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Obs&Gynae > Multiple gestation > Flashcards

Multiple gestation Flashcards

1
Q

what is multiple gestation

A

presence of more than one fetus in the uterus at the same time

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2
Q

how is multiple gestation classified (4)

A
  1. Number of fetuses (twins, triplets, quadriplets)
  2. Number of fertilized eggs: Zygosity
  3. Number of placentae: Chorionicity
  4. Number of amniotic cavities: Amnionicity
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3
Q

what are the 2 types of twin pregnancy

A
  1. Dizygotic twins (70 – 80%), resulting from fertilization of two ova leading to fraternal twin.
  2. Monozyogotic twins (20 – 30%), resulting from fertilization of one ovum followed by splitting of developing zygote leading to identical twin.
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4
Q

what are the types of monozygotic (3)

A
  1. Monochorionic diamniotic 70-75% (MCDA)
  2. Dichorionic diamniotic 25-30% (DCDA)
  3. Monochorionic monoamniotic 1-2% (MCMA)
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5
Q

all monochorionic pregnancies are what

A

monozygotic

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6
Q

not all dichorionic pregnancies are what

A

dizygotic

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7
Q

In M-DCDA when does the egg split

A

day 1-3

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8
Q

In M-MCDA when does the egg split

A

day 4-8

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9
Q

In M-MCMA when does the egg split

A

day 9-12

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10
Q

for conjoint twins when does the egg split

A

day 13-15

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11
Q

what are risk factors for multiple gestation (5)

A
  1. Assisted reproductive techniques
    - In vitro fertilisation
    - Use of fertility medications (clomiphene)
  2. Maternal family history
  3. Race
    - High in African women
  4. High parity (5 gravida onwards)
  5. Increased maternal age (30 – 35 yrs)
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12
Q

what in the history can help you diagnose multiple gestation (6)

A
  1. Hx of ovulation inducing drugs
  2. Maternal family hx of twins
  3. Increase nausea and vomiting in early months
  4. Palpitations or SOB (anemia)
  5. Leg swelling and/or hemorrhoids
  6. Unusual rate of abdominal enlargement
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13
Q

what things on your clinical exam can help you diagnose multiple gestation (5)

A
  1. Signs of anemia
  2. Barrel shape abdomen
  3. SF size/GA discrepancy
  4. Palpation of too many fetal parts
  5. Two distinct fetal heart sounds at separate spots with a silent area in between
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14
Q

how can you tell multiple gestation on sonography (5)

A
  • different fetuses genders
  • number of placentae
  • placenta location
  • T sign
  • lambda sign/ twin peak signwh
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15
Q

when is it most reliable to do a scan for twin gestation to see the gestational sacs

A

6-10 weeks

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16
Q

when is the lambda/twin peak sign best seen

A

11-14 weeks

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17
Q

why is it hard to see dividing membranes as gestation increases

A

the dividing membranes get thinner

18
Q

in twin pregnancy what is a major determinant of pregnancy outcome

A

chorionicity

19
Q

T sign (monochorionic shared placenta) is seen in what type of twin

A

MCDA

20
Q

what type of twin do you see the lambda sign (fused dichorionic placenta)

A

DCDA

21
Q

what are ddx for multiple pregnancy (5)

A
  1. inaccurate menstrual hx
  2. macrosomic baby
  3. polyhydraminos
  4. molar pregnancy
  5. fibroid in pregnancy
22
Q

what are possible maternal complications of multiple gestation (7)

A
  1. Hyperemesis
  2. Abortion
  3. Anaemia
  4. Abruption
  5. Hypertensive disorders of pregnancy
  6. Thromboembiolism
  7. PPH
23
Q

what are the fetal complications of D-DCDA and M-DCDA (6)

A
  1. Preterm birth
  2. Growth restriction
  3. Mal presentation
  4. Vanishing twin
  5. IUFD of one twin
  6. Perinatal mortality
24
Q

what are the fetal complications of M-MCDA (8)

A
  1. Preterm birth
  2. Growth restriction
  3. Mal presentation
  4. Vanishing twin
  5. IUFD of one twin
  6. Perinatal mortality
  7. Twin -twin transfusion syndrome
  8. Fetal anomalies (all organ systems)
25
Q

what are fetal complications of M-MCMA (10)

A
  1. Preterm birth
  2. Growth restriction
  3. Mal presentation
  4. Vanishing twin
  5. IUFD of one twin
  6. Perinatal mortality
  7. Twin -twin transfusion syndrome
  8. Fetal anomalies (all organ systems)
  9. Cord entrapment
  10. Conjoining
26
Q

fetal growth restriction in multiple gestation can be what (2)

A
  • discordant
  • concordant
27
Q

what is the risk of IUGR in DCDA

A

25%

28
Q

what is the risk of IUGR in MC

A

50%

29
Q

what things should you think of in the management of FGR (3)

A
  1. Balance the risk of iatrogenic preterm delivery for a single growth restricted fetus.
  2. Generally, avoid delivery before 28-30weeks
  3. For MC twins, IUFD may lead to death or severe handicap of the co-twin
    - Prefer delivery before IUFD of growth restricted twin
30
Q

what causes twin to twin transfusion syndrome (2)

A
  • Due to abnormal placental vascular anastomoses
  • Unbalanced AV connections in one direction result in TTTS
31
Q

who does TTTS occur in

A

Unique to MC twins
- 10% MCDA
- 5% MCMA

31
Q

in TTTS the donor twin has predominantly what

A

arteries

32
Q

in TTTS the recipient twin has predominantly what

A

veins

33
Q

what risks can occur to the donor twin (5)

A
  1. anemic
  2. growth restricted
  3. hypovolemic
  4. oligohydraminos
  5. renal failure
34
Q

what risks can happen to the recipient twin (4)

A
  1. polycythemic
  2. polyhydraminos
  3. heart strain (congestive HF)
  4. high blood pressure
35
Q

what is the criteria for dx TTTS (5)

A
  1. Single placenta mass
  2. Same gender
  3. Oligohydramnios in one twin and polyhydramnios in the other
  4. Discordant bladder appearences
  5. Haemodynamic and cardiac compromise
36
Q

what is the quintero severity grading for TTTS (5)

A

Stage 1
- Oligohydramnios and polyhydramnios sequence
- Bladder of donor twin visible
- Dopplers normal in both twins

Stage 2
- Oligohydramnios and polyhydramnios sequence
- Bladder of donor twin not visible
- Dopplers normal in both twins

Stage 3
- Oligohydramnios and polyhydramnios sequence
- Bladder of donor twin not visible
- Abnormal dopplers
AEDF/REDF in UAD

Stage 4
- Signs of hydrops in one or both fetuses

Stage 5
- Death of one or both fetuses

37
Q

how can you manage TTTS (6)

A
  1. Expectant
  2. Amnioreduction
  3. Septostomy
  4. Selective feticide
  5. Laser ablation of anastomoses
    - Definitive Rx for TTTS stage 2 and above
  6. Preterm delivery (above 28weeks
38
Q

what is the antenatal care for multiple gestation (5)

A
  1. order uss
    - for dating, chorionicity and amnionicity as early as possible .
    - for anatomy and/or anomalies at 18-20 wks gestation
    - every 2-3 weeks after 28 wks gestation for growth, Doppler if discordant growth
    - For growth discordance > 20%, refer to Central Hospital.
  2. frequency of ANC visits
    - Same as for singleton in first trimester
    - More frequent after 20weeks
    - DC twins
    - 4 weekly until 28 weeks
    - 2 weekly 28-36weeks
    - Weekly 36-38 weeks
  3. MC twins
    - Refer to Central Hospital
    - Steroids at 28weeks
    - Inpatient care with daily CTG from 28weeks till delivery
    - Plan delivery at 32-34 weeks
  4. Nutrition and medications
    - extra daily caloric needs of 600 kcal
    - Encourage normal balanced diet
    - Ensure iron supplementation
    - Prophylactic dexamethasone between 28 and 34 weeks
  5. One antenatal fetal death
    - Admit to inpatient ward for expectant management
    - Monitor for maternal complications of IUFD including infection or DIC
    - Monitor fetal well-being of surviving twin
39
Q

when is c/s indicated in multiple gestation (5)

A
  1. If breech or transverse
  2. Cord prolapse of the leading twin
  3. Previous caesarean section
  4. Triplets (or higher order pregnancy)
  5. Twin with complications: IUGR, conjoint twins
  6. MC twins

Obs&Gynae (24 decks)

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