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 (two babies) -Monozygotic(Division of 1 ova fertilized by the same sperm) -Dizygotic(Fertilization of 2 ova by 2 sperm) -Triplets (three babies) -Quadruplets (four babies)

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 Prior use of oral contraceptive agents Social class Seasonality

Causes of Multiple Gestation Spontaneously In Vitro fertilization –Intrauterine insemination –Assisted Hatching –GIFT, ZIFT –Frozen Embryo Transfer, Blastocyte Embryo Transfer Fertility Drugs –Clomiphene citrate (clomid, serrophene) –Gonadotropins (GonalF, follistim, humagon)

Twins Dizygotic twins (66% of US twins) –Dichorionic – separate chorion (placenta) –Diamniotic – separate amnion (amniotic sac) Monozygotic twin (33% of US twins) Ova division: < 72 hours: Dichorionic, diamniotic 4-8 days: Monchorionic, diamniotic 8-13 days: Monochorionic, monoamniotic > 13 days: conjoined twins

Mono ovular-identical twins, diamniotik monokorionik

EARLY DIAGNOSIS OF TWINS DIZYGOTIC MONOZYGOTIC

DIAGNOSIS OF MULTIFETAL PREGNANCY: SIMULTANEOUS VISUALIZATION two or more embryos two or more embryos or corresponding body parts of twoor corresponding body parts of two or more fetuses or more fetuses

EARLY DIAGNOSIS OF TWINS 2 GESTATIONAL SACS 2 YOLK SAC ( BC / BA ) 1 GESTATIONAL SAC 2 YOLK SACS ( MC / BA 2 YOLK SACS ( MC / BA ) The first visible structures: DIZYGOTICMONOZYGOTIC YOLK SACS fused fused separated

A firm diagnosis of the number of embryos after 7th week ! EARLY DIAGNOSIS OF TWINS EMBRYOS AND AMNIOTIC MEMBRANES

MONOCHORIONICMONOAMNIOTICTWINS

HIGH-ORDER MULTIPLE PREGNANCY Pregnancy with three or more fetuses

three amniotic three chorionic

FRONTBACK

QUADRUPLETS HIGH ORDER PREGNANCY

MONOCHORIONIC BIAMNIOTIC TWINS BICHORIONIC BIAMNIOTIC TWINS

LAMBDA SIGN BICHORIONIC BIAMNIOTIC TWINS

Y-SHAPED THE Y-SHAPED JUNCTION Y-SIGNTRICHORIONICTRIAMNIOTICTRIPLETS “MERCEDES” SIGN “MERCEDES” SIGN

Ultrasonografi kehamilan kembar pada usia kehamilan hari

Conjoined Twins Craniopagus Pygopagus Thoracopagus Cephalopagus Epholothoracopagus Parapagus Ischopagus Omphalopagus Parasitic twins Fetus in fetu

SYMMETRICAL COMPLETE FORM Two fetuses share a certain amount of tissue 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 twins in 20% of twins single fetal demise high-risk surviving twin high-risk surviving twin intrauterine hematomas intrauterine hematomas better prognosis in dichorionic better prognosis in dichorionic thromboplastine embolisation thromboplastine embolisation

Fetus Papyraceous, salah satu fetus yang tidak berkembang

Conjoined Twins (paraphagus)

Days in NICU GA weeks GA weeks GA weeks (quads)55-75 GA weeks25-45 GA weeks (triplets)15-35 GA weeks (twins)10-25 GA weeks1-10

Average age of gestation Number of babies Weeks of Gestation 140 weeks 235 1/2 weeks 333 weeks 429 ½ weeks

Peripartum Complications Prematurity-major cause of neonatal death 50% of twins 90% of triplets and higher Spontaneous abortion Increased anomalies Cord Prolapse IUGR, discordant growth Intracranial Hemorrhage Locked Twins Description: Twins lock heads 1 st twin breech, 2 nd twin vertex

Problems of Prematurity HMD/BPD Pneumothorax Apnea ICH CP Blindness/Retinopathy LBW PDA Hypertension/Hypotension Bradycardia Anemia Hyperbilirubinemia NEC Metabolic disorders Hypothermia HIE Hypotonia Infections

Neonatal Management (Multiple Gestation) Team for each fetus Examine for prematurity and IUGR Examine for congenital anomalies Determine zygosity, examine placenta Assess family support

In ICN RDS Apnea/Asphyxia Hct and BP Wt difference NEC Head Sono + Glucose Blood typing

Second Twin Risks Asphyxia due to premature separation of placenta Fetus papyraceous - twin fetus that died in utero, become flattened and mummified Fetal transfusion Syndrome 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 interlocking)

Monozygotic twins (physical characteristics) Same sex Features alike, including teeth and ears Hair identical Eyes same color and shade Skin same texture and color Hands and feet same conformation and same size Anthropometric values closely agree

Twin-Twin Transfusion Syndrome Monozygotic twins share one placenta 1 placenta causes one baby to receive more blood. One baby (donor) smaller and other larger. Larger baby: excess urine, polyhydramnios. Donor stops producing urine, oligohydramnios. This can lead to pre-term delivery (~24 weeks).

5% - 20% monochorionic twins5% - 20% monochorionic twins arterio venous anastomosesarterio venous anastomoses discordant growthdiscordant growth DONOR RECIPIENT OLIGOHYDRAMNIOS POLYHYDRAMNIOS IUGR MACROSOMIA, HYDROPS MICROCARDIA CARDIOMEGALIA ANEMIA POLYCYTHAEMIA fetal loss 80% TWIN TO TWIN TRANSFUSION SYNDROME

TTTS

VASCULAR ANASTOMOSES IN A TWIN PLACENTA: ARTERIO VENOUS ARTERIO ARTERIOUS VENO VENOUS VENO VENOUS superficial deep

collapsed amniotic membrane DONOR: Stuck twin TWIN TO TWIN TRANSFUSION SYNDROME fixed twin anhydramnios POLYHYDRAMNIOS OF RECIPIENT TWIN

VISUALIZATION WITH POWER ANGIO MODE SURFACE ANASTOMOSES

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