Disclosuresg Objectives I have no disclosures to report. Twins and Beyond: Double Trouble UCSF Antepartum and Intrapartum Management, June 15 2019 Annalisa Post, MD Assistant Professor, Maternal-Fetal Medicine UCSF Obstetrics, Gynecology & Reproductive Sciences Learning Objectives Increasing Incidence Incidence of multiple gestation rising since 1980s Understand Twins: 33/1000, from 18.9/1000 - 76% increase in 3 decades - Diagnose Manage Martin JA, Hamilton BE, Osterman MJK. NCHS data brief, no 80. National Center for Health Statistics. 2012 1
Increasing Incidence Why the increase? - Fertility treatments and technologies: 2/3 Types of Twins - Shift toward older maternal age: 1/3 Martin JA, Hamilton BE, Osterman MJK. NCHS data brief, no 80. National Center for Health Statistics. 2012 Types of Twins Monozygotic Twins Or: “Are my twins identical?” Zygosity : number of oocytes - Dizygotic: “fraternal” Dichorionic-diamniotic - Monozygotic: “identical” Chorionicity: number of placentas Amnionicity: number of amniotic sacs 2
All Twins Twins: 33/1000 Di-di 91% Dizygous Dizygous Monozygous 30/1000 3/1000 Mono-di 7% Monochorionic Dichorionic Dichorionic Monochorionic Diamniotic Diamniotic Diamniotic Monoamniotic Di-di, 2% ~75% 30/1000 ~25% 1-2% Mono-mono, 0.2% Monozygous 2.25/1000 0.75/1000 0.1/1000 Quiz: Identical twins in animals Diagnosis 3
How Do We Know? Ultrasound Diagnosis Early ultrasound Later ultrasound EARLY ultrasound: Dichorionic vs Monochorionic Monochorionic twins Dichorionic- Easily distinguishable: diamniotic 2 gestational sacs If Monochorionic: LATER ultrasound/s: Diamniotic vs Monoamniotic Ultrasound Diagnosis Ultrasound Diagnosis Early ultrasound Later ultrasound Early ultrasound Later ultrasound Monochorionic twins Monochorionic twins Monochorionic- Dichorionic- Easily distinguishable: Thick dividing membrane: Diamniotic diamniotic 2 gestational sacs “lambda” or “twin peak” sign Fetal sex: Discordance Monochorionic- confirms di-di * Monoamniotic 4
Ultrasound Diagnosis Ultrasound Diagnosis Early ultrasound Later ultrasound Early ultrasound Later ultrasound Monochorionic twins Monochorionic twins Monochorionic- +/- Dividing membrane (not Monochorionic- +/- Dividing membrane (not Diamniotic til 8-12wks or later!) Diamniotic til 8-12wks or later!) Monochorionic- No dividing membrane Monochorionic- No dividing membrane Monoamniotic Monoamniotic Ultrasound Diagnosis Ultrasound Diagnosis Early ultrasound Later ultrasound Early ultrasound Later ultrasound Monochorionic twins Monochorionic twins Monochorionic- +/- Dividing membrane (not Thin dividing membrane: Monochorionic- +/- Dividing membrane (not Thin dividing membrane: Diamniotic til 8-12wks or later!) “T” sign Diamniotic til 8-12wks or later!) “T” sign Monochorionic- No dividing membrane Monochorionic- No dividing membrane Monoamniotic Monoamniotic 5
Ultrasound Diagnosis Ultrasound Diagnosis Early ultrasound Later ultrasound Yolk Sac Number Monochorionic twins Monochorionic twins Monochorionic- +/- Dividing membrane (not Thin dividing membrane: Monochorionic- Diamniotic til 8-12wks or later!) “T” sign Diamniotic Monochorionic- No dividing membrane No dividing membrane Monochorionic- Monoamniotic Monoamniotic Cord entanglement Ultrasound Diagnosis Ultrasound Diagnosis Yolk Sac Number Yolk Sac Number Monochorionic twins Monochorionic twins Monochorionic- 2 yolk sacs Monochorionic- 2 yolk sacs Diamniotic Diamniotic Monochorionic- 1 yolk sac Monochorionic- 1 yolk sac Monoamniotic Monoamniotic 6
Ultrasound Diagnosis Quiz: What type of twins? Yolk Sac Number Monochorionic twins Monochorionic- 2 yolk sacs Diamniotic Monochorionic- 1 yolk sac Monoamniotic Pregnancy Risks: Maternal Maternal physiology Blood plasma volume ^ 20% more Cardiac output ^ 20% more Maternal morbidity GHTN, preeclampsia (12.7% vs 6.5) Gestational diabetes (7.7 % vs 4.1%) Pregnancy with Twins Hyperemesis gravidarum Anemia Cesarean Postpartum hemorrhage Depression Death Day MC, Barton JR, O’Brien JM, Istwan NB, Sibai BM. The effect of fetal number on the development of hypertensive conditions of pregnancy. Obstet Gynecol 2005;106:927–31 Schwartz DB, Daoud Y, Zazula P, Goyert G, Bronsteen R, Wright D, et al. Gestational diabetes mellitus: metabolic and blood glucose parameters in singleton versus twin pregnancies. Am J Obstet Gynecol 1999;181:912–4. ACOG practice bulletin 169, October 2016 7
Pregnancy Risks: Fetal Pregnancy Risks: Fetal Di-di • Pregnancy loss Di-di • Pregnancy loss • Growth restriction • Growth restriction • Preterm delivery: avg 35.3wks • Preterm delivery: avg 35.3wks • Prematurity complications • Prematurity complications Mono-di • Risk of birth defects 5-10% • Risk of TTTS 10-15% TTTS Pregnancy Risks: Fetal Di-di • Pregnancy loss Placental vascular anastomoses resulting in unequal fetal • Growth restriction • Preterm delivery: avg 35.3wks blood distribution • Prematurity complications Donor: oligohydramnios, growth restriction, Doppler changes, - Mono-di • Risk of birth defects 5-10% fetal demise • Risk of TTTS 10-15% Recipient: polyhydramnios, Doppler changes, fetal hydrops, fetal - demise 8
Pregnancy Risks: Fetal Higher-Order Multiples: 3+ Di-di • Pregnancy loss • Growth restriction Natural triplet rate: 0.014% • Preterm delivery: avg 35.3wks 2011 triplet rate: 0.137% • Prematurity complications Mono-di • Risk of birth defects 5-10% • Risk of TTTS 10-15% Mono-mono • Risk of birth defects >25% • Risk of TTTS 2-5% • Cord entanglement, fetal demise Higher-Order Multiples: 3+ Quiz: Max litter size Pregnancy loss rate 12-18% Tailless Tenrecs: 32 Average GA at delivery decreases with more fetuses - Triplets 31.2wks - Quadruplets: 29.5 Maternal risks all increased CC BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=401770 9
Fetal Reductions Terminating one or more fetuses from multifetal pregnancy Pregnancy Management - KCL injection - Cord occlusion techniques Fetal Reductions Fetal Reductions Selective reduction Multifetal Reduction Targeting anomalous fetus Triplets > singleton or twins - Reduced pregnancy loss, greater gestational age at delivery, reduced neonatal complications, better maternal outcomes Twins > singleton also improves outcomes 10
Genetic Screening and Testing Fetal Surveillance Di-di • Detailed anatomy ultrasound Genetic Screening: • Serial growth ultrasound • Antenatal testing (i.e. 36wks) Serum screening: less sensitive, specific - cfDNA screening: not validated…. - CVS/Amnio Sampling error - Fetal Surveillance Fetal Surveillance Di-di • Detailed anatomy ultrasound Di-di • Detailed anatomy ultrasound • Serial growth ultrasound • Serial growth ultrasound • Antenatal testing (i.e. 36wks) • Antenatal testing (i.e. 36wks) Mono-di Above plus: Mono-di Above plus: • Fetal echocardiograms • Fetal echocardiograms • TTTS checks- alternating with growth US, Q2wk • TTTS checks- alternating with growth US, Q2wk • Antenatal testing (i.e. 32wks) • Antenatal testing (i.e. 32wks) Mono-mono Above plus: • Discussion of inpatient management (i.e. 26-28wks) 11
Interventions Interventions Progesterone? Betamethasone? No Yes - - Bedrest? Magnesium sulfate? No Yes - - Cerclage? Miller 2014, Roman 2016, Park 2016, Han 2019: Exam-indicated only - Delivery Management Delivery Management Route Timing Route Timing Di-di Vaginal preferred 38wk Di-di Vaginal preferred 38wk • A must be cephalic • A must be cephalic • Discordance of ≤ 20% • Discordance of ≤ 20% • Breech extraction provider available • Breech extraction provider available • Epidural, in OR • Epidural, in OR Mono-di Same as above 36-37 wks 12
Delivery Management Route Timing Di-di Vaginal preferred 38wk • A must be cephalic • Discordance of ≤ 20% Summary of Key Points • Breech extraction provider available • Epidural, in OR Mono-di Same as above 36-37 wks Mono-mono Cesarean delivery recommended 32-34wks? Multiple gestation incidence continues to increase Exam-indicated cerclage has benefit Accurate, early ultrasound diagnosis critical Vaginal delivery preferred* Fetal reduction improves pregnancy outcomes Monoamniotic twins: inpatient management reduces demises Genetic screening/testing is impacted 13
Mirror image twins Tailless Tenrecs Thank you! Armadillos! 14
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