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Multifetal pregnancy (complications (TRAP (Management (Observation if:
…
Multifetal pregnancy
complications
Types
TTTS, TRAP
Umbilical entanglement (monoamniotic pregnancy)
Selective intrauterine growth restriction of one of the fetuses (possible in dichorionic pregnancy as well)
Fetal malformation of one fetus with normal other one
-
Selective sIUGR
I – normal umbilical flow, equivalent of SGA
II – AREDF in umbilical artery, equivalent of IUGR (high risk of intrauterine fetal demise)
III – variable umbilical flow (uncertain prognosis)
TTTS
- Complication of monozygotic, monochorionic pregnancy
- Imbalanced blood flow between fetuses via anastomoses in the common chorion
- Polyhydramnios/oligohydramnios – base of diagnosis: MVP <2cm in donor and >8cm in recipient
Management
observation without treatment
pharmacotherapy
amnioreductions
occlusion of communicating vessels
closing of one umbilical cord
termination of pregnancy
- non-treated:
Perinatal mortality 80-100%
Serious neurological morbidity 25 – 30%
Pharmacotherapy
Indometacin, Sulindac
Digoxin
Amnioreductions
- Pregnancy prolongation
- decrease fluid pressure = decrease placental pressure
- quick but short-lasting effect
- No influence on fetal hemodynamics
- When laser therapy is not available or after 27 weeks of gestation
- symptomatic treatment
TRAP
- Presence of a fetus without hemdynamically sufficient heart
in the uterus („acardiac”)
Management
- Observation if:
Acardiac is small – its estimated weight or AC is smaller than in pump twin
Pump twin has no signs of heart insufficiency
There is no polyhydramnios
-
-
Twin pregnancy
- Monozygotic: Dichorionic 73% (Risk of complications 4x), Mono
chorionic 2% (Risk of complications 10x)
- Dizygotic: Dichorionic 25%
Monozygotic pregnancy
- 0-3 days
dichorionic (two gestational sacs)
diamniotic (two yolk sacs)
dividing membranes:
2 layers of amnion, 2 layers of chorion
- 4-8 days
monochorionic
- 8-13 days
monochorionic
(one gestational sac)
monoamniotic
(one yolk sac)
Conjoined twins
Important organs:
Heart, Respiratory system, Liver, Digestive tract, Urinary system
Complications
- The most frequent – preterm delivery
twin pregnancy average 36 weeks
triplets average 34 weeks
quadruplets average 32 weeks
Risk factors
Multiparas, Older than 35 (FSH?)
Multifetal pregnancy in history
Race (black>white>yellow)
Higher BMI, End of the summer
Higher education level, Smoking
Alcohol, Withdrawal of OC
Diagnosis
- Ultrasound examination:
Two gestational sacs (3-4 weeks of gestation)
Two embryos (5 weeks of gestation)
Heart beat in two embryos (6-7 weeks of gestation)
- Confirmation at 11-13 weeks of gestation – up to 20% multifetal pregnancies before 11 weeks become single („vanishing twin”)
- mnochorionic: Risk of complications 10x increased when compared to singletons
- dichorionic: Risk of complications 4x increased when compared to singletons