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Ob/Gyne 2 > Module 13 : Multiple Gestation Complications > Flashcards

Module 13 : Multiple Gestation Complications Flashcards

1
Q

how much higher mortality rate for twins than singleton

A

5-10 times higher

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2
Q

twinning rate

A
  • higher earlier in pregnancy
    + one may die and reabsorbed in early pregnancy
  • ART and IVF increasing rate of twins
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3
Q

types of twins

A
  • dizygotic

- monozygotic

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4
Q

dizygotic

A
  • fraternal twins
  • zygote = number of eggs
  • not sharing anything
  • have their own placenta and amniotic sac
  • dichorionic diamniotic
  • as similar as siblings
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5
Q

monozygotic

A
  • identical twins
  • one egg
  • chance of splitting early and not sharing anything
  • or splitting late and sharing anything
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6
Q

sharing rule

A
  • less than babies share the better the outcome of survival
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7
Q

dizygotic twins

A
  • 70% of all natural births
  • 1/80 births
  • hereditary on maternal side
  • fertilization of two separate ova
  • genetic similarity sam as siblings
  • have their own genetic mix
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8
Q

increasing chance of dizygotic twins

A 
- maternal age
   \+ young ( < 15)
   \+ old (> 37)
   \+ parity (many children)
- hereditary 
- racial background
- pharmaceutical agents
   \+ clomide and pergonal
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9
Q

monozygotic twins

A
  • 30% of all natural twins
  • 1/250 births
  • random occurrence
  • SINGLE fertilized ovum replicates during the early development
  • genetically the same
  • increased mortality rate is slightly higher than dizygotic twins
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10
Q

types of monozygotic twinning

A
  • dichorionic diamniotic
  • monochorionic diamniotic
  • monochorionic monoamniotic
  • conjoined twins
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11
Q

chorionic

A

placenta

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12
Q

dichorionic diamniotic twins

A 
- occurs with ALL dizygotic twins
   \+ two placentas two amniotic sacs
- can occur in monozygotic twins 
   \+ morula splits before it implants
   \+ 2 days post fertilization 
   \+ each implants separately (2 of everything, 4 layer membrane)
- 18-30% of all monozygotic twins
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13
Q

monochorionic diamniotic twins

A
  • division occurs at blastocyst stage after inner cell mass of embryo forms
  • day 4-8 post fertilization
  • 2 fetuses in separate amniotic sacs with single placenta
  • 2 layer membrane 1 placenta
  • 70% of all monozygotic twins
  • possibility of twin to twin transfusion
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14
Q

monochorionic monoamniotic twins

A
  • division occurs at embryonic disc stage after amnion’s sac develops
  • day 8-12 post fertilization
  • 4% of all monozygotic twins (rare)
  • increased risk of mortality due to cord entanglement
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15
Q

conjoined twins

A
  • incomplete division at embryonic disc stage
  • occurs after day 13 post fertilization
  • no separating of membranes
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16
Q

scanning placentas - what to look for

A
  • identify number of placentas
  • identify presence or absence of a separating membrane
  • identify presence of a peak sign or t sign where the membrane meets the placenta
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17
Q

2 placentas

A
  • with dizygotic twins or di chorionic twins there will be 2 separate placentas
  • or 2 placentas so close there appear fused looking like one placenta
  • look for lambda or t sign
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18
Q

twin peak / lambda sign

A
  • if 2 placentas implant close together some placenta tissue will grow up between the membranes creating a twin peak sign or lambda sign
  • TWO PLACENTAS
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19
Q

t sign

A
  • division occurring after implantation will result in one placenta
  • one placenta with two membranes creates a t sign
  • no placenta will grow between the membranes
  • monochorionic diamniotic
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20
Q

distinguishing between monozygotic DI/DI twins and dyzygotic twins

A
  • can only tell if there is a boy and a girl

+ this means a dizygotic twin pregnancy

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21
Q

clinical indication for twin scan

A
  • strong family history
  • large for gestational age
  • increased maternal hCG
  • two or more heart beats heard by doctor
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22
Q

protocol

A
  • identify number of fetuses
  • position of fetuses
  • label presenting twin (closest to cervix) as A and label which side of the mom uterus baby is on
  • identify presence of
    + membrane
    + number of placentas
    + presence of twin peak sign or t sign
  • treat each fetus as a singleton and complete all documentation of one twin before moving on to the next
  • show similar fetal parts to demonstrate multiple babies
  • rule out polyhydroamnios (5-10%)
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23
Q

demised twin

A
  • usually occurs in first trimester but can happen any time
  • if this happens the boney remains of the demised fetus is termed PAPYRACEUS FETUS
  • imaging of dead fetus only requires sag and trans image
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24
Q

fetal reduction

A
  • increased rate of higher order multiples due to increased use of fertility treatment either with fertility drugs or IVF
  • much higher rate of prematurity
  • option is offered to have a fetal reduction (fetoscide) to improve outcome of pregnancy
25
Q

what are 6 abnormal twinning variations

A
  • conjoined twins
  • TRAP syndrome
  • fetus in fetu
  • hydatidiform mole with coexisting twin
  • heterotopic pregnancy
  • superfetation
26
Q

where are conjoined towns most commonly attached

A
  • chest or abdomen

+ thoracopagus or omphalopagus

27
Q

what is TRAP syndrome

A
  • twin reversed atrial perfusion

- arterial» arterial or venous&raquo_space; venous shunts IN PLACENTA

28
Q

what is the other twin called in TRAP syndrome

A
  • acardiac parabolic twin

- acardiac monster

29
Q

in what type of twinning does TRAP syndrome only occur in

A
  • monochorionic twinning
30
Q

ultrasound appearance of TRAP syndrome

A
  • lack of separating membrane
  • inability to separate fetal parts
  • more than three vessels in cord
  • complex anomalies
31
Q

what are the physical characteristics of the acardiac twin in TRAP syndrome

A
  • either no heart or very abnormal
  • no head/heart which prevents twin from surviving
  • completely perfused by the other donor twin
  • on lower limbs and trunk
32
Q

what condition is the donor twin susceptible to have in TRAP syndrome

A
  • high risk for developing hydrops due to high cardiac output resulting in cardiac failure
33
Q

what is fetus in fetu

A
  • parasitic twin within abdomen of its sibling

- looks like a teratoma

34
Q

what is superfetation

A
  • fertilization of 2 separate ova months apart
35
Q

what are 5 complications with twins

A
  • twin to twin transfusion (TTTS)
  • twin embolization
  • premature delivery
  • congenital anomalies
  • cord accidents
36
Q

in what types of twins does TTTS occur

A
  • monochorionic twins only
37
Q

what is TTTS

A
  • arteriovenous fistulas in the placenta
    + A-A or V-V or A-V
    + A-v the worse because of difference in pressure gradient
38
Q

what will the physical characteristics be of the fetuses with TTTS

A
  • anemic donor
  • fluid overload recipient
    + getting fluid from placenta and donor
39
Q

characteristics of recipient twin in TTTS

A
  • larger
  • hypertensive
  • polyhydramnious
  • edematous
40
Q

characteristics of donor twin in TTTS

A
  • small
  • hypotensive
  • oligohydramnious
  • stuck twin appearance
41
Q

ultrasound appearance of TTTS

A
  • discrepancy in size > 20%
  • disparity in amniotic fluid
  • single placenta seen
  • thin or no membrane seen
  • hydrops of one twin
42
Q

what is a stuck twin

A
  • donor twin in TTTS may have little or no fluid

- amniotic membrane holds baby tightly to uterine wall

43
Q

can stuck twin occur in dichorionic twinning

A
  • yes with placenta insufficiency
44
Q

when does twin embolization syndrome occur and with what type of twins

A
  • demise of a twin

- monochorionic twins

45
Q

what is twin embolization syndrome

A
  • clots pass from demised twin to surviving twin causing infarcts in live fetal brain or liver
46
Q

what can twin embolization syndrome cause

A
  • sever hypotension in surviving twin due to demised twin placenta becoming a low pressure bed allowing blood to pool in placenta causing asphyxia
47
Q

ultrasound appearance of twin embolization syndrome

A
  • ventriculomegaly, porenchephalic cysts, cerebral atrophy, microcephaly
  • papyraceous fetus
48
Q

why does premature delivery occur with twins

A
  • uterus unable to accomadate 2 fetuses to term

- cervix begins to shorten or efface

49
Q

what is the risk of congenital anomalies in monozygotic and dizygotic twins

A
  • more common in monozygotic than singleton

- dizygotic is same risk as singleton

50
Q

what type fo twins have increased risk of cord accidents and what are examples of cord accidents

A
  • mono mono twins

- tangle, prolapse, wrap around fetal neck and strangle

51
Q

what is the usually waveform of the umbilical artery

A
  • low resitance
  • lots of diastolic flow
  • S/D ratio = 2
  • PI at 28 weeks = 11
52
Q

what would be considered bad umbilical artery flow

A
  • no diastolic flow
53
Q

what would be super bad umbilical artery flow

A
  • reverse diastolic flow

- PI = super high

54
Q

what is normal ductus venosus waveform

A
  • triphasic
  • some aliasing
  • no reversal
55
Q

what do the parts of the ductus venosus waveform represent

A
  • first peak ventricular systole
  • second peak passive filling of ventricular diastole
  • reversal A wave
56
Q

what is an abnormal ductus venosus waveform and what does it represent

A
  • increased reversal of A wave
  • myocardial impairnment
  • increased ventricular end diastolic pressure from increased right ventricular afterload
57
Q

what is the normal waveform of the MCA and at what angle do we sample it

A
  • high resistance

- 0º insonation on MCA closest to transducer

58
Q

what would cause an abnormal MCA waveform and what would it look like

A
  • vasodilation occurs with brain sparring IUGR

- PI reduces and increased diastolic flow

Ob/Gyne 2 (19 decks)

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