Multiple pregnancy crossword puzzle. Collection of crosswords on the topic "obstetrics and gynecology". Causes of multiple pregnancies
Related tests:
"Postpartum period"
Instruction: select one correct answer
1. The postpartum period continues:
A) 4 weeks
B) 6-8 weeks
B) 10 weeks
D) 15 weeks
2. The mammary glands produce colostrum during:
A) Every hour
B) Every 2 hours
C) Every 3-4 hours
D) Only in the morning and in the evening
4. The postpartum uterus weighs:
5. For the treatment of lactostasis apply:
A) Antispasmodic drugs
B) Pain medications
C) Narcotic drugs
D) Adrenergic drugs
Instructions: complete the phrase
1. The postpartum period is divided into and
2.M / s with lactostasis should
3. Discharge in the normal course of the postpartum period is carried out for a day
4. Toilet of the external genital organs with bed rest is carried out
5. The fundus of the uterus on the 10th day after childbirth is
Answers:
Glossary on the topic "Female genital organs" (page 2):
1.the area of the abdominal wall rich in subcutaneous fat. Located between the groin folds
2. 2 longitudinal folds of skin covered with hair. Cover all external genitalia, protect them.
3. folds of skin are located under the labia majora.
4. the organ of sexual desire. Located in the upper junction of the labia minora.
5.connective tissue film covering the vaginal opening
6. Paired glands, located in the pelvic cavity, measuring approximately 2x2x3cm. Produce hormones and female reproductive cells
7.space between anus and posterior commissure
8.Muscular organ in the shape of a pear. This is a container for the unborn child.
9. narrow tubes with a pronounced muscle layer, constantly contracting.
10. a solid-tissue canal with a length of 7-8 to 9-10 cm. It is attached to the junction of the cervix into its body.
On a crossword puzzle on the topic "Female genital organs" (p. 3):
1. Ampular
2. Crotch
3. Functional
5. Interstitial
7. Fallopieva
9. Ovaries
10. Clitoris
For tests on the topic "Female genital organs" (page 4):
Complete the phrase:
1. Crotch
3. Alkaline
4. Basal and functional layers
5. Moisturizes the vaginal opening and dilutes the semen
Glossary on "Menstrual cycle" (page 5):
1.periodic discharge of blood, tissue fluid and mucus from the endometrium.
2.first menstruation
3.endocrine gland in the brain that produces hormones
4. a hormone that stimulates the follicles in the ovaries to mature and produce estrogen
5.a sac of secretory fluid surrounding an immature egg in the ovary
6.hormone responsible for the development and maintenance of female genital organs and secondary reproductive functions
7.recovery of the functional layer
8.the release of a mature egg from the ovary into the fallopian tubes
9.the hormone, under the influence of which the corpus luteum is formed and secretes progesterone
10.small temporary endocrine glands that form in the ovaries at the site of a ruptured follicle
11.the corpus luteum hormone, under the influence of which the placenta is formed during pregnancy
12.the mucous membrane of the uterus
13. hormone, under the influence of which the follicle breaks and ovulation occurs
On a crossword puzzle on the "Menstrual cycle" (page 6):
1. Desquamation
2. Ovulation
3. Ovarian
4. Estrogen
5. Endometrium
6. Follicle
7. Prolactin
8. Menarche
9. Pituitary gland
10. Progesterone
For tests on the topic "Menstrual cycle" (page 7):
Choose one correct answer:
Complete the phrase:
1. Fertilization did not occur
2. Darker and non-curdling
3. Moves away
4. Development and rupture of the follicle; development of the corpus luteum
Pregnancy Glossary (page 8):
1.the process of fusion of male and female germ cells to form a zygote
2.the ratio of the fetal back to the left or to right side uterus
3.the outer shell of the zygote (nourishes, secretes enzymes)
4.fertilized egg
5.the own shell of the embryo (develops from trophoblast)
6.the aquatic membrane of the embryo, its own, contains amniotic fluid
7.maternal, modified by the action of progesterone, the functional layer of the uterus
8. complete immersion of the zygote into the functional layer of the uterus
9.in-growth of the vessels of the embryo into the vessels of the mother
10.placental formation
11. "child's seat", an organ that communicates between the mother's body and the fetus
12.lining of organs and systems
13.the ratio of the limbs and head of the fetus to its trunk
14.the ratio of the lowest located large part of the fetus to the birth canal
15. Substances that lyse ("eat") living tissues
On a crossword puzzle on the topic "Pregnancy" (page 9):
1. Vascularization
2. Trophoblast
4. Implantation
5. Placenta
8. Enzymes
9. Fertilization
10. Decidual
On tests on the topic "Pregnancy" (page 10):
Choose one correct answer:
Complete the phrase:
1. Taking anamnesis
2. Gynecological chair
3. The couch
4. Carrying, extragenital
5. Embryo, fetus
Glossary on Physiological Childbirth (page 11):
1.rhythmic contractions of the muscles of the uterus
2.from the periphery, s bottom edge, blood is released freely
3.placenta with membranes and umbilical cord
4.lower segment of the uterus, cervical canal and vagina
5.from the central part with the formation of blood clots
6. contraction of the muscles of the diaphragm, abdominal muscles, pelvic floor and skeletal muscles. Arise reflexively when nerve endings are irritated
On a crossword puzzle on the topic "Physiological childbirth" (p. 12):
1. Timely
2. Harbingers
3. Disclosures
4. Contractions
5. Regional
6. Oxytocin
8. Central
9. Exile
10. Attempts
On tests on the topic "Physiological childbirth" (p. 13):
Choose one correct answer:
Complete the phrase:
1. Contractions and attempts
2. Birth canal
3. Exile
4. Timely; early
5. Placenta, amniotic fluid
Glossary on the postpartum period (page 14):
1.secret from scraps of decidua, blood clots, fragments of blood vessels, mucus, blood corpuscles in the stage of decay
2.primary milk, consists of protein, fat, condensed epithelium of glands, immunoglobulins, lymphocytes
3.Lack of menstruation
4.reverse development of organs
5.place former attachment placenta
6.the inner surface of the uterus after separation of the placenta from its walls
7.excretion of milk
8.inflammation of the mammary glands
9.Stagnation of milk in the ducts of the mammary glands
10.inflammation of the uterine lining
11.pathological spontaneous outflow of milk from the mammary glands without connection with the process of feeding the child
On the postpartum crossword puzzle (page 15):
1. Lactorrhea
2. Prolactin
3. Wound
6. Involution
7. Colostrum
8. Postpartum woman
9. Lactostasis
10. Placental
On tests on the topic "Postpartum period" (p. 16)
Choose one correct answer:
Complete the phrase:
1. Early and late
2. Make a massage and "stretch" the chest
3.5-6 days
4.3 times a day
5. At the upper edge of the pubic articulation
State budgetary educational institution
secondary vocational education
"Medical school number 4
Moscow City Health Department "
by PM. 02 Participation in medical, diagnostic and rehabilitation processes
the topic "Nursing care
in obstetrics and in pathology of the reproductive system in men and women "
Prepared by:
teacher PM.02
E. A. Vinokurova
Crossword 1
The science of physiological and pathological processes associated with pregnancy and childbirth
Great importance has ………… Michaelis
The internal genital organ that performs the reproductive function
One of the levels of regulation of the menstrual cycle
Muscular layer of the uterus
The upper thickened edge of the wing of the ilium
The mucous membrane of the uterus
Paired endocrine gland
Matures in the ovary ... ... ... ..
The first phase of the uterine cycle
The release of a mature egg
Corpus luteum hormone
Pubic articulation
Distinguish between big and small ……….
Crossword 2
Vertically:
2. Fuzzy sheath
9. Examination of the fetal bladder
12. Water shell
Horizontally:
1. Fusion of sperm and egg
11. The ratio of the back of the fetus to the left or right side of the uterus
13. Umbilical cord
Crossword 3
1. Fusion of sperm and egg
2. Fuzzy sheath
3. Children's place
4. The ratio of the axis of the fetus to the axis of the uterus
5. The ratio of the large part of the fetus to the entrance to the small pelvis
6. Instrument for measuring the pelvis
7. Used to listen to the fetal heartbeat
8. Puncture of the amniotic cavity
9. Examination of the fetal bladder
10. Attachment of the ovum to the wall of the uterus
11. The ratio of the back of the fetus to the walls of the uterus
12. Water shell
13. Umbilical cord
14. Presumptive sign of pregnancy
15. Cyanosis of the vaginal mucosa
Crossword 4
Vertically:
1. The ratio of the longitudinal axis of the fetus to the longitudinal axis of the uterus
2. Water shell
4. Used to listen to the fetal heartbeat
5. The process of introducing the ovum into the uterus
7. The ratio of the back of the fetus to the walls of the uterus
Horizontally:
3. Presumptive sign of pregnancy
4. Umbilical cord
5. Fuzzy sheath
6. The placenta, umbilical cord, membranes are …… ..
7. Physiological process of expulsion of the fetus and afterbirth from the uterus
8. Inspection amniotic fluid
9. Cyanosis of the vaginal mucosa
Crossword 5
1. Ancestral banishing forces
2. Contraction of muscle fibers
3. Changing the shape of the head when passing through birth canal
mothers
4. One of the signs of placenta separation
5. The set of movements performed by the fetus during the passage
through the birth canal
6. Physiological process of expulsion from the uterus of the fetus and placenta
7. First stage of labor
8. Children's place
9. Reverse development of the uterus
10. Postpartum discharge
Vertically:
The field of clinical medicine that studies the processes associated with conception, pregnancy, childbirth and the postpartum period
Crossword 6
Vertically:
1. Clinical sign of eclampsia
2. One of the symptoms of nephropathy
3. The presence of protein in the urine
4. Premature ......... normally located placenta
5. General edema
6. Swelling of pregnant women
7. The main symptom of placental abruption
Horizontally:
2. The presence of red blood cells in the urine
3. The condition of the newborn is determined by the scale …… ..
4. Spontaneous miscarriage
5. In case of premature detachment, the uterus is formed ……….
6. Nephropathy is characterized by ………… .. symptoms
7. Clinical sign of placenta previa
8. Severe form of toxicosis
Crossword 7
Vertically:
1. The ratio of the large part of the fetus to the entrance to the small pelvis
2. An instrument for listening to the fetal heartbeat
3. The process of fusion of male and female germ cells
4. Water shell
5. Cord-like formation between mother and fetus
Horizontally:
1. Baby in the womb
2. The organ carrying the fetus
3. Instrument for measuring the pelvis
4. Of great importance is …… ..Michaelis
5. The ratio of the longitudinal axis of the fetus to the longitudinal axis of the uterus
6. Inspection of amniotic fluid
7. Taking amniotic fluid for research
8. The ratio of the back of the fetus to the walls of the uterus
Crossword 8
1. External genital organ
2. Female reproductive gland
3. Hormone of the corpus luteum
4. The fourth phase of the uterine cycle
5. The organ carrying the fetus
6. Collecting data on past illnesses
7. The mucous membrane of the uterus
8. Fuzzy sheath
9. Release of a mature egg
10. Desquamation is actually ………………
11. Founder of psychoprophylactic training
Horizontally:
Physiological process in a woman's body from the moment of conception to childbirth
Crossword 9
Horizontally :
1. The first stage of labor
2. Ancestral exorcists ……… ..
3. Rhythmic contractions of the muscles of the uterus
4. This drug is used to prevent gonoblenorrhea
5. The set of movements that the fetus makes during
passing through the birth canal of the mother
6. Woman after childbirth
7. The first moment of the biomechanism of childbirth
8. Ancestral banishing forces
Vertically:
1. The physiological process of expulsion from the uterus of the fetus of the placenta
2.Contraction of muscle fibers
3. Postpartum discharge
4. The umbilical cord, placenta and membranes are ………….
5. Hemorrhage under the periosteum
6. Second stage of labor
7. Reverse development of the uterus
Crossword 10
1. The presence of red blood cells in the urine
2. This toxicosis is characterized by a triad of symptoms
3. The presence of protein in the urine
4. Increase in blood pressure
5. Form of early toxicosis
6. General edema
7. Bubble ………….
8. The main symptom of eclampsia
9. Spontaneous ……… ..
10. Swelling or ……… ..
Sample answers
for crossword 1
1. Obstetrics
2. Rhombus
3. Uterus
4. Hypothalamus
5. Myometrium
6. Comb
7. Endometrium
8. Ovary
9. Follicle
10. Desquamation
11. Ovulation
12 progesterone
13. Symphysis
14. Pelvis
Sample answers
for crossword 2
Vertically:
2. Chorion
4. Position
5. Presentation
7. Stethoscope
9. Amnioscopy
10. Implantation
12. Amnion
15. Cyanosis
Horizontally:
1. Fertilization
3. Placenta
6. Tazometer
8. Amniocentesis
11. Position
13. Umbilical cord
14. Nausea
Sample answers
for crossword 3
1. Fertilization
2. Chorion
3. Placenta
4. Position
5. Presentation
6. Tazometer
7. Stethoscope
8. Amniocentesis
9. Amnioscopy
19. Implantation
11. Position
12. Amnion
13. Umbilical cord
14. Nausea
15. Cyanosis
Sample answers
for crossword 4
Vertically:
1. Position
2. Amnion
3. Tazometer
4. Stethoscope
5. Implantation
6. Anamnesis
7. Position
Horizontally:
1. Presentation
3. Nausea
4. Umbilical cord
5. Chorion
6. Last
7. Childbirth
8. Amnioscopy
9. Cyanosis
Sample answers
for crossword 5
1. Contractions
2. Contract
3. Configuration
4. Schroeder
5. Biomechanism
6. Childbirth
7. Disclosures
8. Placenta
9. Involution
10. Lochia
Vertically: Obstetrics
Sample answers
for crossword 6
Vertically:
1. Convulsions
2. Hypertension
3. Proteinuria
4. Detachment
5. Anasarka
6. Dropsy
7. Pain
Horizontally:
2. Hematuria
3. Apgar
4. Abortion
5. Couveler
6 the triad
7. Bleeding
8. Eclampsia
Sample answers
for crossword 7
Vertically:
1. Presentation
2. Stethoscope
3. Fertilization
4. Amnion
5. Umbilical cord
Horizontally:
1. Fruit
2. Uterus
3. Tazometer
4. Rhombus
5. Position
6. Amnioscopy
7. Amniocentesis
8. Position
Sample answers
for crossword 8
1. Pubis
2. Ovum
3. Progesterone
4. Secretion
5. Uterus
6. Anamnesis
7. Endometrium
8. Chorion
9. Ovulation
10. Menstruation
11. Platonov
Horizontally: Pregnancy
Sample answers
for crossword 9
Horizontally:
1. Disclosures
2. Forces
3. Contractions
4. Albucid
5. Biomechanism
6. Postpartum woman
7. Flexion
8. Attempts
Vertically:
1. Childbirth
2. Contract
3. Lochia
4. The last
5. Cephalohematoma
6. Exile
7. Involution
Sample answers
for crossword 10
1. Hematuria
2. Nephropathy
3. Proteinuria
4. Hypertension
5. Vomiting
6. Anasarka
7. Skid
8. Convulsions
9. Abortion
10. Dropsy
A multiple pregnancy is a pregnancy with two or more fetuses. In the presence of pregnancy, two fetuses speak of twins, three - triplets, etc. Each of the fetuses in a multiple pregnancy is called a twin. Births of twins occur once in 87 genera, triplets - once in 872 (6400) twins, quadruples - once in 873 (51200) triplets, etc. (according to Gallin's formula).
Causes of multiple pregnancies.
It has been proven that two or more follicles can mature in one ovary. In addition, ovulation can occur simultaneously in both ovaries. In favor of the listed possibilities, the facts of detection during surgery for tubal pregnancy in the same ovary of two flowering yellow bodies or in each of the ovaries one flowering yellow body speak. In addition, there can be two or more eggs in one follicle. The cause of multiple pregnancies can be fertilization with sperm from different partners, fertilization against the background of an existing pregnancy, and induced pregnancy. Twins formed from the fertilization of two eggs are called double eggs, identical twins are caused by atypical cleavage of the egg. Where the separation of the egg occurs completely, two identical twins are formed. Such twins are called identical twins. Identical twins are much less common than fraternal twins (1:10). If, with the complete separation of the egg, both primordia are located in the uterus at a sufficient distance from each other, then the embryos developing from them form each for themselves a separate amnion and remain separate - biamniotic twins. If both amnion sacs are enclosed in one common chorion for both twins, and the septum between them consists of two membranes (two amnions), then such twins are called monochorionic. They have a common placenta. If both primordia lie side by side, this leads to the formation of one amniotic cavity common to both (monoamniotic twins). Identical twins are always same sex - either both boys or both girls, they look alike, their blood type is always the same.
COURSE AND MANAGEMENT OF MULTIPLE PREGNANCY
With multiple pregnancies, due to the heavy load on the body, women note early fatigue, shortness of breath, urinary disorders, and constipation. Frequent and early complications of pregnancy are premature birth (50% of cases), toxicosis and gestosis, varicose veins, polyhydramnios, low weight and immaturity of fetuses, death of one of the fetuses. In some cases, polyhydramnios in one cavity may accompany oligohydramnios in another.
Recognizing multiple pregnancies in the first months is rather difficult and becomes easier in the second half of pregnancy. Pay attention to the discrepancy between the size of the uterus and the gestational age. On palpation, many small parts are determined, two heads, two backs. With auscultation - two or more points for determining the fetal heartbeat and a zone of silence between them. The height of the standing of the fundus of the uterus is greater than with a singleton pregnancy at the same time. When measuring the length of the fetus with a pelvimeter - a large length of the fetus with a small head. The most reliable diagnostic method is ultrasound.
In the overwhelming majority of twins (88.0%), both fetuses are in a longitudinal position and occupy one right, the other - the left half of the uterus. Most often, both fetuses are presented with a head (45.0%). Other options for the location of the fetus in the uterus are possible. One fetus can be in the cephalic presentation, the second in the pelvic presentation (43.0%). Both fruits are in breech presentation(6.0%). One fruit - in the longitudinal position, the other - in the transverse position (5.5%), or both fruits - in the transverse position (0.5%). Medical supervision of pregnant women with multiple pregnancies is carried out taking into account possible complications, highlighting them in the risk group for the development of perinatal pathology.
PROGRESS AND MANAGEMENT OF CHILDBIRTH
The prognosis of pregnancy and childbirth with multiple pregnancies is less favorable than with one fetus. At the slightest deviation from normal flow pregnancy, compulsory hospitalization is indicated. Re-admission to the antenatal department is carried out 2-3 weeks before the due date, the purpose of which is to examine the pregnant woman and determine the time and method of delivery.
Multiple pregnancies are accompanied by frequent complications of childbirth. Most childbirth occurs prematurely, the weight of newborns is less than 2500 g, possibly the pelvic and transverse positions of the second fetus. Frequent untimely discharge of amniotic fluid can be accompanied by the loss of small parts of the fetus and the umbilical cord, which is facilitated by the pelvic and transverse positions and the small size of the fetus.
During the period of disclosure, functional insufficiency of the overstretched, thinned muscles of the uterus manifests itself, weakness of labor forces develops, premature rupture of amniotic fluid occurs, therefore the period of disclosure is delayed.
The period of expulsion can also be delayed due to the development of abnormalities in labor. Prolonged labor is dangerous for the mother (bleeding, infection) and the fetus (hypoxia).
Placental abruption before the birth of the second fetus leads to fetal death. There may be a lateral position of the second fetus, collision of twins (adhesion of two large parts of the body), bleeding in the third stage of labor, in the early postpartum period, delayed involution of the uterus and infectious diseases.
Managing childbirth with multiple pregnancies requires much attention, a clear orientation in the obstetric situation and high qualifications, allowing you to perform any operation. During the period of disclosure, one must carefully monitor the state of the woman in labor and the fetuses. If there is polyhydramnios, the opening of the fetal bladder is shown when the cervix is opened by 4 cm and the slow removal of water (within 1-2 hours).
In order to reduce complications of childbirth with multiple fetuses and perinatal mortality of the second fetus, it is currently recommended to open the fetal bladder of the second fetus immediately after the birth of the first fetus, and immediately start intravenous drip of 5 units. oxytocin in a 5% glucose solution in order to accelerate the II stage of labor to the separation of the placenta. With bleeding, the development of hypoxia of the second fetus or its transverse position for the purpose of rapid delivery, a classic external-internal obstetric rotation of the fetus on the pedicle is shown, followed by its extraction by the pelvic end
Particularly dangerous are the III stage of labor and the early postpartum period by the development of bleeding. After the birth of the placenta, a thorough examination is made to determine the integrity of the lobules and membranes and the type of twins (single or double).
In the postpartum period, careful monitoring of the postpartum woman, prevention of uterine subinvolution is necessary.
Perinatal mortality in case of multiple pregnancies is 2 times more frequent than in case of childbirth with one fetus. Therefore, in modern obstetrics there is a tendency to expand the indications for abdominal delivery in the interests of the fetus. Indications for caesarean section associated with polyhydramnios, consider triplets, the transverse position of both or one of the fetuses, breech presentation of both fetuses or the first of them, and not associated with multiple pregnancies - fetal hypoxia, abnormalities of labor, prolapse of the umbilical cord, extragenital pathology of the mother, severe gestosis, presentation and placental abruption.
The prevention of complications in multiple pregnancies is the prevention of complications during pregnancy.
Frequency of occurrence.
Twins - 1 in 87 births;
1) spontaneous ovulation - 1%;
Abnormalities in the development of the uterus;
Time of conception after stopping the use of combined oral contraceptives: when conceiving within 1 month after discontinuation of drugs, the likelihood of multiple pregnancy doubles;
A high level of secretion of pituitary gonadotropins (more often in women of the Negroid race).
Classification of twins. By zygosity.
1. Dizygotic (double-faced, non-identical). Formed when two eggs are fertilized by two sperm, as a result of which each embryo receives a different genetic material: separately from the mother and from the father. In double twins, fertilized eggs develop independently of each other. After implantation, each embryo has its own amnion and its own chorion, in the future, each twin has its own placenta, their circulatory systems are separated, i.e. all dizygotic twins are dichorionic. Fraternal twins can be same-sex and opposite-sex with the same and different group blood. Two-thirds of all twins are dizygotic.
2. Monozygous (identical, identical). Their similarity is due to the early division of an egg, fertilized by one sperm, into two cell masses containing identical genetic information. Such twins have the same genotype and therefore are of the same sex, with the same blood group. One third of all twins are monozygous.
By chorionality (placentation): there are types of placentation.
1. Bichorial-biamnial(two placentas) - occurs in 80%.
A. Divided placenta. If the embryos are implanted far from each other, their placentas do not touch.
B. Confused placenta. When implanted at a close distance, the embryos have a common decidua, the edges of their placentas are in contact, the septum between two fetal sacs consists of
four shells: two water and two villous. Each placenta has an independent vascular network. Sometimes anastomoses form between the vessels of the placenta, which can be the cause of uneven blood supply to twins and their unequal development. 2. Monochorial(one placenta) - occurs in 20%:
a) monochorial-monoamnial;
b) monochorial-biamnial.
To assess risk factors and determine the tactics of managing women with multiple pregnancies, it is extremely important to establish the type of multiple pregnancy and its placentation as early as possible.
Embryology
There are two main mechanisms that can cause multiple pregnancies.
1. Fertilization of two or more oocytes (origin of multiple twins).
A. Simultaneous ovulation (during one ovarian cycle) followed by fertilization of two or more eggs that have matured in different follicles of one ovary (ovulatio uniovarialis).
B. Simultaneous ovulation followed by fertilization of two or more eggs that have matured in different follicles in both ovaries (ovulatio biovarialis).
B. Ovulation and fertilization of two or more eggs matured in one follicle (ovulatio unifoilicularis).
D. Overfertilization (superfoecundatio)- fertilization of two or more ovulating eggs at the same time with sperm from different men.
D. There is an assumption that it is possible to fertilize an egg that ovulated against the background of an already existing pregnancy.
2. Early division of one fertilized egg - polyembryony (origin of identical twins).
A. Fertilization of multinucleated oocytes by several spermatozoa.
B. Division into two parts of the copceptus at the stage of crushing; an embryo is formed from each part (atypical cleavage of the egg). The most frequent mechanism of multiple pregnancy is the fertilization of several oocytes in one menstrual cycle (2/3 of cases), which leads to the development of bichorionic-biamnial dizygotic twins. In 1/3 case
In teas, multiple pregnancy is the result of the bifurcation of one fertilized egg at the stage of early division. Depending on the time elapsed from fertilization to the bifurcation of the zygote, one of four types of twins can occur:
1) 0-72 h - bifurcation before the formation of the inner cell mass and any differentiation (up to the morula stage) - bichorial-biamnial monozygous twins (25%); fraternal twins have the same type of placentation, which often misleads the researcher who determines the type of zygosity based on the placenta;
2) 4-8th day - division of the embryo at the early stage of the blastocyst after the formation of the inner cell mass, when its nidation and the formation of chorion have already occurred - monochorionic-biamnial monozygous twins (70%);
3) 9-13th day - division occurs after the formation of the embryonic disc, when the chorion and amnion are already formed - monochorionic-monoamnial monozygous twins (5%);
4) after the 13th day - conjoined (connected) twins. It is extremely rare that monozygous and dizygotic twins can occur
simultaneously during pregnancy with three or more embryos (bichorial-triamnial).
Diagnosis of multiple pregnancies
Due to the significant number of complications, multiple pregnancies are rightfully considered a factor of high risk of maternal and perinatal morbidity and mortality, therefore, the tactics of its management differ from the tactics of singleton pregnancy and requires much more careful monitoring from the earliest gestational periods. Diagnosis of multiple pregnancy, its reliability, establishment of the type of multiple pregnancy and placentation, as well as determination of the term of multiple pregnancy are of great importance for the outcome of both the mother and the fetus.
Clinical and anamnestic signs of multiple pregnancy
1. The height of the uterine fundus is 4 cm or more higher than that characteristic of a given gestational age; an increase in abdominal circumference.
2. Inconsistent and insufficiently reliable signs:
a) if the twins are in a longitudinal position, on the front
a longitudinal depression forms on the surface of the uterus; in the transverse position of both fruits, the groove is horizontal;
b) the uterus takes a saddle shape (its corners protrude, a depression forms in the bottom area).
3. The small size of the presenting part in comparison with the volume of the uterus.
4. Determination of large parts of the fetus in different parts of the abdomen.
5. Determination of three or more large parts of the fetus in the uterus during obstetric examination (for example, two heads and one pelvic end).
6. Two points of a distinct fetal heartbeat in different places of the uterus with a zone of silence between them, and the difference in heart rate is at least 10 beats.
7. High rates of hCG and AFP (more than four times higher than those in singleton pregnancy).
8. Ultrasound can diagnose multiple pregnancies from the first half of gestation.
9. Excessive weight gain.
10. Family history.
11. Stimulation of ovulation with gonadotropins, history of clomiphene.
12. History of in vitro fertilization.
Ultrasound is the gold standard in diagnosis multiple pregnancy in women, its accuracy is 99.3%. Ultrasound diagnosis of multiple pregnancy in early dates is based on visualization of several embryos in the uterine cavity and is possible from 6-7 weeks of gestation. The use of vaginal sensors makes it possible to diagnose multiple pregnancies from the 4th to 5th week of gestation. With the help of ultrasound, the chorionicity and the number of amnions are determined, especially in the first 14 weeks of pregnancy. There are two approaches to prenatal diagnosis of multiple pregnancies in women.
1. Selective - identification of prognostic signs of the possibility of occurrence or presence of multiple pregnancies with subsequent verification by ultrasound.
2. Screening program - the implementation of a massive ultrasound examination within 16-22 weeks of all pregnant women within the region.
The ultrasound screening program allows you to accurately and early diagnose multiple pregnancies in women, which gives
the possibility of more effective implementation of special treatment-and-prophylactic measures, therefore, this approach is optimal for early perinatal diagnosis of multiple pregnancies in women. Erroneous diagnostics is possible when accrete twins are identified in the early stages and in the presence of triplets, when only twins can be installed.
Complications of multiple pregnancies
The course of pregnancy and childbirth with multiple pregnancies is accompanied by a significant number of complications, an increased level of fetal loss at all stages of gestation, significant health problems for twins, as well as complications in the postpartum period. The most difficult multiple pregnancy occurs in primiparous women with induced pregnancy: in the first trimester, complications of pregnancy are observed in 94%, in the second - in 69%, in the third - in 100% of women. Complications are classified as maternal and fetal.
Complications in the mother
1. Anemia. Multiple pregnancies contribute to the depletion of iron stores and may cause the development of iron deficiency anemia, which is a common complication. However, the true iron deficiency state must be differentiated from physiological hemodilution, since the physiological increase in plasma volume in multiple pregnancies is more pronounced (2000-3000 ml) than in singleton pregnancies. The lower limit of physiological hemodilution is considered to be 100 g / l of hemoglobin and 3.0 million erythrocytes. Iron deficiency anemia develops in more than 1/3 of women (or twice as often as in singleton pregnancy) already from the first trimester and accompanies a woman throughout pregnancy. Up to 24 weeks, mild anemia predominates. At a later date, moderate and severe anemia is more often observed (about 50%), accompanied by clinical manifestations in the form of physical fatigue, lethargy, drowsiness, dizziness, pallor of the skin and visible mucous membranes, shortness of breath, tachycardia. These women are more likely to develop intrauterine fetal growth retardation. All this ultimately worsens the prognosis for both the mother and the fetus. With increasing gestational age, iron deficiency states progress and are more difficult to correct. Literature data
testify to the reversibility of the iron deficiency state before 32 weeks of pregnancy and to deeper and less corrected changes in the hematopoietic system at the end of pregnancy. Anemia due to multiple pregnancies is detected twice as often in the presence of dizygotic twins than in pregnancy with monozygotic twins. Therefore, it is necessary to carry out early prevention of iron deficiency anemia in women with multiple pregnancies. It is advisable to carry out preventive measures from the moment of diagnosis of multiple pregnancies.
2. Pregnancy-induced hypertension(14-20%) occurs three times more often in multiple pregnancies than in single pregnancies, and is usually more severe. In a significant number of pregnant women with twins, hypertension and edema develop as a result of an excessive increase in intravascular volume, and they are mistakenly referred to the group of pregnant women with preeclampsia. In the cases under consideration, the glomerular filtration rate is increased, proteinuria is insignificant or absent, and the determination of hematocrit in dynamics indicates an increase in plasma volume. For such pregnant women, for a significant improvement in their condition, bed rest should be observed, lying on their left side. With the development of gestosis, proteinuria is significant and typically a decrease in intravascular volume.
3. Early toxicosis pregnant women with multiple births are observed more often. Nausea and vomiting are more severe.
4. Gestosis, including such severe forms as preeclampsia and eclampsia, are detected, according to different authors, in 20-40% of women with multiple pregnancies, which is 2-3 times higher than in singleton pregnancies. Probably, in the presence of multiple pregnancies, there is a high degree of stress in the adaptive mechanisms of the mother, which often leads to the development of preeclampsia and, consequently, a worsening of pregnancy outcomes for the mother and fetuses. According to the results of some studies, early toxicosis and gestosis in dizygotic twins were more severe and the effect of their treatment was worse than in monozygotic ones. According to modern theories of the development of preeclampsia, which includes both immunological and placental, a single link in the pathogenesis of preeclampsia are circulating immune complexes consisting of fetal antigens and maternal antibodies. The higher incidence of gestosis in dizygotic twins than in monozygotic ones can be explained by the fact that in the presence of dizygotic
twins increase the likelihood of an attack by the maternal body with fetal antigens.
5. Spontaneous abortion; their frequency with multiple pregnancies is twice as high. Twins were born only in 50% of women after the detection of several fetal eggs in the uterus in the first trimester of pregnancy, because at an early stage of pregnancy, part of the fetal eggs undergoes resorption for the following reasons.
1. First of all, this is due to anembryony of one of the fetal eggs. In most cases, as the pregnancy progressed, there was a gradual resorption of the egg without the embryo.
2. There was also early death of one of the embryos (in 7-10% of cases), known as the phenomenon of “vanishing twin” or the phenomenon of “disappearance of twins”. Embryo resorption is observed for the most part during the first 7 weeks of gestation and is not noted later than the 14th week. Therefore, some authors recommend refraining from informing patients about the presence of multiple pregnancies in the first 12 weeks of gestation. During pregnancy, 83.3% of pregnant women from this group have bloody discharge from the genital tract due to the death (resorption) of one ovum; they are interpreted as a phenomenon of an incipient miscarriage. In the presence of this phenomenon, 25% of women have spontaneous miscarriage; in other cases, resorption is possibly a factor inducing the threat of termination of pregnancy.
According to studies of early pregnancy loss due to natural conception, live births with twins accounted for 2% of all conceptions of twins, while the total number of live births was 24.2% of all conceptions.
6. The threat of termination of pregnancy with multiple pregnancies, it is detected already in the first trimester of pregnancy in every second woman and subsequently often leads to premature birth, the level of which, according to different authors, ranges from 36.6 to 50%. The triggering mechanism that contributes to the termination of multiple pregnancies is, apparently, overstretching of the uterus and, as a consequence, an increase in its tone and increased contractile activity. The threat of termination of pregnancy is especially strong during gestation periods of 18-22 and 31-34 weeks. The development of isthmic-cervical insufficiency with multiple pregnancies can also lead to abortion or premature birth. With multiple pregnancies, the threat of premature birth of age
it is directly proportional to the decrease in the length of the cervix. Infection of the amniotic membranes, leading to premature rupture, may underlie multiple miscarriages.
7. Premature rupture fetal membranes and rupture of amniotic fluid (in 25% of cases) with multiple pregnancies twice as often, with premature rupture of amniotic fluid in every third woman, and early rupture of amniotic fluid in every fourth woman. Often, untimely discharge of amniotic fluid can be accompanied by the loss of small parts of the fetus and the umbilical cord, which is facilitated by the pelvic and transverse positions and the small size of the fetus. Premature (before the onset of labor and before the full disclosure of the uterine pharynx) discharge of the amniotic fluid of the first fetus slows down the smoothing of the cervix and the opening of the pharynx and is accompanied by weakness of labor.
According to statistics, premature rupture of amniotic fluid is slightly more common during pregnancy with monozygotic twins, possibly due to the higher incidence of polyhydramnios among this category of pregnant twins.
8. Weakness of labor in case of multiple pregnancies, it is explained by overstretching of the muscles of the uterus, by "turning off" from the contraction of the section of the myometrium, in which there are two placentas. In the literature, there are isolated reports of a high activity of oxytocinase in multiple pregnancies, which can lead to a relative deficiency of endogenous oxytocin and, as a consequence, the development of weakness of the contractile activity of the uterus. Conclusion: correction of labor activity by exogenously administered oxytocin is pathogenetically substantiated.
Due to the weakness of labor activity, the period of disclosure is delayed, the woman in labor gets tired, which further inhibits labor activity. The period of exile is often prolonged as well. Prolonged labor is dangerous for the mother (bleeding, infection) and the fetus (hypoxia). Weakness of labor in women with a monozygous pregnancy is found twice as often as with a dizygotic one.
9. Bleeding in the early postpartum period(twenty%). Bleeding is most often observed in near-term pregnancies, when the stretching of the muscle fibers of the uterus reaches its maximum and uterine hypotension develops. Bleeding in successive ne-
Rhode may occur due to incomplete placental abruption or retention in the uterus of a detached placenta due to insufficient contractility of the overstretched uterus. Pathological blood loss in the successive and early postpartum period is equally often observed with monozygotic and dizygotic twins, but massive blood loss of 1 liter or more is twice as common in women who have given birth to dizygotic twins.
10. Delayed involution of the uterus in the postpartum period it happens due to overstretching of its muscle fibers; various surgical interventions on such a uterus can cause postpartum infectious complications.
11. Significant changes in hemodynamics, urodynamics, endocrine status in women with multiple pregnancies, they contribute to the more frequent occurrence of varicose veins of the lower extremities and genitals, the development of pyelonephritis.
12. Impaired glucose tolerance- a common complication of multiple pregnancies.
13. Cholestasis of pregnancy also common in multiple pregnancies.
14. With multiple pregnancies, pregnant women experience earlier fatigue, shortness of breath, increased urination and constipation.
Complications for the fetus
1. High rate of preterm birth(up to 50%) and as a result of them:
Low birth weight (55% have less than 2500);
HAPPY BIRTHDAY;
Intracranial hemorrhage;
Sepsis;
Necrotizing enterocolitis.
The average duration of pregnancy in the presence of two fetuses is 35 weeks, in the presence of three fetuses - 33 weeks, and in the presence of four fetuses - 29 weeks.
Premature birth in multiple pregnancies is one of the causes of high perinatal morbidity and mortality; the latter is 3-4 times higher than in a singleton pregnancy, and it increases in direct proportion to the number of fetuses. The highest perinatal mortality is characteristic of the 2nd and 3rd fetuses. Noted:
the mortality rate of same-sex twins is higher than that of opposite-sex twins, and in opposite-sex couples the mortality of female children is slightly higher.
Among premature twins, monozygotic twins are found 1.5 times more often than dizygotic ones, and, therefore, perinatal morbidity and mortality rates are 2-3 times higher in monozygotic twins than in dizygotic twins.
2. Pathology of the placenta in multiple pregnancies is most often manifested in the form of:
Placental insufficiency;
Placenta previa;
Premature placental abruption (more often in the II stage of labor). With premature placental abruption of one of the twins (or
common placenta) after the birth of the first child, severe bleeding and hypoxia of the unborn fetus occur, which can lead to its death. Placental insufficiency is recorded in almost every pregnant woman with multiple pregnancies. Several authors consider multiple pregnancies to be a model of PN. Analysis of placentas in multiple pregnancies showed that they are less complete than with singleton, both in terms of mass and morphometric. In accordance with the stages of histogenesis of the placenta, the following variants of its development were identified (according to the increase in pathological abnormalities).
1. Normal at 3-5%.
2. Dissociated (uneven maturation of individual cotyledons) in 30-40%.
3. Variant of differentiated intermediate villi (insufficient capillarization of intermediate villi) in 25-30%.
4. Variant of chaotic sclerosed (hypovascularized) villi in 30-40%.
5. Variant of undifferentiated intermediate villi in
6. Variant of embryonic villi - 1-2% (with incompatibility of the blood of the mother and fetuses according to AB0). The lagging of the villous tree occurs at different periods of pregnancy - it is least often observed in the first, more often in the second and early third trimester.
The last two options are characteristic of spontaneous miscarriages and antenatal fetal death. The pathology of chorionic villus maturation is the morphological basis of placental insufficiency,
leading to inadequate prenatal development of twin fetuses. The most pronounced changes in vascularization and increase pathological changes, such as a decrease in the volume of the intervillous space, the vascular bed and the number of syncytiocapillary membranes, as well as an increase in the number of hemorrhage and infarction sites, were found in monochorionic afterbirths.
3. Various options developmental disorders of one or both twin fetuses- a consequence of placental insufficiency. As a result of earlier studies, M.A. Fuchs, according to biometrics, established five types of prenatal development of fetuses from twins.
Types of prenatal development of fetuses from twins (Fuks M.A.)
Physiological development of both fruits - 17.4%.
Fetal hypotrophy with uniform development of both - 30.9%.
Uneven development of twins - 35.3%.
Congenital pathology of fetal development - 11.5%.
The development of twin fetuses with an outcome in antenatal death of one of them is 4.1%.
Revealing the uneven development of fetuses in the second trimester of pregnancy is an unfavorable prognostic sign. Thus, in the case of the dissociated type of intrauterine development of twins, perinatal mortality is more than four times higher than that in the group with non-dissociated development. The presence of hypotrophy in combination with fetal dissociation is an aggravating factor that significantly worsens the prognosis.
There is a relationship between the nature of the structure of the placenta and the type of prenatal development of twin fetuses. It has been established: with normal and dissociated development of the placenta, physiological development of twins is often observed. At the same time, variants of differentiated intermediate villi and chaotic sclerosed villi cause unfavorable development of twin fetuses (hypotrophy and uneven development). With an increase in the incidence of pathological undermaturity of both placentas, the dissociation of the twins' body weights increases. Carrying out therapeutic and prophylactic measures can give a positive effect in the case of dissociated development of the placenta. At the same time, with variants of differentiated intermediate and chaotic sclerosed villi, the possibilities of compensation are sharply reduced.
4. Intrauterine growth retardation with multiple pregnancies, it occurs with a frequency of about 70% (with a singleton pregnancy, 5-10%). Delay in the development of one of the fruits (differences in size and weight more than 15-25%) with a frequency of 15%.
5. Polyhydramnios (hydramnios) occurs in 0.3-0.6% of all births and in 5-8% in twin pregnancies. Polyhydramnios is more often recorded during pregnancy with monozygotic twins than with dizygotic twins, especially with monoamniotic twins. Polyhydramnios can be acute or chronic. In acute polyhydramnios, pregnancy, as a rule, is terminated early, the fetus dies (PN, premature detachment placenta) or is born with malformations, rupture of the uterus or its threat is possible. Acute polyhydramnios before 28 weeks of gestation occurs in 1.7% of twins, while perinatal mortality is close to 90%. In chronic polyhydramnios, the amount of amniotic fluid increases gradually, the prognosis of pregnancy depends on the degree of its severity and the rate of increase.
The diagnosis of polyhydramnios is based on:
An increase in the uterus, the discrepancy between its size (abdominal circumference, the height of the fundus of the uterus above the bosom) and the period of pregnancy; the uterus becomes tight-elastic, tense;
Mobility, unstable position, difficult palpation of parts; muffled heartbeat of the fetus (s);
Ultrasound (the presence of large echo-negative spaces in the uterine cavity, measurement of the amniotic fluid space free from parts of the fetus in two mutually perpendicular sections).
6. Umbilical cord pathology:
Membrane attachment of the umbilical cord (1% for singleton pregnancies and 7% for twins);
Umbilical cord presentation (1.1% for singleton pregnancies, 8.7% for twins);
The only artery of the umbilical cord;
Prolapse of the umbilical cord during labor;
Umbilical cord entanglement (in every fourth fetus).
7. Incorrect position of the fetus during childbirth (50% - 10 times more often than in a singleton pregnancy). With twins, in the overwhelming majority of cases (88%), both fetuses are in a longitudinal position and occupy one right and the other left half of the uterus.
Presentation and fetal position options:
Head-head 45-50%;
Head-pelvic 30-43%;
Pelvic-pelvic 6-10%;
Longitudinal-transverse 5.55 (with dizygotic pregnancy);
Both fetuses in the transverse 0.5% (with dizygotic pregnancy). With poor retraction of the muscles of the uterus after the birth of the first
fetus, the transition of the second fetus to a transverse position may occur, then further childbirth without the use of obstetric operations will become impossible.
8. Clutching twins during childbirth- collision.
It occurs at a frequency of 1: 1000 twins. Perinatal mortality with this complication reaches 62-84%, since the diagnosis is most often made during the period of fetal expulsion. The adhesion of twins occurs when the heads of both twins enter the pelvis at the same time or when the first child is born in a breech presentation, and the second in a cephalic presentation. Other options are also possible. In the overwhelming majority of cases, collision is observed in the breech - cephalic presentation.
9. Congenital malformations. They are observed 2-3 times more often with multiple pregnancies than during pregnancy with one fetus. The frequency fluctuates, according to different authors, in the range from 2 to 17%, of which in half of the cases, malformations are detected in one of the twins. Congenital anomalies in twins they have a number of characteristics, prevailing among male twins.
Facial and neck defects are more common than in singles. The higher the incidence of congenital malformations incompatible with life.
The most common defects: cleft lip (cleft lip), cleft palate (cleft palate), CNS defects (hydrocephalus, neural tube defects), heart defects, persistent foot deformities, skull asymmetry, congenital hip dislocations. All twins are at risk of compression deformities due to intrauterine contraction. In monochorionic twins, anomalies are usually multiple or fatal and are generally twice as common as in bichorionic twins.
10. United twins.
United twins are always monozygous, same-sex, have the same karyotype (are identical) and are always
noamniotic type of placentation. The frequency is 1 in 10 million births, or 1 in 30 thousand to 100 thousand twin pregnancies. This phenomenon is observed mainly in female fetuses (75%), the reason for this is unknown. The classification of such twins is based on the part of the body by which they are connected to each other:
Thoracopagi (25%);
Thoracoomphalopagi (30%);
Omphalopagi (30%);
Craniopagi (8%)
Pygopagi (55);
Ischiopagi (2%);
Incomplete divergence - bifurcation in only one part or area of the child's body;
Stereopagi - fusion of twins with full autonomy internal organs each of them.
Fusion of twins with complete autonomy of the internal organs of each of them (stereopagi) is observed in 10% of cases. Diagnosis of this pathology using ultrasound is possible already from the end of the first trimester of pregnancy, but the most optimal period for its detection is 24-28 weeks of gestation.
11. Stillbirth- a frequent occurrence in multiple pregnancies.
12. Neurological disorders(infantile paralysis, microcephaly, encephalomalacia). In twins born prematurely, the incidence of brain tissue necrosis reaches 14%.
13. Birth traumatism fetuses are also typical for the delivery of multiple pregnancies.
14. Pigtail syndrome- weaving of umbilical cords in monoamniotic twins.
Feto-fetal transfusion syndrome (FFTS) is a special form of impaired placental transfusion, inherent only in multiple pregnancies, and at the same time the main cause of an unfavorable outcome in twins with a monochorionic type of placentation. The development of FFTS is due to the presence of vascular anastomoses, leading to pathological shunting of blood from one fetus to another. This transition of blood from fetus to fetus is called "intrauterine parabiotic syndrome", "transfusion syndrome", "intertwined transfusion syndrome", "fetofetal transfusion syndrome", as well as "linked twin syndrome."
In the vast majority of cases, the syndrome develops in monochorionic identical twins. The occurrence of a similar syndrome has been described in dizygotic twins, when an anastomosis was formed between separate placentas, but this is rather casuistry. FFTS can develop in triplets if all three fetuses share a common circulation in the placenta and are monozygous. The frequency of FFTS varies considerably and amounts to 3.7-20% of cases of multiple monozygous pregnancies. It is known that with multiple pregnancies, perinatal mortality is significantly higher than with singleton, and is 6.8%; at FFTS it reaches 60-100%. One of the twins can die both in utero and after birth, more often during the first 2-3 days. The contribution of FFTS to perinatal mortality of identical twins is significant and ranges from 25 to 34%.
Pathophysiology of FFTS. The etiology of FFTS is well understood. Twins develop from a single fertilized egg, which, for unknown reasons, divides into two (or more) genetically identical embryos. The formation of communicating vessels between them depends on how long after fertilization the zygote will separate, more precisely, on the type of placentation of monozygotic twins.
1. When dividing the zygote on the 1-4th day after fertilization, the type of placentation will be dichorionic diamniotic, which occurs in 25-37% of cases of development of identical twins. It is logical to assume that the probability of anastomosis in such monozygotes is not greater than in dizygotes.
2. When the embryo is divided into two identical ones on the 4-8th day, the type of placentation will be monochorionic diamniotic, which occurs most often during pregnancy with identical twins (in 63-74% of cases). The likelihood of anastomoses in such conditions increases dramatically.
3. When the embryo is cleaved on the 8-13th day, both fetuses will subsequently have one common fetal bladder and one placenta. Occurring in only 1-2% of multiple monozygotic pregnancies, the monochorionic monoamniotic type of placentation does not significantly change the incidence of the syndrome. Vascular anastomoses are found in monochorionic pregnancy in 49-100% of cases and are of two types:
1) superficial, located on the chorionic plate, are arterio-arterial, veno-venous and arteriovenous; they connect two blood circulation systems directly and function in two directions;
2) deep, when arterial blood from one fetus enters the cotyledon, and venous drainage is carried out into the circulation system of the other fetus.
At monochorionic During pregnancy, there is always blood circulation between fetuses, but all anastomoses function in two directions, and the vasculature is balanced. In FFTS, the placenta is characterized by the presence of one deep arteriovenous anastomosis with blood flow only in one direction and a small number or no superficial anastomoses that do not compensate for blood shunting. As a result, one fetus becomes a blood donor and the other a recipient. The resulting redistribution of blood leads to the development of pathological erythrocytosis in one fetus and anemia in another, the severity of which depends on the type, caliber and number of shunts-anastomoses.
The recipient fetus develops: dropsy due to blood volume overload, cardiomegaly, tricuspid regurgitation, ventricular hypertrophy, obstruction of the outflow tract of the right ventricle (varying degrees of severity of pulmonary artery stenosis).
The course of multiple pregnancies with inter-twin transfusion is often complicated by hydramnios in the recipient, the appearance of which during gestation up to 20-23 weeks is an extremely unfavorable prognostic sign. This indirectly indicates the degree of blood transfusion and contributes to premature birth. In addition, the rapid accumulation of amniotic fluid significantly disrupts uteroplacental perfusion by reducing blood flow in the uterine arteries, which further exacerbates the situation for both twins. In the etiology of hydramnios, the leading role is attributed to increased renal excretion in the recipient, which is due to an increase in circulating blood volume and an increase in blood pressure. In turn, this enhances the secretion of amniotic fluid. A significant role in the occurrence of polyhydramnios in the recipient is attributed to the sheathing attachment of the umbilical cord, which is practically not observed in the donor, and the umbilical cord attached to the membranes of the placenta can be easily compressed, reducing the umbilical cord blood flow and provoking
secretion of amniotic fluid. Membrane attachment of the recipient's umbilical cord with polyhydramnios is noted in 63.7% of cases, and without polyhydramnios, such attachment is noted only in 18.5% of cases. The donor has oligohydramnios. More serious complications of FFTS arise with a significant redistribution of blood during gestation up to 25-30 weeks. In this case, one of the twins usually dies in utero or in the early neonatal period. The other twin, the surviving one, has a large mass and size, since between the death of the first one and the birth of twins, 2-3 weeks or even more can pass. However, labor usually occurs shortly after the onset of the shunt-anastomosis due to developing complications of pregnancy, such as hydramnios in the recipient. The widespread opinion that in the case of dissociated development of twins, the donor always dies in or out of utero is often not confirmed. The death of the donor occurs almost as often as the death of the recipient, and no pattern is observed in this. Who will die - the donor or the recipient, depends on who will sooner deplete the compensatory-adaptive mechanisms.
In utero, dead donor fetuses are most often macerated, with pronounced pallor of the skin, often with swelling. At autopsy, partial autolysis of internal organs is noted. Reduced kidneys, liver, thymus gland indicate a failure to compensate for the resulting blood loss. In the case of death in the early neonatal period of a newborn donor, anemia of all its internal organs, cerebral edema, erythroblastosis of the liver, spleen, kidneys, lungs, hepatosplenomegaly, accidental involution of the thymus gland are noted - manifestations of severe chronic anemia. Stillborn recipients have characteristic signs of pletora (hypervolemia) and polycythemia: they are also macerated and, due to prolonged overload with an increased volume of circulating blood, they have myocardial and kidney hypertrophy at autopsy.
The deceased newborn-recipient has plethora of internal organs, often - heart attacks of the brain, lungs, liver due to impaired rheological properties of blood, hepatosplenomegaly due to increased destruction of red blood cells and utilization of bilirubin. With the development of heart failure and death from it, a picture of pulmonary edema can be observed. The intrauterine death of one of the fetuses sometimes does not affect the development of the other in any way, especially if it
occurs before 20-22 weeks of gestation and immediately the communicating vessels are thrombosed. The dead fruit then turns into "paper" or "stone".
At a later date, the message between fruits is usually preserved. Superficial anastomoses are implicated in the consequences of intrauterine death one of the fruits. With a drop in blood pressure in the bed of a dying fetus due to a pressure gradient, blood is released from a living fetus to a dying one through superficial arterial and venous anastomoses. In the case of intrauterine death of one fetus with FFTS in 25% of cases, there is a risk of developing necrotic damage to its twin. Previously, this was explained by the formation of disseminated intravascular coagulation and vascular embolization. Autolysis products, active thromboplastic substances of a macerated fetus can enter the bloodstream of a survivor, usually a recipient, and, as an outcome, cause him DIC syndrome with infarctions of the brain, kidneys, skin and other organs. In addition, getting into the mother's bloodstream, thromboplastic substances provoke the development of DIC syndrome in her body, disrupting the coagulation system with all the ensuing consequences. This complication occurs in 4-5% of multiple pregnancies. Currently, it is believed that necrotic damage to the surviving twin is due to acute hypotension and ischemia due to blood discharge, which occur during the death of the second fetus. Perinatal mortality of the recipient fetus after the death of the donor fetus is about 50% with gestational age up to 34 weeks and 19% after 34 weeks. The consequences of reverse arterial perfusion in multiple pregnancies include acardia syndrome, or acardia-acephaly (acardial monster, pseudocardial anomaly, acephalic acardia, holocardia). This syndrome occurs in 1% of identical monochorionic twins with a frequency of 1 in 35,000 to 40,000 births. As an extreme form of blood transfusion between twins, the absence of myocardium in the recipient is described, the blood supply of which was carried out due to the work of the donor's heart through a shunt in the placenta. Sometimes the donor fetus has polymicrogyria (the absence of grooves and convolutions and underdevelopment of the gray matter in the cerebral hemispheres), heterotopia of the brain in combination with its hypoxic damage, anencephaly as an extreme degree of damage to the central nervous system. In 65%, such pregnancies end in preterm labor, accompanied by
in 50% of cases, perinatal death of the “pump fetus” and in 100% of cases - non-viability of the perfused fetus. Once born, the recipient twin dies immediately. The surviving donor develops hypertrophic cardiomyopathy with insufficient myocardial contractile function and has persistent left ventricular hypertrophy within 6 months after delivery.
A twin with polycythemia is threatened by: respiratory disorders, cardiac activity, the central nervous system in the form of seizures, kernicterus due to hyperbilirubinemia due to increased hemolysis of an excess amount of red blood cells. The donor twin develops chronic anemia, its weight and size may be 10-50% less than those of the recipient or equal to them. Probably, the latter is due to the fact that the shunt-anastomosis begins to "adequately" work for some reason on later dates gestation, closer to childbirth.
FFTS diagnostics
The first clinical manifestations of FFTS develop at 15-25 weeks of gestation. The most unfavorable prognosis is at a gestational age of less than 25 weeks (in the absence of timely treatment, perinatal mortality reaches 80-100%). The diagnosis of FFTS is established by ultrasound (a device with three-dimensional ultrasound scanning is more suitable for this) based on the identification of the following echographic criteria.
1. Echographic criteria typical for the first trimester of pregnancy and the subsequent development of FFTS:
Monochorionic pregnancy;
Expansion of the collar space by more than 3 mm at 10-14 weeks;
Decrease (growth retardation) of one of the fruits;
Formation of folds of the amniotic septum at 10-13 weeks.
2. Echographic criteria specific to II and III trimesters pregnancy:
Monochorionic type of gestation;
The same sex of the fruit;
Thin amniotic septum;
The formation of membrane folds at 14-17 weeks of gestation;
The absence of a lambda-like form of placental tissue in the area of the amniotic septa;
The difference in the amount of amniotic fluid: polyhydramnios in one fetus and oligohydramnios in another;
Difference in the size of the bladder - small size or lack of visualization of the bladder in a fetus with oligohydramnios (donor fetus) and large bladder sizes in a fetus with polyhydramnios (recipient fetus);
The difference in the weight of fruits is more than 20% (observed in 72% of cases);
Close adherence (sign of "sticking") of one of the fetuses to the wall of the uterus (92%);
Dropsy of one fetus (subcutaneous edema more than 5 mm, pleural effusion, pericardial effusion, ascites).
In the case of close adherence of one of the fetuses to the uterine wall, it is necessary to carry out differential diagnostics between FFTS and monoamniotic pregnancy (since, due to oligohydramnios in the donor fetus, the amniotic septum is not clearly visualized). To do this, it is necessary to assess the motor activity of the fetus (flexion, extension of the limbs). With FFTS, fetal movements will be sharply limited.
The combination of the listed signs makes it possible to diagnose fetal-fetal transfusion with a probability of 50% already from 19-20 weeks of pregnancy.
The use of the Doppler method with color contrast to detect abnormal blood flow in the placenta at 20-25 weeks almost completely eliminates the diagnostic error.
With the help of transabdominal cordocentesis under the control of ultrasound scanning, blood can be obtained from the umbilical cords of twins and the degree of blood transfusion between them can be determined by hematological parameters. The difference in the hemoglobin concentration of more than 24 g / l in fetal blood is characterized by a sensitivity of 50% and a specificity of 100% for the diagnosis of FFTS. The difference in the hemoglobin content of 50 g / l in peripheral blood between twins is considered a criterion for blood transfusion between them; without blood transfusion, this figure does not exceed 15-20 g / l. In addition, the content of total protein and albumin in the recipient's umbilical cord blood is higher than that of the donor. As a criterion for the presence of vascular communication between twins for differential diagnosis between FFTS and intrauterine growth retardation of one of the twins, it is proposed to use the level of fetal erythropoietin, which is significant
It is significantly increased in the umbilical cord blood of the donor in comparison with that in the recipient, as well as in single fetuses.
FFTS treatment
Treatment of FFTS in twins after birth is reduced to the treatment of anemia in the donor and polycythemia in the recipient. It often does not give the desired result due to far-reaching pathological changes. In this regard, the attention of most researchers is directed to the prenatal treatment of this pathology, especially to the elimination of shunt anastomosis already in the early stages of pregnancy, immediately after the diagnosis of the syndrome. Currently, the following main methods of treatment are used in FFTS.
1. Conservative treatment implies careful ultrasound dynamic control, Doppler, ECG and CTG. A thorough antenatal assessment of the condition of the fetus allows a timely decision on early delivery and prevention of intrauterine fetal death. The detection of zero or negative diastolic blood flow in the donor's umbilical artery and pulsating blood flow in the recipient's umbilical cord vein indicates a poor prognosis for the fetuses. The survival rate with conservative treatment ranges from 0 to 75%.
2. Amnioreduction- A series of therapeutic amniocentesis for aspiration of amniotic fluid in a twin with hydramnios, the most common treatment. The amount of fluid removed during the procedure is from 1 to 7 liters, and the total volume of aspirated amniotic fluid is from 3 to 14 liters, the number of amniocentesis is from 1 to 12. Amnioreduction increases blood flow through the uterine arteries. It is possible to prolong pregnancy by an average of 46 days, the survival rate of fetuses after amnioreduction ranges from 12.5 to 83%, and the death rate of twins is reduced to 35%. Some researchers explain the effectiveness of multiple amniocentesis with inter-twin transfusion by delaying labor due to the absence of uterine hyperextension by an increased volume of amniotic fluid.
3. Fetoscopic laser coagulation vascular anastomoses (VLKSA). In theory, laser coagulation is an ideal method for treating PFTS because it is pathogenic. A laser beam brought transabdominally through the amniotic cavity, under ultrasound control, coagulates all the vessels on the fetus
the surface of the placenta in the projection of the amniotic septum between twins. The procedure is successful in all cases and allows you to prolong pregnancy by an average of 14 weeks and reduce perinatal mortality. However, the results of FLCA are somewhat disappointing, since the survival rate after this operation in combination with amnioreduction is only 55%, which is less than with isolated amnioreduction. Complications of FLCS: intraamnial bleeding, premature rupture of the fetal bladder, chorioamnionitis, bleeding from the uterine wall.
4. Septostomy- puncture of the amniotic septum, which allows amniotic fluid to circulate between two amniotic cavities. It is performed under ultrasound control. The use of this method is justified by the fact that FFTS is extremely rarely observed with monoamnial twins. Fetal survival with septostomy is 83%. The mechanism of action is unknown. Perhaps the donor fetus corrects its hypovolemia by swallowing amniotic fluid after normalizing its amount.
5. Selective fetal euthanasia- a dubious method of treating FFTS, since its use initially leads to 50% of perinatal mortality. However, this method has a right to exist, especially in cases of intractable FFTS or when intrauterine death of one of the fetuses is inevitable. Since blood bypass is performed along vascular anastomoses from the donor fetus to the recipient fetus, sacrificing the donor fetus is preferable, since it is safer for the remaining fetus. Obliteration of the umbilical cord vessels can be carried out by embolization, coagulation or ligation. Usually, the operation is performed before 21 weeks of pregnancy, since after this period the diameter of the umbilical cord increases and it becomes more edematous, which reduces the effectiveness of the operation. Maternal treatment with digoxin, intrauterine venesection and replacement blood transfusion, previously used in FFTS, were ineffective. Prostaglandin synthetase inhibitors indomethacin and sulindac are contraindicated in the treatment of FFTS, since they reduce urine production, which is already reduced in the donor, which can lead to the development of renal failure in the neonatal period.
With any method, the criteria for successful treatment are:
Accumulation of urine in the bladders of both fetuses, especially the donor fetus;
Normalization of the amniotic fluid index;
The disappearance of signs of heart failure in the recipient fetus.
FFTS is characterized by a higher incidence of neurological disorders in surviving children. The high frequency of lesions of the central nervous system (up to 36%) dictates the need for an echographic examination of the brain in newborns in the first two days of life and careful observation thereafter.
Thus, FFTS, being a relatively rare complication, makes a significant contribution to perinatal mortality in multiple pregnancies with identical twins. It has a well-defined clinical picture during pregnancy. In this regard, prenatal diagnosis is possible and, most importantly, there are prospects for prenatal treatment.
Delivery in multiple pregnancies, given a large number of possible complications in childbirth, preferably by caesarean section.
Through the natural birth canal, childbirth is possible with a cephalic presentation of both fetuses with twins.
A multiple pregnancy is a pregnancy with two or more fetuses.
In the presence of pregnancy, two fetuses speak of twins, three - triplets, etc. Each of the fetuses in a multiple pregnancy is called a twin.
Frequency of occurrence. Multiple pregnancies average 1-2% of the total number of births. The frequency of occurrence with different numbers of fruits is as follows:
Twins - 1 in 87 births;
Triplets (triplets) - 1 in 6400 births, or 1 in 87 twins;
Four fruits - 1 in 51 thousand genera (873), or 1 in 87 triplets. However, the true frequency of multiple pregnancies today in developed countries reaches 1:50, which is 2 times more than 20 years ago - 1: 101.
Multiple pregnancy may be a consequence of:
1) spontaneous ovulation - 1%;
2) the use of ovulation stimulants - 10% (5-13%);
3) the use of human menopausal gonadotropin -
4) the use of in vitro fertilization with embryo transfer - 30%.
Currently, iatrogenic multiple pregnancy accounts for 30-80% of multiple pregnancies, which is due to the introduction of modern methods fertility treatments including hormonal stimulation of ovulation and in vitro fertilization with embryo transfer.
Risk factors affecting the frequency of multiple pregnancies
The frequency of occurrence of monozygous twins is relatively stable and amounts to 0.35-0.5% of all births. The following factors affect the frequency of dizygotic twins:
History of twins (the birth of twins in a given woman, her belonging to twins, etc.);
The mother's age is from 35 to 39 years;
The number of births (the frequency increases with the number of births);
Abnormalities in the development of the uterus;
Belonging to the black race;
The use of assisted reproductive technologies (in vitro fertilization);
