Pregnancy with Twin Infant

10/4/2011
Twins Pregnancy
Fajar Ari Nugroho
Prevalensi
• Sejak tahun 1980  65% angka kejadian bayi
kembar  penggunaan ovulation induction agent
(obat kesuburan) &  insiden kehamilan pada
wanita usia tua
• Dari keseluruhan kejadian kehamilan kembar hanya
3% yang dapat lahir hidup  they responsible of a
disproportionate share of perinatal morbidity and
mortality
• all survivors of preterm multifetal births have an
increased risk of mental and physical handicap.
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Type
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Risk & Problem For Infant
1. Greater risk being premature with IUGR
(intrauterine fetal growth restriction ) or LBW
2. 1/5 of Triple pregnancy & ½ of quadruplet
pregnencies  ≥1 child with a major long-term
handicap (eg. Cerebral palsy)  Triple = ≥ 17 x, Twin
=≥4x
3. Growth –restricted preterm infants
4. NICU admission  ¼ of twin(18days), ¾ of
triples(30days), all quadruplets (58days)
Risk & Problem For Maternal
1. maternal morbidity and associated health care costs
↑
2. period of hospitalization ≥ 6 x
3. Complication  preeclampsia, preterm labor,
preterm premature rupture of membranes,
placental abruption, pyelonephritis and postpartum
hemorrhage
4. Hospital costs ≥ 40%
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Morbidity & Mortality
Characteristics
Twins
Triplets
Quadruplets
Average birth weight
2,347g
1,687g
1,309g
Average gestational age at
delivery
35.3wk
32.2wk
29.9wk
14-25
50-60
50-60
25
75
100
18days
30days
58days
-
20
50
4times more than
singletons
17times more than
singletons
-
7 times higher than
singletons
20 times higher than
singletons
-
Percentage with growth
restriction
Percentage requiring admission
to neonatal intensive care unit
Average length of stay in
neonatal intensive care unit
Percentage with major handicap
Risk of cerebral palsy
Risk of death by age 1year
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Pre cause & Effect
(fertility drugs)
1. result of the increased use of ART (assisted
reproduction therapy) and ovulation-induction
agents  in 1980, 37/100,000 triple or more  By
2002, 184/100,000
2. 3.2% ART, ranging 1%~5% in association with both
ART and ovulation induction  one unexpected
complication  high incidence of monochorionic
twins
Pre cause & Effect
3. Monozygotic twinning  increase the incidence of
high order multiple gestation, complicates fetal
growth and development, can lead to rare
complications(twin-twin transfusion syndrome or
acardiac twinning), increases the morbidity of a
pregnancy reduction procedure.
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Pre cause & Effect
(maternal age)
1. the woman’s age  increasing the a prior risk of a
poor perinatal outcome in a high-order multiple
gestation
2. Growing proportion of older women successfully
undergoing fertility treatment  increase in
pregnancies complicated adult-onset disease (DM,
labor abnormalities, cesarean delivery)
3. Increased maternal age  increases the risk of fetal
trisomies (eg. Down syndrome)
Pre cause & Effect
(maternal age)
1. the woman’s age  increasing the a prior risk of a
poor perinatal outcome in a high-order multiple
gestation
2. Growing proportion of older women successfully
undergoing fertility treatment  increase in
pregnancies complicated adult-onset disease (DM,
labor abnormalities, cesarean delivery)
3. Increased maternal age  increases the risk of fetal
trisomies (eg. Down syndrome)
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Complication: Gestational
Diabetes
1. Incidence  twin pregnancies higher than in
singleton pregnancies (36%), triplet pregnancies
higher than in twin pregnancies (2239%)
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Complication: Gestational
Diabetes
2. Diagnosis & management of gestational diabetes in
multiple gestation remain unexamined  the ideal
number of daily calories, the optimal weight gain 
The best form of insulin to use the best method of
fetal surveillance and the ideal time for delivery are
all currently unknown -
Complication: HypertensionPreeclamsia
1. Preeclampsia  twin gestations ≥ X 2.6 times of
singleton gestations, triplet gestations ≥ twin
gestations
2. Significantly more likely to occur earlier and to be
severe
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Complication: HypertensionPreeclamsia
3. <35wks  gestational hypertension (12.4times in
twin), preeclampsia (6.7times in twin), hypertension
with diastolic BP >110 (2.2 times in twin)
4. Multiple gestations by ART  greater risk of develop
in hypertensive complications than spontaneous
multiple gestations (unknown)
Complication: HypertensionPreeclamsia
5. High-order multiple gestations  more likely to
develop atypical preeclampsia, hypertension
(50%), edema (38%), proteinuria (19%), epigastric
pain (60%), HELLP (hemolysis, elevated liver
enzymes, low PLT (56%))
6. Management of hypertension complications in
high-order multiple gestations has not been
studied prospectively
7. Placental abruption : 8.2 times
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Complication: Acute Fatty Liver
1.  severe coagulopathy, hypoglycemia, hyper
ammonemia  can lead to fetal or maternal death,
halt the disease process by delivery  but in
postpartum period = complicated by pancreatitis or
diabetes insipidus or both
Complication: Acute Fatty Liver
2. Sx  anorexia, nausea, vomiting, malaise 
beginning late in pregnancy and developing over
several days of weeks, vague and nonspecific,
concurrent evidence of preeclampsia (1/3 of
affected women), delayed Dx.
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Complication: Pulmonary
Embolism
1. Factors  multiple pregnancy (m/c),
cesarean delivery, delivery < 36wks,
(body mass index) ≥25, maternal age ≥35
BMI
Complication: Others
1. Pruritic urticarial papules and pustules 
dermatosis that most commonly affects primigravid
women in the 3rd trimester  starts in abdominal
striae
* striae : in multiple gestations (m/c)
d/t wt. gain, abdominal distension
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Complication: Others
2. Fetal reduction  the risks associated with a
quadruplet or higher pregnancy clearly outweigh
Perinatal outcome after fetal reduction
Noted an overall postprocedure pregnancy loss rate:
11.7%
Very early preterm (ig. 25~28wks) delivery rate :
4.5%

Chance of losing either an additional fetus or the
whole pregnancy
Chance of early preterm delivery, increased according
to the starting number of fetuses
Fetuses ≥6 : lost before 24wks of gestation – 23%
delivered at ≥37wks (normal)– 20%
Complication: Note
1. Fetal reduction of a high-order multiple pregnancy
has been associated with an increased risk of
intrauterine fetal growth restriction (IUGR)
2. Monochorionicity : complicate the reduction
procedure one fetus of a monochorionic twin pair is
inadvertently reduced
→ sudden hypotension and thrombotic phenomena
→ death of damage of the remaining twin fetus
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Summary of Recommendation
1. Women with high-order multiple gestations should
be queried about nausea, epigastric pain and other
unusual 3rd-trimester symptoms because they are at
increased risk to develop HELLP syndrome, in many
cases before symptoms of preeclampsia have
appeared.
2. The higher incidence of gestational diabetes and
hypertension in high-order multiple gestations
warrants screening and monitoring for these
complication .
Summary of Recommendation
3. Hospitalization, bed rest, or home uterine activity
monitoring have not been studied in high order
multiple gestations, and, therefore should not be
ordered prophylactically. There currently is no
evidence that their prophylactic use improves
outcome in these pregnancies
4. Women should be counseled about the risks of high
order multiple gestation before beginning ART
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Diet Management
1. An adequate maternal weight gain  optimal
weight gain & infant gestational
2. No specific diet applied
3. Common diet for pregnancy has been shown to be
particularly important in these high-risk pregnancies
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