KEHAMILAN KEMBARKEHAMILAN KEMBAR= MULTIPLE PREGNANCIES == MULTIPLE PREGNANCIES =

(GEMELLI)(GEMELLI)

Pendahuluan

• Two for the price of one” atau “instant family”• High Complication Risk→Morbiditas &

mortalitas ↑ 50% 32-38 minggu, 10% dibawahnya• Pe↑ Malpresentasi:

- kedua janin sungsang 41%- Janin kembar I sungsang 17%- Locked twins (jarang)

• Persalinan operatif & resiko persalinan preterm ↑

Definisi & Klasifikasi

Kehamilan 2 janin atau lebihKembar dizigotik (66%) Binovular-fraternal twins1. fertilisasi 2 ovum oleh 2 sperma2. Dikorionik: Amnion terpisahKembar monozigotik (33%) Mono ovular-identical twins - Pembelahan 1 ovum, fertilisasi oleh sperma sperma yang sama- Pembelahan <72 jam: Dikorionik diamnotik (96%)- Pembelahan 4-8 hari: Monokorionik diamniotik (4%)

Mono ovular-identical twins, diamniotik monokorionik

- Pembelahan 8-13 hari: Monokorionik, Monoamniotik

- Pembelahan >13 hari: Conjoined twins

Fetus Papyraceous

- Salah satu janin kembar tidak berkembang

- Tak berbentuk, mengkerut & rata

Perbandingan Mono/Dizigotik 1:2

Faktor resiko untuk kembar dizigotik:

- ♀ tua

- Multiparitas

- Riwayat keluarga kehamilan kembar dizigotik

Fetus Papyraceous, salah satu fetus yang tidak berkembang

Insiden

1% dari kehamilan, 2/3 dizigot & 1/3 monozigot

Etnik (1:50 Afrika, 1:80 Causasia, 1:50 Asia)

Usia (2% > 35 thn)

Paritas (2% setelah kehamilan ke-4)

Metode konsepsi (20% induksi ovulasi)

Riwayat keluarga

Insidensi menurut hukum Hellin adalah 1 dalam 80n-1 kehamilan

Etiologi

• Bangsa, hereditas, umur & paritas→ binovular fraternal-twins

• Obat klomid & gonadotropin hormon→ dizigotik

• Fertilisasi in vitro & transfer embrio (IVF&ET)

Patofisiologi

Fertilisasi ovum&sperma di tuba falopii

Ovum yang telah dibuahi turun uterus

nidasi dan Pertumbuhan fetus

Selama proses ini kembar dapat terbentuk

Kehamilan berasal dari satu telur terjadi :Akibat adanya kerja faktor penghambat (inhibiting factor) pada masa awal pertumbuhan embrio intrauterin, mempengaruhi segmentasi selanjutnya pada berbagai tingkatan.

Tipe Presentasi

• Janin kembar I presentasi vertex 75%

• Kedua janin presentasi vertex 45%

• Salah satu janin vertex, lainnya bokong 37%

• Kedua janin presentasi bokong 10%

tipe-tipe presentasi

Distribusi dari letak dan posisi janin kembar (dalam %) antara lain:

KEMBARDUA

KEMBAR PERTAMA

Kepala Sungsang Lintang

Kepala 39 13 0,6

Sungsang 26 9 0,6

Lintang 8 4 0,6

Early Diagnosis

Anamnesa Ultrasonografi

Gemelli

Pemeriksaan klinis Radiologi

Diagnosis Awal Twins

DIZYGOTICDIZYGOTIC MONOZYGOTICMONOZYGOTIC

Ultrasonografi kehamilan kembar pada usia kehamilan 38-40 hari

Diagnosa dini gagal → - P↑ PJT & persalinan prematur - P↑ mortalitas & morbiditas perintal - P↑ komplikasi

Berdasarkan observasi

36-37 mgg +++ Amnion <<<

P’tbhan janin 24-35 mgg plasenta matang++

Kematian intra uterin ↑ 37-38 mgg

• Differential Diagnosis

Kehamilan lewat waktu

Polihidramnion

Tumor fibroid uterus

Kista

Mola hidatiforma

Anemia Atonia uteri Hidramnion

PPH Abortus Komplikasi maternal

Retensio plasenta Partus prematur

Inersia uteri Pre-eklampsia

Solusioplasenta Malpresentasi Plasenta Previa

KPD

Komplikasi fetal

Prematuritas

BBLR

Insufisiensi plasenta

Kelainan kongenital

Prolapsus tali pusat

Komplikasi Intrapartum

Plasenta Insufisiensi plasenta

kebutuhan nutrisi>> Polihidramnion

Kondisi lain

Prolapsus tali pusat Malpresentasi

LockedPPH Komplikasi Peripartum Twins

Solusio Plasenta Transfusion Syndrom

Penatalaksanaan

A. Tindakan umum- Diet & Pola makan yang baik- Besi & Asam folat- Aktivitas << & aktivitas +++

B. Pem. Klinis setiap 2mgg setelah 24 mgg- keadaan servik setelah 24 mgg- pengetahuan kehamilan preterm- pergerakan bayi setelah 32 mgg

C. USG setiap 4-6 mgg setelah dignosis- kemungkinan plasenta previa- kemungkinan gangguan pertumbuhan janin- presentasi janin

D. Nonstress test setelah setelah 32mgg- keadaan janin- penekanan taki pusat

E. Konsultasi perinatologi

Kembar discordant: janin resepient lebih besar dari pada janin donor abnormalitas arteriovenous tampak pada permukaan plasenta, darah arteri kaya O2 donor bercampur dengan darah resepient

PENANGANAN PERSALINAN

• KALAU ANAK I SUNGSANG ATAU LINTANG SEBAIKNYA S.CESAR.

• KALAU ANAK I P.KEPALA DIUPAYAKAN DENGAN P/ VAGINAL ANAK KE DUA DENGAN V.EKSTRAKSI.

• SELAMA DJJ NORMAL TIDAK ADA ALASAN UNTUK MEMPERCAPAT KELAHIRAN ANAK KEDUA

• PENGAWASAN YANG KETAT MENENTUKAN OUTCOME PERSALINAN

anak pertama lintang atau sungsang dan anak kedua memanjang (terjadi posisi saling mengunci interlocking)

Panduan penanganan persalinan spontan pada kehamilan kembar

Janin pertamaSiapkan peralatan resusitasi & perawatan bayiPasang infus & cairan intravenaPantau keadaan janin, djjPeriksa presentasi janin- vertex → PSP, monitor persalinan- bokong → indikasi SC- lintang → SC

Tinggalkan klem pada ujung maternal tali pusat

• Janin kedua atau berikiutnya

Segera setelah bayi pertama lahir:

- Palpasi abdomen → letak janin

- lakukan versi luar

- Periksa djj

• Periksa dalam

- Presentasi janin kedua

- keutuhan selaput ketuban

- Prolapsus tali pusat

Monoamniotic twins mortality

• 2 to 5% loss every 2 weeks from 15 to 32 weeks

• 9% at 33 wks 29% at 36-38 wks

• 95% cord entanglement (prenatal diagnosis 28%)

Comparison of rates of complications in singleton and multiple gestations

Complications Rate for twins (increase)

Chorioamnionitis 4-foldPremature rupture of membranes 4-foldFetal asphyxia 5-foldTwin-twin transfusion 1 of 9 monoamniotic twinsCongenital malformations 3-foldHydramnios 1 of 12 twinsAbruptio placentae 2-foldPlacenta previa 2-foldCompression of cord 2-foldBirth injury 10-foldPrematurity 10-foldUmbilical cord knots 2-fold

Maternal morbidity and obstetric complications of quadruplet pregnancy (No. 22)

VARIABLE INCIDENCE (%)

Antepartum hospitalization 100Hyperemesis gravidarum 9.4Hyperemesis gravidarum, total parenteral nutrition required 3.1Gestational diabetes mellitus, A1 18.8Gestational diabetes mellitus, A2 3.1Anemia (Hct < 30%), no antepartum transfusion required 25.0Anemia (Hct < 30%), antepartum transfusion required 15.6Antepartum bleeding 3.1Placenta previa 0.0Preeclampsia 71.9HELLP syndrome 2.5PPROM 18.8PTL 100Twin-twin transfusion syndrome 3.1Chorioamnionitis 6.3

I. Psychological Support and Clinical Counseling

• All parents should be aware that pathologies such as fetal growth retardation, congenital anomalies, abnormal placentation, abruptio placentae, fetal malpresentation and preterm delivery, occur more commonly in multiple than in singleton pregnancy

• These aspects result in higher maternal and perinatal mortality and morbidity.

• Antenatal complications are three to five times higher in multiple pregnancy than in singleton pregnancy.

• From the first trimester onwards is required to help parents to cope with possible negative outcome and also with the socio-economic problems related to multiple birth.

The most important:The most important:

EARLY DIAGNOSISEARLY DIAGNOSIS WHY?WHY?

MULTIPLE MULTIPLE PREGNANCYPREGNANCY

HIGH-RISK HIGH-RISK PREGNANCYPREGNANCY

• COMPLICATIONS DURING PREGNANCYCOMPLICATIONS DURING PREGNANCY• SPECIFIC MALFORMATION SEQUENCESSPECIFIC MALFORMATION SEQUENCES• HIGHER PERINATAL MORBIDITIY AND MORTALITYHIGHER PERINATAL MORBIDITIY AND MORTALITY• INTRAPARTAL COMPLICATIONSINTRAPARTAL COMPLICATIONS

==

DIAGNOSIS OF MULTIFETAL PREGNANCY:SIMULTANEOUS VISUALIZATIONSIMULTANEOUS VISUALIZATION

• two or more embryostwo or more embryos

•or or corresponding bodycorresponding body partsparts of of twotwo or more fetusesor more fetuses

A firm diagnosis ofA firm diagnosis ofthe number of embryosthe number of embryos

after 7th weekafter 7th week ! !

EARLY DIAGNOSIS OF TWINSEARLY DIAGNOSIS OF TWINS

EMBRYOSEMBRYOS AND AMNIOTICAND AMNIOTICMEMBRANESMEMBRANES

MONOCHORIONICMONOCHORIONICMONOAMNIOTICMONOAMNIOTICTWINSTWINS

HIGH-ORDER MULTIPLE PREGNANCYHIGH-ORDER MULTIPLE PREGNANCYPregnancy with three or more fetuses

three amnioticthree amniotic

three chorionicthree chorionic

2D multiplanar imaging2D multiplanar imaging

3D3D reconstructionreconstruction

• volume scanning• volume rendering• spatial reconstruction • plastic imaging

TRIPLETSTRIPLETS

FRONTFRONT BACKBACK

QUADRUPLETS

HIGH ORDER PREHIGH ORDER PREGGNANCYNANCY

HIGH ORDER PREHIGH ORDER PREGGNANCYNANCY

HIGH ORDER PREHIGH ORDER PREGGNANCYNANCYSEPTUPLETSSEPTUPLETS

12 EMBRYOS12 EMBRYOS

HIGH ORDER PREHIGH ORDER PREGGNANCYNANCY

II. Correct Diagnosis andCharacterization of Chorionicity

• Multiple gestation should be suspected when the uterus is larger than predicted by menstrual history.

• Approximately one fifth of multiple gestations are monochorionic and four fifths are dichorionic.

• Type of placentation and chorionicity is helpful in the following three clinical situations: 1) The differentiation of twin to twin transfusion syndrome (TTS) from a twin gestation in which one fetus shows growth retardation; 2) the management of twins with congenital malformations, in which selective feticide may be considered as an option if the gestation is dichorionic and 3) the management of single fetal death in a multiple gestation.

• The thickness of dividing membrane is in 85% of monochorionic twins ~ 2 mm, in DC/DA the membrane is ~ 4 mm

• The “lambda” sign is an indicator of dichorionic pregnancy

II. Correct Diagnosis andCharacterization of Chorionicity

• The following criteria must be fulfilled to diagnose monoamniotic twins:

1. no dividing amniotic membrane is present2. only one placenta is seen3. both fetuses are of the same sex 4. the fetuses must have adequate amniotic fluid

surrounding them5. both fetuses must move freely within the

uterine cavity.

ACCURATE PRENATAL DIAGNOSISACCURATE PRENATAL DIAGNOSISOF CHORIONICITY IS OF PREDOMINANTOF CHORIONICITY IS OF PREDOMINANTIMPORTANCE FOR THE CLINICAL MANAGEMENT IMPORTANCE FOR THE CLINICAL MANAGEMENT OF OF MULTIPLE MULTIPLE PREGNANCIES PREGNANCIES

EARLY DIAGNOSIS OF CHORIONICITYEARLY DIAGNOSIS OF CHORIONICITY

NUMBER OF NUMBER OF GESTATIONAL GESTATIONAL SACSSACS

1st TRIMESTER1st TRIMESTER

ALARM !MONOCHORIONICMONOCHORIONIC

AND / ORAND / ORMONOAMNIOTIC TWINSMONOAMNIOTIC TWINS

FETAL FETAL COMPLICATIONS COMPLICATIONS

EARLY DIAGNOSIS OF AMNIONICITYEARLY DIAGNOSIS OF AMNIONICITYWhy is it important?

TWO SEPARATED PLACENTAS

PLACENTA 2

PLACENTA 1

DETERMINATION OF THE CHORIONICITYIN SECOND TRIMESTER

Sonographic counting of separated placentas is Sonographic counting of separated placentas is an accurate method of determining the an accurate method of determining the

chorionicity in the second trimester chorionicity in the second trimester

MONOCHORIONICBIAMNIOTIC TWINS

BICHORIONICBIAMNIOTIC TWINS

LAMBDA SIGN

BICHORIONIC BIAMNIOTIC TWINSBICHORIONIC BIAMNIOTIC TWINS

BIAMNIOTICBICHORIONIC

TWINS

MONOAMNIOTIC MONOCHORIONIC TWINSMONOAMNIOTIC MONOCHORIONIC TWINS

THE Y-SHAPEDY-SHAPED JUNCTION

Y-SIGNTRICHORIONICTRICHORIONICTRIAMNIOTICTRIAMNIOTIC

TRIPLETSTRIPLETS

““MERCEDES” SIGNMERCEDES” SIGN

III. Close Evaluation of Fetal Anatomy

Fetal Malformations and Prenatal Genetic Diagnosis

•The incidence of malformation in monozygotic twin pregnancies is twice that in dizygotics.

•Chromosomal anomalies are no more common in twins than singletons

•Anomalies not unique to twins but believed to be increased in frequency because of mechanical factors are positional defects (such as clubfoot and congenital dislocation of the hip) due to intrauterine crowding.

•Additional anomalies due to vascular consequences of fetal death are congenital skin defects, microcephaly, hydrancephaly, porencephaly, multicystic encephalomalacia, hydrocephalus, intestinal atresia and limb amputation.

III. Close Evaluation of Fetal Anatomy

Fetoplacental Markers in Twin Pregnancies Affected by Down Syndrome

• Around one-third of twin pregnancies are monozygous and their rate of Down syndrome is relatively independent of race and maternal age.

• Dizygous twins are more common in older mothers and as they arise from separate fertilisation of two simultaneously shed ova there is double the age-related risk than for a singleton pregnancy that either twin will have Down syndrome

CONJOINED (SIAMESE) TWINSCONJOINED (SIAMESE) TWINS INCIDENCE 1: 50 000 BIRTHSINCIDENCE 1: 50 000 BIRTHS

ULTRASOUND CRITERIA FOR DIAGNOSIS:ULTRASOUND CRITERIA FOR DIAGNOSIS:

1) LACK OF SEPARATE VISUALISATION OF FETUSES IN SPECIFIC ANATOMICAL REGIONS

2) FIXED POSITION OF THE TWIN TOWARD EACH OTHER

3) MISSING SEPARATING MEMBRANE

SYMMETRICAL SYMMETRICAL COMPLETE FORMCOMPLETE FORM Two fetuses shareTwo fetuses share a certain amount of tissuea certain amount of tissue

Surgical separation is Surgical separation is possible in general.possible in general.

PATTERNS OF PHYSICAL JOINING

PATTERNS OF PHYSICAL JOINING

SYMMETRICAL SYMMETRICAL INCOMPLETE FORMINCOMPLETE FORM

Surgical separation Surgical separation is usually impossibleis usually impossible

Conjoined twins: Conjoined twins:

subtotal fusionsubtotal fusionwith partial separation with partial separation of fetal headsof fetal heads

EARLY DIAGNOSIS OF CONJOINED TWINS

CONJOINED TWINS

THORACO-THORACO- OMPHALOPHAGUSOMPHALOPHAGUS

lack of separate visualisation of fetuses lack of separate visualisation of fetuses in thoraco-abdominal regionin thoraco-abdominal region

COLOR DOPPLERCOLOR DOPPLERSINGLE SHARED UMBILICAL SINGLE SHARED UMBILICAL CORDCORD

FIVE - VESSEL CORDFIVE - VESSEL CORD

THORACO-OMPHALOPHAGUS

VI. Avoidance of Most Frequent Complications

Complications of multiple pregnancies comprise:• Abortion,• Vanishing twin syndrome• Malformation• Vasa previa• Growth discrepancy• Intra uterine growth restriction (IUGR)• Polyhydramnios• Preeclampsia• Preterm-premature rupture of membranes (P-PROM)• Preterm delivery• Gestational diabetes• Intrauterine fetal death.

VANISHING TWINVANISHING TWIN• in in 20%20% of twin of twinss

• single fetal demisesingle fetal demise• high-risk surviving twinhigh-risk surviving twin• intintrarauterine hematomasuterine hematomas• better prognosis in dichorionicbetter prognosis in dichorionic• thromboplastine embolisationthromboplastine embolisation

VANISHING TWIN

SUBCHORIONIC HAEMATOMA

differentia

l diagnosis

differentia

l diagnosis

MONOCHORONIC / BIAMNIOTICMONOCHORONIC / BIAMNIOTIC::““TWIN TO TWIN” TWIN TO TWIN” TRANSFUSION SYNDROMETRANSFUSION SYNDROME

MONOAMNIOTIC:MONOAMNIOTIC:UMBILICAL CORD ENTAGLEMENTUMBILICAL CORD ENTAGLEMENT

ACARDIAC TWIN - ACARDIAC TWIN - TRAPTRAP SEQUENCE SEQUENCE CONJOINED TWINSCONJOINED TWINS

TTTSTTTS

•5% - 20% monochorionic twins5% - 20% monochorionic twins•arterioarterio venous venous anastomosesanastomoses•discordant growthdiscordant growth

DONOR DONOR RECIPIENTRECIPIENTOLIGOHYDRAMNIOS POLYHYDRAMNIOSOLIGOHYDRAMNIOS POLYHYDRAMNIOS

IUGR IUGR MACROSOMIA, HYDROPS MACROSOMIA, HYDROPS

MICROCARDIA CARDIOMEGALIAMICROCARDIA CARDIOMEGALIA

ANEMIA POLYCYTHAEMIAANEMIA POLYCYTHAEMIA

fetal loss 80%fetal loss 80%

TWIN TO TWIN TRANSFUSION SYNDROMETWIN TO TWIN TRANSFUSION SYNDROME

TWIN TO TWIN TRANSFUSION SYNDROMETWIN TO TWIN TRANSFUSION SYNDROME

RECIPIENT:RECIPIENT: Fetal hydrops

SCALP EDEMASCALP EDEMA

ASCITESASCITES

collapsed amniotic collapsed amniotic membranemembrane

DONOR:Stuck twin

TWIN TO TWIN TRANSFUSION SYNDROME

fixed twinfixed twinanhydramniosanhydramnios

POLYHYDRAMNIOS OF RECIPIENT TWIN

TWIN TO TWIN TRANSFUSION SYNDROME

TWIN TO TWIN TRANSFUSION SYNDROME

PULSATIONS WITHPULSATIONS WITHREVERSE- FLOW AT REVERSE- FLOW AT THE END OF DIASTOLETHE END OF DIASTOLE

UMBILICAL VEIN UMBILICAL VEIN SONOGRAM SONOGRAM IN RECIPIENT TWININ RECIPIENT TWIN

DUCTUS VENOSUSDUCTUS VENOSUSSONOGRAMSONOGRAM

IN RECIPIENT TWININ RECIPIENT TWIN

REVERSAL OF FLOWREVERSAL OF FLOWDURING ATRIALDURING ATRIALCONTRACTIONCONTRACTION

TWIN TO TWIN TRANSFUSION SYNDROME

Recipient : Recipient : venous return patternvenous return pattern

PlethoricPlethoric RECIPIENTRECIPIENT

AnaemicAnaemic DONORDONOR

TWIN TO TWIN TRANSFUSION SYNDROMETWIN TO TWIN TRANSFUSION SYNDROME

Weight difference > 25%Weight difference > 25%Haemoglobin difference >5%Haemoglobin difference >5%

VASCULAR ANASTOMOSES VASCULAR ANASTOMOSES IN A TWIN PLACENTA:IN A TWIN PLACENTA:

ARTERIOARTERIO VENOUSVENOUSARTERIO ARTERIO ARTERIOUSARTERIOUS VENO VENO VENOUSVENOUS

superficialsuperficial

deepdeep

VISUALIZATION WITHVISUALIZATION WITHPOWER ANGIO MODEPOWER ANGIO MODE

SURFACE ANASTOMOSESSURFACE ANASTOMOSES

TWIN REVERSED TWIN REVERSED ARTERIAL PERFUSIONARTERIAL PERFUSION

(TRAP)(TRAP)

IN MONOCHORIONIC TWINS ONE TWIN ( PUMP-TWIN ) ACTIVELY PERFUSES

THE SECOND TWIN ( PERFUSED TWIN ) VIA LARGE A -A AND/OR V - V ANASTOMOSES

1% of monozygotic1% of monozygotic twins are affected twins are affected

Incidence 1 : 35 000 birthsIncidence 1 : 35 000 births

ARTERIAL SUPPLY INTO PLACENTA BY THE PUMP TWIN IS ABLE TO OVERCOME THE BLOOD PRESSURE OF THECO-TWIN SO AS TO PERFUSE THAT TWINBY REVERSED FLOW (TOWARD CO-TWIN)IN THE UMBLICAL ARTERIES OF THE CO-TWIN

PATHOGENESIS

PERFUSED TWIN PERFUSED TWIN ACARDIUSACARDIUS

NORMALNORMAL( PUMP TWIN )( PUMP TWIN )

TRAP BLOOD FLOWS FROM AN BLOOD FLOWS FROM AN UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE PUMP TWIN IN PUMP TWIN IN REVERSE DIRECTIONREVERSE DIRECTION VIA VIA ARTERIO - ARTERIAL ARTERIO - ARTERIAL ANASTOMOSES INTO ANASTOMOSES INTO UMBILICAL ARTERY OF THE UMBILICAL ARTERY OF THE PERFUSED TWIN.PERFUSED TWIN.

THE UMBILICAL VEIN OF THE PARASITIC FETUS RETURNS THE BLOOD INTO THE PLACENTA ANDBACK TO PUMP TWIN

REVERSE FLOW NORMAL FLOWNORMAL FLOW

EARLY REVERSE OF CIRCULATIONEARLY REVERSE OF CIRCULATION

REVERSE PASSIVE PERFUSION OF TWINREVERSE PASSIVE PERFUSION OF TWIN

PERFUSION IN OPPOSITE DIRECTION ANDPERFUSION IN OPPOSITE DIRECTION AND

PERFUSION WITH DEOXIGENATED BLOODPERFUSION WITH DEOXIGENATED BLOOD

INDUCTION OF DEVELOPMENTAL DISORDERSINDUCTION OF DEVELOPMENTAL DISORDERS

REDUCTION ANOMALIES ( EXTREMITIES )REDUCTION ANOMALIES ( EXTREMITIES )

DEVELOPMENTAL ATROPHIES ( HEART AND BRAIN ) DEVELOPMENTAL ATROPHIES ( HEART AND BRAIN )

PATHOGENESIS OF FETAL DYSMORPHIA:PATHOGENESIS OF FETAL DYSMORPHIA:

Ultrasound finding = early ultrasound detection the most bizzarre fetal malformations

PUMP - TWIN

normalmorphology

normaldirection ofblood flow

PERFUSED TWIN

acardius

reduction anomalies of head and extremities

reversed blood flowreversed blood flow

TWINS MC / MA, 15 TWINS MC / MA, 15 wkswks

REVERSEDREVERSEDPERFUSIONPERFUSION

COLORCOLORDOPPLERDOPPLER

ULTRASONIC CRITERIA FOR ACARDIUSULTRASONIC CRITERIA FOR ACARDIUS

An amorphous mass with An amorphous mass with its own umbilical its own umbilical cord in monochorionic- cord in monochorionic- monoamnioticmonoamniotictwin pregnancytwin pregnancy

ACARDIAC - ACEPHALIC

This acardiac twin consists mainly of lower extremities

No heart and brain

No trunkNo trunkand headand head

COMPLICATION SPECIFIC FORMONOAMNIOTIC MONOCHORIONICTWINS

CORD ENTAGLEMENTCORD ENTAGLEMENT

THE CLOSE INSERTION OF THE UMBILICAL THE CLOSE INSERTION OF THE UMBILICAL CORDS INTO PLACENTA IS ASSOCIATED WITH:CORDS INTO PLACENTA IS ASSOCIATED WITH:LARGE-CALIBER ANASTOMOSES LARGE-CALIBER ANASTOMOSES AND AND

HIGH PREDISPOSITION FOR ENTANGLEMENTHIGH PREDISPOSITION FOR ENTANGLEMENT

MONOAMNIOTIC MONOAMNIOTIC TWINNINGTWINNING

CORD ENTANGLEMENTCORD ENTANGLEMENT

POWER DOPPLERPOWER DOPPLERCOLOR DOPPLERCOLOR DOPPLER

CORD ENTANGLEMENTCORD ENTANGLEMENT

Multiple gestations present a significantMultiple gestations present a significantdedecrease in fetal growth crease in fetal growth which is which is

in direct relationship to the number in direct relationship to the number of fetusesof fetuses in in high order pregnancieshigh order pregnancies

TWIN-TO-TWIN TRANSFUSIONTWIN-TO-TWIN TRANSFUSION

should be should be considered when growth discordancy considered when growth discordancy is diagnosed in is diagnosed in monochorionic gestationsmonochorionic gestations

• COMPLEX BODY MOVEMENTS• HICCUPS• HAND-FACE CONTACTS• MOUTH OPENING• SWALLOWING• BREATHING MOVEMENTS• HEAD MOVEMENTS• EXTREMITY MOVEMENTS• JUMPING• TWISTING• STRETCHING• YAWNING

SPONTANEOUS MOTORIC ACTIVITYSPONTANEOUS MOTORIC ACTIVITY

The Ten Commandmentsin Multiple Pregnancies

I. Psychological Support and Clinical CounselingII. Correct Diagnosis and Characterization of

ChorionicityIII. Close Evaluation of Fetal AnatomyIV. Management at Referral CentersV. Individualization of CareVI. Avoidance of Most Frequent ComplicationsVII Consideration of Some Specific PathologiesVIII. Close Monitoring of FetusesIX. Planning of Time and Mode of DeliveryX. Monitoring of the Mother During Postpartum

Ultrasound assessment of multiple pregnancy:Ultrasound assessment of multiple pregnancy:

1. EARLY DIAGNOSIS OF MULTIPLE PREGNANCY1. EARLY DIAGNOSIS OF MULTIPLE PREGNANCY

2. DIAGNOSIS OF CHORIONICITY AND AMNIONICITY2. DIAGNOSIS OF CHORIONICITY AND AMNIONICITY

3. COMPLICATIONS IN MONOCHORIONIC TWINS3. COMPLICATIONS IN MONOCHORIONIC TWINS

4. FETAL CONGENITAL ANOMALIES 4. FETAL CONGENITAL ANOMALIES

5. APPROPRIATE VERSUS DISCORDANT GROWTH5. APPROPRIATE VERSUS DISCORDANT GROWTH

6. COLOR-DOPPLER OF MULTIFETAL PREGNANCY6. COLOR-DOPPLER OF MULTIFETAL PREGNANCY

7. PREDICTION OF PRETERM DELIVERY7. PREDICTION OF PRETERM DELIVERY

8. INTRAPARTUM ULTRASONOGRAPHY8. INTRAPARTUM ULTRASONOGRAPHY