Multiple Gestation

Question 1

5 fold risk of stillbirth and 7 fold risk of neonatal death. primarily due to complications of __

Answer 1

prematurity.

Question 2

women with mutiple gestations are _ times as likely to give birth preterm and _ times more likely to give birth before _ weeks than women of singleton gestations.

Answer 2

6 times more likely to give birth prematurely.

13 times more likely to give birth before 32 wks

Question 3

twins born preterm <32 weeks are at twice the risk of

Answer 3

1. high grade intraventricular hemorrhage
2. periventricular leukomalacia
   which explains increased prevalence of cerebral palsy in multiple gestations.

Question 4

compared with dichorionic twins, monochorionic twins have a higher frequency of fetal and neonatal mortality as well as morbidites such as fetal and congenital anomalies, prematurity, and fetal growth restriction.

Answer 4

true.

Question 5

women with multifetal gestations have increased incidence of ___ associated with pregnancy

Answer 5

hypertensive conditions.

Question 6

hypertensive complications is proportional to total fetal number, singleton __ twins __ triplets __.

Answer 6

singleton 6.5%
wins 12.7%
triplets 20%

Question 7

how is chorionicity determined:

Answer 7

fetal risk largely dependent on chorionicity of a multifetal pregnancy should be established as early in pregnancy as possible, and the optimal timing for determination of chorionicity is in late first trimester / early second trimester.

Question 8

when US shows 2 placentas of differing fetal sex, the pregnancy is

Answer 8

DICHORIONIC

Question 9

if only ONE placenta is visualized, best ultrasonographic characteristic to distinguish chorionicity is the

Answer 9

TWIN PEAK SIGN aka
lambda or delta sign.

(is a triangular projection of tissue with the same echogenicity as the placenta that extends beyond chorionic surface of the placenta and is indicative of a dichorionic gestation. )

Question 10

complications related to monochorionicity

Answer 10

twin-twin transfusion syndrome
single fetal death
monoamniotic gestation

Question 11

can adjunctive tests be used to predict spontaneous preterm birth in women with multiple fetal gestations? ASYMPTOMATIC

Answer 11

TVS cervical length,
digital exam
fetal fibronectin
home uterine monitoring. 
use of these screening methods in asymptomatic women with multifetal pregnancies is NOT recommended.

Question 12

in SYMPTOMATIC WOMEN, positive predictive value of fetal fibronectin test or of a short cervical length alone is POOR. should not be used exclusively to direct management in setting of acute symptoms.

Answer 12

true

Question 13

are there interventions that can prolong pregnancy in women with multifetal gestations?

Answer 13

prophylactic cerclage, routine hospitalization, bed rest, prophylactic tocolytics, prophylactic pessary have NOT been proved to decrease morbidity or mortality therefore should not be used in women with multifetal gestations.

Question 14

prophylactic cerclage WITHOUT A HISTORY of cervical insufficiency has NOT been shown to be beneficial. placement of cerclage in women with twin gestation with an ultrasonographically detected short cervical length has been observed to DOUBLE the rate of spontaneous preterm birth.

Answer 14

placement of cerclage in women with multifetal gestations should be avoided.

Question 15

no role for prophylactic tocolytic agent in women with multifetal gestations including prolonged use of betamimetics for this indication. use of tocolytics has been associated with a greater risk of maternal complications such as

Answer 15

PULMONARY EDEMA.
oral betamimetics have been associated with increased maternal and fetal cardiac stress and gestational diabetes mellitus.

Question 16

prophylactic pessary

Answer 16

13% had poor perinatal outcome (stillbirth, periventricular leukomalacia, severe respiratory distress syndrome, bronchopulmonary dysplasia, intraventricular hemorrhage, necrotizing enterocolitis, proven sepsis, or neonatal death).

Question 17

does progesterone treatment decrease the risk of preterm birth in women with multifetal gestations:

Answer 17

progesterone treatment does NOT reduce incidence of spontaneous preterm birth in unselected women with twin or triplet gestations, and thereofre, is not recommended.

INSUFFICIENT DATA to assess whether progesterone has any beneficial effect in women with multifetal gestations and short cervical length determined by TVS.

Question 18

how is preterm labor managed in women with multifetal gestations? tocolytics

Answer 18

tocolytics may provide short-term prolongation of pregnancy which enables admin of ANTENATAL CORTICOSTEROIDS as well as transport to a tertiary care facility, if indicated.
overall evidence suggests that when tocolytics is used for short-term pregnancy prolongation, calcium channel blockers or NSAIDS should be first line should be 1st line treatment.

Matneral risks associated with tocolytic use include pulmonary edema.

Question 19

corticosteroids - administration of antenatal corticosteroids to women with singleton gestations at risk of delivery between 24-34 weeks of gestation has been shown to decrease incidence of neonatal death, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis.

Answer 19

antenatal corticosteroids should be administered to all patients who are between 24 weeks and 34 weeks of gestation and at risk of delivery within 7 days, irrespectable of fetal number.

Question 20

magnesium sulfate for fetal neuroprotection

Answer 20

prenatal admin of mag sulfate reduced occurrence of cerebral palsy in surviving infants if administered when birth is anticipated before 32 weeks of gestation, regardless of fetal number

Question 21

prenatal screening of women with multifetal gestations different than for singleton pregnancies?

Answer 21

in dizygotic twins, maternal age related risk of having one of the two fetuses affected with a trisomy is double compared with maternal age matched singleton gestation. this equates to a similar age related risk of down syndrome between a 33 y/o woman carrying twins and a 35 y/o woman carrying singleton gestation.

Question 22

Nuchal translucency screening in 1st trimester with option of CVS may be desirable for some women.

Answer 22

in women with twins gestations, first trimester screening combines
1. maternal age
2. nuchal translucency
3. biochemistry serum analytes
identifies 75-85% of pregnancies with DS and 66.7% with trisomy 18