Multiple pregnancy

Question 1

What are the different types of twins?

Answer 1

Dizygotic: two eggs.

Monozygotic: one egg.

Dichorionic diamniotic: division before day 3.

Monochorionic diamniotic: division between days 4-8.

Monochorionic monoamniotic: division between days 9-13 (rare).

Question 2

What are the antepartum complications of multiple pregnancy?

Answer 2

Maternal: GDM, pre-eclampsia, anaemia, preterm labour.

Fetal: greater mortality and long term handicap; preterm delivery, IUGR, monochorionicity; early miscarriage of one twin, or both late.

Question 3

What are the complications of monochorionicity?

Answer 3

Twin-twin transfusion syndrome: one gets anaemia, IUGR, oligohydramnios, the other gets volume overload, polycythaemia, cardiac failure, polyhydramnios. High risk of death in utero or severe prematurity.

IUGR.

Co-twin death: if one dies, drop in blood pressure allows transfusion, hypovolaemia and death / neurological damage in 30%.

Monoamniotic twins: In utero demise common.

Question 4

What are the intrapartum complications of multiple pregnancy?

Answer 4

Malpresentation of the first twin.

Fetal distress is more common.

Intrapartum death of the second twin due to hypoxia, cord prolapse, tetanic uterine contraction, abruption.

PPH.

Question 5

How do you differentiate dichorionic from monochorionic twins?

Answer 5

USS - dichorionic have a lambda sign, monochorionic have a T sign.

Question 6

At what gestation can selective reduction take place?

Answer 6

12-14wks.

Question 7

How do you manage multiple pregnancies?

Answer 7

Consultant led care.

Monochorionic: USS surveillance from 12wks. USS between 16-22wks for TTTS (look for tricuspid regurgitation).

Treat twin-twin anastamoses by laser photocoagulation.

Intrapartum: C-S at 37/38wks (dichorionic) or 34-37 (monochorionic).