Multiple pregnancy/ Twin Pregnancy

Question 1

Define multiple pregnancy

Answer 1

When more than one Fetus simultaneously developed in uterus it is called multiple pregnancy.
Simultaneous development of to Foetus is most common

Question 2

What is zygosity and Chorionicity

Answer 2

zygosity Refers to genetic make up of twin pregnancy
Chorionicity Refers to Type of placentation.

Question 3

Determination of chorionicIty in monozygotic Twin pregnancy.
Important question when is a chorion and amnion formed

Answer 3

It depends upon timing of cleavage of these 2 twins.
<72 hrs = DCDA
4 -8 days (chorion is formed) DAMC. most common
8-12 days (amnion is alsoformed) MAMC
>12 DAYS conjoined twins(siamese twins) (organs are formed)

Question 4

DIFFRENCE IN DADC and DAMC

Answer 4

1)DADC can form from Dizygotic or Monozygotic twins.
2)In DADC placental Tissue goes in between 2 fetuses. Can not go in DAMC.
3) in DADC twin peak sign/lambda sign is positive.
4)DAMC T sign is present.

Question 5

Types of conjoint/siamese twins, and most common of them.

Answer 5

In siamese twins cleavage occurs after 12 days of fertilisation.
1)thoracopagus(most common)
2)Pyopagus (posterior fusion)
3)craniopagus
4)ischipagus(caudal)

Question 6

Complicaqtions of twin pregnancy (maternal)

Answer 6

1)anemia
2)polyhroamnios, pre term labour , cord prolapse , abruptio
3)uterine over distension resulting in :
PHH, subinvolution ,pre term labor , dyspnea and edema (pressure symptoms)
4)greater placental size =
Placenta previa
PIH
GDM , hyper emesis gravidarum ( increased hormone synthesis)

Question 7

Foetal complications of twin pregnancy .
(Macrosmia and Post are pregnancy are never seen

Answer 7

1)pre term labor (M/C/C)
2) IUGR
Do fetal reduction @ 10-13 wks intracardiac injection of KCL.
3)twin to win transfusion syndrome(exclusively in monozygotic twins)

Question 8

Twin to twin transfusion syndrome (TTTS) m/c seen in
C/f
Management

Answer 8

MOST COMMONLY SEEN IN MONZYGOTIC DIAMINIONIC.
When one twin bleed into another through placental deep vascular anastmosis.
Recipient twin become larger with hydroamnios,polycythemia,hypertensive and hypervolemic.
Donor twin smaller with oligohydroamnios,anemic , hypotensive and hypovolemic.
Diagnosis: ultrasound with doppler Blood flow study
Management: a)laser photocoagulation of anstmotic vessel
B) Repeated amniocentesis to control polyhydroamnios
C) septostomy (hole in diving amniotic membrane)
D) Selective reduction of one twin When both are at risk.

Question 9

TRAP

Answer 9

Twin reversed arterial perfusion.
A cardiac twins recieve blood from normal co twin

Question 10

Delivery in multiple pregnancy (twins)

Answer 10

Vaginal delivery is allowed when both twins or at least the first twin is with vertex presentation.

Question 11

Case scenario : how will u deliver 1st twin:vertex
2nd twin : transverse lie

Answer 11

1st twin : vaginal delivery
2nd twin : internal podalic version then assisted breech delivery.

Question 12

Internal podalic version vs external cephalic version
Absolute c/i indicsaation and when is it done

Answer 12

Internal podalic performed in OT and external cephalic performed in OPD
Internal podalic under GA , for ECV no anesthesia.
Indications of IPV : 2nd twin transverse lie
Absotute C/I : previous caesarean section : risk of uterine rupture

Indications of ECV: breech transverse lie : done antenatally > 36 wks

Question 13

Version (define)
Type

Answer 13

Is a manipulative procedure designed to change the lie
1. Spontaneous - 55% of spontaneous version after 32 wks in breech presentation.
2. External - versiona done solely by external manipulation
3. Internal - one hand inside the uterus and other hand on abdomen. Internal version is always podalic and is always completed by extraction of fetus.

Question 14

Indications of external cephalic version : (ECV)
Sucess rate
Purpose
Monitoring
Time of version
Contraindications of ECV

Answer 14

1. • Breech presentation
     - Transverse lie.
2. 65%
3. reduce risk of C-section
4. CTG before and after.
5. From 36 wks onwards
6. • APH
     - hyperextension of head, IUGR
     - multiple pregnancy
     - ruptured membranes
     Uterine malformation
     - contracted pelvis
     - previous c-section
     - obstetric complications: severe pre eclampsia,elderly primi,oligohydroamnios,bad obstetric history
     - rhesus isoimmunization

Question 15

Only indication of IPV
Dondition for IPV

Answer 15

IPV is done only in twin pregnnacy trasnsverse lie.

It is done during labor so cervix must be fully dilated and liquor amnni must be adequate and fetus must be living