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Multiple gestation Flashcards

1
Q

what is multiple gestation

A

presence of more than one fetus in the uterus at the same time

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2
Q

how is multiple gestation classified (4)

A
  1. Number of fetuses (twins, triplets, quadriplets)
  2. Number of fertilized eggs: Zygosity
  3. Number of placentae: Chorionicity
  4. Number of amniotic cavities: Amnionicity
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3
Q

what are the 2 types of twin pregnancy

A
  1. Dizygotic twins (70 – 80%), resulting from fertilization of two ova leading to fraternal twin.
  2. Monozyogotic twins (20 – 30%), resulting from fertilization of one ovum followed by splitting of developing zygote leading to identical twin.
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4
Q

what are the types of monozygotic (3)

A
  1. Monochorionic diamniotic 70-75% (MCDA)
  2. Dichorionic diamniotic 25-30% (DCDA)
  3. Monochorionic monoamniotic 1-2% (MCMA)
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5
Q

all monochorionic pregnancies are what

A

monozygotic

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6
Q

not all dichorionic pregnancies are what

A

dizygotic

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7
Q

In M-DCDA when does the egg split

A

day 1-3

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8
Q

In M-MCDA when does the egg split

A

day 4-8

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9
Q

In M-MCMA when does the egg split

A

day 9-12

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10
Q

for conjoint twins when does the egg split

A

day 13-15

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11
Q

what are risk factors for multiple gestation (5)

A
  1. Assisted reproductive techniques
    - In vitro fertilisation
    - Use of fertility medications (clomiphene)
  2. Maternal family history
  3. Race
    - High in African women
  4. High parity (5 gravida onwards)
  5. Increased maternal age (30 – 35 yrs)
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12
Q

what in the history can help you diagnose multiple gestation (6)

A
  1. Hx of ovulation inducing drugs
  2. Maternal family hx of twins
  3. Increase nausea and vomiting in early months
  4. Palpitations or SOB (anemia)
  5. Leg swelling and/or hemorrhoids
  6. Unusual rate of abdominal enlargement
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13
Q

what things on your clinical exam can help you diagnose multiple gestation (5)

A
  1. Signs of anemia
  2. Barrel shape abdomen
  3. SF size/GA discrepancy
  4. Palpation of too many fetal parts
  5. Two distinct fetal heart sounds at separate spots with a silent area in between
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14
Q

how can you tell multiple gestation on sonography (5)

A
  • different fetuses genders
  • number of placentae
  • placenta location
  • T sign
  • lambda sign/ twin peak signwh
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15
Q

when is it most reliable to do a scan for twin gestation to see the gestational sacs

A

6-10 weeks

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16
Q

when is the lambda/twin peak sign best seen

A

11-14 weeks

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17
Q

why is it hard to see dividing membranes as gestation increases

A

the dividing membranes get thinner

18
Q

in twin pregnancy what is a major determinant of pregnancy outcome

A

chorionicity

19
Q

T sign (monochorionic shared placenta) is seen in what type of twin

20
Q

what type of twin do you see the lambda sign (fused dichorionic placenta)

21
Q

what are ddx for multiple pregnancy (5)

A
  1. inaccurate menstrual hx
  2. macrosomic baby
  3. polyhydraminos
  4. molar pregnancy
  5. fibroid in pregnancy
22
Q

what are possible maternal complications of multiple gestation (7)

A
  1. Hyperemesis
  2. Abortion
  3. Anaemia
  4. Abruption
  5. Hypertensive disorders of pregnancy
  6. Thromboembiolism
  7. PPH
23
Q

what are the fetal complications of D-DCDA and M-DCDA (6)

A
  1. Preterm birth
  2. Growth restriction
  3. Mal presentation
  4. Vanishing twin
  5. IUFD of one twin
  6. Perinatal mortality
24
Q

what are the fetal complications of M-MCDA (8)

A
  1. Preterm birth
  2. Growth restriction
  3. Mal presentation
  4. Vanishing twin
  5. IUFD of one twin
  6. Perinatal mortality
  7. Twin -twin transfusion syndrome
  8. Fetal anomalies (all organ systems)
25
what are fetal complications of M-MCMA (10)
1. Preterm birth 2. Growth restriction 3. Mal presentation 4. Vanishing twin 5. IUFD of one twin 6. Perinatal mortality 7. Twin -twin transfusion syndrome 8. Fetal anomalies (all organ systems) 9. Cord entrapment 10. Conjoining
26
fetal growth restriction in multiple gestation can be what (2)
- discordant - concordant
27
what is the risk of IUGR in DCDA
25%
28
what is the risk of IUGR in MC
50%
29
what things should you think of in the management of FGR (3)
1. Balance the risk of iatrogenic preterm delivery for a single growth restricted fetus. 2. Generally, avoid delivery before 28-30weeks 3. For MC twins, IUFD may lead to death or severe handicap of the co-twin - Prefer delivery before IUFD of growth restricted twin
30
what causes twin to twin transfusion syndrome (2)
- Due to abnormal placental vascular anastomoses - Unbalanced AV connections in one direction result in TTTS
31
who does TTTS occur in
Unique to MC twins - 10% MCDA - 5% MCMA
31
in TTTS the donor twin has predominantly what
arteries
32
in TTTS the recipient twin has predominantly what
veins
33
what risks can occur to the donor twin (5)
1. anemic 2. growth restricted 3. hypovolemic 4. oligohydraminos 5. renal failure
34
what risks can happen to the recipient twin (4)
1. polycythemic 2. polyhydraminos 3. heart strain (congestive HF) 4. high blood pressure
35
what is the criteria for dx TTTS (5)
1. Single placenta mass 2. Same gender 3. Oligohydramnios in one twin and polyhydramnios in the other 4. Discordant bladder appearences 5. Haemodynamic and cardiac compromise
36
what is the quintero severity grading for TTTS (5)
Stage 1 - Oligohydramnios and polyhydramnios sequence - Bladder of donor twin visible - Dopplers normal in both twins Stage 2 - Oligohydramnios and polyhydramnios sequence - Bladder of donor twin not visible - Dopplers normal in both twins Stage 3 - Oligohydramnios and polyhydramnios sequence - Bladder of donor twin not visible - Abnormal dopplers AEDF/REDF in UAD Stage 4 - Signs of hydrops in one or both fetuses Stage 5 - Death of one or both fetuses
37
how can you manage TTTS (6)
1. Expectant 2. Amnioreduction 3. Septostomy 4. Selective feticide 5. Laser ablation of anastomoses - Definitive Rx for TTTS stage 2 and above 6. Preterm delivery (above 28weeks
38
what is the antenatal care for multiple gestation (5)
1. order uss - for dating, chorionicity and amnionicity as early as possible . - for anatomy and/or anomalies at 18-20 wks gestation - every 2-3 weeks after 28 wks gestation for growth, Doppler if discordant growth - For growth discordance > 20%, refer to Central Hospital. 2. frequency of ANC visits - Same as for singleton in first trimester - More frequent after 20weeks - DC twins - 4 weekly until 28 weeks - 2 weekly 28-36weeks - Weekly 36-38 weeks 3. MC twins - Refer to Central Hospital - Steroids at 28weeks - Inpatient care with daily CTG from 28weeks till delivery - Plan delivery at 32-34 weeks 4. Nutrition and medications - extra daily caloric needs of 600 kcal - Encourage normal balanced diet - Ensure iron supplementation - Prophylactic dexamethasone between 28 and 34 weeks 5. One antenatal fetal death - Admit to inpatient ward for expectant management - Monitor for maternal complications of IUFD including infection or DIC - Monitor fetal well-being of surviving twin
39
when is c/s indicated in multiple gestation (5)
1. If breech or transverse 2. Cord prolapse of the leading twin 3. Previous caesarean section 3. Triplets (or higher order pregnancy) 4. Twin with complications: IUGR, conjoint twins 5. MC twins

Obs&Gynae (24 decks)

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