KEHAMILAN = MULTIPLE PR

KEHAMILAN
N KEMBAR
= MULTIPLE PR
REGNANCIES =
(GEME
ELLI)
O
Dr. HOTMA PARTOG
GI PASARIBU SpOG
SUB BAGIAN FETOM
MATERNAL FKFK-USU
RS. PIRNGA
ADI MEDAN
Pendah
huluan
• Two for the price of oneee” atau “instant
instant family
family”
• High Complication Risk
k→Morbiditas &
mortalitas ↑ 50% 32-38
32 38 m
minggu, 10% dibawahnya
• Pe↑ Malpresentasi:
- kedua janin sungsang 41%
4
- Janin kembar I sungsan
ng 17%
- Locked
L k d twins
t i (jarang)
(j
)
• Persalinan operatif & ressiko persalinan preterm ↑
Definisi & Klasifikasi
K
Kehamilan 2 janin atau lebih
h
Kembar dizigotik (66%) Binnovular-fraternal twins
1. fertilisasi 2 ovum oleh 2 sperma
s
2. Dikorionik: Amnion terpiisah
Kembar monozigotik (33%)) Mono ovular-identical twins
- Pembelahan
P b l h 1 ovum, ffertil
tillisasi
li i oleh
l h sperma
sperma yang sama
- Pembelahan <72 jam: Dikorionik diamnotik
(96%)
- Pembelahan 4-8 hari: Monnokorionik diamniotik
(4%)
Mono ovular-iden
ovular iden
ntical twins,
diamniotik mon
nokorionik
- Pembelahan 8-13
8 13 hari: Monokorionik, Monoamniotik
- Pembelahan >13 hari: Conjooined twins
Fetus Papyraceous
- Salah satu janin kembar tidaak berkembang
- Tak berbentuk,
berbentuk mengkerut & rata
Perbandingan Mono/Dizigootik 1:2
Faktor resiko untuk kembarr dizigotik:
- tua
- Multiparitas
M lti it
- Riwayat keluarga kehamilann kembar dizigotik
Fetus Papyraceous, salah satu fetus yang tidak berkembang
Insiiden
1% dari kehamilan, 2/3 dizigot & 1/3 monozigot
Etnik ((1:50 Afrika,, 1:80 Cauusasia,, 1:50 Asia))
Usia (2% > 35 thn)
Paritas ((2%
% setelah kehamillan ke-4))
Metode konsepsi (20% induuksi ovulasi)
Riwayat keluarga
Insidensi menurut hukum Hellin
H
adalah 1 dalam 80n-1
kehamilan
e
Etio
ologi
• Bangsa, hereditas, umur & paritas→ binovular
fraternal-twins
• Obat klomid & gonadotrropin hormon→ dizigotik
• Fertilisasi in vitro & tran
nsfer embrio (IVF&ET)
Patofissiologi
Fertilisasi
ovum&sperm
ma di tuba falopii
Ovum yang telah dibuahi turun
t
uterus
nidasi dan Pertumbuhan feetus
Selama proses ini kem
mbar dapat terbentuk
Kehamilan berasal dari satu telur terjadi :
Akibat adanya kerja faktor penghambat (inhibiting
(
factor)
pada masa awal pertumbuhan
p
p
embrio inttrauterin,,
mempengaruhi segmentasi selanjutnya
pada berbagai tingkatan.
Tipe Preesentasi
•
•
•
•
Janin kembar I presentassi vertex 75%
Kedua janin presentasi vertex
v
45%
Salah satu janin vertex, lainnya
l
bokong 37%
K d jjanin
Kedua
i presentasii bokong
b k
10%
tipe-tipe presentasi
Distribusi dari letaak dan posisi janin
kembar (dalam %) antara lain:
KEMBAR
DUA
KEM
MBAR PERTAMA
Keepala
Sungsang
Lintang
Kepala
39
13
0,6
Sungsang
26
9
06
0,6
Lintang
8
4
0,6
Early Diiagnosis
Anamnesa
Ultrasonografi
Gem
melli
P
Pemeriksaan
ik
klinis
kli i
R di l i
Radiologi
Diagnosis Awal
A
Twins
DIZYGOTIC
MONOZYGOTIC
Ultrasonografi
g f kehamilan kembar ppada usia kehamilan 38-40 hari
Diagnosa dini gagal →
- P↑ PJT & persalinan prem
matur
- P↑ mortalitas & morbiditaas perintal
- P↑ komplikasi
Berdasarkan observasi
o
36-37 mgg +++
P’tbh jjanin
P’tbhan
i 24-35
24 35 mgg
Amnion <<<
plasenta
l
t matang++
t ++
Kematian intra uteerin ↑ 37-38 mgg
iff
i l Diagn
i nosis
i
• Differential
Kehamilan lewat waktuu
Polihidramnion
Tumor fibroid uterus
Kista
Mola hidatiforma
Anemia
Atoonia uteri
Hidramnion
PPH
Abortus
K
Komplikasi
lik i maternal
t
l
Retensio plasenta
Inersia uteri
Partus prematur
Pre-eklampsia
Solusio
plasenta
Malpresentas
si
Plasenta Previa
Prematuritas
KPD
Komplikasi fetal
f
BBLR
I
Insufisiensi
fi i
i plasenta
l
t
Kelainan kongenital
Prolapsus tali pusat
Komplikasi In
ntrapartum
Plasenta
kebutuhan nutrisi>>
Insufisiensi plasenta
Polihidramnion
Kond
disi lain
Prolapsus tali pusat
PPH
Malpresentasi
K
Komplikasi
lik i Peri
P ipartum
i
t
Solusio Plasenta
Locked
T i
Twins
Tran
nsfusion Syndrom
Penatala
aksanaan
A. Tindakan umum
- Diet & Pola makan yan
ng baik
- Besi
B i & Asam
A
ffolat
l t
- Aktivitas << & aktivitaas +++
B. Pem. Klinis setiap 2mgg setelah 24 mgg
- keadaan servik setelah 24 mgg
gg
- pengetahuan kehamilan preterm
- pergerakan bayi setelah
h 32 mgg
C. USG setiap 4-6 mgg seetelah dignosis
C
- kemungkinan plasentta previa
- kemungkinan
kem ngkinan ganggu
gangguan
an pert
pertumbuhan
mb han janin
- presentasi janin
D. Nonstress test setelah setelah 32mgg
- keadaan janin
-p
penekanan taki p
pusatt
E. Konsultasi perinatologgi
Kembar discordant: janin resepien
nt lebih besar dari pada janin
donor
abnormalitas
ab
o alitas arteriovenous
a te iove ous tampa
ta pa
aak pada permukaan
pe u aa plasenta,
plase ta,
darah arteri kaya O2 donor bercam
mpur dengan darah resepient
PENANGANAN
N PERSALINAN
• KALAU ANAK I SUNGS
SANG ATAU LINTANG
SEBAIKNYA S.CESAR.
• KALAU ANAK I P
P.KEPA
KEPA
ALA DIUPAYAKAN
DENGAN P/ VAGINAL ANAK
A
KE DUA DENGAN
V.EKSTRAKSI.
• SELAMA DJJ NORMAL TIDAK ADA ALASAN
UNTUK MEMPERCAPA
AT KELAHIRAN ANAK
KEDUA
• PENGAWASAN YANG KETAT
K
MENENTUKAN
OUTCOME PERSALINA
AN
anak pertama lintang atau sungsang dan anak kedua
memanjang (terjadi posisi saling
s
mengunci interlocking)
Panduan penanganan p
persalinan spontan pada
kehamilan
n kembar
Janin pertama
Siapkan peralatan resusitasii & perawatan bayi
P
Pasang
iinfus
f & cairan
i
intrav
i t vena
Pantau keadaan janin, djj
Periksa presentasi janin
- vertex → PSP, monitor peersalinan
- bokongg → indikasi SC
- lintang → SC
™Tinggalkan klem pada ujungg maternal tali pusat
• Janin kedua atau berikiu
utnya
Segera setelah bayi pertaama lahir:
- Palpasi
P l i abdomen
bd
→ let
l tak
k jjanin
i
- lakukan versi luar
- Periksa djj
• Periksa dalam
- Presentasi janin kedua
- keutuhan
k
h selaput
l
ketub
k ban
- Prolapsus tali pusat
Monoamniotic twins mortality
• 2 to 5% loss every 2 weeeks from 15 to 32 weeks
• 9% at 33 wks → 29% att 36-38 wks
• 95% cord entanglement (prenatal diagnosis 28%)
Comparison of ratess of complications in
singleton and mu
ultiple gestations
Complications
Rate for twins (increase)
Chorioamnionitis
Premature rupture of membranes
Fetal asphyxia
Twin-twin transfusion
Congenital malformations
Hydramnios
d
i
Abruptio placentae
Placenta previa
p
Compression of cord
Birth injury
Prematurity
Umbilical cord knots
4-fold
4-fold
5 fold
5-fold
1 of 9 monoamniotic twins
3-fold
1 off 12 twins
i
2-fold
2-fold
2-fold
10-fold
10 fold
10-fold
2-fold
Maternal morbidity and obstetric complications
off quadruplet
d l preegnancy (No. 22)
VARIABLE
Antepartum hospitalization
Hyperemesis gravidarum
Hyperemesis gravidarum, total parenteraal nutrition required
G t ti l di
Gestational
diabetes
b t mellitus,
llit A1
Gestational diabetes mellitus, A2
Anemia (Hct < 30%), no antepartum tran
nsfusion required
Anemia (Hct < 30%),
30%) antepartum transfu
usion required
Antepartum bleeding
Placenta previa
Preeclampsia
HELLP syndrome
PPROM
PTL
Twin-twin transfusion syndrome
Chorioamnionitis
INCIDENCE (%)
100
9.4
3.1
18 8
18.8
3.1
25.0
15 6
15.6
3.1
0.0
71.9
2.5
18.8
100
3.1
6.3
I. Psychological Su
upport and Clinical
Counsseling
li
• All parents should be awa
are that pathologies such as
f t l growth
fetal
th retardation
t d ti n, congenital
it l anomalies,
li
abnormal placentation, abruptio placentae, fetal
malpresentation and preterm delivery, occur more
commonly in multiple than in
i singleton pregnancy
• These aspects result in hiigher maternal and perinatal
mortality and morbidity.
e three to five times higher in
• Antenatal complications are
multiple pregnancy than in singleton pregnancy.
pregnancy
• From the first trimester onwards
o
is required to help
parents to cope with posssible negative outcome and
also with the socio-econ
nomic problems related to
multiple birth.
The most important:
EARLY DIA
AGNOSIS
WHY?
MULTIPLE
PREGNANCY
•
•
•
•
=
HIGH--RISK
HIGH
PREGNANCY
COMPLICATIONS DURING
G PREGNANCY
SPECIFIC MALFORMATIO
ON SEQUENCES
HIGHER PERINATAL MOR
RBIDITIY AND MORTALITY
INTRAPARTAL COMPLICA
ATIONS
DIAGNOSIS OF
MULTIFETAL PREG
GNANCY:
SIMULTANEOUS VISUALIZATION
V
•
two or more embryos
•or corresponding
p
g bo
ody
yp
parts of two
or more fetuses
EARLY DIAGNOSIIS OF TWINS
The first visiible structures:
1 GESTATIONAL SAC
2 YOLK SACS ( MC / BA )
YOLK SACS
fused
2 GESTATIONAL SACS
2 YOLK SAC ( BC / BA )
DIZYGOTIC
separated
MONOZYGOTIC
EARLY DIAGNOSIS OF TWINS
EMBRYOS AND AMNIO
OTIC
MEMBRANES
A firm diagnosiis of
the number of embrryos
after 7th we
eek !
MONOCHO
ORIONIC
MONOAMN
NIOTIC
TWINS
HIGH--ORDER MULTIP
HIGH
PLE PREGNANCY
Pregnancy with three or more fetuses
three chorionic
three amniotic
2D multiplanar imaging
TRIPLETS
• volume scanning
• volume rendering
• spatial reconstruction
• plastic imaging
3D reconstruction
FRONT
BACK
HIGH ORDER P
PREG
PRE
GNANCY
QUADRUPLETS
HIGH ORDER P
PRE
REG
RE
GNANCY
HIGH ORDER PR
REG
RE
GNANCY
SEPTUPLETS
HIGH ORDER PRE
REG
GNANCY
12 EMBRYOS
II. Correct Diiagnosis and
Characterization
n of Chorionicity
• Multiple gestation should be suspected when the uterus is larger than
predicted byy menstrual history.
p
y
• Approximately one fifth of multiple
e gestations are monochorionic and
four fifths are dichorionic.
• Type of placentation and chorionicity is helpful in the following three
clinical situations: 1) The differe
entiation of twin to twin transfusion
syndrome (TTS) from a twin ge
estation in which one fetus shows
growth retardation; 2) the management of twins with congenital
malformations, in which selective
e feticide may be considered as an
option if the gestation is dichorion
nic and 3) the management of single
fetal death in a multiple gestation.
gestation
• The thickness of dividing membrane is in 85% of monochorionic twins
~ 2 mm, in DC/DA the membrane is ~ 4 mm
• The “lambda” sign is an indicator of
o dichorionic pregnancy
II. Correct Diiagnosis and
Characterization
n of Chorionicity
•
The following criteria m
must be fulfilled to diagnose
monoamniotic twins:
1.
1
2.
3
3.
4.
no dividing amniotic mem
mbrane is present
only one placenta is see
en
both fetuses are of the ssame sex
the fetuses must have adequate
a
amniotic fluid
surrounding them
5. both fetuses must move
e freely within the uterine
cavity.
cavity
Zigosity of spontaneeus vs. ART triplets
Spontaneous triplets
ART
TZ
26%
TZ
84%
Unknown
3%
DZ
52%
MZ
22%
adapted from
m Derom, 2000
DZ MZ
12% 1%
ACCURATE PRENATAL DIAGN
NOSIS
OF CHORIONICITY IS OF PRED
DOMINANT
IMPORTANCE FOR THE CLINIC
CAL MANAGEMENT
OF MULTIPLE PREGNANCIES
S
EARLY DIAGNOSIS O
OF CHORIONICITY
1st TRIMESTER
NUMBER OF
GESTATIONAL
SACS
EARLY DIAGNOSIS
OF AMNIONICITY
G OS S O
O C
6 weeks
NUM
MBER OF YOLK SACS
OR
NUM
MBER OF VISIBLE
VISIB E AMNIONS
7 weeks
EARLY DIAGNOSIS OF AMNIONICITY
Why is it important?
i
ALAR
RM !
MONOCH
HORIONIC
AND
D / OR
MONOAMNIIOTIC TWINS
FETAL COMPLIC
CATIONS
PECULIAR COMPL
LICATIONS
Twin embolisation syndrrome ( vanishingvanishing-twin )
Twin--to
Twin
to--twin transfusioon syndrome ( TTS )
Twin reversed arterial perfusion ( TRAP )
Cord entan
nglement
Conjoined twins
SECOND AND
THIRD TRIMESTE
TRIMESTER
R
NUMBER OF
PLACENTAS
DETERMINATION OF THE CHORIONICITY
IN SECOND TRIMESTER
T
Sonographic counting of separated
s
placentas is
an accurate
t method
th d of
of determining
d t
i i the
th
chorionicity in the second
s
trimester
PLACENTA 1
TWO SEPARATED
PLACENTAS
PLACENTA 2
MONOCHORIONIC
BIAMNIOTIC TWINS
BICHORIONIC
BIAMNIOTIC TWINS
BICHORIONIC BIAMNIIOTIC
IOTIC TWINS
LAMBDA SIGN
BIAMNIOTIC
BICHORIONIC
TWINS
MONOAMNIOTIC MONOC
CHORIONIC
CHORIONIC TWINS
THE Y-S
SHAPE
ED JUNCTION
JU C O
“MERCEDES” SIGN
Y-SIGN
TRICHORIONIC
TRIAMNIOTIC
TRIPLETS
III. Close Evaluation of Fetal Anatomy
y
Fetal Malformations and Prena
atal Genetic Diagnosis
g
• The incidence of malformation in monozygotic
m
twin pregnancies is twice
that in dizygotics.
• Chromosomal anomalies are no morre common in twins than singletons
• Anomalies not unique to twins but believed
b
to be increased in frequency
because of mechanical factors are positional defects (such as clubfoot
and congenital dislocation of the hip) due to intrauterine crowding.
• Additional anomalies due to vascular consequences of fetal death are
congenital
it l skin
ki defects,
d f t
microcep
i
phaly,
h l hydrancephaly,
h d
h l porencephaly,
h l
multicystic encephalomalacia, hydro
ocephalus, intestinal atresia and limb
amputation.
III Close Evaluation of Fetal Anatomy
III.
Fetoplacental Markers in Tw
win Pregnancies Affected by
Down Syndrome
• Around one-third of twin pregnancies
p
are monozygous
and their rate of Dow
wn syndrome is relatively
i d
independent
d t off race and
d ma
aternal
t
l age.
• Dizygous twins are more common in older mothers and
as they
th
arise
i
f
from
se
eparate
t
f tili ti
fertilisation
off two
t
simultaneously shed ova th
here is double the age-related
risk than for a singleton prregnancy that either twin will
have Down syndrome
EPIDEMIOLOGY OF
O CONGENITAL
ANOMALIES
S IN TWINS
Anomaly rates for:
singletons
twins
2- 4 %
5 - 10 %
Incidence of congenital ano
omalies is 2 - 3 x higher in
twin than in singlleton pregnancy.
Monozygotic twins ha
ave an anomaly rate
50% higher
g
than dizygotic
d yg
twins.
CONJOINED (SIAM
MESE) TWINS
INCIDENCE 1: 50 000 BIRTHS
ULTRASOUND CRITERIA FOR DIAGNOSIS:
1) LACK OF SEPARATE VIS
SUALISATION
OF FETUSES IN SPECIFIC
C ANATOMICAL
REGIONS
2) FIXED POSITION OF THE
E TWIN
TOWARD EACH OTHER
3) MISSING
SS G S
SEPARATING
G MEMBRANE
M
PATTERNS OF PHYSIICAL
ICAL JOINING
SYMMETRICAL
COMPLETE FORM
Two fetuses share
a certain amount of tissue
Surgical separation is
possible in general.
PATTERNS OF PHY
YSICAL JOINING
YSICAL
SYMMETRICAL
INCOMPLETE FORM
Surgical separation
is usually impossible
EARLY DIAGNOSIS OF CONJOINED TWINS
Conjoined twins:
subtotal fusion
with partial separation
of fetal heads
CONJOINED
TWINS
THORACO-THORACO
O
OMPHALOPHAGUS
lack of separate vis
sualisation of fetuses
in thoracothoraco-ab
bdominal region
THOR
RACOOMPHALOPHAGUS
FIVE
E - VESSEL CORD
COLOR DOPPLER
SINGLE SHARED UMBILICAL
L
CO
CORD
VI. Avoidance off Most Frequent
Compli
p cations
Complications of multiple pregna
ancies comprise:
• Abortion,,
• Vanishing twin syndrome
• Malformation
• Vasa
V
previa
i
• Growth discrepancy
• Intra uterine growth restriction
n (IUGR)
• Polyhydramnios
• Preeclampsia
• Preterm-premature rupture off membranes (P-PROM)
• Preterm delivery
• Gestational diabetes
• Intrauterine fetal death.
VANISHING TWIN
N
• in 20% of twin
twinss
• single fetal demise
• high
high--risk surviving twin
• int
intra
rauterine
uterine hematomas
• better prognosis in dichorio
onic
• thromboplastine embolisation
e
SUBCHORIONIC
HAEMATOMA
VANISHING TWIN
VII. Consideration
n of Some Specific
Pathologies
Twin to Twin Transfusion Syndrome
S
(TTS)
• Is associated with a high ra
ate of mortality and
and, among
survivors, substantial morb
bidity.
• Diagnostic
g
criteria include: monochorionic pregnancy;
p g
y;
same sex with growth disco
ordance between twins;
olygohydramnios of the gro
owth retarded fetus and
polyhydramnios of the larger twin; an intertwin
hemoglobin difference > 5m
mg/dl (after cordocentesis).
• Antepartum management o
of TTS is not without
controversy, because no su
uggested therapy is without
problems.
• The three types of vascular anastomoses, A-A, V-V
and A-V, are generally pressent in monochorionic
placentae
MONOCHORONIC / BIAMNIOTIC
IAMNIOTIC::
“TWIN TO TWIN”
TTTS
TRANSFUSION SYND
DROME
MONOAMNIOTIC:
UMBILICAL CORD EN
NTAGLEMENT
ACARDIAC TWIN - TR
RAP SEQUENCE
CONJOINED TWINS
TWIN TO TWIN TRANSFUSION SYNDROME
•5% - 20% monochorionic twins
•arterio
veno
ous anastomoses
•discordant growth
DONOR
RECIPIENT
OLIGOHYDRAMNIOS
P
POLYHYDRAMNIOS
IUGR
M
MACROSOMIA,
HYDROPS
MICROCARDIA
C
CARDIOMEGALIA
ANEMIA
P
POLYCYTHAEMIA
fetal loss 80%
TWIN TO TWIN TRANSFUS
SION SYNDROME
SCALP EDEMA
RECIPIENT:
F t l hydrops
Fetal
h d
ASCITES
TWIN TO TWIN TRANSFU
USION SYNDROME
POLYHYDRAMNIOS OF
RECIPIENT TWIN
fixed twin
anhydramnios
h d
i
DONOR:
St k ttwin
Stuck
i
collapsed amniotic
membra
ane
TWIN TO TWIN TRANSFU
USION SYNDROME
TWIN TO TWIN TRANSF
FUSION SYNDROME
TWIN TO TWIN TRANSFU
USION SYNDROME
Recipient :
venous return pattern
UMBILICAL VEIN
SONOGRAM
IN RECIPIENT TWIN
PULSATIONS WITH
REVERSE-- FLOW AT
REVERSE
THE END OF DIASTOLE
DUCTUS VENOSUS
SONOGRAM
IN RECIPIENT TWIN
REVERSAL OF FLOW
DURING ATRIAL
CONTRACTION
TWIN TO TWIN TRANSFU
USION SYNDROME
Plethoric
RECIPIENT
Anaemic
DONOR
Weightt difference > 25%
Haemoglobin difference >5%
VASCULAR AN
NASTOMOSES
IN A TWIN PLACENTA:
superficial
deep
ARTERIO
ARTERIO
VENO
VENOUS
ARTERIOUS
VENOUS
SURFACE ANASTOMOSES
VISUALIZATION WITH
POWER ANGIO MODE
VII. Consideration
n of Some Specific
Pathologies
Twin Reversed Arterial Perfusion (TRAP) Sequence
ation of twin to twin transfusion
• The most extreme manifesta
syndrome, found in approxim
mately 1% of monozygotic twin
pregnancies is acardiac twinning (acardius
chorioangiopagus parasiticuss)
s).
• The underlying mechanism iss thought to be disruption of
normal vascular perfusion an
nd development of the
recipient twin due to an umbiilical arterial-to-arterial
anastomosis with the donor or
o pump twin.
• At least 50% of donor twins die
d due to congestive heart
failure or severe preterm deliivery, the consequence of
polyhydramnios.
polyhydramnios
• All perfused twins die due to the associated multiple
malformations.
TWIN REV
VERSED
ARTERIAL PERFUSION
P
(TRA
AP)
IN MONOCHORIONIC
C TWINS ONE TWIN
( PUMP-TWIN ) ACT
TIVELY PERFUSES
THE SECOND TWIN ( PERFUSED TWIN )
VIA LARGE A -A AND/O
OR V - V ANASTOMOSES
1% of monozygotic twins are affected
Incidence 1 : 3
35 000 births
PATHOGENESIIS
ARTERIAL SUPPLY INTO
O PLACENTA
BY THE PUMP TWIN IS ABLE
A
TO
OVERCOME THE BLOOD
D PRESSURE OF THE
CO TWIN SO AS TO PER
CO-TWIN
RFUSE THAT TWIN
BY REVERSED FLOW (TOWARD CO-TWIN)
IN THE UMBLICAL ARTE
ERIES OF THE
CO-TWIN
TRAP
NORMAL
( PUMP TWIN )
PERFUSED TWIN
ACARDIUS
REVERSE FLOW
NORMAL FLOW
BLOOD FLOWS FROM AN
UMBILICAL ARTERY OF THE
PUMP TWIN IN
REVERSE DIRECTION VIA
ARTERIO - ARTERIAL
ANASTOMOSES INTO
UMBILICAL ARTERY OF THE
PERFUSED TWIN.
THE UMBILICAL VEIN OF THE PA
ARASITIC FETUS
RETURNS THE BLOOD INTO THE
E PLACENTA AND
BACK TO PUMP TWIN
PATHOGENESIS OF FET
TAL DYSMORPHIA:
EARLY REVERSE
E OF CIRCULATION
REVERSE PASSIVE
E PERFUSION OF TWIN
PERFUSION IN OPP
POSITE DIRECTION AND
PERFUSION WITH DEOXIGENATED
D
BLOOD
INDUCTION OF DEVEL
LOPMENTAL DISORDERS
REDUCTION ANOMA
ALIES ( EXTREMITIES )
DEVELOPMENTAL ATROP
PHIES ( HEART AND BRAIN )
Ultrasound finding = early ultrasound detection
the most bizzarre feta
al malformations
PUMP - TWIN
PERFUSED TWIN
normal
morphology
acardius
normal
direction of
blood flow
reduction anomalies of
head and extremities
reversed blood flow
TWINS MC / MA,
MA 15 wks
k
COLOR
DOPPLER
REVERSED
PERFUSION
ULTRASONIC
U
SO C C
CRITERIA FOR
O ACARDIUS
C
US
An am
morphous mass with
its ow
wn umbilical
monochorioniccord in monochorionicmono
oamniotic
twin pregnancy
p
ACARDIAC - AC
CEPHALIC
No trunk
and head
No heart
and
d brain
b i
This acardiac twin
n consists mainly of
lower ex
xtremities
VII. Consideration
n of Some Specific
Pathologies
Stuck Twin
• Refers to the ultrasonog
graphic finding of one of a
monochorionic diamnio
otic twin pair in an
oligohydramniotic sac fixe
ed in a location adjacent to
the uterine wall.
• This is frequently a maniffestation of the twin-to-twin
twin to twin
transfusion syndrome (TT
TS).
• Management may incclude: selective feticide;
umbilical cord ligation of one
o twin; laser occlusion of
anastomosing
placen
ntal
vessels;
serial
amniocentesis.
i
t i
CORD ENTAGLEME
ENT
ENT
COMPLICATION
SPECIFIC FOR
MONOAMNIOTIC
MONOCHORIONIC
TWINS
CORD ENTANGLEM
MENT
MONOAMNIOTIC
TWINNING
THE CLOSE INSERTION OF
F THE UMBILICAL
CORDS INTO PLACENTA IS
S ASSOCIATED WITH:
LARGE--CALIBER ANASTOM
LARGE
MOSES
AND
HIGH PREDISPOSITION
N FOR ENTANGLEMENT
CORD ENTANGLEMENT
ENTANGLEMENT
COLOR DOPPLER
POWER DOPPLER
TWIN--TO
TWIN
TO--TWIN TRANSFUSION
T
should be considered whe
en growth discordancy
i di
is
diagnosed
d iin monoch
h i i gestations
horionic
t ti
Multiple gestations prresent a significant
decrease
de
crease in fetal growth
g
which is
in direct relationship to the number
of fetuses in high orrder pregnancies
VIII Close Monittoring of Fetuses
VIII.
Doppler
D
l Velocimetry
V l i t
• Recent studies have addressed
a
the
usefulness of this tech
hnique in predicting twin
fetuses small for gesta
ational age (SGA) or
IUGR, twins with TTS,, and those with
discordant growth
VIII Close Monittoring of Fetuses
VIII.
Cardiotocography
C
di t
h
• Is not always easy to identify the twins and it
is possible to perform two NSTs on the same
fetus.
• The best method is the simultaneous
g of FHR p
patte
erns on one tracing.
g
recording
SPONTANEOUS MOT
TORIC ACTIVITY
• COMPLEX BOD
DY MOVEMENTS
• HICCUPS
• HAND
HAND-FACE
FACE CO
ONTACTS
• MOUTH OPENIN
NG
• SWALLOWING
• BREATHING MO
OVEMENTS
• HEAD MOVEME
ENTS
• EXTREMITY MO
OVEMENTS
• JUMPING
• TWISTING
• STRETCHING
• YAWNING
FETAL ACT
TIVITY
COMPLEX
BODY
MOVEMENTS
NO INTERTWIN
CONTACTS
FETAL ACT
TIVITY
NO INTERTWIN CONTACTS
EXTREMITY MOVEMENTS
INTER--TWIN CONTACTS
INTER
C
• FIRST REACH AND TOUCH
• FIRST REACTION
• “SLOW” OR “FAST” ARM, LEG, HEAD OR BODY CONTACT
• MOUTH CONTACT
• COMPLEX INTERACTIONS
TRIPLET ACTIVITY AND CONTACTS
HEAD TO BODY
CONTACT
JUMPING
The Ten Com
mmandments
in Multiple P
Pregnancies
I. Psychological
y
g
Support
pp and Clinical
C
Counseling
g
II. Correct Diagnosis and Characterization of Chorionicity
III. Close Evaluation of Fetal Anatomy
A
IV. Management at Referral Centers
C
V Individualization of Care
V.
VI. Avoidance of Most Frequent Complications
VII Consideration of Some Sp
pecific Pathologies
VIII. Close Monitoring of Fetusses
IX Planning of Time and Mode of Delivery
IX.
X. Monitoring of the Mother During Postpartum
Ultrasound
Ult
d assessmentt off multiple
lti l pregnancy:
1.
1
2.
3.
3
4.
5.
5
6.
7.
8.
EARLY DIAGNOSIS OF MULTTIPLE PREGNANCY
DIAGNOSIS OF CHORIONICITY AND AMNIONICITY
COMPLICATIONS IN MONOC
CHORIONIC TWINS
FETAL CONGENITAL ANOMA
ALIES
APPROPRIATE VERSUS DIS
SCORDANT GROWTH
COLORCOLOR-DOPPLER OF MULT
TIFETAL PREGNANCY
PREDICTION OF PRETERM DELIVERY
INTRAPARTUM ULTRASONO
OGRAPHY