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Twin pregnancySome practical aspects

Eduard Gratacós

Center&for&Maternal,fetal&and&Neonatal&Medicine&BarcelonaHospitals&Clínic&and&Sant&Joan&de&Deu,&University&of&Barcelona

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TWIN PREGNANCY

1 – Diagnosis corionicity

2-Evaluation membranes and cords

3 – Prenatal diagnosis

4 - Main Risks and measures to prevent

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TWIN PREGNANCY

1 – Diagnosis corionicity

2-Evaluation membranes and cords

3 – Prenatal diagnosis

4 - Main Risks and measures to prevent

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TWIN PREGNANCY

1 – Diagnosis corionicity

2-Evaluation membranes and cords

3 – Prenatal diagnosis

4 - Main Risks and measures to prevent

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A: CRL 64A: CRL 64mmmm

B: CRL 70B: CRL 70mmmm

Discordance: 8.6 %Discordance: 8.6 %(LCC1 - LCC2/LC 1 x(LCC1 - LCC2/LC 1 x

100)100)

Dating pregnancy: greatest CRL(early restriction can happen, but not early accelerated growth)

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Combined test in twinsCombined test in twins(maternal age + (PAPP-A y fβ-hCG)+NT)

First choice DC: individual risk DR 75-83% (T21) (Chasen et al AJOG 2007)

Lower FPR (Goncé et al.,Prenat Diagn 2006; Chasen et al., AJOG 2007)

769 MC pregnancies 6 cases T21 (Vandecruys et al., 2005)

MC:averagerisk

DCDC-CVS: both-CVS: both

-Amnio: 2 sacs (1-2-Amnio: 2 sacs (1-2punctures)punctures)

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Invasive proceduresInvasive procedurestwinstwins

MCMC-CVS: one sampling-CVS: one sampling-Amnio: 2 punctures-Amnio: 2 punctures

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TWIN PREGNANCY

1 – Diagnosis corionicity

2-Evaluation membranes and cords

3 – Prenatal diagnosis

4 - Main Risks and measures to prevent

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TWIN PREGNANCY

IUGR

PREMATURITY

MALFORMATIONS

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TWIN PREGNANCYIncidence of malformations per fetus

MC > BC >single

MC = BC >single

MC = BC =single

1.

2.

3.

Incidence: 10%

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26 weeksTwin 1 Twin 2

PFE (gr.) p3 p60

Management?Emergency CSCS post-corticoidsNuevo control en 24hrsSeguimiento semanal

1.2.3.4.

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TwinsMean GA@delivery: 36-37 wDelivery <32w: 10%

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Interventions to reduce prematurity in twinsNO EFFECT SO FAR

Prophylactic Cerclage in the Management of Twin Pregnancies.Roman AS, Saltzman DH, Fox N, Klauser CK, Istwan N, Rhea D, Rebarber A.Am J Perinatol. 2013 Jan 9. [

Vaginal progesterone to prevent preterm birth in multiple pregnancy: a randomized controlled trial.Wood S, Ross S, Tang S, Miller L, Sauve R, Brant R.J Perinat Med. 2012 Jul 14. d

Twins: increased perinatal death (RR 1.551), RDS (RR 1.218) and adverse outcome (RR 1.211 ). (Also reported in tripletsCombs CA, AJOG 2010)

Perinatal outcome in women treated with progesterone for the prevention of preterm birth: a meta-analysis.Sotiriadis A, Papatheodorou S, Makrydimas G.Ultrasound Obstet Gynecol. 2012 Sep;40(3):257-66.

Progesterone for the prevention of preterm birth in twin pregnancy (STOPPIT)Norman JE, Mackenzie F, Owen P, et al.Lancet. 2009 Jun 13;373(9680):2034-40.

A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins.Rouse DJ, Caritis SN, Peaceman AM, et alN Engl J Med. 2007 Aug 2;357(5):454-61.

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TWIN PREGNANCY

1 – Diagnosis corionicity

2-Evaluation membranes and cords

3 – Prenatal diagnosis

4 - Main Risks and measures to prevent

www.medicinafetalbarcelona.org/ 22

Acardias/Acephalus

Arterial/flow/from/normal/twin

1/anastomosis/A6A/+/1/anastomosis

V6V

no/own/placenta

Incidence:/1%/MZ/twins

30650%/death/normal/“pump”/twin

Cardiac/failure,/hydrops

Severe/polyhydramnios

••

–

–

••

–

–

Twin Reverse Arterial Sequence

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MONOCHORIONIC TWIN PREGNANCYINTERFETAL ANASTOMOSES

Discordance in AV/VA flow

Chronic/subacute unbalancedtransfusion

TTTSTAPS

Discordance in placentalterritories

sIUGR

Discordance in fetaldefect

Acute feto-fetal transfusion

High risk of hemodynamic accident+

High risk of fetal death

+

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12

14to28

30+

DIAGNOSIS OF CHORIONICITY Evaluation of risk (Anatomy, NT + DV + AC + folding)

SEVERE COMPLICATIONS (mostly managed by intrauterine therapy)

TTTS - Early sIUGR – Discordant malformationClose follow-up and early diagnosis & management

LATE COMPLICATIONS(mostly managed by elective delivery)

Late TTTS – Late sIUGR - TAPS - Single IUFDClose follow up and elective delivery

Monitoring of monochonionic twinpregnancy

3 stages BIOMETRY +DOPPLER

12

20

28

141618

222426

3230

AC + AFASSESSMENT

Elective delivery 36-37s

3436

POLIHYDRAMNIOS-+-ENLARGED-BLADDER(>8$cm$<20w$+$>10$cm$<26w)

OLIGO2ANHYDRAMNIOS-+-COLLAPSED-BLADDER(<2$cm)

Diagnostic-criteria-of-TTTS-Eurofoetus,-Curr-Opin-Obstet-Gynecol-1999--2--WAPM.-J-Perinat-Med-2011

COMPLICATIONS OF MONOCHORIONIC PREGNANCY

Discordant placental territories selective IUGR•

www.fetalmedicinebarcelona.org/Evans et al 1994, 1998

Gestation)at)delivery(wks)

>14 wks

14%

57%

14%

6%

24%

<15 wks

5%

31%

6%

63%

0%

25 - 28 29 - 32 33 - 36 37- 42Loss

12 wks

Miscarriage 5% Delivery <33w 6%

••

20 wks

Miscarriage 14% Delivery <33w 20%

•

•

Selective reductionSelective reductionDICHORIONIC PREGNANCYDICHORIONIC PREGNANCY

>28-30w ?

Success nearly 100%Shalev 99, Lipitz 96

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TWIN PREGNANCY

1 – Diagnóstico corionicidad, evaluaciónmembranas y cordones

2 – Riesgo malformaciones

3 – MC: descartar complicaciones frecuentes

4 – Medición cérvix