5/20/2018 Tinjauan Pustaka Multiple Gestation
1/60
MULTIPLE GESTATION
LEONARD EVAN MELLA 0961050199
NADIA VINKA LISDIANTI 1061050189
5/20/2018 Tinjauan Pustaka Multiple Gestation
2/60
Incidence
The incidence of multiple gestations has risensignificantly, primarily due to increased use of fertility
drugs for ovulation induction, superovulation, andassisted reproductive technologies (ART), such as invitro fertilization (IVF).
The perinatal mortality rate of twins is 34 timeshigherand for triplets much higher stillthan insingleton pregnancies.
Approximately two-thirds of twin pregnancies endin a singleton birth.
5/20/2018 Tinjauan Pustaka Multiple Gestation
3/60
Factors That InfluenceTwinning
Race Maternal Age
Parity
Heredity
Pituitary gonadotropin
Infertility therapy
5/20/2018 Tinjauan Pustaka Multiple Gestation
4/60
Maternal Risks
Spontaneous abortion
Preterm birth
Anemia
Maternal death
5/20/2018 Tinjauan Pustaka Multiple Gestation
5/60
Fetal Risks
Vanishing twin
Congenital malformations
Low birth weight
Twin-twin transfusion syndrome
Fetal demise
5/20/2018 Tinjauan Pustaka Multiple Gestation
6/60
Types of Twins
MultipleGestation
Dizygotic
Monozygotic
A single
fertilized ovum
divides into 2
separate
individuals
Produced
from
separately
fertilized ova.
5/20/2018 Tinjauan Pustaka Multiple Gestation
7/60
5/20/2018 Tinjauan Pustaka Multiple Gestation
8/60
Most commonMonochorionic, Diamniotic
A single placenta
RareMonochorionic,Monoamniotic
A single placenta
Dichorionic, DiamnioticSeparate or fused
placentas
Monochorionic,MonoamnioticFused placenta
Dichorionic, DiamnioticSeparate placenta
MONOZYGOTIC
DIZYGOTIC
5/20/2018 Tinjauan Pustaka Multiple Gestation
9/60
Dizygotic Twins
Twins of different sexes are always dizygotic
(fraternal).
More common among women who becomepregnant soon after cessation of long-term oral
contraception.
5/20/2018 Tinjauan Pustaka Multiple Gestation
10/60
Clinical Findings
Symptoms
Earlier and more pressure in the pelvis
Nausea, backache, varicosities, constipation,hemorrhoids, abdominal distention, difficulty in
breathing
A large pregnancy
Fetal activity is greater and more persistent
5/20/2018 Tinjauan Pustaka Multiple Gestation
11/60
Clinical Findings
Signs
Uterus larger than expected (>4 cm) for dates.
Excessive maternal weight gain that is notexplained by edema or obesity.
Polyhydramnios, manifested by uterine size out of
proportion to the calculated duration of
gestation, is almost 10 times more common inmultiple pregnancy.
History of assisted reproduction.
Elevated maternal serum fetoprotein (MSAFP)
values.
5/20/2018 Tinjauan Pustaka Multiple Gestation
12/60
Clinical Findings
Signs
Outline or ballottement of more than 1 fetus.
Multiplicity of small parts.
Simultaneous recording of different fetal heart
rates, each asynchronous with the mothers pulse
and with each other and varying by at least 8
beats/min. (The fetal heart rate may beaccelerated by pressure or displacement.)
Palpation of 1 or more fetuses in the fundus after
delivery of 1 infant.
5/20/2018 Tinjauan Pustaka Multiple Gestation
13/60
Laboratory Findings
Maternal hematocrit and hemoglobin values an the
red cell count usually are considerably reduced.
Maternal hypochromic normocytic anemia.
5/20/2018 Tinjauan Pustaka Multiple Gestation
14/60
Ultrasound Findings
Dichorionicity:
Fetuses of different genders
Separate placentas
A thick (>2 mm) dividing membrane
A twin peak signin which the membrane inserts
into 2 fused placentas
Monochorionicity: Absence of those findings
A dividing membrane that is so thin (< 2-mm
thick) and magnification reveals only two layers
A T sign
5/20/2018 Tinjauan Pustaka Multiple Gestation
15/60
5/20/2018 Tinjauan Pustaka Multiple Gestation
16/60
Ultrasound Findings
5/20/2018 Tinjauan Pustaka Multiple Gestation
17/60
UNIQUE FETALCOMPLICATIONS
5/20/2018 Tinjauan Pustaka Multiple Gestation
18/60
Conjoined Twins
Conjoined twins result from incomplete
segmentation of a single fertilized ovum between
the 13th and 14th days. If cleavage is further postponed, incomplete
twinning (ie, 2 heads, 1 body) may occur.
5/20/2018 Tinjauan Pustaka Multiple Gestation
19/60
Conjoined Twins
5/20/2018 Tinjauan Pustaka Multiple Gestation
20/60
5/20/2018 Tinjauan Pustaka Multiple Gestation
21/60
EXTERNAL PARASITICTWINS
A grossly defective fetus or merely fetal parts,attached externally to a relatively normal twin.
Usually consists of externally attachedsupernumerary limbs, often with some viscera.
A functional heart or brain is absent.
5/20/2018 Tinjauan Pustaka Multiple Gestation
22/60
FETUS IN FETU
Early in development, one embryo may be
enfolded within its twin. Normal development of this rare parasitic twin
usually arrests in the first trimester. As a result,normal spatial arrangement of and presence of
many organs is lost.
5/20/2018 Tinjauan Pustaka Multiple Gestation
23/60
5/20/2018 Tinjauan Pustaka Multiple Gestation
24/60
Vascular Anastomoses
5/20/2018 Tinjauan Pustaka Multiple Gestation
25/60
Twin-Twin TransfusionSyndrome
Local shunting of blood occurs because of vascular
anastomoses to each twin that are established early
in embryonic life. Affects approximately 15% of monochorionic twin
pregnancies.
Does not occur in dichorionic twins.
5/20/2018 Tinjauan Pustaka Multiple Gestation
26/60
Twin-Twin TransfusionSyndrome
5/20/2018 Tinjauan Pustaka Multiple Gestation
27/60
Twin-Twin TransfusionSyndrome
The recipient twin:
Plethoric, edematous, hypertensive
Ascites and kernicterus The heart, liver, and kidneys are enlarged
Fetal polyuriahydramnios
The donor twin:
Small, pallid, dehydrated (from growth restriction,malnutrition, and hypovolemia)
Oligohydramnios
5/20/2018 Tinjauan Pustaka Multiple Gestation
28/60
Twin-Twin TransfusionSyndrome
5/20/2018 Tinjauan Pustaka Multiple Gestation
29/60
Obstetrical Management
Serial removal of amniotic fluid for polyhydramnios if> 20 weeks gestation
Create an opening in amnion between the twofetuses to allow fluid exchange
Laser ablation of placental vascular anastomoses(high complication rate)
Selective reduction of donor twin if high risk of deathfor both twins
5/20/2018 Tinjauan Pustaka Multiple Gestation
30/60
Large volume amnioreduction
5/20/2018 Tinjauan Pustaka Multiple Gestation
31/60
Amniotic Septostomy
5/20/2018 Tinjauan Pustaka Multiple Gestation
32/60
Fetoscopic Laser Ablation
5/20/2018 Tinjauan Pustaka Multiple Gestation
33/60
Acardiac Twins (TRAP)
A parasitic monozygotic fetus without a heart. It is
thought to develop from reversed circulation,
perfused by 1 arterialarterial and 1 venousvenousanastomosis.
5/20/2018 Tinjauan Pustaka Multiple Gestation
34/60
Treatment
Ultrasound and/or maternal serum testingAmniocentesis and chorionic villus samplingPrenatalDiagnosis
Ultrasonography
Routine growth scans on twins every 4 weeks in the thirdsemester or more frequently if growth restriction isdetected
Iron and calcium supplementation, vitamin and folicacid administration, a high protein diet,supplementation with Mg, Zn, and essential fatty acids
Tocolytic drugs may be used
AntepartumManagement
5/20/2018 Tinjauan Pustaka Multiple Gestation
35/60
Labor and Delivery
Admit the patient to the hospital if:
First sign of suspected labor or preterm labor
There is leakage of amniotic fluid
Significant bleeding occurs
>4 contractions per hour at
5/20/2018 Tinjauan Pustaka Multiple Gestation
36/60
Labor and Delivery
Indications for primary caesarean section: If either twin show signs of persistent compromise
Malpresentation
Monoamniotic twins
Gross disparity in fetal size
Placenta previa
5/20/2018 Tinjauan Pustaka Multiple Gestation
37/60
Labor and Delivery
Intrapartum twin presentations:
5/20/2018 Tinjauan Pustaka Multiple Gestation
38/60
Labor and Delivery
The umbilical cord should be clamped promptly
Perform a vaginal examination immediately after
delivery of twin A Tag and label the cords (twin A and B)
Locked twins can be avoided by caesarean
delivery in all cases
5/20/2018 Tinjauan Pustaka Multiple Gestation
39/60
Labor and Delivery
Increased intravenous oxytocin, elevation, and
massage of the fundus and an intravenous ergot or
prostaglandin product (only after the last fetus isdelivered) may be required.
Manual extraction of the placenta may be
necessary.
Prophylactic rectal misoprostol in the operating
room followed by oral misoprostol every 6 hours for24 hours after delivery for all multiple gestations.
5/20/2018 Tinjauan Pustaka Multiple Gestation
40/60
Laporan Kasus
5/20/2018 Tinjauan Pustaka Multiple Gestation
41/60
I. Identitas(20 Juli 2014 pukul 21.00)
Nama Pasien : Ny. M
Umur : 35 tahun
Pendidikan : SMA
Pekerjaan : Pegawai Swasta
Agama : Islam
Suku : Betawi
Alamat : Duren Sawit
Identitas
5/20/2018 Tinjauan Pustaka Multiple Gestation
42/60
II. Subjektif
KU : Mulas-mulas
KT : -
Subjektif
5/20/2018 Tinjauan Pustaka Multiple Gestation
43/60
Riwayat Penyakit Sekarang
Pasien datang ke IGD RS UKI dengan keluhanperut terasa mulas pada bagian kanan sejak 1minggu SMRS. Keluhan ini dirasakan terus-menerus dan semakin lama terasa semakin
mules. Keluhan tidak berkurang denganperubahan posisi. Keluar cairan bercampurdarah dari vagina disangkal. Pasien selalu kontrolkehamilan di poli RS UKI. Kontrol terakhir 1 mingguyang lalu (12 Juli 2014) dan dinyatakan pasienhamil gemeli. Usia kehamilan saat ini 32 minggu.
5/20/2018 Tinjauan Pustaka Multiple Gestation
44/60
Riwayat Haid
Haid pertama : 9 tahun
Siklus : tidak teratur Lama : 7 hari
Banyak : 4x ganti pembalut /100 cc
HPHT : 5 Des 2013
TP : 12 september 2014
Sakit saat haid : disangkal
Riwayat Perkawinan Status Pernikahan : menikah 1x
Lama perkawinan : 2 tahun
5/20/2018 Tinjauan Pustaka Multiple Gestation
45/60
Riwayat Kehamilan Persalinan, nifas yang lalu: Ini
Riwayat Penyakit Dahulu : Disangkal
Riwayat Penyakit Keluarga : DisangkalRiwayat Operasi : Disangkal
Metode KB : Tidak menggunakan KB
5/20/2018 Tinjauan Pustaka Multiple Gestation
46/60
Riwayat ANC
Waktu hamil periksa di : RS UKI Oleh
dr. Januar Simatupang Sp.OG, Keluhan, kelainan, dan masalah : -
Waktu ANC Usia Kehamilan Tempat Masalah Penatalaksanaan
0 0-12 mg - - -
1x 13-28 mg RS UKIHamil
gemeli-
1x 29 mg sekarang RS UKIHamil
gemeli-
5/20/2018 Tinjauan Pustaka Multiple Gestation
47/60
III. OBJEKTIFA. Pemeriksaan Umum / Status Generalis
Tinggi badan : 160 cm
Berat Badan : 75 kg
Keadaan Umum : BaikKesadaran : Komposmentis
Objektif
5/20/2018 Tinjauan Pustaka Multiple Gestation
48/60
a. Tanda Vital
TD : 110/80 mmHg
Nadi : 84 x/menit
Suhu : 36,2 0C
Pernapasan : 20 x/menit
b. Kepala : normocephali
c. Matai. Konjungtiva : tidak anemis
ii. Sklera : tidak ikterik
iii. Gigi : lengkap, karies (-)iv. THT : dalam batas normal
5/20/2018 Tinjauan Pustaka Multiple Gestation
49/60
d. Leher : KGB tidak teraba membesar
e. Payudara : massa (-/-) retraksi (-/-) nyeri (-/-)
f. Jantung : BJ I & II reguler, gallop (-)murmur (-)
g. Paru-paru : I : pergerakan dinding dada simetris ka/ki
P : VF simetris ka/ki
P : sonor ka/ki
A : BND vesikuler, Rh -/- Wh -/-
5/20/2018 Tinjauan Pustaka Multiple Gestation
50/60
h. Abdomen
I : Perut tampak membuncit
A : BU sulit dinilai
P : Defense muskular (+) hepar dan limpa sulitdinilai
P : nyeri ketok (-)
i. Ekstremitas :
Superior : akral hangat, CRT < 2 , edema -/-
Inferior : akral hangat, CRT < 2, edema +/+
5/20/2018 Tinjauan Pustaka Multiple Gestation
51/60
B. Pemeriksaan Umum / Status Generalis
1. Pemeriksaan Luar
a. I : perut tampak membuncit, linea nigra (+) striaegravidarum (+)
b. P : TFU 36 cm Leopold I :
Teraba 2 bagian terbesar janin bulat, keras, melenting,
kesan kepala janin gemeli Leopold II :
Teraba bagian memanjang tidak terputus-putus padasebelah kiri ibu punggung kiri janin gemeli
Leopold III :
Teraba bagian bawah janin, bulat, lunak, tidak melenting,kesan bokong Leopold IV:
Bayi belum memasuki PAP
5/20/2018 Tinjauan Pustaka Multiple Gestation
52/60
c) Auskultasi : DJJ :
i. Frekuensi : 140 x
ii. Irama : tidak teratur
2. HIS
Frekuensi : 2x / 10 menit
Lamanya : 60
Kekuatan : kuat
Relaksasi : ada, lamanya 5 menit
5/20/2018 Tinjauan Pustaka Multiple Gestation
53/60
3. Pemeriksaan Dalam
a. Inspekulo : tidak dilakukanb. VT
Vulva / vagina : tenang, rugae (+), tidakteraba massa
Portio
Axis : Posterior
Konsistensi : Lunak
Penipisan : 20 %
Pembukaan : 1-2 cm Ketuban : utuh
5/20/2018 Tinjauan Pustaka Multiple Gestation
54/60
c. Denominator : belum dapat dinilai
d. Caput : belum dapat dinilai
e. Moulage : belum dapat dinilai
5/20/2018 Tinjauan Pustaka Multiple Gestation
55/60
IV. ASSESMENT
A. DIAGNOSIS KERJA
Ibu : G1POAO hamil 32 minggu partusprematur iminens
Janin : Janin Gemeli hidup
Assesment
5/20/2018 Tinjauan Pustaka Multiple Gestation
56/60
B. PROGNOSIS
Kehamilan : dubia et malam
Persalinan : dubia et malam
C. DAFTAR MASALAH Janin Gemeli
Assesment
5/20/2018 Tinjauan Pustaka Multiple Gestation
57/60
V. PLANNINGA. Rencana pemeriksaan untuk konfirmasi
diagnosis
Observasi keluhan utama, TTV, DJJ, HIS
Periksa Lab H2TL, MP3, HbSAg Rencana USG
Planning
5/20/2018 Tinjauan Pustaka Multiple Gestation
58/60
B. Rencana pengobatan / penatalaksanaankhusus
Bila berlanjut inpartu RSC
Diet Biasa
Infus RL
MM:
Dexametasone Nifedipine
Tramal Supp 1x1
Planning
5/20/2018 Tinjauan Pustaka Multiple Gestation
59/60
C. Informed Consent
Menjelaskan kepada pasien tentangkehamilan dan rencana persalinan yangdilakukan
Motivasi lakstasi dan KB
Planning
5/20/2018 Tinjauan Pustaka Multiple Gestation
60/60
THANK YOU