17. Multiple pregnancy.

Question 1

what increases the chance of twin pregnancy?

Answer 1

race - africans

maternal predisposition

women the age over 35
clomiphene
gonadotropin

fifth gravida onward.

Question 2

mean gestational delivery age of twins

Answer 2

36 weeks

Question 3

what is increased in multiple pregnancy ?

Answer 3

maternal and fetal morbidity and mortality

Question 4

How does multiple pregnancy occur

Answer 4

fertilisation of single ovum - which splits - identical monozygotic twinning

more common
fertilisation of multiple ovum- dizygotic / non identical/ fraternal/ binovular

Question 5

in monozygotic twinning arrangement of the fetal membranes will depend on ?

Answer 5

when the embryo divides in the embryogenesis - the earlier the embryo splits to make a twin the separate the membrane and placenta will be

Question 6

dichorionic , diamniotic in monozygotic twinning the embryo needs to split when ?

Answer 6

within the first 72 hours of fertilisation (prior to morula stage)

Question 7

diamniotic and monochorionic to occur in monozygosity when does the splitting need to happen?

Answer 7

occurs 4-8 days after development

Question 8

monochorionic and monoamniotic twins residing in a sac with no septum splitting occurs when ?

Answer 8

if division occurs after 8 days

Question 9

which division is most likely in incidence for monozygous twins?

Answer 9

diamniotic a thin two layer septum separation will evolve. But monochorionic

Question 10

which is the least likely in monozygotic twins in terms of the amnion and chorion ?

Answer 10

monochorionic and monoamniotic twins

Question 11

what are the complications for monochorionic and monoamniotic twins ?

Answer 11

there is no intervening membrane the risk for umbilical cord entanglement is very high - resulting in net mortality of these twins to almost 50 percen

Question 12

On extremely rare occasions, if division occurs after 2 weeks?

Answer 12

cleavage will be incomplete leading to conjoined twins , most being thoracopagus

Question 13

dizygotic twin do chorion and amnion morphology ?

Answer 13

separate placentas, separate amnions

Question 14

determination of what is very important after diagnosing multiple pregnancy ? and why ?

Answer 14

DETERMINATION OF ZYGOSITY

monozygotic higher risk for :
congenital anomalies , weight discordancy , twin twin transfusion syndrome , neurological morbidity premature delivery , umbilical cord abnormality

Question 15

methods for diagnosing twins ?

Answer 15

US - and two separate foetuses and heart activities made early as 10 weeks of gestation

use of fertility drugs

feeling larger than previous pregnancies

excessive fetal movements

excessive weight gain - suggestive

excessive uterine fundal growth - suggestive
increased subjective symptoms compared to last pregnancy

Question 16

methods of determining zygosity?

Answer 16

US -
dizygotic - visualisation of thick double aminion chorion septum - twin peak sign or lambda sign
two different placenta which is usually close together

monozygotic :
splitting early the signs above

if septum
quite thin
“T-sign” there is only two amnions and no chorion
and one placenta

or no septum at all present

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twins having opposite sex are almost always dizygotic

If the fetuses are of the same sex and have the same genetic features (dominant blood group), monozygosity is likely

communicating vessels in mono zygotes present but absent in dizygotic

A test skin graft—Acceptance of reciprocal skin graft is almost a certain proof of monozygosity.

investigation of placenta after birth

DNA microbe technique = definite

Question 17

what is the antepartum management ?

Answer 17

diet - increased calories and protein
and folic acid and iron

US

fetal surveillance

routine use of betamimetics or cerclage operation has got no significant benefit on preterm labour !.
Use of corticosteroids to accelerate fetal lung maturation is given

Question 18

Antepartum ultrasound management in twin pregnancy?

Answer 18

between 16-22 weeks - patient seen every two weeks for US

fetal growth monitored by US every 4-6 weeks beginning of the 24th gestation week

after 36 weeks
Non stress testing , or biophysical profile

umbilical artery doppler effect

Question 19

antepartal maternal complications?

Answer 19

anemia - blood volume increases so demand of iron,
increased iron and folate requirement by the two fetuses- megaloblastic anemia

eclampsia and preeclampsia

hydroaminos - usually in second sac

dyspnea ,

orthostatic hypotension due to compression of the vena cava and aorta

compromise of renal function due to compression of the ureters

PROM

placenta abruption

Question 20

labour complications
complications?

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fetal complications ?

Answer 20

malpresentations very common - usually the first baby is in vertex

umbilical cord prolapse ,

PPH - REAL DANGER
atony due to overextension of uterus
longer time for placenta separate and bigger surface area placenta

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miscarriage esp in monozygotic

vanishing twin in second trim

prematurity

intrauterine growth restrictions and discordant twin growth

congenital anomalies- more in monozygotic

as[hyxia and still birth - more in monozygotic

Question 21

what is the management during labour ?

Answer 21

if monoamniotic twin then delivery by c section is usually accomplished by 34-36 weeks because of the increased risk of cord entanglement

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Vaginal delivery is allowed when both the twins are/or at least the first twin is with vertex presentation.

to choose the safest route of delivery the presentation of the foetuses must be known
the presenting twin is designated as twin A and the second twin twin B

(most common) vertex-vertex
vaginal or prefer c section

vertex - breech
twin a - vaginal
twin b - vaginal if not c section

breech -vertex (c cessation)

breech - breech ( c section)

because the second twin is more likely to have cord prolapse ,head entrapment, neck injury and asphyxia , placenta abruption - fetal heart monitoring is always necessary

Question 22

management for delivery of first baby ?

Answer 22

Not to give intravenous ergometrine with the delivery of the first baby.

Liberal episiotomy under local infiltration with 1% lignocaine. (ii) Forceps delivery, if needed, should be done preferably under pudendal block anesthesia.

Clamp the cord at two places and cut in between, to prevent exsanguination of the second baby through communicating vessels in monozygotic twins

At least, 8–10 cm of cord is left behind for administration of any drug or transfusion, if required

Question 23

conduction of vaginal delivery of second twin?

Answer 23

Following the birth of the first baby, the lie, presentation, size and FHS of the second baby should be ascertained through abdominal and US

A vaginal examination is also to be made not only to confirm the but to note the status of the membranes and to exclude cord prolapse,

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Lie longitudinal:
Step 1: Low rupture of the membranes is done after fixing the presenting part on the brim.

Syntocinon may be added to the infusion bottle to achieve this. Internal examination is once more to be done to exclude cord prolapse.

Step 2: If the uterine contraction is poor, 5 units of oxytocin is added to the infusion bottle.

The interval between deliveries should ideally be less than 30 minutes.

Step 3: If there is still a delay (say 30 minutes)

 Vertex: • Low down — Forceps are applied.

• High up — If the first baby is too small and the second one seems bigger, cephalopelvic
disproportion should be ruled out and The possibility of hydrocephalic by ultrasonography. If these are excluded, internal version followed by breech extraction is performed under general anesthesia.
or ventouse

 Breech: The delivery should be completed by breech extraction.

Lie transverse:
corrected by external version into a longitudinal lie preferably cephalic.

If the external version fails, internal version under general anesthesia followed by breech extraction

Question 24

what is twin twin transfusion syndrome ?

Answer 24

EXCLUSIVELY IN MONOZYGOTIC TWINS

one twins circulation perfuses into another - typically atriovenous connections
the arterial blood from the donor twin enters the umbilical arteries and taken by the umbilical venous system belonging to the recipients twin

Question 25

in twin twin transfusion what does the donor twin deal with?

Answer 25

hypovolemia , hypotension , anemia , oligohydroaminos and growth restriction, absent bladder

Question 26

in twin twin transfusion what does the recipient twin deal with?

Answer 26

cardiomegaly , ascities , hydros ,hypervolemia , hydroaminos , hyperviscosity , thrombosis , hypertension , polycethmia , edema and congestive heart failure

Question 27

how is TTS diagnosed ?

Answer 27

ultrasound

Question 28

treatment for TTS

Answer 28

Treatment- serial amniocentesis, fluid reduction from the recipient twin`s sac and laser photocoagulation of the anastomosis vessels

Septostomy (making a hole in the dividing amniotic membrane)

Question 29

what is arterial -arterial placental anastomoses

Answer 29

arterial circulation of donor twin enters the arterial circulation os the recipient twin - causing thrombosis

Question 30

what is retained dead fetus syndrome?

Answer 30

it is not unusual for one twin to die in uteri but it leaves poor outcome of the other twin esp in monochorionic placenta

he surviving twin runs the risk of cerebral palsy, microcephaly, renal cortical necrosis and DIC
due to thromboplastin liberated from the dead twin

if it occurs before 12 weeks of gestation the the dead fetus is reabsorbed

Question 31

Absence of 1 umbilical artery is very significant because in monozygotic twins because ?

Answer 31

is associated with other congenital anomalies (renal agenesis). Marginal and velamentous umbilical cord insertions

Question 32

Postnatally twins on average are shorter and lighter than singletons of similar birth weight until?

Answer 32

4 years of age

Question 33

management of third stage of labour in vaginal delivery ?

Answer 33

risk of postpartum hemorrhage can be minimized by routine administration of 0.2 mg methergine IV or oxytocin 10 IU IM following the delivery of the second baby

blood transfusion given is more than normal blood loss

The patient is to be carefully watched for about 2 hours after delivery.