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TN Obstetrics > 7. Multi-Fetal Gestation and Malpresentation > Flashcards

7. Multi-Fetal Gestation and Malpresentation Flashcards

1
Q

Describe epidemiology: Multi-Fetal Gestation (4)

A
  • incidence of twins is 1/80 and triplets 1/6400 in North America
  • 2/3 of twins are dizygotic (fraternal)
    • risk factors for dizygotic twins: IVF, increased maternal age, newly discontinued OCP, and ethnicity (e.g. certain African regions)
  • monozygous twinning occurs at a constant rate worldwide (1/250)
  • determine zygosity by number of placentas, thickness of membranes, sex, and blood type
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2
Q

Name MATERNAL complications of multiple gestation (7)

A
  • Hyperemesis gravidarum
  • GDM
  • Gestational
  • HTN
  • Anemia
  • Increased physiological stress on all systems
  • Increased compressive symptoms
  • C/S
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3
Q

Name UTEROPLACENTAL complications of multiple gestation (7)

A
  • Increased premature rupture of membranes (PROM)/preterm labour (PTL)
  • Polyhydramnios
  • Placenta previa
  • Placental abruption
  • postpartum hemorrhage PPH (uterine atony)
  • Umbilical cord prolapse
  • Cord anomalies (velamentous insertion, 2 vessel cord)
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4
Q

Name FETAL complications of multiple gestation (7)

A
  • Prematurity
  • intrauterine growth restriction (IUGR)
  • Malpresentation Congenital anomalies
  • Twin-twin transfusion
  • Increased perinatal morbidity and mortality
  • Twin interlocking (twin A breech, twin B vertex)
  • Single fetal demise
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5
Q

Describe management of multiple gestation (4)

A
  • U/S determination of chorionicity must be done within T1 (ideally 8-12 wk GA)
  • increased antenatal surveillance
    • serial U/S q3-4wk from 22 wk GA to assess growth (uncomplicated diamniotic dichorionic)
    • increased frequency of U/S in monochorionic diamniotic and monochorionic monoamniotic twins
    • Doppler flow studies weekly if discordant fetal growth (>30%)
    • biophysical profile (BPP) as needed
  • may attempt vaginal delivery if twin A presents as vertex, otherwise C/S (40-50% of all twin deliveries, 10% of cases have twin A delivered vaginally and twin B delivered by C/S)
  • mode of delivery depends on fetal weights, GA, and presentation
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6
Q

Multiple Gestation has increased rates of what? (The Ps of Multiple Gestation Complications) (13)

A
  • Puking
  • Pallor (anemia)
  • Preeclampsia/Pregnancy-Induced Hypertension (PIH)
  • Pressure (compressive symptoms)
  • PTL preterm labour/ premature rupture of membranes (PROM)/ preterm premature rupture of membranes (PPROM)
  • Polyhydramnios
  • Placenta previa/abruption
  • postpartum hemorrhage (PPH)/ antepartum haemorrhage (APH)
  • Prolonged labour Cord prolapse
  • Prematurity Malpresentation
  • Perinatal morbidity and mortality
  • Parental distress
  • Postpartum depression
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7
Q

Classify this twin pregnancy

A

Monoamniotic

Monochorionic

(forked cord)

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8
Q

Classify this twin pregnancy

A
  • Monoamniotic
  • Monochorionic
  • time of cleavage: 9-12 d
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9
Q

Classify this twin pregnancy

A
  • Monoamniotic
  • Monochorionic
  • (one cord)
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10
Q

Classify this twin pregnancy

A
  • Diamniotic
  • Dichorionic
  • (fused)
  • time of cleavage: 0-72 h
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11
Q

Classify this twin pregnancy

A
  • Diamniotic
  • Dichorionic
  • (separated)
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12
Q

Classify this pregnancy

A
  • Diamniotic
  • Monochorionic
  • time of cleage: 4-8 d
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13
Q

Define: Twin-Twin Transfusion Syndrome (1)

A

formation of placental intertwin vascular anastomoses causes arterial blood from donor twin to pass into veins of the recipient twin

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14
Q

Describe epidemiology: Twin-Twin Transfusion Syndrome (2)

A
  • 10% of monochorionic twins
  • concern if >30% discordance in estimated fetal weight
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15
Q

Describe clinical features of Twin-Twin Transfusion Syndrome: Donor twin (5)

A
  • intrauterine growth restriction IUGR
  • hypovolemia
  • hypotension
  • anemia
  • oligohydramnios
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16
Q

Describe clinical features of Twin-Twin Transfusion Syndrome: Recipient twin (7)

A
  • hypervolemia
  • HTN
  • congestive heart failure (CHF)
  • polycythemia
  • edema
  • polyhydramnios
  • kernicterus in neonatal period
17
Q

Describe investigations: Twin-Twin Transfusion Syndrome (2)

A

detected by

  • U/S screening
  • Doppler flow analysis
18
Q
A
19
Q

Describe management: Twin-Twin Transfusion Syndrome (4)

A
  • therapeutic serial amniocentesis to decompress polyhydramnios of recipient twin and decrease pressure in cavity and on placenta
  • intrauterine blood transfusion to donor twin if necessary
  • laparoscopic occlusion of placental vessels
  • fetoscopic laser ablation of placental vascular anastomoses when indicated and if available
20
Q

Define: Breech Presentation (4)

A
  • fetal buttocks or lower extremity is the presenting part as determined on U/S
  • complete (10%): hips and knees both flexed
  • frank (60%): hips flexed, knees extended, buttocks present at cervix
    • most common type of breech presentation
    • most common breech presentation to be delivered vaginally
  • incomplete (30%): both or one hip partially flexed and both or one knee present below the buttocks, feet or knees present first (footling breech, kneeling breech)
21
Q

Describe epidemiology: Breech presentation (1)

A
  • occurs in 3-4% of pregnancies at term (25% <28 wk)
22
Q

Name MATERNAL risk factors: Breech presentation (4)

A
  • ​pelvis (contracted)
  • uterus (shape abnormalities, intrauterine tumours, fibroids, previous breech)
  • pelvic tumours causing compression
  • grand multiparity
23
Q

Name PLACENTAL risk factors: Breech presentation (1)

A
  • placenta previa
24
Q

Name FETAL risk factors: Breech presentation (8)

A
  • prematurity
  • amniotic fluid (poly-/oligohydramnios)
  • multiple gestation
  • congenital malformations (found in 6% of breeches; 2-3% if in vertex presentations)
  • abnormalities in fetal tone and movement
  • aneuploidy
  • hydrocephalus
  • anencephalus
25
Q

Describe management: Breech presentation (4)

A
  • ECV (external cephalic version): repositioning of singleton fetus within uterus under U/S guidance
  • pre-or early-labour U/S to assess type of breech presentation, fetal growth, estimated weight, placenta position, attitude of fetal head (flexed is preferable); if U/S unavailable, recommend C/S
  • ECV and elective C/S should be presented as options with the risks and benefits outlined; obtain informed consent
  • method for vaginal breech delivery
26
Q

What’s the overall success rate: ECV (external cephalic version)

A
  • of ~60%
27
Q

Name criteras: ECV (external cephalic version) (5)

A
  • >36 wk GA
  • singleton
  • unengaged presenting part
  • reactive non-stress test NST
  • not in labour
28
Q

Name absolute contraindications: ECV (external cephalic version) (7)

A
  • where C/S is required (placenta previa, previous classical C/S),
  • previous myomectomy
  • premature rupture of membranes PROM
  • uteroplacental insufficiency
  • nuchal cord
  • non-reactive non-stress test (NST)
  • multiple gestation
29
Q

Name relative contraindications: ECV (external cephalic version) (4)

A
  • mild/moderate oligohydramnios
  • suspected intrauterine growth restriction (IUGR)
  • HTN
  • previous T3 bleed
30
Q

Name risks: ECV (external cephalic version) (8)

A
  • abruption
  • cord compression
  • cord accident
  • rupture of membranes ROM
  • labour
  • fetal bradycardia requiring C/S (<1% risk)
  • alloimmunization
  • fetal death (1:5000)
31
Q

Describe method: ECV (external cephalic version) (2)

A
  • tocometry, followed by U/S guided transabdominal manipulation of fetus with constant fetal heart monitoring
  • if patient Rh negative, give Rhogam® after the procedure
32
Q
A
33
Q

Name factors of better prognosis: ECV (external cephalic version) (5)

A
  • if multiparous
  • good fluid volume
  • small baby
  • skilled obstetrician
  • posterior placenta
34
Q

Describe: Method for vaginal breech delivery (4)

A
  • encourage effective maternal pushing efforts
  • at delivery of head (after feet), assistant must apply suprapubic pressure to flex and engage fetal head
  • delivery can be spontaneous or assisted; avoid fetal traction
  • apply fetal manipulation only after spontaneous delivery to level of umbilicus
35
Q

Name contraindications to vaginal breech delivery (3)

A
  • cord presentation
  • clinically inadequate maternal pelvis
  • fetal factors incompatible with vaginal delivery (e.g. hydrocephalus, macrosomia, fetal growth restriction)
36
Q

When is C/S recommended for breech presentation? (3)

A
  • the breech has not descended to the perineum in the second stage of labour after 2 h
  • in the absence of active pushing
  • or if vaginal delivery is not imminent after 1 h of active pushing
37
Q

Describe prognosis: Breech presentation? (5)

A

regardless of route of delivery, breech infants have

  • lower birth weights
  • higher rates of perinatal mortality
  • congenital anomalies
  • abruption
  • cord prolapse

TN Obstetrics (16 decks)

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