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MULTIPLE GESTATION

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Monozygotic(Division of 1 ova fertilized by the same sperm) ... Fetus papyraceous -twin fetus that died in utero, become flattened and mummified ... – PowerPoint PPT presentation

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Title: MULTIPLE GESTATION


1
MULTIPLE GESTATION
  • By
  • Sridevi Abboy, MD

2
Definition(Multi-fetal Gestation)
  • MULTIPLE PARITY
  • -Twins (two babies)
  • -Monozygotic(Division of 1 ova fertilized by
    the same sperm)
  • -Dizygotic(Fertilization of 2 ova by 2 sperm)
  • -Triplets (three babies)
  • -Quadruplets (four babies)

3
Incidence
  • Twins - 1 in 100 births
  • African Americans 1 in 70
  • Caucasians 1 in 88
  • Japanese 1 in 150
  • Chinese 1 in 300
  • Triplets are about 1 in 7,500 births
  • Quadruplets are about 1 in 650,00 births

4
Predisposing Factors
  • Maternal age and parity
  • Maternal height and weight
  • Genetic and racial factors
  • Prior use of oral contraceptive agents
  • Social class
  • Seasonality

5
Causes of Multiple Gestation
  • Spontaneously
  • In Vitro fertilization
  • Intrauterine insemination
  • Assisted Hatching
  • GIFT, ZIFT
  • Frozen Embryo Transfer, Blastocyte Embryo
    Transfer
  • Fertility Drugs
  • Clomiphene citrate (clomid, serrophene)
  • Gonadotropins (GonalF, follistim, humagon)

6
Twins
  • Dizygotic twins
  • (66 of US twins)
  • Dichorionic separate chorion (placenta)
  • Diamniotic separate amnion (amniotic sac)
  • Monozygotic twin (33 of US twins)
  • Ova division
  • lt 72 hours Dichorionic, diamniotic
  • 4-8 days Monchorionic, diamniotic
  • 8-13 days Monochorionic, monoamniotic
  • gt 13 days conjoined twins

7
Conjoined Twins
  • Craniopagus
  • Pygopagus
  • Thoracopagus
  • Cephalopagus
  • Epholothoracopagus
  • Parapagus
  • Ischopagus
  • Omphalopagus
  • Parasitic twins
  • Fetus in fetu

8
Conjoined Twins(paraphagus)
http//www.conjoined-twins.i-p.com
9
Multiple Birth Stats (2000)
  • Number of live multiple births in 2000 119,648
  • Number of twin births 118,916
  • Number of triplet births 6,742
  • Number of quad births 506
  • Number of quintuplets and higher birth 77


  • http//www.cdc.gov/nchs/fastats/multiple.htm

10
Cost per infant
  • Infants born 39-42 weeks 9,803
  • Infants born 25-27 weeks 280,146
  • Twins born 25-27 weeks 560,292
  • Triplets born 25-27 weeks 840,438
  • Quads born 25-27 weeks 1,120,584
  • http//www.multiplebirth.com/New_Folder/Articles/
    MultgestEpidemCauseConsequesnces.doc

11
Days in NICU
  • GA 23-25 weeks 100-125
  • GA 25-27 weeks 80-100
  • GA 28-29 weeks (quads) 55-75
  • GA 30-31 weeks 25-45
  • GA 32-33 weeks (triplets) 15-35
  • GA 34-35 weeks (twins) 10-25
  • GA 36-40 weeks 1-10
    http//www.metrohealth.org/clinical/NIC
    U/2000.htm

12
Average age of gestation
  • Number of babies Weeks of Gestation
  • 1 40 weeks
  • 2 35 1/2 weeks
  • 3 33 weeks
  • 4 29 ½ weeks http//www.bestdoctors.com/
    en/conditions/g/gestation/gestation_100200.htm

13
Handicap Rates (per 1000 post-natal survivors)
  • Overall Severe Moderate
  • Singletons 90.6 19.8 70.8
  • Twins 125.6 33.7 92.0
  • Triplets 178.1 57.1 121.0
  • http//www.multiplebirth.com/New_Fo
    lder/Articles/MultgestEpidemCauseConsequesnces.doc

14
Cerebral Palsy
  • Singleton Twin Triplet
  • standardized standardized
    standardized
  • Per 1000 live births 1 4.6 16.6
  • Per 1000 1st year
  • survivors 1 4.6 17.4
  • Per 1000 pregnancies 1 8.3 47
    http//www.multiplebirth.com/New_Fo
    lder/Articles/MultgestEpidemCauseConsequesnces.doc

15
Mortality Rates(per 1000 live births)
  • Infant Neonatal Postnatal
  • (birth to 1 year) (birth to day 28)
    (day 29 to 1 year)
  • Singletons 11.2 7.8 3.4
  • Twins 66.4 55.9 10.5
  • Triplets 190.4 168.8 21.6
  • calculated from the
    vital statistics of the US, 1998
  • http//www.multiplebirth.com/New_Folder/Articles/
    MultgestEpidemCauseConsequesnces.doc

16
Mean birth weight
  • Singletons Twins Triplets
  • Mean BW(gm) 3357 2389 1735
  • lt1500gm 1.1 10.12
    31.88
  • lt2500 gm 6.06 52.24 91.52
  • SGA 9.38 35.63 36.57
    http//www.multiplebirth.com/New_Folder/Articles/M
    ultgestEpidemCauseConsequesnces.doc

17
Peripartum Complications
  • Prematurity-major cause of neonatal death
  • 50 of twins
  • 90 of triplets and higher
  • Spontaneous abortion
  • Increased anomalies
  • Cord Prolapse
  • IUGR, discordant growth
  • Intracranial Hemorrhage
  • Locked Twins
  • Description Twins lock heads
  • 1st twin breech, 2nd twin vertex

18
Prematurity
  • Singletons Twins Triplets
  • lt33 weeks 1.7 14 41.25
  • lt37 weeks 9.4 50.7 91.03
  • http//www.multiplebirth.com/New_Fold
    er/Articles/MultgestEpidemCauseConsequesnces.doc

19
Problems of Prematurity
  • HMD/BPD
  • Pneumothorax
  • Apnea
  • ICH
  • CP
  • Blindness/Retinopathy
  • LBW
  • PDA
  • Hypertension/Hypotension
  • Bradycardia
  • Anemia
  • Hyperbilirubinemia
  • NEC
  • Metabolic disorders
  • Hypothermia
  • HIE
  • Hypotonia
  • Infections

20
Neonatal Management(Multiple Gestation)
  • Team for each fetus
  • Examine for prematurity and IUGR
  • Examine for congenital anomalies
  • Determine zygosity, examine placenta
  • Assess family support

21
In ICN
  • RDS
  • Apnea/Asphyxia
  • Hct and BP
  • Wt difference
  • NEC
  • Head Sono
  • Glucose
  • Blood typing

22
Second Twin Risks
  • Asphyxia due to premature separation of placenta
  • Fetus papyraceous
  • -twin fetus that died in utero, become
    flattened and mummified
  • Fetal transfusion Syndrome
  • Placental AV shunt in monozygotic twins (15)
  • Arterial twin pumps blood to other twin,
    starves self
  • Other twin is bulky and plethoric
  • Operative or difficult delivery

23
Monozygotic twins(physical characteristics)
  • Same sex
  • Features alike, including teeth and ears
  • Hair identical
  • Eyes same color and shade
  • Skin same texture and color
  • Hands and feet same conformation and same size
  • Anthropometric values closely agree

24
Twin-Twin Transfusion Syndrome
  • Monozygotic twins share one placenta
  • 1 placenta causes one baby to receive more blood.
  • One baby (donor) smaller and other larger.
  • Larger baby excess urine, polyhydramnios.
  • Donor stops producing urine, oligohydramnios.
  • This can lead to pre-term delivery (24 weeks).

25
TTTS
http//www.tttsfoundation.org/chart1.htm
26
Prevention(Multiple Gestation)
  • Moniter treatment with fertility drugs
  • Limit embryos transferred during IVF
  • Counseling risks and long-term sequelae
  • Fetal reduction if not against religion

27
  • THE END
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