Professional Documents
Culture Documents
Maternal Labour
complications
Fetal Puerperium
Content
1. Overview
2. Determining
chorionicityand
planningcare
3. Problemspecificto
monochorionic and
monoamniocity twins
4. Recommendationsfor
multifetalpregnancy
• Incidenceofspontaneoustwins
:1in80pregnancies triplets:1in
8,000pregnancies
• Incidenceof
Monozygotictwins:3.5per1000births.
Dizygotic twins: 6.7/1000births(Japan),
40/1000births(Nigeria).
Indonesia: ????
Risk of Multiple Fetal Pregnancy
↑ Spontaneous abortion ( 3 x)
↑ Congenital malformation
NICU
25 %of twins,
75 %of triplets
Content
2. Determining
chorionicityand
planningcare
Key priorities for
implementation
Determining gestational age and
chorionicity
1st trimester ultrasound scan
CRL is 45 -84 mm (11w 0d - 13w6d): GA, chorionicity and screen
for Down's syndrome.
3. Problemspecificto
monochorionic and
monoamniocitytwins
Specific to Monochorionic:
Twin-Twin transfusion syndrome
• 10-15% of monochorionictwins.
• Typically around mid-gestation
GAatbirth
Outcome
Intrauterine fetal brain
ischemia
Specific to Monochorionic
Specific to Monochorionic
• Antenatal diagnosis:
Doppler ultrasound abnormalities
showing an increased peak
systolic velocity in the MCA in the
donor twin, suggestive of fetal
anemia, and decreased velocity in
the recipient twin, suggestive of
polycythemia, without
concomitant signs of TOPS.
Specific to Monochorionic
Specific to Monochorionic:
Twin Reversed Arterial Perfusion
• 1: 35,000 births
• Malformed fetus without a cardiac pump being
perfused by a structurally normal (pump) twin
via an A-to-A anastomosis in a reverse direction.
• Perinatal mortality of the pump : 35 to
55% increased intrauterine volume leading
to preterm delivery, cardiac failure, or
intrauterine growth restriction due to hypoxia
(Lewi L, et all, 2010)
Specific to Monochorionic
Problems for Monoamnionicity
• Rare < 1%
• Mortality rate 10-15%
• Cord entanglement: cord entanglement does not
contribute to prenatal morbidity and mortality
(Rossi AC, Prefumo F, 2013)
• Perinatal mortality
• Preterm Delivery: elective cesarean delivery
starting from 32weeks GA (ACOG 2014)
4. Recommendationsfor
multifetalpregnancy
ACOGpractice bulletin no. 144(2014)
LevelA:
• There is no role for the prophylactic use ofany
tocolytic agent in women with multifetal
gestations, including the prolonged use of
betamimetics for this indication.
• Progesterone treatment does not reduce the
incidence of spontaneous preterm birth in
unselected women with twin or triplet gestations
and, therefore, is not recommended.
ACOGpractice bulletin no. 144 (2014)
Level B
Determination of chorionicity by late first trimester
or early second trimester in pregnancy is important
for counseling and management.