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Peranan USG pada
kehamilan kembar
Sofie Rifayani Krisnadi
Departemen Obstetri dan Ginekologi
Fakultas Kedokteran Universitas Padjadjaran
RSUP Dr. Hasan Sadikin
BANDUNG

?Kehamilan kembar berhubungan dengan risiko tinggi Mortalitas dan Morbiditas Perinatal.
?Tahun 2009, Tingkat kelahiran mati (stillbirth): 12/1000 kelahiran kembar dan 31/1000
kelahiran triplet dibandingkan 5 / 1000 kelahiran tunggal.
?65% kematian neonatal pada kehamilan multipel adalah preterm, dibandingkan 43%
kematian neonatal pada kehamilan tunggal.
Insidensi

Penilaian ultrasound terhadap :
? Biometri janin
? Anatomi
? Doppler velosimetri
? Jumlah cairan amnion
Gangguan pertumbuhan janin kembar dapat dinilai dengan parameter
yang sama dengan kehamilan Tunggal.
Identifikasi dan monitor :
? Uncomplicated twin pregnancy.
? Kehamilan kembar terhadap
outcome yang buruk seperti pada
kondisi TTTS, selective FGR
(sFGR), twin anemia�C
polycythemia sequence (TAPS),
twin reversed arterial perfusion
(TRAP) sequence, conjoined
twins.

Peranan USG pada kehamilan kembar - Prof SRK.pptx

Khalil A, Rodgers M, Baschat A, Bhide A, Gratacos E, et.al. ISUOG Practice Guidelines: role of ultrasound in twin pregnancy. Ultrasound Obstet Gynecol
2016; 47: 247�C263.

Khalil A, Rodgers M, Baschat A,
Bhide A, Gratacos E, et.al.
ISUOG Practice Guidelines: role
of ultrasound in twin pregnancy.
Ultrasound Obstet Gynecol
2016; 47: 247�C263.
Routine
monitoring of
twin pregnancy
with ultrasound

Khalil A, Archer R, Hutchinson V,
et al. Noninvasive prenatal
screening in twin pregnancies with
cell-free DNA using the IONA test:
a prospective multicenter study.
Am J Obstet Gynecol
2021;225:79.e1-13

Dugoff L, Koelper NC, Chasen
ST, Russo ML, Roman AS,
et.al. Cell-free DNA screening
for trisomy 21 in twin
pregnancy: a large multicenter
cohort study. Am J Obstet
Gynecol. 2023
Oct;229(4):435.e1-435.e7.

Screening with cervical length at 18�C22 weeks in multiple pregnancies is
recommended by ISUOG, where the cut off used is <25 mm and SOGC.
BUT routine cervical length screening is NOT currently
recommended by NICEor the ACOG

Society for Maternal-Fetal Medicine (SMFM). McIntosh J, Feltovich H, Berghella V, Manuck T. The role of routine cervical length screening in selected
high- and low-risk women for preterm birth prevention. Am J Obstet Gynecol. 2016;215(3):B2-7.
Langkah-langkah untuk pengukuran panjang
serviks yang tepat
(1) Pastikan pasien mengosongkan kandung kemihnya.
(2) Siapkan probe yang telah dibersihkan.
(3) Masukkan probe dengan lembut ke dalam vagina pasien.
(4) Arahkan probe ke forniks anterior.
(5) Dapatkan gambar sagital, sumbu panjang dari seluruh serviks.
(6) Tarik probe sampai gambar kabur dan kemudian masukkan kembali dengan lembut
sampai gambar jelas (ini memastikan Anda tidak menggunakan tekanan berlebihan).
(7) Perbesar gambar sehingga serviks menempati dua pertiga bagian layar.
(8) Pastikan os internal dan eksternal terlihat jelas.
(9) Ukur panjang serviks di sepanjang kanal endoserviks antara os internal dan eksternal.
(10) Ulangi proses ini dua kali untuk mendapatkan 3 set gambar / pengukuran.
(11) Gunakan pengukuran terbaik yang terpendek

Transvaginal
ultrasound images
of a normal cervix
with slightly
hyperechoic
cervical mucosa
Transvaginal
ultrasound
measurement of
cervical length in the
same patient, with a
full bladder (a) and
with an empty
bladder (b)
Bladder
filled

Transvaginal ultrasound measurements of cervical length in the same patient, illustrating the
effect on the measurement of pressure exerted by the probe: (a) avoiding pressure (correct); (b)
with excessive probe pressure (incorrect), which elongates the cervix and creates a difference in
width between the cervical lips.
Coutinho CM, Sotiriadis A, Odibo A, Khalil A, D��Antonio F, et.al, on behalf of the ISUOG Clinical Standards Committee. ISUOG Practice Guidelines: role of ultrasound in the
prediction of spontaneous preterm birth. Ultrasound Obstet Gynecol 2022; 60: 435�C456

Transvaginal ultrasound measurements of cervical length in the same patient, illustrating the potential
effect on the identification of dynamic changes of the cervix of different degrees of pressure exerted by
the probe. (a) Excessive pressure (incorrect) elongates the cervix, producing a difference in the widths
of the cervical lips. (b,c) Gentle probe pressure (correct) allows identification of funneling and the short
cervical length, with dynamic changes during the course of the examination
Coutinho CM, Sotiriadis A, Odibo A, Khalil A, D��Antonio F, et.al, on behalf of the ISUOG Clinical Standards Committee. ISUOG Practice Guidelines: role of ultrasound in the
prediction of spontaneous preterm birth. Ultrasound Obstet Gynecol 2022; 60: 435�C456

Townsend R, Khalil A. Ultrasound surveillance in twin pregnancy: An update for practitioners. Ultrasound. 2018;26(4):193-205.

Townsend R, Khalil A. Ultrasound surveillance in twin pregnancy: An update
for practitioners. Ultrasound. 2018;26(4):193-205.
In monochorionic twin pregnancy complicated by
sFGR, fetal growth should be assessed at least
every 2 weeks, and fetal Doppler (umbilical
artery and MCA) at least weekly.
If the umbilical artery Doppler is abnormal,
assessment of the DV blood flow should be
undertaken. The aim in managing these
pregnancies is to prolong the pregnancy at least
until viability is achieved, while at the same time
avoiding single IUD with its associated serious
consequences for the surviving cotwin.

Mustafa HJ, Javinani A, Heydari MH, et al. Selective intrauterine growth restriction without concomitant twin-to-twin transfusion syndrome, natural history,
and risk factors for fetal death: A systematic review and meta-analysis. Am J Obstet Gynecol MFM 2023;5:101105.

? As these twins have separate circulations, the pregnancy can be followed as in growth-
restricted singleton pregnancy, monitoring for progressive deterioration of umbilical artery,
MCA and DV Doppler, and of biophysical profile scores.

D'antonio F, Prasad S, Masciullo L, Eltaweel N, Khalil A. Selective fetal growth
restriction in dichorionic diamniotic twin pregnancy: systematic review and
meta-analysis of pregnancy and perinatal outcomes. Ultrasound Obstet
Gynecol. 2024 Feb;63(2):164-172.

In dichorionic twin pregnancy complicated
by sFGR, follow-up visits could be less
frequent, as delivery is usually not
recommended before 32�C34 weeks
gestation.

Dampak kehamilan kembar Monokorioik meningkatkan
risiko terhadap kejadian :
a)Twin-twin transfusion syndrome (TTTS)
b)Twin anemia�Cpolycythemia sequence (TAPS)
c)Twin reversed arterial perfusion (TRAP) sequence
d)Monochorionic monoamniotic (MCMA) twins
e)Conjoined twins

Screening, diagnosis, staging and management of TTTS
a) Up to one third of twin pregnancies are monochorionic. In nearly all monochorionic twins, the
placenta contains vascular anastomoses connecting the two fetal circulations.
b) It is the angioarchitecture of these vascular anastomoses that determines the risk profile.
c) Monochorionic twins are at risk of developing TTTS when there is unequal hemodynamic and
amniotic fluid balance.
d) The diagnosis of TTTS requires the presence of significant amniotic fluid amount.
e) TTTS affects 10�C15% of monochorionic twin pregnancies and is associated with increased
perinatal mortality and morbidity; if untreated, it leads to fetal demise in up to 90% of cases, with
morbidity rates in survivors of over 50%.
f) Early diagnosis, however, may allow intervention with fetoscopic laser ablation, which significantly
improves the prognosis. Laser treatment in these pregnancies results in 60�C70% double survival
and 80�C90% survival of at least one twin.

Townsend R, Khalil A. Ultrasound surveillance in twin pregnancy: An update for
practitioners. Ultrasound. 2018;26(4):193-205.

ULTRASOUND TRAINING WEEK
Divisi Fetomaternal Departemen Obstetri dan Ginekologi RSHS/FKUP

https://www.hopkinsmedicine.org/gynecology-
obstetrics/specialty-areas/fetal-therapy/conditions-
we-treat/complications/taps-ttts

Screening, diagnosis and management of twin anemia�C
polycythemia sequence (TAPS)

a) The incidence of TAPS occurring spontaneously in MCDA twins is up to 5%.
b)Complicate up to 13% of cases of TTTS following laser ablation.
c) The polycythemia twin might have a ��starry sky�� appearance of the liver
pattern due to diminished echogenicity of the liver parenchyma and
increased brightness of the portal venule walls.
d)The antenatal and postnatal severity-based staging classifications.

DONOR RESIPIEN
MCA-PSV > 1.5 multiples of the median (MoM) in
the donor, suggesting fetal anemia
MCA-PSV < 1.0 MoM in the recipient,
suggesting polycythemia.
Placenta bright, thickened section associated with
the donor
Echolucent thin section associated with the
recipient.
Postnatal diagnosis of TAPS the finding of chronic
anemia (including reticulocytosis) in the donor
Polycythaemia in the recipient.

a) Recent evidence suggests that, in monochorionic twins complicated by TAPS, the risk of
neurodevelopmental delay is increased (20%).
b) The commonest options include
1. Conservative management,
2. Early delivery,
3. Laser ablation or intrauterine blood transfusion (IUT) for the anemic twin,
4. Combined IUT for the anemic twin and partial exchange transfusion to dilute the blood of the
polycythemic twin.

https://www.hopkinsmedicine.org/gynecology-obstetrics/specialty-areas/fetal-therapy/conditions-we-
treat/complications/taps-ttts

Twin reversed arterial perfusion (TRAP)
sequence

sequence
? TRAP sequence is a rare complication of monochorionic twin pregnancy (1%
of monochorionic twin pregnancies and 1 in 35 000 pregnancies overall).
? It is characterized by the presence of a TRAP or acardiac mass perfused by
an apparently normal (pump) twin.
? The risk of demise of the pump fetus in TRAP sequence managed
conservatively is up to 30% by 18 weeks gestation.

? Minimally invasive techniques, such as cord coagulation, cord ligation and
photocoagulation of the anastomoses, as well as intrafetal methods, such as RFA
and intrafetal laser therapy, are performed as a means of preventing the demise
of the pump twin. The survival rate of the pump twin using these treatment
modalities is approximately 80%.
? When treatment is necessary, it appears to be preferable before 16 weeks gestation.
? Survival might be improved by elective intervention at 12�C14 weeks gestation.
? The rate of preterm birth before 32 weeks gestation is approximately 10%.
sequence

Monochorionic monoamniotic (MCMA) twins
? Umbilical cord entanglement is almost always present in MCMA twins and does not
appear to contribute to their morbidity and mortality (GRADE OF
RECOMMENDATION: D).
? Delivery by Cesarean section is recommended at 32�C34 weeks (GRADE OF
RECOMMENDATION: D).
? In MCMA twin pregnancies undergoing selective reduction (because of discordant
anomaly, TRAP sequence, severe TTTS or sFGR), cord occlusion and transection
are recommended to prevent fetal demise of the other twin due to cord accidents.

Monoamniotic twin pregnancies are rare, with an estimated incidence of only 8 per
100,000 pregnancies, and result from a single fertilized egg and embryo splitting
between 9 and 13 days after fertilization.
The main characteristic of monoamniotic twin pregnancies is a single shared placenta
and amniotic cavity.
Conjoined twin pregnancies, which are even rarer with an incidence of only 1.5 per
100,000 pregnancies, are a subtype of monoamniotic twin pregnancies and result
from even later embryonic splitting (after 13 days). Besides sharing the placenta and
amniotic cavity, conjoined twins also share parts of their bodies.
Van Mieghem T, Abbasi N, Shinar S, et al. Monochorionic monoamniotic twin pregnancies. Am J Obstet Gynecol MFM
2022;4:100520

? The obvious direct sign of monoamnionicity on ultrasound in the first
trimester of pregnancy is the lack of a dividing amniotic membrane
between the 2 fetuses.
? Indirect (and hence less accurate) ultrasound signs, which help in
assigning amnionicity in the first trimester of pregnancy, include the
presence of cord entanglement which is almost always present in
monoamniotic twins, and the number of yolk sacs.
? Approximately two-thirds of monoamniotic twins will have only 1 yolk
sac, but one-third will present with 2 yolk sacs, similar to diamniotic
twins.

Conjoined
twins
? Conjoined twins are very rare, occurring in approximately 1 in 100 000
pregnancies (1% of monochorionic twin pregnancies).
? Diagnosis with ultrasound in the first trimester is now the norm (on visualizing
close and fixed apposition of the fetal bodies, with fusion of the skin lines at
some point).
? Survival to discharge was only around 25%, and the majority of these had
significant morbidity.
? The most common form is Thoracopagus.
? Approximately 60% of conjoined twin pregnancies will result in stillbirth.

Conjoined twins
Such pregnancies should be assessed at a fetal medicine referral center, with
multidisciplinary assessment and counseling. The pregnancy must be delivered at
a center with expertise in the postnatal medical and surgical management of such
cases. There are associated high rates of postnatal mortality and there is almost
always morbidity

Monochorionic monoamniotic (MCMA) twins

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Peranan USG pada kehamilan kembar - Prof SRK.pptx

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Editor's Notes