Multiple Gestation

Front 1

Incidence\

Rule of 80:
Previously, incidence of twin pregnancy used to occur ..... birth, triplets at....and so on.
Since 1980s this rule was disrupted by the widespread use of ....... i.e. Several ova in one cycle.

Back 1

1:80
1:802
drugs for ovarian superstimulation

Front 2

Predisposing factors

1....
2. .
3. Higher maternal age: above .... years, due to .....

Back 2

-.Ovarian super-stimulation and assisted reproductive techniques.
-Genetic predisposition
-37, diminished antimullarian hormone levels, which normally allow the selection and maturation of one ovum only.

Front 3

Types
Dizygotic:
2 ova are fertilized, each embro has separate placenta[.....] and amniotic sac [....], and may be of different sexes.

Much more common than monozygotic twins.

Monozygotic:
One ovum is fertilized, .....occurs to give 2 identical embryos:
Day 1-3: ....
Day 4-6:.....
Day 7:.....
Day 8: ......

Back 3

dichorionic,diamniotic
cleavage
Day 1-3: dichorionic, diamniotic.
Day 4-6: monochorionic, diamniotic.
Day 7:monochorionic,
monoamniotic.
Day 8: Conjoint twins.

Front 4

Diagnosis
1.......
2. ......
3. ......: as early as ....weeks, ....... sonogram can diagnose multiple gestation.

Chorionicity and amnionicity can be easily diagnosed in the ......trimester.

Back 4

1. Amenorrhea.
2. Positive pregnancy test.
3. Ultrasonogram: as early as 5-6 weeks, transvaginal sonogram can diagnose multiple gestation.

Chorionicity and amnionicity can be easily diagnosed in the first trimester.

Front 5

Clinical picture

1......This is due to ....
2. .....................................larger than dates.

Back 5

1.Exaggerated symptoms of pregnancy: morning sickness, hyperemesis, distension, drowsiness…etc.
This is due to higher levels of pregnancy hormones: HCG, progesterone, relaxin and others.
2.Abdominal distension, dyspnea, lower limb oedema and fundal level larger than dates.

Front 6

:Complications
1......: due to higher levels of hyperglycemic pregnancy hormones e.g. human placental lactogen.
2........: due to higher probability of insufficient trophoblastic implantation to provide adequate blood supply to the fetuses.
3......: due to multiple /or larger placentae, with higher chance of one getting implanted over the lower uterine segment.
4. Higher incidence of ....: due to increased requirements.
5. ....: due to over-distension of the uterus by multiple fetuses.
6. Abnormal presentations: e.g. .....
7......... [rare]: could occur if first is breech and the second is cephalic.
8. .......: after delivery of first twin, due to sudden decompression of the uterine cavity.
9. ......
10. Increased incidence of....

Back 6

Gestational diabetes
Pre-eclampsia
Placenta previa
anemia
Preterm labour
breech
Locked twins
Accidental hemorrhage
Increased atonic and traumatic postpartum hemorrhage.
congenital anomalies.

Front 7

Complications specific to monozygotic twins

1........: in monochorionic twins. One fetus[recepient] gets more blood supply than the other [donor]; due to ......

......: bigger, surrounded by ...., becomes polycythemic and could develop heart failure, hydrops fetalis and die.

........ : smaller [intrauterine growth restricted], surrounded by ...., could die of hypoxia.

2. .......:
Occurs in 25% of cases of monoamniotic twins.

3. ......:
Hypoxia and possible brain injury occurs in the other twin in monochorionic type.
.... may occur to the mother if the death twinis retained for one month or more.

Back 7

1. - Twin-to-twin transfusion syndrome, abnormal anastomoses inside their common placenta -Recepient twin, polyhydramnios
-Donor twin, oligohydramnios

2. Cord entanglement

3. Death of one twin, DIC

Front 8

Management

1. Adequate supplements to the mother: ......
2. Closer ..... and more frequent ......
3. .... and management of complications.

Back 8

1. iron, calcium, proteins, calories…etc.
2. follow up, antenatal visits
3. Screening

Front 9

Management of complications

1. Gestational diabetes: ......
2. Preterm labour: ....

Corticosteroids are adminstered in cases of .....

Back 9

1. diet control and insulin
2. -Calcium channel blockers.
-Progesterone.
-Cervical cerclage [debatable].
-Early treatment of vaginal infections.

preterm labour 26-34 weeks to enhance lung maturity of the fetuses.

Front 10

Delivery
Delivery is preferred at .....

In cases of twin pregnancy with first fetus in ...., vaginal is allowed if there is no other indication for caeserian delivery.

In cases of higher order gestation or twin pregnancy with the first in ...., caeserian section is the choice.

Back 10

-full term
-cephalic presentation
-breech presentation

Front 11

Outcome

Increase in maternal morbidity due to .....
Increased neonatal morbidity and mortality due to ....

Back 11

-increased operative interference, postpartum hemorrhage and other complications.
-prematurity, low birth weight and congenital anomalies.