GEMELLIMentor:

Dr. Pim Gonta, SpOG

Presentant:RenieMariaRicco

Grace AlvinaSteffanus S

SteffiVera

DEFINITION

Pregnancy with two fetus or more.

EpidemiologyGreulich (1930), the frequency of

gemelli in 121 pregnancies are:◦Gemelli 1 : 85◦Triplet 1 : 7.629◦Kuadruplet 1 : 670.743◦Quintiplet 1 : 41.600.000

`

UK data showing temporal trend since 1985 in incidence of twin (solid line, left y axis) and triplet pregnancies (dashed line, right y axis)/1000

maternities (Source: UK Office National Statistics).

Factors that influencing twinningRace.Heredity.Maternal age.Parity.Drugs for ovulation induction and

in vitro fertility (clomid and gonadotropin hormone).

Classification Monozygotic Twins/

identical Dizygotic twins/fraternal

1 ovum, 1 sperm cell and can divide into 2 parts.

Separation time:◦ 3rd /72 hours : 2

amnions, 2 chorions, 2 placentas.

◦ 4th-8th : monozygot, diamnion, monochorion.

◦ 8th-13th :monozygotic, monoamnion, monochorion.

◦ >13th : have embrionic discuscojoined twins/ siamse twins.

2 ovums, 2 sperm cell.

Will have 2 amnions, 2 chorions, 2 placentas but sometimes the placentas can grow to become 1.

TYPE

1. Monozygotic→ from one egg.- Identical twin.- 1/3 from all gemelli.- Death rate ↑

2. Dizygotic→ from two eggs.- Fraternal twin.- 2/3 from all gemelli.

FETAL GROWTHLower birth weight than singleton

pregnancy.Higher incidences for preterm labor.In monozygotic blood vessel

anastomosed to blood vessel in placenta→ anomalies (monstrum) and fetal transfusion syndrome.

In dizygotic one of the fetus is death and still left inside the uterus, become a papiraseus fetal or become a mola.

Segmentation is delayed → after the primitive streak → conjoined twin.

Conjoined twin: ◦thoracophagus (40%).◦sipho-omphalophagus (35%).◦phigophagus (18%).◦ischiophagus (16%).◦craniophagus (12%).

Conjoined twins delivered at 22

weeks and showing a

shared liver.

Conjoined twins in which one was anencephalic.

PositionsBoth of Head presentation : 45 %1 head presentation, 1 breech

presentation : 35 %Both of breech presentation :

10%1 vertical, 1 horizontal : 3%Both of horizontal : 1%

POSITION AND PRESENTATION

SIGN AND SYMPTOMPreterm labor.Anemia.Hydramnion.Pre-eclampsy and eclampsy.Solutio placenta.Shortness of breath, polyuria,

oedema and varices in lower extremities and vulva.

DIAGNOSTICProbably Gemelli :1. Uterine size bigger than ussual.2. Uterine growth faster in several

examination.3. Maternal weight gain over than

normal which not due to oedema or obesity.

4. Many small parts of fetus are palpable.

5. Three or more big parts are palpable.

6. Two ballotements are palpable.

DIAGNOSIS

1. Feel two heads, two buttocks and one or two backs.

2. Hear two fetal heart with different speed at least ten times per minute.

3. Sonogram for diagnosis gemelli in first trimester.

4. Rontgen. 5. USG.

DIFFERENTIAL DIAGNOSIS

1. Hidramnion.2. Pregnancies with myoma uterine

or ovarium cyst.

COMPLICATIONMother :

◦ Anemia◦ Hypertension◦ Preterm labor◦ Atonia uterine◦ Postpartum

bleeding

Fetus :◦ Hydramnion◦ Malpresentation◦ Placenta previa◦ Solutio placenta◦ Premature rupture of

membrane◦ Funiculus prolapsed◦ Delayed fetal growth◦ Congenital

anomalies◦ Perinatal morbidity

and mortality ↑

PREGNANCY CAREAntenatal care. More bed rest is recommended. Use of korset.

INTRAPARTUM CAREPrepare the resucitation for the

baby.Indication for SC : first fetal in

transverse position, funiculus prolapsed, placenta previa.

PROGNOSISMore dangerous in mother.Perinatal mortality is high.Mortality of second child is

higher.Mortality of monozygotic is

higher than dizygotic.

THANK YOU