Isuog, Bali Twin Pregnancy Jje 20091119

Judi Januadi Endjun

Gatot Soebroto Army Central Hospital/ Medical Faculty, University of Indonesia ISUOG, Bali, 2009

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AGENDA Introduction Etiology of twins Diagnosis of twins Vanishing twins Perinatal loss in twins Placentation Complications and Abnormality in twins pregnancy Conclusion Take home messages References JJE-20091119

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INTRODUCTION Definition: any pregnancy in which ≥ 2 embryos or fetuses occupy the uterus simultaneously Epidemic of twins: ART, delayed childbearing, and ovulation induction

USA (2003): 67% twins; 500% triplets and highorder The most profound implication: preterm delivery  Maryam Tarsa et al. Multifetal gestation and malpresentation. In: Essentials of obstetrics and gynecology, 5 Ed infant death th

Young Mi Lee et al. Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach, 2007,304-315

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INTRODUCTION 3.2% of all live births (US 2003) (Natality Data Set, CDC, 1997 – 2002) ± 14 – 25% are IUGR and± 25% require NICU (Mauldin J et al, 1998; Ettner SL et al, 1997)

Cerebral palsy: 4x (gemelli), 17x (triplet)

(Elliott JP et al,

1992; Grether JK et al, 1993)

IUFD: 4x (ACOG, 2004) The likelihood of not surviving the 1st year of life:

7x (Luke B et al, 1994; Kiely JL et al, 1992) Twin-specific problems: TTTS, MCMA, conjoined Maternal complications: preeclampsia, DM: 2 - 3x VJ et al, 1998; Sibai BM et al, 2000)

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(Roach

ETIOLOGY OF TWINS Depending on the number of eggs fertilized at

conception  monozygotic or dizygotic Monozygotic: identical, same genetic make up, the rate is constant throughout the world (1/250 pregnancies), type of placentation (DCDA, MCDA, and MCMA) and the likelihood of complications. ART:  monozygotic twins: alter the zona pellucida around the time of fertilization or delayed blastocyst implantation

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet and gynecology. Callen, 5th Ed,2008;266JJE-20091119

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tp://www.studentconsult.com/common/showimage.cfm?mediaISBN=9781416059400&FigFile=S9781416059400-013-f001.jpg&size

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http://www.youtube.com/watch?v=50JO-YtGshw

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Twinning rate (per 1000 pregnancies) in England and Wales, 1960–1990 for all twins (diamond markers), dizygotic twins (square markers) and monozygotic twins (triangle markers; adapted from Derom et al. 1995)

http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/images/fig05-0

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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/images-thefetus/gem-03

DA-DC Separate placentae

DA-DC Fused placentae

DA-MC Single placentae

MA-MC Single placentae

Frequency

35%

27%

36%

2%

Mortality

13%

11%

32%

44%

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DIAGNOSIS OF TWINS Anamnesis: risk factors Physical examination: difficult ULTRASOUND: should begin with a complete imaging sweep of the uterus FIRST TRIMESTER ULTRASOUND: number of GS and embryo, location of placenta, dividing membrane, AF, YS, and FHR  determine chorionicity  potential complications

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obste and gynecology. Callen, 5th Ed, 2008;266-2 JJE-20091119

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ULTRASOUND IN TWIN There is good evidence that the diagnosis of twin

gestation is improved by the routine use of ultrasound. There is consensus that serial ultrasonographic

evaluation every three to four weeks is indicated in twin gestations. (I B)

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ULTRASOUND IN TWIN Fetal growth differs slightly in twin gestations

and twin specific charts may be used to define the normal growth rate. Precision may also be obtained by using sex

and race specific charts. In clinical practice, however, these differences

are small and singleton growth curves may be used. JJE-20091119

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ULTRASOUND IN TWIN Patterns of fetal growth are more important

than absolute measurements. Both must be interpreted in the light of the

clinical history, together with all the genetic and environmental factors that may affect fetal growth. (III B)

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ULTRASOUND IN TWIN The diagnosis of discordance has been based

on the following: AC difference of 20 mm (sensitivity of 80%,

specificity 85%, PPV 62%) EFW based on BPD and AC or AC and FL > 20 %

(sensitivity 25-55%) (II-2 B)

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1 TRIMESTER ULTRASOUND ST

 Every effort should be made to determine chorionicity

at the time of diagnosis. (II-3 C)

 The optimal time to determine chorionicity is 10-14

weeks. (II-3 C)

 While these recommendations apply to diagnosis of

twin pregnancy with regard to prenatal diagnosis and counseling, there have been no studies relating the establishment of prenatal chorionicity to pregnancy SOGC, Management of twin pregnancy (Part 1), July, 20 outcome.

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VANISHING TWINS EARLY (< 8 weeks)

INTERMEDIATE LATE (> 8 and < 22 (> 22 weeks) weeks)

Delivery < 32 W

1.9%

5.3%

21.4%

NICU > 28 days

8.7%

15.7%

43.8%

Neurodevelopment disorders

3.3%

8.0%

9.7%

Pregnancy outcome

Comparable with singletons

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet and gynecology. Callen, 5th Ed,2008;266-2 JJE-20091119

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PERINATAL LOSS IN TWINS IMR: > 5 x = 32.9/1000 live-born twins (USA, 1999) Survival depends on chorionicity: anomalies, growth problems & prematurity Cumulative loss rate: 3% dichorionic & 15% monochorionic (Sabire et al, 1997) Losses are more likely to occur between 16 – 22 W 

ultrasound examination every 1 – 2 W to screen TTTS Fetal demise of one twin, cerebral palsy Maternal complications: preeclampsia, GDM

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet and gynecology. Callen, 5th Ed,2008;266-2 JJE-20091119

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TWINS DISCORDANT In twins discordant for abnormality, the option of

selective reduction should be offered. The procedure should be performed in a tertiary

level center. Transportation and out-of-province costs should be

covered.

SOGC, Management of twin pregnancy (Part 1), July, 20

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PLACENTATION The most important is the identification of

chorionicity Ultrasound is very useful in determining

placentation (chorionicity and amnionicity) and are very important in predicting twin pregnancy complications

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet and gynecology. Callen, 5th Ed,2008;266-2

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PLACENTATION Chorionicity and amnionicity First, second and third trimester Membrane insertion, “twin-peak” sign Membrane thickness Membrane layers Multiple sonographic markers to determine

chorionicity and amnionicity Monoamniotic twins

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet and gynecology. Callen, 5th Ed,2008;266-2

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Sonographic determination of chorionicity and amnionicity in first trimester twins gestations PlacentationGestational Yolk Sacs Sacs

Embryos / Sac

Amniotic Cavities

DC, DA

2

2

1

2

MC, DA

1*

2

2*

2

MC, MA

1*

1 or partially 2* divided*

1

* Amnionicity cannot be determined by this finding

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstetr and gynecology. Callen, 5th Ed,2008;266-2 JJE-20091119

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CONJOINED TWINS MC, MA twins Embryo divides at 13 to 15 days from conception The two fetal poles may be attached at varying sites (Early

ultrasound finding: bifid appearing fetal pole) Visualizing in the same relative position in all views Direct opposition of the twins from each other Extreme extension of the fetal spine Inseparable skin contour must be persistent Prognosis: very poor

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstet and gynecology. Callen, 5th Ed,2008;266-2 JJE-20091119

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Sumber: Dr. dr. Adityawarman, SpOG(K

Adapted from: Romero, R., Pilu, G., Jeanty, P., Ghidini, A. and Hobbins, J.C.(1988). Prenatal Diagnosis of Congenital Anomalies, p 405. ( courtesy from Philippe Jeant www.thefetus.net )

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Ectoparasitic twins are

parts of

twins implanted in another fetus. In this case what appears to be an omphalocele on the left is a fetal abdomen with lower legs on the extreme left. (Courtesy Glynis Sack, MD, www.TheFetus.net)

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TWIN TO TWIN TRANSFUSION SYNDROME MC twin  placental vascular anastamoses communication of the two fetoplacental circulations; may be arterio–arterial, veno– venous, or arterio–venous in nature (Benirschke K. Twin placenta in perinatal mortality. N Y St J Med 1961;61:1499–508)

This phenomenon of a shared circulation between

monochorionic twins was first described by Schatz in 1882 (Schatz F. Eine besondere Art von einseitiger Polyhydramnie mit anderseitiger Oligohydramnie bei eineiigen Zwillingen. Arch Gynakol 1882;19:329)

http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-final.

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TWIN TO TWIN TRANSFUSION SYNDROME Anatomical studies arterio–venous anastomoses

are deep in the placenta but almost always proceed through the cotyledonary capillary bed (Benirschke K, Kim CK. Multiple pregnancy. N Eng J Med 1973;288:1276–84)

± 25% of MC twins  imbalance in the net flow of

blood across the placental vascular arterio–venous communications from one fetus, the donor, to the other, the recipient, twin-to-twin transfusion syndrome; ± 50% of these casessevere twin-totwin transfusion syndrome acute polyhydramnios in the second trimester

http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-final. JJE-20091119

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NEJM, July, 2004

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Staging of twin to twin transfusion syndrome, Quintero RA et al, 1999 Stage

Amniotic Fluid

Fetal Bladder

MCA Hydrops Doppler, UA or UV

Fetal Demise

I

D: oligo R: poly

Normal

Normal

No

No

II

As above

D: bladder Normal not seen

No

No

III

As above

As above

Abnormal

No

No

IV

As above

As above

Abnormal

Yes, either No twin

V

As above

As above

Abnormal

Yes, either Yes, either twin twin

Egan JFX et al. Ultrasound evaluation of multiple pregnancies. In Ultrasonography in obstetr and gynecology. Callen, 5th Ed,2008;266-2

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Twin reversed arterial perfusion sequence (TRAP) The most extreme manifestation of TTTS ± 1%

of MC twin  is acardiac twinning (acardius chorioangiopagus parasiticus). The underlying mechanism is thought to be

disruption of normal vascular perfusion and development of one twin (the recipient) due to an umbilical arterio–arterio anastomosis with the other (donor or pump) twin (Van Allen MI, Smith DW, Shepard TH. Twin reversed arterial perfusion (TRAP) sequence: study of 14 twin pregnancies with acardius. Semin Perinatol 1983;7:285–93)

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Twin reversed arterial perfusion sequence (TRAP) At least 50% of donor twins die due to

congestive heart failure or severe preterm delivery, the consequence of polyhydramnios50,51. All perfused twins die due to the

associated multiple malformations.

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GENETIC TESTING All women carrying twin pregnancies should

be referred for counseling to a centre for the consideration of invasive testing at age 32. The counseling must be individualized and

the final decision must be taken by the parents since the risk of amniocentesis is uncertain in twin gestation. (II-3 C)

SOGC, Management of twin pregnancy (Part 1), July, 20

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GENETIC SCREENING Biochemical screening for aneuploidy is not

recommended in twins. MS-AFP is useful for detection of open neural tube and

other birth defects. (II-3 C) Evidence is promising that NT screening is useful for

identifying twin pregnancies at high risk of aneuploidy.  This requires further prospective investigation. (II-3 C)

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INVASIVE GENETIC TESTING The fetal loss rates with invasive testing (amniocentesis

and CVS in twins are unclear. (II-3 C) Development of a protocol for standardization of technique (as

determined by expert opinion) is recommended. Invasive testing should be offered to twins according to

the usual standard of care.

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PRETERM BIRTH PREVENTION Routine hospitalization for bed rest in multiple gestation is not

recommended. (I E) There is insufficient evidence to support prophylactic activity

restriction or work leave in multiple gestation. (III C) There is moderate evidence against routine prophylactic cervical

cerclage in multiple gestation. However, cerclage maybe indicated for the treatment of

incompetent cervix or other specific circumstances. (I;II-2 D)

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PROPHYLACTIC TOCOLYSIS There is moderate evidence against

prophylactic tocolysis in the management of multiple gestation, but it may be indicated on other grounds. (I;II-2 D)

SOGC, Management of twin pregnancy (Part 1), July, 2000

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ROUTINE CLINICAL CERVICAL EXAMINATION There is good evidence that premature cervical change

by digital examination predicts preterm birth in twins. (II2 A) Since there are no well designed intervention trials

available, the role of sonographic clinical cervical assessment in the prenatal period has not been determined. (C) JJE-20091119

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SONOGRAPHIC CERVICAL ASSESSMENT There is good evidence that transvaginal

sonographic measurement of cervical length predicts preterm birth in twins. (II-1 A) While the predictive ability of cervical length

measurement is established, there are no intervention studies that have evaluated cervical length measurement in the prevention of preterm birth, and therefore the role of sonographic clinical cervical assessment in theSOGC, prenatal period has not Management of twin pregnancy (Part 1), July, 2000 been determined. (C)PENDIDIKAN DAN HANYA UNTUK JJE-20091119

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Risk of preterm delivery using cervical length at 23 weeks (Heath et al 1998)

Cx

LR

5 mm

52

10 mm

9,1

15 mm

2,7

20 mm

1,2

25 mm

0,7

30 mm

0,5

40 mm

0,5

50 mm

0,4

60 mm

0,1

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FETAL FIBRONECTIN There is good evidence that the presence of

cervicovaginal fetal fibronectin in twins predicts preterm birth. Without well designed intervention trials available,

there is no basis for incorporating fetal fibronectin screening into routine prenatal management of multiple gestation. (C) JJE-20091119

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ULTRASOUND MANAGEMENT a. Performed in 1st trimester:

number, amnionicity,

chorionicity, and NT (10 – 14 W)

b. Detailed US examination:

18 – 20 W, fetal gender,

number of placenta, the thickness and number of layers in membrane, and lambda (twin peak) sign

c. Dichorionic pregnancy:

fetal growth (FG) evaluation every 3

– 4 W (if FG and AFV normal)

d. Monochorionic diamniotic:

evaluation every 2 – 3 W,

TTTS, fetal echocardiography Young Mi Lee et al. Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach, 2007,30

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ULTRASOUND MANAGEMENT e. Dichorionic or monochorionic: if IUGR, discordant fetal growth, discordant AFV NST, Biophysical Profile, Doppler studies f. Monoamniotic: daily NST starting from 24 – 26 W (risk of sudden IUFD from cord entanglement)  variable deceleration  delivery?

Young Mi Lee et al. Multiple pregnancy. In: Management of High-Risk Pregnancy. An Evidence-based Approach, 2007,30

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umulative fetal loss rates in monochorionic (solid line) and Gestational age distribution at delivery of monochorionic (solid bars) and chorionic (dashed line) twin pregnancies, from 12 weeks of gestation20 dichorionic (open bars) twin pregnancies. The proportion of pregnancies delivering very preterm (before 32 weeks) is considerably higher in monochorionic compared to dichorionic twins20

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http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05/chapter-05-final.h

ELECTIVE CAESAREAN SECTION The indications for elective Caesarean section in twin gestations are: a) Monoamniotic twins because the risk of entrapment is too great to permit elective vaginal delivery; b) Conjoined twins other than at gestations remote

from term; c) Indications as for singleton pregnancies. (III C)

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CASE REPORT Mrs I, 34 year, G1P0A0 20 weeks, dizygotic

twin pregnancy (28-03-2008) Fetus: gemelli, breech-breech presentation, boy and girl, no major anomaly seen Placenta: normal, two placenta at right and left side of the uterus Amniotic fluid: normal, amniotic membrane (+) Biometry: equal to 19 weeks, EFW 1: 332 gr and EFW 2: 338 gr JJE-20091119

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CONCLUSIONS ART and delayed childbearing increase multiple

pregnancy High perinatal morbidity and mortality rates Early diagnosis and serial ultrasound studies are

important on maternal and neonatal outcomes

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TAKE HOME MESSAGES a. Diagnose the twin pregnancy (ultrasound !) b. Determination of zygosity: !! Conjoined twins c. Screening for fetal anomaly and growth

disturbances d. When the best time to delivery? e. Confident diagnosis of zygosity may require detailed examination of the placenta after delivery

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REFERENCES a. Tarsa M, Moore TR. Multifetal gestation and

malpresentation. In: Essentials of obstetrics and gynecology, 5th Ed, 2010;160-172

b. Young Mi Lee et al. Multiple pregnancy. In:

Management of High-Risk Pregnancy. An Evidence-based Approach, 2007,304-315

a. Egan JFX, Borgida AF. Ultrasound evaluation of

multiple pregnancies. In: Ultrasonography in obstetrics and gynecology, Callen, 5th Ed, 2008;181-224

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THANK YOU

http://www.youtube.com/watch?v=50JO-YtGsh http://www.facebook.com/judi.j.endjun?ref=profile [email protected] JJE-20091119

http://www.pdfcoke.com/Judi%20Endjun

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