Twin Pregnancies

Question 1

Twin pregnancy sara sanderson presents with to your clinic two days after her eight week ultrasound which identified twins. The examiner will provide results on investigations at your request. Discuss your management plan and counsel this patient.

A lady is found to have twins at 12-week U/S. Counsel the patient regarding what she should expect in her pregnancy.

Answer 1

Impression
Twin pregnancies can be amniotic (share amniotic sac) or chorionic (share placenta/chorionic sac). Twin pregnancies carry increased risk of obstetric complications including placenta praevia, placental abruption, and PPH.

Other risks:

• cord entanglement
• twin-twin transfusion
• Rh factor sensitisation

Priorities:

• conduct thorough assessment, identify any additional obstetric risk factors that may complicate pregnancy
• generate appropriate management plan according to risk profile of the pregnancy, mitigate where appopriate

Question 2

Twin pregnancy - History

Answer 2

History
- sx of pregnancy: REDFLAGS N/V, urinary sx, headaches, swelling, visual changes, fevers, weight loss, etc
- obstetric history (gravidity, parity, complications, results of scans (mo/mo Mo/di vs Di/Di)
o yellow book (torch screening)
o fam hx
o diabetes screening
- natural conception vs IVF?

Question 3

Twin pregnancy - Examination

Answer 3

Examination
- general observation
Normal antenatal examination
- anthropometric measurements (height, weight, BMI)
Antenatal assessment:
- BP, HR
- abdominal palpation
- fundal height
- fetal dopplers

Question 4

Twin pregnancy - Investigations

Answer 4

Investigations

• key/diagnostic is TA-US; needs to be conducted before 14 weeks when chorion and amnion fuse in order to determine chorionicity
• assess for cord entanglement (high MCMA)

Question 5

Twin pregnancy - Management + counselling

Answer 5

Management
Counselling on increased risks associated with twin pregnancy;
- miscarriage
- foetal stillbirth/miscarriage
- preterm birth, low birth weight, SGA, placental insufficiency
- congenital anomalies

Increased risk of;

• if monochorionic, then risk of twin-twin transfusion syndrome (TTTS). Characterised by polyhydramnios in one sac and oligo in the other; volume discordance
• TAPSequence: anaemia/polycythaemia.
• TRAPerfusion syndrome.
• increased risk of obstetric complications (anaemia, increased uterine growth, pre-ecclampsia, GDM, PPH, placental abnormalities

Antenatal management

• referral to high-risk obstetrics clinic for ongoing monitoring
• more regular review periods, US and BP given fundal height is not reliable
• birth planning

Intrapartum

• delivery should be earlier than for singleton pregnancies (32 MCMA; 34 MCDA, 38 DCDA)
• ongoing CTG monitoring during labour
• induction, vs consider elective Caesarean (depends on whether di/mono

Post-partum

• higher risk of PPH
• fetal risks of prematurity (hypoglycaemia, jaundice, IRDS, hypothermia, poor feeding, ICH, NEC)