Twin pregnancy by Dr shagufta naz
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This document discusses multiple pregnancy, specifically twin pregnancy. It defines multiple pregnancy as more than one fetus and classifies twins based on number of fetuses, zygosity, chorionicity, and amnionicity. Twin pregnancy can be either dizygotic (fraternal) twins from two eggs or monozygotic (identical) twins from one egg that splits. Risk factors, complications, management, and delivery considerations are outlined for twin pregnancies. Conjoined twins, which result from a single fertilized egg failing to separate, are also briefly discussed.
Twin pregnancy by Dr shagufta naz
- 2. Definition The period from conception to birth. After the egg is fertilized by a sperm and then implanted in the lining of the uterus, it develops into the placenta and embryo, and later into a fetus
- 3. Multiple pregnancy describes a pregnancy comprising of more than one fetus. Classification: Classification of multiple pregnancy is based on: Number of fetuses: twins, triplets Number of fertilized eggs: zygosity Number of placantae : chorionicity Number of amniotic cavities: amnionicity
- 4. Twin pregnancy means that a woman is carrying two fetuses at a time. Incidence: 2-3% of all pregnancies. Types: Dizygotic twins Monozygotic twins
- 5. Dizygotic twins also called bin ovular, fraternal or unlike twins. Dizygotic twins results when two oocytes are simultaneously released from the same or both ovaries and fertilized by two separate spermatazoa derived at same coitus. Incidence of dizygotic twin is 75% of all twin pregnancies.
- 6. Dizygotic twins have different genetic constitutions and have no special resemblance. They may have same or different blood groups as well as the gender. Within uterine cavity the two the two zygote implant separately each having its own set of placenta and membranes ( dichorionic and diamniotic )
- 7. Monozygotic twins also called uni ovular, identical or like twins. They originate from the fertilization of single ovum by a single sperm which subsequently divides into two. Incidence of monozygotic twins is constant worldwide and is said to be 3-4/1000 births.
- 8. Within the uterine cavity the arrangement of placenta and membranes for the monozygotic twins varies greatly and depends upon the time interval between the fertilization and division of zygote. Sooner the division occurs more independent the twins are, & the dependence over each other & hence the complication rate increases with the prolongation of interval between fertilization and division.
- 10. Age: incidence increases with increasing maternal age, with peak at 37-38years Parity: multipara are more likely to have twin pregnancy. Race: incidence varies among different races; 2/1000 births in Japan 3/1000 births in Asians 49/1000 births in Nigeria
- 11. Recurrence: The incidence of dizygotic twin pregnancy increases 10 fold after one dizygotic twin pregnancy. Family History: Positive family history also cause high incidence. Built: Tall and Fat women are more likely to have twins as they are generally better nourished, and twinning is less often in under nourished women.
- 12. Fertility Drugs: incidence is 8% in patients receiving clomiphene and 20% with menopausal gonadotroin . Role of LH and FSH: High levels of LH and FSH lead to multiple ovulation. High levels of gonadotrophins are found in advance age, obesity, and after treatment with fertility drugs. Moreover low level of gonadotrophin in Japanese and low incidence of twin pregnancy.
- 13. Maternal Complications: Hyper emesis gravidarum Anemia Pregnancy induced hypertension Urinary tract infections Placental abruption Operative delivery Postpartum hemorrhage
- 14. Pressure symptoms: Backache Dyspnea and dyspepsia Supine hypotension syndrome Lower limb edema and varicosities Other maternal complications: Excessive weight gain, 16-20kg Placenta previa Diabetes mellitus
- 15. Congenital malformations: Unique to multiple pregnancy are: conjoined twins, fetal acardia, symmelia More common in multiple pregnancy but not unique to it include: neural tube defects, bowel atresia, cardiac anomalies, congenital dislocation of hip joint & certain chromosomal abnormalities. Polyhydramnios
- 16. Twin-to-twin transfusion syndrome (TTTS, also known as Feto-Fetal Transfusion Syndrome (FFTS) and Twin Oligohydramnios-Polyhydramnios Sequence (TOPS)) . It can affect monochorionic multiples, that is, multiple pregnancies where two or more fetuses share a chorion and hence a single placenta. Severe TTTS has a 60–100% mortality rate
- 17. As a result of sharing placenta blood supplies of monochorionic twin fetuses can become connected, so that they share blood circulation: ,the connecting blood vessels within the placenta allow blood to pass from one twin to the other. Depending on the number, type and direction of the interconnecting blood vessels (anastomoses ), blood can be transferred disproportionately from one twin (the "donor") to the other (the "recipient").
- 19. Stuck twin phenomenon Twin reverse arterial perfusion sequence (TRAP sequence) Inrauterine growth restriction ( IUGR) Malpresentations Preterm labor Locked twins Cord accidents & Rupture of membranes in case of monoamniotic twins
- 20. Hydatidiform mole (0.01%) Combined pregnancy RH incompatibility: more severe due to Excessive fetomaternal hemorrhage Maternal sensitization Prolonged pregnancy (beyond 39 weeks) Perinatal mortality in twin gestation is 5 time higher due to above mentioned risks
- 21. Ultrasound : Conclusive : can verify twin pregnancy at 12 weeks. High HCG Level: Very high level can help in diagnosis but not conclusive, as singleton pregnancy can also have high levels in some conditions. Doppler : Baby Doppler detect heartbeat, two individuals beats can be found.
- 22. Signs and symptoms of pregnancy: sign and symptoms of pregnancy are more pronounced, as: Excessive morning sickness Extreme fatigue Fundal height: large for gestational age Fetal movements: can be felt as early 14 weeks and excessive as well. Weight gain: average weight gain for twin pregnancy is about 10 lb more than with a sigleton pregnancy.
- 23. Management of multiple pregnancy may include the following: increased nutrition Mothers carrying two or more fetuses need more calories, protein, and other nutrients, including iron. Higher weight gain is also recommended for multiple pregnancy. The American College of Obstetricians and Gynecologists recommends women carrying twins gain at least 35 to 45 pounds. more frequent prenatal visits Multiple pregnancy increases the risk for complications. More frequent visits may help detect complications early enough for effective closely. Referrals Referral to a maternal-fetal medicine specialist, called a perinatologist , for special testing or ultrasound evaluations, and to coordinate care of complications, may be necessary. Increased rest Some women may also need bed rest - either at home or in the hospital depending on pregnancy complications or the number of fetuses
- 24. maternal and fetal testing Testing may be needed to monitor the health of the fetuses, especially if there are pregnancy complications. tocolytic medications Tocolytic medications may be given, if preterm labor occurs, to help slow or stop contractions. Tocolytic medications often used include terbutaline and magnesium sulfate. corticosteroid medications Corticosteroid medications may be given to help mature the lungs of the fetus. cervical cerclage Cerclage (a procedure used to suture the cervical opening) is used for women with an incompetent cervix. This is a condition in which the cervix is physically weak and unable to stay closed during pregnancy. Some women with higher-order multiples may require cerclage in early pregnancy.
- 25. Time of delivery: Duration of gestation in twin pregnancy is biologically short, up to 50% of patient deliver before 37 weeks and after 39 weeks twin gestation is considered as prolonged, therefore delivery b/w 37-39 weeks is recommended. Mode of delivery: Elective caesarean section Vaginal delivery
- 26. Twin pregnancy in the presence of any additional risk factor should be better delivered by caesarean section. Indications: Pregnancy induced hypertension Diabetes mellitus Ante partum hemorrhage Malpresentation of first twin Conjoined twins polyhydramnios
- 27. In an uncomplicated twin pregnancy with the first twin in cephalic presentation, vaginal delivery is the route of choice. Induction in twins: Labor should not be induced in complicated twin pregnancy. Uncomplicated pregnancy with the first twin presenting as vertex, induction of labor is safe provided continuous fetal heart monitoring is ensured.
- 28. Management of first stage: Continuous fetal heart rate monitoring Artificial rupture of membrane Use of oxytocin Epidural analgesia Management of second stage: Delivery of first twin: if vertex presentation, same principles as for singleton pregnancy.
- 29. After delivery placental side of umbilical cord must be secured properly to avoid hemorrhages in case f monoamniotic twins. Delivery of second twin: Second twin should better be delivered within 15 minutes of delivery of first twin. If uterine contraction does not resume, ARM is performed. If flexed or footling breech, feet can be grasped and pulled down before rupture of membranes to stabilize he lie of baby.
- 30. Special circumstances for second twin: If the second twin in vertex presentation fails to descend, vacuum extraction may be used. If an abnormal lie is uncorrectable at external version, internal podalic version may b used. Caesarean section is indicated if: Abnormal lie is not corrected at ECV, & IPV is not feasible. Membranes are ruptured and liquor drains with or without cord prolapse .
- 31. Management of third stage: Active management with the administration of oxytocin and even ergometrine if patient is normotensive . Patient should be kept under close observation for any vaginal bleeding as these patients are more likely to have postpartum hemorrhages.
- 32. It results when zygote is divided after 13 days from the time of fertilization. Incidence: 1:200 monozygotic twins Conjoined twins share he body parts and severity increase with the delay in division beyond 12 days. Types: Equal conjoined twins Unequal conjoined twins
- 33. Equal conjoined twins: Two individuals of similar development. Sharing vary from bridge of skin to most vital parts like liver, heart or even trunk . Depending upon site of sharing they may be: Anterior ( thoracopagus ) Posterior ( pyopagus ) Cephalic (craniopagus ) Caudal ( ischiopagus )
- 34. Unequal conjoined twins: A normal fetus has additional major parts attached to it, such as limbs or there is development of partial fetus in the abdomen(fetus in fetu )
- 35. Diagnosis: Ultrasound If twins maintain similar relationship to each other during the whole antenatal period Delivery: Caesarean section Treatment: Surgical separation: Depending upon the degree to which they share their vital organs.