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Multiple pregnancy. Multiple pregnancy, ultrasound with multiple pregnancy If a woman is pregnant with two fetuses, they talk about twins, three fruits - about triplets, etc.
Frequency of occurrence.
Twins - 1 in 87 births;
1) spontaneous ovulation - 1%;
Anomalies in the development of the uterus;
Time of conception after discontinuation of combined oral contraceptives: when conceived within 1 month after discontinuation of drugs, the probability 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 (two-egg, non-identical). They are 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 fraternal twins, fertilized eggs develop independently of each other. After implantation, each embryo has its own amnion and its own chorion, then 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 different-sex with the same and different group blood. Two-thirds of all twins are dizygotic.
2. Monozygotic (identical, identical). Their similarity is associated with the early division of an egg fertilized by one spermatozoon into two cell masses containing identical genetic information. Similar twins have the same genotype and therefore are of the same sex, with the same blood type. One third of all twins are monozygotic.
According to chorionality (placentation): there are types of placentation.
1. Bichorionic-biamnial(two placentas) - occurs in 80%.
A. Divided placenta. If the implantation of the embryos occurred far from each other, their placentas do not touch.
B. Drained placenta. When implanted at a close distance, the embryos have a common decidua, the edges of their placentas are in contact, the septum between the two fetal sacs consists of
four shells: two water and two villous. Each placenta has its own vascular network. Sometimes anastomoses are formed between the vessels of the placenta, which can be the cause of uneven blood supply to the twins and their unequal development. 2. Monochorionic(one placenta) - occurs in 20% of:
a) monochorionic-monoamnial;
b) monochorionic-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
Two main mechanisms 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 matured in different follicles of the same ovary (ovulatio uniovarialis).
B. Simultaneous ovulation with subsequent 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. Superfertility (superfoecundatio)- fertilization of two or more simultaneously ovulated eggs by spermatozoa of different men.
D. There is an assumption that it is possible to fertilize an egg that ovulated against the background of an existing pregnancy.
2. Early division of one fertilized egg - polyembryony, (the origin of identical twins).
A. Fertilization by several spermatozoa of multinucleated eggs.
B. Division into two parts of the copceptus in the stage of crushing; an embryo is formed from each part (atypical crushing of the egg). The most common mechanism of multiple pregnancy is the fertilization of several oocytes in one menstrual cycle (2/3 cases), which leads to the development of bichorial-biamnial dizygotic twins. In 1/3 cases
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 bifurcation of the zygote, one of four types of twins may occur:
1) 0-72 hours - bifurcation before the formation of the inner cell mass and any differentiation (up to the morula stage) - bichorial-biamnial monozygotic twins (25%); fraternal twins have the same type of placentation, which often misleads the researcher who determines the type of zygosity for the placenta;
2) 4-8th day - division of the embryo at an early stage of the blastocyst after the formation of the inner cell mass, when its nidation and the formation of the chorion have already occurred - monochorionic-biamnial monozygotic twins (70%);
3) 9-13th day - division occurs after the formation of the germinal disk, when the chorion and amnion are already formed - monochorionic-monoamnial monozygotic twins (5%);
4) after the 13th day - fused (connected) twins. It is extremely rare for monozygotic and dizygotic twins to occur.
at the same time during pregnancy with three or more embryos (bichorionic-triamnial).
Diagnosis of multiple pregnancy
Due to the significant number of complications, multiple pregnancy is rightly considered a high risk factor for maternal and perinatal morbidity and mortality, so its management differs from that of a singleton pregnancy and requires much more careful monitoring from the earliest stages of gestation. The diagnosis of multiple pregnancy, its reliability, the establishment of the type of multiple pregnancy and placentation, as well as the determination of the term of multiple pregnancy are of great importance for the outcome for 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 the characteristic for this period of pregnancy; an increase in the circumference of the abdomen.
2. Variable and insufficiently reliable signs:
a) if the twins are in a longitudinal position, on the front
the surface of the uterus forms a longitudinal depression; with the transverse position of both fruits, the recess is located horizontally;
b) the uterus takes a saddle shape (its corners protrude, a depression forms in the bottom area).
3. Not big sizes presenting part compared with the volume of the uterus.
4. Determination of large parts of the fetus in different parts of the abdomen.
5. Determination in the uterus of three or more large parts of the fetus 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 levels of hCG and AFP (more than four times higher than those in a singleton pregnancy).
8. Ultrasound allows you to diagnose multiple pregnancy from the first half of gestation.
9. Excessive weight gain.
10. Family history.
11. Stimulation of ovulation by gonadotropins, clomiphene in history.
12. In vitro fertilization in history.
Ultrasound is the gold standard in diagnosis multiple pregnancy in women, its accuracy is 99.3%. Ultrasound diagnosis of multiple pregnancy in the early stages is based on the visualization of several embryos in the uterine cavity and is possible already from 6-7 weeks of gestation. The use of vaginal sensors makes it possible to diagnose multiple pregnancies already from the 4-5th week of gestation. With the help of ultrasound, 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 pregnancy in women.
1. Selective - identifying prognostic signs of the possibility of the occurrence or presence of multiple pregnancies, followed by verification by ultrasound.
2. Screening program - the implementation of a mass ultrasound examination in terms of 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 therapeutic and preventive measures, therefore, this approach is optimal for early perinatal diagnosis of multiple pregnancies in women. An erroneous diagnosis is possible when conjoined twins are detected early and in the presence of triplets, when only twins can be installed.
Complications in multiple pregnancy
The course of pregnancy and childbirth with multiple pregnancies are accompanied by a significant number of complications, an increased level of fetal losses at all gestational ages, significant health problems for twins, as well as complications in the postpartum period. The most severe multiple pregnancy occurs in primiparas with induced pregnancy: in the first trimester, pregnancy complications are observed in 94%, in the second - in 69%, in the third - in 100% of women. Complications are divided into maternal and fetal.
Complications in the mother
1. Anemia. Multiple pregnancy contributes to the depletion of the iron depot and can 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 pregnancies) already from the first trimester and accompanies a woman throughout pregnancy. Up to 24 weeks, mild anemia predominates. In later periods, anemia of moderate severity and severe (about 50%) is more often observed, 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 growth retardation. All this ultimately worsens the prognosis for both the mother and the fetus. With an increase in gestational age, iron deficiency conditions progress and are more difficult to correct. Literature data
testify to the reversibility of the iron deficiency state before 32 weeks of gestation and to deeper and less correctable changes in the hematopoietic system at the end of pregnancy. Anemia associated with 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 the prevention of iron deficiency anemia in women with multiple pregnancies from an early date. It is advisable to carry out preventive measures from the moment of diagnosis of multiple pregnancy.
2. Pregnancy-induced hypertension(14-20%) occurs three times more often in multiple than in singleton pregnancies and is usually more severe. A significant number of pregnant women with twins develop hypertension and edema due to an excessive increase in intravascular volume, and they are erroneously classified as pregnant with preeclampsia. In the cases under consideration, the glomerular filtration rate is increased, proteinuria is insignificant or absent, and the determination of hematocrit over time indicates an increase in plasma volume. For such pregnant women, for a significant improvement in the condition, bed rest should be observed, lying on the left side. With the development of preeclampsia, proteinuria is significant and a decrease in intravascular volume is typical.
3. Early toxicosis pregnant women with multiple pregnancy are observed more often. Nausea and vomiting are more severe.
4. gestoses, 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 tension in the mother's adaptive mechanisms, which often leads to the development of preeclampsia and, consequently, worse pregnancy outcomes for the mother and fetus. According to the results of some studies, early toxicosis and gestosis in dizygotic twins proceeded in a more severe form and the effect of their treatment was worse than in monozygotic twins. According to modern theories of the development of gestosis, including both immunological and placental, a single link in the pathogenesis of gestosis is circulating immune complexes, consisting of fetal antigens and maternal antibodies. The higher incidence of gestosis in dizygotic twins than in monozygotic twins can be explained by the fact that in the presence of dizygotic
twins, the likelihood of an attack by the mother's body with fetal antigens increases.
5. Spontaneous abortions; their frequency with multiple pregnancy is twice as high. Only in 50% of women, after the detection of several fetal eggs in the uterine cavity in the first trimester of pregnancy, twins were born, because in the early stages of pregnancy, part of the fetal eggs undergoes resorption for the following reasons.
1. First of all, this is due to the 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 has also been an early death of one of the embryos (in 7-10% of cases), known as the “vanishing twin” phenomenon or the “twin disappearance” phenomenon. Embryo resorption is observed mostly during the first 7 weeks of gestation and is not observed after 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 fetal egg; they are interpreted as a phenomenon of a miscarriage that has begun. In the presence of this phenomenon, 25% of women have a spontaneous miscarriage; in other cases, resorption may be a factor that induces the threat of abortion.
According to studies of early pregnancy losses due to natural conception, live births with twins accounted for 2% of all twin conceptions, while the total number of live births was 24.2% of all conceptions.
6. Threat of abortion with multiple pregnancy, 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 trigger mechanism that contributes to the termination of multiple pregnancy is, apparently, overstretching of the uterus and, as a result, an increase in its tone and increased contractile activity. The threat of abortion is especially strong at 18-22 and 31-34 weeks of gestation. The development of isthmic-cervical insufficiency in multiple pregnancy can also lead to abortion or premature birth. With multiple pregnancy, the threat of premature birth is age-
is directly proportional to the decrease in the length of the cervix. Infection of the amniotic membranes, leading to their premature rupture, may underlie the prematurity of multiple pregnancies.
7. premature rupture membranes and effusion amniotic fluid(in 25% of cases) with multiple pregnancy twice as often, with premature rupture of amniotic fluid in every third woman, and early rupture of amniotic fluid in every fourth. Often untimely rupture of amniotic fluid can be accompanied by prolapse of small parts of the fetus and 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 opening of the uterine pharynx) discharge of amniotic fluid of the first fetus leads to a slowdown in the smoothing of the cervix and opening of the pharynx and is accompanied by weakness in labor activity.
According to statistics, premature rupture of amniotic fluid is slightly more common during pregnancy with monozygotic twins, perhaps this is due to the higher incidence of polyhydramnios among this category of pregnant twins.
8. Weak labor activity with multiple pregnancies, it is explained due to overstretching of the muscles of the uterus, “turning off” from the contraction of the myometrial area, in which two placentas are located. In the literature, there are isolated reports of high oxytocinase activity in multiple pregnancies, which may cause a relative deficiency of endogenous oxytocin and, as a consequence, the development of weakness in the contractile activity of the uterus. Conclusion: correction of labor activity with exogenously administered oxytocin is pathogenetically justified.
Due to the weakness of labor activity, the period of disclosure is delayed, the woman in labor gets tired, which further inhibits labor activity. Often the period of exile is also prolonged. Prolonged labor poses a risk to the mother (bleeding, infection) and the fetus (hypoxia). The weakness of labor activity in women with monozygotic pregnancy is found twice as often as with dizygotic.
9. Bleeding in the early postpartum period(20%). Bleeding is most often observed in almost full-term pregnancy, when the stretching of the muscle fibers of the uterus reaches its maximum degree and hypotension of the uterus develops. Bleeding in the succession
riode may occur due to incomplete placental abruption or retention in the uterus of the exfoliated placenta due to insufficient contractility of the overstretched uterus. Pathological blood loss in the afterbirth and early postpartum period is equally often observed in monozygotic and dizygotic twins, but massive blood loss in the amount 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 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 a more frequent occurrence of varicose veins of the lower extremities and genital organs, the development of pyelonephritis.
12. Impaired glucose tolerance- a common complication of multiple pregnancies.
13. cholestasis of pregnancy also characteristic of multiple pregnancies.
14. With multiple pregnancy, fatigue, shortness of breath, increased urination and constipation appear earlier in pregnant women.
Complications for the fetus
1. High rate of preterm birth(up to 50%) and as a result of them:
Low birth weight (55% weigh less than 2500);
HAPPY BIRTHDAY;
Intracranial hemorrhages;
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. Noticed:
the mortality of same-sex twins is higher than that of opposite-sex twins, and in opposite-sex pairs the mortality of female children is slightly higher.
Among premature twins, monozygotic twins are 1.5 times more common than dizygotic twins, 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 pregnancy is most often manifested in the form of:
placental insufficiency;
placenta previa;
Premature placental abruption (more often in the second stage of labor). With premature detachment of the placenta 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 his death. Placental insufficiency is recorded in almost every pregnant woman with multiple pregnancy. Some authors consider multiple pregnancy to be a model of PN. Analysis of placentas in multiple pregnancy showed that they are less complete than in singleton, both in terms of weight and morphometric. In accordance with the stages of placental histogenesis, the following variants of its development were identified (according to the increase in pathological abnormalities).
1. Normal in 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. A 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 fetus according to AB0). The backlog of the villous tree occurs at different stages of pregnancy - least often observed in the I, more often in the II and early III trimester.
The last two variants are characteristic of spontaneous miscarriages and antenatal fetal death. The pathology of the maturation of chorionic villi 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 areas of hemorrhages and infarctions, were detected in monochorionic afterbirths.
3. Various options for impaired development of one or both twin fetuses- a consequence of placental insufficiency. As a result of earlier studies, M.A. Fuchs, according to biometric data, established five types of prenatal development of fetuses from twins.
Types of prenatal development of twin fetuses (Fuchs M.A.)
The physiological development of both fetuses is 17.4%.
Hypotrophy of the fetuses with the uniform development of both - 30.9%.
Uneven development of twins - 35.3%.
Congenital pathology of fetus development - 11.5%.
The development of twin fetuses with an outcome in antenatal death of one of them - 4.1%.
Identification of uneven development of fetuses in the second trimester of pregnancy is an unfavorable prognostic sign. Thus, in the dissociated type of intrauterine development of twins, perinatal mortality is more than four times higher than in the group with undissociated development. The presence of malnutrition 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. Established: with normal and dissociated development of the placenta is often observed physiological development twins. 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 frequency of pathological immaturity of both placentas, the dissociation of body weights of twins increases. Carrying out therapeutic and preventive measures can have a positive effect in the case of dissociated development of the placenta. At the same time, in variants of differentiated intermediate and chaotic sclerosed villi, the possibilities of compensation are sharply reduced.
4. intrauterine fetal growth retardation with multiple pregnancy, it occurs with a frequency of approximately 70% (with a singleton pregnancy 5-10%). Delay in the development of one of the fetuses (differences in size and weight of 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% of twin pregnancies. Polyhydramnios is more often recorded during pregnancy with monozygotic twins than with dizygotic twins, especially with monoamniotic twins. Polyhydramnios can be acute and chronic. In acute polyhydramnios, pregnancy, as a rule, is terminated prematurely, the fetus dies (PN, premature detachment of the placenta) or is born with malformations, uterine rupture or its threat are possible. Acute polyhydramnios before 28 weeks of gestation occurs in 1.7% of twins, and perinatal mortality approaches 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.
Polyhydramnios is diagnosed based on:
Enlargement of the uterus, inconsistencies in its size (circumference of the abdomen, the height of the fundus of the uterus above the womb) with the gestational age; the uterus becomes a tight-elastic consistency, tense;
Mobility, unstable position, difficult palpation of parts; muffled heartbeat of the fetus (s);
Ultrasound (presence of large echo-negative spaces in the uterine cavity, measurement of the space of amniotic fluid free from parts of the fetus in two mutually perpendicular sections).
6. Pathology of the umbilical cord:
Sheath attachment of the umbilical cord (1% for singleton pregnancies and 7% for twins);
Umbilical cord presentation (1.1% in singleton pregnancy with 8.7% in twins);
The only artery of the umbilical cord;
Prolapse of the umbilical cord during childbirth;
Umbilical cord entanglement (in every fourth fetus).
7. Incorrect position of the fetus during childbirth (50% - 10 times more often than with a singleton pregnancy). With twins, in the vast majority of cases (88%), both fetuses are in a longitudinal position and occupy one right, the other left half of the uterus.
Options for presentation and position of the fetus:
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. Clutch of twins during childbirth- collision.
Occurs with a frequency of 1:1000 twins. Perinatal mortality in this complication reaches 62-84%, since the diagnosis is most often made during the period of fetal expulsion. The clutch of twins occurs when the heads of both twins enter the pelvis at the same time or when the first child is born in the breech presentation, and the second in the head. Other options are also possible. In the vast majority of cases, collision is observed in breech - head presentation.
9. Congenital malformations. They are observed 2-3 times more often with multiple pregnancies than with pregnancy with one fetus. The frequency varies, 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 have a number of features, they predominate among male twins.
More often than in singleborns, there are defects of the face and neck. Higher frequency of congenital malformations incompatible with life.
The most common defects are: cleft lip (“cleft lip”), non-closure of the hard palate (“cleft palate”), CNS defects (hydrocephalus, neural tube defects), heart defects, persistent foot deformities, skull asymmetry, congenital hip dislocations. All twins are at risk for compression deformities due to intrauterine compression. In monochorionic twins, the anomalies are usually multiple or fatal, and are generally twice as common as in bichorionic twins.
10. United twins.
Conjoined twins are always monozygotic, same-sex, have the same karyotype (are identical), and can always
noamniotic type of placentation. The frequency is 1 in 10 million births, or 1 in 30,000-100,000 twin pregnancies. This phenomenon occurs predominantly in female fetuses (75%), the reason for this is unknown. The classification of such twins is based on the area of \u200b\u200bthe body with which they are connected to each other:
Thoracopagi (25%);
Thoracoomphalopagi (30%);
Omphalopagi (30%);
Craniopaths (8%)
Pigopagi (55);
Ischiopagi (2%);
Incomplete divergence - bifurcation in only one part or area of the child's body;
Stereopagi - fusion of twins with complete 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, however, the most optimal time for its detection is 24-28 weeks of gestation.
11. Stillbirth- a common occurrence in multiple pregnancy.
12. Neurological disorders(infantile paralysis, microcephaly, encephalomalacia). In children from twins born prematurely, the frequency of brain tissue necrosis reaches 14%.
13. Birth injury fetuses is also characteristic of the delivery of multiple pregnant women.
14. pigtail syndrome- Interlacing of the umbilical cords in monoamniotic twins.
Feto-fetal transfusion syndrome (FFTS) is a special form of violation of placental transfusion, inherent only in multiple pregnancy, 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. Such a transfer of blood from fetus to fetus is called "intrauterine parabiotic syndrome", "transfusion syndrome", "intertwin transfusion syndrome", "fetofetal transfusion syndrome", and also "linked twin syndrome".
In the vast majority of cases, the syndrome develops in monochorionic identical twins. The occurrence of a similar syndrome is described in dizygotic twins, when an anastomosis was formed between separate placentas, but this is more of a casuistry. TTTS can develop in triplets if all three fetuses have a common circulation in the placenta and are monozygotic. The frequency of FTTS varies significantly and is in 3.7-20% of cases of multiple monozygotic pregnancies. It is known that in multiple pregnancies, perinatal mortality is significantly higher than in singleton pregnancies, 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 the perinatal mortality of identical twins is significant and ranges from 25 to 34%.
Pathophysiology of FFTS. The etiology of FTTS 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 separation of the zygote occurs, more precisely, on the type of placentation of monozygotic twins.
1. When the zygote is separated 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 no 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 probability of occurrence of anastomoses in such conditions increases dramatically.
3. When the embryo splits 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 hemocirculation 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 another fetus.
At monochorionic During pregnancy, there is always blood circulation between the fetuses, but all anastomoses function in two directions, and the vascular network is balanced. In TTTS, the placenta is characterized by the presence of one deep arteriovenous anastomosis with blood flow only in one direction and few or no superficial anastomoses that do not compensate for blood shunting. As a result, one fetus becomes a blood donor, and the other is a recipient. The redistribution of blood that occurs in this case 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 anastomotic shunts.
The recipient fetus develops: dropsy due to volume overload, cardiomegaly, tricuspid regurgitation, ventricular hypertrophy, obstruction of the right ventricular outflow tract (varying severity of pulmonary stenosis).
The course of multiple pregnancy with intertwin transfusion is often complicated by hydramnios in the recipient, the appearance of which in gestation periods 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 impairs 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 assigned 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 assigned to the membrane 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 squeezed, reducing umbilical cord blood flow and provoking
secretion of amniotic fluid. Sheath attachment of the umbilical cord of a recipient 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 FTTS occur 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 twin, has a large mass and size, since 2-3 weeks or even more can pass between the death of the first and the birth of twins. However, delivery usually occurs soon after the onset of the shunt-anastomosis due to developing complications of pregnancy, such as hydramnios in the recipient. The widespread belief that in the 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 there is no pattern observed in this. Who will die - the donor or the recipient - depends on who will be depleted of compensatory-adaptive mechanisms first.
Intrauterine dead donor fetuses are most often macerated, with severe pallor of the skin, often with swelling. Autopsy showed partial autolysis of internal organs. Reduced kidneys, liver, thymus indicate a failure to compensate for the resulting blood loss. In 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 plethora (hypervolemia) and polycythemia: they are also macerated and, due to prolonged overload with an increased volume of circulating blood, they have hypertrophy of the myocardium and kidneys at autopsy.
The deceased newborn recipient has plethora of internal organs, often - infarcts of the brain, lungs, liver due to a violation of the rheological properties of blood, hepatosplenomegaly due to increased destruction of erythrocytes and utilization of bilirubin. With the development of heart failure and death from it, a picture of pulmonary edema may be observed. The intrauterine death of one of the fetuses sometimes does not affect the development of the other, especially if it is
occurs before 20-22 weeks of gestation and immediately thrombosed communicating vessels. The dead fetus then turns into "paper" or "stone".
At later dates, communication between fetuses usually persists. Superficial anastomoses are involved in the consequences arising from the intrauterine death of one of the fetuses. With a drop in blood pressure in the bed of a dying fetus, due to a pressure gradient, blood is discharged from a living fetus to a dying fetus through superficial arterial and venous anastomoses. In the case of intrauterine death of one fetus with FTTS, in 25% of cases there is a risk of developing necrotic damage to its twin. Previously, this was explained by the formation of DIC and vascular embolization. The products of autolysis, the active thromboplastic substances of the macerated fetus, can enter the bloodstream of the survivor, usually the recipient, and as an outcome cause him to have DIC with infarcts of the brain, kidneys, skin and other organs. In addition, getting into the mother's bloodstream, thromboplastic substances provoke the development of DIC in her body, disrupting the coagulation system with all the ensuing consequences. This complication occurs in 4-5% of cases of multiple pregnancies. It is now believed that necrotic lesions in the surviving twin are due to acute hypotension and shunt ischemia occurring during the death of the second fetus. Perinatal mortality of the recipient fetus after the death of the donor fetus is about 50% at a gestational age of 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, pseudocardiac anomaly, acephalic acardia, holocardia). This syndrome occurs in 1% of identical monochorionic twins with a frequency of 1 case per 35 thousand-40 thousand 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 (absence of furrows and convolutions and underdevelopment of gray matter in the cerebral hemispheres), heterotopia of the brain in combination with its hypoxic damage, anencephaly as an extreme degree of CNS damage. In 65% of such pregnancies end in premature birth, accompanied by
perinatal death of the “pump fetus” in 50% of cases and non-viability of the perfused fetus in 100% of cases. Having been born, the recipient twin immediately dies. The surviving donor develops hypertrophic cardiomyopathy with insufficiency of the contractile function of the myocardium and within 6 months after birth he has persistent left ventricular hypertrophy.
A twin with polycythemia is threatened by: respiratory disorders, cardiac activity, central nervous system in the form of convulsions, nuclear jaundice due to hyperbilirubinemia due to increased hemolysis of an excess amount of red blood cells. The donor twin develops chronic anemia, its weight and dimensions can 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 FTTS 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 FTTS 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. Sonographic criteria specific for the first trimester of pregnancy and the subsequent development of FTTS:
monochorionic pregnancy;
Expansion of the collar space more than 3 mm at 10-14 weeks;
Reduction (growth lag) of one of the fruits;
The formation of folds of the amniotic septum at 10-13 weeks.
2. Sonographic criteria specific to the II and III trimesters of pregnancy:
Monochorionic type of gestation;
The same sex of fruits;
Thin amniotic septum;
The formation of membrane folds at 14-17 weeks of gestation;
The absence of a lambda-shaped form of placental tissue in the region of the amniotic septa;
The difference in the amount of amniotic fluid: polyhydramnios in one fetus and oligohydramnios in another;
Bladder size difference - small or no visualization of the bladder in a fetus with oligohydramnios (donor fetus) and large bladder size in a fetus with polyhydramnios (recipient fetus);
The difference in the mass of fruits is more than 20% (observed in 72% of cases);
Close fit (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 a close fit of one of the fetuses to the wall of the uterus, it is necessary to carry out differential diagnostics between FFTS and monoamniotic pregnancy (since the amniotic septum is not clearly visualized in the donor fetus due to oligohydramnios). To do this, it is necessary to assess the motor activity of the fetus (flexion, extension of the limbs). With FTTS, fetal movements will be severely limited.
The totality of the listed signs makes it possible to make a diagnosis of feto-fetal transfusion with a probability of 50% already from 19-20 weeks of gestation.
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, it is possible to obtain blood from the umbilical cords of twins and determine the degree of hemotransfusion between them by hematological parameters. The difference in 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 TTTS. The difference in 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, there is a higher content of total protein and albumin in the umbilical cord blood of the recipient than that of the donor. It is proposed to use the level of fetal erythropoietin, which is significant
significantly increased in the cord blood of the donor compared with that of the recipient, as well as in single fetuses.
Treatment of FFTS
Treatment of TFTS 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 bypass 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 FTTS.
1. Conservative treatment involves careful ultrasonic dynamic control, Doppler, ECG and CTG. A thorough antenatal assessment of the condition of the fetus allows you to make a timely decision on early delivery and prevent intrauterine fetal death. The detection of zero or negative diastolic blood flow in the donor's umbilical cord artery and blood flow pulsation in the recipient's umbilical cord vein indicates a poor prognosis for the fetus. Survival 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 method of 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 mortality of twins is reduced to 35%. Some researchers explain the effectiveness of multiple amniocentesis in intertwin transfusion by delaying delivery due to the absence of uterine hyperdistension by an increased volume of amniotic fluid.
3. Fetoscopic laser coagulation vascular anastomoses (FLKSA). Theoretically, laser coagulation - ideal method treatment of FFTS, since it is pathogenetic. A laser beam delivered transabdominally through the amniotic cavity, under the control of ultrasound, coagulates all the vessels on the fetus.
the surface of the placenta in the projection of the amniotic septum between the twins. The procedure is successful in all cases and allows prolonging pregnancy by an average of 14 weeks and reducing perinatal mortality. However, the results of FLKSA 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 FLKS: intra-amniotic bleeding, premature rupture of the fetal bladder, chorioamnionitis, bleeding from the uterine wall.
4. Septostomy- puncture of the amniotic septum, allowing amniotic fluid to circulate between the two amniotic cavities. It is performed under ultrasound control. The use of this method is justified by the fact that FTTS is extremely rare in monoamniotic twins. The survival rate of fetuses with septostomy is 83%. The mechanism of action is unknown. It is possible that the donor fetus corrects its hypovolemia by swallowing amniotic fluid after normalizing their amount.
5. Selective fetal euthanasia- a dubious method of treating TTTS, since its use initially leads to 50% perinatal mortality. However, this method has the right to exist, especially in cases of intractable FFTS or when intrauterine death of one of the fetuses is inevitable. Since blood shunting follows vascular anastomoses from the donor fetus to the recipient fetus, killing the donor fetus is preferable because it is safer for the remaining fetus. Obliteration of the vessels of the umbilical cord can be carried out by embolization, coagulation or ligation. Usually, the operation is performed before the 21st week 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. The treatment of the mother with digoxin, intrauterine venesection and exchange transfusion, which were previously used in FFTS, were ineffective. Prostaglandin synthetase inhibitors indomethacin and sulindac are contraindicated in the treatment of TTTS, as they reduce urine production, which is already reduced in the donor, which can lead to the development kidney 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;
Disappearance of signs of heart failure in the recipient fetus.
FFTS is characterized by a higher frequency 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 monitoring thereafter.
Thus, TTTS, 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 the large number of possible complications in childbirth, is preferable by caesarean section.
Through the natural birth canal, childbirth is possible with the head presentation of both fetuses with twins.
A multiple pregnancy is a pregnancy with two or more fetuses.
In the presence of pregnancy with two fetuses, they talk about twins, three - about triplets, etc. Each of the fetuses in a multiple pregnancy is called a twin.
Frequency of occurrence. Multiple pregnancy averages 1-2% of the total number of births. The frequency of occurrence with a different number of fetuses 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 births (873), or 1 in 87 triplets. However, the true frequency of multiple pregnancy today in developed countries reaches 1:50, which is 2 times more than 20 years ago - 1:101.
Multiple pregnancy may be due to:
1) spontaneous ovulation - 1%;
2) the use of ovulation stimulants - 10% (5-13%);
3) use of human menopausal gonadotropin -
4) use of in vitro fertilization with embryo transfer - 30%.
Currently, iatrogenic multiple pregnancies account for 30-80% of multiple pregnancies, which is due to the introduction of modern methods of infertility treatment, 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 monozygotic twins is relatively stable and amounts to 0.35-0.5% of all births. The following factors influence the frequency of dizygotic twins:
History of twins (the birth of twins in this woman, her belonging to twins, etc.);
Mother's age from 35 to 39 years;
Number of births (frequency increases with the number of births);
Anomalies in the development of the uterus;
Belonging to the black race;
Use of assisted reproductive technologies (in vitro fertilization);
A multiple pregnancy is a pregnancy with two or more fetuses. In the presence of pregnancy with two fetuses, they talk about twins, three - about triplets, etc. Each of the fetuses in a multiple pregnancy is called a twin. Twin births occur once in 87 births, triplets - once in 872 (6400) twins, quadruplets - once in 873 (51200) triplets, etc. (according to the Gallin formula).
Causes of multiple pregnancy.
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 these possibilities, the facts of detection during an operation for a 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 pregnancy can be fertilization with sperm from different partners, fertilization against the background of an existing pregnancy, induced pregnancy. Twins, formed from the fertilization of two eggs, are called dizygotic, identical twins result from atypical crushing of the egg. Where the separation of the egg occurs completely, two identical twins are formed. Such twins are called identical. Identical twins are much less common than fraternal twins (1:10). If, with complete separation of the eggs, both rudiments are located in the uterus at a sufficient distance from each other, then the embryos developing from them form a separate amnion each for themselves and remain separate - biamniotic twins. If both amniotic sacs are enclosed in one common chorion for both twins, and the septum between them consists of two shells (two amnions), then such twins are called monochorionic. They share a common placenta. If both rudiments lie side by side, this leads to the formation of one amniotic cavity common to both (monoamniotic twins). Identical twins are always the same sex - either both boys or both girls, they are similar to each other, 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, impaired urination, 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 the fetus, the death of one of the fetuses. In some cases, polyhydramnios in one cavity may be accompanied by oligohydramnios in another.
Recognition of multiple pregnancy in the first months is quite 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. On auscultation - two or more points for determining the fetal heartbeat and a zone of silence between them. The height of the uterine fundus is greater than in a singleton pregnancy at the same time. When measuring the length of the fetus with a tazomer - a large length of the fetus with a small head. The most reliable diagnostic method is ultrasound.
In the vast 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%). There are other options for the location of the fetus in the uterus. One fetus may be in cephalic presentation, the other in breech presentation (43.0%). Both fetuses are in breech presentation (6.0%). One fetus is in the longitudinal position, the other is in the transverse position (5.5%), or both fetuses are in the transverse position (0.5%). Medical supervision of pregnant women with multiple pregnancies is carried out taking into account possible complications, highlighting them as a risk group for the development of perinatal pathology.
COURSE AND MANAGEMENT OF DELIVERY
The prognosis of pregnancy and childbirth with multiple pregnancy is less favorable than with one fetus. At the slightest deviation from the normal course of pregnancy, mandatory hospitalization is indicated. Re-hospitalization in 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 pregnancy is accompanied by frequent complications of the birth act. Most births occur prematurely, the weight of newborns is less than 2500 g, possibly pelvic and transverse positions of the second fetus. Frequent untimely discharge of amniotic fluid may be accompanied by prolapse of small parts of the fetus and 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 the birth forces develops, premature discharge of amniotic fluid occurs, so the period of disclosure is delayed.
The period of exile may also be delayed due to the development of anomalies in labor activity. Prolonged labor is dangerous for the mother (bleeding, infection) and the fetus (hypoxia).
Placental abruption before the birth of the second fetus leads to its intrauterine death. There may be a transverse position of the second fetus, twin collision (adhesion of two large parts of the body), bleeding in the third stage of labor, in the early postpartum period, delayed uterine involution and infectious diseases.
Conducting childbirth with multiple pregnancies requires great attention, a clear orientation in the obstetric situation and high qualifications that allow you to perform any operation. In the period of disclosure, it is necessary to carefully monitor the condition of the woman in labor and the fetus. If there is polyhydramnios, an opening of the fetal bladder is shown when the cervix is 4 cm open and the water is slowly removed (within 1-2 hours).
In order to reduce the complications of childbirth with multiple pregnancies 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 begin intravenous drip administration of 5 units. oxytocin in a 5% glucose solution in order to accelerate the second stage of labor until the placenta separates. 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 leg 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 carried out to determine the integrity of the lobules and membranes and the type of twins (one- or two-egg).
In the postpartum period, careful monitoring of the puerperal, prevention of subinvolution of the uterus is necessary.
Perinatal mortality in multiple pregnancies is 2 times more common than in single births. 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 pregnancy - fetal hypoxia, anomalies in labor, prolapse of the umbilical cord, extragenital pathology of the mother, severe gestosis, presentation and placental abruption.
Prevention of complications in multiple pregnancy is the prevention of complications during pregnancy.
Multiple pregnancy is considered a pregnancy with two or more fetuses at the same time.
What is the birth rate of twins?
The number of identical twins remains relatively stable at about 1 in 225 births, regardless of race and the number of previous births a woman has.
The ability to have fraternal twins in women is hereditary. The French biologist D. Hellin in 1895 formulated the law on the birth of twins, according to which in a population one birth of twins occurs in 85 single births, triplets - in 85 twins, quadruples - in 85 triplets, etc.
Therefore, before the widespread introduction of new fertility treatments, one triplet accounted for approximately 7,000 births, one quadruple for 680,000, and one gear for 4,712,000,000 births. The probability of having fraternal twins increases with the number of births (two times after the second birth, five times after the fifth) and the age of the woman (over 30-35 years old), their tall and overweight. In addition, mothers of such twins most often have AB (IV) blood type. The probability of multiple pregnancy recurrence increases through the generation: if a grandmother had twins at one time, then her granddaughter also has a high risk of multiple pregnancy.
It is impossible to exclude the fact of the existence of men who cause multiple pregnancy in their wives. In Russia, at least two such cases are known. In 1755, the sixty-year-old Yakov Kirillov, a peasant in the village of Vvedenskoye, married twice, was introduced to Empress Elizaveta Alekseevna. The first wife for 21 pregnancies bore him 57 living children, 4 times four, 7 times three and 10 times two. The second - for 7 pregnancies gave birth to I5 children, 1 time three and 6 times two. In total, Kirillov had 72 children from two wives.
In February 1782, an accounting sheet was delivered to Moscow from the Nikolsky Monastery, located in the Shuisky district. It said that the peasant Fyodor Vasiliev, married twice, had 87 children from both marriages. The first wife for 27 births gave birth 4 times four, 7 times three and 16 times two children. The second wife gave birth 2 times three and 6 times two children. Vasiliev then turned 75 years old, and of the living children there were 82.
In different races, the number of twins varies significantly from less than 1 in 100 births in Japan to 1 in 30 births in Nigeria.
Since the development of modern methods of infertility treatment, the number of fraternal twins has doubled, and the number of triplets and more multiple pregnancies has increased by 500%. Today, more than 1% of all pregnancies are multiples.
Twins or twins
There are two types of twins: fraternal (heterozygous, "false") and identical (monozygous, "true"). Children born from twin twins are called "twins", and children from identical twins are called "twins". "Twins" can be both same-sex and different sexes, while "twins" can only be of the same sex. Twins can also be mirrored (one twin is left-handed, and the other is right-handed, the hair on the tops is twisted in different directions).
Heterozygous twins (70% among twins) develop from two eggs when they are fertilized during one menstrual cycle by two different spermatozoa. In this case, two different fetal eggs are formed, which are implanted in the uterus next to each other and subsequently develop autonomously. Each embryo/fetus develops its own placenta, and each is surrounded by its own amniotic and chorionic membranes, creating a four-layer interfetal septum.
Such twins are called bichorionic biamniotic twins. There is no functional relationship between the two embryos/fetuses. Genetically, they are related in the same way as any children of the same parents; they may have different fathers and be conceived more than a week apart. There is a classic case where white woman with an interval of 1 hour gave birth to a white child, the son of a white father, and a mulatto, the son of a Negro (the so-called "overfertilization").
Identical or monozygotic twins (30%) appear when one fertilized egg, under the influence of factors yet unknown to us, divides into two eggs, each of which will further independently develop. Both fetuses, formed from one fetal egg, divided into two equal parts, receive a completely identical set of chromosomes and genes.
After birth, these true twins will become twins, an exact copy of one another with the same blood type, eye color, hair color, position and shape of teeth, identical fingerprints in 95% of cases, or in accordance with the classic formulation “one person in two copies”. This striking similarity is not limited to external data, it applies to the intellect, and to the psyche, and to a predisposition to a number of diseases.
The number of placentas formed in this case will depend on the stage of development of the fetal egg at which its division occurred.
Twins with separate amnions and chorions/placentas appear when separation occurs within 3 days of fertilization. The partition between them consists of four sheets, as in the case of twins. Such twins are called bichorionic biamniotic twins.
If the division of the egg occurs in the period from 3 to 8 days after fertilization, then two embryos, two amnions and only one chorion / placenta are formed. The partition between the fruits is formed from two leaves of the amnion. This type of identical twins is called monochorionic biamniotic.
During the division of the egg in the interval of 8-13 days after fertilization, two embryos and one chorion are formed, surrounded by a single amniotic membrane. The interfetal septum is absent. Such identical twins are called monochorionic monoamniotic.
If separation occurs later than day 13, conjoined twins are formed ( Siamese twins).
Most the best option- this is the presence of two placentas and two amniotic bladders, since in this case the twins do not depend on each other. If the placenta is one for two, there is blood exchange between the children, that is, sometimes one can receive more blood than the other (feto-fetal transfusion syndrome (FFTS) or "donor-recipient" syndrome), the first fetus suffers from excess blood, and the second - from its deficiency (discordant fruit growth). Due to excess blood in the first case, congestive heart failure is possible (the heart has to do overwork, leading to an increase in its size).
In the second case, anemia or growth retardation (hypotrophy) caused by insufficient blood flow is possible. As a result, a woman should be under the constant supervision of a doctor. To identify early signs SFFG pregnant women with twins need to be examined, including ultrasound, more often than with a singleton: examinations after 20 weeks - once every two weeks and after 30 weeks - weekly.
Complications of multiple pregnancy
Multiple pregnancies carry risks for both the mother and the baby, and these pregnancies are more likely to have complications. 54% of twins and 93% of all triplets and more pregnancies are born ahead of time. With multiple pregnancies, late toxicosis (preeclampsia), maternal anemia, miscarriage (including premature birth) occur more often and more severely.
The course of a multiple pregnancy, as already mentioned, is often complicated by a delay in the development of one of the fetuses, the level of which is 10 times higher than in a singleton pregnancy.
One of the most common complications of multiple pregnancies is preterm birth, caused by uterine overstretching due to a large number fetuses and because of the frequent polyhydramnios in these pregnancies. The duration of pregnancy directly depends on the number of fetuses. Duration of singleton pregnancy, pregnancy of twins and triplets averages 39, 36-37 and 34 weeks, respectively. However, nature protects twin newborns: their ability to adapt after giving birth at the indicated time is much higher than that of a child born in a singleton pregnancy.
In order to prevent premature birth, pregnant women with multiple pregnancies are recommended to limit physical activity, increase the duration of daytime rest up to three times 1-2 hours each). You need to lie more on your side so that the heavy uterus does not squeeze the inferior vena cava. And already after the 20th week of pregnancy, a woman is advised to stop engaging in active sports (except, perhaps, swimming), intensive work, and sexual activity. In our country, a woman expecting several children at once is entitled to a longer maternity leave for pregnancy and childbirth: 84 days before (from 28 weeks of pregnancy) and 110 days after childbirth.
To identify the threat of preterm birth, the obstetrician-gynecologist evaluates the condition of the cervix (including its length) using ultrasound every two to three weeks. If it is shortened to 23 weeks, sutures (cerclage) are applied to the neck. Also, the insertion of an obstetric supportive pessary into the vagina gives a good effect. It is important not to miss the time for these procedures. After 23 weeks, in order to eliminate the threat of preterm labor, it is possible to prescribe drugs that reduce the tone of the uterus. With the threat of preterm birth, all pregnant women are given medical prophylaxis of respiratory disorders in newborns who were born prematurely.
Pregnant women with multiple pregnancy from the second trimester should receive prophylactically up to 60 mg of iron and 1 mg of folic acid per day. In addition, iron-rich foods should be included in the diet: liver and other offal, beef, cereals, sardines, artichokes, melons, turnips, jacket-baked potatoes, spinach, soybeans.
The weight of a newborn child with a singleton pregnancy averages 3360 grams, twins - 2400, and triplets - a little more than 1700 grams. As a rule, the difference in body weight between newborn twins is small, amounting to about 200-300 g. Less often, a significant difference in their body weight (dissociated development in FTTS) is detected - up to 1 kg or more.
To minimize the possibility of having small children, a pregnant woman should pay considerable attention to her nutrition, especially in the first trimester. Each child needs up to 400 calories per day.
Women with multiple pregnancies need to know that if in the case of a singleton pregnancy the optimal weight gain is up to 12-13 kg, then in the case of twin pregnancy, the total weight gain per pregnancy should be at least 18-20 kg, while it is important for guaranteed physiological growth of the fetus has a weight gain in the first half of pregnancy of at least 10 kg.
Childbirth with multiple pregnancy
In the case of multiple pregnancy, childbirth is a more complicated process, especially for the second twin; sometimes a caesarean section is the best choice, or the doctor pre-programs exactly the operation.
Indications for operative delivery in multiple pregnancy are: excessive overstretching of the uterus and large fetuses (with a total weight of more than 6 kg); severe course of late toxicosis (gestosis), which is a contraindication to childbirth through the natural birth canal; breech presentation of the first fetus (in primiparas), which entails all the problems associated with childbirth in the breech presentation.
The issue of caesarean section in childbirth during multiple pregnancy can also arise for other reasons: persistent weakness of labor, placental abruption, prolapse of small parts of the fetus, umbilical cord loops during cephalic presentation, signs of acute oxygen starvation of one of the fetuses and others.
If there are no absolute indications, then vaginal delivery is preferable. In the presence of three or more fetuses, regardless of the condition of the woman, it is recommended to perform operative delivery at 34-35 weeks of pregnancy.
How much does pregnancy cost
All services| The program of comprehensive monitoring of a pregnant woman from the first half of pregnancy to childbirth (No. 1) | 135 100 rub. |
| The program of comprehensive monitoring of a pregnant woman from the first half of pregnancy to childbirth in multiple pregnancies (No. 2) | 159 732 rub. |
| The program of comprehensive monitoring of a pregnant woman from the first half of pregnancy to childbirth and postpartum care for one year (No. 3) | 182 232 rub. |
| The program of comprehensive monitoring of a pregnant woman from the first half of pregnancy to childbirth and postpartum care for one year with multiple pregnancies (No. 4) | 204 579 rub. |
| The program of comprehensive monitoring of a pregnant woman from the second half of pregnancy to childbirth (No. 5) | 117 522 rub. |
| The program of comprehensive monitoring of a pregnant woman from the second half of pregnancy to childbirth in multiple pregnancies (No. 6) | 135 927 rub. |
| The program of comprehensive monitoring of a pregnant woman from the second half of pregnancy to childbirth and postpartum care for one year (No. 7) | 163 251 rub. |
| The program of comprehensive monitoring of a pregnant woman from the second half of pregnancy to delivery and postpartum care for one year with multiple pregnancies (No. 8) | 179 649 rub. |
| Comprehensive monitoring program for pregnant women from 36 weeks to delivery (No. 9) | 67 032 rub. |
| The program of comprehensive monitoring of a woman within one year after childbirth (No. 10) | 43 695 rub. |
Related tests:
"Postpartum"
Instruction: choose one correct answer
1. The postpartum period continues:
A) 4 weeks
B) 6-8 weeks
B) 10 weeks
D) 15 weeks
2. 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 uterus after childbirth weighs:
5. For the treatment of lactostasis, apply:
A) antispasmodic drugs
B) Painkillers
B) 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. The toilet of the external genitalia during bed rest is carried out
5. The bottom of the uterus on the 10th day after birth is
Answers:
Glossary on the topic "Female genital organs" (p. 2):
1. a section of the abdominal wall rich in subcutaneous fat. Located between the inguinal folds
2. 2 longitudinal skin folds covered with hair. Cover all external genital organs, protect them.
3. skin folds located under the labia majora.
4. organ of sexual desire. It is located at the superior junction of the labia minora.
5. connective tissue film that covers the entrance to the vagina
6. paired glands, located in the cavity of the small pelvis, approximately 2x2x3 cm in size. 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 an unborn child.
9. narrow tubes with a pronounced muscular layer, constantly contracting.
10. whole-tissue canal with a length of 7-8 to 9-10 cm. It is attached to the place where the cervix passes into her body.
On the crossword on the topic "Female genital organs" (p. 3):
1. Ampoule
2. Perineum
3. Functional
5. Interstitial
7. Fallopian
9. Ovaries
10. Clitoris
For tests on the topic "Female genital organs" (p. 4):
Complete the phrase:
1. Crotch
3. Alkaline
4. Basal and functional layers
5. Moisturizes the entrance to the vagina and thins the seminal fluid
Glossary on the topic "Menstrual cycle" (p. 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. sac of secretory fluid surrounding an immature egg in the ovary
6. hormone responsible for the development and maintenance of female reproductive organs and secondary sexual functions
7. restoration of the functional layer
8. release of a mature egg from the ovary into the fallopian tubes
9. hormone, under the influence of which the corpus luteum is formed and releases progesterone
10. small temporary endocrine glands that form in the ovaries at the site of a burst follicle
11. corpus luteum hormone, under the influence of which the placenta is formed during pregnancy
12. uterine mucosa
13. hormone, under the influence of which the follicle breaks and ovulation occurs
On the crossword on the topic "Menstrual cycle" (p. 6):
1. Desquamation
2. Ovulation
3. Ovarian
4. Estrogen
5. Endometrium
6. Follicle
7. Prolactin
8. Menarche
9. Pituitary
10. Progesterone
For tests on the topic "Menstrual cycle" (p. 7):
Choose one correct answer:
Complete the phrase:
1. Fertilization did not occur
2. Darker and won't curl
3. Moves away
4. Development and rupture of the follicle; development of the corpus luteum
Glossary on the topic "Pregnancy" (p. 8):
1. the process of fusion of male and female germ cells with the formation of a zygote
2. the ratio of the back of the fetus to the left or to right side uterus
3. outer shell of the zygote (nourishes, secretes enzymes)
4. fertilized egg
5. own shell of the embryo (develops from trphoblast)
6. aquatic membrane of the embryo, own, contains amniotic fluid
7. maternal, functional layer of the uterus modified under the action of progesterone
8. complete immersion of the zygote in the functional layer of the uterus
9. ingrowth of the vessels of the embryo into the vessels of the mother
10. placenta formation
eleven. " children's place", an organ that communicates between the mother's body and the fetus
12. laying of organs and systems
13. the ratio of the limbs and head of the fetus to its body
14. the ratio of the lowest located large part of the fetus to the birth canal
15. substances that lyse (“eat”) living tissues
On the crossword on the topic "Pregnancy" (p. 9):
1. Vascularization
2. Trophoblast
4. Implantation
5. Placenta
8. Enzymes
9. Fertilization
10. Decidual
For tests on the topic "Pregnancy" (p. 10):
Choose one correct answer:
Complete the phrase:
1. History taking
2. Gynecological chair
3. Couch
4. Pregnancy, extragenital
5. Embryo, fetus
Glossary on the topic "Physiological childbirth" (p. 11):
1. rhythmic contractions of the muscles of the uterus
2. from the periphery, from the lower edge, the blood is freely released
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, abdominals, pelvic floor and skeletal muscles. Occur reflexively when nerve endings are irritated
On the crossword on the topic "Physiological childbirth" (p. 12):
1. Timely
2. Harbingers
3. Disclosures
4. Contractions
5. Regional
6. Oxytocin
8. Central
9. Exiles
10. Pushing
For tests on the topic "Physiological childbirth" (p. 13):
Choose one correct answer:
Complete the phrase:
1. Contractions and attempts
2. Birth canal
3. Exiles
4. Timely; early
5. Placenta, amniotic membranes
Postpartum Glossary (page 14):
1. a secret from fragments of the decidua, blood clots, fragments of blood vessels, mucus, blood cells in the stage of decay
2. primary milk, consists of protein, fat, condensed epithelium of the glands, immunoglobulins, lymphocytes
3. lack of menstruation
4. reverse development of organs
5. place of the former placenta attachment
6. the inner surface of the uterus after separation of the placenta from its walls
7. milk secretion
8. inflammation of the mammary glands
9. stagnation of milk in the ducts of the mammary glands
10. inflammation of the uterine mucosa
11. pathological spontaneous outflow of milk from the mammary glands out of connection with the process of feeding the child
On the crossword on the topic "Postpartum" (p. 15):
1. Lactorrhea
2. Prolactin
3. Wound
6. Involution
7. Colostrum
8. Postpartum
9. Lactostasis
10. Placental
For tests on the topic "Postpartum period" (p. 16)
Choose one correct answer:
Complete the phrase:
1. Early and late
2. Massage and "drain" the chest
3. 5-6 days
4. 3 times a day
5. At the upper edge of the pubic joint
Multiple pregnancy The likelihood of twins increases: History of twins (belonging to twins) Maternal age from 35 to 39 years Number of births Belonging to the black race Use of assisted reproductive technologies Conception after taking COCs High secretion of pituitary gonadotropins
Multiple pregnancy Classification By zygosity: Dizygous (twin, non-identical) Monozygous (identical, identical) By chorion (placentation): Bichorionic - biamniotic Monochorionic - biamniotic Monochorionic - monoamniotic
Multiple pregnancy Multiple pregnancy Fertilization of two or more oocytes Simultaneous ovulation followed by fertilization of two or more eggs matured in different follicles of the same ovary Simultaneous ovulation followed by fertilization of two or more eggs matured in different follicles in both ovaries Ovulation and fertilization of two or more eggs, matured in one follicle Superfertilization - fertilization of two or more simultaneously ovulated eggs by spermatozoa of different men Fertilization of an egg that ovulated against the background of an existing pregnancy
Multiple pregnancy Early division of a fertilized egg (depending on the time from fertilization to zygote splitting, one of 4 twin options): 0-72 hours - bichorionic - biamniotic monozygotic twins 25% 4-8 days - monochorionic - biamniotic monozygotic twins 70% 9-13 day - monochorionic - monoamniotic monozygotic twins 5% After 13 days - fused (Siamese) twins
Multiple pregnancy Diagnosis Clinical and anamnestic signs: Excessive weight gain The height of the fundus of the uterus is 4 cm or more more than is typical for this period, an increase in the circumference of the abdomen. Palpation of parts of the fetus, the size of the fetal head, not corresponding to the size of the uterus. Auscultation at two or more sites of fetal heartbeat
Multiple pregnancy Ultrasound - the gold standard in the diagnosis of multiple pregnancy Accuracy - 99.3% Possible from 6-7 weeks of gestation When using a vaginal probe from 4-5 weeks of gestation Allows you to determine the number of fetuses, amnions, or reality (especially in the first 14 weeks) Differential diagnosis of bichorial from monochorionic twins is easier in the first trimester and can be performed with transvaginal ultrasound at 5 weeks
Multiple pregnancy Complications in the mother: Anemia (2 times more common than in singleton pregnancies) Spontaneous abortions (2 times more common than in singleton pregnancies) in 50% - fetuses were resorbed - anembryony - death of the embryo "vanishing twin" - phenomenon "disappeared twin" no later than 14 weeks
Multiple pregnancy Complications in the mother during pregnancy: Early toxicosis (nausea and vomiting are more severe) Pregnancy-induced hypertension (3 times more common than in singleton pregnancy) Preeclampsia (in 20-40% of pregnant women with multiple pregnancies) Threatened preterm birth, preterm birth (36 .6%-50%)
Multiple pregnancy Complications in the mother during pregnancy: Premature discharge of amniotic fluid (25% of cases) which is twice the frequency in singleton pregnancies Polyhydramnios occurs in 5-8% of twin pregnancies, especially in monochorionic twins. Acute polyhydramnios before 28 weeks of gestation occurs in 1.7% of twins. Impaired glucose tolerance Cholestasis of pregnancy
Multiple pregnancy Complications in the fetus: High perinatal mortality of 15% increases in direct proportion to the number of fetuses - increases in direct proportion to the number of fetuses - per 1000 births in twins per 1000 births in triplets per 1000 births in triplets
Multiple pregnancy Fetal complications: Prematurity - low birth weight (55% weight less than 2500) - respiratory distress syndrome - intracranial hemorrhage - sepsis - necrotizing enterocolitis Average duration of pregnancy: Twins - 35 weeks Triplets - 33 weeks Quadruples - 29 weeks
Multiple pregnancy Complications in the fetus: Congenital malformations Observed 2-3 times more often than during pregnancy with one fetus Observed 2-3 times more often than during pregnancy with one fetus In monochorionic anomalies, twice as often as in bichorial ones The frequency ranges from 2 to 10 % The frequency ranges from 2 to 10% The most common: cleft lip non-occlusion of the hard palate non-occlusion of the hard palate CNS defects CNS defects heart defects
Multiple pregnancy Complications in the fetus: United twins Frequency - 1: 900 twin pregnancies Classification is based on the area of the body by which they are connected to each other: thoracopagi - fused in the area chest(40%) omphalopagi - fused in the anterior abdominal wall (35%) pygopagi - fused in the sacrum (18%) ischiopagi - fused in the perineum (6%) craniopagi - fused in the head (2%)
Multiple pregnancy Complications in the fetus: Pathology of the umbilical cord and placenta: -placenta previa -placental abruption (more often in the second stage of labor) -sheath attachment of the umbilical cord (7% in twins) -previa of the umbilical cord (8.7% in twins), -prolapse of the umbilical cord in childbirth
Multiple pregnancy Complications in the fetus: Feto-fetal transfusion syndrome (twin transfusion syndrome) complication of monochorionic multiple pregnancy frequency up to 15% frequency up to 15% anastomoses leading to pathological shunting of blood from one fetus to another One fetus becomes a donor and the other recipient
Feto-fetal transfusion syndrome Donor Chronic blood loss Anemia HypovolemiaHypoxia Limited growth Decreased renal blood flow Oliguria Oliguria Amnion compression Recipient Chronic increase in BCC Hypervolemia PolycythemiaHypertension Non-immune dropsy Cardiomegaly Polyuria Polyhydramnios
Multiple pregnancy Complications in the fetus: Malpresentation of the fetus during childbirth (50% - 10 times more often than in singleton pregnancies): -Head-head 50% -Head-pelvic 30% -Pelvic-head 10% two fruits 10%
Multiple pregnancy Complications in the fetus: Collision - Coupling of twins during childbirth Frequency 1: 1000 twins and 1: childbirth Perinatal mortality with this complication reaches 62-84% Diagnosis is made during the period of fetal expulsion Diagnosis is made during the period of fetal expulsion Observed in breech presentation
Multiple pregnancy Complications in the fetus: Various variants of impaired development of one or both twin fetuses - a consequence of placental insufficiency 5 types of prenatal development of twin fetuses (M.A. Fuchs): 5 types of prenatal development of twin fetuses (M.A. Fuchs): physiological development of both fetuses - 17.4% uniform malnutrition of both fetuses - 30.9% uniform malnutrition of both fetuses - 30.9% uneven development of twins - 35.3% congenital pathology of fetal development - 11.5% antenatal death of one fetus - 4 ,1%
Multiple Pregnancy Fetal Complications: Intrauterine fetal growth retardation incidence of 70% compared to 5-10% in singleton pregnancies. Delay in the development of one of the fetuses (differences in size and weight of more than 15-25%) with a frequency of 4-23%. Neurological Disorders: Infantile Paralysis Microcephaly Microcephaly Encephalomalacia Encephalomalacia Premature twins have up to 14% brain tissue necrosis. In children from twins born prematurely, the frequency of brain tissue necrosis reaches 14%.
Multiple pregnancy Pregnancy management: Early diagnosis of multiple pregnancy Dynamic monitoring once every two weeks in the first half of pregnancy, once a week in the second half of pregnancy Good nutrition Bed rest Prevention of iron deficiency anemia
Multiple pregnancy Pregnancy management: ultrasound monitoring of fetal development - Screening (standard) ultrasound per week. to exclude developmental anomalies (taking into account the increased background risk of congenital anomalies) - Dynamic ultrasound starting from 24 weeks. every 3-4 weeks before delivery (to assess fetal growth and timely diagnosis of FTTS)
Pregnancy management: assessment of the state of the fetus according to CTG (non-stress test) should be started at 1 week. and continue weekly until delivery If there is evidence of impaired fetal growth, weekly assessment of the biophysical profile, amniotic fluid index, weekly CTG and umbilical cord blood flow Doppler should be performed from the time this pregnancy complication is diagnosed Multiple pregnancy
Pregnancy management: In case of diagnosed FFTS syndrome: - Conservative treatment (observation, early delivery if necessary) - Amnioreduction (a series of therapeutic amniocentesis 1-12, removal of 1-7 liters) - Fetoscopic laser coagulation of vascular anastomoses - Septostomy (puncture of the amniotic septum) - Septostomy (puncture of the amniotic septum) - Selective euthanasia of the fetus (donor) embolization, coagulation, ligation
Multiple pregnancy Management of labor: At the beginning of the first period, ultrasound is necessary to clarify the position and presentation of the fetuses (the position may change compared to what it was a few days before the onset of labor) Monitoring of both fetuses by recording CTG is necessary during the first stage of labor
Multiple pregnancy Indications for caesarean section: Monoamniotic fetuses regardless of the position of the fetuses Conjoined twins Transverse position of the first fetus Breech presentation of the first fetus with excessive head tilt Transverse position of the second fetus, which remains unchanged after the birth of the first fetus and an attempt to externally rotate the second More than two fetuses
Multiple pregnancy Management of vaginal delivery: If the second fetus is in a transverse position, ultrasound should be performed to monitor for a possible change in its position. External-internal rotation with subsequent extraction of the fetus by the pelvic end is undesirable due to severe traumatic complications for the fetus. After the birth of the second fetus and placenta, it is necessary to prevent bleeding
