Twins and Beyond: Double Trouble UCSF Antepartum and Intrapartum - - PowerPoint PPT Presentation

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Twins and Beyond: Double Trouble

Annalisa Post, MD

Assistant Professor, Maternal-Fetal Medicine UCSF Obstetrics, Gynecology & Reproductive Sciences

UCSF Antepartum and Intrapartum Management, June 15 2019

I have no disclosures to report.

Disclosuresg Objectives Learning Objectives

• Understand
• Diagnose
• Manage

Martin JA, Hamilton BE, Osterman MJK. NCHS data brief, no 80. National Center for Health Statistics. 2012

Increasing Incidence

• Incidence of multiple gestation rising since 1980s
• Twins: 33/1000, from 18.9/1000
• 76% increase in 3 decades

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Increasing Incidence

• Why the increase?
• Fertility treatments and technologies: 2/3
• 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 Types of 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

Monozygotic Twins

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Twins: 33/1000 Dizygous 30/1000 Dichorionic Diamniotic 30/1000 Monozygous 3/1000 Dichorionic Diamniotic ~25% 0.75/1000 Monochorionic Diamniotic ~75% 2.25/1000 Monochorionic Monoamniotic 1-2% 0.1/1000 Di-di 91% Di-di, 2% Mono-di 7% Mono-mono, 0.2%

All Twins

Monozygous

Dizygous

Quiz: Identical twins in animals Diagnosis

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How Do We Know?

• EARLY ultrasound: Dichorionic vs Monochorionic
• If Monochorionic:
• LATER ultrasound/s: Diamniotic vs Monoamniotic

Ultrasound Diagnosis

• Monochorionic twins

Early ultrasound Later ultrasound Dichorionic- diamniotic Easily distinguishable: 2 gestational sacs

Ultrasound Diagnosis

• Monochorionic twins

Early ultrasound Later ultrasound Dichorionic- diamniotic Easily distinguishable: 2 gestational sacs Thick dividing membrane: “lambda” or “twin peak” sign Fetal sex: Discordance confirms di-di *

Ultrasound Diagnosis

• Monochorionic twins

Early ultrasound Later ultrasound Monochorionic- Diamniotic Monochorionic- Monoamniotic

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Ultrasound Diagnosis

• Monochorionic twins

Early ultrasound Later ultrasound Monochorionic- Diamniotic +/- Dividing membrane (not til 8-12wks or later!) Monochorionic- Monoamniotic No dividing membrane

Ultrasound Diagnosis

• Monochorionic twins

Early ultrasound Later ultrasound Monochorionic- Diamniotic +/- Dividing membrane (not til 8-12wks or later!) Monochorionic- Monoamniotic No dividing membrane

Ultrasound Diagnosis

• Monochorionic twins

Early ultrasound Later ultrasound Monochorionic- Diamniotic +/- Dividing membrane (not til 8-12wks or later!) Thin dividing membrane: “T” sign Monochorionic- Monoamniotic No dividing membrane

Ultrasound Diagnosis

• Monochorionic twins

Early ultrasound Later ultrasound Monochorionic- Diamniotic +/- Dividing membrane (not til 8-12wks or later!) Thin dividing membrane: “T” sign Monochorionic- Monoamniotic No dividing membrane

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Ultrasound Diagnosis

• Monochorionic twins

Early ultrasound Later ultrasound Monochorionic- Diamniotic +/- Dividing membrane (not til 8-12wks or later!) Thin dividing membrane: “T” sign Monochorionic- Monoamniotic No dividing membrane No dividing membrane Cord entanglement

Ultrasound Diagnosis

• Monochorionic twins

Yolk Sac Number Monochorionic- Diamniotic Monochorionic- Monoamniotic

Ultrasound Diagnosis

• Monochorionic twins

Yolk Sac Number Monochorionic- Diamniotic 2 yolk sacs Monochorionic- Monoamniotic 1 yolk sac

Ultrasound Diagnosis

• Monochorionic twins

Yolk Sac Number Monochorionic- Diamniotic 2 yolk sacs Monochorionic- Monoamniotic 1 yolk sac

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Ultrasound Diagnosis

• Monochorionic twins

Yolk Sac Number Monochorionic- Diamniotic 2 yolk sacs Monochorionic- Monoamniotic 1 yolk sac

Quiz: What type of twins? Pregnancy with Twins

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

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%) Hyperemesis gravidarum Anemia Cesarean Postpartum hemorrhage Depression Death

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Pregnancy Risks: Fetal

Di-di

• Pregnancy loss
• Growth restriction
• Preterm delivery: avg 35.3wks
• Prematurity complications

Pregnancy Risks: Fetal

Di-di

• Pregnancy loss
• Growth restriction
• Preterm delivery: avg 35.3wks
• Prematurity complications

Mono-di

• Risk of birth defects 5-10%
• Risk of TTTS 10-15%

TTTS

• Placental vascular anastomoses resulting in unequal fetal

blood distribution

• Donor: oligohydramnios, growth restriction, Doppler changes,

fetal demise

• Recipient: polyhydramnios, Doppler changes, fetal hydrops, fetal

demise

Pregnancy Risks: Fetal

Di-di

• Pregnancy loss
• Growth restriction
• Preterm delivery: avg 35.3wks
• Prematurity complications

Mono-di

• Risk of birth defects 5-10%
• Risk of TTTS 10-15%

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Pregnancy Risks: Fetal

Di-di

• Pregnancy loss
• Growth restriction
• Preterm delivery: avg 35.3wks
• 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+

• Natural triplet rate: 0.014%
• 2011 triplet rate: 0.137%

Higher-Order Multiples: 3+

• Pregnancy loss rate 12-18%
• 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

Quiz: Max litter size

• Tailless Tenrecs: 32

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Pregnancy Management Fetal Reductions

• Terminating one or more fetuses from multifetal

pregnancy

• KCL injection
• Cord occlusion techniques

Fetal Reductions

Selective reduction

• Targeting anomalous fetus

Fetal Reductions

Multifetal Reduction

• Triplets > singleton or twins
• Reduced pregnancy loss, greater gestational age at

delivery, reduced neonatal complications, better maternal outcomes

• Twins > singleton also improves outcomes

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Genetic Screening and Testing

• Genetic Screening:
• Serum screening: less sensitive, specific
• cfDNA screening: not validated….
• CVS/Amnio
• Sampling error

Fetal Surveillance

Di-di

• Detailed anatomy ultrasound
• Serial growth ultrasound
• Antenatal testing (i.e. 36wks)

Fetal Surveillance

Di-di

• Detailed anatomy ultrasound
• Serial growth ultrasound
• Antenatal testing (i.e. 36wks)

Mono-di Above plus:

• Fetal echocardiograms
• TTTS checks- alternating with growth US, Q2wk
• Antenatal testing (i.e. 32wks)

Fetal Surveillance

Di-di

• Detailed anatomy ultrasound
• Serial growth ultrasound
• Antenatal testing (i.e. 36wks)

Mono-di Above plus:

• Fetal echocardiograms
• TTTS checks- alternating with growth US, Q2wk
• Antenatal testing (i.e. 32wks)

Mono-mono Above plus:

• Discussion of inpatient management (i.e. 26-28wks)

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Interventions

• Progesterone?
• No
• Bedrest?
• No
• Cerclage?
• Exam-indicated only

Miller 2014, Roman 2016, Park 2016, Han 2019:

Interventions

• Betamethasone?
• Yes
• Magnesium sulfate?
• Yes

Delivery Management

Route Timing Di-di Vaginal preferred

• A must be cephalic
• Discordance of ≤ 20%
• Breech extraction provider available
• Epidural, in OR

38wk

Delivery Management

Route Timing Di-di Vaginal preferred

• A must be cephalic
• Discordance of ≤ 20%
• Breech extraction provider available
• Epidural, in OR

38wk Mono-di Same as above 36-37 wks

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Delivery Management

Route Timing Di-di Vaginal preferred

• A must be cephalic
• Discordance of ≤ 20%
• Breech extraction provider available
• Epidural, in OR

38wk Mono-di Same as above 36-37 wks Mono-mono Cesarean delivery recommended 32-34wks?

Summary of Key Points

• Multiple gestation incidence continues to increase
• Accurate, early ultrasound diagnosis critical
• Fetal reduction improves pregnancy outcomes
• Genetic screening/testing is impacted
• Exam-indicated cerclage has benefit
• Vaginal delivery preferred*
• Monoamniotic twins: inpatient management reduces

demises

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• Mirror image twins
• Tailless Tenrecs
• Armadillos!

Thank you!