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EV, 33 YEAR OLD G2P1(0010), SINGLE Labor pains Chief Complaint (+) HPN, 2005 (+) goiter, Sept (-) PTB, BA, CA Past Medical History

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, 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 High Risk Primary antenatal condition (+) gestational Diabetes Mellitus Quickening 24 weeks AOG

PHYSICAL EXAM General Awake Coherent Stretcher -borne NICRD Vitals 170/110 HR 92 RR 44 T 36.0 Ht 155 cm Wt kg HEENT Pink conjunctiva e Anicteric sclerae (-) CLAD (-) TPC (-) ANM Lungs Equal chest expansion Clear breath sounds (-) rales, wheezes

PHYSICAL EXAM 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 uterin 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; gestational diabetes mellitus, chronic hypertension with superimposed preeclampsia, sublinical hypothyroidism, G2P1 (0010) Assessment Primary low segment cesarian section secondary to malpresentation of 2 nd twin Plan

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

ETIOLOGY OF MULTIFETAL GESTATION  Monozygotic – division of single fertilized ovum

FACTORS THAT INFLUENCE TWINNING  Race  6/1000 livebirths in Asia  E.g. 4.3/1000 in Japan, 11.3/1000 in India, 12.3/1000 in England, Wales  Heredity  Maternal history more important  Mother’s who themselves are twins gave birth to twins at a 1/58 live births  Maternal Age and Parity  Taller, heavier more nutritionally provided women, 25-30% inc in twinning rate  Pituitary Gonadotropin  Inc dizygotic twinning rate w/in 1 mo. of stopping oral contraceptives, associated with sudden surge in gonadotropin  Assisted Reproductive Technology  Responsible for 17% of multiple births in the US

MATERNAL PHYSIOLOGY  Cardiovascular  More hyperdynamic circulation than singleton pregnancy  Cardiac output increases by 20% more in twin gestation than in singleton  15% from stroke volume: due to increase in preload  3.5% from heart rate  GI and Hepatic Changes  Pregnancy nausea and vomiting 50%  Twice the risk for obstetric cholestasis  Twin pregnancy independent risk factor for acute fatty liver, 9-25% of all cases seen in twin pregnancies  Renal  No significant difference from singleton  Increased GFR, leads to decreased BUN, Crea and increased urine protein

MATERNAL PHYSIOLOGY  Respiratory  No significant difference  Increase use of accessory muscles  Exaggerated abdominal distention  Loss of abdominal tone  Hematologic  RBC mass increases by 25% in both single and multifetal gestations  Inc. in plasma volume is 10-20% greater in twin pregnancy vs singleton  Other changes associated with singleton pregnancy occur in the same way  Fall in Hct 1 st -2 nd trimester  Granulocytosis with increase in immature WBCs  Hypercoagulability due to changes in coagulation and fibrinolytic cascades

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  Not all spontaneous  Higher risk for male-male twins  Ave. length of pregnancy 35 wks for twins vs 39 wks for singletons  Gestational DM  May be increased in multifetal gestation though not universally confirmed  Treated the same way in twin pregnancies

MATERNAL COMPLICATIONS  Pregnancy HPN  Gestational HPN - RR 2.04 (95% CI )  Pre-eclampsia – RR 2.62 (95% CI ), w/ earlier onset, greater severity  Gestational HPN and preeclampsia also associated with higher preterm delivery rates  Gestational HPN, <37 wks 51.1% vs 5.9% singleton  Preeclampsia, <37 wks 66.7% vs 19.6% singleton  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  10 times more likely in multiple gestations compared to singletons  Growth Discordance  >=20% difference in EFW  5-15% of twins  Usu. birth weight difference of 15% for twins  34% chance of growth restriction in at least one twin for monochorionic twins, 23% for dichorionic twins  Associated with 6 fold increase in risk for perinatal morbidity and mortality  Congenital anomalies  Studies suggest 2-3x increased risk in twins, with probably 10% of twins born w/ congenital anomalies

FETAL COMPLICATIONS  Spontaneous Pregnancy Loss  Around 14% of twin gestations spontaneously convert to singleton pregnancies before the 1 st trimester – “Vanishing twin”  Remaining fetus a 3x inc risk for abortion  Est. that only 1/8 individuals conceived as a twin is born a twin  Intrauterine Fetal Demise  Overall survival rate of both twins is 93.7%  Death of one or both fetus at wks 5% vs 2% in singletons  Subsequent risk of miscarriage of surviving fetus 24%  Chorionicity important  Monochorionic twin – death of one fetus inc risk of death of the other of 25%  Dichorionic twin – 5-10% risk

FETAL COMPLICATIONS  Twin-to-Twin Transfusion Syndrome (TTTS)  Almost exclusively confined to monochorionic twins, with 10-15% of these having a severe form  Around ¼ of all monochorionic twins have some features of the syndrome  Due to the presence of intertwin anastomosis: A-A, V-V, A-V  A-V and A-A occur in 70% of monochorionic twins  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.  Diagnosed by presence of monochorionic twins with one oligohydramnios twin, other polyhydramnios twin  Most commonly treated with aggressive amniodrainage and laser photocoagulation of anastomoses  Survival rate of at least one twin with laser therapy higher (66%) vs amniodrainage (57%)  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 - death

DIAGNOSIS  Suggested by  Accelerated fundal growth  Multiple fetal parts  Auscultation of 2 FHTs  Sonography – the “sine qua non” of diagnosis  Chorionicity  Fetal viability/diagnosis of intrauterine death  Nuchal translucency thickness  Chromosomal abnormalities  Early TTTS diagnosis  Fetal structural abnormalities  IUGR, discordant growth  Fetal circulation  Placental localization, fetal position

DIAGNOSIS  Chorionicity  Important – highest rate of death in twins occurs before 24 wks, most often due to TTTS  Chorionicity easier to determine at early gestation  What to look for  Separate placentas – diagnostic but usu. difficult  Intertwin membrane – from 2 amnions, 2 chorions, >2mm in dichorionic twins  Extraembryonic coelimic space – 2 in dichorionic  Yolk sacs – 2 in dichorionic  Fetal sexes  Lambda/twin peak sign – diagnostic of dichorionic twins; triangular chorionic tissue from fused dichorionic placenta extending into the intertwin membrane

LABOR MANAGEMENT & DELIVERY  The cornerstone of antepartum care is prevention of preterm labor and delivery  Main cause of high perinatal mortality and complications in twins  Labor and Delivery Problems  Hypotonic uterine inertia  Due to overdistended uterus  Oxytocin just as effective as in single births, dosage, time to delivery, complications same  Intrapartum bleeding  More common in twins due to abruptio or vasa previa

LABOR MANAGEMENT & DELIVERY  Route of Delivery  Vaginal delivery for mature vertex-vertex twins and <1500g vertex-vertex twins – same outcome as CS  CS indications for singleton pregnancy still apply  If the 1 st twin is transverse or breech, CS in favored  Avoid “locked-twins” complication  CS for non-vertex second twin  No improvement in fetal outcome  Inc. maternal febrile morbidity  Best delivered by assisted breech delivery or breech extraction

LABOR AND DELIVERY  Presentation and Position  Most common combination is cephalic-cephalic, cephalic-breech, and cephalic- transverse  Presentations other than cephalic-cephalic are unstable

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 differencein perinatal mortality and neontala mortality in both the CS group and planned vaginal group.