Twin and Triplet pregnancy NICE Flashcards
When determining GA, which baby size to use?
Use the largest baby
What does lamda sign and T sign tell you
Lamda - Dichorio
T sign Mono
When to performed FBC in multiple pregnancy?
20-24 and 28 weeks
How many appointments for DCDA, MCDA twins, TA triplets
DCDA
8 AN app, 2 with specialist
MCDA
11 AN app, 2 with specilist
Triplets
uncomplicated TCTA: 9 AN appointments, 2 with specilist
DCTA or MCTA: 11 AN, 5 with specialist
Shared amnion - tertiary level
How many scans for DCDA
11-14 weeks
Every 4 weeks from 20 weeks
How many scans MCDA twins
11+2-14+2 weeks
Every 2 weeks from 16 weeks
TCTA twins scans
11-14
20, 24 then evert 2 weeks
DCTA or MCTA scans
Every 2 weeks from 16 weeks
How to offer screening for chromosomal abnormalities in triplet pregnancy
High risk of false positive and being offered invasive testing
Use NT and maternal age when CRL 45-84,, (11+2-14+1)
Can you use FFN in twin triplet pregnancy?
No
From when can offer screening for FGR in DC twins or TC triplets?
How often
From 24 weeks
Every 4 weeks DC twins
Every 2 weeks in TC triplets
How to calculate discordance for DCDA twins
(EFW largest / EFW smallest) x 100
How to calculate discordance in triplets
([EFW largest fetus − EFW smallest fetus] ÷ EFW largest fetus) × 100
and
([EFW largest fetus − EFW middle fetus] ÷ EFW largest fetus) × 100
When to increase the scanning to weekly assessing for discordance?
If EFW >20%
Any baby <10th
When to refer to tertiary unit for discordance of DCDA twins or TCTA triplets
If discordance >25% and EFW of a baby is <10th centile
Mains risks with shared placenta
Risk TTS, FGR, TAPs
How often to scan assessing for TTS, when to increase scanning to weekly
Scan every 2 weeks from 16 weeks
Scan weekly if difference >4cm
When to refer to tertiary unit for TTS when
Amniontic sac DVP <2cm
and
Amniotic sac of another baby
>8cm <20 week sor >10cm from >20 weeks
In TTS, when to refer to specilist obstetrician for multiple pregnancy
Amniotic sac of 1 baby has DVP in normal ranger
and
Other baby DVP <2vm or >8cm
What part of USS assess for twin anaemia polycythamia sequence?
MCA-PSV
Who should be offered weekly USS assessing for TAPs?
TTS that has been treated by fetoscopic laser therapy
sGR (discordance >25% and EFW <10th)
Which other cases should TAPs be assessed with MCA-PSV
Monochorionic and evidence
- Cardiovascular compromise
- Unexplained isolated polyhydramnios
- abnormal umbilical artery
Do multiple pregnancies need aspirin?
Moderate RF, so only if other RF present
When should you discuss timing of birth/plans for birth
By 28 weeks
What % twin pregnancies delivery < 37 weeks
60%
What % triplet pregnancies delivery < 35 weeks?
75%
When to delivery
DCDA twins
37 weeks
When to delivery
MCDA
36 weeks
When to delivery
MCMA
32-34 weeks, offer CS
When to delivery TCTA twins by
35 weeks, offer CS
If patient declines delivery at the preposed time how often to offer ANC and USS
Weekly
Which uncomplicated DC or MC twins can have VD
If 1st twin cephalic
No significant size difference between the twin
No obstetric contraindications
>32 weeks
> 32 weeks DC or MC twins having vaginal delivery, how many will require EMCS?
1/3
Small number will need CS for delivery oft he 2nd twin after vaginal delivery of 1st
Who to offer CS DC or MC twins
Planned CS 1st baby not cephalic
EMCS Preterm labour 26-32 weeks
From what gestation to offer CTG in labour for multiple pregnancy?
26 weeks
Located on USS 1st
Can scalp stimulation be performed for pathological CTG
No
What to do if difficult monitoring twins
Bedside USS
Fetal scalp electrodes from twin 1 >34 weeks
If remains unclear - consider CS
1st baby CTG suspicious
correct reversible causes
Fetal scalp electrode if >34 weeks
If CTG pathological 1st baby
Consider fetal blood sampling >34 weeks
CS
If secondary stage - consider vaginal birth if can be achieved within 20 mins
2nd baby suspicious/pathological before the first baby is born
If VD cannot be achieved within 20 mins, consider CS
Why to offer epdiural
Improve chance of success and otimal timing of assisted vaginal delivery
Quicker birth by CS
Risk reduction PPH
Offer active blood stage consider additional uterotonics
How many AN appointments for primps and multip?
P0 10 An appointments
Multip 7 AN appointment
