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Etiology,Management and Delivery of Twins

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Etiology,Management and Delivery of Twins Etiology, management and delivery of twins Dora Melicher MA, MD, PhD Department of Obstetrics and Gynaecology 06/12/2019 Department of Obstetrics and Gynaecology Definition and Classification A multiple pregnancy is a pregnancy in which more than one fetus develops in the uterus at the same time (heterotopic pregnancy: one fetus in utero, the other is extrauterine) Classification Ä number of fetuses: Ê Twins, triplets, quadruplets, etc. Ä number of fertilized eggs: zygosity Ê monozygotic, dizygotic Ä number of placentae: chorionicity Ê monochorion, dichorion Ä number of amniotic cavities: amnionicity Ê monoamnion, diamnion Etiology, management and delivery twins Dora Melicher MA,MD,PhD Classification Etiology, management and delivery twins Dora Melicher MA,MD,PhD Umstad MP, Calais-Ferreira L, Scurrah KJ, Hall JG, Craig JM. (2019) Twins and Twinning. Emery and Rimoin’s Principles and Practice of Medical Genetics and Genomics: Foundations, Chapter 14:387-414. 28 pages. https://doi.org/10.1016/B978-0-12-812537-3.00014-7 Process of Monozygotic Twinning During Postfertilization Etiology, management and delivery twins Dora Melicher MA,MD,PhD Umstad MP, Calais-Ferreira L, Scurrah KJ, Hall JG, Craig JM. (2019) Twins and Twinning. Emery and Rimoin’s Principles and Practice of Medical Genetics and Genomics: Foundations, Chapter 14:387-414. 28 pages. https://doi.org/10.1016/B978-0-12-812537-3.00014-7 Incidence Ä Hellin’s Law: 1:85[n-1] ÊTwins: 1:85 ÊTriplets: 1:852 ÊQuadriplets: 1:853 , etc. Ê This rule applies only to spontaneously conceived multiple pregnancies ¦(drug-induced ovulation or assisted reproductive technology are not involved) Etiology, management and delivery twins Dora Melicher MA,MD,PhD Etiology of multiple pregnancies Ä Dizygotic or fraternal twins: Ê fertilization of two separate oocytes Ê gender: 50% same-sex, 50% different sex Ê etiology and prevalence varies (race, hereditary differences) Ê increasing prevalence (maternal age, infertility therapy) Ä Identical or identical twins: Ê single fertilized oocyte splits in two Ê genetically almost 100% identical fetuses Ê same-sex (including HLA genes) Ê frequency is constant in all races (prevalence 1/250) Etiology, management and delivery twins Dora Melicher MA,MD,PhD Factors that influence the incidence of multiple pregnancies Ä maternal age (>35 years, <18 years) Ä maternal parity Ä genetic factors Ä race/geographic area (Afro-American >> White> Asian) Ê naturally conceived dizygotic twins accounted for 1.3/1000 births in Japan, 8/1000 births in the US and Europe, and 50/1000 births in Nigeria* Ä maternal weight and height Ê obese (body mass index [BMI] ≥30 kg/m2) and tall (≥65 inches [164 cm]) Ä family history Ä endogenous FSH, GnRH level Ä use of fertility stimulating drugs Ê IVF, ovulation induction, superovulation plus intrauterine insemination Etiology, management and delivery twins Dora Melicher MA,MD,PhD Fertil Steril. 2012;97(4):825. Twin and multiple births statistics Ä Twin births account for ∼ 3% of live births and 97% of multiple births in the United States Ä Growth in the United States over the past 25 years Ê twin births increased from 1/53 infants in 1980 to 1/29 infants in 2014 Ê The number of twin pregnancies increased by 76 percent from 1980 through 2009 and stabilized with a birth rate of 33.7 per 1000 births in 2013* Ê The number of live-born twins rose nearly 50%, the number of live-born multiples more than 400% Ê Over one-third of all twin infants born can be attributed to iatrogenic interventions ¦(in vitro fertilization, ovulation induction, superovulation plus intrauterine insemination) Etiology, management and delivery twins Dora Melicher MA,MD,PhD *Natl Vital Stat Rep. 2015 Jan;64(1):1-65. www.update.com. The risk of multiple pregnancies Ä High rate of preterm delivery: Ê less chance of survival Ê Increases risk of life-long disability Ä Twins account for Ê 17% of all preterm deliveries Ê 24% of low birth-weight infants (<2500 g) Ê 26% of very-low-birth-weight infants (<1500 g) Ä fetal malformation (double-frequent) Ä specific diseases Ä Women with twin pregnancy are 6 times more likely to be hospitalized with complications Etiology, management and delivery twins Dora Melicher MA,MD,PhD ACOG practice bulletin. Clinical management guidelines for Obstetrician–Gynecologists. Number 56, 2004 Comparative outcomes of singleton, twin, and triplet pregnancy Etiology, management and delivery twins Dora Melicher MA,MD,PhD Martin JA, Hamilton BE, Sutton PD, et al. Births: final data for 2006. Natl Vital Stat Rep 2009; 57:1. Fetal complications Ä All twins: Ê growth restriction Ê congenital anomalies Ê preterm delivery Ä Monochorionic twins Ê Twin-twin transfusion syndrome (TTTS) Ê Twin anemia-polycythemia sequence (TAPS) Ê Twin reversed arterial perfusion sequence (TRAP) Ê Selective fetal growth restriction (sFGR) Ê Single fetal demise Ä Monoamniotic twins Ê Intertwin cord entanglement Ê Conjoined twins Etiology, management and delivery twins Dora Melicher MA,MD,PhD Assessment of zygosity and chorionicity Ä Monozygotic twins: DDD or MDD or MMD or MMM (DCDA, MCDA, MCMA) Ä Dizygotic twins: DDD or MDD (DCDA) Ä Monochorionic placenta: monozygotic Ä Different sex fetuses: dizygotic Ä Same-sex fetuses and dichorionic placenta: ?? Chorionicity is of high importance !! Ä Monochorionic twins: Ê 3-10-fold perinatal mortality Ê Specific diseases Etiology, management and delivery twins Dora Melicher MA,MD,PhD Lambda sign and T sign Ä Ultrasound (I. screening) Ê Measurements at the end of the first trimester (11-14 weeks): Etiology, management and delivery twins Dora Melicher MA,MD,PhD placenta placenta Decision tree of Zygosity Are the twins the same sex? Yes No Dizygotic How many chorions are present? Monozygotic 1 2 ? Do the twins have the same blood type? Yes ? No Dizygotic Are the zygosity test results identical? Monozygotic Yes Etiology, managementNo and delivery twins DizygoticDora Melicher MA,MD,PhD Histopathological examination after birth Dichorionic placenta No anastomoses! Etiology, management and delivery twins Dora Melicher MA,MD,PhD Courtesy of Professor Enrico Lopriore, Head of Neonatal Intensive Care Unit, Leiden University Medical Center, Start & Hart 2012, TWINS Madrid 2017 Histopathological examination after birth Monochorionic placenta always anastomoses! Start & Hart 2012 Etiology, management and delivery twins Dora Melicher MA,MD,PhD Courtesy of Professor Enrico Lopriore, Head of Neonatal Intensive Care Unit, Leiden University Medical Center, Start & Hart 2012, TWINS Madrid 2017 Complications – MC twins Ä Twin-twin transfusion syndrome (TTTS) Ä Twin anemia-polycythemia sequence (TAPS) Ä Twin reversed arterial perfusion sequence (TRAP) Ä Selective intrauterine growth restriction (sIUGR) Etiology, management and delivery twins Dora Melicher MA,MD,PhD Courtesy of Professor Enrico Lopriore, Head of Neonatal Intensive Care Unit, Leiden University Medical Center, Start & Hart 2012, TWINS Madrid 2017 Twin-to-Twin Transfusion Syndrome (TTTS) Ä Arteriovenous vascular connection in the placenta between the two fetal circulations Ä 5-15% of monochorionic twins are affected Ä Acute: in early pregnancy it can result in early fetal loss Ä Chronic: the blood flow through blood vessel anastomoses becomes unbalanced Ä The smaller twin (donor) does not get enough blood while the larger twin (recipient) becomes overloaded with too much blood. Ä If untreated: 60-100% mortality Etiology, management and delivery twins Dora Melicher MA,MD,PhD TTTS Ä Diagnosis: Ultrasound Ê monochorionic placenta Ê same-sex fetuses Ê weight discordance (no longer used) Ê amniotic fluid discordance with “stuck-twin” Ê Twin oligo - polyhydramnios sequence (TOPS) Ä Recipient: hydrops, heart failure Ä Donor: absent end-diastolic flow Etiology, management and deliverySource: twinstwintwintransFusionsyndrome.weebly.comDora Melicher/diagnosis MA,MD,PhD-of-ttts.html *Malone FD et al. ClinPerinatol 2000; 27: 1033-1046 Staging system in TTTS Ä Stage I.: donor bladder is visible Ä Stage II: donor bladder is no longer visible Ä Stage III.: abnormal Doppler findings: Ê (absent/backward-diastolic flow in the umbilical artery Ê donor: reverse flow in the ductus venosus, Ê recipient: pulsatile flow in the umbilical vein) Ä Stage IV.: ascites or hydrops in both twins Ä Stage V.: death of one or both twins Etiology, management and delivery twins Dora Melicher MA,MD,PhD Quintero RA et al. J Perinatol 1999; 19: 550-555 Treatment of TTTS Ä Conservative management: not recommended Ä Early (2nd trimester) Ê selective abortion Ê termination of the entire pregnancy Ê aggressive management: physical interventions ¦serial amniocentesis ¦septostomy ¦selective laser ablation Ä Mid- to late 3rd trimester Ê less aggressive treatment depending on the severity of the disease Etiology, management and delivery twins Dora Melicher MA,MD,PhD Reduction amniocentesis Septostomy (microseptostomy) Selective lase ablation Complications – MC twins Ä Twin anemia-polycythemia sequence (TAPS) Ê a variant of TTTS in which one twin is anemic and the other twin is polycythemic, but without amniotic fluid volume discordance. Etiology, management and delivery twins Dora Melicher MA,MD,PhD Courtesy of Professor Enrico Lopriore, Head of Neonatal Intensive Care Unit, Leiden University Medical Center, Start & Hart 2012, TWINS Madrid 2017 Complications – MC twins Ä Twin reversed arterial perfusion sequence (TRAP) Ê a rare complication of monochorionic twins in which a living twin perfuses a nonliving (acardiac) twin through patent
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