KEHAMILAN N KEMBAR = MULTIPLE PR REGNANCIES = (GEME ELLI) O Dr.

HOTMA PARTOG GI PASARIBU SpOG SUB BAGIAN FETOM MATERNAL FKFK-USU RS. PIRNGA ADI MEDAN

Pendah huluan
Two for the price of one e atau instant e instant family family High Complication Risk kMorbiditas & mortalitas 50% 32-38 32 38 m minggu, 10% dibawahnya Pe Malpresentasi: - kedua janin sungsang 41% 4 - Janin kembar I sungsan ng 17% - Locked L k d twins t i (jarang) (j ) Persalinan operatif & res siko persalinan preterm

Definisi & Klasifikasi K

Kehamilan 2 janin atau lebih h Kembar dizigotik (66%) Bin novular-fraternal twins 1. fertilisasi 2 ovum oleh 2 sperma s 2. Dikorionik: Amnion terpi isah Kembar monozigotik (33%) ) Mono ovular-identical twins - Pembelahan P b l h 1 ovum, f fertil til li i oleh lisasi l h sperma sperma yang sama - Pembelahan <72 jam: Dikorionik diamnotik (96%) - Pembelahan 4-8 hari: Mon nokorionik diamniotik (4%)

Mono ovular-iden ovular iden ntical twins, diamniotik mon nokorionik

- Pembelahan 8-13 8 13 hari: Monokorionik, Monoamniotik - Pembelahan >13 hari: Conjo oined twins Fetus Papyraceous - Salah satu janin kembar tida ak berkembang - Tak berbentuk, berbentuk mengkerut & rata Perbandingan Mono/Dizigo otik 1:2 Faktor resiko untuk kembar r dizigotik: - tua - Multiparitas M lti it n kembar dizigotik - Riwayat keluarga kehamilan

Fetus Papyraceous, salah satu fetus yang tidak berkembang

Insi iden
1% dari kehamilan, 2/3 dizigot & 1/3 monozigot Etnik ( (1:50 Afrika, , 1:80 Cau usasia, , 1:50 Asia) ) Usia (2% > 35 thn) Paritas ( (2% % setelah kehamil lan ke-4) ) Metode konsepsi (20% indu uksi ovulasi) Riwayat keluarga Insidensi menurut hukum Hellin H adalah 1 dalam 80n-1 kehamilan e

Etio ologi
Bangsa, hereditas, umur & paritas binovular fraternal-twins Obat klomid & gonadotr ropin hormon dizigotik Fertilisasi in vitro & tran nsfer embrio (IVF&ET)

Patofis siologi
Fertilisasi ovum&sperm ma di tuba falopii Ovum yang telah dibuahi turun t uterus nidasi dan Pertumbuhan fe etus Selama proses ini kem mbar dapat terbentuk

Kehamilan berasal dari satu telur terjadi : Akibat adanya kerja faktor penghambat (inhibiting ( factor) pada masa awal pertumbuhan p p embrio int trauterin, , mempengaruhi segmentasi selanjutnya pada berbagai tingkatan.

Tipe Pre esentasi

Janin kembar I presentas si vertex 75% Kedua janin presentasi vertex v 45% Salah satu janin vertex, lainnya l bokong 37% K d j Kedua janin i presentasi i bokong b k 10%

tipe-tipe presentasi

Distribusi dari leta ak dan posisi janin kembar (dalam %) antara lain:
KEMBAR DUA KEM MBAR PERTAMA Ke epala Sungsang Lintang

Kepala Sungsang Lintang

39 26 8

13 9 4

0,6 06 0,6 0,6

Early Di iagnosis
Anamnesa Ultrasonografi

Gem melli

P Pemeriksaan ik klinis kli i

R di l i Radiologi

Diagnosis Awal A Twins

DIZYGOTIC

MONOZYGOTIC

Ultrasonografi g f kehamilan kembar p pada usia kehamilan 38-40 hari

Diagnosa dini gagal - P PJT & persalinan prem matur - P mortalitas & morbidita as perintal - P komplikasi Berdasarkan observasi o 36-37 mgg +++ Ptbh j Ptbhan janin i 24-35 24 35 mgg Amnion <<< plasenta l t matang++ t ++

Kematian intra ute erin 37-38 mgg

iff i l Diagn i nosis i Differential Kehamilan lewat waktu u Polihidramnion Tumor fibroid uterus Kista Mola hidatiforma

Anemia

Ato onia uteri Hidramnion

PPH K Komplikasi lik i maternal t l Retensio plasenta

Abortus

Partus prematur

Inersia uteri

Pre-eklampsia

Solusio plasenta
KPD

Malpresentas si

Plasenta Previa

Prematuritas

Komplikasi fetal f
BBLR Kelainan kongenital

I Insufisiensi fi i i plasenta l t

Prolapsus tali pusat

Komplikasi In ntrapartum Plasenta kebutuhan nutrisi>>

Insufisiensi plasenta Polihidramnion Kond disi lain

Prolapsus tali pusat

Malpresentasi

PPH

K Komplikasi lik i Peri P ipartum i t

Locked T i Twins

Solusio Plasenta

Tran nsfusion Syndrom

Penatala aksanaan
A. Tindakan umum - Diet & Pola makan yan ng baik - Besi B i & Asam A f folat l t - Aktivitas << & aktivita as +++ B. Pem. Klinis setiap 2mgg setelah 24 mgg - keadaan servik setelah 24 mgg gg - pengetahuan kehamilan preterm - pergerakan bayi setelah h 32 mgg

C. USG setiap 4-6 mgg se C etelah dignosis - kemungkinan plasent ta previa - kemungkinan kem ngkinan ganggu gangguan an pert pertumbuhan mb han janin - presentasi janin D. Nonstress test setelah setelah 32mgg - keadaan janin -p penekanan taki p pusat t E. Konsultasi perinatolog gi

Kembar discordant: janin resepien nt lebih besar dari pada janin donor abnormalitas ab o alitas arteriovenous a te iove ous tampa ta pa ak pada permukaan a pe u aa plasenta, plase ta, darah arteri kaya O2 donor bercam mpur dengan darah resepient

PENANGANAN N PERSALINAN
KALAU ANAK I SUNGS SANG ATAU LINTANG SEBAIKNYA S.CESAR. KALAU ANAK I P P.KEPA KEPA ALA DIUPAYAKAN DENGAN P/ VAGINAL ANAK A KE DUA DENGAN V.EKSTRAKSI. SELAMA DJJ NORMAL TIDAK ADA ALASAN UNTUK MEMPERCAPA AT KELAHIRAN ANAK KEDUA PENGAWASAN YANG KETAT K MENENTUKAN OUTCOME PERSALINA AN

anak pertama lintang atau sungsang dan anak kedua memanjang (terjadi posisi saling s mengunci interlocking)

Panduan penanganan p persalinan spontan pada kehamilan n kembar

Janin pertama Siapkan peralatan resusitasi i & perawatan bayi P Pasang i infus f & cairan i intrav i t vena Pantau keadaan janin, djj Periksa presentasi janin - vertex PSP, monitor pe ersalinan - bokong g indikasi SC - lintang SC Tinggalkan klem pada ujung g maternal tali pusat

 Janin kedua atau berikiu utnya Segera setelah bayi perta ama lahir: - Palpasi P l i abdomen bd let l tak kj janin i - lakukan versi luar - Periksa djj Periksa dalam - Presentasi janin kedua - keutuhan k h selaput l ketub k ban - Prolapsus tali pusat

Monoamniotic twins mortality

2 to 5% loss every 2 wee eks from 15 to 32 weeks 9% at 33 wks 29% at t 36-38 wks 95% cord entanglement (prenatal diagnosis 28%)

Comparison of rates s of complications in singleton and mu ultiple gestations

Complications Chorioamnionitis Premature rupture of membranes Fetal asphyxia Twin-twin transfusion Congenital malformations Hydramnios d i Abruptio placentae Placenta previa p Compression of cord Birth injury Prematurity Umbilical cord knots Rate for twins (increase) 4-fold 4-fold 5 fold 5-fold 1 of 9 monoamniotic twins 3-fold 1 of f 12 twins i 2-fold 2-fold 2-fold 10-fold 10 fold 10-fold 2-fold

Maternal morbidity and obstetric complications of f quadruplet d l pre egnancy (No. 22)
VARIABLE Antepartum hospitalization Hyperemesis gravidarum Hyperemesis gravidarum, total parentera al nutrition required G t ti l di Gestational diabetes b t mellitus, llit A1 Gestational diabetes mellitus, A2 Anemia (Hct < 30%), no antepartum tran nsfusion required Anemia (Hct < 30%), 30%) antepartum transfu usion required Antepartum bleeding Placenta previa Preeclampsia HELLP syndrome PPROM PTL Twin-twin transfusion syndrome Chorioamnionitis INCIDENCE (%) 100 9.4 3.1 18 8 18.8 3.1 25.0 15 6 15.6 3.1 0.0 71.9 2.5 18.8 100 3.1 6.3

I. Psychological Su upport and Clinical Couns seling li

All parents should be awa are that pathologies such as f t l growth fetal th retardation t d ti n, congenital it l anomalies, li abnormal placentation, abruptio placentae, fetal malpresentation and preterm delivery, occur more commonly in multiple than in i singleton pregnancy These aspects result in hi igher maternal and perinatal mortality and morbidity. e three to five times higher in Antenatal complications are multiple pregnancy than in singleton pregnancy. pregnancy From the first trimester onwards o is required to help parents to cope with poss sible negative outcome and also with the socio-econ nomic problems related to multiple birth.

The most important:

EARLY DIA AGNOSIS

WHY?

MULTIPLE PREGNANCY

HIGHHIGH -RISK PREGNANCY

COMPLICATIONS DURING G PREGNANCY SPECIFIC MALFORMATIO ON SEQUENCES HIGHER PERINATAL MOR RBIDITIY AND MORTALITY INTRAPARTAL COMPLICA ATIONS

DIAGNOSIS OF MULTIFETAL PREG GNANCY: SIMULTANEOUS VISUALIZATION V

two or more embryos

or corresponding p g bo ody yp parts of two or more fetuses

EARLY DIAGNOSI IS OF TWINS

The first visi ible structures:
1 GESTATIONAL SAC 2 YOLK SACS ( MC / BA )
YOLK SACS

fused

2 GESTATIONAL SACS 2 YOLK SAC ( BC / BA )

DIZYGOTIC

separated

MONOZYGOTIC

EARLY DIAGNOSIS OF TWINS

EMBRYOS AND AMNIO OTIC MEMBRANES A firm diagnosi is of the number of embr ryos after 7th we eek !

MONOCHO ORIONIC MONOAMN NIOTIC TWINS

HIGHHIGH -ORDER MULTIP PLE PREGNANCY

Pregnancy with three or more fetuses

three chorionic

three amniotic

2D multiplanar imaging

TRIPLETS

volume scanning volume rendering spatial reconstruction plastic imaging

3D reconstruction

FRONT

BACK

HIGH ORDER P PREG PRE GNANCY

QUADRUPLETS

HIGH ORDER P PRE REG RE GNANCY

HIGH ORDER PR REG RE GNANCY

SEPTUPLETS

HIGH ORDER PRE REG GNANCY

12 EMBRYOS

II. Correct Di iagnosis and Characterization n of Chorionicity

Multiple gestation should be suspected when the uterus is larger than predicted by p y menstrual history. y Approximately one fifth of multiple e gestations are monochorionic and four fifths are dichorionic. Type of placentation and chorionicity is helpful in the following three clinical situations: 1) The differe entiation of twin to twin transfusion syndrome (TTS) from a twin ge estation in which one fetus shows growth retardation; 2) the management of twins with congenital malformations, in which selective e feticide may be considered as an option if the gestation is dichorion nic and 3) the management of single fetal death in a multiple gestation. gestation The thickness of dividing membrane is in 85% of monochorionic twins ~ 2 mm, in DC/DA the membrane is ~ 4 mm The lambda sign is an indicator of o dichorionic pregnancy

II. Correct Di iagnosis and Characterization n of Chorionicity

The following criteria m must be fulfilled to diagnose monoamniotic twins:
1. 1 2. 3 3. 4. no dividing amniotic mem mbrane is present only one placenta is see en both fetuses are of the s same sex the fetuses must have adequate a amniotic fluid surrounding them 5. both fetuses must move e freely within the uterine cavity. cavity

Zigosity of spontane eus vs. ART triplets

Spontaneous triplets
TZ 26% TZ 84%

ART

Unknown 3% DZ 52% MZ 22% DZ MZ 12% 1%

adapted from m Derom, 2000

ACCURATE PRENATAL DIAGN NOSIS OF CHORIONICITY IS OF PRED DOMINANT IMPORTANCE FOR THE CLINIC CAL MANAGEMENT OF MULTIPLE PREGNANCIES S

EARLY DIAGNOSIS O OF CHORIONICITY

1st TRIMESTER

NUMBER OF GESTATIONAL SACS

EARLY DIAGNOSIS OF AMNIONICITY G OS S O O C

6 weeks

NUM MBER OF YOLK SACS

OR
NUM MBER OF VISIBLE VISIB E AMNIONS
7 weeks

EARLY DIAGNOSIS OF AMNIONICITY Why is it important? i

ALAR RM !
MONOCH HORIONIC AND D / OR MONOAMNI IOTIC TWINS

FETAL COMPLIC CATIONS

PECULIAR COMPL LICATIONS

Twin embolisation syndr rome ( vanishingvanishing-twin ) TwinTwin -to to-twin transfusio on syndrome ( TTS ) Twin reversed arterial perfusion ( TRAP ) Cord entan nglement Conjoined twins

SECOND AND THIRD TRIMESTE TRIMESTER R

NUMBER OF PLACENTAS

DETERMINATION OF THE CHORIONICITY IN SECOND TRIMESTER T

Sonographic counting of separated s placentas is an accurate t method th d of of determining d t i i the th chorionicity in the second s trimester

PLACENTA 1
TWO SEPARATED PLACENTAS

PLACENTA 2

MONOCHORIONIC BIAMNIOTIC TWINS

BICHORIONIC BIAMNIOTIC TWINS

BICHORIONIC BIAMNI IOTIC IOTIC TWINS

LAMBDA SIGN

BIAMNIOTIC BICHORIONIC TWINS

MONOAMNIOTIC MONOC CHORIONIC CHORIONIC TWINS

THE Y-S SHAPE ED JUNCTION JU C O

MERCEDES SIGN

Y-SIGN
TRICHORIONIC TRIAMNIOTIC TRIPLETS

III. Close Evaluation of Fetal Anatomy y

Fetal Malformations and Prena atal Genetic Diagnosis g

The incidence of malformation in monozygotic m twin pregnancies is twice that in dizygotics. Chromosomal anomalies are no mor re common in twins than singletons Anomalies not unique to twins but believed b to be increased in frequency because of mechanical factors are positional defects (such as clubfoot and congenital dislocation of the hip) due to intrauterine crowding. Additional anomalies due to vascular consequences of fetal death are congenital it l skin ki defects, d f t microcep i phaly, h l hydrancephaly, h d h l porencephaly, h l multicystic encephalomalacia, hydro ocephalus, intestinal atresia and limb amputation.

III Close Evaluation of Fetal Anatomy III.

Fetoplacental Markers in Tw win Pregnancies Affected by Down Syndrome Around one-third of twin pregnancies p are monozygous and their rate of Dow wn syndrome is relatively i d independent d t of f race and d ma aternal t l age. Dizygous twins are more common in older mothers and as they th arise i f from se eparate t f tili ti fertilisation of f two t simultaneously shed ova th here is double the age-related risk than for a singleton pr regnancy that either twin will have Down syndrome

EPIDEMIOLOGY OF O CONGENITAL ANOMALIES S IN TWINS

Anomaly rates for:

singletons twins

2- 4 % 5 - 10 %

Incidence of congenital ano omalies is 2 - 3 x higher in twin than in singl leton pregnancy. Monozygotic twins ha ave an anomaly rate 50% higher g than dizygotic d yg twins.

CONJOINED (SIAM MESE) TWINS

INCIDENCE 1: 50 000 BIRTHS

ULTRASOUND CRITERIA FOR DIAGNOSIS:

1) LACK OF SEPARATE VIS SUALISATION OF FETUSES IN SPECIFIC C ANATOMICAL REGIONS 2) FIXED POSITION OF THE E TWIN TOWARD EACH OTHER 3) MISSING SS G S SEPARATING G MEMBRANE M

PATTERNS OF PHYSI ICAL JOINING ICAL

SYMMETRICAL COMPLETE FORM

Two fetuses share a certain amount of tissue Surgical separation is possible in general.

PATTERNS OF PHY YSICAL JOINING YSICAL

SYMMETRICAL INCOMPLETE FORM

Surgical separation is usually impossible

EARLY DIAGNOSIS OF CONJOINED TWINS

Conjoined twins: subtotal fusion with partial separation of fetal heads

CONJOINED TWINS

THORACOTHORACO O OMPHALOPHAGUS
lack of separate vis sualisation of fetuses in thoracothoraco-ab bdominal region

THOR RACOOMPHALOPHAGUS
FIVE E - VESSEL CORD

COLOR DOPPLER SINGLE SHARED UMBILICAL L CO CORD

VI. Avoidance of f Most Frequent Compli p cations

Complications of multiple pregna ancies comprise: Abortion, , Vanishing twin syndrome Malformation Vasa V previa i Growth discrepancy Intra uterine growth restriction n (IUGR) Polyhydramnios Preeclampsia Preterm-premature rupture of f membranes (P-PROM) Preterm delivery Gestational diabetes Intrauterine fetal death.

VANISHING TWIN N

in 20% of twin twins s

single fetal demise

high high-risk surviving twin int intra rauterine uterine hematomas better prognosis in dichorio onic thromboplastine embolisation e

SUBCHORIONIC HAEMATOMA

VANISHING TWIN

VII. Consideration n of Some Specific Pathologies

Twin to Twin Transfusion Syndrome S (TTS) Is associated with a high ra ate of mortality and and, among survivors, substantial morb bidity. Diagnostic g criteria include: monochorionic pregnancy; p g y; same sex with growth disco ordance between twins; olygohydramnios of the gro owth retarded fetus and polyhydramnios of the larger twin; an intertwin hemoglobin difference > 5m mg/dl (after cordocentesis). Antepartum management o of TTS is not without controversy, because no su uggested therapy is without problems. The three types of vascular anastomoses, A-A, V-V and A-V, are generally pres sent in monochorionic placentae

MONOCHORONIC / BIAMNIOTIC IAMNIOTIC: : TWIN TO TWIN TTTS TRANSFUSION SYND DROME MONOAMNIOTIC: UMBILICAL CORD EN NTAGLEMENT ACARDIAC TWIN - TR RAP SEQUENCE CONJOINED TWINS

TWIN TO TWIN TRANSFUSION SYNDROME

5% - 20% monochorionic twins arterio veno ous anastomoses discordant growth

DONOR
OLIGOHYDRAMNIOS IUGR MICROCARDIA ANEMIA fetal loss 80%

RECIPIENT
P POLYHYDRAMNIOS M MACROSOMIA, HYDROPS C CARDIOMEGALIA P POLYCYTHAEMIA

TWIN TO TWIN TRANSFUS SION SYNDROME SCALP EDEMA

RECIPIENT:
F t l hydrops Fetal h d

ASCITES

TWIN TO TWIN TRANSFU USION SYNDROME

POLYHYDRAMNIOS OF RECIPIENT TWIN

fixed twin anhydramnios h d i

collapsed amniotic membra ane

DONOR:
St k t Stuck twin i

TWIN TO TWIN TRANSFU USION SYNDROME

TWIN TO TWIN TRANSF FUSION SYNDROME

TWIN TO TWIN TRANSFU USION SYNDROME

Recipient : venous return pattern

UMBILICAL VEIN SONOGRAM IN RECIPIENT TWIN DUCTUS VENOSUS SONOGRAM IN RECIPIENT TWIN

PULSATIONS WITH REVERSEREVERSE - FLOW AT THE END OF DIASTOLE

REVERSAL OF FLOW DURING ATRIAL CONTRACTION

TWIN TO TWIN TRANSFU USION SYNDROME

Plethoric
RECIPIENT

Anaemic
DONOR Weight t difference > 25% Haemoglobin difference >5%

VASCULAR AN NASTOMOSES IN A TWIN PLACENTA: superficial

deep
ARTERIO ARTERIO VENO VENOUS ARTERIOUS VENOUS

SURFACE ANASTOMOSES
VISUALIZATION WITH POWER ANGIO MODE

VII. Consideration n of Some Specific Pathologies

Twin Reversed Arterial Perfusion (TRAP) Sequence ation of twin to twin transfusion The most extreme manifesta syndrome, found in approxim mately 1% of monozygotic twin pregnancies is acardiac twinning (acardius chorioangiopagus parasiticus s). s) The underlying mechanism is s thought to be disruption of normal vascular perfusion an nd development of the recipient twin due to an umbi ilical arterial-to-arterial anastomosis with the donor or o pump twin. At least 50% of donor twins die d due to congestive heart failure or severe preterm deli ivery, the consequence of polyhydramnios. polyhydramnios All perfused twins die due to the associated multiple malformations.

TWIN REV VERSED ARTERIAL PERFUSION P

(TRA AP)
IN MONOCHORIONIC C TWINS ONE TWIN ( PUMP-TWIN ) ACT TIVELY PERFUSES THE SECOND TWIN ( PERFUSED TWIN ) VIA LARGE A -A AND/O OR V - V ANASTOMOSES

1% of monozygotic twins are affected Incidence 1 : 3 35 000 births

PATHOGENESI IS
ARTERIAL SUPPLY INTO O PLACENTA BY THE PUMP TWIN IS ABLE A TO OVERCOME THE BLOOD D PRESSURE OF THE CO TWIN SO AS TO PER CO-TWIN RFUSE THAT TWIN BY REVERSED FLOW (TOWARD CO-TWIN) IN THE UMBLICAL ARTE ERIES OF THE CO-TWIN

TRAP
NORMAL
( PUMP TWIN )

PERFUSED TWIN

ACARDIUS NORMAL FLOW

REVERSE FLOW

BLOOD FLOWS FROM AN UMBILICAL ARTERY OF THE PUMP TWIN IN REVERSE DIRECTION VIA ARTERIO - ARTERIAL ANASTOMOSES INTO UMBILICAL ARTERY OF THE PERFUSED TWIN.

THE UMBILICAL VEIN OF THE PA ARASITIC FETUS RETURNS THE BLOOD INTO THE E PLACENTA AND BACK TO PUMP TWIN

PATHOGENESIS OF FET TAL DYSMORPHIA:

EARLY REVERSE E OF CIRCULATION
REVERSE PASSIVE E PERFUSION OF TWIN PERFUSION IN OPP POSITE DIRECTION AND PERFUSION WITH DEOXIGENATED D BLOOD INDUCTION OF DEVEL LOPMENTAL DISORDERS

REDUCTION ANOMA ALIES ( EXTREMITIES ) DEVELOPMENTAL ATROP PHIES ( HEART AND BRAIN )

Ultrasound finding = early ultrasound detection

the most bizzarre feta al malformations

PUMP - TWIN
normal morphology normal direction of blood flow

PERFUSED TWIN
acardius
reduction anomalies of head and extremities

reversed blood flow

TWINS MC / MA, MA 15 wks k

COLOR DOPPLER

REVERSED PERFUSION

ULTRASONIC U SO C C CRITERIA FOR O ACARDIUS C US

An am morphous mass with its ow wn umbilical monochorioniccord in monochorionicmono oamniotic twin pregnancy p

ACARDIAC - AC CEPHALIC
No trunk and head No heart and d brain b i

This acardiac twin n consists mainly of lower ex xtremities

VII. Consideration n of Some Specific Pathologies

Stuck Twin Refers to the ultrasonog graphic finding of one of a monochorionic diamnio otic twin pair in an oligohydramniotic sac fixe ed in a location adjacent to the uterine wall. This is frequently a manif festation of the twin-to-twin twin to twin transfusion syndrome (TT TS). Management may inc clude: selective feticide; umbilical cord ligation of one o twin; laser occlusion of anastomosing placen ntal vessels; serial amniocentesis. i t i

CORD ENTAGLEME ENT ENT

COMPLICATION SPECIFIC FOR MONOAMNIOTIC MONOCHORIONIC TWINS

CORD ENTANGLEM MENT

MONOAMNIOTIC TWINNING
THE CLOSE INSERTION OF F THE UMBILICAL CORDS INTO PLACENTA IS S ASSOCIATED WITH: LARGELARGE -CALIBER ANASTOM MOSES AND

HIGH PREDISPOSITION N FOR ENTANGLEMENT

CORD ENTANGLEMENT ENTANGLEMENT

COLOR DOPPLER POWER DOPPLER

TWINTWIN -TO TO-TWIN TRANSFUSION T

should be considered whe en growth discordancy i di is diagnosed di in monoch h i i gestations horionic t ti

Multiple gestations pr resent a significant decrease de crease in fetal growth g which is in direct relationship to the number of fetuses in high or rder pregnancies

VIII Close Monit VIII. toring of Fetuses

Doppler D l Velocimetry V l i t Recent studies have addressed a the usefulness of this tech hnique in predicting twin fetuses small for gesta ational age (SGA) or IUGR, twins with TTS, , and those with discordant growth

VIII Close Monit VIII. toring of Fetuses

Cardiotocography C di t h Is not always easy to identify the twins and it is possible to perform two NSTs on the same fetus. The best method is the simultaneous g of FHR p patte erns on one tracing. g recording

SPONTANEOUS MOT TORIC ACTIVITY

COMPLEX BOD DY MOVEMENTS HICCUPS HAND HAND-FACE FACE CO ONTACTS MOUTH OPENIN NG SWALLOWING BREATHING MO OVEMENTS HEAD MOVEME ENTS EXTREMITY MO OVEMENTS JUMPING TWISTING STRETCHING YAWNING

FETAL ACT TIVITY

COMPLEX BODY MOVEMENTS NO INTERTWIN CONTACTS

FETAL ACT TIVITY

NO INTERTWIN CONTACTS

EXTREMITY MOVEMENTS

INTERINTER -TWIN CONTACTS C

FIRST REACH AND TOUCH FIRST REACTION SLOW OR FAST ARM, LEG, HEAD OR BODY CONTACT MOUTH CONTACT COMPLEX INTERACTIONS

TRIPLET ACTIVITY AND CONTACTS

HEAD TO BODY CONTACT

JUMPING

The Ten Com mmandments in Multiple P Pregnancies

I. Psychological y g Support pp and Clinical C Counseling g II. Correct Diagnosis and Characterization of Chorionicity III. Close Evaluation of Fetal Anatomy A IV. Management at Referral Centers C V Individualization of Care V. VI. Avoidance of Most Frequent Complications VII Consideration of Some Sp pecific Pathologies VIII. Close Monitoring of Fetus ses IX Planning of Time and Mode of Delivery IX. X. Monitoring of the Mother During Postpartum

Ultrasound Ult d assessment t of f multiple lti l pregnancy:

1. 1 2. 3. 3 4. 5. 5 6. 7. 8. EARLY DIAGNOSIS OF MULT TIPLE PREGNANCY DIAGNOSIS OF CHORIONICITY AND AMNIONICITY COMPLICATIONS IN MONOC CHORIONIC TWINS FETAL CONGENITAL ANOMA ALIES APPROPRIATE VERSUS DIS SCORDANT GROWTH COLORCOLOR-DOPPLER OF MULT TIFETAL PREGNANCY PREDICTION OF PRETERM DELIVERY INTRAPARTUM ULTRASONO OGRAPHY