Multiple pregnancy and Puerperium

Question 1

What is the difference between dizygotic and monozygotic twins? (2)

Answer 1

DZ: fertilisation of two different eggs (2/3)
MZ: mitotic division of single zygote

Question 2

What are the three types of monozygotic twins? (3)

Answer 2

Division before day 3: Dichorionic diamniotic (30%)
Division day 3-8: monochorionic, diamniotic (70%)
Division day 9-13: monochorionic, monoamniotic (rare)

Question 3

Name 3 risk factors for DZ twins? (2)

Answer 3

Genetic factors
Increasing maternal age
Assisted conception 
 -IVF (no more than 2 embryos in UK if under 40)
 -Clomifene

Question 4

Name 2 antepartum complications of multiple pregnancy? (2)

Answer 4

Maternal:
Gestational diabetes
Pre-eclampsia
Anaemia

Fetal:
increased mortality
Increased long term handicap
Preterm delivery, IUGR, Twin to twin transfusion syndrome
Miscarriage
Preterm labour

Question 5

What is win-to-twin transfusion syndrome? (2)

Answer 5

Caused by unequal blood distribution through the vascular anastomoses of the shared placenta.
One twin (donor) becomes volume depleted and develops anaemia, IUGR and oligohydramnios. The recipient twin is volume overloaded and may develop polycythaemia, cardiac failure and polyhydramnios.

Question 6

Name 2 intrapartum complications of multiple pregnancies. (2)

Answer 6

Malpresentation (c/s if in first twin)
Fetal distress in labour is more common
Post partum haemorrhage is more common

Question 7

What is the lambda sign on ultrasound? (1)

Answer 7

represents dichorionicity.

T sign in monochorionic twins

Question 8

What is the preferred treatment of twin-to twin transfusion syndrome? (1)

Answer 8

laser photo-coagualtion of placental anastomoses

50% chance of both twins surviving, 80% of one twin surviving.

Question 9

What is the puerperium? (2)

Answer 9

From delivery until 6 weeks after as the body returns to pre-pregnancy state.

Question 10

What is lochia? (1)

Answer 10

Discharge from the uterus after birth. It is bloody for approximately 4 weeks after birth.

Question 11

Why is the risk of VTE most in the puerperium? (1)

Answer 11

Increased platelets and clotting factors

Question 12

What is the biological mechanism of lactation? (2)

Answer 12

Prolactin is from the anterior pituitary, and causes the secretion of milk. There are high levels at birth but it is after birth when the oestrogen and progesterone levels have dropped that the milk is secreted. (O+P are antagonists of prolactin)
Oxytocin is required from the posterior pituitary for the ejection of milk in response to sucking on the nipple. however as oxytocin is produced in the hypothalamus, it is affected by emotional and physical stress.

Question 13

Fiona has decided to breastfeed her baby, and now would like some advice on contraception now little Bonnie is 6 weeks old.
What would you advise her? (2)

Answer 13

COC is contraindicated (can suppress lactation)

Progesterone depots good for long term, or IUD.

Question 14

What is primary post-partum haemorrhage? (2)

Answer 14

Loss of >500ml of blood in less than 24 hours after delivery.
If c/s then 1000ml

Question 15

name 3 risk factors for PPH. (3)

Answer 15

Previous history
Previous c/s
Coagulation defect
Instrumental delivery or c/s
Retained placenta
APH
Polyhydramnios/multiple pregnancy
Grand multiparity
Uterine malformation or fibroids
Prolonged/induced labour

Question 16

name 1 drug that can help prevent PPH? (1)

Answer 16

Use of oxytocin or ergometrine in the the third stage of labour.

Note ergometrine is contraindicated in hypertension

Question 17

What is a secondary PPH? (2)

Answer 17

Excessive blood loss occurring between 24 hours and 6 weeks after delivery.
Often due to endometritis with or without retained placental tissue.

Question 18

name 3 complications of the puerperium. (3)

Answer 18

VTE
Postpartum pyrexia
post partum haemorrhage
post natal depression
baby blues
postpartum thyroiditis

Question 19

What scale can be used to assess post natal depression? (1)

Answer 19

Edinburgh PND scale

Question 20

name 2 risk factors for post natal depression. (2)

Answer 20

Socially/emotionally isolated
previous history
pregnancy complications
(consider postpartum thyroiditis)

Question 21

What is puerperial psychosis? (1)

Answer 21

Abrupt onset of psychotic symptoms usually aroudn the fourth day post partum, requires admission to psychiatric services and sedation.
most likely in primigravids with family history