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ANTENATAL CARE OF
TWIN PREGNANCY
Prof. Gomathy Narayanan
Relevance1. Increasing Incidence:
• Following Induction of ovulation – 5-10%
• Following ART – 32%
• Advanced maternal age at pregnancy
2. Increased Morbidity & Mortality:
• Maternal – 4-fold
• Fetal – 20-fold
3. Technological advances
Complications
I Trimester:
• Hyperemesis
• Threatened abortion
• Miscarriage
• Congenital anomalies
• Vanishing twin
Complications
II Trimester:
• Extreme Preterm labor – 44% / Delivery
• PPROM
• Growth discordance – 15-29%
• IUGR
• Fetal anomaly – 4.9%
• Single fetal demise – 2-5%
Complicationsunique 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
Complicationsunique to
Monoamniotic Twins
• Conjoint twins – 1:50,000 Births
• Cord entanglement
• Fetal death
Maternal complications
• Anemia (Iron / Folic acid)
• Polyhydramnios
• PET / HELLP syndrome
• GDM
• APH
• 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
• 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 Conerstoneof
Managementin
Twin Pregnancy
USG in First Trimester
• Confirmation of number of foetuses
• R/O hetertropic pregnancy
• Viability
• Retroplacental hemorrhage
• Cervical status
• Chorionicity & Amnionicity
• 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 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
• Hospitalization
• Tocolysis
• Progesterone
• Surveillance
• Induction
• Termination
PPROM
• Hospitalization
• Tocolysis
• Antibiotics
• Steroids
• Termination
• Monochorionic II Twin is more at risk of infection than Dichorionic II Twin
Twin to Twin Transfusion Syndrome (TTTS)
• 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
• No intervention: 0 to 30%
• Amnioreduction: 64%
• Laser coagulation: 73%
• Amniotic septostomy: 83%
Twin Anemia Polycythemia Sequence (TAP)
Diagnosis:
• MCA PSV tracing
• Absence of polyhydramnios
Treatment:• Intra uterine transfusion
• Partial exchange transfusion
• Laser coagulation
• Expectant & post delivery treatment
Incidence:• Spontaneous: 3-5%• Post laser: 2-13%
Twin Reversal Arterial Perfusion (TRAP)
• Normal pump twin (Stuck twin)
• Acardiac recipient
Treatment:
• Laser coagulation
• Cord occlusion
Single fetal demise
Surveillance of surviving twin
• Serial USG
• Serial BPP
• Serial Doppler
• MRI
• Maternal coagulation profile
• Anti D if mother is Rh Negative
Conjoint twin
• 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!