1. Dr shakeri Amir hospital
Multiple gestation
Dr shakeri
Amir hospital

2. one of the most common high- risk condition
3% of all live birth
Triplets occurred 1in every 500 deliveries

3. Multiples result in
-17% PTL /23% early PTL(less than 32w)
-24%LBW /26% VLBW
-16% neonatal deaths
-the risk of dying before the first year
. 5 times greater for twins
. triples are at 17-fold greater risk

4. Increased risk of long term mental and physical handicaps
C.p 12 times more
When matched for G.A and birth weight multiples have threefold greater risk of C.P
Increased risk of growth restriction
Rmrm mental and physical

5. Higher rates of congenital anomaly
twin to twin transfusion
monoamnionicity
cord prolaps
PA,PP
intrapartum asphyxia
birth truma

6. Higher health care cost
NICU admission is required by one fourth of twins ,three fourths of triplets and all quadruplets
Six times more hospitalized with an antepartum complications(PTL-PROM-preeclampsia)

7. Epidemiology and zygosity
Monozygotic(MZ) twins
both fetuses arise from single fertilized ova
Dizygotic(DZ) twins
multiple ovulation with fertilization by separate sperm

9. Monozygotic twins Random event
Independent to age ,race ,parity or heredity
Incidence is 3 to 4 per 1000 live births
Increased frequency with ART

10. Dizigotic twins Incidence is extremely variable
The incidence are affected by personal or family history
The chance of second DZ twins is increased twofold
In first-degree relative with twins the risk is increased
Fathers family contributes little or nothing to the hereditary risk

11. more frequent among older women
Peaking in the mid thirties
Majority of Increase has been result with ART and induction ovulation
Maternal race affected the frequency
-7to10 /1000 live births among whites
-10 to 40 /1000 live births among african
-3 /1000 live births among asians
-in white women the risk are more than twice of black women ,which reflects a greater use of ART

12. Increased maternal pariaty
Higher BMI
Recent discontinuation of OCP
Are also associated with higher
rates of DZ twinning

13. placentation
The placentation of DZ will always be diamniotic,dichorionic
Two complete placental units are produced
Separating membrane consist of four layers
Chorion begin to differentiate about day 3
Amnion begins to differentiate by about day8

15. If division occurs in first 3 days , two complete placental units will be formed
If division occurs between days 3and8 ,the placentation will be a single chorion and two amnions
If division occurs between days 8and 13,the twins will share a single amnion and chorion
Division after day13 ,producing conjoined twins

18. Examination of the placenta and dividing membrane are critical to determinated zygosity
Obstetrician can determine zygosity in delivery room in over 50%
Among MZ twins
18% to 36% diamniotic,dichorionic
1%monoamniotic,monochorionic
60%t070%diamniotic,monochorionic

19. Prenatal diagnosis
The risk of aneuploidy is related to zygosity and the mode of conception
In DZ twins ,each fetus has an independent risk for aneuploidy
Like singletons is related to maternal age
33% of naturally occur twins will be MZ and 67%will be DZ
Zygosity can be determined definitely by genetic analysis
But it can be diagnosed by determination of chorionicity and fetal sex

20. First-trimester screening is similar to singleton pregnancy
Second-trimester screening in twins ,although with a decreased sensitivity and higher false positive rate

21. An attractive situation is first-trimester NT measurement
In dichorionic pregnancy ,the sensitivity and SPR(screen positive rate) of NT plus maternal age was similar singletons
In monochorionic pregnancies ,the SPR of NT was higher than singletons
This difference may be an early manifestation of TTTS

22. Maternal complications

23. Cardiovascular risks
Significant expansion of the plasma volume and COP
Increased cardiac demand is well tolerated in the absence of underlying cardiac disease such as MS
Tocolytic therapy have been associated
pulmonary edema
myocardial ischemia
lethal tachyarrhythmia
postpartum cardiomyopathy

24. Hematologic abnormalities
Physiologic hemodilution
Average Hgb is 10 g/dl at20 w
Hgb below11g/dl in first or third trimester represents iron deficiency anemia
Complicated 21%to36% of multiple gestations
Heme-rich animal protein+60mg//day elemental iron+1mg/day folic acid g/

25. Metabolic disorders Lower fasting and postprandial G level
Exaggerated insulin responses to eating
More rapid depletion of glycogen stores and lipid metabolism between meals and during an overnight fast
Increased risk of gestational diabetes two to threefold
B-adrenergic agents and C.S can induce insulin resistance and hyperglycemia

26. preeclampsia
7% in singletons,14% in twins,21%for triplets and 40% for quadruplets
Frequently occurs earlier, sever and atypical
HT is not always the presenting sign
Proteinuria is not universally present
The most common presentation among higher-order multiples was HELLP
Les was

27. PLACENTAL ABRUPTION Threefold increased risk of abruption
Occurs most frequently in the third trimester
Significant risk immediately after vaginal delivery of the first infant

28. Hydramnios Occurs in 2%to 3% of twins
Twins account for 8% to 10% of all cases of hydramnios
May develop as a consequence of TTTS
Idiopathic acute hydramnios with maternal respiratory distress has been reported

29. Urinary tract infection
1.4-fold increased risk of UTI
Usually involve the lower urinary tract
To be a consequence of urinary stasis
The incidence of pyelonephritis is not significantly increased

30. Postpartum hemorrhage
Increased risk of
.Uterine atony retention of placental tissue surgical or mechanical trauma to genital tract pharmacologic effects of medications such as mgso4

31. -cholestatic jaundice
Increased risk of
-cholestatic jaundice
-pruritic urticarial plaques and papules of pregnancy (PUPP)
-hyperemesis
-deep venous thrombosis ,varicose vein
-shortness of breath, loss of balance edema ,constipation and hemorrhoids in

32. Vanishing twin syndrome
Spontaneous abortion or reabsorption of at least one of the multiples
Is most common in the first trimester
Occurred in 20-50% of multiples
When silent reabsorption occurs in first trimester ,the prognosis for surviving twin is excellent

33. Fetal death in utero (acute intertwin transfusion syn)
After the first trimester, single fetal demise occures in 2-5% of twins and 10-15% of triplets
The risk is increased 3 to 4 fold by monochorionicity
Antenatal demise of a monochorionic twin is associated with 25% mortality rate
In dichorionic gestation the risk is minimal although higher rates of PTL and PPROM

34. Injury to the surviving twin was result of DIC and embolism through placental anastomosis
An acute transfusion into the death fetus through the shared placenta
May cause severe fetal hypotension and hypoxic end organ damage
Demise or neurologic injury in have occurred in third trimester

35. Following fetal demise ,management will depend on GA ,chorionicity and maternal and fetal status
In dichorionic twin ,no intervention is requied
Fetal demise In monochorionic twin is an indication for immediate delivery if fetal maturity or near maturity can be inferred

36. Monoamniotic twins Fewer than 1% of MZ Fetal mortality rate 40%
Cord entanglement is present in every cases
At greater risk of congenital anomaly such as conjoining and TTTS
Fetal demise occurred after 32 w

37. Management recommendation for monoamniotic twins
Confirm monoamniocity
Sono at 18 to 20w to exclude congenital anomalies and conjoining
Parental education
Serial sono for assessment of fetal growth
Daily fetal kick counts (26W)
NST three times per week (26w)
Antenatal C.S administration

38. Amniocentesis for lung maturity at 32 w
elective delivery at 34 to 35w if lung maturity not previously confirmed
C/S usually recommended
If vaginal delivery is planned ,continuous fetal monitoring is essential

39. Discordant twin growth
Ultrasound is useful for detection
15-30% of twins exhibit birth weight differences of 20%
When discordance is excessive >20-25%,the smaller infant may be at risk for perinatal mortality and morbidity and disadvantages in long term physical and intellectual development

40. In monochorionic twins ,discordance is more frequent , sever and more likely to be associated with TTTS
Birth weight discordance and IUGR are interrelated
Prematurity and IUGR are mush greater threats than the degree of discordancy
Major cause of growth discordance
- genetic dissimilarity
-local placental implantation factors

41. The sensitivity of sonography for diagnosis discordance is only 60%
In evidence of 20-25% growth discordance or IUGR of either twin at ≥35w delivery is indicated

42. Twin-to-twin transfusion syn
TTTS is a serious complication affecting MZ/MC twins
Vascular communications are present in all monochorionic placentas but 1/3 of them have this syn
Sever TTTS identified in the second trimester is associated with loss rates 100% if untreated

43. The arterial donor twin may be growth retarded ,anemic ,hypotensive and oligohydramniotic
If there is little or no amniotic fluid , the amniotic membrane may lie in close apposition to the smaller fetus , restricting it to the uterine wall(stuck twin)
The venous recipient twin can become hypervolemic ,hyperviscous,hypertensive
and polyhydramniotic

44. Polyhydramnios contributes to a high incidence of premature labor or PPROM
Either twin may become hydropic
The diagnosis of TTTS has become controversial but now is diagnosed by using sonographic criteria including

46. Sonographic criteria of TTTS
Marked size disparity in fetuses of the same sex
Disparity in size between two sacs
Disparity in size of the umbilical cords
Single placenta
Evidence of hydrops
CHF in the recipient

47. Doppler may help to improve diagnostic accuracy and fetal well-being
Quintero have defined TTTS as a deepest vertical pocket≤2cm in the donor with a deepest vertical pocket ≥8cm in the recipient
Management depending on the Quintero stage and GA
Delivery will depend on fetal maturity

48. Quintero staging criteria for TTTS
Stage1: bladder of donor still visible
Stage2: bladder of donor no longer visible
Stage3: critically abnormal doppler stadies
Stage4: hydrops in one or both twins
Stage5: demise of one or both twins

49. Management of TTTS
At earlier GA ,serial decompression amniocentesis and tocolytic therapy have been successful in prolonging pregnancy
Fetoscopy and direct laser occlusion of the placental vascular anomaly has become an option

50. Fetal and newborn complications
Prematurity
IUGR
Congenital anomalies

51. prematurity Risk increases with the number of fetuses
Incidence of PTL IS 30-55% for twins,66-80% for trplets and 100% for quadruplets
Mean GA at delivery is related to fetal number: 39w for singletons-35 to 36w for twins-32 to 33w for triplets

52. IUGR Is more common in multiple gestations
In twins growth velocities similar to singletons until 30 to 32w
Triplet and quadruplet growth velocity begin to slow at 27to 28 and 25 to 26w
1/3 of twins will demonstrate IUGR at w
IUGR in multiples is asymmetric

53. Cause of IUGR relative placental insufficiency abnormal placental implantation umbilical cold abnormalities velamentous or marginal insertions structural or Ch abnormalities TTTS
IUGR is three times more common in twins

54. AF of larger twin should be sampled
After 20w, fetal growth should be evaluated by sonogrphy on a monthly basis
The diagnosis of IUGR should lead to the institution of antenatal fetal surveillance inclusive of NST, BPP, assessment of Af and umbilical artery doppler velocimetry
If amniocentesis is used to assess lung maturity( single sampling necessary)
AF of larger twin should be sampled
dentifi

55. Congenital anomalies Occur twice in multiples
more common in MZ than DZ
The best time for evaluation of fetal anatomy by ultrasound is 18-22w
Sensitivity 88%
Specificity 100%

56. Maternal nutrition
Placental transfer of an adequate nutrient supply is compromised after a combined fetal weight of 3000g is exceeded
In multiples , environmental factors such as nutrition adequacy has a greater influence on fetal growth than in singletons
Maternal weight gains of 24lb by 24w and overall 40 to 50lb are associated with optimal pregnancy outcome defined as twin birth weight >2500g

57. The importance of adequate early weight gain <24W
Poor weight gain prior to 24w has been associated with IUGR and higher perinatal mortality
Weight gain recommendation for twins based on the BMI such as singletons
Recommendation daily calories in twins is 3000 to 4000 kcal per day(20%protein -40%crbohydrates - 40%fat)

58. maternal anemia from iron and folate deficiency are common in multiples
supplemention of prenatal vit + iron 60 mg/day +folic acid 1 mg/day has been recommended
Heme –iron rich sources such as red meat , poultry, fish and eggs are emphasized
Calcium ,magnesium, zinc and their supplementation have recommended

59. ultrasound Plays numerous critical roles in multiples
Diagnosis and presentation
Determination of amnionicity and
chorionicity
Diagnosis of fetal or placental anomaly
Fetal growth and Af volume
Fetal biophysical parameters

60. A thin wispy membrane with a single placenta and same sex fetuses suggest monochorionicity
Thick dividing membrane, twin peak or lambda sign indicated diamniotic dichorionic intertwin membrane
Accuracy is more than 80-90%
The determination is most accurate in the first trimester

62. Multifetal pregnancy reduction
GA and birth weight at term are the two most important factors in perinatal morbidity and mortality
The technique is the transabdominal ,ultrasound-guided fetal intracardiac injection of kcl
Pregnancy loss rate prior to 24w dropped from 15-20% to 5-8%

63. MF.P.R of triplet and higher-order multiple gestations is associated with longer gestations ,higher birth weight , lower rates of perinatal mortality,NICU admission ,maternal antenatal hospitalization and C/S birth
Incidence of PIH ,gestational diabetes and other complications are not changed
Should be included in the counseling of all women with triplets and higher multiples

64. Corticosteroid administration
Recommended to women with
- PTL prior to 34w
- PPROM at <30-32w regardless of plurality
Recommended only a single course

65. Fetal surveillance
Recommended in all situations for singleton pregnancy
NST and BPP
CST is relatively contraindicated
Initiated at 32w in monochorionic twins and at 34w in dichorionic twins
Performed on a weekly basis
In IUGR, abnormal doppler and monoamnionicity performed twice weekly or more frequent

66. Controversial interventions
Serial digital cervical examination
Transvaginal ultrasound cervical length measurements
Ultrasound indicated cerclage
Cervical and vaginal fetal fibronectin
Reduce activities and rest
Home uterine activity monitoring
Tocolytic therapy

67. Serial digital cervical examination
Cervical score is calculated as follows: cervical length minus cervical dilation
CS ≤0 predicted PTL within 14 days
CS greater than 0 are good candidates for continued observation
Should be done every 1-2 w basis between 22 and 35w
Is not associated with obstetric complications

68. Transvaginal ultrasound cervical length measurements
≤25 mm at 24w was the best predictor of PTL in twins
≤15mm at a previable gestation have remarkably poor outcome
Cerclage for short cervix may be harmful in multiples

69. Cervical and vaginal fFN
In the late second and early third trimester is associated with an increased risk of PTL in multiples
Negative fFN is associated with <3% risk of delivery in the next 2 weeks

70. Reduced activities and rest
Has been associated with:
reduced baseline uterine contraction
pregnancy prolongation
increased birth weights

71. Home uterine activity monitoring
The benefits of HUAM in twins remain controversial
There are no prospective data addressing the use of HUAM in triplets

72. Tocolytic therapy
Tocolytic therapy provide a short-term prolongation of pregnancy
Prolongation of 1 week in <32w will be associated with significant reduction in neonatal mortality and morbidity
The use of B-adrenergic agents is associated with increased pulmonary edema ,glucose level ,myocardial ischemia and cardiac arrhythmias

73. Mgso4 is most often used as tocolytic agents
When necessary ,the use of indomethacin in patients< 32w as an adjunct to Mgso4 or as a second line agent indicated To allow for an initial 48h to administrated C.S
Oral nifedipine 10-20mg/6h
Oral or subcutaneous terbutaline sulfate

74. Antepartum management protocol
16-22w(routine visits q2w) ║
routine baseline TVCL (18-20w)
TVCL <15mm consider cerclage especially if HX of prior PTL<32w

75. 22-26 weeks gestation
Routine visit q2w if TVCL >25mm , but q1w if TVCL ≤25mm
TVCL <15mm at≤24w→cerclage or
hospitalized bedrest
TVCL15-25mm or positive fFN or CS≤0
discontinue work and activity/home
bed rest/no intercourse/HUAM
TVCL26-35mm or CS=+1
stop work and modified bed rest
TVCL>35mm or negative Ffn or CS>+1
reassuring

76. 26-35 weeks gestation Routine visits q2w if risk assessment neg
Visit q1w if TVCL<30/+Ffn/CS≤+1
TVCL>35 or neg Ffn or CS>+1/reassuring
TVCL≤35mm,positive fFN,CS≤0
Antenatal corticosteroids
Home bed rest
HUAM
Tocolytic therapy if contractions present
Enhanced nutrition

77. Preterm birth risk assessment
Weekly digital exam
Evaluate symptomatic patient with
TVCL /fFN /urine culture / office UAM
cervical /vaginal wet prep and cultures
if symptomatic discharge

78. Nonbeneficial interventions
Prophylactic cerclage
Prophylactic tocolysis
Routine hospitalization
Prophylactic treatment with 17-OHPC did not reduce the rate of PTL in twins

79. Intrapartum management
Skilled obstetric attendants for labor and delivery
Nursing and neonatal care personnel
Dual-monitoring cardiotocograph
ultrasound scanning capability
Intravenous access(16-18 gauge)
Oxytocin infusion
Nitroglycerin or terbutaline for uterin relaxation

80. Methergine or 15-methyl PGF2a available to treat PPH
Obstetric forceps (piper) and vacuum extractor available
Immediate availability of blood and blood products
Anesthesiologist available at delivery and capability for emergency C/S

81. Timing of delivery The ideal time for delivery is uncertain
The lowest fetal death rate in singleton was 40-41w/ in twins was 36-37w/ in triplets was 34-35w
Significant discordance ,preeclampsia ,oligohydramnios ,IUGR or any other significant maternal-fetal complication after36w with twins or after34w with triplets is indication of delivery

82. data do not support prolongation of a twin or triplet pregnancy beyond 38 or 36 weeks, respectively ,due to the increased fetal and neonatal mortality and morbidity associated with high rates of IUGR

83. Route of delivery Determined on presentation
For twins is generally categorized into three groups
Twin A vertex, twin B vertex
Twin A vertex, twin B nonvertex
Twin A nonvertex

84. Twin A vertex/ Twin B vertex
40% of twin gestations
More than 80% are successfully delivered vaginally
Presentation of second twin should be confirmed following delivery of the first
Change the presentation may occur in 10-20%
If twin B IS larger than A ,safe and successful vaginal delivery is still possible

85. Twin A vertex / Twin B nonvertex
40% of twins in labor
Vaginal delivery of nonvertex second twin by breech extraction appears to be the best approach for infants >1500g /external cervical version is another choice
If the second twin was larger(>500g) than the first ,C/S IS indicated
Decision on C/S for second twins <1500g should be based on the specific clinical situation and the experience of the operator

87. Twin A Nonvertex 20% of cases
Vaginal delivery of these twins is problematic and C/S is indicated
For twins presenting breech/vertex ,the possibility of interlock exists
It is extremely rare but catastrophic
Another complication of twin A is cervical hyperextention
Vaginal delivery is based on the experience of staff and capability for emergency C/S

88. Triplets and higher-order multiples
c/s is recommended
If vaginal delivery is planned ,an experienced obstetric team and capability for emergency C/S is necessary + estimated of weight more than 1500g + at least the first two triplets in a vertex presentation

89. Interval between deliveries
Delayed of more than 1 h have not associated with adverse outcomes for second twin , if continuous FHR monitoring is employed
Internal podalic version and breech extraction only when emergency delivery is mandated and C/S is not immediately available

90. After delivery of the first twin , a period of hypocontractility is happened
If labor has not resumed within the short time ,oxytocin infusion can be started
If the vertex is dipping into the inlet , amniotomy can be performed during contraction with moderate fundal pressure

91. Delayed interval delivery
If extremely preterm and previable birth occurs in twins ,occasionally D.I.D is indicated
This situation occurs in diamniotic, dichorionic twin gestation
CI include :
significant hemorrhage ,hemodynamic instability , intraamniotic infection and monochorionic placentation

92. Following delivery of first, the umbilical cord is tied, cut short and allowed to retract back into the uterus
Cerclage appears to offer a better chance
Aggressive use of perioperative tocolysis and broad –spectrum antibiotic is recommended in most protocols

93. Many clinicians prefer indomethacin for prophylactic tocolysis
Specific pathogens such as gonorrhea, chlamydia and group B streptococci should be identified and treated

94. Tocolytic therapy, antibiotic coverage and hospitalized observation are continued to the third trimester and occasionally to term

95. Postpartum management
Increased risk of uterine atony and PPH
Mather should be monitored during the initial hours after delivery
Lactation consultation may be useful
Follow –up and support for the mother in the early weeks after delivery are important
Postpartum depression is more common