Twin pregnancy

Question 1

What are the first trimester risks important to highlight in twin pregnancy counselling?

Answer 1

#Increased risk of anemia due to increased demand or reduced stores 
#Increased risk of nutrient deficiency 
#Increased risk of hyperemesis gravidarum
#increased risk of congenital malformations 
#increased risk of miscarriages 
#increased clinic visits 
# risks associated with monochorionic monoamniotic twins such as Twin to twin transfusion syndrome and Twin reverse arterial perfusion

Question 2

What are the second trimester risks that must be highlighted in counselling a patient with twin gestation?

Answer 2

#increased risk of PIH 
#increased risk of GDM 
#increased risk of back pains 
#increase risk of spontaneous miscarriages
#increased risk of intrauterine growth restriction
#as baby gets larger mother may experience dyspnea due to uterus impacting diaphragm
#increased fetal movements

Question 3

What are the third trimester risks that must be highlighted in counselling a patient with twin gestation?

Answer 3

#increased risk of placenta praevia and increased risk of antepartum haemorrhage 
#increased risk of polyhydramnios lead to preterm deliveries
#increased risk of preterm labor
#increased risk of gaining more weight

Question 4

What can be seen in examination of a mother with twin gestation?

Answer 4

#Large for gestational age - large SFH
#symptoms of anemia
#hemmhoroids or varicose veins 
#several palpable fetal parts 
#fluid thrill

Question 5

How is twin pregnancy diagnosed?

Answer 5

using a transvaginal ultrasound - CHORIONICITY is the most important factor in determining risk. On ultrasound Lambda sign at 9-14 weeks indicates DICHORIONIC, T sign at 9-14 weeks indicates MONOCHORIONIC DIAMNIOTIC and the absence of both these signs means mono mono

Question 6

What are the maternal complications of twin pregnancy?

Answer 6

# spontaneous miscarriage 
#hyperemesis gravidarum
#Anemia 
#PIH/pre eclampsia 
# Ante partum haemorrhage - abruption and previa 
#PPH - uterine atony secondary to over distension 
# Increased risk of C- section

Question 7

What are the fetal complications of twin pregnancy?

Answer 7

#Prematurity- due to higher risk of PROM, preterm labour 
#IUGR 
#Malpresentation
#Congenital anamolies 
#Twin to twin transfusion syndrome - monochorionic only 
# Twin reverse arterial perfusion - monochorionic only 
#Twin interlocking - twin A breech, twin B cephalic 
#Increased perinatal morbidity and mortality 
#Single fetal demise

Question 8

What are the uteroplacental complications of twin pregnancy?

Answer 8

#Polyhydramnios 
#Cord entanglement 
#Cord prolapse
#placenta previa 
#placental abruption 
#Preterm labour and PROM
#velamentous insertion of the cord (vessels of umbilical cord attach to membranes and are unprotected)

Question 9

outline the types of twin pregnancy and their risk factors as well

Answer 9

Dizygotic and Monozygotic

Risk factors
# geographical location 
#family hx
#increased maternal age
#ovulation induction agents (chlomiphene)
#IVF (22% rate) 

DIZYGOTIC - always diamniotic dichorionic

MONOZYGOTIC CAN BE 
#dichorionic diamnitotic (separates day 0-3)
#monochorionic diamnitotic (day 4-8)
#monochorionic monoamniotic (day 8 or after)
#conjoined (day 13 and after)

Question 10

What is the antenatal management of twin pregnancy?

Answer 10

1. prophylactic iron and folic acid
2. increased antenatal visits (generally 2-3 weeks up to 32 weeks then weekly until delivery)
3. increased fetal surveillance: TV U/S for dating can detect multiple pregnancy and TA U/S can be used to define chorionicity, exclude congenital anamolies, diagnose placenta previa, monitor fetal growth, confirm presentation of twin A, detailed cardiac scan at 24 weeks and fetal echo to detect cardiac abnormalities. Ideally we would also want to have a weekly non stress test and serial ultrasounds every 2-3 weeks. Biophysical profile as needed.
4. In the event of preterm labour, appropriate tocolysis and corticosteroids
5. selective feticide

Question 11

What is the intrapartum management of twin pregnancy?

Answer 11

1. delivery at 38 weeks if uncomplicated
2. can deliver vaginally if twin A is cephalic and no other contraindications present - if not C section
3. C section must be done if: >2 fetuses, monoamniotic twin to avoid cord entanglement
4. If twin B is breech deliver via assisted breech delivery or ICV and extraction
5. C section for twin B is sometimes necessary if there is a : shoulder presentation, cervical contraction, compound presentation, cord prolapse

Question 12

what are the main reasons for fetal distress in the second twin?

Answer 12

1. Premature separation of the placenta - abruption
2. cord entanglement
3. cord prolapse

Question 13

What is the postpartum management in twin pregnacy?

Answer 13

1. ACTIVE MANAGEMENT OF THE THIRD STAGE OF LABOUR

must give prophylaxis for post partum heamorrhage - 1 ampule of syntometrine IM and 40 units of syntocinon in 1L N/S IV infusion

2. remove and Inspect placenta

Question 14

Perinatal mortality in twin pregnancy?

Answer 14

7 times higher than singleton pregnancy