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APGO educational topic number twenty
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multi fetal gestation since nineteen
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eighty there has been a 70 percent
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increase in the frequency of twins and a
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four hundred percent increase in triplet
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and higher order births these rates are
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rising as a result of an increase in
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maternal age and the increased use of
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assisted reproductive technologies and
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ovulation induction agents the
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objectives of this video are to list
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risk factors for multi fetal gestation
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to describe the embryology diagnosis and
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management of multi fetal gestation and
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to describe the unique maternal and
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fetal physiologic changes and
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complications associated with multi
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fetal gestation monozygotic twins
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otherwise known as identical twins
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result when a fertilized ovum divides
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after conception the timing of when this
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divide occurs will decide the Corey
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Anissa T if division occurs within the
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first three days after fertilization
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there will be two core eons to am neons
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to placentas and here are the fetuses
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these will be died a me on ik die
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chorionic twins if division occurs
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within days four to eight after
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fertilization the chorion has already
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developed and there’ll be two am neons
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one placenta and here are the fetuses
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these are died amniotic monochorionic
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twins if division occurs between days
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nine through twelve there’ll be one Cory
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on one am me on one placenta and the
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fetuses will be in a common sac
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these are monochorionic mono amniotic
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twins if division occurs after day 12
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then conjoined twins will develop
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dizygotic twins known as fraternal twins
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occur when two separate OVA are
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fertilized by two separate spur the
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distinction between zygosity and Coriana
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city can be confusing for new learners
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so let’s spend a moment here to
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emphasize some key concepts dizygotic or
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fraternal twins are all died a me otic
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died chorionic monozygotic twins or
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identical twins can be any of the three
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Coriana cities monozygotic twin rates
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are fairly constant around the world at
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1 out of 250 pregnancies in contrast
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dizygotic twin rates are markedly
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different in various populations
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risk factors from multi fetal gestation
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are one increasing maternal age to
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increasing parity and three there are
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increased rates among mothers of
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families with twins all multi fetal gist
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stations are at an increased risk of
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prematurity twins are delivered at an
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average of 35 weeks
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triplets at 32 weeks and quadruplets at
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an average of 30 weeks all multi fetal J
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stations are also to increase risks of
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preeclampsia congenital abnormalities
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intrauterine growth restriction and
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placental abruption
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let’s now move on to risks associated
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with the specific Koreana cities die
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amniotic monochorionic twins referred to
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as DiMeo twins are at increased risks of
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developing twin twin transfusion
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syndrome this is one of the most serious
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complications of die mode twins this
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occurs when there is net flow from one
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twin to another secondary to vascular
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anastomosis between the fetuses there
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will be a donor twin and a recipient
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twin the donor twin can have impaired
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growth anemia hypovolemia all ago Hydra
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meiosis and other problems the recipient
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twin can develop hypervolemia
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hypertension polycythemia congestive
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heart failure and polyhydramnios
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endoscopic intrauterine laser ablation
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of the vascular anastomosis is the
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first-line therapy now for twin twin
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transfusion syndrome mono amniotic
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monochorionic twins otherwise known as
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momo twins are at increased risk of cord
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entanglement and fetal death since the
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two fetuses are sharing the same space
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within the same amniotic sac let’s now
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move on to diagnosis early ultrasound
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can determine the number of fetuses
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estimate the gestational age and
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importantly determine the Coriana City
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Coriana City should be determined as
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early in the pregnancy as possible
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optimally in the late 1st or early
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second trimester here is an ultrasound
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of a diam iana chorionic twin gestation
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note the wedge-shaped protrusion into
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the inter twin space called the lambda
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sign here is an ultrasound of
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monochorionic mono amniotic twins note
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that there is no membrane between the
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fetuses in contrast this ultrasound
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demonstrates dye amniotic monochorionic
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twins with the blue arrow pointing to
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the amnion that separates the fetuses
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once the diagnosis of twins has been
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made then unique care must be given to
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address the
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potential concerns of multi fetal
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gestation so let’s move on to management
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many medical complications are more
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common in multi fetal gestation
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these include hyperemesis gravidarum
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gestational diabetes mellitus and
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postpartum depression additional
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maternal concerns that need to be
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addressed are adequate nutrition twin
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pregnancies require an extra 300
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calories per day there is also an
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increased risk of blood loss at delivery
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so pregnant women with twins should take
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iron to try to prevent anemia women with
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twins are also at increased risk of
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developing pregnancy-induced
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hypertension therefore frequent blood
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pressure monitoring should be performed
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fetal concerns include the increased
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risk of preterm labor and contractions
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and patients should be educated about
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the signs of labor and assessments of
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the cervix should be performed every one
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to two weeks starting in the mid
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trimester when available this should be
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performed through ultrasound assessments
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of cervical length all multi fetal G
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stations are at increased risk of
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discordant growth
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thus periodic ultrasound examinations
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are performed to assess fetal weight
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let’s now move to timing of delivery
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this also depends on the Coriana City
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uncomplicated die amniotic dye chorionic
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or dye dye twins can be delivered at 38
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weeks uncomplicated dye a me Attic
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monochorionic or dye move twins can be
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delivered between 34 and 37 and six
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weeks uncomplicated mono amniotic
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monochorionic pregnancies or Momo twins
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should be delivered between 32 and 34
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weeks this early delivery is secondary
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to the risk of cord entanglement and
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subsequent fetal death the route of
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delivery will depend on the Coriana City
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fetal presentation gestational age and
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experience of the clinician performing
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the delivery momo twins are often
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delivered by caesarian delivery
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secondary to the risk of cord
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complication die die and die mode twin
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pregnancies are candidates for vaginal
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deliveries after 32 weeks the presenting
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fetus needs to be in a cephalic
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presentation 40% of twins enter labor
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with both twins in the cephalic
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presentation after delivery of the first
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twin if the second twin remains cephalic
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then the second twin can be delivered
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also by vaginal delivery if the second
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twin flips two non cephalic after the
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delivery of the first win or if it
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starts out as non cephalic then
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external cephalic version can be used to
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gently guide this second twin into
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cephalic presentation or the second twin
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can be delivered by breached vaginal
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delivery the approach to how best
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deliver the second twin will also factor
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in clinician experience with non
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cephalic presentations in summary molé
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molé pregnancies are delivered by
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caesarian delivery DiMeo and die die
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pregnancies can be delivered by vaginal
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delivery if the presenting twin is
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cephalic however since all twin
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pregnancies are at increased risk of
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caesarean delivery some patients and
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some clinicians may choose to perceive a
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caesarean delivery with all twinges
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stations regardless of Korena City and
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presentation this concludes the aapko
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video on multi fetal gestation we
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reviewed the risk factors and Embryology
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of these pregnancies and reviewed the
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unique maternal and fetal considerations
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associated with multiple gestation