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OB22 Obstetrics
Multi-Fetal Gestation and Malpresentation Toronto Notes 2019
Management
• U/U/Sdeterminationofchorionicitymustbedonewithinfirsttrimester(ideally8-12wkGA)
The Ps of Multiple Gestation Complications
Increased rates of
Puking
Pallor (anemia)
Preeclampsia/PIH
Pressure (compressive symptoms) PTL/PROM/PPROM Polyhydramnios
Placenta previa/abruptio PPH/APH
Prolonged labour
Cord prolapse
Prematurity
Malpresentation
Perinatal morbidity and mortality Parental distress
Postpartum depression
•
• •
increasedantenatalsurveillance
■ serial U/S q 2-3wk from 24 wk GA to assess growth (uncomplicated diamniotic dichorionitic)
■ increased frequency of U/S in monochorionic diamniotic and monochorionic monoamniotic twins ■ Doppler flow studies weekly if discordant fetal growth (>30%)
■ BPP as needed
mayattemptvaginaldeliveryiftwinApresentsasvertex,otherwiseC/S(40-50%ofalltwindeliveries, 10% of cases have twin A delivered vaginally and twin B delivered by C/S)
mode of delivery depends on fetal weights, GA, presentation
Monoamnionic Monochorionic (forked cord)
Diamnionic
Dichorionic (fused) *0-72 h
Monoamnionic Monochorionic *9-12 d
Diamnionic Dichorionic (separated)
*Indicates time of cleavage
Monoamnionic Monochorionic (one cord)
Diamnionic Monochorionic *4-8 d
Figure 4. Classification of twin pregnancies
Twin-Twin Transfusion Syndrome
Definition
• formationofplacentalintertwinvascularanastomosescausesarterialbloodfromdonortwintopass into veins of the recipient twin
Epidemiology
• 10%ofmonochorionictwins
• concernif>30%discordanceinestimatedfetalweight
Clinical Features
• donortwin:IUGR,hypovolemia,hypotension,anemia,oligohydramnios
• recipienttwin:hypervolemia,HTN,CHF,polycythemia,edema,polyhydramnios,kernicterusin
neonatal period
Investigations
• detectedbyU/Sscreening,Dopplerflowanalysis
Management
• therapeuticserialamniocentesistodecompresspolyhydramniosofrecipienttwinanddecreasepressure in cavity and on placenta
• intrauterinebloodtransfusiontodonortwinifnecessary
• laparoscopicocclusionofplacentalvessels
• fetoscopiclaserablationofplacentalvascularanastomoseswhenindicatedandifavailable
© Qing Huang 2004