By: Dr Syuhadah Mentor: Dr Hasniza Multiple pregnancy By: Dr Syuhadah Mentor: Dr Hasniza

Multiple Pregnancy Definition: Any Pregnancy in which 2 or more embryos or fetuses occupy the uterus simultaneously Increased incidence (assisted reproductive technology) Twins account for about 1% of pregnancies Hellins law (80 n-1) - Twins → 1 in 80 - Triplets → 1 in 802 - Quadruplets → 1 in 803

Predisposing Conditions ↑maternal age and parity Assisted reproduction techniques - Ovulation induction agents (gonadotropins) - In-vitro fertilization (IVF) Family history

Monozygotic VS Dizygotic Genesis of twin Monozygotic VS Dizygotic

Types of twins Monozygotic twins (identical) Originate by fertilization of single ovum by single sperm. The twinning may occur at different periods after fertilization and this influences the process of implantation and the formation of the fetal membranes.

Types/Classification of Twinning Monozygotic/ identical/uniovular (1 zygote divide into 2) ~33% Dichorionic Diamniotic (cleavage of embryonic egg <3days ) ~30% MONOchorionic Diamniotic (4-8days) ~69% MONOchorionic MONOamniotic (9-12days) ~1%

MONOZYGOTIC @ UNIOVULAR

DIZYGOTIC @ BINOVULAR Dizygotic twins (non-identical ) Results from fertilisation of two ova by two sperms. Dichorionic and diamniotic twins.

Clinical Presentation History Taking Family history of multiple pregnancy Recent infertility treatment Excessive nausea and vomiting Excessive lower limb swelling and varicosities Excessive fetal movement and abdomen overdistension Extremely fatigue

Clinical Presentation Physical Examination Anaemia & oedema Raised BP Uterus larger than dates Polyhydramnios (> in monozygotic twins) Multiple fetal parts & poles > 1 heart sound with different rates Abnormal weight gain

Ways to determine Zygosity, chorionicity Ultrasound- => Gender discordance = dizygotic DNA fingerprinting, from amniotic fluid sample (amniocentesis), placental tissue (chorionic villi sampling) and fetal blood (cordocentesis) Chorionicity Characteristic of membrane(US)-

A: Thick amnion- chorion septum, Twin- peak sign (lamda sign) ~dichorionic B: Thin amnion-chorion septum, The "T sign" ~monochorionic

Why so important to differentiate??? Prenatal diagnosis of chorionicity is important as monochorionic pregnancies have increased rates and severity of all types of obstetric complications when compared with dichorionic pregnancies.

Complications Maternal Fetal Single fetal death ↑ Sx of early pregnancy (↑HCG) Miscarriage Anaemia (↑ Fe,folate & B12 ) Polyhydramnios (uniovular twins) PIH (↑3-5x) APH (placenta praevia) PPH (uterine atony d2 over stretching) GDM (↑diabetogenic placental hormones) Ineffective labour (malpresentation) Thromboembolic ds (↑pelvic vein compression) Fetal Single fetal death Preterm labour (d2 overdistended uterus, polyH, intrauterine infection) IUGR (discordant growth) Stillbirth Congenital abnormality Twin to twin transfusion syndrome Asphyxia (cord entanglement) Intrauterine death

TWIN-TO-TWIN TRANSFUSION SYNDROME (TTTS)

TTTS is found in MCMA as well as MCDA pregnancies. TTTS is more common in MCDA pregnancies than MCMA pregnancies, possibly reflecting that there are more protective artery–artery anastomoses in the latter. Rarely (in approximately 5% of cases), the transfusion may reverse during pregnancy, with the donor fetus demonstrating features of a recipient fetus and vice versa Unequal placental sharing and peripheral, ‘velamentous’ cord insertions are common in TTTS

Affects 10-15% of monochorionic twin pregnancies. Pathophysiology: Result of transfusion of blood from donor to recipient twin through abnormal artery-to- vein anastomoses in the placenta The donor suffers hypovolaemia and hypoxia → IUGR, smaller in size, oligohydramnios & high output cardiac failure The recipient fetus exhibit hypervolemia → large size, polyhydramnios, cardiomegaly, CCF

More than 90% ends in miscarriage/severe preterm delivery To monitor: US doppler 2 weekly Management: Laser coagulation – occlude the vascular anastomosis between twins (presenting prior to 26weeks of gestation) Amnioreduction every 1 - 2/52, drain amniotic fluid from recipient sac Septotomy (cord entanglement risk) Anticipate preterm delivery – corticosteroid (promote fetal lung maturity

SINGLE FETAL DEMISE Occur in monochorionic twin Fetal demise <14weeks-not increase risk on the survivor twin Confers risk to survivor twin if fetal demise after 14 weeks. Dt transfer of thromboplastin from dead twin > produce thrombotic arterial occlusion > occlusions of ant & mid cerebral arteries > multicystic encephalomalacia & neurologic damage. Induce consumptive coagulopathy in mother.

MANAGEMENT of multiple pregnancy Antenatal Intrapartum

ANTENATAL MANAGEMENT All women with a multiple pregnancy should be offered an ultrasound examination at 10–13weeks of gestation to assess: viability chorionicity major congenital malformation nuchal translucency for designation of risk of aneuploidy and twin-to-twin transfusion syndrome.

Dichorionic twins Ultrasound at 10–13 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy Structural anomaly scan at 20–22 weeks. Serial fetal growth scans e.g 24, 28, 32 and then two- to four-weekly. BP monitoring and urinalysis at 20, 24, 28 and then two-weekly. 34–36 weeks: discussion of mode of delivery and intrapartum care. Elective delivery at 37–38 completed weeks. Postnatal advice and support (hospital- and community-based) to include breastfeeding and contraceptive advice

Ultrasound at 10–13 weeks: (a) viability; (b) chorionicity; (c) NT: aneuploidy/TTTS Ultrasound surveillance for TTTS and discordant growth: at 16 weeks and then two-weekly. Structural anomaly scan at 20–22 weeks (including fetal ECHO). Fetal growth scans at two-weekly intervals until delivery. BP monitoring and urinalysis at 20, 24, 28 and then two-weekly. 32–34 weeks: discussion of mode of delivery and intrapartum care. Elective delivery at 36–37 completed weeks (if uncomplicated). Postnatal advice and support (hospital- and community-based) to include breastfeeding and contraceptive advice. Monochorionic twins

ANTENATAL MANAGEMENT Dietary advice: adequate caloric intake to meet increased demands, supplement of iron (60-80 mg /day), folic acid, calcium, vitamins Monitor for infection, anaemia, PIH, preterm labour & malpresentation Corticosteroid if strong possibility of preterm labour (for lung maturity)

Criteria for vaginal delivery fulfilled Leading twin is cephalic

INTRAPARTUM MANAGEMENT OF TWINS Criteria for vaginal delivery fulfilled Deliver the 1st twin Clamp and cut the cord Note lie of 2nd twin Longitudinal lie Transverse lie Amniotomy with controlled oxytocin infusion if there is uterine inertia Attempt External Cephalic Version and vaginal delivery under GA Note presentation Vertex Breech If unsuccessful C-section Breech extraction or assisted breech delivery Vaginal delivery or optionally outlet forceps or ventouse

MANAGEMENT OF THIRD STAGE OF LABOUR In PIH and cardiac disease: give oxytocin 10 unit i.m Syntometrine 1 ml (5 unit oxytocin and 500 mcg ergometrine i.m) with delivery of anterior shoulder of 2nd baby Placenta delivered with controlled cord traction In high risk of uterine atony and PPH, i.v infusion 40 units oxytocin over 6 hours after delivery) Episiotomy/perineal repair if needed

INDICATION OF CAESAREAN SECTION i) ELECTIVE 1st baby non-cephalic especially shoulder Conjoined twins Congenital abnormality precluding safe vaginal delivery IUGR in dichorionic twin Chronic TTTS Monoamniotic twin Placenta praevia Triplets or more Contracted pelvis Previous C-section Pre-eclampsia ii) EMERGENCY Fetal distress Cord prolapse in 1st baby Non-progress of labour Collision of both twins 2nd twin transverse, version failed after 1st delivery of twin

Thank you….