Multi-foetal Gestations

Question 1

How is chorionicity and amnionicity determined?

Answer 1

On ultrasound look for:
- the number of placental masses
- the presence of amniotic membranes and membrane thickness
- lambda (di) or t-sign (mono)
- discordant fetal sex (di)

Question 2

When and how should chorionicity and amnionicity be determined?

Answer 2

11 - 13+6 weeks using transabdominal u/s or transvaginal if views w/ transabdominal are poor (retrofitted uterus/maternal obesity)

Question 3

Next step if difficulty ascertaining chorionicity and amnionicity on u/s?

Answer 3

T1 u/s should be done by an experienced sonographer. If difficulty determining refer to an experienced sonographer for a second opinion and repeat u/s.

If difficulty still, manage the pregnancy as mono/mono until proven otherwise.

Question 4

T/F anaemia risk is increased in multifetal pregnancy.

Answer 4

True. A CBC at 20-24wks is done due to increased risk of anaemia.
- give iron or folic acid
supplements
Rpt CBC at 28wks as per routine schedule

Question 5

Who comprises the antenatal team?

Answer 5

These patients will require a multidisciplinary team with a core team made up of of Specialist individuals with experience managing multi-feral pregnancies:
Specialist Obstetrician
Specialist midwives
Specialist sonographer

An enhanced team for referrals may be required dependent on the patient’s needs:
Mental health professional
A woman’s health physiotherapist
Infant feeding specialist

Question 6

Describe intrapartum care?

Answer 6

Intrapartum care for multi-foetal gestational should be managed by and MDT of Obstetricians and midwives with experience managing multi-fetal pregnancy.

Question 7

What is the ANC visit schedule for uncomplicated di-di gestation?

Answer 7

Offer at leastb8 visits, 2 if which ate with a specialist Obstetrician.

Combine appointments with u/s scans at:
- 11+2 to 14+1 (crl 45-85mm) to determine chorionicity/amnionicity
- 20, 24, 28, 32, 36 wks
(Q4wkly from 20 wks)

• Offer additional appointments w/o scans at 16 and 34 weeks

Question 8

What is the ANC visit schedule for uncomplicated monochorionic-diamniotic gestation?

Answer 8

Offer atleast 11 ANC visits, at least 2 with a specialist obstetrician.

Combine appointments with u/s scans at:
- 11+2 to 14+1 (crl 45-85mm) to determine chorionicity/amnionicity
- 16, 18, 20, 22, 24, 26, 28, 30, 32 and 34 wks
(Q2wkly from 16 wks)

Question 9

What is the ANC visit schedule for uncomplicated triplet gestation (tri/di/monochorionic)?

Answer 9

Tri/tri gestation:
Offer at least 9 visits, with 2 by specialist obstetrician.

Combine appointments with u/s scans at:
- 11+2 to 14+1 (crl 45-85mm) to determine chorionicity/amnionicity
- 20, 24, 26, 28, 30, 32 and 34 wks
(Rpt assessment 1 month after 20 weeks then Q2wkly from 24 wks)
- offer an additional visit w/o scan at 16 weeks

Dichorio/triamniotic OR monochorio/triamniotic:
- Offer atleast 11 ANC visits, atleast 5 should be with the specialist obstetrician.
-Combine appointments with u/s scans at:
- 11+2 to 14+1 (crl 45-85mm) to determine chorionicity/amnionicity
- 16, 18, 20, 22, 24, 26, 28, 30, 32 and 34 wks
(Q2wkly from 16 wks)

Question 10

How should Twin and Triplet pregnancies with a shared amnion be managed?

Answer 10

These patients should receive individualized care from a consultant in a tertiary level Fetal medicine centre.

Question 11

How should multifetal gestations be screened for chromosomal abnormalities how is the mother counselled?