Multiple pregnancy

Kang Yu Obstetric & Gynecology Hospital of Fudan Universtity

2013-10-15

Multiple Pregnancy Incidence

• Twins ： 1:100

• Triplets ： 1:10,000

• Quadruplets ： 1:1,000,000

• Quintuplets ： 1:100,000,000

Classification

• Dizygotic twins ： 2/3

– influenced remarkably by race, heredity,

maternal age, parity, and especially fertility

treatment

• Monozygotic twins ： 1/3

– independent of race, heredity, age, and

parity

Dizygotic twins

• Two ovum, two sperm • Different gene ：

1. appearance: different or alike

2. gender ： same or different• Placenta ：

1. two placenta

2. fuse to one placenta, twin peak, no communicated blood vessel

Monozygotic twin

• One ovum, one sperm • same gene ：

1. appearance: same

2. gender ： same

dichorionic diamniotic twins:

18 ～ 36%

monochorionic diamniotic twins:

65%

monochorionic monoamniotic twins:

<1%

Postfertilization 0 to 4 days 4 to 8 days 9 to 13 days

Conjoined twins

Classification of monozygotic twin

>13 days

Case One• Shi ××, 26 years old

• Chief complaint ： gravida 1 para 0, 27 weeks of gestation, found dyspnea one week and prostration three days.

• Present history ： last menstrual period (LMP):12, June, 2011. estimated date of conception(EDC):19, March,2012. Urine chorionic gonadotrophin(HCG) was positive at thirty-seven days of gestation and the morning sickness was severe. One sac was found through altrasound in the first trimester. Regular prenatal examination was not perform. Twin pregnancy was found at 25 weeks of gestation. Dyspnea one week and prostration three days.

• Physical examination ： T:36.8°C, P 98 counts per minute ，R 18 counts per minute ， BP 100/65mmHg

Ultrasound results ：

• Fetus A: BPD(biparietal diameter)-HC(head circumference)-

AC(abdominal circumference)-FL(femur length): 75-268-256-

52mm, estimated weight 1454g, AFV(amniotic fluid

volume):26cm, bladder was visible, no abnormal doppers.

• Fetus B: BPD-HC-AC-FL:65-236-206-44 mm, estimated weight 83

2g, AFV:1cm, bladder was visible, no abnormal doppers.

• AFI: 127-98-102-134, 461. no twin peak, amniotic separation was

found.

Question 1:Diagnosis

• Gravida 1 Para 0, 27 weeks of gestation, twin pregnancy

• Monochorionic Diamniotic Twins(MC/DA)

• TTTS(stage 1)

Twin-Twin Transfusion Syndrome Twin-Twin Transfusion Syndrome (TTTS)(TTTS)

• Blood is transfused from a donor twin Blood is transfused from a donor twin to its recipient siblingto its recipient sibling

• The donor becomes anemic and its The donor becomes anemic and its growth may be restricted growth may be restricted

• The recipient becomes polycythemic The recipient becomes polycythemic and may develop circulatory overload and may develop circulatory overload manifest as hydropsmanifest as hydrops

• Donor twin is pale, and its recipient Donor twin is pale, and its recipient sibling is plethoricsibling is plethoric

Anastomoses in monochorionic diamniotic placenta ： arterio-arterial,venous –venous,arterio-venousOnly arterio-venous anastomoses will result to TTTS.

TTTSTTTS

Quintero staging systemQuintero staging system

• Stage I: polyhydramnios(>8cm) in recipient /

aligodramnios(<2cm) in donor, but urine still visible but urine still visible

sonographically within the donor twin's bladder sonographically within the donor twin's bladder

• Stage II: urine is not visible within the donor's bladder urine is not visible within the donor's bladder

• Stage III: abnormal Doppler studies of the umbilical abnormal Doppler studies of the umbilical

artery, ductus venosus, or umbilical vein. artery, ductus venosus, or umbilical vein.

• Stage IV: ascites or frank hydrops in either twinascites or frank hydrops in either twin

• Stage V: demise of either fetus demise of either fetus

Question 2: Management

• An amnioreduction of 6.2 L was performed in the recipient sac.

• Tocolytics (magnesium sulfate ） were administered.• Follow up: ultrasound weekly

Ten days later

• Ultrasound surveillance ：• anuria and virtually no amniotic fluid in the donor twin,

polyuria and excess amniotic fluid in the recipient, and

abnormal umbilical venous and ductus venosus flows in

both twins.

Management

• Termination: Cesarean section

• premature donor and recipient twin boys were delivered, weighing 895 and 1450 g, with haemoglobin levels of 16.4 and 22.9 g/dl

• Both infants required mechanical ventilation and administration of surfactant due to respiratory distress syndrome. The donor twin developed acute renal failure and necrotising enterocolitis which required surgery. The recipient developed the polycythaemiae hyperviscosity syndrome which required a partial exchange transfusion. Both children are alive.

• Check the placenta after delivery: one placenta, two layer of membrane partition that separated twin fetuses

Diagnosis TTTS (Prenatal)1. monochorionicity

2. same-sex gender

3. hydramnios defined if the largest vertical pocket is > 8 cm in one twin and oligohydramnios defined if the largest vertical pocket is < 2 cm in the other twin

4. umbilical cord size discrepancy

5. cardiac dysfunction in the recipient twin with hydramnios

6. abnormal umbilical vessel or ductus venosus Doppler velocimetry

7. significant growth discordance

Diagnosis (Postnatal)

1. Examination in placenta, chorionic

membrane, amniotic membrane

2. Examination in neonate：1.1.DiscordanceDiscordance in hemoglobin: ≥5g/dl

2.2.Discordance in Discordance in body weight : ≥15-20%

Pregnancy Complications

Kang Yu Obstetric & Gynecology Hospital of Fudan Universtity

2013-10-15

Pregnancy Complications

• Heart DiseasesHeart Diseases• HepatitisHepatitis• DiabetesDiabetes• AnemiaAnemia• ……• AppendicitisAppendicitis• CholecystitisCholecystitis• Intestinal obstructionIntestinal obstruction• ……

Heart diseases in pregnancy

Clinical significance of heart disease in pregnancy

Mother: heart failure; infective Mother: heart failure; infective endocarditis; hypoxia and cyanosis; endocarditis; hypoxia and cyanosis; thrombenbolismthrombenbolism

Baby: miscarriage, still birth, fetal growth Baby: miscarriage, still birth, fetal growth restriction, fetal and newborn distress, restriction, fetal and newborn distress, preterm deliverypreterm delivery

Increased caesarean section rateIncreased caesarean section rate

•Interaction between heart disease and pregnancyInteraction between heart disease and pregnancy

Can I have a baby? What is the risk for me and my baby? What should I do during the course of

pregnancy? By which way should I delivery my baby? Any special thing to be paid attention to

after birth?

Heart diseases in pregnancy

Can I have a baby?

YES Mild Cardiac

function I ～ II No history of

heart failure No

complication

• NO Severe Cardiac function Ⅲ 一Ⅳ History of heart failure Pulmonary hypertension Right-to-left shunts Severe arrythmia Active rheumatic heart

disease Acute Myocarditis,

endocarditis >35y with long history of

cardiac disease

During Pregnancy

Determine whether or not the pregnancy should be continued

NO: induced abortion before 12 weeks YES:

Intensive care during pregnancyEarly diagnosis and treatment of congestive

heart failure

During pregnancy

Heart failure ---- prevention Limited physical activity Control of body weight: increase <12Kg

(<0.5Kg / month) Limited salt intake: <4-5g/day Prevent risk factors: infection, anemia,

arrhythmia, hypertensive diseases Dynamic observation of cardiac

function

During Pregnancy

Heart failure---early diagnosis Development of dyspnea and palpitation

on exertion Heart rate >110 bpm; breath rate

>20/min Nocturnal cough Persistent basilar rales

During pregnancy Treatment of heart failure

Digoxin Diuretics Vessel dilating agents Termination of pregnancy:

C-S Timing

Termination after heart failure is controlled C-S when heart failure could not be controlled

Intrapartum management

Pattern of delivery Cesarean section Vaginal delivery

Heart function I-II Very good obstetrical condition

Vaginal delivery---- prevent heart failure First stage: intensive care and sedation Second stage: shorten the course Third stage: Add pressure on abdomen prevent postpartum hemorrhage

Puerperium management

Intensive care during the first 3 days Prevent infection Breast feeding Sterilization

Viral Hepatitis in Pregnancy

Viral Hepatitis in Pregnancy

Interaction between pregnancy and hepatitis

Diagnose, Differential diagnosis and treatment

Pathway of maternal – fetal infection and prevention

Impact of pregnancy on viral hepatitis

Heavier liver burden Compromised defending

ability of liver More complicated and severe

condition in pregnant patients

Impact of hepatitis on pregnancy

Early Pregnancy Serious pregnancy reaction Abortion Malformation

Late pregnancy Hypertension Postpartum hemorrhage Preterm delivery, fetal death, stillbirth

Impact of hepatitis on pregnancy

Maternal - fetal infection HBV Intrauterine Intrapartum—main route of transmission

Fetal swallowing in genital tract Mother blood leaking into fetal circulation

Postpartum: breastfeeding, salivary

Differential diagnosis

Intrahepatic cholestasis of pregnancy （ ICP ） Happen during late pregnancy Pruritus Jaundice Cholic acid fetal death

Differential diagnosis Acute fatty liver of pregnancy Late pregnancy, acute and severe hepatic

disfunction, fat filled hepatic cell HELLP syndrome Hypertension, hemolysis, BPC, elevated liver

enzyme Hyperemesis gravidarum Light liver dysfunction, negative virus marker Drug induced hepatitis History of drug intake

Management

Rest Nutrition Protection of liver function Prevent infection and further damage Fluminant hepatitis

Management

Delivery C-S is preferred Vitamin K1 20-40mg im several days

before delivery Prevent postpartum hemorrhage Fulminant hepatitis: C-S 24 hours after

active treatment

Management

Pureperium Prevent from damaging liver function Breast feeding: Stop if HBsAg, HBeAg,

anti-HBc, HBV-DNA positive

Diabetes complicating pregnancy

Diabetes complicating pregnancy

Gestational diabetes mellitus (GDM) and overt diabetes complicating pregnancy

Diabetes pregnancy

Screening and diagnosis

Management of women complicating diabetes during pregnancy

Diabetes in pregnancy

Pre-existing diabetes Gestational diabetes

Pre-existing diabetesIDDM

(Type1)NIDDM(Type2) True GDM

Gestational diabetes mellitus GDM >90%

•Incidence: 2.9% (1.5-14.0%)

Impact of pregnancy on diabetes

Insulin resistance and insufficiency Increased glucose demands---

hypoglycemia Insulin overdose after delivery

Maternal and fetal effects Maternal effects

Hypertensive disorders （高血压） Infection （感染） Ketoacidosis （酮症酸中毒） Spontaneous abortion （自发流产） Polyhydramnios （羊水过多） Dystocia （难产） and C-S owing to

macrosomia （巨大儿） Recurrent GDM （再次妊娠时复发）

Maternal and fetal effects

Fetal effects Macrosomia （巨大儿） Fetal growth restriction （胎儿宫内生长受限） Spontaneous abortion & Preterm

delivery （自发流产和早产） Malformation （胎儿畸形）

Maternal and fetal effects

Neonatal effects Respiratory distress （呼吸窘迫）

Hyperinsulinemia Pulmonary Surfactant Delayed pulmonary maturation

Hypoglycemia （低血糖）

Diagnosis----GDM

History: family, previous pregnancy, present pregnancy

Screening: 50-g oral glucose challenge test （ 24-28 weeks ）

Confirmed diagnosis OGTT: 75/100-g oral glucose

tolerance test

The 50 gr. GCT (Cutoff >140 mg/dl, 7.8mmol/L)

Sensitivity: 93.3% Specificity: 38.2%

Positive Predictive Value: 78.6 % Negative Predictive Value : 70.0

%

Diagnostic criteria for GDM---OGTT

Method Criteria (mmol/L)

FPG 1 hr. 2 hr. 3 hr.

WHO (75 g) 5.6 10.3 8.6 6.7

Diagnosed when 2 or more values are abnormalFPG: Fasting plasma glucose

Diagnosis—Overt diabetes

polydipsia （多饮） , polyuria （多尿） , unexplained weight loss ， ketoacidosis

Random plasma glucose >200 mg/dL(11.1 mmol/L);

fasting glucose>126mg/dL (7 mmol/L)

Management

Purpose Maintain glucose level within normal

range Minimize fetal and maternal complication Lower peripartum fetal and neonatal

mortality

During pregnancy Diet

To provide the necessary nutrients for the mother and fetus

To control glucose levels To prevent starvation

30-35kcal/kg of ideal body weight 55% carbohydrate 20% protein 25% fat 3 meals and 3 snacks daily

Intensified monitoring Fasting glucose <3.3-5.6mmol/L Postprandial glucose <6.7mmol/L

During pregnancy

Drug treatment: Insulin only Individualized

Assessment of mother

Glucose / ketone monitoring （监测血糖 / 酮体） Retinal photograph ( 眼底 ) Renal function （肾功能） Glycated Haemoglobin （糖化血红蛋

白）

Assessment of fetal well-being

Daily fetal movement counting NST AFV or biophysical profiles

Delivery

WHEN? after 38 completed weeks

Fetal lung muturation Before 38 weeks when

Unsatisfied glucose control Maternal complication: infection, severe

preeclampsia; vascular diesease Fetal distress or FGR

Caution in the use of corticosteroids

Delivery

HOW? Diabetes itself is not the indication for

C-S C-S when indicated: macrosomia,

compromised placenta function, etc. Stop subcutaneous insulin 3 hours

before operation

Delivery

Vaginal delivery Close monitoring Glucose monitoring: >5.6mmol/L

(100mg/dL) Control the whole course within 12 hours

Postpartum

Insulin dose decrease 1/2 -1/3 after delivery Encourage follow up with health care

provider to have OGTT (6 weeks to 6 months 75 g OGTT) weight management, postpartum visit with a registered dietitian Encourage breastfeeding Monitoring occasionally with meter Future pregnancy

Neonatal management

Treated as preterm baby 25% glucose intake 30 minutes after

delivery Prevent complications

Thank you!