Πολύδημες κυήσεις

Κλινική σημασία:
Οι πολύδημες κυήσεις αποτελούν το 1% όλων των κυήσεων. Βρίσκονται σε μεγαλύτερο κίνδυνο ανάπτυξης προγεννητικών και περιγεννητικών επιπλοκών. Ως εκ τούτου συχνότερη παρακολούθηση προγεννητικά είναι αναγκαία για να μειώσει τον κίνδυνο προς την μητέρα και τα έμβρυα.

Συχνότητα:

  • -Δίδυμα: 1:90  των φυσιολογικών συλλήψεων.
  • -Τρίδυμα: 1:7000 γεννήσεις φυσιολογικών συλλήψεων.
  • -Τετράδυμα: 1:600.000  γεννήσεις φυσιολογικών συλλήψεων.

Χοριονικότητα

Διζυγωτικά (μη όμοια) δίδυμα

  • 70% των δίδυμων κυήσεων
  • Δύο ωάρια θα γονιμοποιηθούν από ένα σπερματοζωάριο για να δημιουργήσουν δύο γενετικά μη όμοια έμβρυα.
  • Κάθε έμβρυο έχει το δικό του πλακούντα και αμνιακό σάκο (π.χ.διοχοριονικά διαμνιακά ).

 

Μονοζυγωτικά (όμοια) δίδυμα

  • 30% των δίδυμων κυήσεων
  • Ένα γονιμοποιημένο ωάριο διαιρείται νωρίς και δίνει δύο γενετικά όμοια έμβρυα.

 Χρονική περίοδος που καθορίζει τη χοριονικότητα:

  • 30% διαιρούνται τις πρώτες τρεις ημέρες από την γονιμοποίηση  και σχηματίζουν διχοριονικά  διαμνιακά  δίδυμα, όπου το καθένα έμβρυο έχει το δικό του πλακούντα.
  • 70% διαιρούνται μετά την 3η ημέρα και δημιουργούνται μονοχοριονικά δίδυμα, όπου τα έμβρυα μοιράζονται έναν πλακούντα.
  • 1% διαιρούνται μεταξύ  9 και 12 ημερών δημιουργώντας μονοχοριονικά  δίδυμα με τον ίδιο πλακούντα και αμνιακό σάκο κύησης.
  • Διαίρεση μετά την 12η  εβδομάδα έχει ως αποτέλεσμα τη δημιουργία σιαμαίων διδύμων όπου τα έμβρυα βρίσκονται ενωμένα σε διάφορα σημεία του σώματος τους.

Προσδιορισμός χοριονικότητας:

  • Στα μονοχοριακά δίδυμα έχουμε επικοινωνούντα αγγεία στον πλακούντα, με αποτέλεσμα να έχουμε κακή κυκλοφορία, γεγονός που αυξάνει τον κίνδυνο συγκριτικά με τα διχοριονικά δίδυμα. Το γεγονός αυτό καθιστά τον έγκαιρο προσδιορισμό της χοριονικότητας αναγκαίο, δεδομένου ότι η παρακολούθηση και η αντιμετώπιση είναι τελείως διαφορετική.
  • Το υπερηχογράφημα στις 12 εβδομάδες είναι σχεδόν 100% ικανό να προσδιορίσει τη χοριονικότητα.
  • Μονοχοριακά (όμοια) δίδυμα έχουνε μία λεπτή μεμβράνη εμφανή υπερηχογραφικά που σχηματίζει ‘’Τ’’ στην πρόσφυση της με τον πλακούντα.
  • Διχοριονικά (μη όμοια) δίδυμα έχουμε δύο διαφορετικούς πλακούντες και αμνιακούς σάκους και μια πιο χοντρή μεμβράνη που σχηματίζει το γράμμα ‘’Λ’’ (lamda sign ) στην πρόσφυση της με τον πλακούντα.
  • Δίδυμα διαφορετικού φύλλου είναι πάντοτε διχοριονικά
  • Δίδυμα ίδιου φύλλου μπορεί να είναι μονοχοριονικά ή διχοριονικά.

 

 

Α.    Παρακολούθηση μονοχοριονικών διδύμων

  • Στα  μονοχοριονικά δίδυμα υπάρχει αυξημένος κίνδυνος (περίπου 15% ή 1:6 ) να αναπτύξουνε TTTS (σύνδρομο μετάγγισης διδύμων ) ή επιλεκτική ενδομήτρια καθυστέρηση της ανάπτυξης (SFGR).
  • Συνιστάται υπερηχογραφική παρακολούθηση ξεκινώντας από τις 12 εβδομάδες ,στις 16,18,20,22,26,30 και 34ης εβδομάδες με σκοπό τον τοκετό στις 35-36 εβδομάδες.
  • Σε περιπτώσεις που υπάρχει ένδειξη σοβαρού (TTTS) σύνδρομο  μετάγγισης διδύμων ή (SFGR) επιλεκτικής  ενδομήτριας καθυστέρησης  της ανάπτυξης, θα προταθεί σαν μόνη θεραπεία ενδοσκοπική μικροχειρουργική  με laser για να διαχωριστούν τα επικοινωνούντα αγγεία στον πλακούντα.
  • Υπάρχει επίσης αυξημένος κίνδυνος πρόωρου τοκετού ( περίπου 10% ρίσκο τοκετού πριν τις 32 εβδομάδες ) και συνιστάται μέτρηση του τραχήλου της μήτρας στις 22 εβδομάδες .

Β.    Παρακολούθηση διχοριονικών (μη όμοιων) διδύμων. Αυξημένος κίνδυνος πρόωρου τοκετού (περίπου 10% ρίσκο τοκετού πριν τις 32 εβδομάδες )

  • Αυξημένος κίνδυνος ενδομήτριας καθυστέρησης της ανάπτυξης τουλάχιστον σε ένα από τα δυο έμβρυα (περίπου 10%).
  • Συνιστάται υπερηχογραφική  παρακολούθηση ξεκινώντας από τις 12α εβδομάδες, στις  22,28,32,36 εβδομάδες .

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