L15 - Multiple Pregnancies

Question 1

how has incidence of mul preg changed over time and why

Answer 1

increased
far east Europe Nigeria

maternal age and IVF

Question 2

what are factors for ‘super ovulation’

what are different types of multiple pregnancy

what are the proportions of monozygous and dizygous twins

Answer 2

ethnicity
incr maternal age
incr parity
fam history
fertility treatment

zygosity
chorionicity
amnionicity

mono - 1/3 - identical
di - 2/3 - non identical

Question 3

Dizygotic twins

what can they have/share

Answer 3

DCDA

separate amnions, chorions and placentae

Question 4

Monozygotic twins

what can they have/share

Answer 4

if splitting at 2 cell stage (1/3) then DCDA - separate amnions, chorions and placentae

if splitting in early blastocyst MCDA - yields 2 inter cell masses
- common chorion, separate amnions and joined placentae

if later splitting - 2 embryos from one inner cell mass
MCMA - common chorion amnion and joined placentae

Question 5

how do you diagnose twins

Answer 5

uterine size
up to 50% at delivery worldwide
ultrasound

Question 6

what are the complications of multiple pregnancy

for twin pregnancy what is the causes of mortality

Answer 6

"Everything except post-dates" 
Symptoms of pregnancy 
Anaemia 
Hypertension 
Intrauterine growth restriction 
Pre-term labour 
Delivery problems 
Perinatal mortality 

Twin preqnancy Mortality Stillbirth — after 24 weeks Early neonatal — first 7 days Neonatal — in first 28 days Perinatal — SB + early neonatal Infant — first year Rates are per 1000 births

much high risk at all these than singleton pregnancy. even more for triplets

Question 7

For twin preg what is the first trimester management

what about second trimester management

what about third trimester scanning

Answer 7

• -discuss screening for chromosomal anomalies
• -determine chorionicity
• -discuss fetal reduction if triplets or more

2nd

• -detection of fetal abnormality
• -serial scans for growth for all
• -serial scans for TTs if MC twins
• -maternal complications

3rd
scanning as in 2nd trimester
monitor BP
pre term labour
delivery planning

Question 8

monochorionic twin pregnancy

what are the risks

Answer 8

more fetal malformation
more fetal growth restriction
twin to twin transfusion

• – abnormal shunting of the blood: unbalanced anastomises of placental blood. one gets more than the other.
• • unbalanced placental vascular anastomoses
• -donor smaller and decr liquour anastomoses
• -high mortality
• -Rx - laser or amnioreduction
• -early delivery by caesarean

Question 9

twin preg deliver planning

what week is recommended
what do you look out for

twin preg labour management
what do you monitor and what are you looking out for

puerperium management

Answer 9

Delivery planning
37-38 weeks for DC twins vaginal birth or caesarean

Presentation of twin
36-37 weeks for MC twins
?all MC twins by caesarean?

Pregnancy complications

labour:
monitoring both twins
problems in delivering twin 2
risk of postpartum bleed

puerperium:
may have feeding difficulties
may need emotional and social support

Question 10

for higher order multiples of pregnancies

what would you consider and think about and plan and deliver and risks

Answer 10

• • fetal reduction to be considered
• -determine chorionicity
• • high risk of preterm labour
• • deliver preterm by caesarean
• -postpartum haemorrhage
• • difficult puerperium and after