MULTIPLE GESTATION

By Dr. HOTMA PARTOGI PASARIBU SpOG SUB DIVISION OF FETOMATERNAL MEDICAL FACULTY --USUUSU RSHAM ––RSPMRSPM MEDAN 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) -QdQuadrup lt(fbbi)lets (four babies)

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 Predisposing Factors

• Maternal age and parity • Maternal height and weight • Genetic and racial factors • PiPrior use of oral contracepti ve agents • Social class • Seasonality Causes of Multiple Gestation

• Spontaneously • In Vitro fertilization – Intrauterine insemination – Assisted Hatching – GIFT, ZIFT – Frozen Embryo Transfer, Blastocyte Embryo Transfer • Fertilityyg Drugs – Clomiphene citrate (clomid, serrophene) – Gonadotropins (GonalF, follistim, humagon) Twins

• Dizygotic twins • Monozygotic twin (()66% of US twins) (33% of US twins) – Dichorionic – separate Ova division: chorion (placenta) • < 72 hours: Dichorionic, diamniotic • 4-8 days: Monchorionic, – Diamniotic – separate diamniotic amnion (amniotic sac) • 8-13 days: Monochorionic, monoamniotic • > 13 days: conjoined twins Mono ovular-identical twins, diamniotik monokorionik EARLY DIAGNOSIS OF TWINS

DIZYGOTIC MONOZYGOTIC DIAGNOSIS OF MULTIFETAL PREGNANCY: SIMULTANEOUS VISUALIZATION

• twotwoormoreembryos or more embryos

•or corresppgyonding body parts of two or more fetuses EARLY DIAGNOSIS OF TWINS The first visible structures: 1 GESTATIONAL SAC 2 YOLK SACS ( MC //BABA )

YOLK SACS fused

2 GESTATIONAL SACS separated 2 YOLK SAC ( BC //BABA)

DIZYGOTIC MONOZYGOTIC EARLY DIAGNOSIS OF TWINS

EMBRYOS AND AMNIOTIC MEMBRANES

A firm diagnosis of the number of embryos after 7th week ! MONOCHORIONIC MONOAMNIOTIC TWINS HIGH-ORDER MULTIPLE PREGNANCY Pregnancy with three or more fetuses three chorionic

three amniotic FRONT BACK HIGH ORDER PREGNANCY

QUADRUPLETS MONOCHORIONIC BIAMNIOTIC TWINS

BICHORIONIC BIAMNIOTIC TWINS BICHORIONIC BIAMNIOTIC TWINS

LAMBDA SIGN THE Y-SHAPED JUN CTI ON

“MERCEDES” SIGN

Y-SIGN TRICHORIONIC TRIAMNIOTIC TRIPLETS Ultrasonoggfrafi kehamilan kembar pada usia kehamilan 38-40 hari Conjoined Twins

• Craniopagus • Parapagus •Pygo pa gus •Ischoppgagus • Thoracopagus • Omphalopagus •Cepppghalopagus • Parasitic twins • Epholothoracopagus • Fetus in fetu PATTERNS OF PHYSICAL JOINING

SYMMETRICAL COMPLETE FORM

Two fetuses share a certain amount of tissue

Surgical separation is possible in general. PATTERNS OF PHYSICAL JOINING

SYMMETRICAL INCOMPLETE FORM

Surgical separation is usually impossible VANISHING TWIN • in 20% of twintwinss

• single fetal demise • highhigh--riskrisk surviving twin • intrauterine hematomas • better prognosis in dichorionic • thromboplastine embolisation Fetus Papyraceous, salah satu fetus yang tidak berkembang Conjoined Twins (paraphagus) Days in NICU

• GA 23-25 weeks 100-125 • GA 25-27 weeks 80-100 • GA 28-29 weeks (quads) 55-75 • GA 30-31 weeks 25-45 • GA 32-33 weeks (triplets) 15-35 • GA 34-35 weeks (twins) 10-25 • GA 36-40 weeks 1-10 Average age of gestation

Number of babies Weeks of Gestation 1 40 weeks

2 35 1/2 weeks

3 33 weeks

4 29 ½ weeks Peripartum Complications

• Prematurity-major cause of neonatal death 50% of twins 90% of triplets and higher •Spontaneous abortion • Increased anomalies • Cord Prolapse • IUGR, discord ant growth • Intracranial Hemorrhage • Locked Twins Description: Twins lock heads 1st twin breech, 2nd twin vertex Problems of Prematurity

•HMD/BPD • Bradycardia • Pneumothorax • Anemia • Apnea • Hyperbilirubinemia •ICH •NEC • CP • MtblidiMetabolic disord ers • Blindness/Retinopathy • Hypothermia • LBW • HIE •PDA • Hypotonia •Hypertension/Hyp otension • Infections Neonatal Management (Multiple Gestation) • Team for each fetus • Examine for prematurity and IUGR • Examine for congenital anomalies • DiDetermine zygos ity, exami ilne placenta • Assess family support In ICN

•RDS •NEC

• Apnea/Asphyxia • Head Sono +

• Hct and BP • Glucose

• Wt difference • Blood typing Second Twin Risks

• Asphyxia due to premature separation of placenta •Fetus pppyapyraceous -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 anak pertama lintang atau sungsang dan anak kedua memanjang (terjadi posisi saling mengunci iitelocig)nterlocking) Monozygotic twins (physical characteristics) • Same sex • Features alike,,g 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 Twin-Twin Transfusion Syndrome

• Monozygotic twins share one placenta •1 ppylacenta causes one baby to receive more blood. • One baby (donor) smaller and other larger. • Larggyer baby: excess urine, ,pyy polyhydramnios. • Donor stops producing urine, oligohydramnios. • This can lead to pre -term delivery (24 (~24 weeks). TWIN TO TWIN TRANSFUSION SYNDROME •5% - 20% monochorionic twins •arterio venous anastomoses •discordant growth DONOR RECIPIENT OLIGOHYDRAMNIOS POLYHYDRAMNIOS IUGR MACROSOMIA, HYDROPS MICROCARDIA CARDIOMEGALIA ANEMIA POLYCYTHAEMIA fetal loss 80% TTTS VASCULAR ANASTOMOSES IN A TWIN PLACENTA: superficial

deep ARTERIO VENOUS ARTERIO ARTERIOUS VENO VENOUS TWIN TO TWIN TRANSFUSION SYNDROME

POLYHYDRAMNIOS OF RECIPIENT TWIN fixed twin DONOR: anhdhydramn ios Stuck tw in

collapsed amniotic membrane

SURFACE ANASTOMOSES

VISUALIZATION WITH POWER ANGIO MODE TWIN TO TWIN TRANSFUSION SYNDROME Kembar discordant: janin resepient lebih besar dari pada janin donor abnormalitas arteriovenous tampak pada permukaan plasenta, darah arteri kaya O2 donor bercampur dengan darah resepient Prevention (Multiple Gestation) • Monitor treatment with fertility drugs

• Limit embryos transferred during IVF

• Counseling risks and long-term sequelae

• Fetal reduction if not against religion