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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
Q

In twin-twin transfusion syndrome both twins are at risk of demise from what?

A

Heart failure

26
Q

How is TTTS diagnosed and what is seen in the donor twin vs recepient?

A
  • US
    • Donor: smaller, stuck in appearance and oligohydramnois
    • Recep: larger, polyhydramnois, ascites
27
Q

What occurs in Acardiac Twin?

A
  • 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
Q

What is the most common umbilical cord abnormalities, which are MC in monozygotic twins?

A

Velamentous umbilical cord insertions > no umbilical as.

29
Q

If retained dead fetus syndrome occurs >20 weeks gestation, what complication can develop in the mother; how should she be managed?

A
  • Can devlop DIC
  • So check platelets and fibrinogn levels weekly
30
Q

What is fetus papyraceus?

A

When retained dead fetus syndrome occurs >12 weeks and the fetus shrinks, dehydrates, and flattens

31
Q

What is vanishing twin syndrome?

A

When retained dead fetus syndrome occurs < 12 weeks, dead fetus is reabsorbed.

32
Q

Maternal complications of multiple gestations

A
  1. Polyhydramnois
  2. Anemia
  3. Gestational HTN/DB
  4. Post-partum hemorrhage d/t uterine atony
  5. C-section and preterm labor
33
Q

When should mother with monoamniotic twins be hospitalized and they should be delivered at how many weeks; WHY?

A
  • 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
Q

How do you manage multiple gestations in the 1st and 2nd trimester?

A
  1. Visit doc office every 2 weeks
  2. US cervical length assessment
35
Q

How do you manage multiple gestations in the 3rd trimester?

A
  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
Q

NST rate of stillbirth

BPP rate of still birh

A
  • NST = 1.9%
  • BPP = 0.7%
37
Q

If no complications during pregnancy, it is recommended to deliver twins at how many weeks?

A

38 weeks, but most are delivered at 35-6.

38
Q

What is the best presentation to deliver twins vaginally?

A

Vertex-vertex

39
Q

During vertex-vertex presentation the 2nd twin is at increased risk for what complications; we should be prepared for what complication in mom?

A
  • 2nd twin = ↑ risk of cord prolapse, placental abruption, and malpresentation
  • Be prepared for postpartum hemorrhage due to uterine atony
40
Q

If first twin is vertex, but other twin is transverse/breech how should they be delivered?

A

CAN be vaginally, but will often be by C-section

41
Q

How are breech-breech or breech-vertex twins delivered?

A

C-section

42
Q

What is the perinatal mortality in twins compared to singletons and why?

A
  • 5x greater due to prematurity and congenital anomalies (respiratory distress syndrome, intracranial hemorrhage and birth asphyxia => 2nd twin is more likely to die).
43
Q

How are triplets/quads delivered?

A

C-section

44
Q

More than 2 fetuses

  • Most commonly due to _________.
  • As the number of fetuses increase => prematurity increases
    • Triplets delivered at ______ weeks
    • Quads delivered at ____ weeks
A
  • Iatrogenic causes (agents that induct ovulation)
  • Triplets => 33 weeks
  • Quads => 29 weeks
45
Q

What is malpresentation and what is the most common?

A

Presentation other than vertex

BREECH is the most common.

46
Q

What is the most common breech presentation?

A
  • Frank
  • Thighs are flexed
  • Knees are extented
47
Q

What is breech and what is the most common factor associated with breech?

A
  • BBs butt or LE presents in pelvis
  • Prematurity
48
Q

How are breech presentation dx?

A
  1. Leopold maneuver
  2. US
  3. Pelvic exam
49
Q

What happens if a women wants a vaginal delivery, but is in breech presentation?

Where must it be done

A

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
Q

CI for ECV

A
    1. Oligohydramnois
    1. Non- reassuring fetal monitoring
    1. Placental previa
    1. Previous uterine sugery
51
Q

Before performing external cephalic version (ECV) patient should be NPO for how long?

A

7 hours

52
Q

What is the standard of care in most practices in terms of how to deliver a breech presenation?

A

All by C-section

53
Q

What did the 2000 Term Breech Trial say about delivering breech vaginally?

A

Found that in planned c-section groups = neonatal mortality/morbidity, but no difference in maternal morbidty/mortality.

54
Q

If doing a vaginal breech delivery how far should the baby be out before applying any traction?

A

Allow fetus to deliver to the scapulae

Traction too early can cause head deflexion => head entrapment.

55
Q

If doing a vaginal breech delivery, how do you deliver the head?

A
  • Apply pressure on fetus MAXILLA to keep the head flexed.
  • But often head is easily delivered with contractions, suprapubic pressure and gentle traction
56
Q

Which special type of forceps are used in assisted breech vaginal deliveries?

A

PIPER forceps

57
Q

Why are c-sections ESPECIALLY done in premature breeches?

A

bc largest part of fetus is head => can get entrapped => fetal asphyxia

58
Q

BROW PRESENTATION

  • What is it?
  • How are they delivered.
A
  • 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
Q

What is face presentation?

What is seen in 1/3 of the cases?

A
  • Head and neck are fully extended, with the occiput against the upper back
  • Anecephaly
60
Q

With a face presentation the fetal chin is the point of designation. Which of these babies CAN and which CANNOT be delivered vaginally?

A
  • Mentum anterior => vaginally (MA can deliver vainally)
  • Mentum posterior=> C-section
61
Q

what is the presenting part in face presentation?

A

Trachelobragmatic diameter (12.6)

62
Q

What is a compound presentation?

delivery?

A

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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