Presentation on the topic of multiple pregnancy. All about the development of multiple pregnancy

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Lecturer:
head Department of Obstetrics and Gynecology
Professor Krut Yuri Yakovlevich

Pregnancy is called multiple pregnancy
in which in a woman’s body
two or more fetuses develop.
The birth of two or more children is called
multiple births.
Multiple pregnancy
called a pregnancy in which
the uterine cavities develop more than one
embryo.

If a woman is pregnant with two fetuses, they speak of twins, with three fetuses, they speak of triplets, etc. Children born from a multiple pregnancy are called

If a woman is pregnant with two fetuses, they say
twins, three fruits - about triplets, etc. Children,
born from multiple pregnancy,
are called twins.
Multiple pregnancies occur in 0.7-1.5%
cases.
Spontaneous occurrence rate
pregnancy with a large number of fetuses
extremely small.
To calculate the frequency of spontaneous
the occurrence of multiple pregnancy is possible
use Heylin's rule: twins
occur with a frequency of 1:80 births, triplets - 1:802
(6400) births, quadruplets - 1:803 (512000) births,
quintuplets - 1:804 births.

However, in recent decades this has been the rule
stopped working due to significant
the incidence of multiple births has increased
pregnancy, which is associated with active use
assisted reproductive methods
technologies - hyperstimulation of ovulation or IVF in
women with infertility.
Due to the high incidence of miscarriage and
other complications of multiple pregnancy
in most Western European countries currently
time a law was introduced according to which it is prohibited
introduce more than two into the uterine cavity, and in some
countries and more than one embryo. However, it is not uncommon
cases when the embryo divides after replanting in
uterine cavity, which leads to triplets
or quadruplets.

The main factors contributing to
multiple pregnancy include:
mother's age is over 30-35 years,
hereditary factor (maternal line),
high parity (multiparous),
abnormal development of the uterus (doubling),
pregnancy immediately after termination
use of oral contraceptives,
against the background of the use of stimulation agents
ovulation, with IVF.
Prevention of multiple pregnancy is possible only with
use of assisted reproductive devices
technology and is to limit the number
transferred embryos.

CLASSIFICATION

Depending on the number of fetuses in multiple pregnancies
they talk about twins, triplets, quadruplets, etc.
There are two types of twins: fraternal (dizygotic) and
identical (monozygous).
Children born from fraternal twins are called "twins"
(in foreign literature - “not identical”), and children from an identical mother
twins - twins (in foreign literature - “identical”).
Children of fraternal or dizygotic twins can be either one or the same
different sexes, whereas identical or monozygotic twins -
only same-sex.
Fraternal twins are the result of fertilization of two eggs,
the maturation of which, as a rule, occurs within one
ovulatory cycle in one or possibly both ovaries.

Cases of superfetation are described in the literature
(superfetation), or pregnancy during
pregnancy - interval between fertilizations
two eggs is more than one
menstrual cycle, i.e. is happening
fertilization of two different eggs
ovulation periods,
superfecundation - fertilization of two or more
eggs from the same ovulation period
sperm of various males.

Gametes (from Greek γᾰμετή - wife, γᾰμέτης - husband) -
reproductive (sex) cells that have
haploid (single) set of chromosomes and
participating in gametes, in particular, sexual
reproduction.
When two gametes fuse, a zygote is formed.
developing into an individual (or group of individuals) with
hereditary characteristics of both parents
organisms that produce gametes.
Zygote (from ancient Greek ζυγωτός - paired,
doubled) - diploid (containing complete
double set of chromosomes) a cell formed in
result of fertilization (fusion of egg and
sperm).

Main stages of human embryogenesis

Cleavage - a series of successive mitotic divisions
a fertilized or initiated egg.
Crushing represents the first period
embryonic development, which is present
in the ontogenesis of all multicellular animals.
The egg divides into smaller and smaller cells -
blastomeres.
Morula (lat. morula - mulberry) is a stage of early
embryonic development of the fetus, which begins with
completion of zygote division. Morula cells divide
homoblastic. After several cell divisions
the embryo forms a spherical structure,
resembling a mulberry.

Main stages of human embryogenesis

Subsequently, a cavity appears inside the embryo -
blastocoel. This stage of development is called blastula.
A blastula is formed in the first 3 days after fertilization.
1 - morula,
2 - blastula.
On the 4-8th day after fertilization at the blastocyst stage,
the formation of the inner layer of embryoblast cells occurs, as well as the laying of the chorion from the outer layer
trophoblast.

Main stages of human embryogenesis

Gastrula (lat. gastrula) - embryonic stage
development of multicellular animals, following
blastula. A distinctive feature of the gastrula
is the formation of the so-called
germ layers - layers (layers) of cells.
In multicellular animals at the gastrula stage
three germ layers are formed: outer
-ectoderm, internal - endoderm and middle
- mesoderm. Gastrula development process
called gastrulation.

Main stages of human embryogenesis

One of the mechanisms of gastrulation is intussusception
(invagination of part of the wall of the blastula inward
embryo)
1 - blastula,
2 - gastrula.
On the 9-10th day after fertilization, it ends
amnion is formed and an embryo is formed
amniotic sac.

Main stages of human embryogenesis

On the 13-15th day after conception occurs
embryonic disc formation – neurulation –
the neurula stage that follows the gastrula.
At this stage of embryonic development,
formation of the neural plate and its closure in
neural tube.
The early neurula is formed as a result of gastrulation and
is a three-layer embryo, consisting of layers
which internal organs begin to form.
The ectoderm forms the neural plate and integumentary
epithelium.
The mesoderm forms the notochord primordium.
The endoderm grows towards the dorsal side of the embryo and
surrounding the gastrocoel forms the intestine.

Main stages of human embryogenesis

Organogenesis - the last embryonic
the stage of individual development begins after 2-3
weeks after fertilization.
During the process of histogenesis, body tissues are formed.
Nervous tissue is formed from the ectoderm
and the epidermis of the skin with skin glands, of which
subsequently the nervous system and organs develop
senses and epidermis.
The notochord and epithelial tissue are formed from the endoderm.
tissue from which mucous membranes are subsequently formed,
lungs, capillaries and glands (except genital and skin).
Muscle and connective tissue are formed from the mesoderm
textile. The musculoskeletal system, blood, heart, kidneys and reproductive organs are formed from muscle tissue.
glands.

periods of human intrauterine development (1)
A - 2 - 3 weeks;
1.
2.
3.
4.
B - 4 weeks
amnion cavity
embryo body (embryoblast)
yolk sac
trophoblast.

The position of the embryo and germinal membranes in different
periods of human intrauterine development (2)
B - 6 weeks
G - fetus 4 - 5 months:
1.
2.
3.
4.
5.
fetal body
amnion
yolk sac
chorion
umbilical cord.

Types of twins. The reasons for their occurrence.

There are two main types of twins:
dizygotic (dizygotic, heterologous) and
identical (monozygotic, homologous,
identical).
Dizygotic twins occur when
fertilization of two separate eggs.
The maturation of two or more eggs can
occur both in one ovary and in two.
Dizygotic twins can be either uni- or
different sexes and are in the same genetic
dependencies as siblings.

Fraternal (dizygotic) twins.

Dizygotic twins are always characterized by
dichorionic, diamniotic type
placentation.
In this case, there will always be two autonomous placentas,
which may fit tightly, but can be
divide.
Each fertilized egg that
penetrates the decidua, forms
own amniotic and chorionic membranes,
from which their own separate
placenta.
The septum between the two fetal sacs consists of
of four membranes: two amniotic and two
chorionic.

amnion
Two chorions
amnion

Fraternal (dizygotic) twins.

One of the main reasons for the formation of dizygotic
twins is a powerful hormonal
ovarian stimulation. High FSH levels may
cause maturation and ovulation at the same time
several follicles in one or both ovaries
or the formation of two in one follicle
eggs. Most often, two eggs come from
one follicle.
A similar picture of polyovulation against the background of increased
FSH levels may also develop during
stimulation of ovulation with clomiphene citrate,
clostilbegit, human chorionic gonadotropin.

Fraternal (dizygotic) twins.

A certain relationship was noted between the series
factors and the incidence of dizygotic twins.
Thus, among women with multiple pregnancies, more often
There are patients aged from 35 to 39 years. Among
These women are predominantly multipregnant, with
relatively large body weight and height.
For those women who have already had dizygotic twins
there is a greater chance of it occurring again. More likely
total predisposition to the development of dizygotic
twins may be inherited on the maternal side by
recessive type.
There is a higher incidence of twins with anomalies
development of the uterus (bicornuate uterus, septum in the uterus). At
bifurcation of the uterus more often than with its normal structure,
maturation occurs simultaneously of two or more
eggs that can be fertilized.

Monozygotic twins are formed due to
separation of one fertilized egg into different
stages of its development and make up 1/3 of all twins.
Unlike dizygotic twins, the frequency
The prevalence of monozygotic twins is
a constant value of 3-5 per 1000
childbirth
In contrast to the dizygotic variant, the prevalence
monozygotic twins does not depend on ethnicity
belonging, mother's age, parity
pregnancy and childbirth.

Identical (monozygotic) twins.

The division of a fertilized egg can occur
as a result of delayed implantation and oxygen deficiency
saturation.
The cause of polyembryony may be mechanical
separation of blastomeres (in the early stages of cleavage),
resulting from cooling, disruption
acidity and ionic composition of the environment, exposure
toxic and other factors. This theory also allows
explain the higher incidence of developmental anomalies
among monozygotic versus dizygotic twins.
The occurrence of monozygotic twins is also associated with
fertilization of an egg that has two or more nuclei.
Each nucleus is connected to nuclear matter
spermatozoon, resulting in the formation of embryonic
rudiments.

Identical (monozygotic) twins.

During the development of the fertilized egg, first
the chorion is laid down, then the amnion and, in fact,
embryo
Therefore, the nature of placentation during formation
monozygotic twins depends on the stage of fetal development
the egg on which division occurred.
If separation of the fertilized egg occurs in the first 3 days
after fertilization, i.e. before the formation of internal
layer of cells - embryoblast (in the blastocyst stage) and
converting the outer layer of blastocyte cells into
trophoblast, then monozygotic twins have two chorions and
two amnions.
In this case, monozygotic twins will be
diamniotic and dichorionic. This option
occurs in 20-30% of all monozygotic twins.

Identical (monozygotic) twins.

If division of the fertilized egg occurs between the 4th and 8th
in the afternoon after fertilization at the blastocyst stage, when
the formation of the inner layer of embryoblast cells has been completed, the formation of the chorion from the outer layer has occurred
layer, but before the laying of amniotic cells, will form
two embryos, each in a separate amniotic sac.
The two amniotic sacs will be surrounded by a common
chorionic membrane. Such monozygotic twins will be
monochorionic and diamniotic.
Most monozygotic twins (70-80%)
represented by this type.

amnion
no chorion tissue
amnion

Identical (monozygotic) twins.

If separation occurs on the 9-10th day after
fertilization, by the time the amnion is completed, then
two embryos are formed with a common amniotic sac.
Such monozygotic twins will be monoamniotic and
monochorionic.
Among monozygotic twins, this is the rarest type,
occurring in approximately 1% of all monozygotic
twins and representing the highest degree
risk in terms of pregnancy.
When the egg divides at a later date on the 13th-15th
day after conception (after the formation of the embryonic
disk) the partition will be incomplete, resulting in incomplete
cleavage - fusion of twins (Siamese twins).
This type is quite rare, approximately 1
observation per 1500 multiple pregnancies or 1:50
000-100,000 newborns.

Dizygotic
Monozygotic
Time of egg division
˂3 days
Dichorionic
Diamniotic
>13 days
Dichorionic
Diamniotic
Monochorionic
Diamniotic
Monochorionic
Monoamniotic
30% twins
66% twins
1-2% twins
Undivided
twins
0.3% twins

Dichorionic
ddd twins
same sex of fruits
Monozygotic
twins
Monochorionic
twins
same gender
fruits
Dichorionic twins
same sex of fruits
10%
35%
20%
35%
Dizygotic
twins
Dichorionic twins
different sexes of fruits

Before the introduction of ultrasound into obstetric practice, diagnosis
multiple pregnancies were often diagnosed late
terms or even during childbirth.
It is possible to assume the presence of multiple pregnancies
in patients whose uterus is larger than
gestational norm as during vaginal examination (on
early stages), and during external obstetric examination
(at later stages).
In the second half of pregnancy it is sometimes possible
palpate many small parts of the fetus and two large ones
parts (fruit heads).
Auscultatory signs of multiple pregnancy are
heart sounds heard in different parts of the uterus
fruits Cardiac activity of fetuses in multiple pregnancies
can be registered simultaneously with special
heart monitors for twins.

Diagnosis of multiple pregnancy.

The most accurate method for diagnosing multiple pregnancy
is an ultrasound examination.
Ultrasound diagnosis of multiple pregnancies in early
timing is based on imaging at 3-4 weeks in the uterine cavity
several fertilized eggs, and from the 5-6th week of pregnancy - two and
more embryos.
To develop the correct tactics for managing pregnancy and childbirth during
early pregnancy is crucial (in the first trimester)
determination of chorionicity (number of placentas).
It is chorionicity (and not zygosity) that determines the course
pregnancy, its outcomes, perinatal morbidity and
mortality.
The most unfavorable in terms of perinatal complications
monochorionic pregnancy, which is observed in 65% of cases
identical twins. PS in monochorionic twins is 3-4 times
exceeds that of dichorionic.

Ultrasound diagnosis of chorionicity.

The presence of two separately located placentas, thick
interfetal septum (more than 2 mm) serve as reliable
criterion for dichorionic twinning.
If a single “placental mass” is identified, it is necessary
differentiate "single placenta"
(monochorionic twins) from two fused twins (bichorionic
twins).
Availability of specific ultrasound criteria:
T- and λ-signs formed at the base of the interfruit
partitions, with a high degree of reliability allow
make a diagnosis of mono- or bichorionic twins.
Detection of the λ-sign by ultrasound at any stage of gestation
indicates a bichorionic type of placentation, T-sign
indicates monochorionicity.
It should be taken into account that after 16 weeks of pregnancy the λ-sign
becomes less accessible for research.

Dichorionic twins
Monochorionic twins

Sign
Monochorionic
twins
Dichorionic
twins
Definition of λ- and
T-sign
T-sign
λ-sign
Counting placentas
1 placenta
1 or 2 placentas
Gender Determination
fruits
Same-sex
Same-sex and
heterosexual
Definition
˂ 2 mm (2 layers, both
thickness
amniotic)
interamniotic
membranes
> 2 mm (4 layers: 2
chorionic, 2
amniotic)

Dichorionic
Monochorionic

Ultrasonography

It is also necessary, starting from an early stage, to carry out
comparative ultrasound fetometry for
predicting FGR in later stages of pregnancy.
According to ultrasound fetometry data for multiple pregnancies
pregnancy highlight the physiological development of both
fruits;
dissociated (discordant) development of fruits (difference in
fruit weight 20% or more);
growth retardation of both fetuses (FGR).
In addition to fetometry, as with a singleton pregnancy,
attention must be paid to assessing the structure and extent
maturity of the placenta/placentas, amount of OM in both amnions.
Particular attention is paid to the assessment of fetal anatomy for
exclusion of congenital birth defects, and in case of monoamniotic twins - for
exclusion of conjoined twins.

Ultrasonography

One of the important points for choosing the optimal
delivery tactics for multiple pregnancies
is to determine the position and presentation of the fetuses to
end of pregnancy.
Most often, both fetuses are in a longitudinal position
(80%); head-head, pelvic-pelvic, head-pelvic, pelvic-head.
The following position options are less common
fruits: one in a longitudinal position, the second - in
transverse; both are in a transverse position.
To assess the condition of fetuses in multiple pregnancies
use generally accepted functional methods
diagnostics: CTG, Doppler blood flow in vessels
mother-placenta-fetus system.

Options for the location of fetuses in the uterus
45%
5%
37%
2%
10%
0,5%

Frequency of different options
presentation/fetal position
Head/Head
Head/pelvic
Oblique or Transverse
Other options

COURSE OF PREGNANCY

In case of multiple pregnancy, significantly
the risk of such complications increases:
- Premature birth (from 30 to 60% of multiple births)
pregnancies).
- Preeclampsia of varying degrees of severity.
- Anemia.
- Retarded growth of one of the fruits.
- Premature rupture of fruit membranes.
- Premature detachment of a normally located
placenta.
- Gestational diabetes.
- Pyelonephritis and others.

Premature birth rate and average
gestational age for MB
Singleton
Singleton
pregnancy
pregnancy
Preterm birth (%)
twins
triplets
quadruplets
twins
Average gestational age (weeks)

Birth weight
singleton
pregnancy
Low (˂2500g)
twins
triplets
quadruplets
Very low (˂1500g)

COURSE OF PREGNANCY

The course of multiple pregnancy is often
complicated by growth retardation of one of the fetuses (FGR),
whose frequency is 10 times higher than that at
singleton pregnancy and is equal to mono- and
bichorionic twins 34 and 23%, respectively.
The dependence on the type of placentation is more pronounced
incidence of growth retardation in both fetuses: 7.5% with
monochorionic and 1.7% with bichorionic twins.

Developmental delay (FGR) with multiple births
pregnancy
Discordant twins, 32 weeks. gestation.
Birth weight 1550.0 and 450.0
respectively
The same twins at the age of 2.5 years

COURSE OF PREGNANCY

The most unfavorable in terms of perinatal
complications is monochorionic pregnancy.
Perinatal mortality in monochorionic twins,
regardless of zygosity, 3-4 times higher than that
with dichorionic.
Monochorionic twins versus dichorionic twins
is accompanied by a significantly higher risk:
Perinatal death (11.6% for monochorionic and 5.0%
with dichorionic).
Intrauterine fetal death after 32 weeks.
Severe discordant (uneven) development
fetuses (discordance >20%).
Necrotizing enterocolitis in fetuses.

Pregnancy management

Patients with multiple pregnancies should visit the antenatal clinic
consultation more often than with a singleton: 2 times a month
before 28 weeks, after 28 weeks - once every 7-10 days.
During pregnancy, patients should
visit a therapist.
Given the increased caloric needs,
proteins, minerals, vitamins for multiple births
During pregnancy, special attention must be paid
issues of complete balanced nutrition
pregnant.
Optimal for multiple births, as opposed to singletons
pregnancy, total gain of 20-22kg.

Pregnancy management

You should use a gravigram developed specifically
for MB.
Screening ultrasound examinations
For MB, standard screening tests are recommended.
ultrasound examinations at 10-13 weeks and 20-21 weeks
a week.
Prevention of neural tube defects
All MB women should be offered
folic acid 1 mg/day for the first three months
for the prevention of neural tube defects.
Prevention of anemia
The use of iron as a dietary supplement in a dose of 60-100
mg/day, starting from 12-22 weeks, reduces the frequency by 74%
detection of hemoglobin level<110 г/л и на 66% частоту
detection of iron deficiency in late pregnancy.

Pregnancy management

Preventing preeclampsia
All women from MB should be recommended
taking calcium as a dietary supplement in doses
1 g elemental calcium per day starting at 16 weeks
pregnancy, in a high-risk group (GB, obesity and
so on) - the incidence of preeclampsia is reduced by 80%.
Maternal morbidity and mortality rate
significantly reduced by 20%.
Taking low-dose aspirin (50-150 mg/day) from 20 weeks
pregnancy significantly reduces the incidence of preeclampsia
by 13%.

Pregnancy management

Prevention of preterm birth in MB
Detection and treatment of bacterial vaginosis, trichomoniasis and
candidiasis, including asymptomatic cases, reduces the incidence
premature births by 45%, the frequency of births of children with
small body weight less than 2500 g - by 52%, less than 1500 g by 66%.
Prenatal cervical length screening (transvaginal
cervicometry) is indicated for pregnant women who have high
risk of premature birth (in particular for women from MB).
Shortening of the cervix is associated with an increased risk
premature birth.
Transvaginal cervicometry alone does not reduce
frequency of premature births, but makes it possible
promptly refer the pregnant woman to the appropriate institution
for delivery and conduct a course of RDS prevention.

Pregnancy management

In addition to standard screening tests in
first trimester and at 16 weeks, it is recommended to
Ultrasound at 20, 26, 30, 33, 36 weeks.
The goal of each study is to conduct a thorough
fetometry for timely detection of discordant
fetal growth and MGVP/IUGR.
To develop tactics for managing pregnancy and childbirth, in addition to
fetometry, with multiple pregnancy as well as with singleton
pregnancy, assessment of the condition is of great importance
fetuses (CTG, Doppler blood flow in the mother-placenta-fetus system, biophysical profile).
Determining the quantity becomes essential
amniotic fluid (multiple and oligohydramnios) in both amnions.

Specific complications of multiple pregnancy

In case of multiple pregnancy it is possible
development of specific, not typical for
singleton pregnancy, complications:
Feto-fetal transfusion syndrome
(SFG),
reverse arterial perfusion,
intrauterine death of one of the fetuses,
congenital malformations of one of the fetuses,
conjoined twins,
chromosomal pathology of one of the fetuses.

Feto-fetal transfusion syndrome (FTS)

Feto-fetal blood transfusion syndrome (FTS),
first described by Schatz in 1982, complicates the course of 525% of multiple identical pregnancies.
Perinatal mortality in SFFG reaches 60-100% of cases.
Morphological substrate of SFFG - anastomosing
vessels between two fetal systems
blood circulation - a specific complication for
monozygotic twins with monochorionic type
placentation, which is observed in 63-74% of cases
monozygotic multiple pregnancy.
The likelihood of anastomoses occurring in
monozygotic twins with bichorionic type of placentation
no more than in dizygotic twins.

Pathogenesis of SFFT:
Arteriovenous anastomoses
Fetal artery II
Cotyledon

Superficial anastomies
Recipient
Deep anastomies

Hypervolemia
Hypovolemia
Polycythemia
Anemia
Polyuria
Oliguria
Low water
recipient
Polyhydramnios
Hyperosmolarity
Stunting
Heart
failure
Crushing
"donor" fetus
Edema
Transfer of blood from donor to
to the recipient
Absorption of liquid from
maternal blood

Classification of SFFT by severity
Uric
Oligohydramnios bubble
Terminal
And
no donor
Stage
blood flow
polyhydramnios is visualized
Edema
Death
one or
several
fruits
І
+
―
―
―
―
ІІ
+
+
―
―
―
ІІІ
+
+
+
―
―
IV
+Can be observed at any stage of gestation and as a result of this
there may be “death” of one fertilized egg in the first trimester,
which is noted in 20% of observations, and “paper fruit” in II
trimester of pregnancy.
Average frequency of death of one or both fetuses in early
gestational age is 5% (2% for singleton
pregnancy).
Frequency of late (in the II and III trimesters of pregnancy)
intrauterine death of one of the fetuses is 0.5-6.8%
for twins and 11.0-17.0% for triplets.
The main causes of late intrauterine death in
monochorionic placentation - SFFG, and for dichorionic placentation -
FGR and membrane attachment of the umbilical cord.
At the same time, the frequency of intrauterine fetal death with
monochorionic twins is 2 times higher than that for
dichorionic twins.

Intrauterine death of one of the fetuses during multiple pregnancy

In case of intrauterine death of one of the fetuses
dichorionic twins - considered optimal
prolongation of pregnancy.
With monochorionic type of placentation, the only
way out to save a viable fetus is cesarean section
section performed as soon as possible after death
one of the fruits, when damage has not yet occurred
brain of the surviving fetus.
In case of intrauterine death of one of the fetuses from
monochorionic twins at earlier stages (before
achieving viability) the method of choice is
immediate occlusion of the umbilical cord of a dead fetus.

COURSE AND MANAGEMENT OF LABOR

The course of labor in multiple pregnancy is characterized by high
frequency of complications:
primary and secondary weakness of labor,
premature rupture of amniotic fluid,
loss of umbilical cord loops and small parts of the fetus.
One of the serious complications of the intrapartum period
- PONRP of the first or second fetus.
The cause of placental abruption after the birth of the first
the fetus may experience a rapid decrease in uterine volume and
decreased intrauterine pressure, which represents
particular danger in monochorionic twins.

Optimal timing
planned birth with MB
Twins
Dichorionic
37 – 38
weeks
Monochorionic
diamniotic
36 – 37 weeks
Triplets
Monochorionic
monoamniotic
32 weeks
36
weeks

Fruit A head /
Fetus B is head
Vaginal
birth for both
fruits
Fruit A is not
head
Monoamniotic twins.
Triplets.
Undivided
twins.
Scar on the uterus.
Obstetrics
indications.
Caesarean section for both fetuses

MANAGEMENT OF CHILDREN

Importance for determining tactics
childbirth has a clear knowledge of the type of placentation, since
with monochorionic twins along with high
frequency of FFH there is a high risk of acute
intrapartum transfusion, which may be
fatal for the second fetus (severe acute
hypovolemia with subsequent damage
brain, anemia, intrapartum death),
therefore we cannot exclude the possibility
delivery of patients with monochorionic
twins by caesarean section.

MANAGEMENT OF CHILDREN

The greatest risk to fruits is
pregnancy with monochorionic
monoamniotic twins, which require special
careful ultrasound monitoring of growth and
condition of the fruits and in which, in addition to specific
complications inherent in monochorionic twins are often
twisting of the umbilical cords of the fetuses is observed, which can
lead to intrapartum death of children.
The optimal method of delivery for this type
multiple pregnancy (monochorionic monoamniotic
twins) is a cesarean section (CS) at 32-33 weeks
pregnancy.

MANAGEMENT OF CHILDREN

In addition, the indication for elective CS for twins is
consider pronounced overdistension of the uterus due to
large children (total weight of fruits 6 kg or more).
During pregnancy with three or more fetuses
Delivery by CS at 34-35 weeks is indicated.
Also
Resolution is also carried out by CS in case of fused
twins
(If
given
complication
was
diagnosed late in pregnancy).
When diagnosing conjoined twins in the early stages
pregnancy up to 12 weeks. interrupt shown
pregnancy for medical reasons.

MANAGEMENT OF CHILDREN

When managing childbirth through the natural birth canal
need to be closely monitored
condition of the woman in labor and constantly monitor cardiac
activity of both fruits.
Childbirth in case of multiple pregnancy is preferably carried out in the position
women in labor on their side to avoid the development of compartment syndrome
inferior vena cava.
After the birth of the first child, external
obstetric and vaginal examinations to clarify
obstetric situation and position of the second fetus.
It is also advisable to perform an ultrasound.
When the second fetus is in a longitudinal position, the fetus is opened
bladder, slowly releasing amniotic fluid: later
childbirth is carried out through the natural birth canal.

MANAGEMENT OF CHILDREN

Question about caesarean section during childbirth
multiple pregnancy may result in the following:
causes:
persistent weakness of labor;
loss of small parts of the fetus or umbilical cord loops during
cephalic presentation;
symptoms of acute hypoxia (distress) of one of the fetuses;
transverse position of the second fetus, after
independent birth of the first child;
placental abruption and others.
In the afterbirth and early postpartum period due to
overstretching of the uterus, possibly hypotonic
bleeding. During multiple births, it is mandatory
carry out the prevention of bleeding in the afterbirth and
postpartum periods.

The possibility that it is possible to bear two, three or more babies can, to say the least, surprise any parents. In addition to physical stress, it is also a very big psychological burden. Therefore, when the possibility of multiple pregnancy becomes a reality, future parents need to be provided with increased psychological support.

Multiple pregnancy, reasons

The occurrence of several embryos in a woman’s body can be due to various reasons. First of all, this is inheritance from ancestors; if there have already been such cases in the family, then the likelihood of two-, three-, or more embryonic pregnancies is much higher. Also, multiple pregnancy after IVF is even more likely. This occurs due to the introduction of several fertilized eggs at once. Therefore, when considering IVF, a multiple pregnancy is almost guaranteed.

Pregnancies with multiple embryos are common among older women. The reason for this is the hormone gonadotropin, which stimulates the development of the egg and its release from the ovary. Multiple pregnancy, the symptoms of which may vary, can also occur after taking hormonal medications. The occurrence of several embryos can occur both after taking fertility drugs and after contraceptives.

In order to know how to determine multiple pregnancy, you need to listen to your body even more. If a large fat stripe is visible on the test, this is one of the sure signs of multiple pregnancy. Signs of multiple pregnancy before ultrasound are as follows:
· Severe toxicosis.
· Extreme fatigue.
· Early fetal activity.
· Facial skin reaction in the form of acne.

It must be remembered that in this case there are much more dangers than with one baby. Therefore, multiple pregnancy still carries complications and it is better to be prepared for all possible risks. This will significantly increase the chances of bearing healthy, full-fledged babies.

Problems that may arise during the gestation stage

Miscarriage. The development of multiple pregnancies, unfortunately, does not always go well. The most common problem is the inability to bear children. The gestation time in this case varies depending on the number of embryos. A multiple pregnancy with twins lasts about 36-37 weeks; if there are three fetuses, then the period is reduced to 34-35 weeks. Premature birth is caused by an overly stretched uterus or amniotic fluid that accumulates too much.

To resolve this situation, management of multiple pregnancies must be special. The doctor must constantly monitor the mother. After all, the duration of a multiple pregnancy is reduced, in contrast to the time of bearing one baby. From the middle of pregnancy, the expectant mother needs to rest more, and sometimes even adhere to bed rest. If the cervix shortens after 23 weeks, sutures may be placed on it. If this does not stop the activity of the uterus and the stomach also feels tight during multiple pregnancies, tocolytics or corticosteroids are prescribed to speed up the maturation of the internal organs of the fetus.

Possibility of complications. Symptoms of multiple pregnancy can be accompanied by anemia and toxicosis, both in the early and late stages. To eliminate anemia, pregnant women are prescribed large doses of folic acid and iron. If the doctor determines that this is a multiple pregnancy, an ultrasound is done not only to detect it, but also to monitor the development of the babies. You can also monitor the amount of amniotic fluid and the placenta.

Problematic fruit development. In terms of the frequency of defects, a fraternal pregnancy is similar to a pregnancy with one fetus, and a singleton pregnancy is twice as susceptible to such risks. The reason for this is the nutrition of the embryos. Multiple pregnancy in the early stages of this type is complicated by the fact that the nutrition of the embryos occurs along a chain. First from the placenta to one baby, and then from the first to the second. This is what can cause insufficient development of one of the fruits. In domestic medicine, nothing except the release of excess amniotic fluid is expected, which will simply extend the gestation period.

A small increase in fetal weight. When the birth of a multiple pregnancy occurs, the weight of the babies usually does not exceed 2500 grams. The difference in weight between children is approximately 200-300 grams. To avoid this situation, you need to pay special attention to proper nutrition, especially in the first half of pregnancy. In some cases, reduction during multiple pregnancies is a necessary step to preserve the strongest fetuses.

Multiple pregnancy The likelihood of twins increases: History of twins (being a twin) Mother's age from 35 to 39 years Number of births Belonging to the black race Use of assisted reproductive technologies Conception after taking COCs High level of secretion of pituitary gonadotropins

Multiple pregnancy Classification By zygosity: Dizygotic (dizygotic, non-identical) Monozygotic (monozygotic, identical) By chorionicity (placentation): Bichorionic - biamniotic Monochorionic - biamniotic Monochorionic - monoamniotic

Multiple pregnancy Multiple pregnancy Fertilization of two or more oocytes Simultaneous ovulation followed by fertilization of two or more eggs matured in different follicles of one ovary Simultaneous ovulation followed by fertilization of two or more eggs matured in different follicles in both ovaries Ovulation and fertilization of two or more eggs, matured in one follicle Superfertilization - fertilization of two or more simultaneously ovulated eggs by sperm from different men Fertilization of an egg ovulated against the background of an existing pregnancy

Multiple pregnancy Early division of a fertilized egg (depending on the time from fertilization to bifurcation of the zygote, one of 4 options for twins): 0-72 hours - bichorionic - biamniotic monozygotic twins 25% 4-8 days - monochorionic - biamniotic monozygotic twins 70% 9-13 day - monochorionic - monoamniotic monozygotic twins 5% After 13 days - conjoined (Siamese) twins

Multiple pregnancy Diagnosis Clinical and anamnestic signs: Excessive weight gain The height of the uterine fundus is 4 cm or more more than is typical for this period, an increase in abdominal circumference. Palpation of parts of the fetus, the size of the fetal head does not correspond to the size of the uterus. Auscultation at two or more fetal heartbeat sites

Multiple pregnancy Ultrasound is the gold standard in the diagnosis of multiple pregnancy Accuracy - 99.3% Possible from 6 - 7 weeks of gestation When using a vaginal sensor from 4-5 weeks of gestation Allows you to determine the number of fetuses, amnions, but reality (especially in the first 14 weeks) Differential diagnosis of bichorionic from monochorionic twins is easier in the first trimester and can be performed with transvaginal ultrasound at 5 weeks

Multiple pregnancy Complications in the mother: Anemia (2 times more often than in a singleton pregnancy) Spontaneous abortions (2 times more often than in a singleton pregnancy) in 50% - fetuses were subjected to resorption - anembryony - death of the “vanishing twin” embryo - “disappeared” phenomenon twin” no later than 14 weeks

Multiple pregnancy Complications for the mother during pregnancy: Early toxicosis (nausea and vomiting are more severe) Pregnancy-induced hypertension (3 times more often than with a singleton) Gestosis (in 20-40% of pregnant women with multiple pregnancy) Threat of premature birth, premature birth (36 .6%-50%)

Multiple pregnancy Complications for the mother during pregnancy: Premature rupture of amniotic fluid (25% of cases), which is twice the frequency of singleton pregnancies. Polyhydramnios is observed in 5-8% of twin pregnancies, especially with monochorionic twins. Acute polyhydramnios before 28 weeks of pregnancy occurs in 1.7% of twins. Impaired glucose tolerance Cholestasis of pregnancy

Multiple pregnancy Complications in the fetus: High perinatal mortality is 15% increases in direct proportion to the number of fetuses - increases in direct proportion to the number of fetuses - per 1000 births in twins per 1000 births in triplets per 1000 births in triplets

Multiple pregnancy Complications in the fetus: Prematurity - low birth weight (55% weight less than 2500) - respiratory distress syndrome - intracranial hemorrhage - sepsis - necrotizing enterocolitis Average duration of pregnancy: Twins - 35 weeks Triplets - 33 weeks Quadruples - 29 weeks

Multiple pregnancy Complications in the fetus: Congenital malformations Observed 2-3 times more often than during pregnancy with one fetus Observed 2-3 times more often than during pregnancy with one fetus Monochorionic anomalies are twice as likely as bichorionic ones Frequency ranges from 2 to 10 % Frequency ranges from 2 to 10% The most common are: cleft lip cleft palate cleft palate defects of the central nervous system defects of the central nervous system heart defects

Multiple pregnancy Complications in the fetus: Conjoined twins Frequency - 1: 900 twin pregnancies Classification is based on the part of the body by which they are connected to each other: thoracopagus - conjoined in the chest area (40%) omphalopagus - conjoined in the anterior abdominal wall (35%) pygopagus - fused in the sacral area (18%) ischiopagus - fused in the perineal area (6%) craniopagus - fused in the head area (2%)

Multiple pregnancy Complications in the fetus: Pathology of the umbilical cord and placenta: - placenta previa - placental abruption (usually in the second stage of labor) - velamentous attachment of the umbilical cord (7% in twins) - umbilical cord previa (8.7% in twins), - umbilical cord prolapse in childbirth

Multiple pregnancy Complications in the fetus: Feto-fetal transfusion syndrome (twin transfusion syndrome) a complication of monochorionic multiple pregnancy with a frequency of up to 15% frequency of up to 15% The development of FFTS is due to the presence of vascular anastomoses, leading to pathological shunting of blood from one fetus to another The development of FFTS is due to the presence of vascular anastomoses leading to pathological shunting of blood from one fetus to another. One fetus becomes a donor and the other a recipient

Feto-fetal transfusion syndrome Donor Chronic blood loss Anemia HypovolemiaHypoxia Restricted growth Reduced renal blood flow Oligohydramnios Oliguria Amnion compression Recipient Chronic increase in blood volume Hypervolemia PolycythemiaHypertension Non-immune hydrops Cardiomegaly PolyuriaPolyhydramnios

Multiple pregnancy Complications in the fetus: Incorrect presentation of the fetus during childbirth (50% - 10 times more often than in singleton pregnancy): -Cecephalic-cephalic 50% -Cecephalic-pelvic 30% -Pelvic-cephalic 10% -Transverse for one or two fruits 10%

Multiple pregnancy Complications in the fetus: Collision - Coupling of twins during childbirth Frequency 1: 1000 twins and 1: births Perinatal mortality with this complication reaches 62-84% Diagnosis is made during the period of expulsion of fetuses Diagnosis is made during the period of expulsion of fetuses Observed in breech-cephalic presentation

Multiple pregnancy Complications in the fetus: Various options for impaired development of one or both twin fetuses - a consequence of placental insufficiency 5 types of prenatal development of fetuses from twins (M.A. Fuchs): 5 types of prenatal development of fetuses from twins (M.A. Fuchs): physiological development of both fetuses - 17.4% uniform malnutrition of both fetuses - 30.9% uniform malnutrition of both fetuses - 30.9% uneven development of twins - 35.3% congenital pathology of fetal development - 11.5% antenatal death of one fetus - 4 ,1%

Multiple pregnancy Complications in the fetus: Intrauterine growth restriction of the fetus frequency is 70% compared to 5-10% in singleton pregnancy. Delay in the development of one of the fruits (differences in size and weight of more than 15-25%) with a frequency of 4-23%. Neurological disorders: infantile paralysis microcephaly microcephaly encephalomalacia encephalomalacia In twins born prematurely, the incidence of brain tissue necrosis reaches 14%. In twins born prematurely, the incidence of brain tissue necrosis reaches 14%.

Multiple pregnancy Management of pregnancy: Early diagnosis of multiple pregnancy Dynamic observation once every two weeks in the first half of pregnancy, once a week in the second half of pregnancy Good nutrition “Bed rest” position Prevention of iron deficiency anemia

Multiple pregnancy Management of pregnancy: Ultrasound monitoring of fetal development - Screening (standard) ultrasound per week. to exclude developmental anomalies (taking into account the increased background risk of congenital anomalies) - Dynamic ultrasound starting from 24 weeks. every 3-4 weeks. before delivery (to assess fetal growth and timely diagnosis of FFTS)

Pregnancy management: assessment of the condition of the fetus according to CTG (non-stress test) should begin within a week. and continue weekly until delivery If there is evidence of deterioration in fetal growth, weekly assessment of the biophysical profile, amniotic fluid index, weekly CTG and Doppler blood flow in the umbilical cord is necessary from the moment of diagnosis of this pregnancy complication Multiple pregnancy

Management of pregnancy: For diagnosed FFTS syndrome: - Conservative treatment (observation, early delivery if necessary) - Amnioreduction (a series of therapeutic amniocentesis 1-12, removal of 1-7 liters) - Fetoscopic laser coagulation of vascular anastomoses - Septostomy (puncture of the amniotic septum) - Septostomy (puncture of the amniotic septum) - Selective euthanasia of the fetus (donor) embolization, coagulation, ligation

Multiple pregnancy Management of labor: At the beginning of the first period, an ultrasound is necessary to clarify the position and presentation of the fetuses (the position may change compared to what it was a few days before the onset of labor) Monitoring of both fetuses by recording CTG is necessary during the first stage of labor

Multiple pregnancy Indications for cesarean section: Monoamnial fetuses, regardless of the position of the fetuses Conjoined twins Transverse position of the first fetus Breech presentation of the first fetus with excessive tilting of the head Transverse position of the second fetus, which remains unchanged after the birth of the first fetus and an attempt at external rotation of the second More than two fetuses

Multiple pregnancy Management of vaginal birth: If the second fetus is transversely positioned, an ultrasound scan should be performed to monitor possible changes in its position. External-internal rotation followed by extraction of the fetus by the pelvic end is undesirable due to severe traumatic complications for the fetus. After the birth of the second fetus and placenta, it is necessary to prevent bleeding

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Presentation on the topic of multiple pregnancy. All about the development of multiple pregnancy

If a woman is pregnant with two fetuses, they speak of twins, with three fetuses, they speak of triplets, etc. Children born from a multiple pregnancy are called

CLASSIFICATION

Main stages of human embryogenesis

Main stages of human embryogenesis

Main stages of human embryogenesis

Main stages of human embryogenesis

Main stages of human embryogenesis

Main stages of human embryogenesis

Types of twins. The reasons for their occurrence.

Fraternal (dizygotic) twins.

Fraternal (dizygotic) twins.

Fraternal (dizygotic) twins.

Identical (monozygotic) twins.

Identical (monozygotic) twins.

Identical (monozygotic) twins.

Identical (monozygotic) twins.

Diagnosis of multiple pregnancy.

Ultrasound diagnosis of chorionicity.

Ultrasonography

Ultrasonography

COURSE OF PREGNANCY

COURSE OF PREGNANCY

COURSE OF PREGNANCY

Pregnancy management

Pregnancy management

Pregnancy management

Pregnancy management

Pregnancy management

Specific complications of multiple pregnancy

Feto-fetal transfusion syndrome (FTS)

Intrauterine death of one of the fetuses during multiple pregnancy

COURSE AND MANAGEMENT OF LABOR

MANAGEMENT OF CHILDREN

MANAGEMENT OF CHILDREN

MANAGEMENT OF CHILDREN

MANAGEMENT OF CHILDREN

MANAGEMENT OF CHILDREN

Multiple pregnancy, reasons

Problems that may arise during the gestation stage

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