Continue… ( multiple - PowerPoint Presentation

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Continue… ( multiple

gestatioins

)

ADONIA HADDDAD

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Complications of multiple gestation

Maternal complications

1)During pregnancy

↑↑ physiological changes of pregnancy

↑ cardiac output

↑ volume expansion

↑

haemodilution

↑ diaphragmatic splinting

↑ weight gain

↑

lordosis

.

↑ ↑ Minor symptoms of (nausea ,vomiting and heartburn)

Anemia (↑↑requirements )

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●

polyhydramnios

(10%) more common in MZ due to ↑ renal perfusion →↑ increased urinary output

●

Malpresentation

In about 70% cases, the first baby is presented by vertex and in 50%, both presented by vertex.

Malpresentation

is thus more common in the second baby

● Antepartum hemorrhage

↑ incidence of placenta

previa

is due to the bigger size of the placenta encroaching on to the lower

segmen

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● Preeclampsia (25%)

is increased 3X over singleton.

Exposure to superabundance of chorionic villi

● Mechanical distress

such

aspalpitation

, dyspnea, varicosities and hemorrhoids

●

Malpresentation

In about 70% cases, the first baby is presented by vertex and in 50%, both presented by vertex.

Malpresentation

is thus more common in the second baby

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● Preterm labor (50%)

Due to over distension of the uterus,

polyhydramnios

and premature rupture of the membranes

i

. Twins: 35-36 weeks

ii. Triplets: 32-33 weeks

iii. Quadruplets: 28-29 weeks

●Gestational diabetes

(2X higher in twins than singletons)

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2)During labor

PPROM (6 times higher in twins than singletons)

Cord prolapse (5 times higher in twins than singletons) / more common in

relation to the second baby.

Prolonged labor though (theoretically )

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Increased operative interference ( due to high prevalence of

malpresentation

with its associated complications.)

Bleeding (

intrapartum

) following the birth of the first baby , and is due

toseparation

of the placenta following reduction of placental site.

Postpartum hemorrhage , due to:

–

atony

of the uterine muscle due to

overdistension

of the uterus,

– a longer time taken by the big placenta to separate,

– bigger surface area of the placenta exposing more uterine sinuses

– implantation of a part of the placenta in the lower segment which is less

retractile.

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3)During

puerperium

Subinvolution

by bigger size of the uterus

Infection

increased operative interference, preexisting anemia and blood loss during

Delivery

lactation failure

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Fetal complications

1) Preterm

2)

Miscacarriage

, (2 times higher in twins) , MZ

3) IUGR

4)Discordant twin growth

5) Asphyxia

6)Fetal

anomaies

7)Intrauterine death of one fetus

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• COMPLICATIONS OF MONOCHORIONIC TWINS

1) Twin-twin transfusion syndrome (TTTS)

2)Twin reversed arterial perfusion (TRAP)

3) Conjoined twin

4)

Monoamniocity

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Asphyxia and stillbirth are more common due

1) increased prevalence of preeclampsia,

malpresentation

, placental abruption

2) increased operative interferences.

The second baby is more at risk and Complications are more

monochorionic

twin pregnancies.

• Fetal anomalies ( 2–4%)

more in monozygotic twins.

anencephaly, hydrocephalus, microcephaly, cardiac anomalies or Down’s syndrome

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Preterm delivery

spontaneous or – iatrogenic due to the occurrence of other adverse pregnancy complications such as pre-

eclampsia

or FGR

↑↑ Morbidity and mortality due to :

hyperbilirubinemia

, respiratory distress syndrome,

intraventricular

hemorrhage, patent

ductus

arteriosus

, necrotizing

enterocolitis

, sepsis,

bronchopulmonary

dysplasia, death

– Educate patient regarding symptoms (cramping, back pain, vaginal discharge, bleeding)

– bed rest, Smoking cessation

– Cervical examinations (digital or

sonographic

), serial uterine activity monitoring

– Fetal

fibronectin

testing

– Progesterone supplementation

–

Cerclage

–

tocolysis

for the completion of corticosteroids not for prevention of preterm labor

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IUGR

–

dichorionic

pregnancy ــــ 25% chance that at least one of the fetuses will be small for gestational age.

–

monochorionic

twins pregnancy ــــ 50%

– in

dichorionic

twin pregnancies delivery should be avoided before 28–30 weeks’ gestation, even if there is evidence of imminent intrauterine death of the smaller twin

– in

monochorionic

twins. • Below 30 weeks gestation, the aim is to prolong the pregnancy as far as possible without risking the death of the growth-restricted twin.

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Discordant twin growth

• size inequality of twin fetuses

• true pathological discordance involve estimated weight difference of 25% or more

• If >20% discordance, more frequent ultrasounds – due to

1) twin–twin transfusion syndrome

2) placental insufficiency

3) IUGR in one fetus

4) structural anomalies occurring in one fetus

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Intrauterine death of one fetus

• The deaths are due to cord compression, competition for nourishment or congenital malformation.

• Neurological damage of the survivor (cerebral palsy, microcephaly, renal cortical necrosis) results from

1)– Transfer of

thromboplastin

from dead twin causing thrombotic arterial occlusion in second twin

2)– Acute hypotensive episode

• Maternal DIC (rare)

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• If a loss occurs in first trimester (most common)→ the affected fetus Vanishes by

resorption

. With no developmental consequence in surviving twin

• If loss occur in the second or third trimester

– In

dichorionic

twins → may be associated with the onset of

labour

, although in some cases the pregnancy may continue uneventfully and even result in delivery at term.

– in

monochorionic

twins → immediate complications in the survivor

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Management of death of one twin - not immediate delivery

Maternal Monitoring : Weekly coagulation profile (platelet, PT, PTT, BT) , FDP, D-dimer

2

)Fetal Monitoring

- Daily fetal movement count

-Twice weekly: NST in pregnancies > 32 weeks , biophysical profile and Doppler

– Delivery time:

•

Steriods

after 28 weeks

•

Individualised

(around 34 weeks)

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Twin-twin transfusion syndrome (TTTS)

• Results from imbalance of vascular anastomoses of placental vessels between fetuses leading to “loss” of volume/blood from 1 twin (donor) to other (recipient)

– 10% -15%of

monochorionic

diamniotic

pregnancies and 5% of

monoamniotic

– Diagnosis by assessing

monochorionic

pregnancies every 2 weeks from 16 weeks’ gestation to

atleast

24 weeks’ gestation

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• TTTS diagnosis following ultrasound criteria:

1) mono chorionic twin : Single placental mass, Concordant gender.

2)

Oligohydramnios

with maximum vertical pool (MVP) less than 2 cm in one sac and

polyhydramnios

in the other sac (MVP >8 cm).

• Stuck twin : The donor twin may appear “stuck” due to severe

oligohydramnios

.

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Management: TTTS

• Suspected patients should be referred for a tertiary referral

amnioreduction

: (serial) amniocentesis to control

polyhydramnios

in the recipient twin is done

2.

Septostomy

(making a hole in the dividing amniotic membrane

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3.

Fetoscopic

laser ablation : Better outcome compared with

amnio

-reduction

– (the definitive treatment) for severe (defined as Quintero stage II or above) TTTS between 16 and 26 weeks’ gestation. (2nd trimester)

– Above 26 weeks, delivery may be considered.

4. Selective reduction (feticide) of one twin is done when survival of both the fetuses is at risk

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Twin reversed arterial perfusion (TRAP)

“

acardiac

perfused twin” having blood supply from a normal co-twin via large

arterio

-arterial or vein to vein anastomosis .

– The arterial pressure of the donor twin being high, the recipient twin receives the “used” blood from the donor.

– The perfused twin is often chromosomally abnormal , may appear as an amorphous mass.

– In majority the co-twin dies (in the perinatal period) due to high output cardiac failure.

– Management of TRAP is controversial.

• Ligation of the umbilical cord of the

acardiac

twin under

fetoscopic

guidance.

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Monoamniocity

• (2% of all twins - 1 in 10,000 pregnancies)

– leads to high perinatal mortality due to cord problems (entanglement).

•

Sulindac

, a prostaglandin synthase inhibitor has been used to reduce fetal urine output, creating borderline

oligohydramnios

and to reduce the excessive movements.

– ↑↑ congenital anomalies including neural tube defects and abdominal wall and urinary tract malformations.

– Discordant

birthweight

(20% )

– close surveillance with ultrasound is essential.

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– patients are hospitalized from 28 weeks’ gestation and fetal heart auscultation performed several times daily using

cardiotocography

in an effort to detect signs of cord compression.

– delivery by caesarean section generally at 32–34 weeks’ gestation.

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Conjoined twin

Conjoined twin is rare (1.3 per 100,000 births).

>> A marked female predominance with 72%.

– Diagnosis: ( often diagnosed during delivery):

1) when there is obstruction in the second stage , failure of traction to deliver the first twin in the second stage

2) inability to move one twin without moving the other

3)Presence of a bridge of tissue between the fetuses on vaginal examination confirms the diagnosis.

4)Antenatal diagnosis

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– Antenatal diagnosis is important. Benefits are:

1)Reduces maternal trauma and morbidity and to Improves fetal survival

2) Helps to plan the method of delivery , Allows time to organize the pediatric surgical team.

– The survival of conjoined twins depends on the severity of malformations both at the site of union and distant from the site of union.

– Management depends on : Extent and site of union , Possibility of surgical separation and Size of the fetuses and possibility of survival

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Management : depends on

1)

Extent and site of union

2)

Possibility of surgical separation and

3)

Size of the fetuses and possibility of survival.

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TRIPLETS, QUADRUPLETS, ETC.

Triplets may develop from

fertilization of a single ovum or two or even three ova ; similarly with quadruplets and quintuplets.

Female

fetususually

outnumber the male one.

The diagnosis is accidental following

sonography

, or during births.

Clinical course and complications are intensified compared to twins.

Perinatal loss is markedly increased due to prematurity.

Preterm delivery is common (50%) and usually delivery occurs by 32–34 weeks (mean 33.5 weeks) time.

Discordance of fetal growth is more common than twins.

Perinatal loss is inversely related to birth weight.

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Thank you