15.-Sarcina-multipla

7/25/2019 15.-Sarcina-multipla

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Curs15:SarcinaMultipla

Poatefidefinitacasiapariia,dezvoltareaievoluiasimultan si

concomitentncavitateauterin adoisaumaimulifei,rezultaidintrunulsau

maimulteovocite fecundate.

Numarulsiratasarcinilorgemelaresimultipleaucrescutinultimeledecade

lavalorifaraprecedent.Intre1980si 2001numarulsarcinilorgemelareacrescut

cu77lasutasialsarcinilormultiplecu460lasuta.Inaceeasiperioadasporul

demograficacrescutcu11lasuta(datedinSUA).

Perspectivadevia scadecuattmaimultcuctnumrulfeilorestemai

mare.nultimii10aniau fostmenionaicvintupliinPolonia,Japonia,Pakistan

iLiban.PrimulcazdeseptupliviabiliafostsemnalatnSUAn1997.Aumaifost

nregistratedou cazurideseptupli:nHawai(autrit11zile)inSuedia(autrit

7zile).Nusecunoscoctupli.

Aceastarataascendentaasarciniimultipleesteasociatacuocresterea

mortalitatiisimorbiditatiineonatalesimaterne.

IncidentasesupunelegiiluiHellin,conformcreiafrecvenasarcinii

multipleestede1la80n1,undenestenumrulfeilor:

gemelara1la80

tripla1la80

cvadrupla1la80etc.

Etiopatogeniaimplicafactorii:


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genetici,ereditari:frecvenaapariieisarciniimultipleestemaimarela

priniinscuilarndullordintrosarcin multipl,lafemeiereditateaareun

impactdeosebitseparecaactioneazaprintrogenaautosomaldominanta

prezentalaaproximativ15lasutadinpopulatie(aceastagenaardetermina

ovulatiamultiplalafemeie;

climaterici:inciden crescut vara,cndzilelesuntmailungi(luminasolar

arstimulahipofiza,inducndohipersecreiedeFSHiLH,faptceardetermina

ovulaiapolifocal);

paritatea:inciden crescut lamarilemultipare;

zonageografic (datoritatemperaturiisi luminii):fostaURSS(inciden de

2,23%),Frana,Spania,Italia(1,2%),Japonia(0,8%);nRomniaincidenaestede1/961/93;ClinicaSf.Pantelimonaproximativ1/85;ceamaimareincidenta

cunoscutaoareNigeria1/38.Rasaneagraprezintaofrecventamaimarede

aparitieasarciniimultiple.

factoriiatrogeni:inducereaovulaieilafemeilecusterilitatedetermin

cretereafrecveneisarciniimultiple(gonadotropiicorioniciiceihipofizaricresc

incidenala45%,iarclomifenulla8,5%);fertilizareainvitro(FIV)determin

cretereafrecveneisarciniimultipledeoarecenecesit ostimularepreovulatoriecurecoltareaamaimulteovule(dup fertilizareaacestoraseimplanteaznuter

maimulteou,fiepentruacreteprocentulreuiteiprocedurii,fiechiarpentrua

obineosarcin multipl),recomandareaestedealimitatransferuldeembrioni

lamaximtreipeprocedura,

sarcinileobtinutelafemeilacareafostopritadecurandterapia

anticonceptionala,datoritaeliminariibrusteablocajuluidelanivelulhipofizei

anterioare.

maximulincidenteisarciniimultipleestelaaproximativ37deanicand

stimulareahormonalacrescutainducecresterearateiovulatieiduble(secretie

crescutadeFSH).


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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

lungimeaminimaaunuiciclu menstrual(ovulatielaolunadelaprima

fecundatie).

Superfecundatiasereferalafertilizareaadouaovociteformateintimpul

aceluiasiciclumenstrualdarnudupaacelasicontactfecundant.


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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,determinat ecograficnprimultrimestru.

Prezenaadou placenteseparateiogrosime,ngeneral,de2mmsaumai

mare,amembranelorinteramnioticesustineundiagnosticuldedicorionicitate.

nsarcinilencareosinguramasaplacentar esteidentificata,poatefi

dificils sedisting oplacentaunicamarededou placentesituatealturat.

Examinanareaoriginiimpririimembraneipesuprafaaplacentaranepoate

clarificaaceast situaie,oproiecietriunghiularadetesutplacentarse

vizualizeazaaseextindedincolodesuprafatacorionicaintrestraturilemembranei

divizate,atunciexist dou placentefuzionatesemnulvrfurilorgemene.

nschimb,sarcinilemonochorioniceauomembranainteramnioticaattde

subireincatnupoatefivzut pn inaldoileatrimestru.Membranaesten

generalmaisubtirede2mm,iarmrireaimaginiidezvluienumaidou straturi.

Aceast legaturanunghidreptntremembraneiplacenta,faranicioextindere

aparent aplacenteintremembranadivizataestecunoscutasubdenumireade

semnulT.Ecograficevaluareadiviziuniimembranaresefacecelmaiuorimai

exactnprimajumtateasarcinii,atuncicndfetuiisuntmaimici.

Evaluareaclinica,paraclinicasiistoriculpersonaltrebuiedublatede

examenulecografic.Examenulclinicestedificildeefectuat,diagnosticulde

sarcinagemelaraemaifacilcandsepalpeazadouacapetefetaleculocalizarein

cadranediferite.Insarcinileavansatepotfidetectatedouasaumaimultefocare

deauscultatoriialeBCFurilorcetrebuiedistinsedeactivitateacardiacamaterna.


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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%

dinsarcinilegemelaresi aproximativ85%dinsarcinilecutripletiseconstata

gradediferitederestrictiedecrestereintrauterina.Inultimiianiaufostelaborate

curbedecresterepentrusarcinamultiplacuvalorispecifice.Diferenteaparsilasarciniledicorionicedatoritaimplantarii inzonecupotentialmaimical aportului

desangepentruschimburileplacentare.Restrictiadecresterepoatefidatoratasi

anomaliilordecordonombilicalinsertiemarginalasivelamentoasasauvasa

praevia.Greutateaestemaimicainspeciallasarcinilemonozigotice

monocoriale,unde,alocareainegalaablastomerelor,anastomozelevasculare


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placentarecudistributiainsuficientasiinegalaanutrientilorsioxigenului,

anomaliilestructuraledatorateprocesuluidediviziunesunttotatateamotive

pentruaparitiatulburarilordecrestereintrauterina.

DuratamedieagestatieipentrusarcinagemelarainSUAestede35desaptamani,latripletiestede32desaptamaniiarlacvintupletisicvadrupletieste

de30respectiv29desaptamani.

Termenuldenasterepentrusarcinagemelaraeraconsideratcelde40de

saptamani.Dupaultimelestudiidepasireavarsteidesarcinade39desaptamani

lasarcinilegemelarefacecarisculdeoprireinevolutieasarciniisadepaseasca

beneficiile.

Dezvoltareaneuropsihicasifizicaestecomparabilacuacopiilorprovenitidinsarcinileunice.Totusiexistaunusorretardsioadaptaremaidificilala

colectivitate.Laoricevarstadincopilariegemeniiauinmedieogreutatecu6luni

subcopiiidinsarcinileunicesioinaltimecu3lunisubacestia.

Gemeniimonoamnioticisuntovarietaterara(aproximativ1%),dar

grevatadeomorbiditatesimortalitatemare.

Gemeniiconjugatifunctiedeparteacorpuluicareesteimpartitaseimpart

intoracopagianterior,pygopagiposterior,craniopagicefalic,ischiopagi

caudal.

Anastomozelevasculareintrefetiaparaproapeexclusivlasarcinile

monocorionice.Totusiexistadiferenteimportantededimensiuni,numarsivolum

desangecetreceprinacestesunturivasculare.Insindromultransfuzor

transfuzatsangeledelagemenultransfuzorestetransferatlaceltransfuzatcu

dezvoltareauneirestrictiidecresteresiauneianemiisecundare.Gemenul

transfuzatpoateprezentainsuficientacardiacaprinhipervolemiesicrestereavascozitatiisangelui.Prognosticulsindromuluiestedeobiceirezervatdatorita

complicatiiloracestuia:leziunicerebrale,oprireainevolutieaunuiadintrefeti,

moarteneonataladupanastereprematura.Tratamentulsindromuluiinclude

amnioreductia,septostomie,ablatiaculaseraanastomozelorvascularesau

feticidselectiv.


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Casiobiectivealemanagementuluisarcinilormultiplesunt

urmatoarele:1.prevenireanasterilorpremature

2.extragereafatuluisaufetilorinaintedeoprireainevolutieaacestora

3.evitareatraumatismuluifetalintimpultravaliuluisiaexpulziei

4.asistentaneonataladecalitate

MonitorizareaTAesteobligatorieHTAfiindde3orimaifrecventala

gravidelecusarcinamultipla.

Monitorizareaecograficatrebuiesaincludaevaluarealichiduluiamniotic

prinAFI(amnioticfluidindex)caretrebuiesaaibavaloriintre8si24mmsi

velocimetrieDopplerinspeciallanivelulcordonuluiombilicalsiartereicerebralemedii(fluxenddiastolicabsentfiindcorelatcurestrictiadecrestere

simortalitateperinatala).

Profilaxianasteriiprematureevitareaefortuluifizicmare,terapia

tocoliticaderutinanuesteindicatadatoritarisculuidesupraincarcare volemica

cuasociereaedemuluipulmonar.Administrareadecorticosteroiziesteindicata

pentruprofilaxiadetreseirespiratoriilafelcasilanastereaprematura.Cerclajul

areaceleasiindicatiicasiinsarcinaunica.Nuseindicacerclajulprofilactic.

Rupturaprematurademembranetrebuieabordataasemanatorcusarcina

unica.

Nastereaunuifatcuamanareanasteriiceluidealdoilea/treileafat,se

poatefacedupanastereaprimuluifatprinadministrareatocoliticelorsi

antibioticelor(sistemicsilocal)siefectuareaunuicerclajlacaldalcoluluiuterin,

acoloundecircumstantelelocaleoimpun.

Lasarcinilegemelaresepotasociatoateprezentatiile.Celemaifrecvente

suntcranianacraniana,cranianapelvianasicranianatransversala.De

subliniatestecaacesteprezentatiisimaialesceacranianacranianasunt

instabileinaintesimaialesintimpultravaliuluisiexpulziei.


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Analgeziaepiduralaesterecomandatademaimultiautori.Eaareavantajul

casepoateextindeincazulincareseimpunefectuareademanevreobstetricale

saucezariana.Intimpuleipacientasicopiiitrebuiemonitorizatiatentdatorita

risculuidehipotensiunematernacuscadereaperfuzieiplacentare.

Nastereapecalevaginalasepoateproducespontansauinstrumental

atuncicandprimulfatesteinprezentatiecraniana.Dacaprimulfatestein

prezentatiepelviana,lafelcalasarcinaunicaaparurmatoarelesituatiiceimpun

nastereaprinoperatiecezariana:

candfatulareDBP(diametrulbiparietal)peste100mmsaucandareloc

angajareaprecoceamembrelor/tunchiuluifetalexistaposibilitateaderetinerea

capuluifetal

prolabareacordonuluiombilicalodatacurupereamembraneloramniotice

altesituatii

Lafetiisituatiinprezentatietransversalanastereapoateavealocdupa

versiuneinternasauprinoperatiecezariana.

Incazulsarcinilormultipledeordinultreisaumaimultmajoritateastudiilor

recomandanastereaprinoperatiecezariana,cuexceptiacazurilorcandfetiisuntcompromisisaugravidaprezintaopatologiecareiarpuneviatainpericolin

eventualitateauneiinterventiichirurgicale.


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