MULTIPLE GESTATION

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MULTIPLE GESTATION

• By
• Sridevi Abboy, MD

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Definition(Multi-fetal Gestation)

• MULTIPLE PARITY
• -Twins (two babies)
• -Monozygotic(Division of 1 ova fertilized by
  the same sperm)
• -Dizygotic(Fertilization of 2 ova by 2 sperm)
• -Triplets (three babies)
• -Quadruplets (four babies)

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Incidence

• Twins - 1 in 100 births
• African Americans 1 in 70
• Caucasians 1 in 88
• Japanese 1 in 150
• Chinese 1 in 300
• Triplets are about 1 in 7,500 births
• Quadruplets are about 1 in 650,00 births

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Predisposing Factors

• Maternal age and parity
• Maternal height and weight
• Genetic and racial factors
• Prior use of oral contraceptive agents
• Social class
• Seasonality

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Causes of Multiple Gestation

• Spontaneously
• In Vitro fertilization
• Intrauterine insemination
• Assisted Hatching
• GIFT, ZIFT
• Frozen Embryo Transfer, Blastocyte Embryo
  Transfer
• Fertility Drugs
• Clomiphene citrate (clomid, serrophene)
• Gonadotropins (GonalF, follistim, humagon)

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Twins

• Dizygotic twins
• (66 of US twins)
• Dichorionic separate chorion (placenta)
• Diamniotic separate amnion (amniotic sac)

• Monozygotic twin (33 of US twins)
• Ova division
• lt 72 hours Dichorionic, diamniotic
• 4-8 days Monchorionic, diamniotic
• 8-13 days Monochorionic, monoamniotic
• gt 13 days conjoined twins

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Conjoined Twins

• Craniopagus
• Pygopagus
• Thoracopagus
• Cephalopagus
• Epholothoracopagus

• Parapagus
• Ischopagus
• Omphalopagus
• Parasitic twins
• Fetus in fetu

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Conjoined Twins(paraphagus)
http//www.conjoined-twins.i-p.com
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Multiple Birth Stats (2000)

• Number of live multiple births in 2000 119,648
• Number of twin births 118,916
• Number of triplet births 6,742
• Number of quad births 506
• Number of quintuplets and higher birth 77
• 
  
  http//www.cdc.gov/nchs/fastats/multiple.htm

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Cost per infant

• Infants born 39-42 weeks 9,803
• Infants born 25-27 weeks 280,146
• Twins born 25-27 weeks 560,292
• Triplets born 25-27 weeks 840,438
• Quads born 25-27 weeks 1,120,584
• http//www.multiplebirth.com/New_Folder/Articles/
  MultgestEpidemCauseConsequesnces.doc

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Days in NICU

• GA 23-25 weeks 100-125
• GA 25-27 weeks 80-100
• GA 28-29 weeks (quads) 55-75
• GA 30-31 weeks 25-45
• GA 32-33 weeks (triplets) 15-35
• GA 34-35 weeks (twins) 10-25
• GA 36-40 weeks 1-10
  http//www.metrohealth.org/clinical/NIC
  U/2000.htm

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Average age of gestation

• Number of babies Weeks of Gestation
• 1 40 weeks
• 2 35 1/2 weeks
• 3 33 weeks
• 4 29 ½ weeks http//www.bestdoctors.com/
  en/conditions/g/gestation/gestation_100200.htm

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Handicap Rates (per 1000 post-natal survivors)

• Overall Severe Moderate
• Singletons 90.6 19.8 70.8
• Twins 125.6 33.7 92.0
• Triplets 178.1 57.1 121.0
• http//www.multiplebirth.com/New_Fo
  lder/Articles/MultgestEpidemCauseConsequesnces.doc
  

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Cerebral Palsy

• Singleton Twin Triplet
• standardized standardized
  standardized
• Per 1000 live births 1 4.6 16.6
• Per 1000 1st year
• survivors 1 4.6 17.4
• Per 1000 pregnancies 1 8.3 47
  http//www.multiplebirth.com/New_Fo
  lder/Articles/MultgestEpidemCauseConsequesnces.doc

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Mortality Rates(per 1000 live births)

• Infant Neonatal Postnatal
• (birth to 1 year) (birth to day 28)
  (day 29 to 1 year)
• Singletons 11.2 7.8 3.4
• Twins 66.4 55.9 10.5
• Triplets 190.4 168.8 21.6
• calculated from the
  vital statistics of the US, 1998
• http//www.multiplebirth.com/New_Folder/Articles/
  MultgestEpidemCauseConsequesnces.doc

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Mean birth weight

• Singletons Twins Triplets
• Mean BW(gm) 3357 2389 1735
• lt1500gm 1.1 10.12
  31.88
• lt2500 gm 6.06 52.24 91.52
• SGA 9.38 35.63 36.57
  http//www.multiplebirth.com/New_Folder/Articles/M
  ultgestEpidemCauseConsequesnces.doc

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Peripartum Complications

• Prematurity-major cause of neonatal death
• 50 of twins
• 90 of triplets and higher
• Spontaneous abortion
• Increased anomalies
• Cord Prolapse
• IUGR, discordant growth
• Intracranial Hemorrhage
• Locked Twins
• Description Twins lock heads
• 1st twin breech, 2nd twin vertex

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Prematurity

• Singletons Twins Triplets
• lt33 weeks 1.7 14 41.25
• lt37 weeks 9.4 50.7 91.03
• http//www.multiplebirth.com/New_Fold
  er/Articles/MultgestEpidemCauseConsequesnces.doc

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Problems of Prematurity

• HMD/BPD
• Pneumothorax
• Apnea
• ICH
• CP
• Blindness/Retinopathy
• LBW
• PDA
• Hypertension/Hypotension

• Bradycardia
• Anemia
• Hyperbilirubinemia
• NEC
• Metabolic disorders
• Hypothermia
• HIE
• Hypotonia
• Infections

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Neonatal Management(Multiple Gestation)

• Team for each fetus
• Examine for prematurity and IUGR
• Examine for congenital anomalies
• Determine zygosity, examine placenta
• Assess family support

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In ICN

• RDS
• Apnea/Asphyxia
• Hct and BP
• Wt difference

• NEC
• Head Sono
• Glucose
• Blood typing

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Second Twin Risks

• Asphyxia due to premature separation of placenta
• Fetus papyraceous
• -twin fetus that died in utero, become
  flattened and mummified
• Fetal transfusion Syndrome
• Placental AV shunt in monozygotic twins (15)
• Arterial twin pumps blood to other twin,
  starves self
• Other twin is bulky and plethoric
• Operative or difficult delivery

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Monozygotic twins(physical characteristics)

• Same sex
• Features alike, including teeth and ears
• Hair identical
• Eyes same color and shade
• Skin same texture and color
• Hands and feet same conformation and same size
• Anthropometric values closely agree

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Twin-Twin Transfusion Syndrome

• Monozygotic twins share one placenta
• 1 placenta causes one baby to receive more blood.
• One baby (donor) smaller and other larger.
• Larger baby excess urine, polyhydramnios.
• Donor stops producing urine, oligohydramnios.
• This can lead to pre-term delivery (24 weeks).

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TTTS
http//www.tttsfoundation.org/chart1.htm
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Prevention(Multiple Gestation)

• Moniter treatment with fertility drugs
• Limit embryos transferred during IVF
• Counseling risks and long-term sequelae
• Fetal reduction if not against religion

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• THE END