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Twin pregnancySome practical aspects
Eduard Gratacós
Center&for&Maternal,fetal&and&Neonatal&Medicine&BarcelonaHospitals&Clínic&and&Sant&Joan&de&Deu,&University&of&Barcelona
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TWIN PREGNANCY
1 – Diagnosis corionicity
2-Evaluation membranes and cords
3 – Prenatal diagnosis
4 - Main Risks and measures to prevent
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TWIN PREGNANCY
1 – Diagnosis corionicity
2-Evaluation membranes and cords
3 – Prenatal diagnosis
4 - Main Risks and measures to prevent
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TWIN PREGNANCY
1 – Diagnosis corionicity
2-Evaluation membranes and cords
3 – Prenatal diagnosis
4 - Main Risks and measures to prevent
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A: CRL 64A: CRL 64mmmm
B: CRL 70B: CRL 70mmmm
Discordance: 8.6 %Discordance: 8.6 %(LCC1 - LCC2/LC 1 x(LCC1 - LCC2/LC 1 x
100)100)
Dating pregnancy: greatest CRL(early restriction can happen, but not early accelerated growth)
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Combined test in twinsCombined test in twins(maternal age + (PAPP-A y fβ-hCG)+NT)
First choice DC: individual risk DR 75-83% (T21) (Chasen et al AJOG 2007)
Lower FPR (Goncé et al.,Prenat Diagn 2006; Chasen et al., AJOG 2007)
769 MC pregnancies 6 cases T21 (Vandecruys et al., 2005)
MC:averagerisk
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DCDC-CVS: both-CVS: both
-Amnio: 2 sacs (1-2-Amnio: 2 sacs (1-2punctures)punctures)
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Invasive proceduresInvasive procedurestwinstwins
MCMC-CVS: one sampling-CVS: one sampling-Amnio: 2 punctures-Amnio: 2 punctures
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TWIN PREGNANCY
1 – Diagnosis corionicity
2-Evaluation membranes and cords
3 – Prenatal diagnosis
4 - Main Risks and measures to prevent
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TWIN PREGNANCY
IUGR
PREMATURITY
MALFORMATIONS
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TWIN PREGNANCYIncidence of malformations per fetus
MC > BC >single
MC = BC >single
MC = BC =single
1.
2.
3.
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Incidence: 10%
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26 weeksTwin 1 Twin 2
PFE (gr.) p3 p60
Management?Emergency CSCS post-corticoidsNuevo control en 24hrsSeguimiento semanal
1.2.3.4.
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TwinsMean GA@delivery: 36-37 wDelivery <32w: 10%
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Interventions to reduce prematurity in twinsNO EFFECT SO FAR
Prophylactic Cerclage in the Management of Twin Pregnancies.Roman AS, Saltzman DH, Fox N, Klauser CK, Istwan N, Rhea D, Rebarber A.Am J Perinatol. 2013 Jan 9. [
Vaginal progesterone to prevent preterm birth in multiple pregnancy: a randomized controlled trial.Wood S, Ross S, Tang S, Miller L, Sauve R, Brant R.J Perinat Med. 2012 Jul 14. d
Twins: increased perinatal death (RR 1.551), RDS (RR 1.218) and adverse outcome (RR 1.211 ). (Also reported in tripletsCombs CA, AJOG 2010)
Perinatal outcome in women treated with progesterone for the prevention of preterm birth: a meta-analysis.Sotiriadis A, Papatheodorou S, Makrydimas G.Ultrasound Obstet Gynecol. 2012 Sep;40(3):257-66.
Progesterone for the prevention of preterm birth in twin pregnancy (STOPPIT)Norman JE, Mackenzie F, Owen P, et al.Lancet. 2009 Jun 13;373(9680):2034-40.
A trial of 17 alpha-hydroxyprogesterone caproate to prevent prematurity in twins.Rouse DJ, Caritis SN, Peaceman AM, et alN Engl J Med. 2007 Aug 2;357(5):454-61.
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TWIN PREGNANCY
1 – Diagnosis corionicity
2-Evaluation membranes and cords
3 – Prenatal diagnosis
4 - Main Risks and measures to prevent
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Acardias/Acephalus
Arterial/flow/from/normal/twin
1/anastomosis/A6A/+/1/anastomosis
V6V
no/own/placenta
Incidence:/1%/MZ/twins
30650%/death/normal/“pump”/twin
Cardiac/failure,/hydrops
Severe/polyhydramnios
••
–
–
••
–
–
Twin Reverse Arterial Sequence
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MONOCHORIONIC TWIN PREGNANCYINTERFETAL ANASTOMOSES
Discordance in AV/VA flow
Chronic/subacute unbalancedtransfusion
TTTSTAPS
Discordance in placentalterritories
sIUGR
Discordance in fetaldefect
Acute feto-fetal transfusion
High risk of hemodynamic accident+
High risk of fetal death
+
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12
14to28
30+
DIAGNOSIS OF CHORIONICITY Evaluation of risk (Anatomy, NT + DV + AC + folding)
SEVERE COMPLICATIONS (mostly managed by intrauterine therapy)
TTTS - Early sIUGR – Discordant malformationClose follow-up and early diagnosis & management
LATE COMPLICATIONS(mostly managed by elective delivery)
Late TTTS – Late sIUGR - TAPS - Single IUFDClose follow up and elective delivery
Monitoring of monochonionic twinpregnancy
3 stages BIOMETRY +DOPPLER
12
20
28
141618
222426
3230
AC + AFASSESSMENT
Elective delivery 36-37s
3436
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POLIHYDRAMNIOS-+-ENLARGED-BLADDER(>8$cm$<20w$+$>10$cm$<26w)
OLIGO2ANHYDRAMNIOS-+-COLLAPSED-BLADDER(<2$cm)
Diagnostic-criteria-of-TTTS-Eurofoetus,-Curr-Opin-Obstet-Gynecol-1999--2--WAPM.-J-Perinat-Med-2011
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COMPLICATIONS OF MONOCHORIONIC PREGNANCY
Discordant placental territories selective IUGR•
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www.fetalmedicinebarcelona.org/Evans et al 1994, 1998
Gestation)at)delivery(wks)
>14 wks
14%
57%
14%
6%
24%
<15 wks
5%
31%
6%
63%
0%
25 - 28 29 - 32 33 - 36 37- 42Loss
12 wks
Miscarriage 5% Delivery <33w 6%
••
20 wks
Miscarriage 14% Delivery <33w 20%
•
•
Selective reductionSelective reductionDICHORIONIC PREGNANCYDICHORIONIC PREGNANCY
>28-30w ?
Success nearly 100%Shalev 99, Lipitz 96
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TWIN PREGNANCY
1 – Diagnóstico corionicidad, evaluaciónmembranas y cordones
2 – Riesgo malformaciones
3 – MC: descartar complicaciones frecuentes
4 – Medición cérvix