supervisor : prof.salah roshdy presented by : tasneem al-ajlan
TRANSCRIPT
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SupervisorSupervisor: : Prof .Salah Prof .Salah
RoshdyRoshdy Presented byPresented by : :
Tasneem Al-Tasneem Al-ajlanajlan
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OBJECTIVESOBJECTIVES: :
• Definition.• Incidence and epidemiology.• Classification.• Diagnosis.• Complications.• Abnormalities of the twinning process.• Management.
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: :DEFINITIONDEFINITION
• Any pregnancy which two or more embryos or fetuses present in the uterus at same time.
• It is consider as a complication of pregnancy due to ; - The mean gestational age of delivery
of twins is approximately 36 weeks.- The perinatal mortality &morbidity
increase.
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Terminology vs. numberTerminology vs. number
Singletons one fetus. Twin two fetuses.
Triplets three fetuses. Quadruplets four
fetuses. Quintuplets five
fetuses. Sextuplets six
fetuses. Septuplets seven fetuses.
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Mean gestational age of Mean gestational age of deliverydelivery
Number of babies Weeks of Gestation
1 40 weeks
2 36 weeks
3 33 weeks
4 29 ½ weeks
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Incidence & epidemiologyIncidence & epidemiology• The incidence of multiple pregnancy in
US is approximately 3 % (increase annually due to ART ). • Monozygotic twins ( approx.1 in 250
births ).• Triplet pregnancies (approx. 1 in 8000
births ).• Multiple gestation increase morbidity &
mortality for both the mother & the fetuses.
• The perinatal mortality in the developed countries– Twins = 5 – 10 % births.– Triplets = 10 – 20 % births.
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Factors are associated with Factors are associated with higher incidence:higher incidence:1. Racial: more in Negro.2. Family history of multiple pregnancies.3. Induction of ovulation: clomifene(8%), gonadotrophins(30%).4. Multiparas than primiparas.5. Maternal age: common in women over 35 years6. Previous multiple pregnancy.
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DDx of uterus that is greater DDx of uterus that is greater than expected for gestational than expected for gestational
ageage::
1- Gestational trophoplastic disease
2- Macrosomia. 3- Placental abruption.4- Polyhydramnios.5- Uterine fibroid.6- Ovarian mass.
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ClassificationClassification
Monozygotic (<30%)Monozygotic (<30%)Dizygotic (>70%)Dizygotic (>70%)
Monochorionic/Monoamniotic(1%)
Monochorionic/Monoamniotic(1%)
Monochorionic/Diamniotic(20%)
Monochorionic/Diamniotic(20%)
Dichorionic/Diamniotic (8%)
Dichorionic/Diamniotic (8%)
Dichorionic/DiamnioticDichorionic/Diamniotic
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Important notesImportant notes::
1- Monozygotic twins having same sex & blood group.
2- Process of formation of chorion is earlier than formation of amnion.
3-Dizygotic twins must be dichorionic/diamniotic.
4- There is no dichorionic/ monoamniotic.
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:A- Dizygotic twins A- Dizygotic twins (fraternal)(fraternal)
• Most common represents 2/3 of cases.• Developed from two separate ova which may
or may not come from the same ovary and fertilized by two separate spermatozoa.
• The twins are of the same or different sex.• The similarity between them is not more than
that between members of the same family.• They have : - two placenta, -two chorions, -
two amnions, - two umbilical cords.
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ContCont....
The incidence of dizygotic twins is higher in :
1.Certain families .2. Race ;African Americans .3.Increases with maternal age, parity, weight
and height .4.Ovulation induction.
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• Constitutes 1/3 of twins• Developed from a single ovum which after
fertilization, by a single sperm, has undergone division to form two embryos.
• The twins are of the same sex.• They have similar physical and mental
characters as well as the blood group but not finger prints.
• The timing of cleavage determines the placentation of the pregnancy.
• Constant incidence .• Not affected by heredity.• Not related to induction of ovulation.
B- Monzygotic (identical ) B- Monzygotic (identical ) twinstwins::
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Time of cleavage
Nature of membranes
% Perinatal mortality
0 - 72 hr diamniotic,dichorionic
30 8.9%
4 – 8 days diamniotic,monochorionic
69 25%
9-12days monoamniotic,monochorionic
1 50-60%
>13 days Conjoined twin ---- -----
The timing of cleavage The timing of cleavage determines the placentation of determines the placentation of the pregnancythe pregnancy..
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History :-History :-
- Family hx of dizygotic twins.- Use of fertility drugs.- Sensation of excessive fetal movements.- Exaggerated symptoms of pregnancy (hyperemesis gravidarum ).
: :DiagnosisDiagnosis
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( weight gain, Pre-eclampsia signs )• Inspection: More enlargement of the abdomen.• Palpation:1. Fungal level: higher than that
corresponds to the period of amenorrhoea.2. Fundal, umbilical and first pelvic grips:
can detect multiple foetal poles. • Auscultation: Foetal heart sounds: are heard with
maximum intensity in 2 separate points .
ExaminationExamination::
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• Ultrasonography ( diagnostic ):- demonstrating two separate fetuses
and heart activities .- can be made as early as 6 weeks of
gestation.
• HCG & serum alpha-fetoprotein levels are elevated for gestational age.
investigation :investigation :
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::DETERMINATION OF ZYGOSITYDETERMINATION OF ZYGOSITY
• Very important as most of the complications occur in monochorionic monozygotic twins.
By :Ultrasound : genders , number of placentas,Blood groups.HLA.DNA analysis.
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• Very accurate in the first trimester, two sacs, presence of thick chorion between amniotic membrane .
• Less accurate in the second trimester the chorion become thin and fuse with the amniotic membrane .
• Different sex indicates dizygotic twins.
• Separate placentas indicates dizygotic twins.
During pregnancy by US :During pregnancy by US :
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A: Real-time ultrasound with a thick vertical amnion-chorion septum (membrane) separating one twin on the left side from the second twin on the right. - The arrow points to a "peak or inverted V" suggesting dizygotic twins.
:: DizygoticDizygotic
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B: Ultrasound of a thin vertical membrane separating one twin on the left side from the second twin on the right, suggesting a monochorionic gestational sack.
:: MonozygoticMonozygotic
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After birth :After birth :
• By examination of the MEMBRANE, PLACENTA,SEX , BLOOD group .
• Examination of the newborn DNA and HLA may be needed in few cases.
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USUS
gendergender same different
1Monozygotic
twinsMonozygotic
twins
2
sameBlood group Blood group HLA & DNA
analysis HLA & DNA
analysis
samedifferent
Number of placenta
Number of placenta
different
dizygotic twins
dizygotic twins
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Findings Zygosity Freq.
Different genders 30%
Two placentas , same gender
different blood groups
27%
One placentas
23%
Two placentas , same gender
Same blood group
20%
DETERMINATION OF DETERMINATION OF ZYGOSITYZYGOSITY: :
dizygotic
dizygotic
HLA & DNA analysis
monozygotic
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Septum Placental type Twin type
1 -None Monochorionic/Monoamniotic
monozygotic
2 -Amnion only
Monochorionic/Diamniotic
monozygotic
3 -Amnion &
chorion
Dichorionic/ diamniotic
Dizygotic or monozygotic
4 -No common septum
Dichorionic/ diamniotic
dizigotic
1 2 3 41 2 3 4
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• A - Maternal:– Antepartum:
• Miscarriage • Anemia: (because of the increased foetal
demand for iron and folic acid ).• Hyperemesis gravidarum.• Preeclampsia :( 40% in twins & 60% in
triplets ).• Polyhydramnios : ( 5 – 8% ) • Preterm Delivery :( Twin account for 10%
of all PTL & 25% of all preterm perinatal deaths ).
• Cervical incompetence .
ComplicationsComplications::
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ContCont....
- Intrapartum: - CS - Retained second twin - locked twins- Postpartum: - Postpartum hemorrhage due to: a. Atony results from over distended uterus and prolonged labor, b. large placental site, c. placenta praevia or early separation of the placenta after delivery of the first twin. - Postpartum endometritis .
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ContCont.. ..
• B - Fetal:• Congenital anomalies(Monozygotic
twins have a risk of 2% to 10% for developmental defects ).
• Fetal Malpresentation .• Placenta previa and Abruptio placenta .• Premature rupture of the membranes
( PROM ).• Prematurity .• Umbilical cord prolapse .• Intrauterine growth restriction ( IUGR ).• Increased perinatal morbidity and
mortality .
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Causes of perinatal morbidity Causes of perinatal morbidity and mortality in twinsand mortality in twins: :
• Respiratory distress syndrome . • Birth trauma .• Cerebral hemorrhage . • Birth asphyxia .• Birth anoxia .• Congenital anomalies .• Stillbirths .• Prematurity .
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Abnormalities of the twinning Abnormalities of the twinning processprocess: :
• Conjoined Twins .• Locked twins .• Fetal Malformations .• Interplacental Vascular Anastomosis .• Twin-Twin Transfusion Syndrome .• Discordant Twin Growth .• Umbilical Cord Abnormalities .• Single fetal death . • Rupture of membrane in single sac .
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Conjoined Twins : “ siameseConjoined Twins : “ siamese“ “
• Etiology : It result from cleavage of the embryo is incomplete because it happen very late ( after 13 days, when the embryonic disc has completely formed ).
• Incidence : once in 70,000 deliveries .
• Classification :- Thoracopagus (antreior) “most common” .- Pygopagus ( posterior ).- Craniopagus ( cephalic ).- Ischiopagus ( caudal ).
• Delivery by C.S.
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ThoracopaguThoracopagu
ss CraniopagusCraniopagus
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PygopaguPygopagus s
IschiopaguIschiopagus s
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Locked twins :Locked twins :
- Rare condition (1 in 817 twin gestations ). - It occurs with breech/vertex twins . - When the body of twin A delivers, but the
chin locked behind the chin of twin B - Risk factors : Hypertonicity, monoamniotic twinning, or
oligohydraminous . - Deliver by CS .
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Locked twinsLocked twins
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• It occurs almost exclusively in monochorionic twins at a rate of 90% or more.
• Type :- Arterial_artarial(most common).- Arterial_venous.- Venous_venous.
• Complications : - Abortion.- Hydramnios.- Twin-twin transfusion syndrome ( TTTS ).- Fetal malformations .
Interplacental Vascular Interplacental Vascular AnastomosesAnastomoses: :
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Twin-Twin Transfusion Twin-Twin Transfusion Syndrome ( TTTS )Syndrome ( TTTS )
• Definition :– The presence of unbalanced anastomosis in
the placenta (typically arterial-venous connections) leads to a syndrome in which one twin’s circulation perfuses the other Twin .
– In about 10% of monozygotic twins .– The arterial blood from the "donor twin"
enters the placenta (through the umbilical artery) and is taken up by the umbilical venous system belonging to the "recipient twin," which results in a net transfer of blood from the donor to the recipient twin .
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Donor[ Recipient
Hypotensive Hypertensive
Anemic Polycythemic
Oligohydramnios Polyhydramnios
growth restriction Overgrown Hydrops fetalis
Hypovolemia Hypervolemia
Heart failure 2ry to anemia
Congestive heart failure
TTTS TTTS ( cont.. )( cont.. )
Both: risk of demise & PTL .
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Management of TTTsManagement of TTTs: :
• Serial amniocentesis and fluid reduction for the recipient twin. • Intrauterine blood transfusion for the donor twin. • Indomethacin. • Fetoscopic laser ablation of placental anastomoses.
• If not treated death occurs in 80-100% of cases.
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Fetal MalformationsFetal Malformations: :
• Incidence:– Twice as common in twins & 4 times
more common in triplets than in singleton infants.
– Monozygotic > Dizygotic.• Etiology:
– Usually result from arterial-arterial anastomosis.
– Common deformations in twins include limb defects, plagiocephaly, facial asymmetry, and torticollis.
– Acardia and twin-reversed arterial perfusion (TRAP) “ rare but unique to multiple pregnancy”.
• Amniocentesis:– If U/S shows abnormality.
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Acardiac twinNormal
(pump) twin
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Umbilical Cord Umbilical Cord AbnormalitiesAbnormalities: :
• Absence of one umbilical artery occurs in about
3% to 4% of twins (30% of case absence of one artery associated with other congenital anomalies (e.g. ”renal agenesis” ).
• Cord entanglement ( esp. in monochorionic monoamniotic twins ).
• primarily associated with monochorionic twins .
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Discordant Twin GrowthDiscordant Twin Growth: :
• Definition:- Discrepancy of more than 20% in the
estimated fetal weights .• Causes :
- TTTS .- Chromosomal or structural anomalies .- Discordant viral infection .
When weight discordance exceeds 25%, the fetal death rate increases 6.5-fold and the neonatal death rate 2.5-fold .
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1-Antepartum :1-Antepartum :
• Frequent antenatal visits .• Adequate nutrition:
Adequacy of maternal diet is assessed due to the increased need
for overall calories, iron, vitamins, and folate .
• Periodic U/S assessment “ every 3 - 4 weeks from
23 weeks’ gestation “ to monitor the growth and detection of
discordant growth or TTTS.• Fetal surveillance:
- Performance of NST is not indicated before 34 wks unless to
confirm IUGR or discordant growth . - ( avoid CST ) might precipitate preterm delivery .
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Cont.Cont.
•Adequate rest : to improve placental blood flow and avoid preterm labor.• Prophylactic tocolytics or cerclage .• Amniocentesis : ( If indicated for prenatal diagnosis of a fetal condition, including genetic disorders or isoimmunization ).
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In case of death of one fetus is managed based on the gestational age and condition of the surviving fetus .
1- fetal surveillance evidence weekly
measured Until
2- maternal clotting profiles of fetal lung maturity in the
surviving fetus is exhibited
Delivery should be considered if : 1) Fetal lung maturity is demonstrated . 2) If compromise of the remaining fetus
develops . 3) If evidence of disseminated intravascular
coagulation in the mother is present . In the setting of TTTS, the death of one twin
should prompt consideration of delivery, particularly after 28 weeks, given the high rates of embolic complications in the surviving twin.
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2- Intrapartum:2- Intrapartum:
• The route of delivery depends on :- Presentation of the twins .- Gestational age .- Presence of maternal or fetal
complications .- Experience of obstetrician .- Availability of anesthesia & neonatal
intensive care .
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DeliveryDelivery: :
• Vertex / Vertex ( 43% ):- Vaginal delivery. ( Successful in 70 - 80%
of cases ).
• Vertex / Nonvertex ( 38% ):- Vaginal delivery ( better ) ( in absence of
discordant growth ).- Either external cephalic version or podalic
version with breech extraction of twin B may be attempted.
• Nonvertex Twin A ( 19% ):- CS .
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Caesarean section is Caesarean section is indicated inindicated in::1- Conjoined twins.
2- Locked twins. 3- Non vertex presentation of first twin (transverse
lie)4- Fetal distress in the first stage.5- Cord prolapse , TRAP6- Retained second twin when it is : - transverse lie. - membranes are ruptured. - uterus is retracted . - cervix is not fully dilated. 7- Triplets or more are safer delivered by C.S.8- Other indications of C.S as placenta praevia,
contracted pelvis , IUGR .
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3-Postpartum :3-Postpartum :• Active management . • By giving oxytocin in the 3nd stage of
labor just after delivery of both fetuses and
placentas.
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Any Question?
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REFERENCESREFERENCES
• Essentials of Obstetrics and Gynecology .
• Johns Hopkins Manual of Gynecology and Obstetrics, The, 3rd Edition .
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