Twins and Malpresentation

Question 1

What is Multiple Gestation?

Answer 1

Any pregnancy where the uterus is occupied by 2+ fetus/embryos

Question 2

What has increased the incidence of multiple gestation?

Answer 2

Assisted reproductive technology

Question 3

What are the risks for having Dizygotic (fraternal) Twins?

Answer 3

• Family history

- Maternal age > 35

Question 4

What are the risks for having Monozygotic (identical) Twins?

Answer 4

Frequency is constant across all populations

Question 5

Dizygotic (fraternal) Twins

Answer 5

2 ova are fertilized by 2 separate sperm

Question 6

How will the setup be in the uterus for Dizygotic (fraternal) twins?

Answer 6

Dichorionic Diamnionic

Question 7

Monozygotic (identical) Twins

Answer 7

Cleavage of 1 ova that was fertilized by 1 sperm

Question 8

What does the setup in the uterus depend on for Monozygotic Twins?

Answer 8

The time at which cleavage (separation) occurs

Question 9

If Monozygotic twins split between 0-3 days, what is the setup?

Answer 9

Dichorionic Diamnionic

Question 10

If Monozygotic twins split between 4-8 days, what is the setup?

Answer 10

Monochorionic Diamnionic

Question 11

If Monozygotic twins split between 9-12 days, what is the setup?

Answer 11

Monochorionic Monoamnionic

Question 12

If Monozygotic twins split after 13 days, what is the setup?

Answer 12

Conjoined twins

Question 13

What is the most common setup in the uterus for Monozygotic (identical) twins?

Answer 13

Monochorionic Diamnionic (split at 4-8 days)

Question 14

What is the most dangerous setup for Monozygotic twins and why?

Answer 14

Monochorionic Monoamnionic (split between 9-12 days)
=> risk of cord entanglement

Question 15

If Conjoined Twins are present, where are the usually attached?

Answer 15

(>13 day split)

- Joined at chest wall (thoracopagus)

Question 16

Why is it important to determine Zygosity?

Answer 16

Major factor for prognosis and morbidity of twins

Question 17

Which Zygosity is at the highest risk for issues and abnormalities?

Answer 17

Monozygotic Twins

Question 18

How do you determine Zygosity?

Answer 18

Ultrasound

Question 19

How do you determine Zygosity?

Answer 19

Ultrasound

Question 20

What will be seen on ultrasound with Dizygotic Twins?

Answer 20

• 2 genders maybe

- Thick amnion-chorion septum with a peak/inverted V at base

Question 21

If you see a thick amnion-chorion septum with a peak/inverted V at the base, what zygosity are the twins?

Answer 21

Dizygotic (fraternal)

Question 22

What will be seen on ultrasound with Monozygotic Twins?

Answer 22

THIN dividing membrane

Question 23

If you see a thin dividing membrane on ultrasound, what zygosity are the twins?

Answer 23

Monozygotic (identical)

Question 24

If ultrasound is unable to determine zygosity of the twins, what are 2 other ways?

Answer 24

DNA analysis

Inspection of the placenta after delivery

Question 25

Twin Twin Transfusion Syndrome is an abnormality seen with Identical twins. How does it occur?

Answer 25

Arteriovenous malformation deep in monochorionic placenta | => net transfer of blood flowing from 1 twin to the other

Question 26

Donor twin attributes with TTTS

Answer 26

Hypovolemia Hypotension Anemia Decreased growth

Question 27

Recipient twin attributes with TTTS

Answer 27

``` Hypervolemia Hypertension Polycythemia Polyhydramnios Edema ```

Question 28

What are BOTH twins at risk for with TTTS?

Answer 28

Demise due to heart failure

Question 29

What will the donor twin look like on ultrasound with TTTS?

Answer 29

Small and oligohydramnios

Question 30

What will the recipient twin look like on ultrasound with TTTS?

Answer 30

Polyhydramnios and large

Question 31

How do you treat TTTS?

Answer 31

Laser photocoagulation of anastomosing vessels

Question 32

Acardiac twin is an abnormality that can be seen with Identical twins. How does it arise?

Answer 32

Arterial to Arterial anastomoses | => Arterial blood from one twin enters arterial circulation of other twin

Question 33

Which twin is the Acardiac twin?

Answer 33

Recipient twin | -- receives blood from other twins artery

Question 34

The Acardiac twin is perfused with poorly oxygenated blood and fails to develop. How will it present?

Answer 34

Fully formed LE | NO structures above the abdomen

Question 35

With Retained Dead Fetus Syndrome, it involves single fetal death. What occurs if gestation is before and after 12 weeks gestation respectively?

Answer 35

< 12 weeks = dead fetus resorbed = "vanishing twin syndrome" | > 12 weeks = dead fetus flattened and shrinks = "fetus papyraceus"

Question 36

When should Monoamniotic Twins delivery and why?

Answer 36

32 weeks | -- cord entanglement risk

Question 37

A Majority of twins delivery around 35/36 weeks. When should you recommend they are delivered by?

Answer 37

38 weeks

Question 38

What is the best and normal presentation for delivery of twins?

Answer 38

Vertex - Vertex

Question 39

What is the most favorable presentation of twins for vaginal delivery?

Answer 39

Vertex - Vertex

Question 40

Which 2 presentations for twins can potentially be delivered by vaginal or C-section?

Answer 40

Vertex - Transverse | Vertex - Breech

Question 41

Which 2 presentations for twins can NOT be delivered vaginally and must be delivered by C-section?

Answer 41

Breech - Vertex | Breech - Breech

Question 42

What is Fetal Malpresentation?

Answer 42

Any fetal position other than Vertex!

Question 43

What is the most common fetal malpresentation?

Answer 43

Breech

Question 44

Frank Breech

Answer 44

Hips are flexed and knees extended up | -- most common

Question 45

Complete Breech

Answer 45

Hips are flexed and knees are flexed

Question 46

Incomplete Breech

Answer 46

1 or both hips are extended with 1 or both feet below butt

Question 47

Breech occurs with the fetal butt or LE presents into the maternal pelvis. What is a major associated factor?

Answer 47

Prematurity

Question 48

With a breeched baby, what can you try at 36 weeks if there are no contraindications?

Answer 48

ECV | = External Cephalic Version

Question 49

What is External Cephalic Version?

Answer 49

With a breeched baby, apply pressure to mom's abdomen to turn the fetus to achieve Vertex position

Question 50

What are 2 contraindications for performing External Cephalic Version?

Answer 50

Placenta Previa | Non-reassuring fetal monitoring

Question 51

What is the most common delivery option for a breeched baby? What can you do but is risky?

Answer 51

Usually = C-section | -- Vaginal delivery is possible but risky

Question 52

In order to do a vaginal delivery of a breeched baby, it must be frank/complete and head flexed. Describe the steps.

Answer 52

- Delivery to scapulae - ER of each thigh with pelvis rotation to delivery legs - Push arms to chest to deliver arms - Maintain head flexion with pressure on fetal MAXILLA

Question 53

Where should you maintain pressure on the fetus with a breeched vaginally delivery to ensure head flexion? What forceps can be used?

Answer 53

Pressure on the maxilla | -- Piper forceps can be used for head flexion

Question 54

Brow Malpresentation

Answer 54

Presenting part is between facial orbits and anterior fontanelle

Question 55

Face Malpresentation

Answer 55

Extension of neck and head to where baby's occiput is against upper back

Question 56

With Face Malpresentation, when can you deliver vaginally?

Answer 56

Mentum (chin) ANTERIOR

Question 57

Compound Malpresentation

Answer 57

Fetal extremity is prolapsed alongside presenting fetal head

Question 58

Fetal extremity is prolapsed alongside presenting fetal part, usually the head

Answer 58

Compound Malpresentation

Question 59

How should most Malpresentations be delivered?

Answer 59

C-section

Question 60

How should you delivery a Face Malpresentation with Mentum Posterior?

Answer 60

C-section