Multiple Pregnancy

Question 1

What are the predisposing factors for multiple pregnancy?

Answer 1

ART (clomiphene 10%, IUI 20%, IVF 30%)

Increasing maternal age

Increasing parity

Previous multiple pregnancy

Family history

Ethnicity

Question 2

What are the types of multiple pregnancy?

Answer 2

2/3 Dizygotic
(Variable rate, autosomal recessive , higher maternal age and multiparity)

1/3 Monozygotic
(constant worldwide rate)

<3 days. DCDA 30%
4-7 days. MCDA 70%
8-12 days. MCMA <1%
>12 days. Conjoined twins

Question 3

What is the best time for USS to assess chorionicity?

Answer 3

Late 1st trimester @ 6-9 weeks

Estimate gestational age with the larger fetus

Establish chorionicity

Screen for Down’s syndrome

Question 4

How do you establish chorionicity in a multiple pregnancy?

Answer 4

USS

Number of placental masses
Lambda sign
T sign
Membrane thickness 
Discordant fetal sex

Question 5

What are the complications of multiple pregnancy?

Answer 5

High maternal mortality & morbidity

High perinatal mortality and morbidity

MATERNAL
Hyperemesis 
Anemia 
PTL
PIH / PET
GDM
PP
APH
PPH
Polyhydramnios
Thromboembolism
Decompensation of pre-existing disease

FETAL
Miscarriage 
PTB
Congenital anomalies 
Vanishing twin / IUD
IUGR
TTTS
TRAP
CP
TAPS

Question 6

What are the maternal complications of multiple pregnancy?

Answer 6

Hyperemesis 
Anemia 
PTL
PIH / PET
GDM
PP
APH
PPH
Polyhydramnios
Thromboembolism
Decompensation of pre-existing disease

Question 7

What are the fetal complications of multiple pregnancy?

Answer 7

Miscarriage 
PTB
Congenital anomalies 
Vanishing twin / IUD
IUGR
TTTS
TRAP
CP
TAPS

Question 8

When would you deliver multiple pregnancies?

Answer 8

TWIN
36+0 for monochorionic (dexa)
37+0 for dichorionic
Don’t go beyond 38+0

TRIPLET
35+0 after dexa

Question 9

How would you deliver a twin pregnancy?

Answer 9

Offer elective delivery
MOD
VD if twin 1 is cephalic, weighs less than twin 2, and no complications in pregnancy
LSCS for all others

Prepare the mother, inform the MDT, reserve blood, reserve US and OT

Intrapartum care
Maintain partogram 
Continuous CTG for both fetuses 
Epidural anesthesia and IV access
Episiotomy 
ARM for twin 1, can augment with oxytocin 

Confirm twin 2 presentation
If non-cephalic, attempt ECV or IPV
Continue oxytocin and wait for engagement
ARM for twin 2 and deliver

Active management of 3rd stage of labor
Monitor for PPH
Episiorraphy

Post natal advice on breastfeeding

Question 10

What are the complications specific to monochorionic pregnancy?

Answer 10

TTTS
TRAP and acardiac twin
Cord entanglement
Conjoint