Management of Twin Pregnancy PDF

Management of multiple pregnancy Dr Wedisha Gankanda MD, MRCOG Dip in Laparoscopy, Urogyneacology, ART Consultant Obstetrician and Gyneacologist Reproductive health module Univ...

Management of multiple pregnancy Dr Wedisha Gankanda MD, MRCOG Dip in Laparoscopy, Urogyneacology, ART Consultant Obstetrician and Gyneacologist Reproductive health module University of Moratuwa Lesson learning outcomes (LLOs) Describe the incidence and epidemiology of multiple pregnancy. Describe the embryology of multiple pregnancies. Discuss the importance of amnionicity and chorionicity in multiple gestations. Recognize the complications of multiplepregnancy. Outline the principles of management of multiple pregnancies. Explain the delivery options available for multiple pregnancies.  Multiple pregnancies Classification 1. Number of fetuses- twins ,triplelts, quadruplets, ect. 2. Number of fertilized eggs- zygocity 3. Number of placentae- chorionicity 4. Number of amniotic cavities- amnionicity  Outline Basic embryology Incidence Risks associated with twin pregnancy Basic physiology of inter twin transfusion Current standard care for twin pregnancy Delivery of twin pregnancy Evidences RCOG guideline on ‘Management of MC twins’ NICE guideline on ‘AN care for multiple pregnancy’ Monozygotic Zygosity Within 3 days DCDA Within 4-8 days MCDA After 8 days MCMA Dizygotic DCDA MZ Twins Conjoined twins Placenta Risk factors for multiple pregnancy Advanced maternal age High parity Maternal family history Assisted reproduction techniques. Ovulation induction. IVF- multiple embryo transfer. Complications of twin pregnancy Maternal complications Hyperemesis gravidarum Anaemia -40% Hypertension complicating pregnancy- 10 times Increased risk of Cesarean delivery Increased risk of PPH Antenatal/Post natal psychological distress Complications of twin pregnancy Fetal complications Complications common to both DC/MC twins Complications unique to MC  Adverse perinatal outcome Adverse outcome DC MC Miscarriage 11-23 weeks X2 x 10 Perinatl death >24 weeks X2 X4 FGR X 20 X 30 Preterm delivery 84mm) Discordance of fetal sex + all routine parameters. If chorionicity determination is difficult second opinion from senior sonographer should be sought. If it is still difficult to assess chorionicity manage the pregnancy as monochorionic.  labeling of fetuses Should be assigned top/bottom or left/right orientation. 10% 90% Down syndrome screening/ Major structural anomalies For Down syndrome combined test should be used. Nuchal thickness( CRL 45-84mm) + S. β HCG + PAPP-A ( 87% detection rate with 5% of FPR) MC twin/triplets- Risk of having Down Xn is calculated per pregnancy. DC twins- Risk of having Down Xn is calculated per fetus. At dating USS- Anencephaly, large cystic hygromas ect. Should be detected. Recommended AN care plan for DC twin pregnancies ISUOG Recommended AN care plan for MC twin pregnancies ISUOG  Screening for TTTS, sGR,TAPS Mainly by USS assessments At each USS examination from 16 wks onwards. Fetal biometric measurements. – (EFW calculation from 20 weeks) Liqour volume- DVP of each sac. Evaluation of fetal bladder – visibility/size. Doppler flow assessment Umbilical artery PI Ductus venosus PI MCA peak systolic velocity(PSV)  Diagnosis of TTTS 1. Significant amniotic fluid discordance. *Donor sac- DVP 8cm before 20weeks DVP > 10cm after 20 weeks 2. Discordance of bladder appearance No urine in donor fetal bladder 3. Haemodynamic & cardiac compromise. In one or both twins Staging of TTTS Quintero staging system I. Significant discordance in amniotic fluid index. II.Bladder of donor twin is not visible. III. Doppler studies abnormal in either donor/ recipient. IV.Fetal hydrops features in recipient. ascites, pleural, pericardial effusion V. Death of one or both twins. This is not the ‘best’ but ‘best available’ tool Management of TTTs Management options are offered according to the Quintero staging. Severe TTTS has 90% perinatal mortality in one or both twins if untreated. Treatment with Laser ablation or amnioreduction reduces it to 50%. Stage – I Expectant management or serial amnioreduction. Stage – II or more- Laser ablation of communicating arteries. Impending death -laser Serial amnioreduction vs laser ablation Mortality rate of one or both twins in TTTS – no difference between amnioreduction and laser. ( 2014 Cochrane review) Long term neurodevelopment outcome- Superior in laser ablation group.  Fetoscopy laser ablation Quintero stage II or more. Quintero stage I with polyhydroamnios >8cm/ cervicle length 20% should be followed up in expertise fetal medicine unit. Selective growth restriction (sGR) Three stages I- Growth discordance but positive diastolic velocities in both fetal UAs. ( Mx- Plan delivery by 34-36 weeks) II – Growth discordance with absent or reversed end diastolic velocities in one or both twins. III- Growth discordance with cyclical UA wave forms. (Stage II/III- plan delivery after 32 weeks) Selective growth restriction (sGR)  Event of co-twin death Surviving twin is always at risk of death or neurological damage. DC MC Death of co twin 1% 15% Neurological damage 4% 26% In DC pregnancy expectant management is considered depending on the POA. In MC pregnancy Immediate delivery if >32 POA and diagnosis is early. If diagnosis is late, fetal MRI at 4 weeks brain should be considered to decide on TOP if hypoxic brain damage has already occurred. Maternal complications of twin pregnancy Hypertension Prevalence of hypertensive diseases are 10 times more in twin pregnancies compared to singletons. Diagnosis and management is similar to singleton pregnancy. Indications for Asprin 75mg from 12 weeks in twins or triplets Primigravida Age 40 years or older Pregnancy interval > 10 years BMI> 35 at booking Family Hx of pre-eclampsia Delivery of multiple pregnancy Timing of delivery Mode of delivery  Delivery of multiple pregnancy Timing of delivery In women with uncomplicated MC twin- elective delivery from 36- 38 weeks. DC twins – elective delivery from 37-38 weeks. TCTA triplets- 35- 36 weeks MCMA- 32 weeks Peri-natal mortality slightly increased after 38 weeks for both MC & DC. No strong evidence for this increased mortality after 38 weeks, provided pregnancy is otherwise uncomplicated.( need weekly monitoring) Antenatal corticosteroids Administration of corticosteroid should be targeted and planned according to expected timing of delivery. Do not use single or multiple untargeted (routine) courses of corticosteroids in twin or triplet pregnancies. Inform women that there is no benefit in using untargeted administration of corticosteroids. ( NICE 2011) Mode of delivery The ‘Twin Birth Study’ a multicenter international RCT , including 600 uncomplicated MCDA twins concluded, Between 32+0 and 38+6 weeks (when leading twin is cephalic) Planned CS did not decrease /increase the risk of fetal or neonatal death or serious newborn morbidity compared to vaginal delivery. No significant interaction of chorionicity with the primary outcomes.  Mode of delivery Vaginal delivery Decided upon presentation of leading twin at onset of labour. ( 70% cephalic 30% breech) Presentation of second twin is not considered. Vertex- Vertex presentation ✓ Vaginal delivery of first twin as for singleton. ✓ Clamp the cord to prevent bleeding in second twin if anastomotic circulation present.  Vaginal delivery of twins ctd.. Abdominal examination of 2nd twin for presentation, lie and engagement. Amniotomy should be performed only after head is well engaged to pelvic inlet. Can use Oxytocin if uterine inertia present after delivery of 1st twin. No evidence for time restrains to deliver T2 , provided CTG monitoring is normal.  Vaginal delivery Vertex-Non vertex presentation Internal podalic version followed by breech extraction can be offered when T2 is in presentation other than cephalic or when spontaneous delivery delayed. Mode of delivery Offer EL/LSCS for following indications ▪ Triplets and higher order multiples. ▪ Non vertex 1st twin. ▪ Twin pregnancy with previous uterine scar. ▪ Twins with abnormal growth, Doppler studies. ▪ MCMA twins- (By 32 weeks) Analgesia during labour Epidural preferred. Continue during 2nd stage to facilitate external cephalic version if needed. Thank you References: Kilby MD, Bricker L on behalf of the Royal College of Obstetricians and Gynaecologists. Management of monochorionic twin pregnancy. BJOG 2016; DOI: 10.1111/1471-0528.14188. NICE guideline on ‘AN care for multiple pregnancy’ Ten teachers Obstetrics and gyneacology Dewhurst's Textbook of Obstetrics & Gynaecology Evidence-based Obstetrics and Gynecology (Evidence-Based Medicine) [email protected]