Twins for undergraduate
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Transcript of Twins for undergraduate
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Twins
Dr Manal Behery 2014
Defintion When more than one fetus simultaneously develops in the UTERUS3 fetuses : triplets4 fetuses : quadruplets5 fetuses : quintuplets6 fetuses : sextuplets
HELLINS RULETwins 1 in 80Triplets 1 in 80^2Quadruplets 1 in 80^3
Types of twins Monozygotic (1/3 rds) Dizygotic (2/3 rd) Results from fertilization Results from fertilization of a single ova of two ovum
Dizygotic
amnion
amnion2 chorionsAlways dichorionic & diamnionic
Factors affecting dizygotic twinningEthnic groupIncreasing maternal age
Increasing parityFamily h/o twinning, esp maternal
Ovulation induction
ART
Monozygotic twinning is independent of race, heredity,age & Parity.INCIDANCE 1/25O
MONOZYGOTIC
4-7 days
>8days
>DAY 13
THORACOPAGUSISCHIOPAGUSCRANIOPAGUSRACHYPAGUSPYOPAGUSOMPHALOPAGUS
MONOZYGOTIC TWINS
Diagnosis
History
Previous history of twinning; high parity
Older maternal age > 37yrs
History of ovulation induction or pregnancy following ART
Family history of twinning
Clinically Symptoms Exaggerated pregnancy symptoms.
Fetal activity is greater and more persistent in twinning than in singleton pregnancy.
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Signs (1) Uterus > dates of amenorrehea .
(2) Excessive maternal weight gain that is not explained by edema or obesity.
(3)palpation of 2 fetal heads/presence of three fetal poles.
4) Simultaneous recording of different fetal heart rates, each asynchronous with the mothers pulse and with each other and varying by at least 8 beats per minute.
Ultrasound Determination of ChorionicityNumber of sacs. [ before 10 weeks ] 2 sacs dichorionic Single sac - monochorionic
Placenta
Sex
Intertwin membrane
thicker and more echogenic in dichorionic.
Ideal time for assessing of chorionicity is before 14 weeks
Dizygotic
Lambda sign
MONOCHORIONIC & DIAMNIONICT sign
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Importance of chorionicity ?????
Problems Specific to Monochorionic twins Nearly 100% of monochorionic twin placentas have vascular anatomizes2 patterns of vascular anastomosis twin-to-twin transfusion syndrome (TTTS) acardiac twinning or twin reversed arterial perfusion (TRAPS)
Maternal ComplicationAntenatal :Hyperemesis gravidarumchances of abortionhydramnios PIH Placenta previa, abruptioAnemiaExaggerated minor problems: pressure symptoms, etc
Intrapartum complicationsProlonged labor (uterine inertia)Malpresentation Cord prolapseAbruptio placenta for 2nd twinInterlocking of twinsPPH
Fetal complicationsPreterm deliveryIUGRCongenital AbnormalitiesCord abnormalities : Single umbilical artery Velamentous insertion Cord entanglement Cord prolapseMonochorionic twins : Discordant growthTwin to twin syndromeSingle fetal Demise
Cord entanglement
TTTS:Arterio venous anastomoses with net flow in one direction..
Donor(arterial side)
recipient
Severe IUGRpoor renal perfusionAnuriasevere oligohydramnios
HypervolemiaPolyuria with polyhydramniosCCF..hydropsdeath
Serial amnio reduction,fetoscopic laser ablation of anastomosis
Ultrasound in TTS Stuck Twin Sign
Vanishing twinCessation of cardiac activity in a previously viable foetus
Fetus papyraceous
TRAP sequence
PUMP TWINACARDIAC TWIN
Acardiac twins
APARNA P2009 MBBSManagement
1.Prenatal care
More frequent antenatal visits.
prophylactic iron 60-100mg and folic acid 1mg daily should be given.
Nutritional advice-calorie req is 300kcal/day more than that recommended for uncomplicated pregnancy.
Restriction of activity and increased rest at home.
Prophylactic steroids risk for preterm labour or IUGR.
2.Ultrasound scanAt 9-11 wks : confirmation, chorionicity determination, assessment of gestational age and nuchal translucency.
anomaly scan at 20 wks
4 weekly scans in 3rd trimester to assess fetal growth, diagnose complications like TTS
Nuchal Translucency
Mid Trimester Amniocentesis is the gold standard
Delivery prereqistsCTG with dual monitoring capabilityForceps or vacuum Oxytocin infusion Tocolytic agent for uterine relaxation Methergin, 15-methyl PGF2 alpha Immediate availability of blood Access for emergency C/S
1.Place of delivery- Fully equipped hospital having intensive neonatal care unit.
2.Timing of deliveryRCOG recommends elective termination of pregnancy at 37-38 weeksMonochorionic pregnancy best delivered at 36-37 weeks
Mode of deliveryDepend on presentation of 1st twinBoth vertex / 1st twin vertex vaginal deliveryIndication for Elective LSCS-More than 2 fetuses -1st twin malpresentation, CPD-Scarred uterus-MCMA-Conjoint twin-IUGR in dichorionic twin-TTTS
Delivery of 1st twin twin
Delivery Of Second TwinPalpate abdomen immediately to ensure lie,presentation.
If required-ultrasound examination done.
Vaginal examination is also done to exclude cord prolapse.
Acceptable interval between deliveries 30 mins
Longitudinal lie
2ND Twins
Internal podalic versionTo do or not to do ?? Experienced operator EFW > 1500 gm Adequate liquor Available anesthesia for effective uterine relaxation Simultaneous preparation for emergency C/S
Rapid Delivery BY emergancy CS
Severe vaginal bleeding
Cord prolapse in second twin
Inadvertent use of IV ergometrine with delivery of anterior shoulders of first baby2nd twin is transverse, version failed after delivery of 1st twin
Fetal distress
Third StageCross matched blood should be readily available.
Risk of atonic PPH is more.
Oxytocin infusion & i/v ergometrine 0.25mg or methergine 0.2mg given following delivery of anterior shoulder of second baby.
Prostaglandins-15 methyl PG F2alpha can also be used.
Placenta examined for completeness, confirm chorionicity.
Selective fetal reduction-one fetus in a multiple gestation is abnormal
Multifetal reduction-in higher order pregnancy
Iatrogenic fetal death us guided fetal heart puncture or inj kcl
One member of monochorionic pair should never be selected
Multifetal and selective pregnancy reduction
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