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Week 19 (OC, Dermatoses Of Pregnancy, Multiple Pregnancy) > Multiple Pregnancy > Flashcards

Multiple Pregnancy Flashcards

1
Q

How to estimate gestational age from USS

A

Largest baby to avoid the risk of estimating it from a baby with early growth pathology

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2
Q

How to determine chorionicity and amnio I city

A

Number of placental masses
Presence of amniotic membranes and membrane thickness
Lambda or T-sign

If USS after 14 weeks - also use discordant fetal sex

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3
Q

When to additionally test for anaemia

A

20-24 weeks

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4
Q

Triplet pregnancy 2nd trimester screening

A

Do NOT use

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5
Q

When to refer to fetal med

A

EFW >25% discordance AND EFW of any of the babies is below the 10th centile

20% discordance in MCDA twins

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6
Q

Monitoring in mono pregnancy for defo-fetal transfusion syndrome

A

USS every 14 days from 16 weeks until birth
Increase frequency to weekly if difference in dVP depth of 4cm or more between babies
Do MCA PSV after 20 weeks
Check growth, DVPs, bladder volumes, and UAPI each time

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7
Q

Diagnosis of feto-fetal transfusion syndrome

A 
Amniotic sac of 1 baby DVP <2cm
AND
Amniotic sac of another baby has a DVP depth of 
  -over 8cm before 20 weeks of pregnancy
OR
  -over 10cm from 20 weeks
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8
Q

Calculate EFW discordance

A

EFW larger fetus - EFW smaller fetus divided by EFW larger fetus

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9
Q

TAPS monitoring

A

Weekly USS from 16 weeks using MCA PSV for
Feto-fetal transfusion syndrome that has been treated with laser therapy OR
Selective FGR (EFW discordance 25% and one baby below the 10th

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10
Q

No use in twin preg

A

Arabin peasant
Bed rest
Cervical cerclage
Oral tocolytics

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11
Q

Number preterm births in twin pregnancies

A

60%

<32 weeks 9%

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12
Q

Triplet births before 35 weeks

A

75%

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13
Q

DCDA twins when to deliver

A

From 37 weeks
No increased risk of serious neonatal adverse outcomes
Continuing beyond 37 weeks increases the risk of fetal death 6-9:1000

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14
Q

MCDA twins when to deliver

A

36 weeks

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15
Q

MCMA twins when to deliver

A

32-33+6

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16
Q

Tri tri or tri di

A

Deliver before 36 weeks

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17
Q

When ok to try for vaginal birth for MCDA and DCDA

A 
Uncomplicated
>32 weeks
No obstetric contraindications to labour
Lead twin cephalic
No significant size discordance between twins
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18
Q

When to offer caeser for dcda or MCDA

A

Lead twin not cephalic at time of planned birth

Lead twin not cephalic and in prem labor between 26 and 32 weeks

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19
Q

Time before need to bail out

A

Anything worrying, need to be able to deliver within 20 minutes (both babies out!)

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20
Q

First USS

A 
Between 11 and 13+6
Assess viability
Gestational age
Chorionicity
Exclude major congenital malformations
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21
Q

MCDA twins compared to DCDA

A

Higher rate of fetal loss

Higher risk of associated neurodevelopmental morbidity

22
Q

MCDA USSs

A

Always assess LV and UAPI
Visualize fetal bladders
Fetal biometry from 16 weeks (2 weekly intervals)

23
Q

Maternal signs of TTTS

A

Sudden increase in abominable size

Breathlessness

24
Q

Quintero staging of TTTS

A 
1 bladder of donor twin still visible
2 bladder of donor twin no longer visible, no critical abnormal Doppler
3 critical abnormal Doppler waveforms
4 hydrops
5 demise of one or both twins
25
Q

TTTS studies at time of diagnosis

A

Quintero stage
MCA PSV
DV studies
UA Doppler

26
Q

Treatment of TTTS before 26 weeks

A

Fetoscopic laser ablation

27
Q

Timing of del MCDA treated TTTS

A

Between 34-36+6

28
Q

Timing of delivery in selective growth restriction

A

Type 1 34-36 weeks

Type II and III - 32 unless abnormal or worsening dopplers

29
Q

Risk to other twin after death of twin in MCDA

A

Death 15%
Neurological abnormality 26%

Mechanism: hypotension and ischaemai

30
Q

Complications with inter-twin vascular anastomoses

A 
TTTS
SGR
TAPS
TRAP
IUD
31
Q

Rate of TTTS

A

15%

32
Q

TAPS

A

Signs of fetal anaemia in the donor and polycythaemia in recipient without significant oligo/polyhydramnios being present
Donor has elevated MCA PSV, opposite for recipient

2% MCDA
13% MCDA with laser ablation

Donor >1.5 MoM
Recipient <0.80 MoM

33
Q

SGR grading

A

I growth discordance but positive diastolic velocities in both fetal umbilical arteries
II growth discordance with absent or reveresed EDV in one or both
III growth discordance with cyclical UA diastolic waveforms (intermittent AREDV)

34
Q

TRAP

A

1% MCDA

Acardiac twin being perfumed by the anatomically normal pump twin through a large artery-artery anastomosis

35
Q

Epidemiology
Birth rate
Mortality
Morbidity

A

15.8:1000
37:1000
8x greeter risk CP

36
Q

Embryology day division

A

Before day 3 - Dcda
Day4-8 - MCDA
Day 8-13 MCMA
After that - conjoined twins

37
Q

Types of placental communication in MCDA

A

A-A: superficial
V-V: superficial
A-V: deep anastomoses; unidirectional flow

38
Q

Pathophysiology of TTTS of donor twin

A 
Hypovolaemia in donor twin leads to:
Activation renin-angiostensin system
Increased ADH
Results in:
Vasoconstriction
Oliguria
Oligohydramnios
Growth restriction
39
Q

Pathophysiology TTTS in recipient twin

A

Hypervolaemia results in
Increased secretion of atrial natriuretic factor
Results in:
Polyuria
Polyhydramnios
HTN - may cause cardiac hypertrophy, hydrops, death (HTN caused by volume overload and passive transfer of angiotensin from donor twin)

40
Q

Laser ablation survival, complications and loss

A

70% survival
Complications:SROM, infection, miscarriage/preterm delivery
Half result in the loss of one or both twins

41
Q

TRAP pump twin mortality cause

A

50% die
CHF and hydrops
OR
Prematurity induced by polyhydramnios

42
Q

MCMA twins incidence and loss rate

A

2-5% of MC pregnancies
10-15% perinatal loss
Largely due to cord entanglement

43
Q

Overall risk of congenital malformation in twins

A

600 per 10000

MC twins have 2-3x higher risk than DC
MZ defects: holoprosencephaly, NTDs and cloacal extrophy
CHD - 9% (7% for MCDA, 57% for MCMA)

44
Q

Risk of neurological abnormality to second twin after one twin demises in MCDA

A

18%

45
Q

Management if one fetus demises

A

Delivery earlier doesn’t prevent any further damage and have complication of prematurity
Can consider MRI to diagnose neurological damage secondary to hypovolaemia
MCA surveillance ongoing
IUT if evidence of severe anaemia

46
Q

TRAP

A

Twin reversed arterial perfusion sequence

47
Q

Incidence of multiple pregnancy

A

32 per 1000 livebirths

Older mums
Fertility treatment

48
Q

Maternal complications

A 
Hyperemesis
Anaemia
GDM
Preterm birth
HTN
VTE
APH
Polyhydramnios
Operative delivery
PPH
Postnatal depression
Maternal mortality 2.5x risk
49
Q

Fetal complications

A 
Mortality
Congenital abnormalities (structural, chromo)
FGR
Feeding difficulties
Long term disability (CP 4-*x risk)
50
Q

TAPs fetal complications

A

Double IUD
Neonatal anaemia/polycythaemia
Neurodevelopmental impairment (20%)

51
Q

Acute fetal-fetal transfusion syndrome

A

Sudden drop in pressure and/or HR of one twin
Sudden and large unidirectional flow from the co-twin ‘acute donor’
Consequences depend on size, type and direction of anastomoses
Large AV or AA connections allow larger volume of flow
May lead to death and severe brain injury
Laser protective

Week 19 (OC, Dermatoses Of Pregnancy, Multiple Pregnancy) (3 decks)

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