MULTIPLE GESTATION

LEONARD EVAN MELLA

NADIA VINKA LISDIANTI
Incidence
The incidence of multiple gestations has risen
significantly, primarily due to increased use of fertility
drugs for ovulation induction, superovulation, and
assisted reproductive technologies (ART), such as in
vitro fertilization (IVF).

The perinatal mortality rate of twins is 34 times
higherand for triplets much higher stillthan in
singleton pregnancies.

Approximately two-thirds of twin pregnancies end
in a singleton birth.
Maternal Risks
Hypertension
Preterm birth
Anemia
Gestational diabetes mellitus
Postpartum hemorrhage
Maternal death
Placenta previa
Fetal Risks
Congenital malformations
Low birth weight
Twin-twin transfusion syndrome
Fetal growth restriction
Fetal demise (death of one fetus puts other at risk for DIC)
Vanishing twin


Types of Twins
Multiple
Gestation
Dizygotic
Monozygotic
A single
fertilized ovum
divides into 2
separate
individuals
Produced
from
separately
fertilized ova.
Most common
Monochorionic, Diamniotic
A single placenta
Rare
Monochorionic,
Monoamniotic
A single placenta
Dichorionic, Diamniotic
Separate or fused
placentas
Monochorionic,
Monoamniotic
Fused placenta

Dichorionic, Diamniotic
Separate placenta


MONOZYGOTIC
DIZYGOTIC
Dizygotic Twins
Twins of different sexes are always dizygotic
(fraternal).
More common among women who become
pregnant soon after cessation of long-term oral
contraception.
Clinical Findings
Symptoms
Earlier and more pressure in the pelvis
Nausea, backache, varicosities, constipation,
hemorrhoids, abdominal distention, difficulty in
breathing
A large pregnancy
Fetal activity is greater and more persistent

Clinical Findings
Signs
Uterus larger than expected (>4 cm) for dates.
Excessive maternal weight gain that is not
explained by edema or obesity.
Polyhydramnios, manifested by uterine size out of
proportion to the calculated duration of
gestation, is almost 10 times more common in
multiple pregnancy.
History of assisted reproduction.
Elevated maternal serum fetoprotein (MSAFP)
values.
Clinical Findings
Signs
Outline or ballottement of more than 1 fetus.
Multiplicity of small parts.
Simultaneous recording of different fetal heart
rates, each asynchronous with the mothers pulse
and with each other and varying by at least 8
beats/min. (The fetal heart rate may be
accelerated by pressure or displacement.)
Palpation of 1 or more fetuses in the fundus after
delivery of 1 infant.
Laboratory Findings
Maternal hematocrit and hemoglobin values an the
red cell count usually are considerably reduced.
Maternal hypochromic normocytic anemia.
Ultrasound Findings
Dichorionicity:
Fetuses of different genders
Separate placentas
A thick (>2 mm) dividing membrane
A twin peak sign in which the membrane inserts
into 2 fused placentas
Monochorionicity:
Absence of those findings
Ultrasound Findings


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UNIQUE FETAL
COMPLICATIONS



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Conjoined Twins
Conjoined twins result from incomplete
segmentation of a single fertilized ovum between
the 13th and 14th days.
If cleavage is further postponed, incomplete
twinning (ie, 2 heads, 1 body) may occur.
Conjoined Twins
Described by site of union:

EXTERNAL PARASITIC
TWINS
This is a grossly defective fetus or merely fetal parts,
attached externally to a relatively normal twin.
A parasitic twin usually consists of externally attached
supernumerary limbs, often with some viscera.
A functional heart or brain is absent. Attachment mirrors
those sites described earlier for conjoined twins.
Parasites are believed to result from demise of the
defective twin, with its surviving tissues attached to and
vascularized by its normal twin.

FETUS IN FETU
Early in development, one embryo may be enfolded
within its twin.
Normal development of this rare parasitic twin usually
arrests in the first trimester. As a result, normal spatial
arrange- ment of and presence of many organs is lost.


Vascular Anastomoses
Twin-Twin Transfusion
Syndrome
Local shunting of blood occurs because of vascular
anastomoses to each twin that are established early
in embryonic life.
Affects approximately 15% of monochorionic twin
pregnancies.
Does not occur in dichorionic twins.
Interestingly, does not occur in monochorionic,
monoamniotic twins.
Twin-Twin Transfusion
Syndrome
Twin-Twin Transfusion
Syndrome
The recipient twin:
Plethoric, edematous, hypertensive
Ascites and kernicterus
The heart, liver, and kidneys are enlarged
Fetal polyuria hydramnios
The donor twin:
Small, pallid, dehydrated (from growth restriction,
malnutrition, and hypovolemia)
Oligohydramnios

Twin-Twin Transfusion
Syndrome
Obstetrical Management
Serial removal of amniotic fluid for polyhydramnios if
> 20 weeks gestation
Create an opening in amnion between the two
fetuses to allow fluid exchange
Laser ablation of placental vascular anastomoses
(high complication rate)
Selective reduction of donor twin if high risk of death
for both twins
Large volume amnioreduction
Amniotic Septostomy
Fetoscopic Laser Ablation
Acardiac Twins (TRAP)
A parasitic monozygotic fetus without a heart. It is
thought to develop from reversed circulation,
perfused by 1 arterialarterial and 1 venousvenous
anastomosis.
Treatment
Ultrasound and/or maternal serum testing
Amniocentesis and chorionic villus sampling
Prenatal
Diagnosis
Ultrasonography
Routine growth scans on twins every 4 weeks in the third
semester or more frequently if growth restriction is
detected
Iron and calcium supplementation, vitamin and folic
acid administration, a high protein diet,
supplementation with Mg, Zn, and essential fatty acids
Tocolytic drugs may be used
Antepartum
Management
Labor and Delivery
Admit the patient to the hospital if:
First sign of suspected labor or preterm labor
There is leakage of amniotic fluid
Significant bleeding occurs
>4 contractions per hour at <34 weeks gestation
Ultrasound evaluation
Continuous electrical fetal heart rate monitoring
Insert an IV line and send specimen of blood for
typing, antibody screening, and CBC
Labor and Delivery
Indications for primary caesarean section:
If either twin show signs of persistent compromise
Malpresentation
Monoamniotic twins
Gross disparity in fetal size
Placenta previa
Labor and Delivery
Intrapartum twin presentations:
Labor and Delivery
The umbilical cord should be clamped promptly
Perform a vaginal examination immediately after
delivery of twin A
Tag and label the cords (twin A and B)
Locked twins can be avoided by caesarean
delivery in all cases
Labor and Delivery
Increased intravenous oxytocin, elevation, and
massage of the fundus and an intravenous ergot or
prostaglandin product (only after the last fetus is
delivered) may be required.
Manual extraction of the placenta may be
necessary.
Prophylactic rectal misoprostol in the operating
room followed by oral misoprostol every 6 hours for
24 hours after delivery for all multiple gestations.
Laporan Kasus
I. Identitas (20 Juli 2014 pukul 21.00)
Nama Pasien : Ny. M
Umur : 35 tahun
Pendidikan : SMA
Pekerjaan : Pegawai Swasta
Agama : Islam
Suku : Betawi
Alamat : Duren Sawit

II. Subjektif :
1. KU : Mulas-mulas
2. KT : -

3. Riwayat Penyakit Sekarang
Pasien datang ke IGD RS UKI dengan keluhan perut terasa
mulas pada bagian kanan sejak 1 minggu SMRS.
Keluhan ini dirasakan terus-menerus dan semakin lama
terasa semakin mules. Keluhan tidak berkurang dengan
perubahan posisi. Keluar cairan bercampur darah dari
vagina disangkal. Pasien selalu kontrol kehamilan di
poli RS UKI. Kontrol terakhir 1 minggu yang lalu (12
Juli 2014) dan dinyatakan pasien hamil gemeli. Usia
kehamilan saat ini 32 minggu.
4. Riwayat Haid
Haid pertama : 9 tahun
Siklus : tidak teratur
Lamanya : 7 hari
Banyaknya: 4x ganti
pembalut /100 cc
HPHT : 5 Des 2013
TP : 12 september
2014
Sakit saat haid : disangkal
5. Riwayat Perkawinan :
Status Pernikahan : menikah
Jika menikah : 1
Lama perkawinan : 2 tahun
6. Riwayat Kehamilan Persalinan, nifas yang lalu : Ini
7. Riwayat Penyakit Dahulu : Disangkal
8. Riwayat Penyakit Keluarga : Disangkal
9. Riwayat Operasi : Disangkal
10. Metode KB : Tidak menggunakan KB
11. Riwayat ANC
Waktu hamil periksa di : RS UKI Oleh dr. Januar
Simatupang Sp.OG, Keluhan, kelainan, dan masalah :

Waktu ANC Usia Kehamilan Tempat Masalah Penatalaksanaa
n
0 0-12 mgg - - -
1x 13-28 mgg RS UKI Hamil
gemeli
-
1x 29 mgg sekarang RS UKI Hamil
gemeli
-
II. OBJEKTIF
A. Pemeriksaan Umum / Status Generalis
Tinggi badan : 160 cm
Berat Badan : 75 kg
Keadaan Umum : baik
Kesadaran : Komposmentis
1. Tanda Vital
TD : 110/80 mmHg
Nadi : 84 x/menit
Suhu : 36,2
0
C
Pernapasan : 20 x/menit


2. Kepala
Mata :
i. Konjungtiva: tidak
anemis
ii. Sklera : tidak ikterik
iii. Gigi : Lengkap,
karies (-)
iv. THT : dalam batas
normal
3. Leher : KGB tidak
teraba membesar
4. Thoraks :
a. Payudara : massa (-/-)
retraksi (-/-) nyeri (-/-
)
b. Jantung : BJ I & II
reguler, gallop (-)
murmur (-)

C . Paru-paru :
I : pergerakan dinding
dada simetris ka/ki
P : VF simetris ka/ki
P : sonor ka/ki
A : BND vesikuler, Rh -
/- Wh -/-
5. Abdomen :
I : Perut tampak
membuncit
A : BU sulit dinilai
P : Defense muskular
(+) hepar dan limpa
sulit dinilai
P : nyeri ketok (-)


6. Ekstremitas :
Superior : akral
hangat, CRT < 2
edema -/-
Inferior : akral
hangat CRT < 2
edema +/+
B. Pemeriksaan
Obstetrik
1. Pemeriksaan Luar
a) I : perut tampak
membuncit, linea nigra
(+) striae gravidarum
(+)
b) P : TFU 36 cm
Leopold I :
Teraba 2 bagian terbesar
janin bulat, keras,
melenting, kesan kepala
janin gemeli
Leopold II :
Teraba bagian memanjang
tidak terputus-putus pada
sebelah kiri ibu punggung
kiri janin gemeli
Leopold III :
Teraba bagian bawah janin,
bulat, lunak, tidak
melenting, kesan bokong
Leopold IV
2. Perabaan Perlimaan :
3. HIS :
Frekuensi : 2x / 10 menit
Lamanya : 60
Kekuatan : kuat
Relaksasi : ada, lamanya
5 menit

c) Auskultasi :
DJJ :
i. Frekuensi : 140 x
ii. Irama : tidak teratur

2. Pemeriksaan Dalam
a. Inspekulo : tidak
dilakukan
b. VT :
Vulva / vagina :
tenang, rugae (+)
tidak teraba massa
Portio
Axis : posterior
Konsistensi : Lunak
Penipisan : 20 %
Pembukaan : 1-2 cm
Ketuban : utuh
Bagian terendah janin :
Turunnya bagian terendah : Hodge
Denominator : belum dapat dinilai
Caput : belum dapat dinilai
Moulage : belum dapat dinilai
Taksiran Berat Janin (TBJ) :

III. ASSESMENT
A. DIAGNOSIS KERJA :
Ibu : G1POAO hamil 32 minggu partus prematur
iminens

Janin : Janin Gemeli hidup
B. PROGNOSIS :
Kehamilan : dubia et malam
Persalinan : dubia et malam

C. DAFTAR MASALAH
1. Janin Gemeli
IV. PLANNING
1. Rencana pemeriksaan untuk konfirmasi diagnosis
Observasi keluhan utama, TTV, DJJ, HIS
Periksa Lab H2TL MP3 HbSAg
Rencana USG
2. Rencana pengobatan / penatalaksanaan khusus
Bila berlanjut inpartu RSC
Diet Biasa
Infus RL
MM :
Dexametasone
Nifedipine
Tramal Supp 1x1

3. Informed Consent
Menjelaskan kepada pasien tentang kehamilan dan
rencana persalinan yang dilakukan
Motivasi lakstasi dan KB
THANK YOU