preeclampsia postpartum hemorrhage maternal death Labor and delivery complications preterm
labor uterine contractile dysfunction abnormal presentation umbilical cord prolapse premature separation of the placenta immediate postpartum hemorrhage Etiology ovadizygotic
or frater nal twins maturation and fertiliz ation of two ova monozygotic or identical twins
Genesis of Monozygotic Twins "Vanishing Twin" one twin is lost or "vanishes" maternal serum alpha-fetoprotein level amnionic fluid alpha-fetoprotein level
amnionic fluid acetylcholinesterase assay + Determination of Chorionicity Sonographic Evaluation
Placental Examination Infant Sex and Zygosity Diagnosis History and Clinical Examination Sonography Radiological Examination Biochemical Tests
large uterus for gestational age Multiple fetuses Elevation of the uterus by a distended bladder Inaccurate menstrual history Hydramnios Hydatidiform mole Uterine leiomyomas A closely attached adnexal mass Fetal macrosomia (late in pregnancy)
Duration of Gestation Unique Complications Vascular Anastomoses between Fe tuses Antepartum Management of Twin Pregnancy Delivery
of markedly preterm neonates be prevented Fetal-growth restriction be identified and afflicted fetuses be delivered before they become moribund Fetal trauma during labor and delivery be avoided Expert neonatal care be available Recommendations for intrapartum management
An appropriately trained obstetrical attendant should remain with the mother throughout labor. Continuou s external electronic monitoring is employed. If mem branes are ruptured and the cervix dilated, then sim ultaneous evaluation of both the presenting fetus by internal electronic monitoring and the remaining sibli ng(s) by external monitors is typically used
Blood transfusion products are readily available An intravenous infusion system capable of deliverin g fluid rapidly is established. In the absence of hemo rrhage, lactated Ringer or an aqueous dextrose solu tion is infused at a rate of 60 to 125 mL/hr Recommendations for intrapartum management
An obstetrician skilled in intrauterine identification of fetal parts and in intrauterine manipulation of a fetus should be present A sonography machine is made readily available to help e valuate position and status of the remaining fetus(es) after
delivery of the first Experienced anesthesia personnel are immediately availa ble in the event that intrauterine manipulation or cesarean delivery is necessary For each fetus, two attendants, one of whom is skilled in r esuscitation and care of newborns, are appropriately infor med of the case and remain immediately available The delivery area should provide adequate space for all te am members to work effectively. Moreover, the site must be appropriately equipped to provide maternal and neonat al resuscitation
Presentation and Position admission for delivery: cephalic-cephalic, cephalic-breech, and cephalic- transverse Vaginal delivery When How Evaluation
(TTTS) blood is transfused from a donor twin to its recipient sibling the donor becomes anemic and it s growth may be restricted
the recipient becomes polycythe mic and may develop circulatory overload manifest as hydrops donor twin is pale, and its recipie nt sibling is plethoric Diagnosis--sonographic suspedted Monochorionicity same-sex gender
hydramnios defined if the largest vertical pocket i s > 8 cm in one twin and oligohydramnios define d if the largest vertical pocket is < 2 cm in the ot her twin umbilical cord size discrepancy cardiac dysfunction in the recipient twin with hyd ramnios abnormal umbilical vessel or ductus venosus Do ppler velocimetry significant growth discordance.
Quintero staging system Stage Idiscordant amnionic fluid volumes as de scribed above, but urine still visible sonographic ally within the donor twin's bladder Stage IIcriteria of stage I, but urine is not visible within the donor's bladder Stage IIIcriteria of stage II and abnormal Doppl er studies of the umbilical artery, ductus venosus , or umbilical vein
Stage IVascites or frank hydrops in either twin Stage Vdemise of either fetus Disorders of Amnionic Fluid Volume The role of amnionic fluid a physical space promotes normal fetal lung development
avert compression of the umbilical cord
Permitting fetal movement and the development of the musculoskeletal system. Swallowing of amniotic fluid enhances the growth and d evelopment of the gastrointestinal tract. The ingestion of amniotic fluid provides some fetal nutriti on and essential nutrients. Amniotic fluid volume maintains amniotic fluid pressure t hereby reducing the loss of lung liquid - an essential co mponent to pulmonary development. (Nicolini, 1989). Protects the fetus from external trauma.
Protects the umbilical cord from compression. It's constant temperature helps to maintain the embryo's body temperature. It's bacteristatic properties reduces the potential for infec tion. Pathway Pathway ml/day ml/day
to amniotic to the fetus fluid Fetal swallowing 500-1000 - Oral secretions
- 25 Secretions from the respiratory tract 170 170
Fetal urination - 800-1200 Intramembranous flow across the placenta, umbilical co rd and fetal 200-500
- Transmembraneous flow from the amniotic cavity into th e uterine circulation 10 Normal Amnionic Fluid Volume 1 L by 36 weeks, decreases thereafter to les
s than 200 mL at 42 weeks Diminished fluid is termed oligohydramnios more than 2 L of amnionic fluid is termed hyd ramnios or polyhydramnios Measurement of Amnionic Fluid amnionic fluid index, AFI adding the vertical depths of the largest po cket in each of four equal uterine quadrant
s hydramnios : 24 cm Sonogram of a pocket of amniotic flu id in a patient with hydrops fetalis an d polyhydramnios. Two small segme nts of umbilical cord (arrows) are se en traversing the measured pocket o f amniotic fluid. The placenta (P), wh ich appears normal to prominent in t his case, is, in fact, abnormally thick
ened. Hydramnios Causes fetal
malformations gastrointestinal anomalies nonimmune hydrops chromosomal abnormalities central nervous system TTTS fetal pseudohypoaldosteronism
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