monitor the fetal development for these pregnancies

 Abd Halim: Dr Shaiful, i have 2 cases of Monochorionic Diamniotic Twins.

I just wanna ask how to we monitor the fetal development for these pregnancies.

Cos my patient stated that:

"Satu baby kecik, satu besar."

Faiz Johari: patient ad HT ke hazwan?

Faiz Johari: guna Ultrasound?

 Abd Halim: PIH. 32 weeks POA ade elevated BP.

 Abd Halim: Ultrasound tu betul, tp how can we describe the finding? What i got was:

✅ Fetal growth (how do we compare?)
✅ Fetal lie (when do we start measuring)
✅ Fetal movement (how can we know?)
✅ Amniotic fluid index (If diamniotic)

Jeng jeng jeng.

Dr Shaiful Ehsan: Assalam halim, thanks for asking, I will reply later in afternoon after work...tq.
Btw...good observation....

 Abd Halim: Geng2 ni pon byk soklan dr, cuma x tahu nk start tanye dr mana.

 Dr Shaiful Ehsan: Keep on asking guys...InsyaAllah the more u ask...the more brighten ur future is...

 Dr Shaiful Ehsan: Halim:
In monochorionic twins (MCDA), the monitoring should begins since the 1st time patient suspected prenancy,
Early booking should be done and early confirmation of the chorionicity should be done....as early as before 14 weeks to see the lambda sign or T sign (MCDA)
Monitoring and follow up of twins pregnancy should be done by primary care (FMS) together with O&G team at tertiary center...

Aims of monitoring is for fetal monitoring and maternal monitoring..., to detect early complications to mother (eg anaemia in pregnancy, hypertension, DM)

Dr Shaiful Ehsan: And to detect complications to fetus eg discordance growth, Twin to twin tranfusion syndrome and others...

Dr Shaiful Ehsan: So usually TAS is 2 weekly to 4 weekly...

 Dr Shaiful Ehsan: If more than 26 weeks....usually we do every 2 weeks..

Dr Shaiful Ehsan: Aim for delivery is around 34-36 weeks for MCDA......

Dr Shaiful Ehsan: If MCMA around 32-34 weeks by ELLSCS....risk of IUD and cord entaglement is higher in MCMA...

Dr Shaiful Ehsan: For fetal growth....we measure by clinical SFH and TAS for BPD , HC , FL and AC...any SGA or IUGR is depends on centile per gestational age....need to plot the chart...

Dr Shaiful Ehsan: Any lie is considered normal unless at term...completed 37 weeks...abnormal lie is by definition at 37 weeks..

Dr Shaiful Ehsan: Fetal movement patient need to count since 28 weeks....that is universal rule...
By fetal quickeming usually felt at 16-20 weeks...

Dr Shaiful Ehsan: AFI is important in any pregnancy...in twin we cant measure the total AFI....but the deepest pole...

Abd Halim: Cop dr saiful. 4 weekly maksudnye once every 4 weeks kan? 2 weekly one every 2 weeks kan?

Dr Shaiful Ehsan: Yupp...TAS after 26 - 28 weeks is done 2 weekly for monochorionic....for DCDA can done 4 weekly...

management cor IUD of one fetus in twin pregnancies

Dr shaiful: Assalamualaikum, 5th month of pregnancy...so it would be after age of viability...which means more than 24 weeks gestations...which we called intrauterine death (IUD) or fetal demise...
For fetal demise of one fetus in twin pregnancy, mx depends on type of chorionicity, gestation and causes of fetal demise...

Dr. Shaiful: But for monochorionic twins (shared placenta) the risk of IUD of the paired twin is there...can be as high as 20%...even if survive...there is still risk of neurological damage to the surviving fetus...
I have encounter certain hospital giving MgSo4 (not for PE) but for cerebral protection in potential severe prem baby (eg htaa) which can be applied as well in this case of reducing risk of morbidity of surviving 2nd fetus...
Time of delivery is basically still grey area in monochorionic twins...and opinions from fetomaternal specialist (eg Dr Anna) is really required...
If conservative is choosed, some suggest delivery as early as 28 weeks for MCMA, and up to 34 weeks for MCDA...

Dr. Shaiful: Lets begin with DCDA twin (2 sacs 2 placentas = 2 different sets of rooms). If one fetus IUD, and the causes is not related to systemic or uteroplacental insufficieny, and most likely not gonna cause another IUD to the surviving fetus...conservative managememt can be done and wait for delivery at least till 34 weeks (most studies showed that 90% of preterm baby salvageable at 34 weeks)

Dr. Shaiful: Im forwarding my answers to ur fren in other posting asking about management cor IUD of one fetus in twin pregnancies....
Above are the answers...
Hope its useful...

Dr. Shaiful:My homework for u guys are events occur at 34 weeks...
Tq.

Faiz Roslan: Dr, one of the events occur during 34 weeks is that the amniotic fluid is at its max. Betul ke dr?

6oct2015