Multiple Pregnancy for TPC

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www.totalpregnancycare.com
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Multiple Pregnancy

• Dr Shantala Vadeyar
• MD, FRCOG, DM (UK)
• Advanced Obstetric Ultrasound (RCO/RCR)
• Subspecialist in Maternal-Fetal Medicine (RCOG)
• Consultant Obstetrics, Fetal Maternal Medicine
• Kokilaben Dhirubhai Ambani Hospital, Mumbai

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Incidence

• Increased with Assisted Reproduction
• Clomiphene citrate / Letrozol/ HMG, hCG
• Advanced Age
• Race Afro-carribeans
• 180-100

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Risks in Multiple Pregnancy
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DC twins - lambda sign
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MC twins - T sign
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Chorionicity v/s Zygosity
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Techniques for invasive testing
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Loss rates Amniocentesis in Twins
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Chorionic Villous Sampling in Twins
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Selective Fetocide / ER
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Management Antenatal
Maternal and Fetal Surveillance
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Ultrasound in Multiples

• Diagnosis and Chorionicity determinaiton
• Dating, Chromosomal Structural Normality
• Growth, Dopplers
• Amniotic fluid assessment
• Twin twin transfusion syndrome
• Invasive procedures amniocentesis, CVS
• Cervical length and funnelling
• Prediction of preterm labour
• Timing of delivery Dopplers, BPS in IUGR, etc

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Complications in TwinsBased on Chorionicity
EVENT DICHORIONIC MONOCHORIONIC
Miscarriage (11-23 weeks) 2 10
Perinatal Death (gt23 weeks) 2 4
Fetal Growth Restriction (one /both) 20 30
Preterm delivery (lt32 weeks) 5 10
Major birth defects 1 4
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Early screening for Preterm delivery
Prevalence of spontaneous early preterm birth
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Twin Twin Transfusion Syndrome

• Anastomoses in TTTS

• Monochorionic twins
• Donor twin is small, growth restriction
• Recepient twin is big
• Oligo / polyhydramnios
• Big bladder, heart enlarged in recepient
• Oliguria, donor
• Abnormal Dopplers

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Prognosis - TTTS

• Staging (Quintero)
• Stage I
• Recipient hydramnios
• Donor bladder visible/present
• Stage II
• Recipient hydramnios
• Donor bladder remains empty (stuck twin)
• Stage III
• Abnormal Doppler studies
• absent or reversed end-diastolic flow in Donor UA
  OR
• abnormal venous Doppler pattern in Recipient UA
  (reverse flow in the ductus venosus or pulsatile
  umbilical venous flow)
• Stage IV
• Fetal hydrops means stage IV and the end
• Stage V
• Fetal death of one or both twins.

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Treatment of TTTS by selective laser ablation of
A-V Anastamoses
Laser ablation
Stuck donor twin wrapped in membrane
Feely floating recipient twin In hydramnios
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Electronic Fetal Heart Rate monitoring in labour
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Epidural Analgesia(painless labour)
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Timing and Mode of Delivery

• Dichorionic twins 38 weeks
• Monochorionic twins 36 wks
• Vaginal delivery in uncomplicated DC or MC twins
  if cephalic, cephalic presentations
• Precious pregnancy, abnormal presentations,
  complications like IUGR, preterm, maternal DM/HT
  usually delivered by LSCS
• Increased risk of placenta praevia and APH, PPH

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Complications

• Post-partum haemorrhage
• Bimanual massage
• Uterotonics
• Prophylactic Misoprostol PR
• Syntocinon infusion
• B Lynch Suture
• Uterine Artery Ligation
• Uterine Artery Embolisation
• Hysterectomy

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Profile

• Total Pregnancy Care is an online guide for
  pregnancy, childbirth and motherhood related
  information. Women wanting to conceive, pregnant
  women, expecting parents, and new mothers can use
  this pregnancy portal for a healthy pregnancy,
  fulfilling childbirth and joyful motherhood. With
  pregnancy at its core, this portal covers various
  important aspects and especially addresses those
  matters that the Indian Woman always wanted to
  know but did not know whom to ask.
• This website is compiled by Dr. Shantala, an
  Indian Obstetrician and Gynaecologist. She has
  over 20 years of extensive medical and
  diagnostics experience in areas commonly related
  to the Maternity and Pregnancy fields. She has
  studied and practiced in India as well as in the
  United Kingdom and thus brings about the fusion
  of best practices of the Oriental East and the
  Progressive West.
• A mother of three children, she has complete
  understanding of the emotional, mental and
  physical needs of the New Age Pregnant Woman. Her
  patients appreciate her empathic approach and
  wholeheartedly express their gratitude for her
  generosity and care. Dr.Shantala is presently a
  full time Obstetrics and Gynaecology Consultant
  at the Kokilaben Dhirubhai Ambani Hospital and
  Medical Research Institute, a premier health care
  initiative of the Reliance ADA Group. Dr.Shantala
  has a clear vision to promote a holistic
  pregnancy approach and her mission is to provide
  comprehensive maternity care. This website,
  www.TotalPregnancyCare.com, is her first step
  towards this future.

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Services Offered

• Pre-pregnancy counseling
• Genetic counseling
• Antenatal care, Labour Delivery
• Specialist Ultrasound scans
• Viability scan
• The First trimester scan / Nuchal translucency
  scans
• Detailed anatomy / anomaly scans
• Fetal Echocardiograph
• 3D / 4D scans
• Assessment of the High risk Fetus and Mother
• Amniocentesis
• Chorionic Villous sampling
• Cordocentesis
• Intra-uterine transfusions
• Embryo Reduction / Selective fetocide
• Second opinion scans

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Topics covered

• Pre-Conception
• Working on getting pregnant or just starting to
  think about a family, this is the place for you
• Pregnancy
• From trying to conceive to the first trimester to
  labor, learn what to expect during your pregnancy
  and more
• Labor Delivery
• From that first contraction to the final push,
  here's what to expect during labor and delivery
• Post-Pregnancy
• Learn more about your diet and workouts,
  shopping, feeding and your child's health

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Interactive Corner

• Month by Month happenings
• Articles
• FAQs
• Gestation Calendar

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Society Memberships

• British Maternal Fetal Medicine Society
• Fetal Medicine Centre
• Kokilaben Dhirubhai Ambani Hospital Medical
  Research Institute
• Royal College of Obstetricians and
  Gynaecologists
• International Society of Ultrasound in
  Obstetrics and Gynecology

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Contact Us

• Email shantala_at_totalpregnancycare.com
• Mobile [phone]
• KDAH Board line 91 22 30999999

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THANK YOU
www.totalpregnancycare.com