Multiple Gestations

Question 1

Risk factors of multiple gestations

Answer 1

IVF
Maternal age
Family History
Black race

Question 2

Classifying multiple pregnancies is based on…

Answer 2

of fetus
# of fertilized eggs (Zygosity)
# of placenta (chorionicity)
# of amniotic cavities (amniocity)

Question 3

Fraternal twins (non-identical)

Answer 3

Dizygotic
Dichorionic
Diamniotic

Question 4

Monozygotic twins (Identical)

Answer 4

Monozygotic
Same-sex
Mono/Di chorionic
Mono/Di amniotic

Question 5

Etiology of dizygotic twins

Answer 5

IVF
Induction
Familial
Racial

Question 6

Types of monozygotic depends on

Answer 6

when split occurs

Question 7

If monozygotic split occurs within 3 days of conception

Answer 7

Pregnancy will be
Dichorionic
Diamniotic

Question 8

If monozygotic split occurs within 4-8 days, pregnancy will be

Answer 8

monochorionic
diamniotic

Question 9

Maternal and fetal effects of multiple gestation

Answer 9

Maternal: physio changes are exaggerated
Fetal: monochorionic placenta has unique ability to develop vascular connection btwn fetal circulations (increases complications)

Question 10

Complications of multiple gestation

Answer 10

1. Miscarriage + Severe preterm
2. Increased Perinatal mortality
3. Increased stillbirths in monochorionic pregnancies
4. Death of one fetus

Question 11

The avg Gestational age @ delivery for multi-preg

Answer 11

37 wks

Question 12

Percentage of twins born preterm

Answer 12

50%

Question 13

Percentage of babies requiring NICU in twin pregnancy

Answer 13

20-25%

Question 14

Perinatal mortality is how many times higher in multiple gestation

Answer 14

5.5 times higher than singleton

Question 15

The intrauterine death of one twin in the first trimester increases the chance of

Answer 15

poor outcome for co-twin and complications (DIC)

Question 16

Mono/ DI chorionic differences in death of one fetus

Answer 16

Dichorionic: death of one twin in 2nd or 3rd tri. associated with onset of labour

Monochorionic: death of one twin leads to complications , death and/or brain damage in survivor twin (30%)

Question 17

Mono/Di chorionic differences in FGR multiple pregnancies

Answer 17

Dichorionic : x2 the risk of low fetal birth weight. avoid delivery before 28-30 wks.

Monochorionic: death of one twin results in handicap or death of co twin due to secondary hypotenstion to placental anastamoses.
Prolong delivery without risk to co-twin

Question 18

Di/Mono chorionic differences in Fetal anomalies

Answer 18

Dichorionic: x2 risk of structural anomalies like spina bfida

Monochorionic: x4 risk of anomalies

Question 19

Management of Multi pregnancy where one fetus has anomaly

Answer 19

Monitor and manage accordingly or fetocide given in lethal conditions where healthy twin is @ risk (ex: Anacephaly causing polyhydramnios and preterm labour of both)

Question 20

Chromosomal anomalies in monozygotic twins

Answer 20

Anomaly will effect both or neither due to identical genetic make up

Question 21

Complication of Monochorionic pregnancy

Answer 21

Placental vascular anastomoses allows communication between to feto-placental circulations.
Imbalance of bloodflow leads to Twin to Twin Transfusion Syndrome

Question 22

Twin to Twin transfusion syndrome

Answer 22

One twin is overperfused and other is under-perfused

Question 23

What happens to underperfused twin in TTTS

Answer 23

hypovolemic, oliguric, oligohydramnios

Question 24

What happens to overperfused twin in TTTS

Answer 24

hypervolemic, polyuria, polyhydramnios, myocardial damage, high output cardiac failure

Question 25

Diagnosing TTTS

Answer 25

via U/S in 2nd trimester. Over perfused baby will have increased abdominal girth

Question 26

Treatment of TTTS

Answer 26

Amniocentesis every 1-2 wks prolongs pregnancy and increases survival Fetoscopal laser coagulation to disrupt communication

Question 27

Complication of monoamniotic

Answer 27

Increase in cord accidents. Opt for CS @ 32-34 wks

Question 28

Differential Diagnosis of Multi Preg

Answer 28

Any large for date preg Polyhydramnios Uterine fibroids Urinary retention Ovarian masses

Question 29

Antenatal Managment of multi preg

Answer 29

Routine care: HTN + Gestational DM more likely in multiple pregnancy ROutine supplementation of iron and folic acid due to increase in demand

Question 30

When and how to determine chorionicity

Answer 30

via U/S in late first trimester (10-12wks). Dichorionic= V shaped extension of placentaltissue into base of inter-twin membrane (lambda or twin peak) Monochorionic : T shape

Question 31

Test for fetal abnormalities

Answer 31

Trisomy 21 @ 12 wks Rest optimally @ 20wks

Question 32

Monitoring of fetal growth + wellbeing done via

Answer 32

U/S including fetal measurement, activity, lies and amniotic fluid volume

Question 33

Signs of TTTS via U/S

Answer 33

Difference in 1. fetal size 2. fetal activity 3. bladder volumes 4. amniotic fluid 5. cardiac size

Question 34

Threatened preterm labour

Answer 34

Maternal steroid therapy (fetal lung) Educate on signs of preterm labour Advanced planning Screen for strep B

Question 35

Diagnosing preterm labour via

Answer 35

Transvaginal/Cervical U/S most promising predictor

Question 36

Intrapartum prep

Answer 36

Twin CTG portable U/S for delivery Standard oxytocin IV for 2nd twin Second higher oxytocin dose in case of PPH 2 neonatal resucitation sets 2obstetricians + 2 paediatricians

Question 37

Analgesic given in Multi-preg labour

Answer 37

Epidural recommended, kept running through second stage of labour

Question 38

Fetal well-being during labour

Answer 38

Monitor FHR continuously abnormal HR assessed via scalp sampling. Abnormal HR in 2nd baby-> CS (watch for cord prolapse or placenta separation)

Question 39

Vertex-Vertex Delivery how to assess lie of 2nd baby

Answer 39

via abdominal palpation and U/S

Question 40

If lie is cephalic (vertex-vertex)

Answer 40

wait for descent of head then amniosotomy w/ contractions

Question 41

When to give oxytocin in vertex vertex delivery

Answer 41

If no contractions after 1st baby for 5-10 mins

Question 42

If 1st baby cephalic, 2nd breech

Answer 42

Breech extraction can be performed

Question 43

If 2nd baby is transverse

Answer 43

Perform ECV if fails internal podalic can take place, rupture membrane as late as possible

Question 44

Non vertex 1st twin

Answer 44

ELective CS

Question 45

Requirements of twin delivery

Answer 45

Large room Operating theatre ready Anaesthesiologist present Senior Obs 2 midwives Twin resucitation Forceps at hand Blood IV access Neonatologists Oxytocin infusions

Question 46

Postpartum Haemorrhage

Answer 46

Increased risk in multi pregnancies. High dose of oxytocin given after delivery as prophylaxis

Question 47

Higher multiples (3+ babies)

Answer 47

IVF main cause Increased risks Median G.A= 33wks CS usually