Twins and APH Flashcards
When the fundal height reaches the umbilicus what gestation is the fetus?
20 weeks
When the fundal height is at the symphysis pubis how many weeks gestation?
12 weeks
When the fundal height is at the xiphysternum how many weeks gestation?
36 weeks
Causes of baby being large for dates at 12 weeks?
wrong dates, twins, hydatiform mole, fibroids, full bladder, ovarian cyst
How do you check the gestational age of the fetus below 14 weeks and above 14 weeks?
Below = CRL Above = HC and BPD
What does dichorionic and diamniotic mean?
Dichorionic = have their own placentas Diamniotic = have their own sacs
If monozygotic twins occur before day 3 after fertilisation, what type of pregnancy will form (30% of cases)?
Dichorionic Diamniotic
If monozygotic twins occur between day 3-9 after fertilisation then what pregnancy will form (70% of cases)
Monochorionic Diamniotic
If monozygotic twins occur between day 9-12 after fertilisation then what pregnancy will form (less than 1%)
Monochorionic Monoamniotic
If monozygotic twins occur after day 12 of fertilisation then what pregnancy will form?
Conjoined twins
What is the lambda sign on USS of a twin pregnancy?
Thich V shaped echogenic area at the edge of the placental membrane to represent the thick dividing membrane made up of 2 chorions and 2 amnions
What is the T sign on USS of a twin pregnancy?
Representing the thing dividing membrane seen on USS of the 2 amnions and no chorion present in MCDA twins?
How much higher is perinatal mortality in twin pregnancies?
10 times higher
What are twin pregnancy risks of twins?
Stillbirth, premature rupture of membranes, IUGR, congenital abnormalities, Prematurity, fetal death, Cord accident, cerebral palsy in babies, low apgar scores
During the first trimester carrying a twin pregnancy, what are the potential maternal risks assocaited?
Vanishing twin syndrome, increased risk of miscarriage, increased pregnancy symptoms and potentially hyperemesis gravidarum
What maternal risks are associated with a twin pregnancy in the second and third trimester?
Hypertension and preeclampsia, Pressure symptoms and back ache, breathlessness, UTI, anaemia, preterm labour and delivery, APH,polyhydramnios
What do you need to monitor for development of within a twin pregnancy?
PIH
What supplementation is given from second trimester in twin pregnancy?
Folic acid and iron
When are growth scans started during a twin pregnancy?
Serial growth scans 24 weeks onwards
Difference between arterioarterial and venovenous anastomoses in TTTS compared to arteriovenous
Arterioarterial and venovenous are both bidirectional and superficial whereas arteriovenous is unidirectional and deep allow blood to directly pour from one twin to the other
Unidrectional vs bidirectional TTS?
unidirectional is dangerous (arteriovenous anastomoseS) compare to bidirectional which is protective (AA or VV)
What happens to the donor twin in TTTS?
Anaemia, hypovolaemia, growth restriction, oligouria, oligohydramnios
What happens to the recipient twin in TTTS?
Polycythaemia, hypervolaemia, polyuria, polyhydramnios, hydrops fetalis
How is TTTS diagnosed and monitored for its development during a MCDA/MCMA pregnancy?
2 weekly USS scan between 16-24 weeks
In minor placenta pravia detected at the anomaly scan, how is it managed?
Another scan at 36 weeks to check for placental migration
In major placenta praevia detected at the anomaly scan, how is it managed?
Another scan at 34 weeks and management plan
What are the 4 grades of placenta praevia and which are major and minor classified?
Grade 1 is placenta doesn’t reach cervical os but is low lying - minor
Grade 2 is placenta reaches cervical os but doesn’t cover - minor
Grade 3 is placenta covers part of cervical os - major
Grade 4 is cervical os is completely covered by placenta - major
Risk factors for placenta praevia?
Previous CS, parity, age, smoking, cocaine, history of, history of miscarriage
Maternal risks caused by placenta praevia?
PPH, CS risks, surgical risks, placenta accreta, post partum sepsis
Risks to fetus caused by placenta praevia?
preterm birth, growth restriction, congenital malformation
Who needs to be informed in cases of placenta praevia?
Blood bank
Questions to ask about in case of PV bleeding during known placenta praevia?
Quantity of blood, character of bleeding (are they still bleeding? sudden or gradual onset?), has this happened before during the pregnancy, any pain associated with the bleeding, any uterine contractions, Initiatin factors (any trauma? coitus?)
How do you initially manage a patient who has PV bleeding during placenta praevia?
2 IV wide bore cannulas inserted, take bloods - FBP, U&E, coag screen, keihauer, cross match. IV fluids, consider group o neg transfusion if taking to long with the crossmatch. Anti D if she is rh neg (plus more if kleihauer is positive)
4 Ts that can cause APH?
Tone - uterine laxity due to multiparity or overdistension of uterus
Tissue - retained placenta
Thrombus - retained placenta
Trauma - episiotomy, lacerations, tears, cervical injury
What monitoring does the mother need if she is experiencing PV bleeding during pregnancy?
Obs, shock symptoms - clammy hands, cold peripheries, decreased skin turgor, restless, lie and presentation of fetus, vaginal exam with speculum (not in placenta praevia) USS to see placental site and any retroplacental clots
Fetal monitoring required when PV bleeding is evident?
CTG, USS of fetal heart, fetal movements
Differentials of placenta praevia?
Placental abruption, cervical lesions, premature labour, infection, trauma
What signs suggest the mother is experiencing placental abruption and not placental praevia?
Shock more than BP suggests or less bleeding than BP drop suggests, marked pain, decreased fetal movements
What signs suggest the mother is experiencing placenta praevia PV bleeding rather than placental abruption?
Large amount of blood passed in keeping with BP drop, painless, normal fetal movements, if shock is present it is in keeping with blood loss
What is vasa praevia? symptoms? key sign?
umbilical cord blood vessels passing by internal cervical os, bleeding can be variable, not usually in shock but painless and key feature is decreased/absent fetal movements
Initial management of heavy PV bleeding during pregnancy?
admit for obs, steroids in case, no tocolytics, anticoagulation if high risk VTE, stockings regardless
How do you confirm placenta accreta? what do you need to inform and prepare with the patient?
MRI, colour doppler, potential hysterectomy, uterine artery embolization, internal iliac artery ligation
Placenta praevia what are you expecting?
Massive obstetric haemorrhage
How does a CS placenta accreta delivery differ to a normal CS?
Different consent, potential for hysterectomy, senior anaethetist/obstetrician/gynaecologist, cross matched blood, HDU informed, neonatologist, radiologist
Mechanical methods of labour induction?
artificial rupture of membranes, cervical sweep, membrane sweep
What pharmacological methods of labour induction are there?
Oxytocin (after membrane sweep), prostaglandins
