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Quản lý thai kỳ với đa thai Khuyến cáo từ RCOG 2000 Đồng thuận từ RCOG 2006 Trình bày bởi phòng KHTH

URL § § http: //www. sogc. org/guidelines/public/91 E-CONS 1 July 2000. pdf http: //www. rcog. org. uk/files/rcog-corp/uploadedfiles/Study. Group. Consensus. Views. Multiple. Pregnancy. pdf

Các khuyến cáo chung Ai? Ở đâu? Như thế nào? § § The lead clinician for MP clinics should have expertise in ultrasound and in the intrapartum care of MP There is good evidence that the diagnosis of twin gestation is improved by the routine use of ultrasound. There is consensus that serial ultrasonographic evaluation every three to four weeks is indicated in twin gestations

Tầm soát lệch bội trong đa thai Vai trò của các khảo sát xâm lấn § § § Nuchal translucency based screening should be offered as the preferred method of aneuploidy screening in women with multiple pregnancy All women carrying twin pregnancies should be referred for counselling to a centre for the consideration of invasive testing at age 32. The counselling must be individualized and the final decision must be taken by the parents since the risk of amniocentesis is uncertain in MP The fetal loss rates with invasive testing (amniocentesis and chorionic villus sampling (CVS)) in twins are unclear

Siêu âm trong theo dõi thai kỳ đa thai một nhau Bất thường tim mạch và Hội chứng truyền máu § § All monochorionic twins should have a detailed ultrasound scan which includes extended views of the fetal heart Monochorionic twins require increased ultrasound surveillance from 16 weeks of gestation onwards to detect twin-to-twin transfusion syndrome and growth discordance. This should be offered at an interval of 2 weeks

Khảo sát tăng trưởng trong thai kỳ đa thai Hình dáng biểu đồ là quan trọng nhất § § Fetal growth differs slightly in twin gestations and twin specific charts may be used to define the normal growth rate. Precision may also be obtained by using sex and race specific charts. In clinical practice, however, these differences are small and singleton growth curves may be used Patterns of fetal growth are more important than absolute measurements. Both must be interpreted in the light of the clinical history, together with all the genetic and nvironmental factors that may affect fetal growth

Tăng trưởng chênh lệch của 2 thai Các cut-off và giá trị cuả chúng § § An abdominal circumference (AC) difference of 20 mm § Sensitivity 80% § Specificity 85% § Positive predictive value 62% Estimated fetal weight (EFW) based on bi-parietal diameter (BPD) and AC or AC and femur length (FL) > 20 percent § Sensitivity 25 -55%

Song thai với bất thường hình thái của một thai Vấn đề giảm thai § § Twins that are discordant for fetal anomaly should be managed in fetal medicine centres with specific expertise In twins discordant for abnormality, the option of selective reduction should be offered. The procedure should be performed in a tertiary level center. Transportation and out-of-province costs should be covered

Song thai với một thai chết Phải lo lắng cho cả 2 thai § § § Single-twin demise in a monochorionic twin pregnancy should be referred and assessed in a regional fetal medicine centre The survivor after single-twin demise in monochorionic twins should have follow-up ultrasound and, if normal, an MRI examination of the fetal brain 2 -3 weeks after the cotwin death. Counselling should include the long-term morbidity in this condition Fetoscopic laser ablation is the treatment of choice in severe twin-to-twin transfusion syndrome presenting prior to 26 weeks of gestation

Thái độ theo dõi thai kỳ đa thai Các động thái không cần thiết hay ích lợi không rõ § § There is insufficient evidence to support prophylactic activity restriction or work leave in multiple gestation Routine hospitalization for bedrest in multiple gestation is not recommended There is moderate evidence against routine prophylactic cervical cerclage in multiple gestation. However, cerclage may be indicated for the treatment of incompetent cervix or other specific circumstances There is moderate evidence against prophylactic tocolysis in the management of multiple gestation, but it may be indicated on other grounds

Theo dõi thai kỳ đa thai Khám cổ tử cung qua khám âm đạo § There is good evidence that premature cervical change by digital examination predicts preterm birth in twins

Theo dõi thai kỳ đa thai Khảo sát cổ tử cung qua siêu âm đường âm đạo § § § Since there are no well designed intervention trials available, the role of sonographic clinical cervical assessment in the prenatal period has not been determined There is good evidence that TVS measurement of cervical length predicts preterm birth in twins While the predictive ability of cervical length measurement is established, there are no intervention studies that have evaluated cervical length measurement in the prevention of preterm birth, and therefore the role of sonographic clinical cervical assessment in the prenatal period has not been determined

Chấm dứt thai kỳ chủ động trong đa thai Bài toán không dễ tìm lời giải § In view of the increased risk of stillbirth in twin pregnancy, elective delivery is recommended between 37 and 38 weeks of gestation

Đồng thuận RCOG 2006 Song thai 2 nhau

Đồng thuận RCOG 2006 Song thai 1 nhau