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A - ObsNGynae > obs - multiple pregnancy > Flashcards

obs - multiple pregnancy Flashcards

1
Q

types of multiple pregnancy? aetiology? most common?

A

Most common = Dizygotic twins 66%

  1. Dizygotic twins : 2 oocytes. fraternal
  2. Monozygotic twins:
    a. DCDA: dichorionic diamniotic
    • cleavage of morula (day 1-3)

b. MCDA: monochorionic diamniotic - 70%
- cleavage of the blastocyst (d 4-8)

c. MCMA: monochorionic monoamniotic
- cleavage of implanted blastocyst (d 8-13)

d. Conjoined
- cleavage of formed embryonic disk (13-15)
- or incomplete division

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2
Q

how is multiple pregnacy diagnosed?

A

Physical examination:
 Vomiting more marked in early pregnancy
 Uterus larger than expected for dates
 Palpable before 12 weeks

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3
Q

complicatoins of multiple pregnancy?

A

Maternal:
All obstetric risks exaggerated:
- DM, pre eclampsia

Fetal:
IUGR - superficial artery-artery anastomoses
Preterm delivery
Increased risk of handicap
Breech delivery
TTTS - in monochorionic ones
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4
Q

which twins are at risk of TTTS?

A

MCDA monochorionic diamniotic

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5
Q

how do twins present in TTTS? prognosis?

A

One twin = donor -> volume depleted, develops anaemia, IUGR and oligohydramnios

One twin = recipient -> volume overloaded, polycythaemia, cardiac failure, polyhydramnios

50% chance both will survive

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6
Q

how does co-twin death occur?

A

If one twin dies, the drop in BP allows acute transfusion of blood from the other -> hypovolaemia

15% chance of co-twin death. risk is higher if 1st death is before 24 weeks. if survive, high risk neurological damage.

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7
Q

why does 2nd twin have incresaed chance of dying?

A

due to hypoxia, cord prolapse, tetanic uterine contraction or placental abruption

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8
Q

which signs would you see on US depending on the type of twin pregnancy?

A

DC: dividing membrane is thicker as it meets the placentas = lambda sign

MC: thin and perpendicular to the placenta = T sign

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9
Q

when is TTTS usually diiagnosed?

Management?

A

16-22 weeks

  1. Refer to specialist foetal medicine centre
  2. If < 26 weeks – foetoscopic laser ablation of placental anastomoses - definitive in severe cases
  3. Or Expectant management - weekly ultrasound
  4. delivered between 34-37 weeks

others - see other card

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10
Q

what is the risk with MCMA: monochorionic monoamniotic twins?

A

cords always get entangled -> fetal death in utero

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11
Q

how are multiiple pregnancies managed?

how are breech deliveries conducted?

A

Lots of monitoring throughout pregnancy, looking out for complications

Obstetrciian led care.

Can deliver vaginally
- may end up in c-section if 2nd twin not coming

Elective section usually offered.

Inform that 60% of twin pregnancies result in spontaneous birth before 37 weeks!!

Sumary of monitoring:
▪ Monochorionic: 2-weekly growth and Doppler from 16 weeks
(refer to foetal medicine specialist)
▪ Dichorionic: 4-weekly growth and Doppler from 20 weeks

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12
Q

Maternal risks of multiple pregnancy?

A

1st trimester - increased pregnancy sx , anemia

2nd

3rd - PPH, Preterm labour

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13
Q

Fetal risks of multiple pregnancy?

A

1st. - congenital malformations , cerebral palsy

2nd - growth restriction, TTTS, TRAP

3rd trimester - preterm birth, cord entanglement (all monochorionic will have this).

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14
Q

What is risk of death in twin pregnancy?

Don’t forget in paces, woman may come to discuss her twin pregnancy. - so know risk factors for twins etc.

A

Perinatal mortality 37 in thousand - twins

52 in thousand - triplets

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15
Q

Which sign on the dating scan indicates dichorionic pregnancy? And monochorionic?

A

Lambda - dichroic

T sign - mono

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16
Q

TTTS can occur in dizygous twins, true or false?

A

False

17
Q

Which twins have the highest risk of mortality?

A

MCMA - 30-70%

18
Q

In twins what can Nuchal translucency scan tell you in multiple pregnancy?

A

Chromosome Anomaly
TTTS

Note; accuracy is less than for single pregnancy.

19
Q

What does cervical length tell us?

A

If less than 25mm, this predicts delivery before 34 weeks

20
Q

What is ANCare like for multiple pregnancy?

A

Specialist twin clinic. - obstetrician

Multiple births foundation

21
Q

What is risk of malformations with twins?

A

2-3x higher than for Singleton

Midline malformations higher - haloprosencephaly etc

22
Q

What are the different forms of placental anastomoses?

A

V-V
A-V
A-A?

23
Q

When does TTTS become obvious to diagnose?

A

2nd trimester

Oligo and Polyhydramnios

24
Q

what are the options for TTTS treatment?

A

Amnioreduction - controls Polyhydramnios

Septostomy - hole in amniotics sac to allow the amniotic fluid to move from one baby to the other. alternative to amnioreduction

Laser ablation

25
Q

What is the mecahnsim and treatment for TRAP?

How can selective termination be done!

A

Arterio arterio anastomoses

Recipient twin doesn’t develop vital structures eg heart! And limbs etc

Pump twin gets hydrops as trying to perfume other twin

Separate cardiovascular circulations by bipolar diathermy!

Can’t do KCL for selective feticide due to connected circulation. Use occlusive techniques.
Once termination in done, baby stays in uterus till term.

26
Q

What are the risks of Intrauterine death?

A

Neurotic neurological and renal lesions in surviving twin - 1 in 4 chance

Hypotension and ischaemia - surviving twin pumps blood to dead twins circulation.

27
Q

What are the options for twins to be delivered?

A

MCMA - 32 weeks elective C-section!!
MCDA - 36 weeks IOL or ECS
DC - 37 weeks IOL or ECS

If want to deliver vaginally; 1st twin Must be cephalic. Continuous monitoring of both twins required. We hope both are born within 30 minutes.
With this: there’s risk of 2nd twin being born by section! So might as well have section to start.

Can deliver 2nd twin breech though BUT only 2nd twin

28
Q

Why don’t we rupture membranes before baby is well stationed?

A

If it’s too high and you rupture, baby can go into transverse lie

29
Q

All multiple pregnancy mums must be on which drugs?

A

Iron, folate

Bp and urine monitoring for pre eclampsia
Urine monitoring for gestational diabetes

30
Q

what is a sign that is used to assess risk of TTTS?

what to do if you see this sign?

A

Membrane folding

UP the monitoring from 2 weekly scans to 1 weekly.

31
Q

which multiple pregnancies need to be referred to fetal medicine specialist? - VERY VERY IMPORTANT

A

MCMA

Triplets

32
Q

what suggests growth restriction in multiple pregnancy?

A

> 20% discordance in biometric parameters for growth measured

A - ObsNGynae (37 decks)

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