Lecture 14Lecture 14

MULTIPLE PREGNANCY.MULTIPLE PREGNANCY.

THE UTERINE RUPTURETHE UTERINE RUPTURE

Prof. Vlad TICA, MD, PhDProf. Vlad TICA, MD, PhD

MULTIPLE PREGNANCYMULTIPLE PREGNANCY

MULTIPLE PREGNANCY

Twin pregnancy represents 2 to 3% of all pregnancies

The PNMR is 5 times that of singleton

DIZYGOTIC TWINSMost common represents 2/3 of cases

Fertilization of more than one egg by more than one sperm

Non identical, may be of different sex

Two chorion and two amnion

Placenta may be separate or fused

FACTORS AFFECTING IT’S INCIDENCEInduction of ovulation, 10% with clomide and 30%

with gonadotrophins

Increase maternal age ? Due to increase gonadotrophins production

Increases with parity

Heredity usually on maternal side

Race: Nigeria 1:22; North America 1:90

MONOZYGOTIC TWINS

Constant incidence of 1:250 births

Not affected by heredity

Not related to induction of ovulation

Constitutes 1/3 of twins

0-72 hours Diamniotic dichorionic

4-8 days Diamniotic monochorionic

9-12 days Monoamnio monochorionic

>12 days Conjoined twins

RESULTS FROM DIVISION OF FERTILIZED EGG

RESULTS FROM DIVISION OF FERTILIZED EGG

MONOZYGOTIC TWINS

70% are diamniotic monochorionic

30% are diamniotic dichorionic

DETERMINATION OF ZYGOSITY

Very important as most of the complications occur in monochorionic monozygotic twins

During pregnancy by USS

Very accurate in the first trimester, two sacs, presence of thick chorion between amniotic membranes

Less accurate in the second trimester the chorion become thin and fuse with the amniotic membranes

Different sex indicates dizygotic twins

Separate placentas indicates dizygotic twins

DETERMINATION OF ZYGOZITY AFTER BIRTH

By examination of the MEMBRANES, PLACENTA, SEX, BLOOD group

Examination of the newborn DNA and HLA may be needed in few cases

COMPLICATIONS OF MULTIPLE GESTATION

AnemiaHydramniosPreeclampsiaPreterm labourPostpartum

hemorrhageCesarean delivery

MalpresentationPlacenta previaAbruptio placentaePremature rupture of

the membranesPrematurityUmbilical cord

prolapseIntrauterine growth

restrictionCongenital anomalies

Maternal Fetal

SPECIFIC COMPLICATIONS IN MONOCHORIONIC TWINS

TWIN-TWIN transfusion

Results from vascular anastomosis between twins vessels at the placenta

Usually arterio (donor) venous (recipient)

Occurs in 10% of monochorionic twins

TWIN-TWIN transfusion

Chronic shunt occurs, the donor bleeds into the recipient so one is pale with oligohydraminos while the other is polycythemic with hydraminos

If not treated death occurs in 80-100% of cases

SPECIFIC COMPLICATIONS IN MONOCHORIONIC TWINS

Possible methods of treatment:

Repeated amniocentesis from recipient

Indomethacin

Fetoscopy and laser ablation of communicating vessels

SPECIFIC COMPLICATIONS IN MONOCHORIONIC TWINS

Congenital malformation. Twice that of

singleton.

Umbilical cord anomalies. In 3 – 4 %.

Conjoined twins. Rare 1:70000 deli varies. The majority are thoracopagus

PNMR of monochorionic is 5x that of dichorionic twins (120 vs. 24 / 1000 births)

OTHER COMPLICATIONS IN MONOCHORIONIC TWINS

OTHER COMPLICATIONS IN MONOCHORIONIC TWINS

- pigopagus

- thoracopagus

OTHER COMPLICATIONS IN MONOCHORIONIC TWINS

- craniopagus

craniopagus parasiticus

- xyphopagu

s

MATERNAL PHYSIOLOGICAL ADAPTATION

Increase blood volume and cardiac output

Increase demand for iron and folic acid

Maternal respiratory difficulty

Excess fluid retention and edema

Increase attacks of supine hypotension

DIAGNOSIS OF MULTIPLE PREGNANCY

Positive family history mainly on maternal side

Positive history of ovulation induction

Exaggerated symptoms of pregnancy

Marked edema of lower limb

Discrepancy between date and uterine size

Palpation of many fetal parts

Auscultation of two fetal heart beats at two different sites with a difference of 10 beats

USS

Two sacs by 5 weeks by TV USS

Two embryos by 7 weeks by TV USS

DIAGNOSIS OF MULTIPLE PREGNANCY

ANTENATAL CAREAIM

Prolongation of gestation age, increase fetal weight

Improve PNM and morbidity

Decrease incidence of maternal complications

Follow Up

Every 2 weeks

Iron and folic acid to avoid anemia

Assess cervical length and competency

ANTENATAL CARE

Fetal Surveillance

Monthly USS from 24 weeks to assess fetal growth and weight

A discordinate weight difference of >25% is abnormal (IUGR)

Weekly CTG from 36 weeks

ANTENATAL CARE

3D USS – TWIN PREGNANCIES

Vertex-Vertex (50%)

Vaginal delivery, interval between twins not to exceed 20 minutes

Vertex-Breech (20%)

Vaginal delivery by senior obstetrician

METHOD OF DELIVERY

Breech-Vertex (20%)

Safer to deliver by CS to avoid therare interlocking twins (1:1000 twins)

Breech-Breech (10%)

Usually by CS

METHOD OF DELIVERY

PERINATAL OUTCOME PNMR is 5 times that of singleton (30-

50/1000 births)

RDS accounts for 50% 0f PNMR. 2nd twin is more affected

Birth trauma – 2nd twin is 4 times affected than 1st

Incidence of SB is twice that of singleton

Congenital anomalies is responsible for 15% of PNMR

Cerebral hemorrage and birth asphyxia are responsible for 10% of PNMR

Cerebral palsy is 4 times that of singleton

50% of twins babies are born with low birth (<2500 gms) from prematurity & IUGR

PERINATAL OUTCOME

INTRAUTERINE DEATH OF ONE TWIN Early in pregnancy usually no risk

In 2nd or 3rd trimester:

Increase risk of DIC

Increase risk of thrombosis in the a live one

The risk is much higher in monochorionic than in dichorionic twins

The a life baby should be delivered by 32-34 weeks in monochorionic twins

HIGH RANK MULTIPLE GESTATIONSpontaneous triplets 1:8.000 births

Spontaneous quadruplets 1:700.000 births

The main risk is sever prematurity

CS is the usual and safe mode of delivery

High PNMR of 50-100 / 1000 births

COMPLICATIONS OF MULTIPLE PREGNANCY

A. MATERNAL:

1. Anemia due to increase demand

2. Increase incidence of PET(5 times)

3. Polyhydramnios in monochorionic monozygotic twins

4. Increase incidence of premature labor

A. MATERNAL:

5. Increase incidence of CS. And operative delivery

6. Increase incidence of placenta praevia and abruptio placentae

7. Increase incidence of hypotonic postpartum hemorrhage

COMPLICATIONS OF MULTIPLE PREGNANCY

B. FETAL:

1. Increase perinatal morbidity and mortality

2. Prematurity with / without rupture of membrane

3. Increase incidence of malpresentation

COMPLICATIONS OF MULTIPLE PREGNANCY

B. FETAL:

4. Increase incidence of cord prolapse

5. Higher incidence of IUGR

6. Increase incidence of congenital anomalies

COMPLICATIONS OF MULTIPLE PREGNANCY

THE UTERINE RUPTURETHE UTERINE RUPTURE

DEFINITIONSeparation of the muscular wall of the uterus

Usually occurs during labor

Occasionally happen during the later weeks of pregnancy

During pregnancy

Weak scar after previous operations on the uterus

History of cesarean section (VBAC - vaginal birth after C-section)

Myomectomy

Excision of a uterine septum

Previous perforation of uterus (D&C, hysteroscopy, forceps delivery

CAUSES

During labor:

uterine hyper-stimulation (oxytocin with pitocin induction or augmentation of labor)

obstructed labor (macrosomia, fetopelvic disproprotion)

intrauterine manipulation (internal version, manual removal of an adherent placenta)

forcible dilatation (cervical tear)

a weak scar (C-section or other operations)

CAUSES

Incomplete rupture

Complete rupture

Depending on whether the peritoneal coat is torn through or not

TYPES

1. Rupture of scar

be gradual that symptom is very slight in incomplete rupture

abdominal pain wrongly attributed to the onset of labor

severe pain and shock occurs in complete (suddenly pain)

fetal distress

bleeding in vagina

SYMPTOMS AND SIGNS

2. Spontaneous rupture during obstructed laborprolonged laborviolent uterine actionspathologic retraction ringdisporpotion, malpresentation(transverse lie)fetal distressa sharp, tearing pain in lower abdomenpulse rapidblood pressure fallfetus may be felt in the abdominal cavity

SYMPTOMS AND SIGNS

PATHOLOGIC RETRACTION RING

3. Rupture by oxytocin drugs:

be follow the administration of oxytocin

the danger is less if the drug is given as a dilute intravenous drip given in an increasing fashion

SYMPTOMS AND SIGNS

has a high mortality

peri-natal morbidity is high

PROGNOSIS

Women’s general condition must be improved giving morphine, blood transfusion, glucose

solution)

immediate laparotomy

hysterectomy

wide-spectrum antibiotics

TREATMENT

THANKS FOR

YOUR ATTENTION !