Scribd
Upload
11 views

RDF 6 TG 7 Yh

xecdfvgbhnmdr7tf gy

Uploaded by

Dafer Dalaien
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
11 views

RDF 6 TG 7 Yh

xecdfvgbhnmdr7tf gy

Uploaded by

Dafer Dalaien
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
You are on page 1/ 41

Course in Obstetrics

& Gynecology
Presented by Dr Rawan Yaseen
Specialist in Obstetrics and gynecology
Member of the Jordanian and the Arab board
Multiple
Pregnancy
Dizygotic twins varies Monozygotic twins -- stable
among populations worldwide at 3 -5 /1000 births and
not affected by patient-specific
factors
Dizygotic twins varies among populations

Monozygotic twins is relatively stable worldwide at 3 to 5 per 1000


births and not affected by patient-specific factors, except for those
undergoing in vitro fertilization (IVF).
Risk factors
• Use of fertility enhancing treatments
Dizygotic twins are more common in pregnancies conceived with IVF
than in naturally conceived
IVF is the only risk factor for monozygotic twinning
• Maternal age
• Race/geographic area
• Parity
• Family history
• Maternal weight and height
CLINICAL PRESENTATION
• By ultrasound examination which performed in early pregnancy
• Uterine size that is large for dates
• family history
• use of assisted reproductive technology
• hyperemesis gravidarum

Diagnosis by Ultrasound
SONOGRAPHIC DIAGNOSTIC EVALUATION

• Determination of gestational age — Gestational age is determined by


ultrasound examination, unless – IVF
If there is a discrepancy ---- larger twin

• Assessment of chorionicity and amnionicity —


chorionicity and amnionicity
• Identification of two separate placentas
chorionicity and amnionicity
• The presence/absence of the intertwin membrane

Monochorionic/monoamniotic –
1- Visualization of intertwined
umbilical cords is diagnostic of
monoamniotic twins

2- intertwin membrane is absent


• Dichorionic/diamniotic –
1- intertwin membrane with the
"twin peak" or "lambda (λ)“

2- intertwin membrane is
thicker --- four layers

3- identification of fetuses of different sex


• Monochorionic/diamniotic –
1- intertwin membrane
with the "T" sign

2- thin intertwin membrane


composed of two amnions
PRENATAL CARE
• higher gestational weight gain
• small differences in micronutrient supplementation
• routine administration of preeclampsia prophylaxis
• differences in choice of method for Down syndrome screening
• differences the frequency and target of ultrasound monitoring
COMPLICATIONS
• Vanishing twins — Early spontaneous reduction from twin to
singleton pregnancy --- very common

• the first trimester demise of a dichorionic twin has no negative affect


on the surviving twin
Fetal complications

All twins
• Preterm birth --- most common
• Growth restriction
• Congenital anomalies
Monochorionic twins
• Twin-twin transfusion syndrome (TTTS) –
• Twin anemia polycythemia sequence (TAPS) –
• Selective fetal growth restriction (sFGR) –
• Twin reversed arterial perfusion sequence (TRAP)
• Single fetal demise –
• Congenital anomalies
Monoamniotic twins
• Intertwin cord entanglement
• Conjoined twins –
Maternal complications

• Maternal hemodynamic changes


• Gestational hypertension and preeclampsia
• Gestational diabetes
TIMING OF DELIVERY

• Dichorionic/diamniotic — planned delivery at 38+0 to 38+6 weeks of


gestation

• Monochorionic/diamniotic — planned delivery at 36+0 to 36+6


weeks.
• Monochorionic/monoamniotic
between 32+0 and 34+0 weeks by cesarean section
Thank You
Intrauterine Growth
Restriction
Why ???
ASSESSMENT OF FETAL GROWTH
• Assessment of gestational age –
menstrual history and ultrasound biometry, ideally the crown-rump
length in the first trimester

• Assessment of fetal size –


Ultrasound is the accepted standard to assess fetal size --- Hadlock
formula
Hadlock formula
• ultrasound measurements of
the biparietal diameter (BPD),
head circumference (HC),
abdominal circumference
(AC), and femur length (FL),
typically in pregnancies ≥24
weeks of gestation
• Growth standards –
The calculated EFW is compared
with a reference growth standard
to determine the percentile for
gestational age.
DEFINITIONS
• FGR --- estimated fetal weight (EFW) or abdominal circumference (AC)
<10th percentile for gestational age
• Severe FGR is defined as an EFW or AC <3rd percentile for gestational age
• Early-onset FGR (in the absence of congenital anomalies) defines FGR
identified before 32 weeks gestation
• Late-onset FGR (in the absence of congenital anomalies) defines FGR
identified after 32 weeks of gestation
• Small for gestational age (SGA) is defined as a newborn <10th percentile for
birth weight for gestational age --- constitutionally small
• Infants with FGR can be divided
into:
• Symmetric FGR –20 -30 %---
reductions in all organ systems with
the body, head, and length
proportionally affected--- early in
gestation
• Asymmetric FGR –70 -80 % ---
disproportionate growth restriction
in which head circumference is
preserved, length is somewhat
affected, and weight is
compromised to a greater degree.
RISK FACTORS
• Placenta –
1- Placental insufficiency --- most common
2- placental abnormalities--- velamentous cord insertion, circumvallate placenta, and single umbilical
artery
• Maternal –
1- Maternal vascular disease (such as chronic hypertension), renal disease, diabetes, collagen vascular
disease, and antiphospholipid syndrome
2- Tobacco and substance use, including cocaine, alcohol, and opioids
3- Medication exposures, such as certain anti-seizure and chemotherapeutic medications and warfarin
• Fetal –
1- Fetuses with genetic abnormalities, syndromes, and congenital anomalies
2- Fetal infection with TORCH
SCREENING
DIAGNOSIS

The diagnosis of a small fetus is based on sonographic estimation of


fetal weight (EFW) <10th percentile or fetal abdominal circumference
(AC) <10th percentile on population-based or customized growth curves
Characteristics that support a diagnosis of a constitutionally small
fetus include:

• Modest smallness (ie, estimated weight between the 5th and 10th percentiles)
• Normal growth velocity across gestation
• Normal physiology (ie, normal amniotic fluid volume and umbilical artery
Doppler)
• Abdominal circumference growth velocity above the 10th percentile
• Appropriate size in relation to maternal characteristics (height, weight,
race/ethnicity)
Determine the cause
• Maternal History and Examination —
• Fetal survey — A detailed fetal anatomic survey should be performed in all
cases
• Fetal genetic studies —
1- FGR that is all of the following: Early (<24 weeks), severe (<5th percentile),
and symmetrical.
2- FGR with major fetal structural abnormalities.
3- FGR with soft ultrasound markers associated with an increased risk of
aneuploidy
• Work-up for infection — when ultrasound findings are suggestive of an
intrauterine infection
IUGR
pulsatility index of both the umbilical
artery and middle cerebral artery
(MCA)

If one is abnormal
Both normal
NSTs or BPPs -- weekly
If umbilical artery diastolic flow is present but Umbilical artery absent Umbilical artery
Doppler examination in two-week intervals
decreased diastolic flow reversed diastolic flow
we perform weekly Doppler evaluation
BPP two times per week
<3rd percentile ---
eliver these pregnancies deliver these pregnancies deliver at 37+0
between 33+0 and 34+0 between 30+0 and 32+0
weeks weeks
deliver at 37+0
≥3rd and
If <33 weeks If <30 weeks <10th percentile –delive
daily NST or BPP testing daily NST or BPP testing r 39+0
ductus venosus ductus venosus

If any abnormal ---


deliver
• Betamethasone is given to pregnancies <34+0 weeks of gestation in
the week before preterm delivery is anticipated

• Magnesium sulfate is given before delivery by 24 hs For fetuses less


than 32 weeks of gestation for neuroprotection.
Route of delivery
• Vaginal delivery --- by IOL

• persistent reversed flow of the umbilical artery --- give patients the
option
• Prevention in subsequent pregnancies
1- address any potentially treatable causes of FGR
2- Low-dose aspirin

• Management of subsequent pregnancies


1- Accurate dating by early ultrasonography
2- intermittent ultrasound examinations
Thank You

You might also like