• intintrarauterine hematomasuterine hematomas•• intintrarauterine hematomasuterine hematomas•• better prognosis in dichoriobetter prognosis in dichorio•• thromboplastine ethromboplastine e•• thromboplastine ethromboplastine e
NNNN•• in in 20%20% of twinof twinss
oniconicembolisationembolisationembolisationembolisation
VANISHING TWIN
SUBCHORIONIC HAEMATOMA
VII. ConsiderationPathoPatho
Twin to Twin Transfusion S• Is associated with a high raIs associated with a high ra
survivors, substantial morb• Diagnostic criteria include: g
same sex with growth discoolygohydramnios of the gropolyhydramnios of the largpolyhydramnios of the larghemoglobin difference > 5m
• Antepartum management oAntepartum management ocontroversy, because no suproblems.
• The three types of vasculaand A-V, are generally presplacentae
n of Some Specific logieslogies
Syndrome (TTS)ate of mortality and amongate of mortality and, among bidity.
monochorionic pregnancy; p g y;ordance between twins; owth retarded fetus and er twin; an intertwiner twin; an intertwin mg/dl (after cordocentesis).of TTS is not withoutof TTS is not without uggested therapy is without
r anastomoses, A-A, V-V sent in monochorionic
MONOCHORONIC / BMONOCHORONIC / B“TWIN TO TWIN” “TWIN TO TWIN” TRANSFUSION SYNDTRANSFUSION SYND
MONOAMNIOTIC:MONOAMNIOTIC:UMBILICAL CORD ENUMBILICAL CORD ENUMBILICAL CORD ENUMBILICAL CORD ENACARDIAC TWIN ACARDIAC TWIN -- TRTRCONJOINED TWINSCONJOINED TWINSCONJOINED TWINSCONJOINED TWINS
IAMNIOTICIAMNIOTIC::
DROMEDROME TTTSTTTS
NTAGLEMENTNTAGLEMENTNTAGLEMENTNTAGLEMENTRAPRAP SEQUENCE SEQUENCE
TWIN TO TWIN TRANSFTWIN TO TWIN TRANSF••5% 5% -- 20% monochor20% monochor••arterioarterio venoveno
TWIN TO TWIN TRANSFTWIN TO TWIN TRANSF
••arterioarterio venoveno••discordant growthdiscordant growth
DONOR DONOR OLIGOHYDRAMNIOS POLIGOHYDRAMNIOS POLIGOHYDRAMNIOS POLIGOHYDRAMNIOS PIUGR IUGR MMMICROCARDIA CMICROCARDIA CMICROCARDIA CMICROCARDIA CANEMIA PANEMIA Pfetal loss 80%fetal loss 80%fetal loss 80%fetal loss 80%
USION SYNDROMEUSION SYNDROMEionic twinsionic twins
ousous anastomosesanastomoses
USION SYNDROMEUSION SYNDROME
ous ous anastomosesanastomoses
RECIPIENTRECIPIENTPOLYHYDRAMNIOSPOLYHYDRAMNIOSPOLYHYDRAMNIOSPOLYHYDRAMNIOSMACROSOMIA, HYDROPSMACROSOMIA, HYDROPSCARDIOMEGALIACARDIOMEGALIACARDIOMEGALIACARDIOMEGALIAPOLYCYTHAEMIAPOLYCYTHAEMIA
TWIN TO TWIN TRANSFUSTWIN TO TWIN TRANSFUS
SCALP EDEMASCALP EDEMA
RECIPIENT:RECIPIENT:F t l h dFetal hydrops
ASCITESASCITES
SION SYNDROMESION SYNDROME
TWIN TO TWIN TRANSFU
POLYHYDRAMRECIPIENT RECIPIENT
fixed twinfixed twinh d ih d ianhydramniosanhydramnios
collapsed acollapsed amembramembra
USION SYNDROME
NIOS OF TWIN TWIN
DONOR:St k t iStuck twin
mniotic mniotic aneane
TWIN TO TWIN TRANSFUUSION SYNDROME
TWIN TO TWIN TRANSFFUSION SYNDROME
TWIN TO TWIN TRANSFU
UMBILICAL VEIN UMBILICAL VEIN SONOGRAM SONOGRAM IN RECIPIENT TWININ RECIPIENT TWININ RECIPIENT TWININ RECIPIENT TWIN
PULSATIONS WITHPULSATIONS WITHREVERSEREVERSE-- FLOW ATFLOW ATREVERSEREVERSE-- FLOW AT FLOW AT THE END OF DIASTOLETHE END OF DIASTOLE
USION SYNDROMERecipient : Recipient : venous return patternvenous return pattern
DUCTUS VENOSUSDUCTUS VENOSUSSONOGRAMSONOGRAM
IN RECIPIENT TWININ RECIPIENT TWIN
REVERSAL OF FLOWREVERSAL OF FLOWDURING ATRIALDURING ATRIALDURING ATRIALDURING ATRIALCONTRACTIONCONTRACTION
TWIN TO TWIN TRANSFUTWIN TO TWIN TRANSFU
PlethoricPlethoricRECIPIENTRECIPIENT
AnaemicAnaemicAnaemicAnaemicDONORDONOR
Weight Weight HaemoHaemo
USION SYNDROMEUSION SYNDROME
t difference > 25%t difference > 25%globin difference >5%globin difference >5%
VASCULAR ANVASCULAR ANVASCULAR ANVASCULAR ANIN A TWIN IN A TWIN
superficialsuperficial
ARTERIOARTERIOARTERIOARTERIOARTERIO ARTERIO
VENOVENOVENO VENO
NASTOMOSES NASTOMOSES NASTOMOSES NASTOMOSES PLACENTA: PLACENTA:
VENOUSVENOUSdeepdeep
VENOUSVENOUSARTERIOUSARTERIOUSVENOUSVENOUSVENOUSVENOUS
SURFACE ANASTOMOSESSURFACE ANASTOMOSES
VISUALIZATION WITHVISUALIZATION WITHPOWER ANGIO MODEPOWER ANGIO MODE
VII. ConsiderationPathoPatho
Twin Reversed Arterial Perfu• The most extreme manifestaThe most extreme manifesta
syndrome, found in approximpregnancies is acardiac twinchorioangiopagus parasiticuschorioangiopagus parasiticus
• The underlying mechanism isnormal vascular perfusion annormal vascular perfusion anrecipient twin due to an umbianastomosis with the donor o
• At least 50% of donor twins dfailure or severe preterm delipolyhydramniospolyhydramnios.
• All perfused twins die due to malformations.
n of Some Specific logieslogiession (TRAP) Sequence
ation of twin to twin transfusionation of twin to twin transfusionmately 1% of monozygotic twin ning (acardius s)s).s thought to be disruption of nd development of thend development of the ilical arterial-to-arterial or pump twin.die due to congestive heart ivery, the consequence of
the associated multiple
TWIN REVTWIN REVTWIN REVTWIN REVARTERIAL PARTERIAL P
(TRA(TRAIN MONOCHORIONIC
( PUMP-TWIN ) ACTTHE SECOND TWIN (THE SECOND TWIN (
VIA LARGE A -A AND/O
1% of monozygotic1% of monozygoticIncidence 1 : 3Incidence 1 : 3Incidence 1 : 3Incidence 1 : 3
VERSEDVERSEDVERSED VERSED PERFUSIONPERFUSIONAP)AP)C TWINS ONE TWIN TIVELY PERFUSES( PERFUSED TWIN )( PERFUSED TWIN )
OR V - V ANASTOMOSES
twins are affected twins are affected 35 000 births35 000 births35 000 births35 000 births
PATHOGENESI
ARTERIAL SUPPLY INTO
PATHOGENESI
ARTERIAL SUPPLY INTOBY THE PUMP TWIN IS AOVERCOME THE BLOODCO TWIN SO AS TO PERCO-TWIN SO AS TO PERBY REVERSED FLOW (TIN THE UMBLICAL ARTECO-TWIN
IS
O PLACENTA
IS
O PLACENTA ABLE TO D PRESSURE OF THE
RFUSE THAT TWINRFUSE THAT TWINOWARD CO-TWIN)
ERIES OF THE
NORMALNORMAL( PUMP TWIN )( PUMP TWIN )
PERFUSED TWIN PERFUSED TWIN ACARDIUSACARDIUS
REVERSE FLOW NORMAL FLOWNORMAL FLOW
THE UMBILICAL VEIN OF THE PARETURNS THE BLOOD INTO THEBACK TO PUMP TWINBACK TO PUMP TWIN
TRAPBLOOD FLOWS FROM AN BLOOD FLOWS FROM AN UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE PUMP TWIN IN PUMP TWIN IN REVERSE DIRECTIONREVERSE DIRECTION VIA VIA ARTERIO ARTERIO -- ARTERIAL ARTERIAL ANASTOMOSES INTO ANASTOMOSES INTO UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE PERFUSED TWIN.PERFUSED TWIN.
ARASITIC FETUS E PLACENTA AND
PATHOGENESIS OF FETPATHOGENESIS OF FET
EARLY REVERSEEARLY REVERSE
REVERSE PASSIVEREVERSE PASSIVE
PERFUSION IN OPPPERFUSION IN OPPPERFUSION WITH DPERFUSION WITH D
INDUCTION OF DEVELINDUCTION OF DEVEL
REDUCTION ANOMAREDUCTION ANOMADEVELOPMENTAL ATROPDEVELOPMENTAL ATROPDEVELOPMENTAL ATROPDEVELOPMENTAL ATROP
TAL DYSMORPHIA:TAL DYSMORPHIA:
E OF CIRCULATIONE OF CIRCULATION
E PERFUSION OF TWINE PERFUSION OF TWIN
POSITE DIRECTION ANDPOSITE DIRECTION ANDDEOXIGENATED BLOODDEOXIGENATED BLOOD
LOPMENTAL DISORDERSLOPMENTAL DISORDERS
ALIES ( EXTREMITIES )ALIES ( EXTREMITIES )PHIES ( HEART AND BRAIN )PHIES ( HEART AND BRAIN )PHIES ( HEART AND BRAIN ) PHIES ( HEART AND BRAIN )
Ultrasound finding = earlyUltrasound finding = early the most bizzarre feta
PUMP - TWIN
normalmorphology
normalnormaldirection ofblood flow
ultrasound detectionultrasound detectional malformations
PERFUSED TWIN
acardius
reduction anomalies ofreduction anomalies of head and extremities
reversed blood flowreversed blood flow
COLORCOLORDOPPLERDOPPLER
REVERSEDREVERSEDPERFUSIONPERFUSIONPERFUSIONPERFUSION
TWINS MC / MA 15 TWINS MC / MA 15 kkTWINS MC / MA, 15 TWINS MC / MA, 15 wkswks
ULTRASONIC CRITERIULTRASONIC CRITERIU SO C CU SO C C
An amAn amits owits owits owits owcord cord monomonomonomonotwin ptwin p
A FOR ACARDIUSA FOR ACARDIUSO C USO C US
morphous mass with morphous mass with wn umbilicalwn umbilicalwn umbilical wn umbilical in monochorionicin monochorionic--
oamnioticoamnioticoamnioticoamnioticpregnancypregnancy
ACARDIAC ACACARDIAC - AC
No trunkNo trunkand headand head
No heart d b i
This acardiac twin
and brain
This acardiac twinlower ex
CEPHALICCEPHALIC
n consists mainly ofn consists mainly of xtremities
VII. ConsiderationPatho
Stuck TwinStuck Twin• Refers to the ultrasonog
monochorionic diamniooligohydramniotic sac fixethe uterine wall.
• This is frequently a manif• This is frequently a maniftransfusion syndrome (TT
• Management may incManagement may incumbilical cord ligation of oanastomosing placen
i t iamniocentesis.
n of Some Specific logies
graphic finding of one of aotic twin pair in aned in a location adjacent to
festation of the twin to twinfestation of the twin-to-twinTS).clude: selective feticide;clude: selective feticide;one twin; laser occlusion ofntal vessels; serial
CORD ENTAGLEMECORD ENTAGLEMEENTENT
COMPLICATION SPECIFIC FORMONOAMNIOTIC MONOCHORIONICTWINSTWINS
CORD ENTANGLEMCORD ENTANGLEMCORD ENTANGLEMCORD ENTANGLEM
MONOAMNIOTIC MONOAMNIOTIC TWINNINGTWINNING
THE CLOSE INSERTION OFTHE CLOSE INSERTION OFCORDS INTO PLACENTA ISCORDS INTO PLACENTA ISLARGELARGE--CALIBER ANASTOMCALIBER ANASTOMANDANDAND AND HIGH PREDISPOSITIONHIGH PREDISPOSITION
MENTMENTMENTMENT
F THE UMBILICAL F THE UMBILICAL S ASSOCIATED WITH:S ASSOCIATED WITH:MOSES MOSES
N FOR ENTANGLEMENTN FOR ENTANGLEMENT
CORD ENTANGLECORD ENTANGLECOLOR DOPPLERCOLOR DOPPLER
CORD ENTANGLECORD ENTANGLEMENTMENTPOWER DOPPLERPOWER DOPPLER
MENTMENT
TWINTWIN--TOTO--TWIN TTWIN TTWINTWIN--TOTO--TWIN TTWIN Tshould be should be considered wheconsidered whe
i di d ii di d i hhis diagnosed in is diagnosed in monochmonoch
Multiple gestations prMultiple gestations prMultiple gestations prMultiple gestations prdedecrease in fetal gcrease in fetal g
in direct relationshiin direct relationshiin direct relationshiin direct relationshiof fetusesof fetuses in in high orhigh or
TRANSFUSIONTRANSFUSIONTRANSFUSIONTRANSFUSIONen growth discordancy en growth discordancy h i i t tih i i t tihorionic gestationshorionic gestations
resent a significantresent a significantresent a significantresent a significantgrowth growth which is which is p to the numberp to the numberp to the number p to the number rder pregnanciesrder pregnancies
VIII Close MonitVIII. Close Monit
D l V l i tDoppler Velocimetry• Recent studies have a
usefulness of this techfetuses small for gestaIUGR, twins with TTS,discordant growth
toring of Fetusestoring of Fetuses
addressed the hnique in predicting twin ational age (SGA) or , and those with
VIII Close MonitVIII. Close Monit
C di t hCardiotocography• Is not always easy to
is possible to performfetus.
• The best methodrecording of FHR patteg p
toring of Fetusestoring of Fetuses
identify the twins and ittwo NSTs on the same
is the simultaneouserns on one tracing.g
SPONTANEOUS MOTSPONTANEOUS MOT
• COMPLEX BOD• HICCUPS• HAND-FACE COHAND FACE CO• MOUTH OPENIN• SWALLOWING
BREATHING MO• BREATHING MO• HEAD MOVEME• EXTREMITY MO• JUMPING• TWISTING• STRETCHINGSTRETCHING• YAWNING
TORIC ACTIVITYTORIC ACTIVITY
DY MOVEMENTS
ONTACTSONTACTSNG
OVEMENTSOVEMENTSENTSOVEMENTS
FETAL ACT
COMPLEXBODYBODY MOVEMENTS
NO INTERTWIN CONTACTS
TIVITY
FETAL ACT
NO INTERTWIN CONTACTS
EXTREMITY MOVEMENTSEXTREMITY MOVEMENTS
TIVITY
INTERINTER--TWIN CTWIN C
• FIRST REACH AND TOUCH• FIRST REACTION• “SLOW” OR “FAST” ARM, LEG, • MOUTH CONTACT• COMPLEX INTERACTIONSCOMPLEX INTERACTIONS
CONTACTSCONTACTS
HEAD OR BODY CONTACT
TRIPLET ACTIVITYTRIPLET ACTIVITY
HEAD TO BODYCONTACT
JUMPINGJUMPING
AND CONTACTSAND CONTACTS
The Ten Comin Multiple Pin Multiple P
I. Psychological Support and Cy g ppII. Correct Diagnosis and ChaIII. Close Evaluation of Fetal AIII. Close Evaluation of Fetal AIV. Management at Referral CV Individualization of CareV. Individualization of CareVI. Avoidance of Most FrequeVII Consideration of Some SpVII Consideration of Some SpVIII. Close Monitoring of FetusIX Planning of Time and ModIX. Planning of Time and ModX. Monitoring of the Mother D
mmandmentsPregnanciesPregnanciesClinical Counselinggracterization of Chorionicity
AnatomyAnatomyCenters
nt Complicationspecific Pathologiespecific Pathologiessese of Deliverye of Deliveryuring Postpartum
Ult d t fUlt d t fUltrasound assessment ofUltrasound assessment of
1 EARLY DIAGNOSIS OF MULT1 EARLY DIAGNOSIS OF MULT1. EARLY DIAGNOSIS OF MULT1. EARLY DIAGNOSIS OF MULT2. DIAGNOSIS OF CHORIONIC2. DIAGNOSIS OF CHORIONIC3 COMPLICATIONS IN MONOC3 COMPLICATIONS IN MONOC3. COMPLICATIONS IN MONOC3. COMPLICATIONS IN MONOC4. FETAL CONGENITAL ANOMA4. FETAL CONGENITAL ANOMA5 APPROPRIATE VERSUS DIS5 APPROPRIATE VERSUS DIS5. APPROPRIATE VERSUS DIS5. APPROPRIATE VERSUS DIS6. COLOR6. COLOR--DOPPLER OF MULTDOPPLER OF MULT7. PREDICTION OF PRETERM 7. PREDICTION OF PRETERM 8. INTRAPARTUM ULTRASONO8. INTRAPARTUM ULTRASONO
f lti l f lti l f multiple pregnancy:f multiple pregnancy:
TIPLE PREGNANCYTIPLE PREGNANCYTIPLE PREGNANCYTIPLE PREGNANCYITY AND AMNIONICITYITY AND AMNIONICITY
CHORIONIC TWINSCHORIONIC TWINSCHORIONIC TWINSCHORIONIC TWINSALIES ALIES
SCORDANT GROWTHSCORDANT GROWTHSCORDANT GROWTHSCORDANT GROWTHTIFETAL PREGNANCYTIFETAL PREGNANCYDELIVERYDELIVERYOGRAPHYOGRAPHY