Multiple Pregnancy and Related Complications Flashcards by Duha Mahmood

What is a multiple pregnancy?

A pregnancy where two or more fetuses develop in the uterus at the same time.

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What are the two main types of twins?

Monozygotic twins (identical): Formed from one zygote splitting into two embryos.
Dizygotic twins (non-identical): Formed from two separate ova fertilized by two different sperm.

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What is the difference between monochorionic and dichorionic twins?

Monochorionic twins share a single placenta.
Dichorionic twins each have their own placenta.

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In a __________ pregnancy, twins share a single placenta.

Monochorionic

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What are the clinical features of multiple pregnancy?

Larger-than-expected uterine size for gestational age.
Higher levels of beta-hCG.
Excessive maternal symptoms (e.g., nausea, vomiting).
Multiple fetal heartbeats on Doppler.

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How is a multiple pregnancy diagnosed?

By ultrasound, which confirms:

Number of fetuses.
Chorionicity and amnionicity.
Placental position.

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Why is determining chorionicity and amnionicity important in multiple pregnancy?

Helps assess risk level.
Monochorionic twins are at higher risk of complications like twin-twin transfusion syndrome (TTTS).
Dichorionic twins have fewer complications.

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True/False
Q: Dizygotic twins are always dichorionic.

true.

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What are the maternal complications associated with multiple pregnancy?

Hyperemesis gravidarum.
Anemia.
Increased risk of gestational diabetes and preeclampsia.
Preterm labor.
Increased risk of postpartum hemorrhage.

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What are the fetal complications associated with multiple pregnancy?

Prematurity.
Low birth weight.
Twin-twin transfusion syndrome (TTTS) (monochorionic twins).
Growth discordance.
Increased perinatal mortality.

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How is a multiple pregnancy managed antenatally?

Regular ultrasound scans to monitor growth and complications.
Determine chorionicity and amnionicity early.
Monitor for complications (e.g., preeclampsia, TTTS).
Additional maternal nutrition and iron supplementation.
Planned delivery timing depending on chorionicity:
Dichorionic twins: Delivered around 37 weeks.
Monochorionic twins: Delivered around 36 weeks.
Monochorionic-monoamniotic twins: Delivered around 32–34 weeks.

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What is twin-twin transfusion syndrome (TTTS)?

A complication in monochorionic twins, where abnormal blood flow between twins via shared placental vessels causes one twin (donor) to be underperfused and the other (recipient) to be overperfused.

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What factors determine the mode of delivery in multiple pregnancy?

Presentation of the leading twin (cephalic vs non-cephalic).
Gestational age.
Fetal and maternal condition.
Monochorionic-monoamniotic twins often require planned cesarean section.

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In multiple pregnancy, monochorionic twins should be delivered by __________ weeks to reduce risks of complications.

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What is the prognosis for multiple pregnancy?

Good with proper monitoring and management.
Increased risk of complications, but advances in care improve outcomes for mother and babies.

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A 30-year-old pregnant woman is found to have dichorionic twins on a dating scan. What antenatal management plan should be put in place?

Regular ultrasound scans every 4 weeks to monitor growth.
Screen for maternal complications (e.g., preeclampsia, anemia).
Plan for delivery at 37 weeks.

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What is cephalopelvic disproportion (CPD)?

CPD is a condition in which the fetal head is too large to pass through the maternal pelvis due to either a small pelvis, a large fetus, or both.

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CPD occurs when there is a size mismatch between the fetal ___ and the maternal ___.

head; pelvis

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What are the maternal factors contributing to CPD?

Maternal factors include a small pelvis, pelvic abnormalities (e.g., rickets or trauma), or a history of pelvic fracture.

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True/False: Cephalopelvic disproportion can only result from maternal factors.

False. It can also result from fetal factors.

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What fetal factors contribute to CPD?

Fetal macrosomia, hydrocephalus, or abnormal fetal positioning can contribute to CPD.

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Matching: Match the condition to its contribution to CPD:

Fetal macrosomia

Small pelvis

Hydrocephalus

Abnormal presentation

1 - Large fetus; 2 - Maternal factor; 3 - Excess head size; 4 - Position-related mismatch

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What are the common clinical features of CPD?

Prolonged labour, lack of progress despite good uterine contractions, and signs of maternal or fetal distress.

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woman in active labour has had no cervical dilation progress for 3 hours despite strong contractions. What condition should be suspected?

Cephalopelvic disproportion (CPD).

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Prolonged ___ or ___ labour are key signs of possible CPD.

first-stage; second-stage

What maternal complications can arise from CPD?

Uterine rupture, maternal exhaustion, postpartum hemorrhage, and trauma to the pelvic tissues.

True/False: CPD is often diagnosed early in pregnancy.

False. It is typically diagnosed during labour.

What investigations are used to assess CPD?

Clinical examination, ultrasound to estimate fetal size, and pelvimetry.

What is pelvimetry?

Pelvimetry is the measurement of the maternal pelvis to assess its capacity to accommodate the fetal head.

___ ultrasound can be used to estimate fetal weight and head circumference in suspected CPD

Obstetric

True/False: Ultrasound is 100% accurate in diagnosing CPD.

False. It provides an estimation but is not definitive.

What is the primary management approach for suspected CPD during labour?

Continuous monitoring of labour progress with interventions if necessary, such as assisted delivery or cesarean section.

Labour is not progressing, and fetal heart rate monitoring shows decelerations. What is the next step?

Consider cesarean section.

If CPD is suspected and labour does not progress, ___ delivery is often recommended

cesarean

When might instrumental delivery be considered in CPD?

If the fetal head is low enough in the pelvis and there are no signs of fetal distress.

True/False: Vaginal delivery is always contraindicated in CPD.

False. In some cases, vaginal delivery may be attempted if conditions are favourable.

What are the risks of delaying intervention in CPD?

Increased risk of uterine rupture, fetal distress, neonatal hypoxia, and maternal complications.

How can antenatal care help reduce the risk of CPD?

Early identification of risk factors (e.g., maternal obesity, diabetes, or suspected macrosomia) and planning for appropriate delivery.

Managing ___ and ___ conditions during pregnancy can help lower the risk of CPD

maternal weight; pre-existing

Why is close monitoring recommended in women with a history of CPD?

To plan for potential early interventions and discuss delivery options.

What conditions should be considered as differentials for CPD?

Fetal malpresentation, uterine inertia, and false labour.

True/False: Fetal malpresentation can mimic CPD.

True.

How can fetal malpresentation be distinguished from CPD?

Ultrasound and clinical examination can help identify fetal position.

What is uterine rupture?

Uterine rupture is a full-thickness tear in the uterine wall that can occur during pregnancy or labour, potentially leading to severe maternal and fetal complications.

Uterine rupture involves a complete tear through the uterine ___, including the endometrium, myometrium, and serosa.

wall

What are common causes of uterine rupture?

Causes include previous uterine surgery (e.g., cesarean section or myomectomy), excessive uterine contractions, obstructed labour, or trauma.

True/False: Uterine rupture is most commonly associated with a history of cesarean section

True.

What factors increase the risk of uterine rupture?

Factors include previous uterine surgery, high parity, induction or augmentation of labour, uterine overdistension, and fetal macrosomia.

What are the typical clinical signs of uterine rupture?

Sudden abdominal pain, vaginal bleeding, loss of uterine contractions, abnormal fetal heart rate patterns, and maternal shock.

A sudden cessation of ___ during labour can indicate uterine rupture

contractions

What fetal signs may indicate uterine rupture?

Fetal bradycardia, variable decelerations, or absent fetal heart tones.

True/False: Vaginal bleeding is always present in uterine rupture

False. Bleeding may be concealed.

A woman in labour with a history of previous cesarean presents with sudden abdominal pain and fetal bradycardia. What should be suspected?

Uterine rupture.

How is uterine rupture diagnosed?

Diagnosis is usually clinical, based on maternal and fetal signs. Ultrasound may be used if time allows, but it is not always definitive.

___ heart rate abnormalities are often the first sign of uterine rupture during labour

Fetal

True/False: Imaging is always required to confirm uterine rupture.

False. It is primarily a clinical diagnosis.

What is the immediate management for uterine rupture?

Immediate emergency cesarean section and surgical repair of the uterus or hysterectomy if repair is not possible.

he primary goal of management in uterine rupture is to ___ maternal and fetal outcomes through rapid intervention.

optimize

A woman with suspected uterine rupture undergoes emergency cesarean. During surgery, a full-thickness tear is identified. What is the appropriate next step?

Repair the uterine tear or perform a hysterectomy if necessary.

What are the indications for hysterectomy in uterine rupture?

Hysterectomy is indicated if uterine repair is not possible or if there is uncontrollable hemorrhage.

True/False: Vaginal delivery is contraindicated after a uterine rupture

True.

What are the maternal complications of uterine rupture?

Hemorrhage, shock, disseminated intravascular coagulation (DIC), infection, and maternal death.

What fetal complications are associated with uterine rupture?

Fetal hypoxia, brain injury, stillbirth, and neonatal death.

Uterine rupture can lead to severe ___ hemorrhage, resulting in maternal hypovolemic shock

postpartum

True/False: Early detection and rapid intervention can significantly reduce the risks of uterine rupture.

True.

How can uterine rupture be prevented?

Preventive measures include careful monitoring during labour, avoiding unnecessary induction or augmentation, and counselling women with previous uterine surgery about delivery options.

Women with a history of previous cesarean section should be counselled on the risks and benefits of ___ delivery versus trial of labour.

elective cesarean

Why is close monitoring during a trial of labour after cesarean (TOLAC) essential?

To detect early signs of uterine rupture and intervene promptly.

True/False: Trial of labour after cesarean (TOLAC) is contraindicated in women with a history of uterine rupture.

True.

What conditions should be considered as differentials for uterine rupture?

Placental abruption, uterine atony, and maternal hypotension.

True/False: Placental abruption can mimic the clinical presentation of uterine rupture.

True.

How can uterine rupture be differentiated from placental abruption?

Uterine rupture often presents with sudden cessation of contractions and palpable fetal parts, while placental abruption typically involves painful vaginal bleeding with a firm uterus.