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MRCOG part 2 * > Twins > Flashcards

Twins Flashcards

1
Q

How many stages in quintero staging system for TTTS

A

Stages 1 to 5

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2
Q

Complications seen in Monochorionic twins

A

Twin to twin transfusion syndrome TTTS
Single intrauterine death
Twin anaemia polycythemic sequence TAPS
Selective growth restriction SGR
Twin reverse arterial perfusion TRAP

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3
Q

What is twin to twin transfusion syndrome TTTS?

A

Unidirectional vascular artery-vein anastomoses in placental bed.
Causes haemodynamic imbalance within the twin circulation as one twin receives more blood than the other

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4
Q

Key features of TTTS on USS?

A

Significant amniotic fluid discordance - oligo DVP <2cm in donor and poly DVP >8cm in recipient
Discordant bladder appearances - no urine in donor fetal bladder
Haemodynamic and cardiac compromise in both twins

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5
Q

Stage 1 TTTS?

A

Oligohydramnios and Polyhydramnios
Donor bladder is visible

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6
Q

Stage 2 TTTS

A

Donor bladder not visible
Severe oligohydramnios due to anuria
Dopplers OK

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7
Q

Stage 3 TTTS

A

Doppler studies ABNORMAL
Donor has abnormal umb art doppler
Recipient has abnormal venous doppler (e.g. reversed flow in ductus venosis)

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8
Q

Stage 4 TTTS?

A

Ascites, pericardial/pleural effusion, scalp oedema, hydrops

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9
Q

Stage 5 TTTS?

A

One or both babies have died

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10
Q

How is TTTS treated?

A

Laser ablation of placental vascular anastomoses <26weeks

Amnioreduction is 2nd line

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11
Q

In treated TTTS, what is the follow up and delivery plan?

A

Weekly USS
Fetal cardiac USS
Deliver 34-36weeks

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12
Q

Morbidity in single intrauterine death in MC twins?

A

50% intact survivors
25% co-twin death
25% major neurological sequelae
MRI 4 weeks after twin death to look for co-twin brain damage

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13
Q

When to delivery uncomplicated MCDA

A

From 36 weeks

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14
Q

When to deliver MCMA twins?

A

32 weeks LSCS

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15
Q

What is selective growth restriction in MC twins?

A

EFW discordance of >20% due to differing placental territories between each twin

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16
Q

Classification of sGR (selective growth restriction)

A

Type 1, 2, 3

17
Q

Type 1 sGR

A

Growth discordance
Normal dopplers

18
Q

Type 2 sGR

A

Growth discordance
Absent or reversed end-diastolic velocities in 1/2 fetuses
Delivery by 32w

19
Q

Type 3 sGR

A

Growth discordance
Cyclical umbilical artery diastolic waveforms - positive>absent>reversed over minutes
Delivery by 32w

20
Q

Treatment for sGR in MC twins?

A

Laser ablation
Delivery if abnormal dopplers and >26w
Consider fetal reduction

21
Q

What is twin anaemic polycythaemia sequence TAPS?

A

A form of TTTS with discordance in Hb between twins but no significant amniotic fluid discordance.

Occurs due to slow transfusion of blood from donor to recipient through SMALL arteriovenous anastomoses

Occurs in 2% of MCDA twins.
More likely to occur after laser ablation for TTTS

22
Q

How to diagnose TAPS on USS?

A

Anaemic baby has raised MCA PSV, dilated heart
Polycythaemic baby has decreased MCA PSV, starry sky liver

23
Q

Which baby is more likely to have neurodevelopmental delay in TAPS?

A

Polycythaemic twin

24
Q

How to manage TAPS?

A

Laser ablation
IU blood transfusion
Deliver 30-32weeks

25
Q

What is twin reversed arterial perfusion TRAP sequence?

A

Acardiac twin is perfused by the other twin through a large arterial anastomosis on the placenta

26
Q

What proportion of MC twins does TRAP occur in?

A

1%

27
Q

Why is TRAP so bad?

A

50% of pump twins die before/after birth due to congestive heart failure

28
Q

How to treat TRAP?

A

Selective feticide of acardiac twin

29
Q

What is the lambda sign and what does it represent in a twin pregnancy?

A

Dichorionic twins - thicker and V shaped

30
Q

What is the T sign and what does it represent in a twin pregnancy?

A

Monochorionic twins - thinner membrane

31
Q

What proportion of twin pregnancies are monochorionic?

A

30%

32
Q

How do you perform combined screening in twins?

A

As normal
90% detection in DCDA twins
MC twins have a higher FPR because raised NT in one twin is an early manifestation of TTTS. Risk is calculated for each fetus and averaged.

33
Q

Risk of fetal death in MCMA twins?

A

Up to 70%

34
Q

Ultrasound regime for MC twins?

A

2 weekly from 16 weeks

MRCOG part 2 * (47 decks)

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