Transcript antenatal care of twin pregnancy

ANTENATAL CARE
OF
TWIN
PREGNANCY
Prof. Gomathy Narayanan
Relevance
1. Increasing Incidence:
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Following Induction of ovulation – 5-10%
Following ART – 32%
Advanced maternal age at pregnancy
2. Increased Morbidity & Mortality:
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Maternal – 4-fold
Fetal – 20-fold
3. Technological advances
Complications
I Trimester:
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Hyperemesis
Threatened abortion
Miscarriage
Congenital anomalies
Vanishing twin
Complications
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II Trimester:
Extreme Preterm labor – 44% / Delivery
PPROM
Growth discordance – 15-29%
IUGR
Fetal anomaly – 4.9%
Single fetal demise – 2-5%
Complications
unique to
Monochorionic Twins
• TTTS – 15-30%
(Twin to Twin Transfusion Syndrome)
• TAP – 3-5%
(Twin Anemia Polycythemia Sequence)
• TRAP – 1%
(Twin Reversal Arterial Perfusion)
• Selective IUGR
Complications
unique to
Monoamniotic Twins
• Conjoint twins – 1:50,000 Births
• Cord entanglement
• Fetal death
Maternal complications
• Anemia (Iron /
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Folic acid)
Polyhydramnios
PET / HELLP
syndrome
GDM
APH
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Acute fatty liver
Choliestasis
Pressure effects DVT
Pulmonary edema
(Tocolysis)
• Chorioamnionitis
(PPROM)
Antenatal Care
Increased:
• AN visits
• Hospitalization
• Intervention
Where to care antenatally?
• PHC not recommended
• Uncomplicated Twins:
District hospital / Similarly equipped
Nursing Home
• Complicated Twins:
Tertiary center / Fetal Medicine units
Uncomplicated Twins
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No bed rest or hospitalization
Restricted physical activity
Diet:
300 Kcal more than singleton pregnancy
Elemental iron: 60 mg/day
Folic acid: 1 mg/day
Calcium: 2500 mg/day
Preterm Prophylaxis
Indicated only when Short cervix or Preterm
labour:
• Tocolysis
• Cervical cerclage
• Progesterone
• Steroids
• Home uterine activity monitoring
USG is the Conerstone
of
Management
in
Twin Pregnancy
USG in First Trimester
• Confirmation of
number of foetuses
• R/O hetertropic
pregnancy
• Viability
• Retroplacental
hemorrhage
• Cervical status
• Chorionicity &
Amnionicity
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NT Scan
Down Screening
Fetal anomalies
CVS & Karyotyping
Fetal reduction
Screening for Downs
• Combination of NT & Maternal age
acceptable
• Serum Screening increases rate of pick up
• Vanishing twin can confuse alfa fetoproteins
• Increased NT may be early manifestation of
TTTS
USG in II & III Trimester
• Growth assessment (Every 2-4 weeks in
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Monochorionic & 4-6 weeks in Dichorionic Twins)
Growth discrepancy
Selective IUGR
Biophysical profile
Fetal demise
Vascular aberrations
Fetal Doppler, Echo & MRI
Special Situations
Preterm Labour
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Hospitalization
Tocolysis
Progesterone
Surveillance
Induction
Termination
PPROM
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Hospitalization
Tocolysis
Antibiotics
Steroids
Termination
Monochorionic II Twin is more at risk of
infection than Dichorionic II Twin
Twin to Twin Transfusion
Syndrome (TTTS)
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Incidence: 15% in Monochorionic Twins
Manifests at midpregnancy
Single placenta
Polyhydramnios in the Recipient and
Oligoamnios in donor
• Growth discordancy
• Hemodynamic & Cardiac compromise in
Recipient twin
Outcome in TTTS
Survival depends on Gestational age &
severity
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No intervention: 0 to 30%
Amnioreduction: 64%
Laser coagulation: 73%
Amniotic septostomy: 83%
Twin Anemia Polycythemia
Sequence (TAP)
Incidence:
• Spontaneous: 3-5%
• Post laser: 2-13%
Treatment:
• Intra uterine
transfusion
Diagnosis:
• Partial exchange
• MCA PSV tracing
• Absence of
polyhydramnios
transfusion
• Laser coagulation
• Expectant & post
delivery treatment
Twin Reversal Arterial Perfusion
(TRAP)
• Normal pump twin (Stuck twin)
• Acardiac recipient
Treatment:
• Laser coagulation
• Cord occlusion
Single fetal demise
Surveillance of surviving twin
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Serial USG
Serial BPP
Serial Doppler
MRI
Maternal coagulation profile
Anti D if mother is Rh Negative
Conjoint twin
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Termination in I & II trimester
If diagnosed later, CS
Plan separation after delivery
Prognosis poor
Avoid Iatrogenic Twinning
• Mono follicular induction of
ovulation
• Mono embryo transfer
Thank you!