Complications
Fetal causes
A) Maternal complication: 🔹 Twins → Acute polyhydramnios is almost always
During Pregnancy
1.Abortion 🔹
associated with Univoular twins
🔹 Congenital fetal anomalies (20%)
2.Preterm labour
3.Pre-eclampsia (25%) 🔹
🔹
Anencephaly & open spina bifida
Cong. Obstruction of oesophagus or duodenum
4.Placenta previa
5.Malpresentation 🔹 Hypoplastic lungs
Knot of umbilical cord, cardiac abnormalities, &
6.Non engagement of presenting part
7.Pressure symptoms 🔹
cirrhosis of fetal liver
🔹 Chorioangioma
Fetal neurological or muscular abnormalities (e.g.
The amniotic fluid is increased.
In general a deepest pool of >8cm or an AFI
During Labour
>22 is abnormal.
1.P.R.O.M
2.Prolapse of arm, cord, or both 🔹
myotonic dystrophy, anencephaly)
🔹AHydrops
large placenta
fetalis (Rh isoimmunization)
Causes of polyhydramnios
1-Maternal Causes
3.Obstructed labour due to malpresentation
2-Fetal causes
4.Abruptio placenta
3-Idiopathic
🔹
5.Uterine atony Maternal Causes
🔹 Diabetes mellitus →(30%)
6.Retained placenta
🔹
7.PPH Causes of generalized edema
🔹Syphilis
8.Splanchnic shock if leads to fetal liver cirrhosis
During puerperium 1. Subinvolution maternal prolactin
B) Fetal complication: Idiopathic cause
1.Prematurity and it is complications ( 30-50% ).
2.Congenital fetal malformation (25%) (mild)
3. Cord prolaps
Acute Polyhydramnios :
🔹
Clinical Picture
Symptoms:
Abdominal pain
Nausea & vomiting
Pressure symptoms
🔹Signs
-General examination→Pre-eclampsia
-Abdominal→ Huge, Fetal parts & fetal heart
sounds can not be detected + fluid thrill
🔹
-Vaginally → high cervix, partially dilated
Differential Diagnosis:
a. Accidental haemorrhage
Clinical Types
■ Acute ployhdramnios
- Extremely rare (1 in 3,000 pregnancies)
b. Retroverted gravid uterus
- Sudden onset (few days)
c. Hydatidiform mole
- In early pregnancy (16-20wk)
- Almost always associated with uniovular twins
- Leads to abortion or preterm labour
🔹
Chronic Polyhydrmnios
Symptoms: ■ Chronic Polyhdramnios
- Common (1 in 100 pregnancies)
Polyhydramnios
🔹
- Abdominal discomfort Dizygotic twins
🔹Signs:
- Pressure symptoms - Insidious onset (few weeks) Dizygotic twins result from two separate ova being fertilized by
- In late pregnancy >28wks different sperm, simultaneously implanting and developing.
Abdominal→ Huge, Fetal parts difficult to feel,
malpresentation (common), fetal heart faint, These fetuses will have separate amniotic membranes and
fluid thrill placenta(dichorionic and diamniotic). Twins may be different sexes.
vagina→ cervix is partially dilated
Ultrosound → for diagnosis, multiple This mechanism of twinning accounts for two-thirds of multiple
pregnancy, fetal anomalies, presentation pregnancies; and most affected by predisposing factorse (race, familial
tendency, increased maternal age, parity, height, weight, and ovulation
🔹 Differential Diagnosis:
a. Twins pregnancy
drugs (clomiphene & menopausal gonadotrophins
🔹
b. Pregnancy with huge ovarian cyst DEFINITION Monozygotic twins
c. Maternal ascites Simultaneous development of more than Result from division into two of a single, already developing, embryo and will
🔹
one fetus in the uterus
Twins is the commonest
be genetically identical and, therefore, always the same sex. depends on the
stage of development when the embryo divides.
1. Under local anaesthesia and u/s guide drain 1500-
2000 ml in a slow rate 500ml per hour Types
2. Complications: rupture of membranes, preterm Management
•Acute Polyhydramnios
Uniovular
(Monozygotic,Identical) 🔻 Timing of division in monozygotic twins
• < 3 days l DCDA 30%.
labour, chorioamnionitis, abruptio placenta, bowel injury, twins 30%
•Pregnancy is terminated Binovular • 4 –7 days l monochorionic, diamniotic (MCDA) 70%.
🔷
injury to fetus, cord or placenta
•Rupture of membranes (Dizygotic, Fraternal) • 8 –12 days l monochorionic, monoamniotic (MCMA) <1%.
Amniotic fluid Twins 70% • > 12 days l conjoined twins (very rare).
Indomethacin 25mg 6 hourly X 4 days -after 20wks largely consists of fetal urine.
🔹
-The volume depends on urine production, fetal
swallowing, and absorption. 🔹
Medical Terms
Superfecundation: is the fertilization of two different ova released in the
Investigations
Exclude maternal diabetes with a glucose
-Normal volume varies with gestation, and is 🔹
same cycle, by separate acts of coitus within a short period of time
Superfetation is fertilization of two ova released in different menstrual
tolerance test (GTT).
Ultrasound examination of fetus.
highest between 24 and 36wks.
-The volume is measured by ultrasound, either by 🔹
cycles
Fetus papyraceous or compressus: one of the fetuses dies early &
🔹 Care of The Newborn:
After delivery; the fetus is examined for
measuring the deepest vertical pool, or by adding
up the deepest pools in the four quadrants of the
compressed b/w the membrances and uterine wall more common in
🔹
univoular twins
Fetus acardiacus: one fetus becomes parasitic without heart occurs
congenital malformation and a soft rubber
catheter is passed into the stomach to test for
oesophageal atresia
uterus (AFI). but, as a general rule,
🔹
only in uniovular twins
Vanishing twin: one fetus dies and if pregnancy within 14 weeks, it
vanishes by resorption
Diagnosis
definition
.a deepest pool of <2cm or an AFI of <8cm is
▪️History:
Family history: +ve
considered low.
▪️
H/o of ovulation induced drugs
🔹
Symptoms:
🔹
Complications ETIOLOGY:
🔹 ↑Nausea and vomiting in early months
🔹Ruptured membranes
Related to cause:
🔹
Cardio-respiratory embarrassment in later months
-preterm rupture of the membranes is commonly followed by delivery
and/or intrauterine infection
-IUGR is an important cause of fetal and neonatal mortality and long-term
🔹 Urinary tract malformation→ Bilateral renal 🔹
🔹
↑ Tendency of swelling of legs, varicose veins & hemorrhoids
Unusual abdominal size
🔹
morbidity.
Related to reduced volume:
🔹
agenesis (Potter syndrome)
🔹 Obstruction to fetal urine output: 🔹 Excessive fetal movements
However, the vast majority are diagnosed on ultrasound in the 1st trimester
-lung hypoplasia if occurs <22wks
-limb abnormalities, e.g. talipes, if prolonged oligohydramnios before 22wks 🔹
fetal abnormalities such as posterior urethral
valves. ▪️General Examination:
has a very poor prognosis.
Club foot
🔹 fetal renal failure
🔹Intrauterine growth retardation IUGR
↑ incidence of anemia
Unusual weight gain
🔹Fetal chromosomal abnormalities →Trisomies ▪️
Postterm pregnancy Pre-eclampsia 20-50%
-Amputation of a limb due to compression
-Breech presentation (common)
-Meconium aspiration syndrome 🔹Placental insufficiency → PET 🔹
Abdominal Examination:
Diagnosis:
Oligohydramnios 🔹Fundal
Inspection:→ Huge abdomen
Palpation:
level is higher than period of amenorrhea
🔹
Fundal level is lower than the period of Investigations Palpation of two heads or 3 poles→ sure sign
amenorrhea
Breech presentation 🔹 US of fetus, including Doppler.
Speculum examination to look for ruptured 🔹
All causes of an Oversized Uterus:
🔹Wrong calculation 🔹 Auscultation:
Fetal parts are easily felt
Decrease fetal movement 🔹
membranes.
If suspected spontaneous rupture of membranes 🔹
🔹
Multible pregnancy.
Bleeding in early pregnancy misdiagnosed as menstruation
Auscultation of two fetal heart sounds at two points far away from each other and heard simulatoneously by two
observers with difference of at least 10 beats per minutes is Diagnostic
FHS are clearly heard
Ultrasound.
(SROM): CRP, FBC, and vaginal swabs should be taken.
🔹
🔹
Large fetus
Fetal malformation as hydrocephalus
▪️
Arnoux sign (Suggestive)→ overlapping of two fetal hearts sounds giving a galloping rhythm
Vaginal Examination:
🔹
🔹
Hydatidiform mole
Polyhydramnios
▪️
Twins is suspected during labour if the presenting part is small in relation to the size of the uterus
🔻
Management of oligohydramnios
If SROM at 34–36 or more weeks, Induce labour unless CS is indicated 🔹Tumours as fibroids or ovarian cyst Ultrasound:
Confirms diagnosis, position and presentation
🔻
for another reason. 🔹Abruption placenta with concealed haemorrhage
Ascites with pregnancy. -2 Gestational sacs appears as early as 4.5wks by TVU
🔹
🔹
If SROM before 34, Give prophylactic oral erythromycin.
Monitor for signs of infection (4-hourly temperature and pulse).
-2 Heads can be detected at 12th week
-For assessment of placentation sonar is done between 16-24 wks
🔹Daily CTG. -For assessment of IUGR→ repeated every 2-3wks
🌟
Consider induction by 34–36wks -Zygosity could be determined by identifying the intervening layers
🔻
🔹IfManage
IUGR
according to umbilical artery Doppler and CTG.
Chorionicity:
Determining chorionicity allows risk stratification for multiple pregnancy and is best done by ultrasound in the 1st
trimester or early in the 2nd.(11-14 wk).
🔻
🔹 If isolated oligohydramnios
The key indicators are:
• Obviously widely separated sacs or placentae—DC.
🔻
🔹
Intervention is not usual if umbilical artery Dopplers are normal.
If fetal renal tract abnormality Refer to fetal medicine centre.
• Membrane insertion showing the lambda (λ) sign—DC.
• Absence of λ sign <14wks diagnostic of MC.
🔹During labour, FHS should be observed frequently for early detection of
fetal distress
• Fetuses of different sex—DC (dizygotic).
▪️
Fetal distress → caesarean section
Maternal risks associated with multiple pregnancy:
• Hyperemesis gravidarum.
• Anaemia.
• Pre-eclampsia (5× greater risk with twins than singletons).
🔹
Definition
Fetal weight at birth is 4 kg or 4.5 Kg (in USA) or more, or
the birth weight is above the 90th percentile for gestational
• Gestational diabetes.
• Polyhydramnios.
• Placenta praevia.
🔹
age
• Antepartum and post-partum haemorrhage.
Incidence → 5-10% with all pregnancies
• Operative delivery.
🔹20-50% with gestational D.M ▪️ Fetal risks associated with multiple pregnancy
antenatal care
🔻
• All fetal risks increased with MC twins.
🔹
Aetiology All multiple pregnancies are by definition ‘high risk’ • Risk of miscarriage : especially with MC twins.
🔹
Complications: Large size of one or both parents, especially • Establish chronicity—most accurately diagnosed in 1st trimester (absence of lamda sign diagnostic), so an early US • Congenital abnormalities more common only in MC twins including:
Multiple pregnancy
Caesarean section,🔹forceps, and ventouse 🔹
Obstructed labour with increase rate of mother (genetic factor) should be considered with any indications of multiple pregnancy (e.g. fundus palpable before 12wks or exaggerated • neural tube defects
🔹
delivery 🔹 Maternal obesity → most common
Excessive maternal weight during pregnancy
Unusual uterine
symptoms of early pregnancy).
• Routine use of iron and folate supplements should be considered.
• cardiac abnormalities
• gastrointestinal atresia.
🔹
🔹
Shoulder dsytocia
🔹
>20 kg Maternal D.M
Macrosomia • A detailed anomaly scan should be undertaken. • IUGR: up to 25% of twins.
🔹
Vaginal lacerations Multiparity • Preterm labour: main cause of perinatal morbidity and mortality:
🔹PPH 🔹 Postterm size • A dvise aspirin 75microgram od if additional risk factors for pre eclampsia.
• Serial growth scans from 20 untill 36wks every 4wk for DC twins. different in MCDA • 40% twins deliver before 37wks
🔹Hydrops
Newborn obesity fetalis • More frequent antenatal checks because risk of pre-eclampsia. • 10% twins deliver before 32wks.
Previous macrosomic baby • Discuss mode, timing and place of delivery. •Risk of disability (mainly, but not entirely, due to prematurity and low birth
• Establish presentation of leading twin by 34wks. weight).
•Incidence of cerebral palsy (CP):
by fatema okoff Management • Offer delivery at 37–38wks: induction or lower segment Caesarean section (LSCS).
Surveillance needs to be more intensive for MC twins particularly <24wks, or higher multiples, so referral to a
Proper control of hyperglycemia in diabetic specialist fetal medicine team is advisable.
Intrapartum risks associated with multiple pregnancy:
patients Malpresentation.
Proper control of weight gain during pregnancy Preterm delivery and multiple pregnancy
• Incidence increased: principal cause of morbidity and mortality. Fetal hypoxia in second twin after delivery of the first.
🔹
During delivery → trial of labour
1.
Indications of Caesarean Section:
Fetal weight ≥ 4.5 kg
• Predictable with transvaginal cervical scanning.
• Not thought to be preventable by cervical cerculage.
Cord prolapse.
Operative delivery.
• Beneficial effect of progesterone limited at best. Post-partum hemorrhage.
2. Fetal weight ≥ 4 kg in Diabetic patient Rare:
3. PH of shoulder dystocia or Erb’s palsy cord entanglement (MCMA twins only)
4. Breech presentaion head entrapment with each other:
‘locked twins’
fetal exsanguination due to vasa praevia.
🔹
Twin-to-twin transfusion syndrome (TTTS)
🔹 This affects about 15% of MC twin pregnancies and left untreated has an 80% mortality rate.
It is caused by aberrant vascular anastamoses within the placenta, which redistribute the fetal
blood. Effectively, blood from the ‘donor’ twin is transfused to the recipient’ twin.
Fetal death means death prior to complete
expulsion or extraction from the mother of a
product of human conception irrespective of
🔹 MC twins require intensive monitoring, usually in the form of serial USS every 2wks from 16–24wks
and every 4wks until delivery.
the duration of pregnancy and which is not an Twin reversed arterial perfusion (TRAP)
induced termination of pregnancy.
🔸
The treatment options potentially available include:
Laser ablation of the placental anastamoses, leads to survival of at least one in 80% and both in •In this rare condition, one of an MC twin pair is structurally very
abnormal with no or a rudimentary heart, and receives blood from
🔸
50%.
Selective feticide by cord occlusion is reserved for refractory disease. the other (umbilical artery flow direction is reversed), which is called
the ‘pump twin’.
🔸
Effects of twin-to-twin transfusion on the fetus
Donor twin
•This normal twin may die of cardiac failure, and unless the abnormal
🔹
Risk Factor: Hypovolaemic and anaemic.
twin is very small or flow to it ceases, selective termination using
🔹 advanced maternal age Oligohydramnios: appear ‘stuck’ to the placenta or uterine wall
radiofrequency ablation or cord occlusion is indicated.
🔹 🔹
African-American race 🔸
Growth restriction.
Recipient twin
🔹 smoking illicit drug use
maternal medical diseases—such as overt diabetes or
Hypervolaemic and polycythaemic.
Large bladder and polyhydramnios.
🔹
chronic hypertension; Cardiac overload and failure.
🔹 assisted reproductive technology
🔻
Evidence of fetal hydrops (ascites, pleural, and pericardial effusions).
This twin is often more at risk than the donor.
🔹
🔹
cholestatites of pregnancy, renal disease.
nulliparity,
🔹 obesity;
prior adverse pregnancy outcomes—such as prior
Management of labour and delivery for twins
-Should have IV.
🔹
stillbirth, -Continuous fetal monitoring with CTG
-This becomes imperative after the first twin has delivered to avoid hypoxia in the second.
prior preterm birth or growth-restricted newborn
-An epidural may be helpful, especially if there are difficulties delivering the second twin, but is
not essential.
🔹
Dignosis
Early in pregnancy, before 20 weeks, the diagnosis of fetal death
(missed abortion) is suspected by lack of uterine growth or cessation
-Leading twin should be delivered as for a singleton,
After delivery of first baby, the lie of the second twin should be checked and gently ‘stabilized’
by abdominal palpation
of symptoms of pregnancy. Diagnosis is confirmed with serially
-abdominal palpation while a VE is performed to assess the station of the presenting part.
Other secondary features for IUFD might be falling (hCG) and ultrasound documentation
-Once the presenting part enters the pelvis the membranes can be broken and the second twin is
🔹
seen:
🔹 spalding sign 🔹 After week 20, fetal death is suspected with absence of fetal
usually delivered within 20min of the first.
-Judicious use of oxytocin may help if the contractions diminish after delivery of the first twin.
🔹
🔹
hydrops and gross skin oedema
unrecognisable fetal mass due to maceration.
Intrafetal gas (within the heart, blood vessels
movement noted by the mother or absence of uterine growth,
🔹
confirmed by ultrasound.
Given the importance of making an appropriate,, the absence of
-If fetal distress occurs in the second twin, delivery may be expedited with either forceps or
ventouse.
If this is inappropriate, the choice is between CS .
🔹
and joints)
occult placental abruption.
fetal heart motion is usually verified by two clinicians.
If Imaging technically difficult, (maternal obesity, abdominal scars and
oligohydramnios), views can be augmented with colour Doppler of the
-Breech extraction involves gentle and continuous traction on one or both feet, and must only be
performed by an experienced obstetrician.
It is never used to deliver singleton breeches.
fetal heart and umbilical cord.
🔹 Delivering Twin B When Non cephalic Transverse :
‐
_Internal podalic version/complete breech extraction if trained.
🔹 Well women with intact membranes and no evidence of DIC or
bleeding should have the option of expectant management because >
ECV Breech delivery is reasonable choice when:
–ECV is unsuccessful or not attempted
–Strong labor and twin B is deep in the pelvis with imminent delivery
🔹
85% of women will labour spontaneously within three weeks of diagnosis
Women who delay labour for > 48 hours should be advised to have IUFD
Management of labour and delivery for twins
🔹
–Trained clinician and no other contraindications for vaginal breech
🔻 Management of Difficult Cases of Twins
🔹
testing for DIC twice weekly
Women with expectant management should be advised that: the
value of postmortem may be reduced.
• For all multiple pregnancies mode of delivery is debated.
• The second twin is at increased risk of perinatal mortality.
The leading twin should be cephalic (80%), and there should be no 🔻
Conjoined twins:
It is extremely rare Diagnosed by U/S and treatment by Caesarean Section
Triplets, Quadruplets, ETC
🔹
The baby's appearance may deteriorate.
Vaginal birth is the recommended mode of delivery, but CS may be
absolute contraindication (e.g. placenta previa).
• Triplets and higher-order multiples are usually delivered by CS. 🔻
Treated by Caesarean Section unless the fetuses are markedly premature 35wk
Selective Embryo Reduction
🔹
considered with some obstetrics causes.
🔹
Timing and mode of birth
Options for timing and mode of birth depends on:
• Some authorities advise CS for MC twins. -It is done if first trimester
🔹
Vaginal birth can be achieved within 24 hours of induction of labour In the presence of 3 or more fetuses to reduce the number to twins
in about 90% of women. - the mother‟s preferences Recommended Mode of Delivery for Twins Aim: to reduce fetal morbidity & mortality resulting from preterm labour
- her medical condition Twin A Noncephalic: Cesarean Procedure:
- previous intrapartum history. Twin A Cephalic, Twin B Cephalic: Vaginal Under G.A→ needle passed abdominally or vaginally under U/S guide →inject 1.5ml of 15%
EVALUATION OF THE STILLBORN FETUS
Determining the cause of fetal death aids maternal coping, permits more 🔹
immediate delivery is concidered if there is
🔹 sepsis,
Twin A Cephalic, Twin B Noncephalic: Controversial potassium chloride into fetal thorax→ leads to cardiac arrest and death of the first embryo
accurate counseling regarding recurrence risk, and may prompt therapy
or intervention to prevent a similar outcome in subsequent pregnancies 🔹
🔹
preeclampsia,
placental abruption
🔹
Clinical Examination
Examination of the placenta, cord, and chorioamnionic membranes.
membrane rupture Indications of Caesarean Section :
🔹
Laboratory Evaluation 🔹
🔹
If the first fetus is non-vertex
Intrauterine growth retardation (of one or both twins)
🔹 Autopsy and chromosomal studies are performed, up to 35 percent of 🔹 Conjoined twins
Retained second twin when the cervix reforms and
🔹
stillborn fetuses are discovered to have major structural anomalies,
In the absence of anatomic dysmorphology, up to 5 percent of stillborn 🔹
becomes incompletely dilated
If induction of labour is indicated as in case of pre-
🔹
fetuses will have a chromosomal abnormality
chromosomal microarray analysis (CMA)—are now replacing standard
karyotyping for chromosomal analysis of stillborn fetuses
🔹Any degree of placenta praevia .
eclampsia
🔹
Management of Subsequent Pregnancy after Stillbirth
🔹 Preconceptional or Initial Prenatal Visit
🔹
🔹
Detailed medical and obstetrical history
Review evaluation of prior stillbirth
🔹
🔹
Determination of recurrence risk
Discuss recurrence of comorbid obstetric complications
🔹 Smoking cessation
Preconceptional weight loss in obese women
🔹
Genetic counseling if family
genetic condition exists
🔹
Diabetes screen
🔹Thrombophilia screen: antiphospholipid antibodies (only if history indicates)
Support and reassurance
🔹 First Trimester
-Dating sonography
-First-trimester screen: pregnancy-associated plasma protein A, human chorionic gonadotropin, and
nuchal translucencya
-Support and reassurance
🔹 Second Trimester
-Fetal sonographic anatomical survey at 18–20 weeks’ gestation
-Maternal serum screening (quadruple) or single-marker alpha fetoprotein if first trimester screening
elected
-Possible uterine artery Doppler studies at 22–24 weeks’ gestationa
-Support and reassurance
🔹 Third Trimester
-Sonographic screening for fetal-growth restriction, starting at 28 weeks
Kick counts starting at 28 weeks
-Antepartum fetal surveillance starting at 32 weeks or 1–2 weeks earlier than prior stillbirth
-Support and reassurance
-Delivery, Elective induction at 39 weeks, before 39 weeks only with documented fetal lung maturity by
amniocentesis
Fetal causes
A) Maternal complication: 🔹 Twins → Acute polyhydramnios is almost always
During Pregnancy
1.Abortion 🔹
associated with Univoular twins
🔹 Congenital fetal anomalies (20%)
2.Preterm labour
3.Pre-eclampsia (25%) 🔹
🔹
Anencephaly & open spina bifida
Cong. Obstruction of oesophagus or duodenum
4.Placenta previa
5.Malpresentation 🔹 Hypoplastic lungs
Knot of umbilical cord, cardiac abnormalities, &
6.Non engagement of presenting part
7.Pressure symptoms 🔹
cirrhosis of fetal liver
🔹 Chorioangioma
Fetal neurological or muscular abnormalities (e.g.
The amniotic fluid is increased.
In general a deepest pool of >8cm or an AFI
During Labour
>22 is abnormal.
1.P.R.O.M
2.Prolapse of arm, cord, or both 🔹
myotonic dystrophy, anencephaly)
🔹AHydrops
large placenta
fetalis (Rh isoimmunization)
Causes of polyhydramnios
1-Maternal Causes
3.Obstructed labour due to malpresentation
2-Fetal causes
4.Abruptio placenta
3-Idiopathic
🔹
5.Uterine atony Maternal Causes
🔹 Diabetes mellitus →(30%)
6.Retained placenta
🔹
7.PPH Causes of generalized edema
🔹Syphilis
8.Splanchnic shock if leads to fetal liver cirrhosis
During puerperium 1. Subinvolution maternal prolactin
B) Fetal complication: Idiopathic cause
1.Prematurity and it is complications ( 30-50% ).
2.Congenital fetal malformation (25%) (mild)
3. Cord prolaps
Acute Polyhydramnios :
🔹
Clinical Picture
Symptoms:
Abdominal pain
Nausea & vomiting
Pressure symptoms
🔹Signs
-General examination→Pre-eclampsia
-Abdominal→ Huge, Fetal parts & fetal heart
sounds can not be detected + fluid thrill
🔹
-Vaginally → high cervix, partially dilated
Differential Diagnosis:
a. Accidental haemorrhage
Clinical Types
■ Acute ployhdramnios
- Extremely rare (1 in 3,000 pregnancies)
b. Retroverted gravid uterus
- Sudden onset (few days)
c. Hydatidiform mole
- In early pregnancy (16-20wk)
- Almost always associated with uniovular twins
- Leads to abortion or preterm labour
🔹
Chronic Polyhydrmnios
Symptoms: ■ Chronic Polyhdramnios
- Common (1 in 100 pregnancies)
Polyhydramnios
🔹
- Abdominal discomfort Dizygotic twins
🔹Signs:
- Pressure symptoms - Insidious onset (few weeks) Dizygotic twins result from two separate ova being fertilized by
- In late pregnancy >28wks different sperm, simultaneously implanting and developing.
Abdominal→ Huge, Fetal parts difficult to feel,
malpresentation (common), fetal heart faint, These fetuses will have separate amniotic membranes and
fluid thrill placenta(dichorionic and diamniotic). Twins may be different sexes.
vagina→ cervix is partially dilated
Ultrosound → for diagnosis, multiple This mechanism of twinning accounts for two-thirds of multiple
pregnancy, fetal anomalies, presentation pregnancies; and most affected by predisposing factorse (race, familial
tendency, increased maternal age, parity, height, weight, and ovulation
🔹 Differential Diagnosis:
a. Twins pregnancy
drugs (clomiphene & menopausal gonadotrophins
🔹
b. Pregnancy with huge ovarian cyst DEFINITION Monozygotic twins
c. Maternal ascites Simultaneous development of more than Result from division into two of a single, already developing, embryo and will
🔹
one fetus in the uterus
Twins is the commonest
be genetically identical and, therefore, always the same sex. depends on the
stage of development when the embryo divides.
1. Under local anaesthesia and u/s guide drain 1500-
2000 ml in a slow rate 500ml per hour Types
2. Complications: rupture of membranes, preterm Management
•Acute Polyhydramnios
Uniovular
(Monozygotic,Identical) 🔻 Timing of division in monozygotic twins
• < 3 days l DCDA 30%.
labour, chorioamnionitis, abruptio placenta, bowel injury, twins 30%
•Pregnancy is terminated Binovular • 4 –7 days l monochorionic, diamniotic (MCDA) 70%.
🔷
injury to fetus, cord or placenta
•Rupture of membranes (Dizygotic, Fraternal) • 8 –12 days l monochorionic, monoamniotic (MCMA) <1%.
Amniotic fluid Twins 70% • > 12 days l conjoined twins (very rare).
Indomethacin 25mg 6 hourly X 4 days -after 20wks largely consists of fetal urine.
🔹
-The volume depends on urine production, fetal
swallowing, and absorption. 🔹
Medical Terms
Superfecundation: is the fertilization of two different ova released in the
Investigations
Exclude maternal diabetes with a glucose
-Normal volume varies with gestation, and is 🔹
same cycle, by separate acts of coitus within a short period of time
Superfetation is fertilization of two ova released in different menstrual
tolerance test (GTT).
Ultrasound examination of fetus.
highest between 24 and 36wks.
-The volume is measured by ultrasound, either by 🔹
cycles
Fetus papyraceous or compressus: one of the fetuses dies early &
🔹 Care of The Newborn:
After delivery; the fetus is examined for
measuring the deepest vertical pool, or by adding
up the deepest pools in the four quadrants of the
compressed b/w the membrances and uterine wall more common in
🔹
univoular twins
Fetus acardiacus: one fetus becomes parasitic without heart occurs
congenital malformation and a soft rubber
catheter is passed into the stomach to test for
oesophageal atresia
uterus (AFI). but, as a general rule,
🔹
only in uniovular twins
Vanishing twin: one fetus dies and if pregnancy within 14 weeks, it
vanishes by resorption
Diagnosis
definition
.a deepest pool of <2cm or an AFI of <8cm is
▪️History:
Family history: +ve
considered low.
▪️
H/o of ovulation induced drugs
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Symptoms:
🔹
Complications ETIOLOGY:
🔹 ↑Nausea and vomiting in early months
🔹Ruptured membranes
Related to cause:
🔹
Cardio-respiratory embarrassment in later months
-preterm rupture of the membranes is commonly followed by delivery
and/or intrauterine infection
-IUGR is an important cause of fetal and neonatal mortality and long-term
🔹 Urinary tract malformation→ Bilateral renal 🔹
🔹
↑ Tendency of swelling of legs, varicose veins & hemorrhoids
Unusual abdominal size
🔹
morbidity.
Related to reduced volume:
🔹
agenesis (Potter syndrome)
🔹 Obstruction to fetal urine output: 🔹 Excessive fetal movements
However, the vast majority are diagnosed on ultrasound in the 1st trimester
-lung hypoplasia if occurs <22wks
-limb abnormalities, e.g. talipes, if prolonged oligohydramnios before 22wks 🔹
fetal abnormalities such as posterior urethral
valves. ▪️General Examination:
has a very poor prognosis.
Club foot
🔹 fetal renal failure
🔹Intrauterine growth retardation IUGR
↑ incidence of anemia
Unusual weight gain
🔹Fetal chromosomal abnormalities →Trisomies ▪️
Postterm pregnancy Pre-eclampsia 20-50%
-Amputation of a limb due to compression
-Breech presentation (common)
-Meconium aspiration syndrome 🔹Placental insufficiency → PET 🔹
Abdominal Examination:
Diagnosis:
Oligohydramnios 🔹Fundal
Inspection:→ Huge abdomen
Palpation:
level is higher than period of amenorrhea
🔹
Fundal level is lower than the period of Investigations Palpation of two heads or 3 poles→ sure sign
amenorrhea
Breech presentation 🔹 US of fetus, including Doppler.
Speculum examination to look for ruptured 🔹
All causes of an Oversized Uterus:
🔹Wrong calculation 🔹 Auscultation:
Fetal parts are easily felt
Decrease fetal movement 🔹
membranes.
If suspected spontaneous rupture of membranes 🔹
🔹
Multible pregnancy.
Bleeding in early pregnancy misdiagnosed as menstruation
Auscultation of two fetal heart sounds at two points far away from each other and heard simulatoneously by two
observers with difference of at least 10 beats per minutes is Diagnostic
FHS are clearly heard
Ultrasound.
(SROM): CRP, FBC, and vaginal swabs should be taken.
🔹
🔹
Large fetus
Fetal malformation as hydrocephalus
▪️
Arnoux sign (Suggestive)→ overlapping of two fetal hearts sounds giving a galloping rhythm
Vaginal Examination:
🔹
🔹
Hydatidiform mole
Polyhydramnios
▪️
Twins is suspected during labour if the presenting part is small in relation to the size of the uterus
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Management of oligohydramnios
If SROM at 34–36 or more weeks, Induce labour unless CS is indicated 🔹Tumours as fibroids or ovarian cyst Ultrasound:
Confirms diagnosis, position and presentation
🔻
for another reason. 🔹Abruption placenta with concealed haemorrhage
Ascites with pregnancy. -2 Gestational sacs appears as early as 4.5wks by TVU
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🔹
If SROM before 34, Give prophylactic oral erythromycin.
Monitor for signs of infection (4-hourly temperature and pulse).
-2 Heads can be detected at 12th week
-For assessment of placentation sonar is done between 16-24 wks
🔹Daily CTG. -For assessment of IUGR→ repeated every 2-3wks
🌟
Consider induction by 34–36wks -Zygosity could be determined by identifying the intervening layers
🔻
🔹IfManage
IUGR
according to umbilical artery Doppler and CTG.
Chorionicity:
Determining chorionicity allows risk stratification for multiple pregnancy and is best done by ultrasound in the 1st
trimester or early in the 2nd.(11-14 wk).
🔻
🔹 If isolated oligohydramnios
The key indicators are:
• Obviously widely separated sacs or placentae—DC.
🔻
🔹
Intervention is not usual if umbilical artery Dopplers are normal.
If fetal renal tract abnormality Refer to fetal medicine centre.
• Membrane insertion showing the lambda (λ) sign—DC.
• Absence of λ sign <14wks diagnostic of MC.
🔹During labour, FHS should be observed frequently for early detection of
fetal distress
• Fetuses of different sex—DC (dizygotic).
▪️
Fetal distress → caesarean section
Maternal risks associated with multiple pregnancy:
• Hyperemesis gravidarum.
• Anaemia.
• Pre-eclampsia (5× greater risk with twins than singletons).
🔹
Definition
Fetal weight at birth is 4 kg or 4.5 Kg (in USA) or more, or
the birth weight is above the 90th percentile for gestational
• Gestational diabetes.
• Polyhydramnios.
• Placenta praevia.
🔹
age
• Antepartum and post-partum haemorrhage.
Incidence → 5-10% with all pregnancies
• Operative delivery.
🔹20-50% with gestational D.M ▪️ Fetal risks associated with multiple pregnancy
antenatal care
🔻
• All fetal risks increased with MC twins.
🔹
Aetiology All multiple pregnancies are by definition ‘high risk’ • Risk of miscarriage : especially with MC twins.
🔹
Complications: Large size of one or both parents, especially • Establish chronicity—most accurately diagnosed in 1st trimester (absence of lamda sign diagnostic), so an early US • Congenital abnormalities more common only in MC twins including:
Multiple pregnancy
Caesarean section,🔹forceps, and ventouse 🔹
Obstructed labour with increase rate of mother (genetic factor) should be considered with any indications of multiple pregnancy (e.g. fundus palpable before 12wks or exaggerated • neural tube defects
🔹
delivery 🔹 Maternal obesity → most common
Excessive maternal weight during pregnancy
Unusual uterine
symptoms of early pregnancy).
• Routine use of iron and folate supplements should be considered.
• cardiac abnormalities
• gastrointestinal atresia.
🔹
🔹
Shoulder dsytocia
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>20 kg Maternal D.M
Macrosomia • A detailed anomaly scan should be undertaken. • IUGR: up to 25% of twins.
🔹
Vaginal lacerations Multiparity • Preterm labour: main cause of perinatal morbidity and mortality:
🔹PPH 🔹 Postterm size • A dvise aspirin 75microgram od if additional risk factors for pre eclampsia.
• Serial growth scans from 20 untill 36wks every 4wk for DC twins. different in MCDA • 40% twins deliver before 37wks
🔹Hydrops
Newborn obesity fetalis • More frequent antenatal checks because risk of pre-eclampsia. • 10% twins deliver before 32wks.
Previous macrosomic baby • Discuss mode, timing and place of delivery. •Risk of disability (mainly, but not entirely, due to prematurity and low birth
• Establish presentation of leading twin by 34wks. weight).
•Incidence of cerebral palsy (CP):
by fatema okoff Management • Offer delivery at 37–38wks: induction or lower segment Caesarean section (LSCS).
Surveillance needs to be more intensive for MC twins particularly <24wks, or higher multiples, so referral to a
Proper control of hyperglycemia in diabetic specialist fetal medicine team is advisable.
Intrapartum risks associated with multiple pregnancy:
patients Malpresentation.
Proper control of weight gain during pregnancy Preterm delivery and multiple pregnancy
• Incidence increased: principal cause of morbidity and mortality. Fetal hypoxia in second twin after delivery of the first.
🔹
During delivery → trial of labour
1.
Indications of Caesarean Section:
Fetal weight ≥ 4.5 kg
• Predictable with transvaginal cervical scanning.
• Not thought to be preventable by cervical cerculage.
Cord prolapse.
Operative delivery.
• Beneficial effect of progesterone limited at best. Post-partum hemorrhage.
2. Fetal weight ≥ 4 kg in Diabetic patient Rare:
3. PH of shoulder dystocia or Erb’s palsy cord entanglement (MCMA twins only)
4. Breech presentaion head entrapment with each other:
‘locked twins’
fetal exsanguination due to vasa praevia.
🔹
Twin-to-twin transfusion syndrome (TTTS)
🔹 This affects about 15% of MC twin pregnancies and left untreated has an 80% mortality rate.
It is caused by aberrant vascular anastamoses within the placenta, which redistribute the fetal
blood. Effectively, blood from the ‘donor’ twin is transfused to the recipient’ twin.
Fetal death means death prior to complete
expulsion or extraction from the mother of a
product of human conception irrespective of
🔹 MC twins require intensive monitoring, usually in the form of serial USS every 2wks from 16–24wks
and every 4wks until delivery.
the duration of pregnancy and which is not an Twin reversed arterial perfusion (TRAP)
induced termination of pregnancy.
🔸
The treatment options potentially available include:
Laser ablation of the placental anastamoses, leads to survival of at least one in 80% and both in •In this rare condition, one of an MC twin pair is structurally very
abnormal with no or a rudimentary heart, and receives blood from
🔸
50%.
Selective feticide by cord occlusion is reserved for refractory disease. the other (umbilical artery flow direction is reversed), which is called
the ‘pump twin’.
🔸
Effects of twin-to-twin transfusion on the fetus
Donor twin
•This normal twin may die of cardiac failure, and unless the abnormal
🔹
Risk Factor: Hypovolaemic and anaemic.
twin is very small or flow to it ceases, selective termination using
🔹 advanced maternal age Oligohydramnios: appear ‘stuck’ to the placenta or uterine wall
radiofrequency ablation or cord occlusion is indicated.
🔹 🔹
African-American race 🔸
Growth restriction.
Recipient twin
🔹 smoking illicit drug use
maternal medical diseases—such as overt diabetes or
Hypervolaemic and polycythaemic.
Large bladder and polyhydramnios.
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chronic hypertension; Cardiac overload and failure.
🔹 assisted reproductive technology
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Evidence of fetal hydrops (ascites, pleural, and pericardial effusions).
This twin is often more at risk than the donor.
🔹
🔹
cholestatites of pregnancy, renal disease.
nulliparity,
🔹 obesity;
prior adverse pregnancy outcomes—such as prior
Management of labour and delivery for twins
-Should have IV.
🔹
stillbirth, -Continuous fetal monitoring with CTG
-This becomes imperative after the first twin has delivered to avoid hypoxia in the second.
prior preterm birth or growth-restricted newborn
-An epidural may be helpful, especially if there are difficulties delivering the second twin, but is
not essential.
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Dignosis
Early in pregnancy, before 20 weeks, the diagnosis of fetal death
(missed abortion) is suspected by lack of uterine growth or cessation
-Leading twin should be delivered as for a singleton,
After delivery of first baby, the lie of the second twin should be checked and gently ‘stabilized’
by abdominal palpation
of symptoms of pregnancy. Diagnosis is confirmed with serially
-abdominal palpation while a VE is performed to assess the station of the presenting part.
Other secondary features for IUFD might be falling (hCG) and ultrasound documentation
-Once the presenting part enters the pelvis the membranes can be broken and the second twin is
🔹
seen:
🔹 spalding sign 🔹 After week 20, fetal death is suspected with absence of fetal
usually delivered within 20min of the first.
-Judicious use of oxytocin may help if the contractions diminish after delivery of the first twin.
🔹
🔹
hydrops and gross skin oedema
unrecognisable fetal mass due to maceration.
Intrafetal gas (within the heart, blood vessels
movement noted by the mother or absence of uterine growth,
🔹
confirmed by ultrasound.
Given the importance of making an appropriate,, the absence of
-If fetal distress occurs in the second twin, delivery may be expedited with either forceps or
ventouse.
If this is inappropriate, the choice is between CS .
🔹
and joints)
occult placental abruption.
fetal heart motion is usually verified by two clinicians.
If Imaging technically difficult, (maternal obesity, abdominal scars and
oligohydramnios), views can be augmented with colour Doppler of the
-Breech extraction involves gentle and continuous traction on one or both feet, and must only be
performed by an experienced obstetrician.
It is never used to deliver singleton breeches.
fetal heart and umbilical cord.
🔹 Delivering Twin B When Non cephalic Transverse :
‐
_Internal podalic version/complete breech extraction if trained.
🔹 Well women with intact membranes and no evidence of DIC or
bleeding should have the option of expectant management because >
ECV Breech delivery is reasonable choice when:
–ECV is unsuccessful or not attempted
–Strong labor and twin B is deep in the pelvis with imminent delivery
🔹
85% of women will labour spontaneously within three weeks of diagnosis
Women who delay labour for > 48 hours should be advised to have IUFD
Management of labour and delivery for twins
🔹
–Trained clinician and no other contraindications for vaginal breech
🔻 Management of Difficult Cases of Twins
🔹
testing for DIC twice weekly
Women with expectant management should be advised that: the
value of postmortem may be reduced.
• For all multiple pregnancies mode of delivery is debated.
• The second twin is at increased risk of perinatal mortality.
The leading twin should be cephalic (80%), and there should be no 🔻
Conjoined twins:
It is extremely rare Diagnosed by U/S and treatment by Caesarean Section
Triplets, Quadruplets, ETC
🔹
The baby's appearance may deteriorate.
Vaginal birth is the recommended mode of delivery, but CS may be
absolute contraindication (e.g. placenta previa).
• Triplets and higher-order multiples are usually delivered by CS. 🔻
Treated by Caesarean Section unless the fetuses are markedly premature 35wk
Selective Embryo Reduction
🔹
considered with some obstetrics causes.
🔹
Timing and mode of birth
Options for timing and mode of birth depends on:
• Some authorities advise CS for MC twins. -It is done if first trimester
🔹
Vaginal birth can be achieved within 24 hours of induction of labour In the presence of 3 or more fetuses to reduce the number to twins
in about 90% of women. - the mother‟s preferences Recommended Mode of Delivery for Twins Aim: to reduce fetal morbidity & mortality resulting from preterm labour
- her medical condition Twin A Noncephalic: Cesarean Procedure:
- previous intrapartum history. Twin A Cephalic, Twin B Cephalic: Vaginal Under G.A→ needle passed abdominally or vaginally under U/S guide →inject 1.5ml of 15%
EVALUATION OF THE STILLBORN FETUS
Determining the cause of fetal death aids maternal coping, permits more 🔹
immediate delivery is concidered if there is
🔹 sepsis,
Twin A Cephalic, Twin B Noncephalic: Controversial potassium chloride into fetal thorax→ leads to cardiac arrest and death of the first embryo
accurate counseling regarding recurrence risk, and may prompt therapy
or intervention to prevent a similar outcome in subsequent pregnancies 🔹
🔹
preeclampsia,
placental abruption
🔹
Clinical Examination
Examination of the placenta, cord, and chorioamnionic membranes.
membrane rupture Indications of Caesarean Section :
🔹
Laboratory Evaluation 🔹
🔹
If the first fetus is non-vertex
Intrauterine growth retardation (of one or both twins)
🔹 Autopsy and chromosomal studies are performed, up to 35 percent of 🔹 Conjoined twins
Retained second twin when the cervix reforms and
🔹
stillborn fetuses are discovered to have major structural anomalies,
In the absence of anatomic dysmorphology, up to 5 percent of stillborn 🔹
becomes incompletely dilated
If induction of labour is indicated as in case of pre-
🔹
fetuses will have a chromosomal abnormality
chromosomal microarray analysis (CMA)—are now replacing standard
karyotyping for chromosomal analysis of stillborn fetuses
🔹Any degree of placenta praevia .
eclampsia
🔹
Management of Subsequent Pregnancy after Stillbirth
🔹 Preconceptional or Initial Prenatal Visit
🔹
🔹
Detailed medical and obstetrical history
Review evaluation of prior stillbirth
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🔹
Determination of recurrence risk
Discuss recurrence of comorbid obstetric complications
🔹 Smoking cessation
Preconceptional weight loss in obese women
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Genetic counseling if family
genetic condition exists
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Diabetes screen
🔹Thrombophilia screen: antiphospholipid antibodies (only if history indicates)
Support and reassurance
🔹 First Trimester
-Dating sonography
-First-trimester screen: pregnancy-associated plasma protein A, human chorionic gonadotropin, and
nuchal translucencya
-Support and reassurance
🔹 Second Trimester
-Fetal sonographic anatomical survey at 18–20 weeks’ gestation
-Maternal serum screening (quadruple) or single-marker alpha fetoprotein if first trimester screening
elected
-Possible uterine artery Doppler studies at 22–24 weeks’ gestationa
-Support and reassurance
🔹 Third Trimester
-Sonographic screening for fetal-growth restriction, starting at 28 weeks
Kick counts starting at 28 weeks
-Antepartum fetal surveillance starting at 32 weeks or 1–2 weeks earlier than prior stillbirth
-Support and reassurance
-Delivery, Elective induction at 39 weeks, before 39 weeks only with documented fetal lung maturity by
amniocentesis
