1. MULTIPLE GESTATION By Sridevi Abboy, MD

2. 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)

3. 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

4. Predisposing Factors Maternal age and parity Maternal height and weight Genetic and racial factors Prior use of oral contraceptive agents Social class Seasonality

5. 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)

6. 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

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

8. Conjoined Twins (paraphagus) http://www.conjoined-twins.i-p.com

9. Multiple Birth Stats (2000) Number of live multiple births in 2000: 119,648 Number of twin births: 118,916 Number of triplet births: 6,742 Number of quad births: 506 Number of quintuplets and higher birth: 77 http://www.cdc.gov/nchs/fastats/multiple.htm

10. Cost per infant Infants born 39-42 weeks $9,803 Infants born 25-27 weeks$280,146 Twins born 25-27 weeks$560,292 Triplets born 25-27 weeks$840,438 Quads born 25-27 weeks $1,120,584 http://www.multiplebirth.com/New_Folder/Articles/MultgestEpidemCauseConsequesnces.doc

11. Days in NICU GA 23-25 weeks100-125 GA 25-27 weeks80-100 GA 28-29 weeks (quads)55-75 GA 30-31 weeks25-45 GA 32-33 weeks (triplets)15-35 GA 34-35 weeks (twins)10-25 GA 36-40 weeks1-10 http://www.metrohealth.org/clinical/NICU/2000.htm

12. Average age of gestation Number of babies Weeks of Gestation 140 weeks 235 1/2 weeks 333 weeks 429 ½ weeks http://www.bestdoctors.com/en/conditions/g/gestation/gestation_100200.htm

13. Handicap Rates (per 1000 post-natal survivors) Overall Severe Moderate Singletons 90.619.8 70.8 Twins 125.633.7 92.0 Triplets 178.157.1121.0 http://www.multiplebirth.com/New_Folder/Articles/MultgestEpidemCauseConsequesnces.doc

14. Cerebral Palsy SingletonTwin Triplet standardized standardized standardized Per 1000 live births1 4.6 16.6 Per 1000 1 st year survivors1 4.6 17.4 Per 1000 pregnancies1 8.3 47 http://www.multiplebirth.com/New_Folder/Articles/MultgestEpidemCauseConsequesnces.doc

15. Mortality Rates (per 1000 live births) Infant Neonatal Postnatal (birth to 1 year) (birth to day 28) (day 29 to 1 year) Singletons11.27.83.4 Twins66.455.910.5 Triplets190.4168.821.6 calculated from the vital statistics of the US, 1998 http://www.multiplebirth.com/New_Folder/Articles/MultgestEpidemCauseConsequesnces.doc

16. Mean birth weight SingletonsTwins Triplets Mean BW(gm) 33572389 1735 % <1500gm 1.110.12 31.88 % <2500 gm 6.0652.24 91.52 % SGA 9.3835.63 36.57 http://www.multiplebirth.com/New_Folder/Articles/MultgestEpidemCauseConsequesnces.doc

17. 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

18. Prematurity SingletonsTwins Triplets %<33 weeks 1.714 41.25 %<37 weeks9.450.7 91.03 http://www.multiplebirth.com/New_Folder/Articles/MultgestEpidemCauseConsequesnces.doc

19. 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

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

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

22. 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

23. 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

24. 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).

25. TTTS http://www.tttsfoundation.org/chart1.htm

26. Prevention (Multiple Gestation) Moniter treatment with fertility drugs Limit embryos transferred during IVF Counseling risks and long-term sequelae Fetal reduction if not against religion