1
Q
Def of Multifetal Pregnancy
A
Pregnancy that results in > 1 fetus.
2
Q
Incidence of Multifetal Pregnancy
A
3
Q
Types of Multifetal Pregnancy
A
- Monozygotic Twins
- Dizygotic Twins
4
Q
Percentage of Monozygotic Twins
A
33%
5
Q
Synonyms of Monozygotic Twins
A
Uniovular twins, identical twins or
homologous twins
6
Q
Incidence of Monozygotic Twins
A
1/250 of deliveries
7
Q
Mechanism of Monozygotic Twins
A
8
Q
RF for Monozygotic Twins
A
Not related to risk factors
9
Q
Characters of Monozygotic Twins
A
They are similar in sex, morphological features, psychological & mental profile & HLA typing
- Differ in finger prints, iris pattern & voice
10
Q
Percentage of Dizygotic Twins
A
67%
11
Q
Synonyms of Dizygotic Twins
A
Binovular twins, non-identical twins or
heterologous twins
12
Q
Incidence of Dizygotic Twins
A
Varies according to risk factors
13
Q
Mechanism of Dizygotic Twins
A
14
Q
RF for Dizygotic Twins
A
Related to certain risk factors
15
Q
Characters of Dizygotic Twins
A
Sex & morphological features are as
any sisters or brothers
16
Q
Determination of zygosity
A
17
Q
RF for Dizygotic Twins
A
18
Q
Complications of Multifetal Pregnancy
A
- Maternal
- Fetal
19
Q
Complications of Multifetal Pregnancy During Pregnancy
- Maternal
A
- During pregnancy
- During Labor
- During Puerperium
20
Q
Maternal Complications of Multifetal Pregnancy During Pregnancy
A
21
Q
Maternal Complications of Multifetal Pregnancy During Pregnancy
- PROM
A
- 3 times more common than singleton pregnancy specially if associated è polyhydramnios or abnormal presentation.
22
Q
Maternal Complications of Multifetal Pregnancy During Pregnancy
- APH
A
- Due to placenta previa (due to large placenta encroaching on LUS) or placental abruption (due to higher incidence of PIH).
23
Q
Maternal Complications of Multifetal Pregnancy During Pregnancy
- PIH
A
Usually of early onset.
24
Q
Maternal Complications of Multifetal Pregnancy During Pregnancy
- Anemia
A
Due to increased requirements & plasma expansion.
25
Maternal Complications of **Multifetal Pregnancy** During Pregnancy
- Malpresentation
25
Maternal Complications of **Multifetal Pregnancy** During Pregnancy
- Pressure Manifestations
26
Maternal Complications of **Multifetal Pregnancy** During Pregnancy
- Psychological
Due to prolonged rest & hospitalization.
27
Maternal Complications of **Multifetal Pregnancy** During labor
28
Maternal Complications of **Multifetal Pregnancy** During Puerperium
29
Fetal Complications of **Multifetal Pregnancy**
30
Fetal Complications of **Multifetal Pregnancy**
- IUFD
- More in monozygotic type than in dizygotic type due to less placental perfusion & increases chance of vascular connections.
31
Fetal Complications of **Multifetal Pregnancy**
- Intrapartum Fetal Death
**Death of 1st fetus:**
- Due to cord prolapse or locked twin.
**Death of 2nd fetus:**
- Due to excessive sedation, premature separation of placenta, hypoxia, constriction ring or operative manipulation.
32
Fetal Complications of **Multifetal Pregnancy**
- IUGR
Due to relatively deficient resources that may affect one fetus > other.
33
Fetal Complications of **Multifetal Pregnancy**
- TTTS
....
34
Fetal Complications of **Multifetal Pregnancy**
- Increased Incidence of Congenital Anomalies
- Major anomalies develop in 2% & minor anomalies develop in 4% of twins.
- Incidence in monozygotic type is twice that in dizygotic type.
- Incidence increaeses in monoamniotic type.
35
Fetal Complications of **Multifetal Pregnancy**
- umbilical Cord Problems
36
Fetal Complications of **Multifetal Pregnancy**
- Cerebral Palsy
- times more common in twins than in singleton pregnancy & it occurs due to single fetal demise, IUGR, discordant growth or TTTS.
37
Fetal conditions unique to multifetal pregnancy
- Vanishing Twin syndrome
- Single fetal Demise
- Discordant Growth
- TTTS
- Conjoint Twins (Siamese twins or disomata)
- Locked Twins
- Retained 2nd Twin
38
Def of **Vanishing twin syndrome**
- 1st trimesteric spontaneous loss or arrest of development è subsequent resorption of at least 1 embryo or fetus which was viable & previously confirmed ultrasonically.
39
Dx of **Vanishing twin syndrome**
- Viable multifetal pregnancy is diagnosed by ultrasound in ist trimester & not confirmed on later ultrasound examination.
40
Def of **Single fetal demise**
- Death of 1 fetus remote from term but pregnancy continues è ≥ 1 living fetus.
41
Incidence of **Single fetal demise**
6% of twins.
42
RF for **Single fetal demise**
Monochorionicity, same sex fetuses & weight discordancy.
43
Complications of **Single fetal demise**
44
Def of **Discordant Growth**
Size inequality of fetuses that may be sign of pathological UGR in one fetus.
45
Incidence of **Discordant Growth**
10-15% of twins.
46
Etiology of **Discordant Growth**
47
Complications of **Discordant Growth**
- Increased incidence of congenital anomalies.
- Physical & intellectual sequels late in life.
48
Dx of **Discordant Growth**
- ≥ 15% difference in estimated fetal weight by ultrasound (larger twin is used as index)
49
Def of **TTTS**
- Blood transfusion from one fetus (donor) to the other (recipient) due to presence of uncompensated intraplacental A-V shunts è preferential blood flow () 2 fetuses.
50
Incidence of **TTTS**
15% of monochorionic twins (it is rare in dichorionic twins).
51
Pathology in **TTTS**
52
Dx of **TTTS**
53
Managment of **TTTS**
54
Synonyms of **Conjoint Twins**
Siamese twins or disomata
55
Def of **Conjoint Twins**
- Twins bodies are fused in certain sites.
- 0.5% of monozygotic twins & is more in female than male fetuses (3:1)
56
Types of **Conjoint Twins**
57
Dx of **Conjoint Twins**
58
Managment of **Conjoint Twins**
CS or vaginal delivery in extreme prematurity.
59
Def of **Locked Twins**
One fetus impedes descent & delivery of the other.
60
Incidence of **Locked Twins**
1/50000 of deliveries & it is more common in primigravidas.
61
Types of **Locked Twins**
62
Risks of **Locked Twins**
63
Dx of **Locked Twins**
Early diagnosis is rare but it must be anticipated.
64
Prevention of **Locked Twins**
By performing elective CS if 1st twin is breech & 2nd twin is cephalic.
65
Managment of **Locked Twins**
66
Managment of **Locked Twins**
- Collision, impaction & compaction
67
Managment of **Locked Twins**
- Chin to chin interlocking
68
Def of **Retained 2nd Twin**
Failure of delivery of 2nd twin vaginally after delivery of 1st one for > 30 minutes.
69
Risks of **Retained 2nd Twin**
70
Managment of **Retained 2nd Twin**
CS
71
Dx of **Multifetal Pregnancy**
- During Pregnancy
- During Labor
72
Dx of **Multifetal Pregnancy**
- During Pregnancy
73
Dx of **Multifetal Pregnancy** During pregnancy
- Hx
74
Dx of **Multifetal Pregnancy** During pregnancy
- General Ex
75
Dx of **Multifetal Pregnancy** During pregnancy
- Abdominal Examination
76
Dx of **Multifetal Pregnancy** During pregnancy
- US
77
US of **Multifetal Pregnancy** During pregnancy
78
US of **Multifetal Pregnancy** During pregnancy
- frequency
Frequency:
- In dichorionic twins: Every 4-6 weeks.
- In monochorionic twins: Every 2 weeks.
79
US of **Multifetal Pregnancy** During pregnancy
- Value
80
US of **Multifetal Pregnancy** During pregnancy
- determination of Chorionicity & Amnionicity
81
US of **Multifetal Pregnancy** During pregnancy
- Lambda Sign
82
US of **Multifetal Pregnancy** During pregnancy
- T sign
83
Dx of **Multifetal Pregnancy** During Labor
84
DDx of **Multifetal Pregnancy**
Other causes of oversized uterus.
85
Prevention of **Multifetal Pregnancy**
A) Proper use of vulation induction drugs.
B) Single embryo transfer in IVF programs è cryopreservation of other embryos.
86
Managment of **Multifetal Pregnancy**
- During pregnancy
- During Labor
87
Managment of **Multifetal Pregnancy**
- During Prenancy
88
Managment of **Multifetal Pregnancy** During Pregnancy
- Adequate ANC
- As any high-risk pregnancy (visits are every 2 weeks till 28 weeks then every week till 36 weeks then hospitalization).
89
Managment of **Multifetal Pregnancy** During Pregnancy
- General Lines
90
Managment of **Multifetal Pregnancy** During Pregnancy
- Observation
91
Managment of **Multifetal Pregnancy** During Pregnancy
- Selective Fetal Reduction
92
**Selective Fetal Redution** in Multifetal Pregnancy
- Def
Reduction of selected fetus or fetuses in dichorionic multifetal pregnancy to enhance survival of other fetuses.
93
**Selective Fetal Redution** in Multifetal Pregnancy
- Time
Performed at 9-12 weeks.
94
**Selective Fetal Redution** in Multifetal Pregnancy
- Techniques
Ultrasound guided KCI injection into heart or thorax of each selected fetus.
95
**Selective Fetal Termination** in Multifetal Pregnancy
96
**Selective Fetal Termination** in Multifetal Pregnancy
- Def
Selective destruction of abnormal fetuses.
97
**Selective Fetal Termination** in Multifetal Pregnancy
- Time
- Performed later in pregnancy than selective reduction (because anomalies are typically not discovered till 2nd trimester).
98
**Selective Fetal Termination** in Multifetal Pregnancy
- Techniques
a) Ultrasound guided intracardiac KCI injection.
b) Fetoscopic ligation or laser coagulation of umbilical cord.
99
Managment of Multifetal Pregnancy
- Delivery
100
**Managment of Multifetal Pregnancy in Delivery**
- Time
- The ideal time for delivery of uncomplicated multifetal pregnancy is uncertain however, pregnancies shouldn't go beyond 40 weeks because postmaturity is difficult to deal è in twin pregnancy.
101
**Managment of Multifetal Pregnancy in Delivery**
- Place
In well-equipped hospital.
102
**Managment of Multifetal Pregnancy in Delivery**
- Methods
- Vaginal or CS
103
Vaginal Delivery in **Multifetal Pregnancy**
104
Vaginal Delivery in **Multifetal Pregnancy**
- Indications
It is the rule in twin pregnancies unless CS is indicated.
105
Vaginal Delivery in **Multifetal Pregnancy**
- Prerequesities
106
Vaginal Delivery in **Multifetal Pregnancy**
- managment of 1st stage
107
Vaginal Delivery in **Multifetal Pregnancy**
- Managment of 2nd Stage
108
Vaginal Delivery in **Multifetal Pregnancy**
- Delivery of 1st fetus
Is according to ordinary rules of labor è avoidance of
AROM, difficult forceps or ventouse (if cephalic) & breech extraction (if breech).
109
Vaginal Delivery in **Multifetal Pregnancy**
- After Delivery of 1st fetus
110
Vaginal Delivery in **Multifetal Pregnancy**
- delivery of 2nd Fetus
111
Vaginal Delivery of 2nd Fetus in multifetal Pregnancy
- If there is amniotic Sac (diamniotic twins & no ROM) & there is no fetal distress
112
Vaginal Delivery of 2nd Fetus in multifetal Pregnancy
- If there is amniotic Sac (diamniotic twins & no ROM) & there is no fetal distress
- Cephalic
Moderate fundal pressure to guide head in birth canal then do AROM & leave for spontaneous delivery.
113
Vaginal Delivery of 2nd Fetus in multifetal Pregnancy
- If there is amniotic Sac (diamniotic twins & no ROM) & there is no fetal distress
- Breech
114
Vaginal Delivery of 2nd Fetus in multifetal Pregnancy
- If there is amniotic Sac (diamniotic twins & no ROM) & there is no fetal distress
- Oblique & Transverse
1. ECV or EPV then delivery as cephalic or breech.
2. IPV on intact membrane during period of uterine quiescence then AROM followed by breech extraction.
115
Vaginal Delivery of 2nd Fetus in multifetal Pregnancy
- If there is NO amniotic Sac (monoamniotic twins or ROM) or there is cord prolapse or fetal distress or if delivery of 2nd fetus is delayed > 1/2 an hour
116
Vaginal Delivery of 2nd Fetus in multifetal Pregnancy
- If there is NO amniotic Sac (monoamniotic twins or ROM) or there is cord prolapse or fetal distress or if delivery of 2nd fetus is delayed > 1/2 an hour
- Cephalic
Cephalic presentation:
1. Head is engaged: Ventouse or forceps.
2. Head isn't engaged: IPV followed by breech extraction.
117
Vaginal Delivery of 2nd Fetus in multifetal Pregnancy
- If there is NO amniotic Sac (monoamniotic twins or ROM) or there is cord prolapse or fetal distress or if delivery of 2nd fetus is delayed > 1/2 an hour
- Breech
Breech extraction.
118
Vaginal Delivery of 2nd Fetus in multifetal Pregnancy
- If there is NO amniotic Sac (monoamniotic twins or ROM) or there is cord prolapse or fetal distress or if delivery of 2nd fetus is delayed > 1/2 an hour
- Oblique or transverse
IPV followed by breech extraction.
119
Vaginal Delivery in **Multifetal Pregnancy**
- managment of 3rd Stage
120
CS in **Multifetal Pregnancy**
- indications
121
Managment of **Multifetal Pregnancy**
- Neonatal Care
For detection & management of any complication.
122
Managment of **Multifetal Pregnancy**
- Postnatal Care
1. Observation of patient during puerperium.
2. Contraception.
123
Prognosis of **Multifetal Pregnancy**
FFF
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