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OUTLINE  Case Profile  Epidemiology and Etiology of Twinning  Maternal Physiology  Fetal Complications  Labor Management and Delivery  Open Forum

EV, 33 YEAR OLD G2P1(0010), SINGLE Labor pains Chief Complaint (-) HPN, goiter, PTB, BA, CA, DM (-) previous surgeries Past Medical History

CASE PROFILE

EV, 33 YEAR OLD G2P1(0010), SINGLE (+) HPN, parents (-) DM, BA, PTB, CA Family Medical History HS graduate, secretary (-) smoking, alcohol, drugs First coitus at 23 y.o. with1 nonpromiscuous sexual partner (-) OCP use, IUD Personal/Social History

EV, 33 YEAR OLD G2P1(0010), SINGLE Menarche at 10 y.o. Interval of days 4 days duration 4 pads per day LNMP: Jan 21, 2011, unsure PMP: Dec 2010 EDC: Oct 28, 2011 AOG: 36 4/7 weeks by early UTZ Menstrual History

EV, 33 YEAR OLD G2P1(0010), SINGLE Obstetric History GDateAOGMode of Delivery mos. Spontaneous Abortion 22011Present pregnancy

HISTORY OF PRESENT ILLNESS OBAS Labor pains Watery vaginal discharge Good fetal movement

REVIEW OF SYSTEMS abdominal pain fluid leakage fever headache BOV vomiting dec fetal movement vaginal bleeding dysuria edema

EV, 33 YEAR OLD G2P1(0010), SINGLE Antenatal visits Lying-in clinic >10x c/o PGH OB OPD Primary antenatal condition Stable Quickening 24 weeks AOG

PHYSICAL EXAMINATION

General Awake Coherent Ambulato ry NICRD Vitals 110/70 HR 82 RR 20 T 36.0 Ht 155 cm Wt 127 lb BMI 24 HEENT Pink conjunctiva e Anicteric sclerae (-) CLAD (-) TPC (-) ANM Lungs Equal chest expansion Clear breath sounds (-) rales, wheezes

Heart Adynamic precordium Distinct heart sounds Normal rate Regular rhythm (-) murmurs Abdomen Globular FH 36 cm EFW kg FHT 130s RLQ, 140s LPU Cephalic- transverse IE Normal external genitalia Nulliparous vagina Cervix open Uterus enlarged to AOG (-) AMT Adequate pelvimetry

BPP/BIOMETRY/DOPPLER STUDIES Twin live intauterine pregnancies, both with good cardiac and somatic activites Impression Cephalic in presentation, 34 weeks by BPD and 33 weeks by FL. Adequate amniotic fluid volume. EFW is AGA. BPP 10/10. Doppler flow studies show normal values. Twin A

BPP/BIOMETRY/DOPPLER STUDIES In transverse presentation, 33 weeks by BPD and 33 weeks by FL. Adequate amniotic fluid. EFW is AGA. BPP 10/10. Doppler flow studies of the umbilical artery show normal values. Twin B Placenta is anterior, high-lying, grade II. Placentation appears monochorionic, diamnionic. Doppler flow studies of the uterine contractions show normal values.

EV, 33 YEAR OLD G2P1(0010), SINGLE Pregnancy uterine, 36 4/7 weeks AOG by early UTZ, twin gestation, cephalic- transverse in preterm labor G2P1 (0010) Assessment Primary low segment cesarian section secondary to malpresentation of 2 nd twin Plan

ETIOLOGY & EPIDEMIOLOGY OF TWINNING

PREVALENCE OF SPONTANEOUS TWINNING  1 in 80 live births (1 in 40 babies)  10-20/1000 live births in US, Europe  40/1000 in Africa  6/1000 in Asia

ETIOLOGY OF MULTIFETAL GESTATION  Dizygotic – fertilization of 2 ova  Monozygotic – division of single fertilized ovum

ETIOLOGY OF MULTIFETAL GESTATION

FACTORS THAT INFLUENCE TWINNING  Race  Heredity  Maternal Age and Parity  Pituitary Gonadotropin  Assisted Reproductive Technology

MATERNAL PHYSIOLOGY

 Cardiovascular  More hyperdynamic circulation than singleton pregnancy  GI and Hepatic Changes  Nausea and vomiting in 50%  Obstetric cholestasis  Acute fatty liver,  Renal  No significant difference from singleton

MATERNAL PHYSIOLOGY  Respiratory  No significant difference  Increased use of accessory muscles  Hematologic  RBC mass increases by 25% in both single and multifetal gestations  Increase in plasma volume is 10-20% greater in twin pregnancy vs singleton  Other changes associated with singleton pregnancy occur in the same way

COMPLICATIONS  Antepartum complications  preterm labor  gestational diabetes  preeclampsia  preterm premature rupture of the membranes  intrauterine growth restriction  intrauterine fetal demise  TTTS  80% in multiple gestations vs 25% in singleton pregnancies

MATERNAL COMPLICATIONS  Preterm Delivery  57% of twin gestations are preterm  Average length of pregnancy is 35 wks for twins  Gestational DM  May be increased in multifetal gestation  Treated the same way in twin pregnancies

MATERNAL COMPLICATIONS  Pregnancy HPN  Gestational HPN  Pre-eclampsia  PPROM  Occurs in 7-10% of twin pregnancies  Typically occurs in the presenting sac  Management same as in singleton pregnancies

FETAL COMPLICATIONS

 Fetal Growth Restriction  Growth Discordance  >=20% difference in EFW  5-15% of twins  Associated with 6 fold increase in risk for perinatal morbidity and mortality  Congenital anomalies  2-3x increased risk in twins

FETAL COMPLICATIONS  Spontaneous Pregnancy Loss  Intrauterine Fetal Demise  Overall survival rate of both twins is 93.7%  Chorionicity important

FETAL COMPLICATIONS  Twin-to-Twin Transfusion Syndrome (TTTS)  Almost exclusively confined to monochorionic twins  Due to the presence of intertwining anastomosis: A-A, V-V, A-V  Classically due to A-V anastomoses carrying unidirectional blood flow from donor to recipient twin

FETAL COMPLICATIONS  TTTS  Donor twin may become anemic and growth restricted  Recipient twin may become polycythemic, w/ circulatory overload and heart failure  Diagnosed by UTZ at wks.  Aggressive amniodrainage and laser photocoagulation of anastomoses  Acute twin-to-twin transfusion  Antepartum complication in the interval of cord clamping of 1 st twin and delivery of the 2 nd twin  2 nd twin left alone with 2 placentas, where its blood may be pumped into, leading to death

DIAGNOSIS  Suggested by  Accelerated fundal growth  Multiple fetal parts  Auscultation of 2 FHTs  Sonography – the sine qua non of diagnosis

DIAGNOSIS  Chorionicity  Easier to determine at early gestation  What to look for  Separate placentas  Intertwin membrane  Extraembryonic coelimic space  Yolk sacs  Fetal sexes  Lambda/twin peak sign

LABOR MANAGEMENT & DELIVERY

 Prevention of preterm labor and delivery  Labor and Delivery Problems  Hypotonic uterine inertia  Intrapartum bleeding

LABOR MANAGEMENT & DELIVERY  Route of Delivery  Vaginal delivery for mature vertex-vertex twins and <1500g vertex-vertex twins  CS indications for singleton pregnancy still apply  If the 1 st twin is transverse or breech, CS in favored  CS for non-vertex second twin

LABOR AND DELIVERY  Presentation and Position

VAGINAL DELIVERY  Cephalic-cephalic: spontaneous or forceps-assisted  Cephalic-noncephalic: vaginal delivery of the noncephalic twin can be done if the weight >1500g  VBAC: same risk of uterine rupture as in singleton pregnancy

CESAREAN SECTION  Breech, CS if:  Large fetus, and the aftercoming head is larger than the birth canal  Small fetus, the extremities and trunk may deliver through an inadequately effaced and dilated cervix, but the head may become trapped above the cervix  The umbilical cord prolapses

 In this study there was no significant difference in perinatal mortality and neontal mortality in both the CS group and planned vaginal group.

OPEN FORUM