Twins Flashcards

1
Q

% of monochorionic preg

A

30% of twins

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2
Q

Complications for mum

A
  • PTB
  • FGR
  • PET
  • PPH
  • PN complications- Adverse mood changes, feeding diff
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3
Q

Complications for fetus

A
  • TTTS
  • sGR
  • TAPS (T anaemia-polycythaemia seq)
  • TRAP (reverse arterial perfusion)
  • Single IUD
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4
Q

Twins risk bases on type

A

MCMA - highest risk of loss <24w
MCDA
DCDA - least risk but still higher than singleton

Higher neuro disability in MC also

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5
Q

TTTS- mainly in MCDA

A
  • Affect 15% of MC preg
  • Usually BEFORE 26w
  • Unidirectional blood flow
  • Affects fetal cardiac, placenta, renal function
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6
Q

TTTS staging

A

I - sig discordance in LV
DVP <2cm in donor and >8cm in recipient
Normal doppler and bladder.

II - Bladder of donor not visible, severe oligo.
Doppler not critically abnormal.

III - Dopplers are critically abnormal

IV - Ascites, pericardial/pleural effusion, scalp oedema or hydrops in recipient

V- one or both babies have died

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7
Q

TTTS mx

A

Stage I - might only need monitoring

  • If <26w- Laser ablation - Soloman technique
    In tertiary centre (at least 15procedures/year)
  • Weekly scan for 2 weeks then back to every 2 week scans
  • > 26w- consider amnio- reduction
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8
Q

TTTS recurrence

A

14% of preg treated w laser w or wo TAPS

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9
Q

TAPS

A
  • 13% of twin after laser ablation for TTTS
    or 2% of twins
  • Slow tx of blood from donor to recipient
  • Anaemia in donor (MCA PSV >1.5x normal)
    Recipient ( MCA PSV <1.0)
  • No oligo/poly
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10
Q

TAPS mx

A
  • Difficult to mx due to very small anastomosis
  • Mx with laser, IU tx
  • Outcomes can vary
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11
Q

Selective GR %

A
  • 15% of MC twin wo TTTS
  • 50% w TTTS
  • Wt difference >20%

Diff to TTTS as one will be oligo and other normal LV

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12
Q

sGR staging

A

I - growth discordance but + diastolic flow in both umbilical arteries.
90% survival

II - Growth discordance w absent or reversed EDV.
29% risk of demise

III - GD w cyclical UA diastolic waveforms, intermittent AREDV.
10-20% risk of demise

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13
Q

sGR mx

A
  • Selective reduction- inc risk of neuro disability in surviving T
  • sGR delivery-
    T I- 34-36w
    T II/ III- 32 weeks

or cCTG STV <4.0

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14
Q

Impact on surviving T after fetal death of co-twin

A
  • 15% risk of death
  • 26% risk of neuro disability
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15
Q

Monitoring of surviving twin

A
  • Fetal MRI 4 weeks after twin death
  • Monitor MCA PSV for anaemia
  • Delivery only if close to term
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16
Q

Diagnosis of twins

A
  • Dating scan (11-14w)- Determine chorionicity based on placental mass and membrance thickness
  • Save photo electronically and in pt notes of membrance attachment
  • If unsure, take photo to get 2nd opinion
  • If still unsure, urgent FM review

Chorionicity should be known before 14w

17
Q

Aneuploidy screening

A

MC- overall preg risk, DC- fetus specific risk

  • CST at 11-13+6 (higher false positive (10%) than singleton (2.5%))
  • Quad test after

NIPT if high risk outcome

18
Q

Anomaly scan

A

Routine at 18-20 weeks
No need for specialist scan ie cardiac unless concerns

19
Q

USS f/u for twins

A

MC-
Every 2 weeks from 16 weeks.
Check DVP, umbilical artery doppler, EFW, bladder.

DC-
Every 4 weeks from 24 weeks

20
Q

Dopplers if suspected TTTS

A
  • UAPI
  • MCA PSV and pulsatility index
  • DV doppler
21
Q

Growth discordance calculation

A

(Smaller T- larger T)/ Large T x 100

22
Q

Delivery

A

MCMA- 32-34w by CS
High risk of cord entanglement

MCDA uncomplicated- 36w onwards

MCDA w TTTS/TAPS prev- Deliver bet 34-36+6

DCDA- 37 weeks

23
Q

Selective reduction

A
  • Offer to all preg >2
  • Offer before any ivasive testing ie. Amnio
  • Use laser ablation for monochorionic T
  • Monitoring of DIC is not needed in SR