TOPIC REVIEW : MULTIFETAL PREGNANCY

Ext. 2555

Multifetal Pregnancy

The term used to describe pregnancy with more than one fetus. Almost every maternal and obstetric problem occurs more frequently in multiple pregnancy. Perinatal mortality rate in twins is 5 times higher, and in triplets 10 times higher than in singletons.

Incidences

Etiology

Type of Zygosity

Monozygotic Twins (30 %)

True

Twins 1 Ovum + 1 Sperm -> differentiation from morula to embryo (2 wks)

Dizygotic Twins (70 %)

False

Twins 2 Ovums + 2 Sperms = Diamnion Dichorion

Different or subsequent

cycle -> Superfetation Same cycle -> Superfecundation

Factors that Influence Twinning

Race
Heredity Maternal age and parity Nutritional factors Pituitary Gonadotropin Infertility Therapy Assisted Reproductive Technology (ART)

Important of Determination of Zygosity

Overview of the Incidence of Twin Pregnancy Zygosity and Corresponding Twin-Specific Complications Rates of Twin-Specific Complication in Percent Placental Fetal-Growth Preterm Perinatal Type of Twinning Twins Vascular Restriction Delivery Mortality Anastomosis 80 25 40 0 1012 Dizygous 20 40 50 1518 Monozygous 67 30 40 0 1820 Diamnionic/dichorionic 1314 50 60 100 3040 Diamnionic/monochorionic 40 6070 8090 5860 Monoamnionic/monochorionic <1 Conjoined
0.002 to 0.008 7080 100 7090

Source: Fetal biophysical profile scoring. In Fetal Medicine: Principles and Practices, 1995.Copyright The McGraw-Hill Companies, Inc.

Overview Summary

Diagnosis and Investigation

Diagnosis of Multiple Fetuses

History
A

maternal personal or family history of twins Advanced maternal age High parity Large maternal size Recent administration of either clomiphene citrate or gonadotropins or pregnancy accomplished by ART

Diagnosis of Multiple Fetuses

Physical Examination
Fundal

height, average approximately 5 cm greater than expected for singletons of the same fetal age. Palpation of fetal Two fetal heartbeats (Difference between 8-10 bpm)

Differential Diagnosis

Sonographic Evaluation

About gestational age 6 7 wks

separate

gestational sacs can be identified early in twin pregnancy

Routine midgestation sonographic examinations

99

% of multifetal gestations before 26 weeks, if performed for specific indications.

Higher-order multifetal gestations are more difficult to evaluate.

Sonographic Evaluation (Cont.)

Chorionicity can sometimes be determined sonographically in the first trimester.

Two

separate placentas and a thickgenerally 2 mm or greater dividing membrane -> presumed diagnosis of

Fetuses of opposite gender are almost always dizygotic, thus dichorionic

Sonographic Evaluation (Chorionicity)

Twin Peak Sign Dichorion

T sign Monochorion

Placental Examination

One common amnionic sac, or with juxtaposed amnions not separated by chorion arising between the fetuses,
the

fetuses are monozygotic.

If adjacent amnions are separated by chorion,

the

fetuses could be either dizygotic or monozygotic, but dizygosity is more common

Zygosity

If the neonates are of the same sex, blood typing of cord blood samples may be helpful.
Different

blood types confirm dizygosity, Same blood type in each fetus does not confirm monozygosity

For definitive diagnosis, more complicated techniques such as DNA fingerprinting can be used. Twins of opposite sex are almost always dizygotic.
Rarely,

monozygotic twins may be discordant for phenotypic sex. This occurs if one twin is phenotypically female due to Turner syndrome (45,X) and her sibling is 46,XY.

Complication

Maternal Complication

Anemia Placenta previa

PIH Abruptio placentae Postpartum Hemorrhage

Preterm Labor

Preterm PROM Prolapsed cord

Vasa previa Postpartum Infection

Preterm Labor

Fetal Complication
Abnormal Twinning Vascular Anastomoses between Fetuses Discordant Twins Twin Demise

Abnormal Twinning

Conjoined Twin

Acardiac or TRAP

Fetal Complication (Cont.)

Vascular Anastomoses between Fetuses

artery-to-venous

(AV) artery-to-artery (AA) vein-to-vein (VV)

Found with monochorionic placentas

Twin-Twin Transfusion Syndrome (TTTS)

Blood is transfused from a donor twin to its recipient sibling

The

donor becomes anemic and its growth may be restricted. The recipient becomes polycythemic and may develop circulatory overload manifest as hydrops.

Donor (Stuck twin)

Growth

Restriction, Contratures Pulmonary hypoplasia and Heart failure

Recipient
PROM

Twin-Twin Transfusion Syndrome (TTTS)

Quintero staging : Divided into 5 stages

Oligo and Polyhydramnios Absent Urine in Donor Bladder + + + + Abnormal Doppler Blood Flows + + + Hydrops Fetalis Fetal Demise

Stage

I II III IV V

+ + + + +

+ +

Discordant Twins

Size inequality of twin fetuses

be

a sign of pathological growth restriction in one fetus calculated using the larger twin as the index

Usually develops late in the second and early third trimester and is often asymmetrical Earlier discordancy is usually symmetrical and indicates higher risk for fetal demise.

Twin Demise

Death of One Fetus

Common in monochorion Early demise "vanishing twin"

Not appear to increase the risk of death in the surviving fetus after the first trimester

Late demise
Twin embolization syndrome Triggers DIC in mother

Impending Death of One Fetus

Abnormal antepartum test results of fetal health in one twin fetus

Death of Both Twins

Antepartum Assessment

Antepartum Care

Early Diagnosis -> Identified complication

Preterm Labor, Pregnancy induced hypertension

Good diet, iron and folic acid supplementation Rest at home -> After 28 wks No SI in third trimester Ultrasound

For anomaly screeing Evaluate gestational age Position of fetus Placenta attachment Growth assessment -> Identify IUGR

Non stress test

Intrapartum and Postpartum Assessment

Presentation and Position

Delivery

Vertex - Vertex
Suggest

Vaginal Delivery

Vertex Non vertex

First

Choice : Vaginal Delivery (If have experiences doctor) When was delivered first twin
Check the position

of another twin

If

delivery if unsuccessful -> Cesarean section If fetal distress in second or other twins
First

choice : Internal Podalic Version or Breech Extraction Second choice : Cesarean section

Internal Podalic Version

Postpartum Care

Prevent postpartum hemorrhage such as uterine atony

Give

oxytocin drug in the third stage of labor and postpartum stage If hypovolemic shock due to excessive blood loss should replace fluid adequated

Prevent postpartum infection in:

Large

amount of postpartum bleeding Preterm or prolong premature rupture of membrane Manual internal version Manual placenta removal

Thank you for your kind attentions.