Multifetal Gestation

00:01 Now we'll discuss multifetal gestation.

00:06 So multifetal gestation pregnancies have increased due to artificial productive technologies such as invitrofertilization.

00:14 The higher the order of multiples meaning twins versus triplets, versus quadruplets, the great the risk of complication.

00:25 So chorionicity.

00:26 There are four different types of chorionicities that we see in pregnancy.

00:29 And it's determine by the day that the division takes place.

00:33 So if the division happens 0 to 4 days after conception, then we have a dichorionic and diamniotic pregnancy.

00:42 So two chorions to amnions.

00:44 If the division takes place 4 to 8 days afterwards, then we have a monochorionic, diamniotic pregnancy.

00:52 So one chorion, two amnion.

00:54 If it happens 8 to 14 days after conception, then we have monochorionic, monoamniotic pregnancy.

01:03 So one chorion, one amnion.

01:05 And then if it happens after 14 days, this is what we see conjoint twins.

01:10 So chorionicity is most easiest to see at the 1st trimester ultrasound.

01:16 And what you're looking for is something called the Lambda sign where you can see the actual division between the two fetuses.

01:23 It's a little difficult to see in the picture here.

01:25 But you can see that thin line that's dividing the two babies there.

01:29 So complications associated with multifetal gestation.

01:33 Again the higher the number of multiples, the great the risk of complications.

01:38 The first is Preterm labor.

01:41 So even as one order multiple such as a twin gestation, there is an increased risk of preterm labor.

01:50 Twin-twin transfusion is common in monochorionic diamniotic.

01:55 And basically what happens is that the recipient twin which is the larger twin, gets more blood flow from the smaller twin which is the donor twin.

02:03 The recipient twin often has polyhydramnios and can actually suffer from high cardiac output.

02:10 And with that they can actually have cardiac failure.

02:13 The donor twin experience is oligohydramnios and is growth restricted.

02:19 Now treatment has evolved over the years.

02:21 Previously delivery was the only option.

02:24 And so often times one twin had to be sacrificed for the other twin.

02:28 But now through fetal surgery we can actually ablate those blood vessels going between the fetuses.

02:33 One of the other complications is fetal growth restriction.

02:37 Because there are multiple fetuses in one uterus, then that can restrict the growth.

02:42 And so each baby is not able to grow to their full potential.

02:46 And then we do find hypertensive disorders also increase with multifetal gestation.

02:52 Hypertensive disorders being gestational hypertension and preeclampsia with either mild or severe features.

03:00 Additional complications that are associated with multifetal gestation are anemia, gestational diabetes, malpresentation, increased need for Cesarean delivery, and postpartum hemorrhage and thromboemolism.

03:13 Because of all these risks, some complications that we discussed, it is recommended that we increase antepartum surveillance during pregnancy.

03:23 So women should undergo ultrasound for fetal growth every 2 to 3 weeks.

03:27 So let's do a case.

03:30 A 26 year old Gravida 1 Para 0 female with a diamniotic-dichorionic twin gestation presents for routine prenatal visit at 35 weeks and 3 days.

03:41 She is concerned about the complications that may be associated with her delivery.

03:46 All of the above are complications of delivery of multifetal gestation except: A. Postpartum hemorrhage B. Preterm birth C. The need for C-section or D. Shoulder dystocia.

04:00 What do you think? The answer is D.

04:04 Shoulder dystocia.

04:05 Multifetal gestation is not associated with shoulder dystocia.

04:09 Definitely there is an increase risk of postpartum hemorrhage because the uterus is distended from the number of fetuses that are in there.

04:15 And that increases the risk for hemorrhage.

04:17 Preterm birth is a risk as we discussed because of the risk of preterm labor.

04:22 And depending on the presentation of the fetuses, very rarely can a vaginal delivery be performed.

04:28 So the need for C-section is increased.

04:30 However, shoulder dystocia that is not an increased risk associated with multifetal gestation.