Deteksi
• Pada pasien asimptomatik tidak dianjurkan melakukan tindakan intervensi yang bertujuan untuk skrining risiko preterm
• Pada pasien simtomatik dapat dilakukan pengukuran panjang serviks dan skrining fetal fibronectin sebagai bantuan untuk prediksi risiko kelahiran preterm. Panjang serviks 25mm adalah cut-off paling sering digunakan pada trimester kedua
Pencegahan • Belum ada Tindakan intervensi yang direkomendasikan untuk memprolong masa kehamilan
Manajemen
• Tokolitik dapat diberikan untuk memperpanjang masa kehamilan jangka pendek
• Pemberian kortikosteroid antenatal untuk wanita hamil usia 24-34 minggu mengurangi insiden kematian neonatal karena distres pernapasan
• Pemberian magnesium sulfat prenatal dapat dilakukan untuk mengurangi terjadinya cerebral palsy
FETAL
Gambar 2. Overview insidensi komplikasi kehamilan ganda (Cunningham, 2014)
KOMPLIKASI
Tabel 1. Insidensi komplikasi fetal pada kehamilan Multifetal (Rauh-Hain et al., 2009; Anca et al., 2015; Buyukkaya, Tekbas and Buyukkaya, 2015; Johnson, 2015; K.Behavkova, 2016; Lanna et al., 2019; Antonakopoulos et al., 2020; Gleeson et al., 2020)
KOMPLIKASI
Twin to Twin Trnasfussion syndrome
Mempengaruhi 15% dari kehamilan multifetal monochorionic.
FETAL
• Treament of choice adalah ablasi laser pada quintero stage II (Rekomendasi: A)
• Konservatif management dilakukan pada quintero stage I (Rekomendasi B)
• Amnioreduction bertahan sebelum usia kehamilan 26 minggu (Rekomedasi A) (Khalil et al., 2016)
MANAGEMENT
KOMPLIKASI
Twin Anemia – Polycyteamia Sequence (TAPS)
Mempengaruhi 2% dari kehamilan multifetal dan 13% setelah mendapatkan terapi ablasi laser
FETAL
Pilihan terapi pada TAPS bergantung kasus per kasus. Terapi paling umum adalah konservatif, early delivery, ablasi laser, transfusi intrauterine, partial exchange transfusion (Evidence Level 3) (Khalil et al., 2016).
MANAGEMENT
KOMPLIKASI
Twin Reversed Arterial PerfusionSequence (TRAPS) FETAL
Terapi utama dari TRAPS adalah discontinuation transfusion dari janin acardiac, dengan cara ligasi tali pusat dari janin acardiac (Evidence Level 3).
(Khalil et al., 2016)
Twin Reverse Arterial Perfussion (TRAP) terjadi pada 1% kehamilan multifetal dengan janin kedua acardiac.
MANAGEMENT
KOMPLIKASI
Selective Intra Uterine Growth Restriction
FETAL
Terminasi merupakan pilihan utama dimana bila termasuk dalam tipe I direkomendasikan pada usia kehamilan 34-36 minggu, sedangkan pada tipe II dan III disarankan dilakukan terminasi pada usia kehamilan 32 minggu
MANAGEMENT
• sFGR, secara konvensional, didefinisikan sebagai suatu kondisi di mana satu janin memiliki EFW <10 percentile dan diskrepansi EFW dengan kembarannya > 25%
• Terjadi pada 10-15% kehamilan multifetal
• Tipe I, waveform doppler arteri umbilikalis terdapat positive end-diastolic flow
• Tipe II, terdapat absent or reversed end-diastolic flow (AREDF).
• Tipe III, terdapat pola AREDF yang memebntuk siklus/intermittent
11. All except which of the following complications are increased in multifetal
gestations?
• a. Preeclampsia
• b. Hysterectomy
• c. Maternal death
• d. Postterm delivery
• 12. Which of the following mechanisms may result in monozygotic twins being discordant for malformations or traits?
• a. Prezygotic mutation
• b. Variable expression of the same genetic disease
• c. Skewed lyonization in male fetuses with differential expression of X-linked traits or diseases
• d. All of the above
• 13. A 37-year-old G1 comes to establish prenatal care with you
after being discharged from her reproductive endocrinologist. This pregnancy was conceived via single embryo transfer in vitro
fertilization. Which one of the following is true regarding her situation?
• a. Assisted reproductive technology increases the incidence of monozygotic twins two- to fivefold.
• b. If a single zygote splits 8 days post fertilization, a monochorionic diamnionic twin gestation results.
• c. Because this pregnancy is known to have begun with one embryo, you can be certain that she will have monochorionic twins, but amnionicity depends on timing of split.
• d. All of the above
• 14. A 29-year-old G1P1 conceived dichorionic twins via gonadotropin
stimulation and intrauterine insemination (IUI) with her husband’s semen. Her blood type is O-negative, so prior to receiving anti-D immune globulin the neonates’
blood type is assessed. One neonate is A-positive and the other is O-negative. Her husband is A-positive. This finding can be explained to the parents by describing which of the following phenomena?
• a. Superfetation
• b. Superfecundation
• c. This is not atypical for dichorionic twins
• d. This cannot be explained without alleging infidelity or poor technique by her reproductive endocrinologist’s office.
• 15. Which of the following factors increases the risk for monozygotic twinning?
• a. Maternal age
• b. Increased parity
• c. Race and family history
• d. None of the above
• 16. Which hormone is the most likely underlying cause of increased twinning seen in some racial and ethnic groups?
• a. Estrogen
• b. Progesterone
• c. Luteinizing hormone
• d. Follicle-stimulating hormone
• 17. Which of the following statements regarding
atypical twinning is not true?
• a. Monochorionic twins are never dizygotic.
• b. Twins of opposite sex are not always dizygotic.
• c. Monochorionic twins are not always the same sex.
• d. None of the above is true
• 18. Maternal physiological
adaptation to twin pregnancy in comparison to a singleton
pregnancy is accurately described in which of the following
statements?
• a. Cardiac output increases 40%
above that of a woman carrying a singleton fetus.
• b. Blood volume expansion
averages 70%, which is greater than the 40–50% seen in women carrying
• a singleton.
• c. The increased cardiac output in twin gestation is primarily due to increased stroke volume rather than increased heart rate.
• d. All of the above
• 19. It is well known that miscarriage is more likely with a multifetal
gestation. Which of the following statements is not true?
• a. Before 12 weeks, one or more
fetuses are lost in about 50% of initial triplet pregnancies.
• b. Twins conceived via assisted
reproductive techniques are at greater risk for spontaneous loss.
• c. Spontaneous loss of a cotwin before the second trimester occurs in 10–40%
of all twin gestations.
• d. None of the above is true.
• 20. A 34-year-old G2P1 at 12 weeks’ gestation presents to discuss aneuploidy
screening. This pregnancy started out with dichorionic twins, but spontaneously reduced to singleton at 7–8 weeks’ gestation. Which of the following is the most appropriate?
• a. First-trimester screening is not recommended.
• b. Since the cotwin demise occurred prior to 9 weeks, routine first-trimester screening is not affected and remains a valid option.
• c. Since it has been at least 4 weeks since cotwin demise, routine first-trimester screening is not affected and remains a valid option.
• d. Second-trimester maternal serum alpha fetoprotein will be falsely elevated, so a detailed anatomy ultrasound is recommended to assess for neural tube
defect.
• 21. Characteristically,
menopausal transition begins with a variable period of
menstrual cycle irregularity and extends to 1 year after permanent cessation of
menses. The menopause
transition typically spans how many years?
• a. 1 to 2 years
• b. 2 to 4 years
• c. 4 to 7 years
• d. 7 to 10 years
• 22. Premature ovarian failure is associated with a persistently elevated follicle-stimulating
hormone (FSH) level and is further de ned as cessation of menses before what age?
• a. 35 years
• b. 40 years
• c. 45 years
• d. 51 years
• 23. Several factors can alter ovarian aging. Which of the following is
LEAST likely to shift menopause to an earlier age?
• a. Smoking
• b. Chemotherapy
• c. Pelvic radiation
• d. Oral contraceptive pills
• 24. During menopausal transition, erratic
fluctuations in female reproductive hormones lead to an array of physical and psychological symptoms. These symptoms include all of the following EXCEPT:
• a. Headache
• b. Poor memory
• c. Vision changes
• d. Urinary incontinence
• 25. During the reproductive life of a woman, gonadotropin- releasing hormone is released in a pulsatile fashion from which of the
following?
• a. Corpus lutea
• b. Ovarian follicles
• c. Pituitary gonadotrophs
• d. Arcuate nucleus of the hypothalamus