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Curs15:SarcinaMultipla

Poatefidefinitacasiapariia,dezvoltareaievoluiasimultansi
concomitentncavitateauterinadoisaumaimulifei,rezultaidintrunulsau
maimulteovocitefecundate.

Numarulsiratasarcinilorgemelaresimultipleaucrescutinultimeledecade
lavalorifaraprecedent.Intre1980si2001numarulsarcinilorgemelareacrescut
cu77lasutasialsarcinilormultiplecu460lasuta.Inaceeasiperioadasporul
demograficacrescutcu11lasuta(datedinSUA).

Perspectivadeviascadecuattmaimultcuctnumrulfeilorestemai
mare.nultimii10aniaufostmenionaicvintupliinPolonia,Japonia,Pakistan
iLiban.PrimulcazdeseptupliviabiliafostsemnalatnSUAn1997.Aumaifost
nregistratedoucazurideseptupli:nHawai(autrit11zile)inSuedia(autrit
7zile).Nusecunoscoctupli.

Aceastarataascendentaasarciniimultipleesteasociatacuocresterea
mortalitatiisimorbiditatiineonatalesimaterne.

IncidentasesupunelegiiluiHellin,conformcreiafrecvenasarcinii
multipleestede1la80n1,undenestenumrulfeilor:

gemelara1la80

tripla1la80

cvadrupla1la80etc.

Etiopatogeniaimplicafactorii:


genetici,ereditari:frecvenaapariieisarciniimultipleestemaimarela
priniinscuilarndullordintrosarcinmultipl,lafemeiereditateaareun
impactdeosebitseparecaactioneazaprintrogenaautosomaldominanta
prezentalaaproximativ15lasutadinpopulatie(aceastagenaardetermina
ovulatiamultiplalafemeie;

climaterici:incidencrescutvara,cndzilelesuntmailungi(luminasolar
arstimulahipofiza,inducndohipersecreiedeFSHiLH,faptceardetermina
ovulaiapolifocal);

paritatea:incidencrescutlamarilemultipare;

zonageografic(datoritatemperaturiisiluminii):fostaURSS(incidende
2,23%),Frana,Spania,Italia(1,2%),Japonia(0,8%);nRomniaincidenaestede
1/961/93;ClinicaSf.Pantelimonaproximativ1/85;ceamaimareincidenta
cunoscutaoareNigeria1/38.Rasaneagraprezintaofrecventamaimarede
aparitieasarciniimultiple.

factoriiatrogeni:inducereaovulaieilafemeilecusterilitatedetermin
cretereafrecveneisarciniimultiple(gonadotropiicorioniciiceihipofizaricresc
incidenala45%,iarclomifenulla8,5%);fertilizareainvitro(FIV)determin
cretereafrecveneisarciniimultipledeoarecenecesitostimularepreovulatorie
curecoltareaamaimulteovule(dupfertilizareaacestoraseimplanteaznuter
maimulteou,fiepentruacreteprocentulreuiteiprocedurii,fiechiarpentrua
obineosarcinmultipl),recomandareaestedealimitatransferuldeembrioni
lamaximtreipeprocedura,

sarcinileobtinutelafemeilacareafostopritadecurandterapia
anticonceptionala,datoritaeliminariibrusteablocajuluidelanivelulhipofizei
anterioare.

maximulincidenteisarciniimultipleestelaaproximativ37deanicand
stimulareahormonalacrescutainducecresterearateiovulatieiduble(secretie
crescutadeFSH).


dupa37deani,datoritascaderiirezerveifoliculareapareoscaderea
incidenteisarciniimultiple.

gravidelecuinaltimesigreutatemaimareprezintaofrecventadeaparitie
cucca30%crescutafatadecelecuinaltimesigreutatemaimica

Infunctiedenumarulfetilorgemelara,tripla,cvadrupla,cvintuplaetc.

Sarcinagemelararezultacelmaifrecventdinfertilizareaadouaovocitesi
estedenumitasarcinadizigotica.Multmairar(aproximativ1/3dinsarcinile
gemelare)sedezvoltadintrunsingurovulfertilizatcaresedivideindoizigoti
similarisarcinagemelaramonozigoticagemeniidentici.Pentrusarcinile
multipleprocesulesteasemanator(sarcinacvadruplapoateapareprinfertilizarea
aunulpanalapatruovocite).

Genezasarcinilormultiplemonozigoticeestedeterminatadeintarzierea
transportuluiovocituluiprintrompeleuterine.Astfelfunctiedemomentul
diviziuniisevorforma:

1.dacadiviziuneaarelocinprimele72deoredinprimeledoua
blastomereseformeazaosarcinagemelaramonozigotica,diamnioticasi
dicorionica(deobicei)sauadouaplacentecefuzioneaza.

2.diviziuneaarelocintreziuaapatrasiaoptaseformeazaosarcina
monozigotica,diamniotica,monocorionica

3.diviziuneaarelocinziuaaoptapostfertilizaresarcinaeste
monozigotica,monoamniotica,monocorionica

4.producereadiviziuniidupaziuaaoptaducelaformareagemenilor
conjugatitoracopagi,ischiopagi,xifopagi,craniopagietc

Superfetatiareprezintafecundareaadouaovuleintrunintervaldetimpcu
lungimeaminimaaunuiciclumenstrual(ovulatielaolunadelaprima
fecundatie).

Superfecundatiasereferalafertilizareaadouaovociteformateintimpul
aceluiasiciclumenstrualdarnudupaacelasicontactfecundant.


Incidentasarcinilormultiplemonozigoticeinlumeestede1/250desarcini
cuvariatiifunctiederasa,paritate,varsta,ereditate,tratamentepentru
fertilitate.Sarcinilemonocorioniceauoincidentacrescutaaavortului.Uneorise
opresteinevolutieunuldintrefetiasanumitulvanishingtwin.

Lasarcinamultipla,pemasuracenumaruldefetusicreste,procentulfetilor
desexmasculinscadeusor,ajungandlacvadrupletila53,5%femininisi46,5%
masculini.Incazulsarcinilormonocorialemonoamnioticesexulfemininal
produsilordeconceptieestede70%iarlagemeniiconjugatela75%.Sexulopus
alfetusilorrelevaaproapeintotdeaunaosarcinadizigotica.

Corionicitateapoatefi,uneori,determinatecograficnprimultrimestru.
Prezenaadouplacenteseparateiogrosime,ngeneral,de2mmsaumai
mare,amembranelorinteramnioticesustineundiagnosticuldedicorionicitate.
nsarcinilencareosinguramasaplacentaresteidentificata,poatefi
dificilssedistingoplacentaunicamarededouplacentesituatealturat.
Examinanareaoriginiimpririimembraneipesuprafaaplacentaranepoate
clarificaaceastsituaie,oproiecietriunghiularadetesutplacentarse
vizualizeazaaseextindedincolodesuprafatacorionicaintrestraturilemembranei
divizate,atunciexistdouplacentefuzionatesemnulvrfurilorgemene.
nschimb,sarcinilemonochorioniceauomembranainteramnioticaattde
subireincatnupoatefivzutpninaldoileatrimestru.Membranaesten
generalmaisubtirede2mm,iarmrireaimaginiidezvluienumaidoustraturi.
Aceastlegaturanunghidreptntremembraneiplacenta,faranicioextindere
aparentaplacenteintremembranadivizataestecunoscutasubdenumireade
semnulT.Ecograficevaluareadiviziuniimembranaresefacecelmaiuorimai
exactnprimajumtateasarcinii,atuncicndfetuiisuntmaimici.

Evaluareaclinica,paraclinicasiistoriculpersonaltrebuiedublatede
examenulecografic.Examenulclinicestedificildeefectuat,diagnosticulde
sarcinagemelaraemaifacilcandsepalpeazadouacapetefetaleculocalizarein
cadranediferite.Insarcinileavansatepotfidetectatedouasaumaimultefocare
deauscultatoriialeBCFurilorcetrebuiedistinsedeactivitateacardiacamaterna.


Valoareatestelorbiochimiceinsarcinamultiplaestemodificata,beta
HCGulsialfafetoproteinaauvalorimaimaridecatlasarcinaunica.Acestevalori
nupotpunesingurediagnosticuldesarcinamultipla.Semneledesarcinasunt
accentuate,inspecialgreturilesivarsaturile.Volumulsanguinestecrescutcu
aproximativ40%insarcinaunicasicuaproximativ60%insarcinagemelara.
Pierdereadesangelanastereapecalevaginalaestedeaproximativ900mlfata
deaproximativ500mllanastereaunica,predispunandlaaparitiaanemiei.

Uropatiaobstructivaestemaiimportantainsarcinamultipladatorita
volumuluiuterincrescutsipresiuniiexercitatepeureteresivezicaurinaramai
alesdacaseasociazasicuungraddehidramnios.Sepoatedezvotaungradde
hidronefrozamaternacumodificareaclearenceuluiurinar(crestereureesi
creatinina),reversibiletotaldupanastere.

Avortulspontanestedetreiorimaifrecventincazulsarciniimultiple.
Sarcinilemonozigoticereprezintaaproximativ65%dinacesteavorturi.Incidenta
malformatiilorcongenitaleestecrescutainmodapreciabil.Celemajoreaparla
aproximativ2%iarceleminorelaaproximativ4%dinsarcini.Acestedefectesunt
legateaproapeexclusivdedefectestructuraleceaparlasarcinilemonozigotice.

Defectestructurale:gemeniconjugati,anomaliidedezvoltare
cardiaca,sirenomelia,defecteledetubneural,anomaliivasculareanastomoze,
defectedatoratepozitiilorvicioaseintrauterine(piciorstrambcongenitaletc),
samd.

Greutatealanastereesteinfluentatadenumaruldefeti.Cucatsunt
maimultifeticuatatgreutatealorlanastereestemaimica.Laaproximativ60%
dinsarcinilegemelaresiaproximativ85%dinsarcinilecutripletiseconstata
gradediferitederestrictiedecrestereintrauterina.Inultimiianiaufostelaborate
curbedecresterepentrusarcinamultiplacuvalorispecifice.Diferenteaparsila
sarciniledicorionicedatoritaimplantariiinzonecupotentialmaimicalaportului
desangepentruschimburileplacentare.Restrictiadecresterepoatefidatoratasi
anomaliilordecordonombilicalinsertiemarginalasivelamentoasasauvasa
praevia.Greutateaestemaimicainspeciallasarcinilemonozigotice
monocoriale,unde,alocareainegalaablastomerelor,anastomozelevasculare

placentarecudistributiainsuficientasiinegalaanutrientilorsioxigenului,
anomaliilestructuraledatorateprocesuluidediviziunesunttotatateamotive
pentruaparitiatulburarilordecrestereintrauterina.
DuratamedieagestatieipentrusarcinagemelarainSUAestede35de
saptamani,latripletiestede32desaptamaniiarlacvintupletisicvadrupletieste
de30respectiv29desaptamani.
Termenuldenasterepentrusarcinagemelaraeraconsideratcelde40de
saptamani.Dupaultimelestudiidepasireavarsteidesarcinade39desaptamani
lasarcinilegemelarefacecarisculdeoprireinevolutieasarciniisadepaseasca
beneficiile.
Dezvoltareaneuropsihicasifizicaestecomparabilacuacopiilorproveniti
dinsarcinileunice.Totusiexistaunusorretardsioadaptaremaidificilala
colectivitate.Laoricevarstadincopilariegemeniiauinmedieogreutatecu6luni
subcopiiidinsarcinileunicesioinaltimecu3lunisubacestia.
Gemeniimonoamnioticisuntovarietaterara(aproximativ1%),dar
grevatadeomorbiditatesimortalitatemare.
Gemeniiconjugatifunctiedeparteacorpuluicareesteimpartitaseimpart
intoracopagianterior,pygopagiposterior,craniopagicefalic,ischiopagi
caudal.
Anastomozelevasculareintrefetiaparaproapeexclusivlasarcinile
monocorionice.Totusiexistadiferenteimportantededimensiuni,numarsivolum
desangecetreceprinacestesunturivasculare.Insindromultransfuzor
transfuzatsangeledelagemenultransfuzorestetransferatlaceltransfuzatcu
dezvoltareauneirestrictiidecresteresiauneianemiisecundare.Gemenul
transfuzatpoateprezentainsuficientacardiacaprinhipervolemiesicresterea
vascozitatiisangelui.Prognosticulsindromuluiestedeobiceirezervatdatorita
complicatiiloracestuia:leziunicerebrale,oprireainevolutieaunuiadintrefeti,
moarteneonataladupanastereprematura.Tratamentulsindromuluiinclude
amnioreductia,septostomie,ablatiaculaseraanastomozelorvascularesau
feticidselectiv.


Casiobiectivealemanagementuluisarcinilormultiplesunt
urmatoarele:1.prevenireanasterilorpremature
2.extragereafatuluisaufetilorinaintedeoprireainevolutieaacestora

3.evitareatraumatismuluifetalintimpultravaliuluisiaexpulziei

4.asistentaneonataladecalitate

MonitorizareaTAesteobligatorieHTAfiindde3orimaifrecventala
gravidelecusarcinamultipla.
Monitorizareaecograficatrebuiesaincludaevaluarealichiduluiamniotic
prinAFI(amnioticfluidindex)caretrebuiesaaibavaloriintre8si24mmsi
velocimetrieDopplerinspeciallanivelulcordonuluiombilicalsiarterei
cerebralemedii(fluxenddiastolicabsentfiindcorelatcurestrictiadecrestere
simortalitateperinatala).
Profilaxianasteriiprematureevitareaefortuluifizicmare,terapia
tocoliticaderutinanuesteindicatadatoritarisculuidesupraincarcarevolemica
cuasociereaedemuluipulmonar.Administrareadecorticosteroiziesteindicata
pentruprofilaxiadetreseirespiratoriilafelcasilanastereaprematura.Cerclajul
areaceleasiindicatiicasiinsarcinaunica.Nuseindicacerclajulprofilactic.
Rupturaprematurademembranetrebuieabordataasemanatorcusarcina
unica.
Nastereaunuifatcuamanareanasteriiceluidealdoilea/treileafat,se
poatefacedupanastereaprimuluifatprinadministrareatocoliticelorsi
antibioticelor(sistemicsilocal)siefectuareaunuicerclajlacaldalcoluluiuterin,
acoloundecircumstantelelocaleoimpun.
Lasarcinilegemelaresepotasociatoateprezentatiile.Celemaifrecvente
suntcranianacraniana,cranianapelvianasicranianatransversala.De
subliniatestecaacesteprezentatiisimaialesceacranianacranianasunt
instabileinaintesimaialesintimpultravaliuluisiexpulziei.

Analgeziaepiduralaesterecomandatademaimultiautori.Eaareavantajul
casepoateextindeincazulincareseimpunefectuareademanevreobstetricale
saucezariana.Intimpuleipacientasicopiiitrebuiemonitorizatiatentdatorita
risculuidehipotensiunematernacuscadereaperfuzieiplacentare.
Nastereapecalevaginalasepoateproducespontansauinstrumental
atuncicandprimulfatesteinprezentatiecraniana.Dacaprimulfatestein
prezentatiepelviana,lafelcalasarcinaunicaaparurmatoarelesituatiiceimpun
nastereaprinoperatiecezariana:
candfatulareDBP(diametrulbiparietal)peste100mmsaucandareloc
angajareaprecoceamembrelor/tunchiuluifetalexistaposibilitateaderetinerea
capuluifetal
prolabareacordonuluiombilicalodatacurupereamembraneloramniotice
altesituatii
Lafetiisituatiinprezentatietransversalanastereapoateavealocdupa
versiuneinternasauprinoperatiecezariana.
Incazulsarcinilormultipledeordinultreisaumaimultmajoritateastudiilor
recomandanastereaprinoperatiecezariana,cuexceptiacazurilorcandfetiisunt
compromisisaugravidaprezintaopatologiecareiarpuneviatainpericolin
eventualitateauneiinterventiichirurgicale.

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