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JJE-20091119
AGENDA
Introduction
Etiology of twins
Diagnosis of twins
Vanishing twins
Perinatal loss in twins
Placentation
Complications and Abnormality in twins pregnancy
Conclusion
Take home messages
References
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INTRODUCTION
Definition: any pregnancy in which 2 embryos or
fetuses occupy the uterus simultaneously
Epidemic of twins: ART, delayed childbearing, and
ovulation induction
INTRODUCTION
3.2% of all live births (US 2003) (Natality Data Set, CDC, 1997 2002)
14 25% are IUGR and 25% require NICU (Mauldin J et
al, 1998; Ettner SL et al, 1997)
(Elliott JP et al,
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(Roach
ETIOLOGY OF TWINS
Depending on the number of eggs fertilized at
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DA-DC
Separate
placentae
DA-DC
Fused
placentae
DA-MC
Single
placentae
MA-MC
Single
placentae
Frequenc
y
35%
27%
36%
2%
Mortality
13%
11%
32%
44%
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DIAGNOSIS OF TWINS
Anamnesis: risk factors
Physical examination: difficult
ULTRASOUND: should begin with a complete
imaging sweep of the uterus
FIRST TRIMESTER ULTRASOUND: number of GS
and embryo, location of placenta, dividing membrane,
AF, YS, and FHR determine chorionicity
potential complications
Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstetrics
and gynecology. Callen, 5th Ed, 2008;266-296)
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ULTRASOUND IN TWIN
There is good evidence that the diagnosis of
ULTRASOUND IN TWIN
Fetal growth differs slightly in twin gestations
ULTRASOUND IN TWIN
Patterns of fetal growth are more important
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ULTRASOUND IN TWIN
The diagnosis of discordance has been based
on the following:
AC difference of 20 mm (sensitivity of 80%,
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1ST TRIMESTER
ULTRASOUND
Every effort should be made to determine chorionicity
at
the time of diagnosis. (II-3 C)
weeks. (II-3 C)
twin
pregnancy with regard to prenatal diagnosis and
counseling, there have been no studies relating the
establishment of prenatal chorionicity to pregnancy
SOGC, Management of twin pregnancy (Part 1), July,
outcome.
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HANYA UNTUK PENDIDIKAN DAN
KESEHATAN
VANISHING TWINS
EARLY
(< 8 weeks)
INTERMEDIAT
E
(> 8 and < 22
weeks)
Delivery < 32 W
1.9%
5.3%
21.4%
8.7%
15.7%
43.8%
Neurodevelopmen
t disorders
3.3%
8.0%
9.7%
Pregnancy
outcome
LATE
(> 22 weeks)
Comparable
with singletons
Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstetrics
and gynecology. Callen, 5th Ed,2008;266-296)
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PERINATAL LOSS IN
TWINS
IMR:
> 5 x = 32.9/1000 live-born twins (USA,
1999)
Survival depends on chorionicity: anomalies, growth
problems & prematurity
Cumulative loss rate: 3% dichorionic & 15%
monochorionic (Sabire et al, 1997)
Losses are more likely to occur between 16 22 W
TWINS DISCORDANT
In twins discordant for abnormality, the option of
level center.
Transportation and out-of-province costs should be
covered.
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PLACENTATION
The most important is the identification of
chorionicity
Ultrasound is very useful in determining
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PLACENTATION
Chorionicity and amnionicity
First, second and third trimester
Membrane insertion, twin-peak sign
Membrane thickness
Membrane layers
Multiple sonographic markers to determine
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Yolk Sacs
Embryos /
Sac
Amniotic
Cavities
DC, DA
MC, DA
1*
2*
MC, MA
1*
1 or partially 2*
divided*
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CONJOINED TWINS
MC, MA twins
Embryo divides at 13 to 15 days from conception
The two fetal poles may be attached at varying sites
Adapted from: Romero, R., Pilu, G., Jeanty, P., Ghidini, A. and Hobbins, J.C.(19
Prenatal Diagnosis of Congenital Anomalies, p 405. ( courtesy from Philippe
www.thefetus.net )
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parts of
twins
implanted in another fetus.
In this case what appears to be
an omphalocele on the left is a
fetal abdomen with lower legs
on the extreme left.
(Courtesy Glynis Sack, MD,
www.TheFetus.net)
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TWIN TO TWIN
TRANSFUSION SYNDROME
MC twin placental vascular anastamoses
communication of the two fetoplacental
circulations; may bearterioarterial, veno
venous, or arteriovenous in nature (Benirschke K. Twin
placenta in perinatal mortality. N Y St J Med 1961;61:1499508)
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TWIN TO TWIN
TRANSFUSION SYNDROME
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Amniotic
Fluid
Fetal
Bladder
MCA
Hydrops
Doppler,
UA or UV
Fetal
Demise
D: oligo
R: poly
Normal
Normal
No
No
II
As above
D:
bladder
not seen
Normal
No
No
III
As above
As above
Abnormal
No
No
IV
As above
As above
Abnormal
Yes, either No
twin
As above
As above
Abnormal
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GENETIC TESTING
All women carrying twin pregnancies should
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GENETIC SCREENING
Biochemical screening for aneuploidy is not
recommended in twins.
MS-AFP is useful for detection of open neural tube and
INVASIVE GENETIC
TESTING
The fetal loss rates with invasive testing (amniocentesis
PRETERM BIRTH
PREVENTION
Routine hospitalization for bed rest in multiple gestation is
not recommended. (I E)
There is insufficient evidence to support prophylactic activity
PROPHYLACTIC
TOCOLYSIS
There is moderate evidence against
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SONOGRAPHIC CERVICAL
ASSESSMENT
There is good evidence that transvaginal
KESEHATAN
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5 mm
LR
52
(Heath et al 1998)
10 mm
9,1
15 mm
2,7
20 mm
1,2
25 mm
0,7
30 mm
0,5
40 mm
0,5
50 mm
0,4
60 mm
0,1
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HANYA UNTUK PENDIDIKAN DAN
KESEHATAN
FETAL FIBRONECTIN
There is good evidence that the presence of
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ULTRASOUND
MANAGEMENT
Performed in 1 trimester:
st
number, amnionicity,
Detailed US examination:
18 20 W, fetal gender,
Dichorionic pregnancy:
Monochorionic diamniotic:
evaluation every 2 3 W,
Young Mi Lee et al. Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach, 2
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ULTRASOUND
MANAGEMENT
Dichorionic or monochorionic: if IUGR,
discordant fetal growth, discordant AFV NST,
Biophysical Profile, Doppler studies
Monoamniotic: daily NST starting from 24 26 W
(risk of sudden IUFD from cord entanglement)
variable deceleration delivery?
Young Mi Lee et al. Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach, 2
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ELECTIVE CAESAREAN
SECTION
from term;
c) Indications as for singleton pregnancies. (III C)
CASE REPORT
Mrs I, 34 year, G1P0A0 20 weeks, dizygotic
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CONCLUSIONS
ART and delayed childbearing increase
multiple pregnancy
High perinatal morbidity and mortality rates
Early diagnosis and serial ultrasound studies
disturbances
When the best time to delivery?
Confident diagnosis of zygosity may require
detailed examination of the placenta after
delivery
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REFERENCES
Tarsa M, Moore TR. Multifetal gestation and
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THANK
YOU
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