Multiple pregnancies

Question 1

Risk factors

Answer 1

Hx and Fx
Increased parity and maternal age

Assisted reporuction:

• clomiphene = 10%
• IUI - 15%
• IVF - 25% (NB. IVF now only 2 embryos)

Question 2

Classification of monozygotic twins

Answer 2

Divide by:

• day 3 (30%) - dichorionic, diamniotic
• day 4-8 (70%) - monochronionic, diamniotic (shared placenta)
• 9-13 days (rare) - monochronioic, monoamniotic
• 13+ days - conjoined twins

NB. Monochorionic has increased risk of foetal loss, especially <24weeks

Question 3

Clues for diagnosis

Answer 3

Hyperemesis gravidarium
Large uterus
3+ poles felt at 24 weeks
2 foetal HS

Question 4

Diagnosis

Answer 4

USS in first trimester (dating or nuchal translucency scan)

Determine chronicity - 1st/2nd trimester scan

Question 5

Antepartum complciations

Answer 5

Foetal:

• mortality (6x) and handicap (5x)
• Preterm delivery (40% twins, 80% triplets)
• IUGR
• IUD - monochorionic = death in 20%, cerebral damage in 25%
• congenital abnormalities -

Question 6

Monochorionicity twins

Answer 6

20% twin to twin transfusion syndrome (TTSS) - unequal blood distribution though placenta

Donor twin - volume depleted, amaemic, IUGR and oligohydramnios

Recipient twin - volume overload, polycythaemia, cardiac failure, massive polyhydramnios

Both have high risk of IUD or preterm delivery and IUGR

Question 7

intrapartum complications

Answer 7

Malpresentation - 20% of 1st twin

Foetal distress

PPH

Question 8

Maternal complications

Answer 8

Pre-eclampsia (x5)
Hyperemesis gravidarum
Anaemia
GDM
Polyhydramnios
Placenta praevia
Operative delivery

Question 9

Antenatal management

Answer 9

Serial growth scans - 28, 32, 36
More frequent ANC checks
Give aspirin 75mg for pre-eclampsia

Adequate diet - 5mg folic acid, iron supplements,

Fetal abnormality - discuss TOP (intracardiac injection with KCl) must be done before 14 weeks

MC twins: USS surveillance from 12 weeks - scan every 2 weeks

Question 10

Management of TTSS

Answer 10

Laser ablation of anastomoses
Selective foeticide
Serial amnio-reductions
Septostomy

Question 11

Intrapartum management

Answer 11

MOD - CS - esp. if first twin is malpositioned
Triplets always = CS

Timing:
DC = 37-38 weeks
MC = 34-37 weeks

Question 12

Management of labour

Answer 12

CTG both twins
2 paeds staff, 2 midwives, anaesthetist

Syntocin for 2nd twin
ECV for 2nd twin

2nd twin normally delivered 20 mins after first - if distressed use forceps