multiple gestation

MULTIPLE GESTATION
By
Dr. HOTMA PARTOGI PASARIBU SpOG
SUB DIVISION OF FETOMATERNAL
MEDICAL FACULTY - USU
RSHAM – RSPM
MEDAN
Definition
(Multi-fetal Gestation)
MULTIPLE PARITY
-Twins
Twins (two babies)
-Monozygotic(Division of 1 ova fertilized by the same sperm)
-Dizygotic(Fertilization of 2 ova by 2 sperm)
-Triplets (three babies)
-Quadruplets
Q d l t (four
(f
babies)
b bi )
Incidence
• Twins - 1 in 100 births
–
–
–
–
African Americans: 1 in 70
Caucasians: 1 in 88
Japanese: 1 in 150
Chinese: 1 in 300
• Triplets are about 1 in 7,500 births
• Quadruplets are about 1 in 650,00 births
Predisposing Factors
•
•
•
•
•
•
Maternal age and parity
Maternal height and weight
Genetic and racial factors
P i use off orall contraceptive
Prior
i agents
Social class
Seasonality
Causes of Multiple Gestation
• Spontaneously
• In Vitro fertilization
–
–
–
–
Intrauterine insemination
Assisted Hatching
GIFT ZIFT
GIFT,
Frozen Embryo Transfer, Blastocyte Embryo Transfer
• Fertilityy Drugs
g
– Clomiphene citrate (clomid, serrophene)
– Gonadotropins (GonalF, follistim, humagon)
Twins
• Dizygotic twins
((66% of US twins))
– Dichorionic – separate
chorion (placenta)
• Monozygotic twin
(33% of US twins)
Ova division:
• < 72 hours: Dichorionic,
diamniotic
• 4-8 days: Monchorionic,
– Diamniotic – separate
amnion (amniotic sac)
diamniotic
• 8
8-13
13 days:
Monochorionic,
monoamniotic
• > 13 days: conjoined
twins
Mono ovular-identical
ovular identical twins,
diamniotik monokorionik
EARLY DIAGNOSIS OF TWINS
DIZYGOTIC
MONOZYGOTIC
DIAGNOSIS OF
MULTIFETAL PREGNANCY:
SIMULTANEOUS VISUALIZATION
•
two or more embryos
•or corresponding
p
g body
yp
parts of two
or more fetuses
EARLY DIAGNOSIS OF TWINS
The first visible 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 AMNIOTIC
MEMBRANES
A firm diagnosis of
the number of embryos
after 7th week !
MONOCHORIONIC
MONOAMNIOTIC
TWINS
HIGH--ORDER MULTIPLE PREGNANCY
HIGH
Pregnancy with three or more fetuses
three chorionic
three amniotic
FRONT
BACK
HIGH ORDER PREG
PREGNANCY
QUADRUPLETS
MONOCHORIONIC
BIAMNIOTIC TWINS
BICHORIONIC
BIAMNIOTIC TWINS
BICHORIONIC BIAMNIOTIC TWINS
LAMBDA SIGN
THE Y-S
SHAPED JU
JUNCTION
C O
“MERCEDES” SIGN
Y-SIGN
TRICHORIONIC
TRIAMNIOTIC
TRIPLETS
Ultrasonografi
g f kehamilan kembar ppada usia kehamilan 38-40 hari
Conjoined Twins
•
•
•
•
•
Craniopagus
yg p g
Pygopagus
Thoracopagus
p
p g
Cephalopagus
Epholothoracopagus
•
•
•
•
•
Parapagus
Ischopagus
p g
Omphalopagus
Parasitic twins
Fetus in fetu
PATTERNS OF PHYSICAL JOINING
SYMMETRICAL
COMPLETE FORM
Two fetuses share
a certain amount of tissue
Surgical separation is
possible in general.
PATTERNS OF PHYSICAL JOINING
SYMMETRICAL
INCOMPLETE FORM
Surgical separation
is usually impossible
VANISHING TWIN
• in 20% of twin
twinss
• single fetal demise
• high
high--risk surviving twin
• int
intra
rauterine
uterine hematomas
• better prognosis in dichorionic
• thromboplastine embolisation
Fetus Papyraceous, salah satu fetus yang tidak berkembang
Conjoined Twins
(paraphagus)
Days in NICU
•
•
•
•
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GA
GA
GA
GA
GA
GA
GA
23-25 weeks
25-27 weeks
28-29 weeks (quads)
30-31 weeks
32-33 weeks (triplets)
34-35 weeks (twins)
36-40 weeks
100-125
80-100
55-75
25-45
15-35
10-25
1-10
Average age of gestation
Number of babies
1
Weeks of Gestation
40 weeks
2
35 1/2 weeks
3
33 weeks
4
29 ½ weeks
Peripartum Complications
• Prematurity-major cause of neonatal death
50% of twins
90% of triplets and higher
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•
•
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•
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Spontaneous
p
abortion
Increased anomalies
Cord Prolapse
IUGR di
IUGR,
discordant
d growthh
Intracranial Hemorrhage
Locked Twins
Description: Twins lock heads
1st twin breech, 2nd twin vertex
Problems of Prematurity
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•
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HMD/BPD
Pneumothorax
Apnea
ICH
CP
Blindness/Retinopathy
LBW
PDA
yp
yp
Hypertension/Hypotension
•
•
•
•
•
•
•
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Bradycardia
Anemia
Hyperbilirubinemia
NEC
M t b li disorders
Metabolic
di d
Hypothermia
HIE
Hypotonia
Infections
Neonatal Management
(Multiple Gestation)
•
•
•
•
•
Team for each fetus
Examine for prematurity and IUGR
Examine for congenital anomalies
D
Determine
i zygosity,
i examine
i placenta
l
Assess family support
In ICN
• RDS
• NEC
• Apnea/Asphyxia
• Head Sono +
• Hct and BP
• Glucose
• Wt difference
• Blood typing
Second Twin Risks
• Asphyxia due to premature separation of placenta
p py
• Fetus papyraceous
-twin fetus that died in utero, become flattened and mummified
• Fetal transfusion Syndrome
y
Placental AV shunt in monozygotic twins (~15%)
Arterial twin pumps blood to other twin, starves self
Other twin is bulky and plethoric
• Operative or difficult delivery
anak pertama lintang atau sungsang dan anak kedua
memanjang (terjadi posisi saling mengunci
i te loc i g)
interlocking)
Monozygotic twins
(physical characteristics)
•
•
•
•
•
•
•
Same sex
g teeth and ears
Features alike,, including
Hair identical
y same color and shade
Eyes
Skin same texture and color
Hands and feet same conformation and same size
Anthropometric values closely agree
Twin-Twin Transfusion Syndrome
•
•
•
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Monozygotic twins share one placenta
placenta causes one baby
y to receive more blood.
1p
One baby (donor) smaller and other larger.
g baby:
y excess urine,, polyhydramnios.
p y y
Larger
Donor stops producing urine, oligohydramnios.
This can lead to pre
pre-term
term delivery ((~24
24 weeks)
weeks).
TWIN TO TWIN TRANSFUSION SYNDROME
•5% - 20% monochorionic twins
•arterio
venous anastomoses
•discordant growth
DONOR
RECIPIENT
OLIGOHYDRAMNIOS
POLYHYDRAMNIOS
IUGR
MACROSOMIA, HYDROPS
MICROCARDIA
CARDIOMEGALIA
ANEMIA
POLYCYTHAEMIA
fetal loss 80%
TTTS
VASCULAR ANASTOMOSES
IN A TWIN PLACENTA:
superficial
deep
ARTERIO
ARTERIO
VENO
VENOUS
ARTERIOUS
VENOUS
TWIN TO TWIN TRANSFUSION SYNDROME
POLYHYDRAMNIOS OF
RECIPIENT TWIN
fixed twin
anhydramnios
h d
i
collapsed amniotic
membrane
DONOR:
St k ttwin
Stuck
i
SURFACE ANASTOMOSES
VISUALIZATION WITH
POWER ANGIO MODE
TWIN TO TWIN TRANSFUSION SYNDROME
Kembar discordant: janin resepient lebih besar dari pada
janin donor
abnormalitas arteriovenous tampak pada permukaan
plasenta,
darah arteri kaya O2 donor bercampur dengan darah
resepient
Prevention
(Multiple Gestation)
• Monitor treatment with fertility drugs
• Limit embryos transferred during IVF
• Counseling risks and long-term sequelae
• Fetal reduction if not against religion