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Multifetal pregnancy (:silhouettes: Factors influence twining (Maternal…

- - - - Opposite sex ➯ Dizygotic
      - Postzygotic loss of Y chr* ➯ 46,XY // 45,X (rare)
      - Related to Chorionicity (more clinical significant)
  - - - Def — outermost Fetal membrane around the embryo (Aka รก)
      - Composed of Trophoblasts & Mesenchyme
      - Chorion + Amnion = Amniotic sac/Fetal membrane
    - - Sonographic evaluation
        
        1st trimester
        
        Dichorion: Two seperate placenta (seperate placental ring)
        
        Monochorion: Single placental ring
        
        2nd trimester
        
        Dichorion
        
        Thick dividing membrane (≥ 2mm)
        
        Twin peak sign (Lambda sign) — triangular portion of placenta between amniochorion layers
        
        Monochorion
        
        Thin dividing membrane (< 2mm)
        
        T sign — seperated only membrane
- - - - 1% of monozygotic twins
      - High fetal death rate
      - Effects :bulb:
        
        :star:Cord entanglement (unpredictable)
        
        Congenital anomalies
        
        Preterm birth
        
        :star: Twin-twin transfusion syndrome
      - Mx :green_heart:
        
        Fetal heart rate monitoring begins at GA 26 - 28 wks
        
        Steroids for promote lung maturation
        
        C/S delivery at GA 34 wks
    - - Def — incomplete splitting of an embryo (eg Siamese twins)
      - Most common type is Thoracopagus
      - Mx :green_heart:
        
        Targeted examination :red_flag:
        
        Organ connection
        
        Vital organs sharing
        
        :star2::MRI examination
        
        Family counseling :family:
        
        Surgical seperation
        
        Termination of pregnancy
        
        Vital organ sharing
        
        :star2:C/S delivery
    - - Twin-twin transfusion syndrome (TTTS) :boy: :girl:
        
        Transfused blood between twins (Donor-Recipient)
        
        Donor
        
        Anemic
        
        Restricted growth
        
        Oligohydramnios
        
        Recipient
        
        Polycythemic
        
        Polyhydramnios
        
        Circulatory overload
        
        Hydrops fetalis
        
        Develops in mid pregnancy — Polyhydramnios-oligohydramnios-syndrome
        
        Significant volume differences between twins
        
        :champagne: Dx criteria
        
        Monochorionic Diamnionic preg
        
        Hydramnios (DVP > 8 cm) in one twin
        
        Oligohydramnios (DVP < 2 cm) in other twin
        
        :champagne: Quintero staging (TTTS)
        “น้ำ ฉี่ สี บวม ตาย”
        
        :evergreen_tree: Mx
        
        1. Amnioreduction
        
        For Recipient ที่น้ำเยอะ
        
        Purpose
        
        To :arrow_down: intraamniotic and Placental intravascular pressure
        
        To :arrow_down: Maternal RS discomfort and rate of Preterm labor
        
        2. Intentional septostomy
        
        Procedure: perforate inter-twin membrane with needle
        
        Abandoned ➯ led to monoamniotic twin
        
        Purpose: turning into MAMC
        
        :yellow_heart: 3. Fetoscopic laser photocoagulation — gold standard :large_orange_diamond:
        
        Dichorionization
        
        Purpose/goal ➯ seperate Placenta into 2 regions
        
        Preferred For TTTS stage II, III, IV
        
        Complications
        
        Bleeding
        
        PPROM
        
        Fetal death
        
        4. Selective reduction
        
        Indication considered in Severe amniotic / Growth disturbances developed early than 20 wks
        
        Procedure: Occlude fetal circulation by
        
        Radiofrequency
        
        Cauterization
        
        Usu. select Recipient out
      - Acardiac twin :red_cross::<3:
        
        Donor
        (need to pump blood to Recipient :arrow_up:)
        
        Cardiomegaly
        
        High-output heart failure
        
        Hydrops fetalis
        
        Recipient
        
        *Lacks of heart
    - - :koala: Monochorionic twins
        
        Placental vascular anastamosis
        
        Usu. develops in Late 2nd trimester or 3rd trimester
      - :koala::koala: Dichorionic twins
        
        Different genetic growth potential
        
        Suboptimal of placental implantation site
      - Percent discordance :grapes:
      - Weight difference ≥ 20 percent ➯ Growth discordance
      - Sonographic evaluation of growth
        
        Monochorionic q 4 wks
        
        Dichorionic q 6 wks
- - - - :goal_net:Goal = Close observation
        
        Maternal & fetal complications
        
        Prevent Preterm delivery (if possible)
      - :glass_of_milk:Diet
        
        :arrow_up: caloric intake 40-45 kcal/kg/d
        (normal 30-35 kcal/kg/d)
        
        Carb : Protein : Lipid = 40:20:40
        
        3 meals & 3 snacks
      - :bird:Surveillance of fetal growth
        
        Serial sonographic examinations
      - :male-scientist::skin-tone-4:Tests of Fetal well-being
        
        NST, BPP ➯ same I/C as singleton pregnancy
        
        High false positive
      - :pill: Steroids & Tocolytic
        
        Same as Singleton pregnancy
        (*no double dose)
        
        Preterm prevention ➯ no evidence
  - - - Continuous external fetal monitoring
      - Blood transfusion available
      - Skillful neonatal resuscitator for each newborn
    - - Noncephalic first twin ➯ C/S
      - Cephalic-Cephalic presentation ➯ Vx delivery can be considered
        (beware of abruptio placenta after 1st twin)
      - Cephalic-Noncephalic presentation ➯ *controversial
        
        tho Noncephalic 2nd twin
        (weight < 1,500 gm and EFW larger than 1st twin > 20 percent ➯ C/S)
      - Twin A — lower twin
        
        Breech ➯ C/S
        
        Breech-Breech ➯ NL
- - - - :arrow_down: Mean birth weight
        (Singleton 3,296g; Twins 2,336g; Triplets 1,660g; Quadruplets 1,291g)
      - :arrow_down: GA
        (Singleton 38.7wks, Twins 35.3wks, Triplets 31.9wks, Quadruplets 29.t wks)
      - :arrow_up: placenta previa, preterm, PPH