Multiple Pregnancy

Question 1

What are features of multiple pregnancy?

Answer 1

Early:
Uterus large for dates
Hyperemesis

Later:
Polyhydramnios
>2 poles 
Multiplicity of fatal parts
2 fetal heart rates
US confirms diagnosis

US at 11+0-13+6 distinguishes monochorionic from dichorioinic twins by placental masses

Question 2

What are complications of multiple pregnancy?

Answer 2

Poplyhydramnios
Pre-eclampsia
Anaemia (iron and folate requirements increased)
APH risk rises from abruption and placenta praevai (due to large placenta)
Gestational diabetes
Operative delivery risk

Question 3

What is the mean gestation for twins? Triplets?

Answer 3

Twins - 37 weeks

Triplets - 33 weeks

Question 4

How can twins develop?

Answer 4

Dizygotic (non-identical) or monozygotic (develop from single ovum that has divided into 2 embryos)
Monochorionic or dichorionic
Monoamniotic or diamniotic

Question 5

What are mono amniotic monozygotic twins at risk of?

Answer 5

Increased spontaneous micarriage
Increased malforations, IUGR, prematurity
Twin-twin transfusion dystome

Question 6

What is twin to twin transfusion syndrome?

Answer 6

Placental vascular anastomoses may result in disparate twin size and one twin acting as the ‘donor’ and one as the ‘recipient’
Recipient is larger
Placental anastomoses can be ablated by laser coagulation in utero

Question 7

What are complications in labour?

Answer 7

Malpreantation
Ce/Br
Br/Br

Vasa praevia rupture
Cord prolapse
Placental abruption
Cord entanglement

Question 8

What are predisposing factors to dizygotic twins?

Answer 8

Previous twins
FHx
Increasing maternal age
Multigravida
Induced ovulation and IVF
Race - Afro-Caribbean

Question 9

What are fetal complications?

Answer 9

Prematurity
Light for date baies
Malfroatmion

Question 10

What is management for multiple pregnancy?

Answer 10

US for diagnosis + monthly checks
Additional iron and folate
More antenatal care (weekly from 30w)
Precautions at labour
Tell mother how to identify labour

Question 11

When is elective birth offered for twins? Triplets?

Answer 11

37+0 for uncomplicated dichorionic twins
36+0 with steroids for uncomplicated monochorionic twins
35+0 with steroids for uncomplicated triplets

Paediatricians (one per baby) present at delivery in case resuscitation needed