Multiple pregnancy

Question 1

Risks to mother

Answer 1

Miscarriage
Anaemia
Hypertensive disorders
Haemorrhage (particularly PPH)
Operative delivery
Postnatal illness

Question 2

Risks to fetuses

Answer 2

Stillbirth
Preterm birth
Twin-twin transfusion syndrome (monoschorionic twins)
IUGR
Congenital abnormalities
Malpresentation
Cord prolapse

Question 3

Antenatal care

Answer 3

10-12 weeks: dating scan, chorionicity, Downs screen
MDT care: specialist obstetricians, midwives and ultrasonographers
Monitoring for IUGR: US scans from 20w (every 4 weeks for dichorionic; 2 weeks for monochorionic)

Question 4

Delivery

Answer 4

Uncomplicated monochorionic twins: 36w+
Dichorionic: 27w+
Vaginal birth if first twin cephalic
First twin malpresentation 20% of time
Increased rates of fetal distress in labour
Second twin has increased risk of death after first has been delivered due to hypoxia, cord prolapse, tetanic uterine contraction or breech presentation

Question 5

Twin-twin transfusion syndrome (TTTS)

Answer 5

Only in MCDA twins
Unequal blood distribution through vascular anastomoses of the shared placenta
‘Donor’ twin: Anaemia, IUGR, oligohydramnios
‘Recipient’ twin: polycythaemia, cardiac failure and polyhydramnios

Question 6

Risks

Answer 6

Intrauterine death
Preterm delivery
Optimal treatment: Both twins survive 50% time; one 80%
10% survivors neurological disability