TWINS

1
TWINS
????????? ???. ??????? ??????????? ???. ??????
????????????? ???. ?????? ????????????? ?????????
??????? ??. ?.?. ????? ????????? ??. ?.?. ?????
????????????
2
????????????????? ???? 25 ?? ????????????
????????????? ???????? ???????????????????????
???????????????????? ???????????

• CC ????????? 1.00?. ( 3 ??. 44 )
• ?????????????????????

3
History

• PI 1.00 (3 ?.?.44 ) ????????????????????????????
  ??????????????? ???????????????? ??????????
• PH ???????????????? , ????????
• FH ?????????????????????????????????????
• ????????????????????

4
History(cont.)

• Personal History ????????????
  ????????????????
• Obstetric History G2P0 366 wk by date
• First pregnancy Criminal abortion ?????????
  6 ??????? ????? 5
  ??????
• LMP 18 ?.?. 43
• EDC 25 ?.?. 44
• ANC ??.????? 9 ?????

5
History(cont.)

• Menstrual History LMP 18 ??????? 2543 ?? 3 ???
• ????????????
  28 ??? regular

6
Risk

• Criminal Abortion -----? Placenta Previa /
  Adherens

-         

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ANC RECORD

• First ANC 25 / 10 / 43
• GA 9 6 weeks

8
Physical Examination

• Height 146 cm
• Weight 41 kg ----? 42.4 kg at first ANC
• BP 100/70 PR 80 /R
• HEENT not pale
• Breasts normal
• Thyroid gland no enlargement

9
Physical Examination(cont.)

• Heart normal S1 S2 . no murmur
• Lungs clear
• Abdomen spleen / liver cant be palpated
• FH cant be palpated
• Extremities no edema

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Lab investigation

• Rh positive
• Hb 13.1 g, Hct 39.0
• VDRL non reactive
• HBsAg negative
• Anti-HIV negative
• TT X 2

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ANC record (1)
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Problem

• 1.      Date-size discrepancy ? size gt date
• 2.      Excessive weight gain 2.7 kg/mo. ????
  1-2 kg/mo.

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Causes

• 1.      Twin pregnancy ? risk
• 2.      Hydramnios
• 3.      Hydrop fetalis
• 4.      Macrosomia ? DM? ? risk
• Another Investigations 1. OGCT
• 2. USG ??? 17 ?.?. 44

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- ???????????????? -

• ?????? 17 ?.?. 44 ? ?? USG Est. Fetal Weight
  472 / 347
  26.48 discordance
• 
  - AC 174 142 32 mm (gt20 mm)
• Impression twin pregnancy with
  single fetal discordance
• ?????????? USG 1 ?.?. 44, 1 ??.?. 44,
  29 ??.?. 44, 12 ??.?. 44

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Management

• Antepartum
• 1. ????????????????????????????????
• - PIH
• - Preterm
• - PROM
• - Anemia ? ??? FeSO4
• 2.      ????????????????????????????????????
• 3.      ?????????? Vitamin, Iron, Folic acid

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Management (cont.)

• 4.      rest
• 5.      ??USG ????? 1) ???????????
• 2)
  ?????????????
• 3)
  ???????
• 4)
  ?????????????
• 5)
  ?????????????
• 6)
  Chorionicity
• 6.      ???????????????????????????????????? ?
  ??? USG

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ANC record (2)
date weight Urine/ blood BP Sign/symptom HF Presenting part FHS GA ?????/???? diag/treat
17/1/44 48.3 Alb Sugar - 100/60 ???????? ¼gto Br/cep / 21 USG 1/2/44
14/2/44 51.8 neg 100/70 ???????? 33cm. - / 255 USG 1/3/44
18
ANC record (cont.)
date weight Urine/blood BP Sign/symptom HF Presenting part FHS GA ?????/???? diag/treat
14/3/44 55.5 neg 100/60 ???????? 35cm. ?/cep / 30wk
28/3/44 57.9 neg 110/70 ??Complain 37cm. Br/cep / 32wk USG 29/3/44
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ANC (cont.)
date weight Urine/blood BP Sign/symptom HF Presenting part FHS GA ?????/???? diag/treat
11/4/44 58.6 neg 110/70 ???????? 38cm. - / 34wk USG 12/4/44
25/4/44 61.7 neg 110/60 ???????? 40cm - / 36wk ??? 9/5/44
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?? Ultrasound

• 1 ?.?. 44 15 wt discordance
  ???????????????? (criteria gt 20)
• MCDA twins ,UA EDF both
• 1 ??.?. 44 19 wt discortance (28 wk)
• UA EDF both
• 29 ??.?. 44 42 wt discortance (32 wk)
• UA EDF both back

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Problem

• 32 wk pregnancy with twins with 42 discordance
  
• ?? USG AC ??? GA ? ???????? 2 SD ? ???????????
  IUGR
• HC ??? GA ?? range
  ???? ? IUGR ???? Asymmetry
• BPD ??? GA
• Impression 32 wk pregnancy with twin with
  discordance due to asymmetrical IUGR

?
Plan ? ?
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ANTEPARTUM MANAGEMENT

• 1.      cause ??? correct
• maternal cause underlying ? ?????
• ??????, ?????
  (????????????????????? 2 ???)
• Fetal cause intrinsic factor ? chromosome
  abnormal
• ?
  infection TORCH
• Note ? ????????????? 2 ??? ? monochorian
  diamnion
• Placenta cause twin-twin transfusion
• Cord ? ????? /
  abnormal

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ANTEPARTUM MANAGEMENT

• 2.      Rest
• 3.      ?????????????????????
• ??? USG ??? 2 wk ? ??? USG 12 ??.?.
• 4.      ?????????????????????? 1-2 wk
• NST, Biophysical profile
•  5. ??????? termination ?????????????? 34 w
  ???? ?? lung maturity
• ?? case ?????????????? ????????????????????????
  ?
• ????? ANC ????????? ?? ??????????????????????????
  ? BACK

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• ?? USG 12 ??.?.44 341 wk pregnancy with
  discordant due to IUGR
• UA EDF both
• AFI (11.6 ?7.0 )
• ANC ???????????? 25 ??.?. 44 FHS ???????
• Imp. G2P0 GA 36 wk twin pregnancy with
  discordance due to IUGR .
• Plan of management ?

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Problem

• 1. G 2P0 GA 36 wk twin pregnancy with discordant
  due to IUGR
• Plan - monitor fetal well being ? NST,
  Biophysical profile
• Result
• ????? Fetal well being ????? ? ??????????
  Termination ?
• ???????????????.????????????? PROM,
  preterm??????? ????????? ???????

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???????????????????????????
?????risk ???????????????
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RISKS

• Twins pregnancy (discordance)
• Preterm
• IUGR

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Physical examination(3 ?.?. 44)

• PR 72/min
• BP 100/80 Hg
• RR 20/min
• BT 36.8 C
• General appearance good
• HEENT not pale

• Heart normal s1 s2 no murmurs
• Lung clear
• Abdomen liver and spleen cant be
  palpated
• Uterus HF ¾ gt umbilicus
• FHS 140,144
• Extremities no edema
• Neurological exam intact
• reflex 2

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Physical examination (cont.)

• Pelvic examination
• diagonal diameter gt 13.5 cm.
• Interspinous diameter gt 10.5 cm.
• Ischial spine - not prominence
• sacral curve - good
• Subpubic angle gt 85 degrees

• Cervix
• consistency soft
• effacement 70
• dilatation 2 cm.
• Membranes - intact

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???????????????????????????????

• Diagnosis
• A Thai woman, G2P0 GA 366 weeks by date with
  discordant twins with intrauterine growth
  retardation (T2) with preterm labor in latent
  phase

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LABOR RECORD (1)
Date/time 3??.44 Character of contraction Character of contraction Condition of cervix Condition of cervix Condition of presenting part Condition of presenting part membrane Fetal heart sound Blood pressure Pulse rate Medications,remarks
Date/time 3??.44 interval duration effacement dilatation station Suture/ position membrane Fetal heart sound Blood pressure Pulse rate Medications,remarks
3.50 500 mild 40 70 1FB -1 cephalic MI 140,144/R 120/80 84 Next page
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Medications, remarks

• G2P0 GA 366 weeks by date
• risks
• 1. twins pregnancy (Vx/Br) with discordant
  twins
• 2. intrauterine growth retardation (T2)
• 3. preterm labor in latent phase
• Pelvis adequate
• ??????????????management

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Plan of management

• Observe contraction, fetal heart sound
• EFM
• ARM in active phase
• Try vaginal delivery

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??????? LABOR RECORD

• ??????????????????????????????
  ?????????????????????
• ?????????????????????? ???????????????????????
  (??????????????)
• 
  ??????????????????????????????????
• 
  ?????????????????
• 
  PROM
• 
  FETAL DISTRESS

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??????? LABOR RECORD(cont.)

• ???????????????IUGR ???????
• ?????????????
• ?????????????IUGR
• ???????????????????
• ??????????????????????????

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??????? LABOR RECORD(cont.)

• ?? case ????????????????????????
  ??????????????????????????? severe IUGR
  ??????????chronic hypoxia ????? ?????? try vagina
  ????????????????? ????????? cervix
  ???????????????????????? ??????????????????Breech.

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LABOR RECORD (2.)
Date/time 3??.44 Character of contraction Character of contraction Condition of cervix Condition of cervix Condition of presenting part Condition of presenting part membrane Fetal heart sound Blood pressure Pulse rate Medications,remarks
Date/time 3??.44 interval duration effacement dilatation station suture or position membrane Fetal heart sound Blood pressure Pulse rate Medications,remarks
5.30 520mild 45 70 140,144 112/80 80 USG
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Medication,Remarks,Examiner

• USG
• Twin A GA352 weeks cephalic presentation,
  viable fetus, FHS positive
• Twin B GA27 weeks breech presentation, aviable
  fetus, FHS negative
• Problem list ?
• Twin B death in utero.

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Impression

• G2P0 366 weeks twins pregnancy with single fetal
  demise (T2)
• Plans of management
• CBC , PT (10.2/12.1), PTT (35.5/38)
• M/G
• Continuous fetal monitoring beware another twin
• Try vaginal delivery
• Lt c/s ??????? obstetric complication

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Twins demise

• ???????? 0.5-0.8
• ??????? monozygotic twins
• ??????????????????????????????????????????????????
  ??
• ??????????????????????????????????????????
  ????????????????????????????????????????????
• Acute twin-twin transfusion syndrome
• ?????????? DIC ?????????????????????????

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Management

• ???????????????????????????? ??? lung maturity
  ????????????????????
• ?????????????? ? ???????????????
  ????????????????????????
• ??????????????????????????????????????????????????
  ????
• ????????????????? obstetric complication
• case ??? ???try vagina ???? c/s

42
Management

• ??case ????????? try vagina ?????
  ?????????????????????????
• Acute twin-twin transfusion syndrome
  ????????????????
• MCDA ????????????????????????????????????????
  ? ?????????imbalance ??? anastomosis vessel
  ????????????????
• ???? severe anemia and ischemia ???

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LABOR RECORD (3)
Date/time 3??.44 Character of contraction Character of contraction Condition of cervix Condition of cervix Condition of presenting part Condition of presenting part membrane Fetal heart sound Blood pressure Pulse rate Medications,remarks
Date/time 3??.44 interval duration effacement dilatation station suture or position membrane Fetal heart sound Blood pressure Pulse rate Medications,remarks
7.10 7.30 450 mild 45 70 1FB -1 cepha-lic MI 133/R 112/80 72
44
LABOR RECORD (4)
Date/time 3??.44 Character of contraction Character of contraction Condition of cervix Condition of cervix Condition of presenting part Condition of presenting part membrane Fetal heart sound Blood pressure Pulse rate Medications,remarks
Date/time 3??.44 interval duration effacement dilatation station suture or position membrane Fetal heart sound Blood pressure Pulse rate Medications,remarks
8.00 420 mild 40 140/R
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Labor record

• 09.00? G2P0 366 weeks twins pregnancy with
  single fetal demise
• Plan set Lt c/s emergency ????????? case
  ?????????????? complication ???????????? fetal
  death ???? 2 ??

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Operative note

• Position supine
• Incision Low midline incision
• Finding Gravid uterus well-formed lower
  segment
• Clear AF 200ml in sac1
  
• Serosangurous discharge
  100ml in sac2

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Operative note (cont.)

• First twin - near term alive female fetus
• - cephalic
  presentation
  
  - Apgar 1min9, 5 min10
• Second twin - near term death female fetus.
• - macerated fetus.
• - footling breech
  presentation
• - no gross
  abnormality.
• Placenta monochorion diamnion
• Normal both tubes and ovaries.
• next

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Problem

• CC ??????? ??????????????
• PE mild pretibial edema
• reflex 1 all
• BP 110/70 mmHg
• back

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Questions

• 1. ?????????????????????????????????????????
• a. Preterm labor
• b. PROM
• c. PIH
• d. Postterm labor
• Ans. d.

50

• 2. ???????????????????????????c/s
• a.First twin has breech presentation
• b.Dizygotic twins with single fetal demise
• c.Twins with severe IUGR
• d.Twins with discordance
• Ans
  b.

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• 3.Monozygotic twins ????? dichorion diamnion
  ???????????????????????????
• a. ???? two-cell stage
• b. ???? ????????form inner cell mass and outer
  cell mass
• c. ????????????????????? embryonic disc
• d. ???????form neural tube
• Ans a.

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• 4.Which presenting parts are common found in
  twins pregnancy?
• a. Vx/Br
• b. Br/Br
• c. Vx/Vx
• d. Br/Vx
• Ans c.

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• 5. ??case Monochorian diamnion twin???
  ???????????????????????set emergency c/s ?????
• a. ?????????? DIC ?????????????????????????
• b. Acute twin-twin transfusion syndrome
• c. Placental abruption
• d. Severe pre-eclamsia
• 
  Ans b.