Post-dates, Induction, Multiple pregnancy, Malpresentation

Question 1

What are important counselling points for post-date management?

Answer 1

• What it means - Normal gestation is 40W but full maturity from 37W, anything beyond 40W considered post-term
• Explanation of aetiology - unknown why, about 50% pregnancies will reach 40 weeks
• Why it’s significant - increasing risk of foetal complications (macrosomia, shoulder dystocia, malnutrition) and stillbirth, risks slightly higher until ~41+3 (10days over) and then risk substantially increases
• Discuss the options
  1. Wait and watch - monitor the baby closely for any signs of distress and wait for spontaneous labour. Generally happy to do this until ~41W and then consider induction
  2. Cervical sweep - VE where cervix is assessed and fingers sweep the membranes. Can be painful and result in some bleeding. Increases the chance of labour in next 48hrs and also use to assess cervix for induction
  3. Induction
  4. C-section

Question 2

Describe the process of induction

Answer 2

Induction is the process to cause the onset of labour artificially

1. Cervical sweep/assessment - VE
2. Prostaglandin gel the evening prior if cervix unfavourable - allows it to soften and begin to dilate (small risk of overstimulation of the uterus and rupture, C/I if previous uterine scar)
3. ROM with toothed forceps - may feel gush of fluid or will slowly loose fluid with time (small risk of cord prolapse)
4. IV Syntocinon to start uterine contractions
   It may involve providing some hormone to soften the cervix and help it dilate (N+V, hyponatraemia, small risk of overstimulation & rupture)
5. Continuous CTG monitoring throughout labour

Tell them that not all inductions are successful and their is a possibility that they may require an emergency C-section

Question 3

What are important counselling features for multiple pregnancies?

Answer 3

• Age, gestation
• Ask if babies sharing sac or placenta
• Normal antenatal history
• Emphasise positive but also highlight that there are increased risks to be aware of and monitor in multiple pregnancy

Risks/issues that require monitoring/Rx

• Anaemia - previous hx? Take Fe supplements in addition to folate and iodine supplement
• Increased nutritional needs - importance of good diet + additional protein and calcium supplements
• Increased risk of most complications - big or small baby, GDM, birth trauma/complications, need for instrumental or operative delivery and PET
• Aspirin during pregnancy due to risk of PET and more requirement monitoring for any issues
• Additional mood and relationship stress

Additional antenatal monitoring - will have CTG and U/S every 2-4 weeks from 2nd trimester

Advise that may require preterm delivery (induced or surgical) due to these increased risks

Question 4

What are dizygotic twins and their features?

Answer 4

Non-identical twins
Do not share a gestational sac or placenta (dichorionic, diamniotic)

2/3s of all twins

Associated with FHx/genetics

Question 5

What are monozygotic twins and their features?

Answer 5

Identical twins resulting from spliting after fertilisation
The timing of the split determines whether they are mono- or di- chorionic and amniotic

No FHx/genetic association (random)
Increased risk with IVF - esp. bc better pregnancy rate if transfered on Day 5, but higher risk of twins

Question 6

What days of splitting result in the different amniocity and choronicities of twins?

Answer 6

Early cleavage (<4 days) results in DA/DC
- 1/3 MZT 

Late cleavage (4-8 days) results in DA/MC
- 2/3 MZT

Very late (>8 days) results in MA/MC 
- ~1%

Question 7

What are the general increased risks for all twin pregnancies?

Answer 7

• Psychosocial - PND, marriage dysharmony
• Anaemia and increased nutritional needs
• PET, IUGR
• Hyperemesis
• Macrosomia, shoulder dystocia
• Prematurity (average gestation 35W cf. 39W)
• Increased size and discomfort - Need to working earlier (~28W cf. ~34W)

Question 8

What are the additional risks associated with monochorionic twins?

Answer 8

1. TTTS - twin-twin transfusion syndrome
2. Selective IUGR
3. Single foetal death

Question 9

What are additional risks associated with monoamniotic twins?

Answer 9

1. Cord entanglement

2. TRAP syndrome

Question 10

What is TTTS and it’s management?

Answer 10

Asymmetrical/unbalanced inter-twin vascular connections - results in maldistribution of blood volume

Results in an increased net flow away from one twin (donor) to the other twin (recipient)

Recipient twin

• Hypervolaemic
• Congestive heart failure and polyhydramnios

Donor twin

• Hypovolaemic
• Anhydramnios, hypoxia

Without treatment mortality rate is ~90%
Rx decreases risk to ~30%, but still risk of survival with disability

Laser treatment - ablate some inter-twin connections to balance vascular communications

Question 11

What is selective IUGR?

Answer 11

Unequal sharing of the placenta (cf. blood volume in TTTS)

One baby obtains more nutrients and oxygen for growth and development at the expense of the other

Question 12

What are the causes of breech presentation?

Answer 12

1. Foetal issues

2. Maternal issues

Question 13

What gestation is breech baby unlikely to move to cephalic?

Answer 13

After 36W the chance of spontaneous version is low (~25%)