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GESTATION (MFG)
Types OF MFG
Monozygotic or Identical twins
Dizygotic or Fraternal twins Higher Order MG
MFG-Incidence
Dramatic increase in the past 30 years
ART
Old maternal age at birth
Superfetation Vs Superfecundation
In superfetation, an interval as long as or longer
MZ Twinning
Despite virtually the same genetic heritage,
MZ twins Usually are not identical bs/e of
Unequal sharing of protoplasm
Discordant mutations
Postzygotic mutation
Inherited mutations with varying expression
Eg. differential expression of sex linked traits and
diseases in female fetuses due to skewed lyonization
(Glinianaia, 2008).
Post zygotic loss of Y chrs X0 (Turners) with female phenotype
and Normal 46XY male sibling
MZ Twining
MZT may vary by amniocity and chorionicity
depending on division time after fertilization.
1. Dichorionic, Diamniotic
cleavage at 0-4days (at morula stage)
single fused or two separate placenta
The lowest risk among monozygotic
2. Monochorionic+diamniotic
cleavage at 4-8days( Blastula)
I.e.one placenta two AF.
Risk of TTT
3. Monochorionic+monoamniotic
8-12 days( embryonic disc cleavage)
The highest risk ( mainly cord entanglement)
5/14/2016
SAMUEL BEZABIH
11
Dizygotic(Fraternal) Twining- DZ
Risk factors
Race ( Yorube tribe of Nigeria ,1/ 20 birth ,
high level of FSH- High rate of DZ twins, the reverse is true
for Japanese women) (Knox and Morley (1960)
Age
peak at the age of 37:,
Maximal FSH stimulation - multiple follicles (Beemsterboer, 2006)
Increased ART use- more likely older women Ananth 2012 )
DZT frequency 4x increase b/n 15 and 37 (painter 2010)
Heredity
the family history of the mother is more important than
that of the father
Risk factors---DZT
Parity
Increasing parity has been shown to
independently increase the incidence of twinning
in all populations studied.
Infertility Treatment
Ovulation induction (FSH +CGTH /Ccitrate) and ART
(IVF-Transfer of multiple embryos- lkelihood of MG)
DZT.RFs
This may be due to the sudden release of
pituitary gonadotropin in amounts greater
than usual during the 1st spontaneous cycle
after stopping hormonal contraception.
Indeed, the paradox of declining fertility but
increasing twinning with advancing maternal
age can be explained by an exaggerated
pituitary release of FSH in response to
decreased negative feedback from impending
ovarian failure (Beemsterboer, 2006).
Sex Vs Zygosity
Chorionicity Vs Zigosity
Monochorionic twins are always MZ,
Approximately 70% of MZ twins are
monochorionic and 30% will have a
dichorionic placentation
Rarely, however, MC twins may in fact be dizygotic
(Hack, 2009).
Mechanisms for this are not yet clear but all
reported cases were concieved by ART
procedures. Ekelund and coworkers (2008)
Diagnosis Of MFG
Clinical
Ultrasound is used to determine Fetal number,
Chorionicity and Amniocity
Chorionicity
DC-lambda/ Twin Peak sign
T sign
Vanishing Twin
Loss /death of one fetus before 2nd trimester
The other develop to term and delivered as
singleton
The incidence of twins in the first trimester is
much greater than the incidence of twins at
birth.
one twin is lost or vanishes before the
second trimester in up to 10 to 40 percent of
all twin pregnancies (Brady, 2013).
The incidence is higher in the setting of ART.
Pregnancy Complication in MG
Fetal and infant complications
Abortions/Miscarriages
Preterm delivery
Low birthweight
FGR
Cerebral Palsy
PNM
Fetus acardiacus
Fetus papyraceous
Congenital anomalies
Pregnancy Complication in MG
The incidence of congenital malformations is appreciably increased
in multifetal gestations compared with singletons.
Glinianaia and associates (2008) reported that the rate of
congenital malformations was 406 per 10,000 twins versus 238
per10,000 singletons.
MC 2X more risk than DC
III.
Pregnancy Complication in MG
Pregnancy Complications
Low Birth Weight
LBW more in MG than singletones due to FGR and
PT birth
Weight parallels that of singleton till 28 -30wk, then
lags with clear divergence beginning 35-36 weeks
Incidence of overt FGR at 38 wk- 4x & half of twins
are affected
Based on growth curve of singletons
Pregnancy Complication in MG
Maternal Complications
Increased medical complications than in
singleton pregnancies
HEG, GDM, HTN, Anemia
Hemorrhage
Polyhydramnios + 20 obstructive uropathy
Cesarean Delivery
Post partum Depression
Pregnancy Complications
Prolonged Pregnancy
Bennett and Dunn (1969) suggested that a twin
pregnancy of > 40 weeks should be considered
postterm.
Twin stillborn neonates delivered at > 40 weeks
commonly had features similar to those of
postmature singletons
Incidence of Twin Pregnancy Zygosity and Corresponding TwinSpecific Complications Will 24th
Monoamniotic Twins
1% of MZ / 1 in 20 MC twins
High fetal death rate -10% resulting from
MA Twins
Color flow Doppler Sonography can be used to
diagnose entanglement
women with Monoamniotic twins are
recommended to undergo 1 hour of daily fetal
heart rate monitoring, beginning at 26- 28 weeks.
With initial testing, a course of betamethasone is
given to promote pulmonary maturation.
If fetal testing remains reassuring, cesarean
delivery is performed at 34 weeks and after a
second course of betamethasone.
Deep AV anastomosis
Common villous compartment/3rd circulation
Shunt depending on pressure and gradient
ConsequencesTwin Twin Transfusion syndrome (TTTS) ,
TRAP Sequence, Acardiac Twinning
TTTS
The prevalence TTTS is app 1- 3 /10,000 births (Simpson, 2013).
Unidirectional Blood flow through AV anastomosis
(Donor Recipient)an imbalance in blood volumes
Deoxygenated O blood in the Donors (D) Umbilical Artery is pumped
into shared Cotyledon Oxygenation in the chorionic villus Blood
leaves Villus through the Recipients (R) placental Vein
Donor
anemic, growth restricted, oligohydramnios- Stuck, Pale
contractures, and pulmonary hypoplasia
Recipient
polycythemic, Plethoric appearance
Circulatory overload/ Hypervolemia-Heart Failure-Hydrops,
Hydramnios
Hyperviscosity~~ Occlusive thrombosis,
Hyperbilirubinemiakernicterus
TTTS
Clinically important TTTS chronic with significant
vascular volume difference
Typical presentation ( mid pregnancy )
Hypovolemic Donor- reduced RBF Oliguria,
Oligohydramnios stuck (No AF, No motion)
Recipient- too much urine- Severe Hydramnios
polyhydramnios-oligohydramniossyndromepolyoli.
Staging
Quintero staging system(1999)
TTTS- Staging
Stage II
criteria of stage I, but urine is not visible within the donor's
bladder.
Stage III
criteria of stage II and abnormal Doppler studies of the umbilical
artery, ductus venosus, or umbilical vein
Umbilical Artery- Abscent/Reverse EDF,
Ductus Venosus- abscent/ REDF,
Umbilical Vein-Pulsatile flow
Stage IV
ascites or frank hydrops in either twin; and
Stage V
demise of either fetus.
Treatment Options
Serial amnioreduction
Laser ablation of anastomosis
Septostomy
Selective feticide
Methods
UV/Umbilcal cord occlusion of the selected T using;
radiofrequency ablation,
fetoscopic ligation, or
coagulation with laser, monopolar, or bipolar cauterization
(Challis, 1999; Chang, 2009; Donner, 1997)
Growth Discordance
Affects ~15% of Twin pregnancies
More common in MC than DC (b/se of
unequal sharing of the common placenta,
aside from TTTS)
Typically occurs late 2nd or 3rd T
Poor prognosis if seen before 20week
Diagnosis
AC difference of > 20mm
Wt difference of > 20% ( >25-30%- most accurately
predict adverse perinatal outcome)
DZ
Vascular anastomosis
Unequal sharing of
placenta (probably the
Difference in genetic
growth potential Esp.
in opposite sexes
Placental implantation
site difference- sub optimal
most important
determinant)
Discordance for
structural anomalies
implantation site- GR
Placental pathology
Iux crowding
Growth Discordance-Management
Delivery
no sufficient data about optimal time
Size discordance alone doesnt prompt delivery,
except occasionally at advanced GA
RCOG (2008)- 37wk for MC and 38wk for DC
The
End
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