Beruflich Dokumente
Kultur Dokumente
Kahlo
Multiple pregnancy
- diagnosis and follow up-
Dr. Ilinca Gussi
– Spontaneous abortion
– Premature birth
– Preeclampsia
– IUGR (intrauterine growth restriction)
– IUFD (in utero fetal demise) of one twin
– C/S
– Postpartum hemmorage
– Fetal perinatal mortalitaty and morbidity
– TTTS (twin-to-twin transfusion syndrome)
Multiple pregnancy- management
• Diagnosis
• Prenatal follow up
• Treatament of complications
• Delivery
• Postpartum
Multiple pregnancy- management
• Diagnosis
• Prenatal follow up
• Treatament of complications
• Delivery
• Postpartum
Zygotism & chorionicity
• Monozygotic versus poli-/dizygotic
1/3 2/3
poli-/di-chorionic
Zygotism & chorionicity
• Monozygotic versus poli-/dizygotic
1/3 2/3
1/250 1/80-100
Preeclampsia x4
Ultrasound diagnosis of
chorionicty
• Ultrasonography detects:
– Fetal sex: diferent = ALWAYS dichorionic
– Nr and position of placenta: when distinc (rarely)
is sign of dichorionicity
– Interamniotic membrane aspect: thicker in
dichorionic twins
» Detectable at 6-9 wks
» Lambda sign at the insertion up to 12 wks
Ultrasound diagnosis of
chorionicty
• Ultrasonography detects:
– Fetal sex: diferent = ALWAYS dichorionic
– Nr and position of placenta: when distinc (rarely)
is sign of dichorionicity
– Interamniotic membrane aspect: thicker in
dichorionic twins
» Detectable at 6-9 wks
» Lambda sign at the insertion up to 12 wks
Ultrasound diagnosis of
chorionicty
• Ultrasonography detects:
– Fetal sex: diferent = ALWAYS dichorionic
– Nr and position of placenta: when distinc (rarely)
is sign of dichorionicity
– Interamniotic membrane aspect: thicker in
dichorionic twins
» Detectable at 6-9 wks
» Lambda sign at the insertion up to 12 wks
Diagnosing chorionicity
in the first trimester
• Specific complications:
TTTS (twin-to-twin transfusion sy.) appears in
30% cases and in ½ is severe
What risks are screened ?
• Specific complications:
e.g. TTTS (twin-to-twin transfusion sy.)
appears in 30% cases and in ½ is severe
• Functional cervical length
< 26 mm = threatened Premat
Birth
Iams et al, NEJM 1996
normal threatened PB
www.fetalmedicine.com
Distribution of Subjects among Percentiles for Cervical Length Measured by Transvaginal
Ultrasonography at 24 Weeks of Gestation (Solid Line) and Relative Risk of Spontaneous Preterm
Delivery before 35 Weeks of Gestation According to Percentiles for Cervical Length (Bars)
26 mm
• Specific complications:
TTTS (twin-to-twin transfusion sy.) appears in
30% cases and in ½ is severe
• US follow up key points:
• Specific complications:
TTTS (twin-to-twin transfusion sy.) appears in
30% cases and in ½ is severe
Prognosis f(chorionicity)
S Di ch Mono ch
Spontaneous abortion
1% 2% 10%
(prior to 24 SA)
Perinatal mortality 2% 5%
Preeclampsia x4
• Fetal hypoxia screening:
> 8 cm
Neonatal criteria do not apply!
< 2 cm
= growth or Hb discordance are
not relevant for diagnosis
Monochorionic- diamniotic pregnancy
complicated with TTTS
• TTTS appears in 30% cases and in ½ is severe
Unbalanced inter-twin
blood transfer through
placental shunts
Severly
UB donor UB donor modified
visible un visible Dopplers Hidrops IUFD
I II III IV V
Evolution is unpredictable.
!!!! Fetal distress and fetal anemia!!!
- Admitted at 38 wks
2465g
Cord entanglement
2788g
GN 2650g=2650g
• Intensive follow-up
• Early admission
• Multifetal pregnancy reduction to twins should
be offered
• C/S rate 70%
• MAJOR post-partum bleeding risk
• Breast feeding extremly difficult
• Support (both psychological and material)
must be organised in advance