DMSM 109 Obstetrical Sonography Part I

Lecture 8 Ultrasound Evaluation of Multiple Pregnancies Holdorf SON 2121 OBSTETRICAL SONOGRAPHY PART I Important stuff Zygosity

Monozygotic Twinning Dizygotic Twinning Clinical Complications associated with Twin

Pregnancy Maternal Complications Fetal Complications Complications of Twin Gestations Vanishing twin Twin-twin Transfusion syndrome (TTTS) Twin embolization syndrome Conjoined twins

Acardiac twin (Parabiotic twin) But firstIs it twins? Pregnant mothers often suspect that they are carrying more than one baby. Here are some of the most common signs of a twin or multiple pregnancies. Could your patient be having more than one? Check her symptoms against this list.

1. Ultrasound Confirmation Seeing is believing... the only way to indisputably confirm a twin or multiple pregnancy is to see it -- via ultrasound. An ultrasound image can indicate without a doubt if there is more than one fetus. Ultimately, no matter what

other signs or symptoms your patient has, the only way to know for sure is to have an ultrasound. 2. Doppler Heartbeat Count The Doppler system amplifies fetal heart sounds, usually distinguishable

late in the first trimester. An experienced Sonographer can detect more than one heartbeat, indicating a multiple pregnancy. However, the sounds can be misleading; what appears to be a second heartbeat may actually be background noise or, rarely, the

mother's own heartbeat. 3. Elevated HcG Levels For various reasons, doctors may monitor HcG (human chorionic gonadotropin) levels. HcG is a hormone detectable in pregnant women's blood or urine about 10

days post-conception; it increases at a rapid rate, peaking about 10 weeks into the pregnancy. Twins may produce an elevated level of HcG. However, the standard HcG level for twins also falls within the normal range for singletons. 4. Abnormal AFP Test Results AFP (Alphafetoprotein) screening is

a blood test performed on pregnant mothers during the second trimester. Also known as maternal serum screening or triple marker screen, it is used to identify increased risks of certain birth defects. A twin

pregnancy can produce an usually high -- or "positive -- result. 5. Measuring Large for Gestational Age Throughout the pregnancy, the doctor may measure the height of the uterine fundus (from the top of the pubic bone to the top of the uterus) as a way of indicating

gestational age. A twin or multiple pregnancy may cause the patients uterus to expand beyond the range of a single pregnancy. However, other factors may also increase the measurements. 6. Weight Gain Just as a multiple pregnancy may cause a mother to measure large, it

may also result in an increased weight gain. How much weight a woman gains can vary depending on her height, body type and how much she weighed pre-pregnancy. Increased or rapid weight gain more than likely reflects eating choices rather than twins; generally, mothers

of twins only gain about 10 lbs. more than singleton mothers 7. Excessive Morning Sickness About 50% of pregnant women experience some amount of vomiting or nausea associated with their pregnancy. Moms of

multiples certainly aren't exempt, but neither are they doomed to a double dose. Only about 15% of mothers reported enhanced morning sickness symptoms as an indicator of their multiple pregnancies. Experiences vary widely -- some do, some don't.

8. Early/Frequent Fetal Movement Feeling a baby -- or babies -- move inside the womb is one of the most thrilling aspects of pregnancy. Although many moms of multiples do experience more frequent or earlier

fetal movement, there is considerable disagreement among medical professionals on the subject. For some women, recognizable feelings of movement occur earlier in subsequent pregnancies, whether there is one baby or more.

9. Extreme Fatigue This is the most commonly reported complaint during pregnancy with multiples. Sleepiness, lethargy and exhaustion during the first trimester can be enhanced because the body is working overtime to nurture more than one baby. In some cases, the fatigue can be attributed to other

factors (work, stress, poor nutrition, having other children), but it can also be an indication of multiples. 10. History/Hunches While the other items in this list refer to some kind of visible evidence -- exaggerated symptoms, abnormal test results, etc. dont totally disregard the power of a mother's

intuition. A family history of multiples or a powerful hunch can be convincing indicators. Outline: Part I Twins are two

offspring resulting from the same pregnancy, usually born in close succession. They can be th e same or different sex. Twins can either be monozygotic (identical) or dizygotic ( fraternal). The general term for more than one offspring in the same pregnancy (multiple birth) is multiples; a fetus which develops alone in the womb is cal

led a singleton. Due to the limited size of the mother's womb, multiple pregnancies are much less likely to carry to full term than singleton births, with twin pregnancies lasting only 37 weeks (3 weeks less than full term) on average. Since There are five common variations of twinning. The three most common

variations are all dizygotic: male-female twins are the most common result, at about 40 percent of all twins born female DZ twins (sometimes called sororal twins) male DZ twins. The other two variations are

monozygotic twins: female MZ twins male MZ twins (least common). Dizygotic twins (commonly known as fraternal twins, but also referred to as non-identical twins or biovular twins) usually occur when two

fertilized eggs are implanted in the uterine wall at the same time. Whe n two eggs are independently fertili zed by two different sperm cells, DZ twins result. The tw o eggs, or ova, form two zygotes, hence the terms dizygotic and biovular. Dizygotic twins, like any other siblings, have an extremely small chance of

having the exact same chromosome Monozygotic twins, frequently referred to as identical twins, occur when a single

egg is fertilized to form one zygote (monozygotic) which then divides into two separate embryos. They are the same sex and their traits and physical app earances are very similar but not exactly the same; although they have nearly identical DNA. The two embryos develop into fetuses sharing the same womb.

When one egg is fertilized by on In about 12% of MZ twinning the splitting occurs late enough to result in both a shared placenta and a shared sac

called monochorionic monoamniotic (mono/mono) twins. Finally, the zygote may split extremely late, resulting in conjoined twins. Mortality is highest for conj oined twins due to the many complications r

esulting from shared organs. Mono/mono twi ns have an overall in-utero mortality of abou t 50 percent, principally due to cord entangl ement prior to 32 weeks gestation. If expecti ng parents choose hospitalization, mortality can decrease through consistent monitoring of the babies. Hospitalization can occur begi nning at 24 weeks, but doctors prefer a later date to prevent any complications due to pr

Zygosity, chorionicity and amniocity The two types of twins, monozygotic and dizygotic, are generally referred to as zygocity. Zygocity reflects the genetic type of twins. Two others terms define twin types: chorionity and amniocity. Chorionity refers to the number of chorionic sacs, while amniocity refers to the number of amniotic sacs. The number of chorionic and amnionic sacs can sometimes reveal the zygocity. Monoamniotic twins indicate monozygotic twins. However, two

placentas does not provide information about zygocity since monozygotic twins can have two placentas. Chorionicity and amniocity are a result of the division time. Dichorionic twins divide within the first 4 days. Monoamnionic twins divide after the first week. Complications Vanishing twins Researchers suspect that as many as

1 in 8 pregnancies start out as multiples, but only a single fetus is brought to full term, because the other has died very early in the pregnancy and has not been detected or recorded. Early obstetric ultrasonography exams som etimes reveal an "extra" fetus, which

fails to develop and instead disintegra Conjoined twins Conjoined twins (or the term "Siamese twins") are monozygotic twins whose bodies are joined together during pregnancy. This occurs where the single zygote of MZ twins fails to separate completely, and the zygote starts to split after day 13 following fertilization. This condition occurs in about 1 in 50,000 human

pregnancies. Most conjoined twins are now evaluated for surgery to attempt to separate them into separate functional bodies. The degree of difficulty rises if a vital organ or structure is shared between twins, such as the brain, heart or liver. Partial molar twins A very rare type of parasitic twinning is one where a single viable twin is

endangered when the other zygote becomes cancerous, or molar. This means that the molar zygote's cellular division continues unchecked, resulting in a cancerous growth that overtakes the viable fetus. Typically, this results when one twin

has triploidy, resulting in little or no fetus and a cancerous, overgrown placent Miscarried twin Occasionally, a woman will suffer a miscarriage early in pregnancy, yet t he pregnancy will continue; one twin was miscarried but the other was abl e to be carried to term. This occurren

ce is similar to the vanishing twin syndrome, but typicall y occurs later than the vanishing twi n syndrome. Low birth weight Twins typically suffer from the lower birth weights and greater likelihood o f prematurity that is more commonly a

ssociated with the higher multiple pr egnancies. Throughout their lives twi ns tend to be smaller than singletons on average. Twin-to-twin transfusion syndrome Monozygotic twins who share a placenta can develop twin-to-twin transfusion syndrome. This condition means that blood from one twin is

being diverted into the other twin. One twin, the 'donor' twin, is small and anemic, the other, the 'recipient' twi n, is large and polycythemic. The lives of both twins are endangered by this condition. The Heart of the matter: Part II

Zygosity Multiple gestations can occur several ways, and the term Zygosity refers to the number of zygotes involved. Multiple fetuses from one zygote are called monozygotic; Dizygotic means two zygotes originated.

Monozygotic Twins Dizygotic Twins Monozygotic Twinning Arising from a single fertilized ovum, monozygotic twins are considered TRUE or IDENTICAL twins. A single ovum is fertilized by a single sperm, and the

twins are always of the same gender. This type of twinning occurs about 2-4 times per 1,000 pregnancies. It is associated with increased complications. A variety of placental and membrane

combinations can occur in monozygotic twinning. The specific configuration is determined by when the division occurs, and results in a varied number

of placentas, chorionic membranes, and amniotic membranes. It is imperative to establish sonographically if there are separate

amniotic cavities. Sonographic considerations Careful evaluation of placental number and presence and appearance of membranes is essential. First trimester Sonography is more accurate for determining chorionicity and amnioicity

Monozygotic twins: One turns into two Dizygotic twins: Mom has two kids: but at the same time. Twinning Chart Dizygotic Twinning Dizygotic twins arise from separate ova fertilized

by separate sperm cells, and produce fraternal twins. The Twins may be the same or different genders. This type of twinning occurs about 1 in 83 conceptions. Two zygotes will always have two amnions, two

chorions and two separate placentas (that may Appear fused). As the sacs grow in size, the chorion levae and decidua capsularis thin, and likewise the Intertwine membrane. Some factors associated with Dizygotic twinning include: Recent cessation of long term oral

contraceptives Maternal family history of multiple gestations Maternal age 35-40 years old Sonographic findings of Dizygotic twins Can identify dichorionic features most easily in early pregnancy Presence of a thick membrane

Possible identification of two separate placental sites Dizygotic Twinning Chart Clinical findings in twin Pregnancy Typical signs of pregnancy Increased maternal serum AFP Earlier and more severe pressure problems in the pelvis such as

hemorrhoids, constipation Backaches, difficulty breathing Increased fetal activity Increased uterine size Shortness of breath Dichorionic, Diamniotic, Double Placenta May be fusedSonographically identical to Dizygotic results when

division occurs before the morula. Staged (day 5) after conception. Dichorionic-Diamniotic Twins Monchorionic, Diamniotic, Single Placenta MOST COMMON: Results when division occurs after differentiation of

the chorion but before differentiation of the amnion (5-10 days after conception). Monchorionic, Diamniotic, Single Placenta Monochorionic, Monoamniotic, Single placenta

LEAST COMMON: Results when division occurs after differentiation of the chorion and amnion days 10-13 post conception. Monochorionic, Monoamniotic, Single placenta IF THE DIVISION OF THE

CONCEPTUS OCCURS AFTER THE SECOND WEEK, THEN CONJOINED TWINS RESULTS. CLINICAL COMPLICAITONS ASSOCIATED WITH TWIN PREGNANCY The stress of multiple pregnancy can affect the maternal respiratory,

gastrointestinal, Renal and musculoskeletal systems. Maternal complications. Women with multiple gestations are at risk for a number of complications, including: Anemia Urinary tract infection Preeclampsia/eclampsia

Prepartum hemorrhage Fetal complications Fetuses are closely monitored throughout the pregnancy. Complications that may occur include: Premature delivery Difficulty delivery due to abnormal presentation

Prolapsed, entanglement or compression of an umbilical cord Hypoxia of one second twin due to premature separation of the placenta Growth restriction due to placental insufficiency. COMPLICATIONS OF TWIN GESTATIONS Vanishing twin: The resorption of a nonviable fetus in

a twin gestation that was previously demonstrated Sonographically. The Vanishing twin sac may mimic an implantation bleed in the endometrial Cavity, or a submembranous bleed. Vanishing Twin Cont. Sonographic findings Failure to demonstrate multiple sacs

on subsequent sonograms Failure of sac growth in a twin Irregular marginated sac Vanishing Twin Twin-Twin Transfusion Syndrome TTTS This serious condition occurs in monozygotic

twins with a shared, Monochorionic placenta And is referred to as Cross-transfusion or third circulation. It results from an anomalous development of the vascular supply of each twin to the shared placenta (with artery-to-vein anastomosis). In its most serious form, significant artery to vein Anastomosis shunt blood away from the donor twin to the recipient twin.

TTTS Sonographic findings DONOR TWIN Small for dates Oligohydramnios STUCK twin with empty bladder and restricted movement TTTS RECIPIENT TWIN

Hydropic Ascites Enlarged liver, heart and kidneys Polyhydramnios Twin-Twin Transfusion Syndrome Twin-Twin Transfusion Syndrome TWIN EMBOLIZATION SYNDROME

The passage of thromboplastic material or blood clots from a dead Monchorionic twin to the remaining live twin through shared intraplacental vasculature can result in neurological, Gastrointestinal or genitourinary defects. Sonographic findings Intrauterine death of co-twin Hydrops Polyhydramnios

Intraparenchymal hemorrhage Ventriculomegaly, microcephaly Enlarged, echogenic kidneys Conjoined Twins The incomplete division of a fertilized ovum after 13 days post-conception results in conjoined Twins. They are describe by the site of

union THORACOPAGUS (chest) most common PYGOPAGUS (sacrum)

CRANIOPAGUS (head) OMPHALOPAGUS (abdominal wall) ISCHIOPAGUS (Pelvis) Conjoined Twins-THORACOPAGUS (chest) PYGOPAGUS (sacrum) CRANIOPAGUS (head)

OMPHALOPAGUS (abdominal wall) ISCHIOPAGUS (Pelvis) Conjoined Twins cont. Sonographic findings Single thorax (Thoracopagus) Grossly abnormal fused abdomen

(Omphalopagus) Fused head (Craniopagus) Acardiac Twin (Parabiotic Twin) A bizarre form of monozygotic twinning in which a severely malformed Acardiac (and often anencephalic) twin is perfused by the normal twin. Perfusion is accomplished through two anastomosis, one vein to vein and one artery to artery.

The non-viable, anomalous twin usually does not have a heart (Acardiac). Due to the increased cardiac burden on the PUMP twin, it is at risk for high-output congestive heart failure and Hydrops. Acardiac Twin (Parabiotic Twin) cont. Pathologically, the following

characteristics are seen: Extremely limited upper body development Absence of head or, it present may be small and Holoprosencephaly

Absent or hypoplastic thorax, cervical spine and arms Absent heart, lungs and abdominal viscera Dorsal, multi-loculated cystic Acardiac Twin (Parabiotic Twin) cont. Sonographic findings: Polyhydramnios

Monozygotic or Monchorionic/Monoamniotic Acardiac Twin Homework Submit images depicting the following: Monozygotic twins Dichorionic Diamniotic twins

Hydropic twin Discordant dichorionic-diamniotic sacs Dichorionic Diamniotic twins Monochorionic Diamniotic twins Monochorionic, Monoamniotic twins Stuck twins in TTTS Omphalopagus Acardiac Parabiotic twin Callen Homework

Chorionicity equals the number of gestational sacs. Explain. Amnionicity equals the number of yolk sacs. Explain. When and why is the thickness of the intertwine membrane important? What is a vanishing twin?

How does a conjoined twin come into being? What types of conjoined twins are there? Part III - recap Monozygotic twins Arise from a single ovum and produce "true" or identical twins. When a single

ovum is fertilized by a single sperm. Twins are always of the same gender. Occurs about 2 - 4 times per 1,000 pregnancies. Associated with increased complications Monozygotic twins PLACENTAL VARIATIONS A variety of placental and membrane

combinations can occur in monozygotic twinning. The specific configuration is determined by the timing of the division of the embryonic disk and results in a varied number

of placentas, chorionic membranes and amniotic membranes. Monozygotic twins Dichorionic, diamniotic, double placenta may be fused

IDENTICAL TO DIZYGOTIC results when division occurs before the morula stage (Day 5) and implantation Monochorionic, diamniotic, single placenta: MOST COMMON Results when division occurs after differentiation of the amnion

(5 - 10 days after conception) Monochorionic, monoamniotic, single placenta: LEAST COMMON Results when division occurs after differentiation of the trophoblast (days 10 - 14) IF DIVISION OF THE CONCEPTUS OCCURS AFTER THE SECOND WEEK, CONJOINED TWINS RESULT

Dizygotic twins Always have two amnions, two chorions and two separate placentas. The placentas may be fused. As the sacs grow in size, the chorion levae and decidua capsularis become thin and the space between the sacs disappears.

Dizygotic twins arise from separate ova fertilized by separate sperm cells and produce "false" or fraternal twins. May be the same or different gender. Occurs about 1 in 83 conceptions. Some factors associated

with dizygotic twinning include: Recent cessation of long term contraceptives Maternal family history of twinning Maternal age 35 - 40 year old oral

SONOGRAPHIC FINDINGS: Can differentiate monozygotic from dizygotic in early pregnancy Presence of a "thick" membrane Identification of two separate placental sites CLINICAL SIGNS Typical signs of pregnancy

Earlier and more severe pressure problems in the pelvis such as hemorrhoids, constipation, backaches, difficulty breathing increased fetal activity Increased uterine size Shortness of breath CLINICAL COMPLICATIONS ASSOCIATED WITH TWIN

PREGNANCY: The stress of multiple pregnancy can affect the maternal respiratory, gastrointestinal, renal and musculoskeletal systems. Maternal complications include: Anemia Urinary tract infection Preeclampsia/eclampsia Prepartum hemorrhage

Fetal complications may include: Premature delivery Difficult delivery due to abnormal position Prolapse, entanglement or compression of an umbilical cord Hypoxia of the second twin due to premature separation of the placenta Growth retardation due to placental

insufficiency Vanishing twin The resorption of a nonviable gestation that was previously demonstrated sonographically. May represent resorption of blood in the endometrial cavity related to implantation bleeding. SONOGRAPHIC FINDINGS: Failure to demonstrate multiple gestations

on subsequent sonograms Failure of sac growth in a twin Irregularly marginated sac Vanishing Twin Twin-twin transfusion syndrome This serious condition occurs in monozygotic twins with a fused placenta and is also referred to as

"cross-transfusion" or "third circulation". It results from an anomalous development of the vascular supply to each twin (artery to vein anastomosis). In its most serious form, significant artery to vein anastomoses shunt blood away from the donor twin to the recipient twin Twin-twin transfusion

syndrome SONOGRAPHIC FINDINGS: Donor twin Small for dates Oligohydramnios Stuck twin with empty bladder and restricted movement TTTS (stuck Twin)

Recipient Twin Recipient twin Hydropic Ascites Enlarged liver, heart and kidneys Polyhydramnios Twin embolization syndrome The

passage of thromboplastic material or blood clots from a dead monochorionic twin to the remaining live twin through shared intraplacental vasculature. Neurological, gastrointestinal

or genitourinary deficits may result from infarction. SONOGRAPHIC FINDINGS: Intrauterine death of co-twin Hydrops Polyhydramnios Ventriculomegaly, porencephaly,

microcephaly Enlarged, echogenic kidneys Stuck twin (fetus papyraceous) The presence of a small, growth retarded twin an oligohydramniotic sac. May be the result of twin to twin transfusion syndrome. The restricted fetus has limited motion of the extremities.

SONOGRAPHIC FINDINGS: Twin pregnancy One twin in sac with normal fluid One twin in sac with oligohydramnios Restricted movement of "stuck" twin Conjoined twins (Siamese) The incomplete division of a fertilized ovum between the 8th and 14th day results in conjoined twins. They are

described by the site of union: Thoracopagus (chest) MOST COMMON Pygopagus (sacrum) Craniopagus (head) Omphalopagus (abdominal wall) Ischiopagus (pelvis) SONOGRAPHIC FINDINGS: Movement in unison, no independent

major movements Single thorax (thoracopagus) Grossly abnormal Fused abdomen (omphalopagus) Fused head (craniopagus) Acardiac twin (parabiotic twins) A bizarre malformation of monozygotic twinning in which a severely malformed twin is maintained by the normal twin. Perfusion is

accomplished through two anastomoses, one vein to vein and one artery to artery. The non-viable usually does not have a heart (acardiacus) and would have been a simple first trimester twin death. Due to the increased cardiac burden on the pump twin, it is at risk for high-output congestive heart failure. PATHOLOGY: Extremely limited upper body development

Absence of head or, if present, small with holoprosencephaly Absent or hypoplastic thorax, cervical spine and arms Absent heart, lungs and abdominal viscera Dorsal, multiloculated cystic hygroma To Summarize What is monozygotic twinning? Monozygotic twinning arises from a

single fertilized ovum that divides into two separate but identical embryos. What are the possibilities placental/membrane configurations for monozygotic twins? Monozygotic twins, depending on

when the separation takes place after fertilization, can result in: two placentas, two chorions, and two amnions a single placenta, one chorion, and two amnions a single placenta, one chorion, and one amnion

What is dizygotic twinning? Dizygotic twinning occurs when two separate ovum are fertilized, and two embryos with separate blastocysts result. What are the possible placental/membrane

configurations for dizygotic twins? Dizygotic twins, then can only have the following placental and membrane configuration: Two placentas, two chorions, and two amnions.

Twin-twin transfusion syndrome (TTTS) is a serious complication of monozygotic twinning. What is the etiology of this complication? Twin-twin transfusion syndrome occurs when there is a vascular anastomosis in the shared placenta between the two fetuses. Blood in shunted away from one twin,

increasing perfusion to the other twin. What are the sonographic findings for the donor twin in TTTS? The donor twin ( from whom blood is shunted) sonographically is small for dates

has Oligohydramnios has an empty bladder and appears STUCK with restricted movement What are the sonographic findings for the recipient twin in TTTS? The recipient twin sonographically

is Hydropic with ascites has organ-megaly (enlarged liver, heart and kidneys) has Polyhydramnios Twin embolization syndrome occurs when one of the twins demises in utero and thromboplastic material passes to the remaining twin via shared intraplacental vasculature. What

are the complications for the surviving twin? The surviving win in twin embolization syndrome is at risk for hydrops Polyhydramnios Intraparenchymal hemorrhage ventriculomegaly, porencephaly,

microcephaly Enlarged echogenic kidneys Define Thoracopagus Thoracopagus is twins who are conjoined at the thorax (chest) Define Omphalopagus

Omphalopagus is twins who are conjoined at the abdominal wall Define Craniopagus Craniopagus is twins who are conjoined at the cranium (head) How do the conjoined

anomalies occur? Conjoined twins occur when the fertilized ovum fails to completely separate, after day 13 post conception. The end. Oh waityour 4 oclock patient just showed up.

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