High risk Pregnancy

Question 1

List some risk factors for multiple pregnancy:

Answer 1

IVF / assisted conception
Family history on maternal side
increasing maternal age
Geography
Ethnicity (higher rates in african origin)
Tall women > small women
Multiparity

Question 2

What type of twins are the highest risk and why?

Answer 2

Monochorionic monozygotic (monoamniotic)
i.e. identical twins sharing on placenta and amniotic sac
Biggest risk of twin-twin transfusion syndrome

Question 3

How regularly should a mother with monochorionic twin pregnancy be scanned?

Answer 3

Every two weeks

It is extremely important to prevent TTTS

Question 4

In a multiple pregnancy, what is checked for in the fortnightly scans?

Answer 4

Deep vertical pool depth
Umbilical artery
Bladder

Question 5

What is Twin Twin transfusion syndrome?

Answer 5

This is when one twin receives a significantly higher proportion of blood supply.
Well supplied twin will have an increased urine output, polyhydramnios, polycythaemia and eventually heart failure
The poorly supplied twin will have restricted growth, poor urine output, oligohydramnios and anaemia.

Question 6

Can dichorionic pregnancies result in identical twins?

Answer 6

Yes roughly 30% of dichorionic pregnancies will have been monozygotic eggs

Question 7

What might be an early sign of multiple pregnancy?

Answer 7

Exaggerated pregnancy symptoms e.g. hyperemesis gravidarum

Question 8

What are some of the main risks to the mother in a multiple pregnancy? (at least 4)

Answer 8

Miscarriage
Hyperemesis
Anaemia
Pre eclampsia
Gestational diabetes
Antepartum haemorrhage 
Placenta previa
Operative delivery 
Post natal depression

Question 9

What are the main risks to the foetus in a multiple pregnancy?
(at least 4)

Answer 9

Preterm labour
IUGR
Intrauterine death
Twin twin transfusion syndrome
Congenital anomalies
Malpresentation
Cerebral palsy (8x more likely)

Question 10

What will occur if a monozygotic egg splits later than day 13?

Answer 10

Conjoined twins

Question 11

At what point after fertilization when the egg splits will the foetus be monozygotic and monochorionic?

Answer 11

Days 8-13

Question 12

What is the rate of multiple pregnancy in natural conception? (not assisted)

Answer 12

1/ 80 twins

1/10000 triplets

Question 13

What clinical signs would be suggestive of a multiple pregnancy? (3 points)

Answer 13

Large for dates uterus
Raised Alpha fetoprotein
Multiple foetal poles

Question 14

Why is hyperemesis gravidarum more common in multiple preganancy?

Answer 14

The level of hCG is directly linked to the severity of hyperemesis gravidarum, therefore multiple foetus = higher hCG.

Question 15

What are the risks attached to a prolonged pregnancy?

Answer 15

Stillbirth
Meconium aspiration
Large for dates baby - obstetric complications during delivery
Respiratory distress

Question 16

What vessels do we observe using USS in the 3rd trimester in high risk pregnancies and why?

Answer 16

umbilical artery - an increase in resistance is indicative of foetal hypoxia
Foetal middle cerebral artery - an increase in peak systolic volume is indicative of foetal anaemia

Question 17

Other than USS, what investigative imagery is considered safe?

Answer 17

MRI

Question 18

What is the most common, direct cause of maternal mortality?

Answer 18

Venous thromboembolism

Question 19

What is the most common indirect cause of maternal mortality?

Answer 19

Cardiac causes

Question 20

What is the leading cause of maternal death within the first year post partum?

Answer 20

Suicide

Question 21

A pregnant lady is brought in following a collapse at home. There is obvious respiratory distress with O2% at 87%, her lips are blue and her JVP is raised. There are signs of anaphylaxis and pulmonary hypertension. What is the potential cause?

Answer 21

Amniotic fluid embolism

Question 22

What is the management for an amniotic fluid embolism?

Answer 22

REsuscitation and coagulopathy correction
Immediate delivery once stable
Supportive management once stabilised