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Multiple Pregnancy for TPC
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www.totalpregnancycare.com
www.totalpregnancycare.com
www.totalpregnancycare.com
Multiple Pregnancy
Dr Shantala VadeyarMD, FRCOG, DM (UK)
Advanced Obstetric Ultrasound (RCO/RCR)Subspecialist in Maternal-Fetal Medicine (RCOG)
Consultant Obstetrics, Fetal & Maternal MedicineKokilaben Dhirubhai Ambani Hospital, Mumbai
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Incidence
• Increased with Assisted Reproduction• Clomiphene citrate / Letrozol/ HMG, hCG• Advanced Age• Race – Afro-carribeans• 1:80-100
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Risks in Multiple Pregnancy
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DC twins - lambda sign
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MC twins - T sign
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Chorionicity v/s Zygosity
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Techniques for invasive testing
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Loss rates: Amniocentesis in Twins
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Chorionic Villous Sampling in Twins
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Selective Fetocide / ER
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Management: Antenatal
Maternal and Fetal Surveillance
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Ultrasound in Multiples• Diagnosis and Chorionicity determinaiton• Dating, Chromosomal & Structural Normality• Growth, Dopplers• Amniotic fluid assessment• Twin twin transfusion syndrome• Invasive procedures – amniocentesis, CVS• Cervical length and funnelling• Prediction of preterm labour• Timing of delivery – Dopplers, BPS in IUGR, etc
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Complications in Twins:Based on Chorionicity
EVENT DICHORIONIC MONOCHORIONIC
Miscarriage (11-23 weeks) 2% 10%
Perinatal Death (>23 weeks) 2% 4%
Fetal Growth Restriction (one /both) 20% 30%
Preterm delivery (<32 weeks) 5% 10%
Major birth defects 1% 4%
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Delivery <34 wks 1.8%Delivery <34 wks 1.8%
SpontaneousSpontaneous2/32/3rdrd
IatrogenicIatrogenic1/31/3rdrd
• Previous affected pregnancy (15%)Previous affected pregnancy (15%)• Nulliparous / No previous PTD (85%)Nulliparous / No previous PTD (85%)
Prevalence of spontaneous early preterm birthPrevalence of spontaneous early preterm birth
25% reduction (4% of total)
Cervical cerclage or Progesterone
Early screening forEarly screening forPreterm deliveryPreterm delivery
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Twin Twin Transfusion Syndrome• Monochorionic twins• Donor twin is small, growth
restriction• Recepient twin is big• Oligo / polyhydramnios• Big bladder, heart enlarged in
recepient• Oliguria, donor• Abnormal Dopplers
Anastomoses in TTTS
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Prognosis - TTTS• Staging (Quintero)
– Stage I • Recipient hydramnios• Donor bladder visible/present
– Stage II• Recipient hydramnios• Donor bladder remains empty (“stuck twin”)
– Stage III • Abnormal Doppler studies:
– absent or reversed end-diastolic flow in Donor UA OR– abnormal venous Doppler pattern in Recipient UA (reverse flow in
the ductus venosus or pulsatile umbilical venous flow) – Stage IV
• Fetal hydrops means stage IV and the end – Stage V
• Fetal death of one or both twins.
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Treatment of TTTS by selective laser ablation of A-V
Anastamoses
Laser ablation
Stuck ‘donor twin’ wrapped in membrane
Feely floating ‘recipient twin’In hydramnios
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Electronic Fetal Heart
Rate monitoring
in labour
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Epidural Analgesia(painless labour)
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Timing and Mode of Delivery
• Dichorionic twins – 38 weeks• Monochorionic twins – 36 wks• Vaginal delivery in uncomplicated DC or MC twins if
cephalic, cephalic presentations• Precious pregnancy, abnormal presentations,
complications like IUGR, preterm, maternal DM/HT usually delivered by LSCS
• Increased risk of placenta praevia and APH, PPH
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Complications• Post-partum haemorrhage
– Bimanual massage– Uterotonics– Prophylactic Misoprostol PR– Syntocinon infusion– B Lynch Suture– Uterine Artery Ligation– Uterine Artery Embolisation– Hysterectomy
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Profile• Total Pregnancy Care is an online guide for pregnancy, childbirth and motherhood related information.
Women wanting to conceive, pregnant women, expecting parents, and new mothers can use this pregnancy portal for a healthy pregnancy, fulfilling childbirth and joyful motherhood. With pregnancy at its core, this portal covers various important aspects and especially addresses those matters that the Indian Woman always wanted to know but did not know whom to ask.
• This website is compiled by Dr. Shantala, an Indian Obstetrician and Gynaecologist. She has over 20 years of extensive medical and diagnostics experience in areas commonly related to the Maternity and Pregnancy fields. She has studied and practiced in India as well as in the United Kingdom and thus brings about the fusion of best practices of the Oriental East and the Progressive West.
• A mother of three children, she has complete understanding of the emotional, mental and physical needs of the New Age Pregnant Woman. Her patients appreciate her empathic approach and wholeheartedly express their gratitude for her generosity and care. Dr.Shantala is presently a full time Obstetrics and Gynaecology Consultant at the Kokilaben Dhirubhai Ambani Hospital and Medical Research Institute, a premier health care initiative of the Reliance ADA Group. Dr.Shantala has a clear vision to promote a holistic pregnancy approach and her mission is to provide comprehensive maternity care. This website, www.TotalPregnancyCare.com, is her first step towards this future.
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Services Offered• Pre-pregnancy counseling • Genetic counseling • Antenatal care, Labour Delivery • Specialist Ultrasound scans
– Viability scan – The First trimester scan / Nuchal translucency scans – Detailed anatomy / anomaly scans – Fetal Echocardiograph – 3D / 4D scans
• Assessment of the High risk Fetus and Mother • Amniocentesis • Chorionic Villous sampling • Cordocentesis • Intra-uterine transfusions • Embryo Reduction / Selective fetocide • Second opinion scans
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Topics covered
• Pre-Conception– Working on getting pregnant or just starting to think about a family, this is
the place for you
• Pregnancy– From trying to conceive to the first trimester to labor, learn what to
expect during your pregnancy and more
• Labor Delivery– From that first contraction to the final push, here's what to expect
during labor and delivery
• Post-Pregnancy– Learn more about your diet and workouts, shopping, feeding and your
child's health
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Interactive Corner
• Month by Month happenings• Articles• FAQs• Gestation Calendar
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Society Memberships• British Maternal & Fetal Medicine Society • Fetal Medicine Centre• Kokilaben Dhirubhai Ambani Hospital &
Medical Research Institute• Royal College of Obstetricians and
Gynaecologists• International Society of Ultrasound in
Obstetrics and Gynecology
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Contact Us
• Email: [email protected]• Mobile: +91 9324304212• KDAH Board line: +91 22 30999999
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THANK YOUwww.totalpregnancycare.com