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Practice bulletins > #169 Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies > Flashcards

#169 Multifetal Gestations: Twin, Triplet, and Higher-Order Multifetal Pregnancies Flashcards

1
Q

Why is there an increased incidence in multifetal gestations?

A
  1. Shift toward older maternal age at conception

2. Increased use of ART

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2
Q

What is the principal complication encountered with multifetal gestations?

A

Spontaneous preterm birth

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3
Q

What is the risk of stillbirth and neonatal death in multifetal compared to singleton gestations?

A

Fivefold increase in stillbirth.

Sevenfold increase of neonatal death (primarily d/t complications of prematurity)

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4
Q

Women with multifetal gestations are ___ times more likely to give birth preterm than singletons?

A

6

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5
Q

Women with multifetal gestations are ____ times more likely to deliver before 32 wks than singletons

A

13

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6
Q

What are the mean birthweights and GAs of singletons, twins, triplets, quads?

A

Singleton: 3296g/38.7wks
Twins: 2336g/35.3wks
Triplets: 1660g/31.9wks
Quads: 1291g/29.5wks

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7
Q

What percent of pregnancies are born less than 32 weeks (singletons, twins, triplets, quads)?

A

1.6, 11.4, 36.8, 64.5

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8
Q

What percent of pregnancies are born less than 37 weeks (singletons, twins, triplets, quads)

A

10.4, 58.8, 94.4, 98.3

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9
Q

What are the rates of cerebral palsy per 1000 live births (singletons, twins, triplets)?

A

1.6, 7, 28

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10
Q

What is the infant mortality rate per 1000 live births (singletons, twins, triplets, quads)

A

5.4, 23.6, 52.5, 96.3

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11
Q

True or false: twins born at <32wks are at the same risk of high-grade intraventricular hemorrhage and periventricular leukomalacia when compared to singletons of same GA?

A

False. Twice the risk

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12
Q

When is assessment of chorionicity most accurate?

A

Early in gestation, first trimester or early second trimester

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13
Q

Do monochorionic twins or dichorionic twins have higher frequency of fetal and congenital anomalies?

A

Monochorionic

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14
Q

Do monochorionic or dichorionic twins have higher frequency of prematurity and fetal growth restriction?

A

Monochorionic

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15
Q

What medical complications are more common in women with multifetal gestations?

A

Hyperemesis, gestational DM, hypertension, anemia, hemorrhage, cesarean delivery, and postpartum hemorrhage, placental abruption

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16
Q

What is the incidence of hypertensive conditions in single, twin, triplet pregnancies?

A

6.5%, 12.7%, 20%

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17
Q

Does preeclampsia occur earlier, later, or at the same time in multifetal compared to singleton pregnancies?

A

Earlier

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18
Q

Older women are more likely to have which of the following compared to younger women: gestational hypertension, gestational DM, placental abruption

A

All of them

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19
Q

What is the rate of multiples in women <20 compared to women >40?

A

16.3 per 1000 live births vs 71.1 per 1000 live births

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20
Q

Which ART techniques may have the most significant effect on increase of multifetal pregnancies?

A

IVF and controlled ovarian hyperstimulation with gonadotropins

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21
Q

Does multifetal reduction lead to decreased risk of preeclampsia?

A

Yes

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22
Q

Do pregnancy reduction from triplets > twins lead to lower pregnancy loss, antenatal complications, preterm birth, SGA infants, cesarean delivery, neonatal deaths

A

Yes

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23
Q

Is it better in multifetal pregnancy reduction to reduce a dichorionic or monochorionic? Why?

A

Dichorionic. If one fetus of a monochorionic twin pair is reduced, the negative effects on the development of other are unknown. For this reason, usually recommended that both fetuses of a monochorionic pair are reduced

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24
Q

What is the unintended loss rate after selective fetal termination in higher order multiples compared with twin gestations?

A

11.1% vs 2.4%

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25
Q

What are ultrasound signs of a dichorionic pregnancy?

A

Two placentas visualized, differing fetal sex, twin peak sign (lambda or delta sign)

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26
Q

What screening methods and interventions are available to help prevent preterm birth in asymptomatic multifetal gestations?

A

No interventions that prevent preterm delivery in multifetal gestations identifed to be at risk based on screening methods. Use of screening methods in these asymptomatic women not recommended

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27
Q

In women with multifetal gestations and symptoms of preterm labor are fetal fibronectin tests and short cervical length predictive/helpful?

A

Positive predictive value is poor, should not be used exclusively to direct management in setting of acute symptoms

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28
Q

Are there interventions that can prolong pregnancy in women with multifetal gestations?

A

No. Prophylactic cerclage, routine hospitalization and bed rest, prophylactic tocolytics, prophylactic pessary have not been proven to decrease morbidity and mortality and, therefore, should not be used in women with multifetal gestations

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29
Q

What is the effect of ultrasound indicated cerlage placement for twin gestation?

A

Doubles the rate of spontaneous preterm birth

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30
Q

Is prophylactic cervical pessary recommended in multifetal pregnancies?

A

No

31
Q

Does progesterone treatment reduce the incidence of spontaneous preterm birth in unselected women with twin or triplet gestation?

A

No, so not recommended

32
Q

Is magnesium sulfate recommended for neuroprotection for multifetal gestations <32wks?

A

Yes, regardless of fetal number

33
Q

Can amniocentesis and CVS be performed in multifetal gestations?

A

Yes

34
Q

What is the procedure-associated pregnancy loss rate for amnio and CVS in multifetal gestations?

A

1 - 1.8%

35
Q

Does CVS of amniocentesis have a lower chance of sampling error in multifetal gestation?

A

Amniocentesis

36
Q

What is the risk of sampling error in CVS with multifetal gestation?

A

1%

37
Q

How do you perform an amniocentesis of a multifetal gestation to ensure you do not have a sampling error?

A

Sample the first sac, then inject indigo carmine before removing the needle. Sample the second sac (with a second needle), and make sure it is a clear colored sample

38
Q

What is the definition of growth discordance between twins? What is the equation?

A

20% difference in EFW between larger and smaller fetus.

Discordance = difference in weights/weight of larger twin

39
Q

Are multifetal gestations with discordant, but appropriate-for-gestational-age growth at increased risk of fetal or neonatal morbidity or mortality?

A

No increased risk

40
Q

Are multifetal gestations with discordant growth with at least one growth-restricted fetus at an increased risk of neonatal morbidity?

A

Yes, 7.7 fold increased risk in major neonatal morbidity

41
Q

What is the probability of a “vanishing twin” (spontaneous reduction of one or more fetuses) in twins, triplets, quads during first trimester?

A

36% for twins, 53% for triplets, and 65% for quadruplets

42
Q

In the second and third trimesters, what % of twins and triplets undergo death of one or more fetuses?

A

Up to 5% in twins and 17% in triplets

43
Q

After demise of one twin after 14 weeks, what is the risk of death in the co-twin in monochorionic and dichorionic gestations?

A 
Monochorionic = 15%
Dichorionic = 3%
44
Q

After demise of one twin after 14 weeks, what is the risk of neurologic abnormality in the surviving twin in monochorionic and dichorionic gestations?

A 
Monochorionic = 18%
Dichorionic = 1%
45
Q

What is next step in management in monochorionic gestation in late second or early 3rd trimester with demise of one twin?

A

Do not delivery before 34 weeks in absence of another indication. Immediate delivery of co-twin has not been shown to have benefit

46
Q

Does the growth rate of twins match the growth rate of singletons?

A

At first, until about 28-32wks, when the growth rate of twins slows.

47
Q

What is the recommendation for antepartum fetal surveillance/ultrasounds in uncomplicated dichorionic pregnancies?

A
  • Establish chorionicity in 1st or early 2nd trimester.
  • Anatomy scan 18-22wks.
  • Reasonable to do ultrasounds q 4-6wks (in absence of preg complications)
  • No need for antenatal fetal surveillance if uncompicated
48
Q

What % of mono-di pregnancies are affected by twin-twin transfusion syndrome?

A

Approximately 10-15%

49
Q

What causes twin-twin transfusion syndrome?

A

Arteriovenous anastomoses in a monochorionic placenta

50
Q

How should you monitor mono-di twins for twin-twin transfusion syndrome? When does it usually present?

A

Ultrasound examination q2 wks beginning at 16wks. Usually presents in second trimester

51
Q

What is the criterion for diagnosis of twin-twin transfusion syndrome with ultrasound?

A

Mono-di twin gestation with oligohydramnios (MVP <2cm) in one sac and polyhydramnios (MVP >8cm) in the other sac.

52
Q

What determines the prognosis of twin-twin transfusion syndrome?

A

Gestational age and severity of the syndrome?

53
Q

How do you treat twin-twin transfusion syndrome?

A

Laser coagulation or amnioreduction

54
Q

What is the name of the staging system for twin-twin transfusion synddrome?

A

Quintero staging system

55
Q

What are the stages of twin-twin transfusion syndome?

A 
Stage 1: oligo/poly
Stage 2: absent (empty) bladder in donor
Stage 3: Abnormal doppler US findings [one of more: absent or reversed diastolic flor; ductus venosus absent or reversed diastolic flow; umbilical vein pulsatile flow]
Stage 4: hydrops
Stage 5: Death of one or both twins
56
Q

What is the “natural” incidence of monochorionic twins?

A

1 in 10,000

57
Q

What is the unique concern for mono-mono twins?

A

Cord entanglement

58
Q

What is the typical delivery time for mono-mono twins?

A

32-34wks

59
Q

When do clinicians often offer inpatient admission for mono-mono twins?

A

Beginning at 24-28wks

60
Q

In what type of gestation can you see an acardiac twin?

A

Unique to monochorionic gestation

61
Q

What is an acardiac twin?

A

A fetus lacking a normally developed heart and head

62
Q

What percentage of monochorionic twins have an acardiac twin?

A

1%

63
Q

Describe what happens in a monochorionic pregnancy with an acardiac twin

A

There is an acardiac twin and a “pump twin.” The acardiac twin can survive in utero because of placental anastomoses shunting blood from the pump twin. Pump twin can develop high cardiac output and cardiac failure, leading to intrauterine or neonatal death in 50% of cases.

64
Q

What is the inutero/neonatal mortality rate of monochorionic pregnancy with acardiac twin (for pump twin)?

A

50%

65
Q

What is the incidence of conjoined twins?

A

1 in 50,000 to 1 in 100,000 births

66
Q

What is the survival rate of one twin from ultrasonographic diagnosis of conjoined twins to successful separation?

A

18%

67
Q

On average, women with twin pregnancies give birth at what gestational age?

A

36wks

68
Q

At what gestational age does the risk of perinatal mortality begin to increase in twin pregnancies?

A

38 weeks

69
Q

What are the recommended delivery times for uncomplicated twin gestsions: di-di, mono-di, mono-mono?

A 
Di-di = 38 weeks
Mono-di = 34-37w6d
Mono-mono = 32-34
70
Q

Which type(s) of twins should always be delivered by cesarean section?

A

Mono-mono

71
Q

At what gestational age can you consider a vaginal delivery in twins with Twin A vertex, regardless of position of Twin B?

A

32 weeks and up

72
Q

Can you plan for vaginal delivery for triplets?

A

Yes, if presenting is vertex and you have experienced providers

73
Q

Can women with prior cesarean section and twin gestation TOLAC?

A

Yes, as long as otherwise appropriate candidates for twin vaginal delivery?

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