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Endo/Repro II Test 1 > 15. Multifetal Gestation and Malpresentation > Flashcards

15. Multifetal Gestation and Malpresentation Flashcards

1
Q

What is multiple gestation?

A

2 or more embryos/fetus are in the uterus at the same time.

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2
Q

What are fraternal twins?

A
  • Dizygotic twins that form when 2 diff sperm fertilize two diff ova => 2 pregnancies in 1 uterus => each as own amnoin, chorion and placenta
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3
Q

What are identical twins?

A
  • Monozygotic twins that occur when 1 fertilzed ovum CLEAVES at different stages of embryogenesis.
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4
Q

How does the nature of the membranes for monozygotic twins change if the embryo is cleaved at 0-3, 4-8, 9-12, or >13 days?

A
  • 0-3 days = dichorionic, diamniotic (separated)
  • 4-8 days = monochorionic, diamniotic
  • 9-12 days = monochorionic, monoamniotic
  • >13 days = conjoined twins
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5
Q

What is the most common presentation of membranes for monozygotic twins?

A

Monochorionic, diamniotic (1 choroin and 2 amnions) due to cleaveage at days 4-8

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6
Q

In dichorionic, diamniotic monozygotic twins, which form when embryo splits at days _____, what type of placentas do they have?

A

0-3 days

seperate or fused

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7
Q

Which presentation of monozygotic twins is the most dangerous and why?

A

Monochorionic monoamniotic bc their are not seperate amnoins, which can result in cord entanglement.

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8
Q

If the embryo splits at 13-15 days => monochorionic/monoamnionitic (conjoined twins) are formed with 1 placenta and 1 choroin.

How are they defined?

A

By where they are connected.

  1. Craniopagus => head
  2. Thoracopagus => chest wall (MC)
  3. Ischiopagus (coccyx and sacrum)
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9
Q

2/3’s of spontaneous twins are (mono- or dizygotic)?

A

Dizygotic (fraternal)

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10
Q

Having dizygotic twins is 2x more common when?

In what races?

A
  • After 35 YO
  • Highest in blacks = low in asians.
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11
Q

When should you suspect multiple gestations based on hCG, size of the uterus, ascultation?

A
  • Higher than NL (more than 2x/every 2 days)
  • Uterus palpates larger than date
  • Ausculate more than 1 fetal heart
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12
Q

How do we confirm multiples?

A

US:

  • Determine number of fetuses, gestational sacs and chorions
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13
Q

What is the most important step after diagnosing a twin pregnancy?

A

Determine zygosity, because prognosis and morbidity is dependent.

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14
Q

Monozygotic twins have increased incidence of what?

A
  1. Congenital anomalies and neuro problems
  2. Weight discordancy
  3. TTTS (twin-twin transfusion syndrome)
  4. Premature delivery
  5. Fetal demise
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15
Q

How can a dizygotic twins be determined on U/S?

A
  1. Different genders
  2. Thick amnion-chorion septum
  3. “Peak” or “inverted V” sign at base of septum
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16
Q

How can monozygotic twins be determined on US?

A

Fairly thin dividing membrane

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17
Q

If US does not determine zygosity, what do we do?

A
  1. Inspect placenta after delivery
  2. DNA analysis
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18
Q

90% of interplacental vascular anastomoses occur in what type of twins and what is the most common type of anastomosed vessels?

A
    • 90% occur in monochorionic twins
    • Most common type is arterial-arterial > arterial venous > v-v
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19
Q

Interplacental vascular anastomosis (vascular communition between 2 fetuses through placenta) can cause what complications?

A
  1. Abortion
  2. Polyhydramnois
  3. TTTS
  4. Fetal malformation
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20
Q

How are conjoined twins delivered?

When is elective termination performed?

A
  • C-section
  • Cardiac/cerebral fusion is found
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21
Q

What is twin-twin transfusion syndrome?

A

Uncompensated arterial-venous anastomoses in a monochorionic placenta, causing net transfer of blood from 1 twin to the other.

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22
Q

What are treatment options for twin-twin transfusion syndrome?

A
  • Laser photocoagulation of the anastomosis vessles on the placenta is performed nowadays
  • Serial amniocentesis w/ amniotic fluid reduction has been historically done
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23
Q

What complications do we see in the donor twin in TTTS?

A
  • Net loss of blood
    1. Hypovolemia
    2. Hypotension
    3. Oligohydramnois
    4. Anemia
    5. Growth restriction
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24
Q

What complications do we see in the recepient twin in TTTS?

A
  1. Receives blood
    1. Hypervolemia/edema
    2. HTN
    3. Polydramnois
    4. Polycythemia
    5. Cardiomegaly/ CHF
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25
In twin-twin transfusion syndrome both twins are at risk of demise from what?
***Heart failure***
26
How is TTTS diagnosed and what is seen in the donor twin vs recepient?
* US * Donor: smaller, stuck in appearance and oligohydramnois * Recep: larger, polyhydramnois, ascites
27
What occurs in **Acardiac Twin**?
- **Arterial to arterial anastomoses** between twins - Recipient twin is perfused w/ poor oxygenated blood =\> thrombosis/atresia of organs =\> fails to develop normally =\> ACARDIAC TWIN =\> Fully formed LE's w/ NO anatomic structures above of abdomen
28
What is the **most common umbilical cord abnormalities,** which are MC in **_monozygotic_** twins?
**Velamentous** umbilical cord insertions \> no umbilical as.
29
If **retained dead fetus syndrome** occurs _\>20 weeks gestation,_ what complication can develop in the mother; how should she be managed?
- Can devlop **DIC** - So check *platelets* and *fibrinogn* levels *weekly*
30
What is **fetus papyraceus**?
When retained dead fetus syndrome occurs **\>12 weeks** and the **fetus shrinks**, **dehydrates**, and **flattens**
31
What is **vanishing twin syndrome**?
When retained dead fetus syndrome occurs **\< 12 weeks,** dead fetus is *reabsorbed*.
32
Maternal complications of multiple gestations
1. Polyhydramnois 2. Anemia 3. Gestational HTN/DB 4. Post-partum hemorrhage d/t uterine atony 5. C-section and preterm labor
33
When should mother with **monoamniotic twins** be _hospitalized_ and they should be _delivered_ at how many weeks; _WHY_?
- **Hospitalize** at _26 weeks_ (give steroids and monitor FHR several times a day) and **deliver** at _32 weeks_ - Secondary to ↑ risk of lethal _cord entaglement_
34
How do you manage multiple gestations in the 1st and 2nd trimester?
1. Visit doc office every 2 weeks 2. US cervical length assessment
35
How do you manage multiple gestations in the **3rd** trimester?
1. **Cervical length** 2. **Serial US q 4-6 weeks** begining at 24 weeks to look for _discordant fetal growth_ (20% reduction in fetal weight of smallest fetus compared to largest) 3. **Antepartum testing** (NST or weekly BPP) 4. **Bed rest**
36
NST rate of stillbirth BPP rate of still birh
* NST = **1.9%** * BPP = **0.7%**
37
If no complications during pregnancy, it is recommended to **deliver twins** at how many weeks?
**38 weeks,** but most are delivered at 35-6.
38
What is the best presentation to deliver twins vaginally?
**Vertex-vertex**
39
During vertex-vertex presentation the _2nd twin_ is at increased risk for what complications; we should be prepared for what complication in _mom_?
- 2nd twin = ↑ risk of **cord prolapse**, **placental abruption**, and **malpresentation** - Be prepared for **postpartum hemorrhage due to uterine atony**
40
If first twin is **vertex,** but other twin is **transverse/breech** how should they be delivered?
**CAN** be **vaginally**, but will often be by C-section
41
How are **breech-breech** or **breech-vertex** twins delivered?
**C-section**
42
What is the **perinatal mortality** in twins compared to singletons and why?
* **5x greater** due to *prematurity* and *congenital anomalies* (respiratory distress syndrome, intracranial hemorrhage and birth asphyxia =\> 2nd twin is more likely to die).
43
How are triplets/quads delivered?
**C-section**
44
**_More than 2 fetuses_** * Most commonly due to \_\_\_\_\_\_\_\_\_. * As the number of fetuses increase =\> prematurity increases * Triplets delivered at ______ weeks * Quads delivered at ____ weeks
* Iatrogenic causes (agents that induct ovulation) * Triplets =\> 33 weeks * Quads =\> 29 weeks
45
What is malpresentation and what is the most common?
**Presentation other than vertex** **BREECH** is the most common.
46
What is the most common **breech** presentation?
* Frank * Thighs are flexed * Knees are extented
47
What is **breech** and what is the **most common factor** associated with breech?
* **BBs butt** or **LE** presents in pelvis * **Prematurity**
48
How are **breech** presentation dx?
1. **Leopold maneuver** 2. **US** 3. **Pelvic exam**
49
What happens if a women wants a **vaginal delivery,** but is in **breech presentation**? Where must it be done
**ECV (external cephalic version)** =\> turn bb forward or backward summersault into vertex position if they are at **36 weeks and NOT in labor.** - must be done in a hospital where an immediate c-section can be done-
50
CI for ECV
* 1. Oligohydramnois * 2. Non- reassuring fetal monitoring * 3. Placental previa * 4. Previous uterine sugery
51
Before performing external cephalic version (ECV) patient should be NPO for how long?
**7 hours**
52
What is the standard of care in most practices in terms of how to deliver a breech presenation?
All by C-section
53
What did the 2000 Term Breech Trial say about delivering breech vaginally?
Found that in planned c-section groups = neonatal mortality/morbidity, but no difference in maternal morbidty/mortality.
54
If doing a **vaginal breech delivery** how far should the baby be out before applying any traction?
Allow fetus to deliver to the scapulae Traction too early can cause **head deflexion =\> head entrapment.**
55
If doing a vaginal breech delivery, how do you deliver the head?
* Apply pressure on **fetus MAXILLA** to keep the head flexed. * But often head is easily delivered with contractions, suprapubic pressure and gentle traction
56
Which special type of forceps are used in **assisted breech vaginal deliveries?**
**PIPER forceps**
57
Why are c-sections ESPECIALLY done in premature breeches?
bc largest part of fetus is head =\> can get entrapped =\> fetal asphyxia
58
**BROW PRESENTATION** * What is it? * How are they delivered.
* Presenting part of the fetus is the **supraoccipitomental diameter** (between the facial orbits and anterior fontanelle) = 13.5 cm * Deliver * Most extend to face presentation or flex to vertex =\> deliver * If brow persists =\> MUST do c-section
59
What is face presentation? What is seen in 1/3 of the cases?
* Head and neck are fully extended, with the occiput against the upper back * **Anecephaly**
60
With a **face presentation** the _fetal chin is the point of designation_. Which of these babies CAN and which CANNOT be delivered vaginally?
- Mentum anterior =\> **vaginally** (MA can deliver vainally) - Mentum posterior=\> **C-section**
61
what is the presenting part in **face presentation?**
**Trachelobragmatic diameter (12.6)**
62
What is a compound presentation? delivery?
When fetal extremity (usually the hand) is found prolapsed alongside the presenting fetal part (head) Delivery * May resolve on its own as it goes into pelvis * if not =\> c-section

Endo/Repro II Test 1 (23 decks)

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