Multiple pregnancies

Question 1

What is meant by multiple pregnancies

Answer 1

Pregnancy involving more than 1 foetus
RF- old, IVF, previous
occcurs 1 in 80 preg

Monozygous- division of 1 egg-identical -20%
25% split at 0-4 days- 2 placenta/2sacs- Delta sign on Ix
75% split at 4-8days- 1placenta 2 sacs- T sign
1% split at 8-12d- 1 placenta 1 sac- T sign, entangled cords
<1% split after- cojoined

Dizigous- fertilisation of 2 ovums by 2 sperms- non identical- 80% of twins
seperate everything

Question 2

“sx” and Ix of multiple pregnancies

Answer 2

1st trimester USS when CRL 45-84 (11-13w) to determine gestational age, chorionicity, downs syndrome
(use largest to estiamte gestational age)

Chorionicity- refers to type of placentaions (what matters)- 1 or 2 placentas
USS
examine junction betewen interfetal membrane and placenta
–Dichiorionic- delta sign (triangulr tissue proj)
MC- no tissue prokection (T Signs)

“Sx”- 1st trim- incidental, emesis
2nd- large tummy, multiple parts on abdo exam

Question 3

PReterm management of multiple pregnancies

Answer 3

If no complications–
FBC at 20-24w- query extra nutrients- folic acid/supplemtns
BP (increase pre-eclampsia), GTT (increased Diabees change)

TTTS monitor/growth scans- 16w then every 2w for shared placentas
202 then every 4 for non shared placentas
dichorionic triplets count as SHARED

specialist- monochorionic- seen by obstetrician 2x and 9x healthcare
Dichorionic- 8x healcare, 2x obstetrician
monochorionic/dichorionic triplets 11x healthcare, 2x obs
Trichiorionic triplets- 7x scans 2x obs

Question 4

management pre-term and term birth of multiple pregnancies

Answer 4

PTL- 60% of twins-
preventing- no use those-
Bed rest at home, IM/vaginal progesterine, cervical cerclage, oral tocolytics
corticosteroids- useful if PTL likely

At borth-
most before 37w
offer continuous CTG
Offer ellective birth -if decline see obs every week

vaginal delivery- 1st baby cephalic, 2nd can be breech but thats ok
can turn 2nd with internal cephalic version

Question 5

Complications of multiple pregnancies

Answer 5

Foetal complications-
IUGR -one can be SGA and other LGA- monitor- if 20% difference bad
Downs syndrome
Structural abnormalitie
Twin to twin tranfsuion syndrome (TTTS)
Intrauterine death

Maternal-
nmore pre-eclampsia, diabetes
hyperemesis gravidarum
APH/PPH
aneamia, thrombocytopenia

Question 6

Mx of complications of multiple pregnancies

Answer 6

TTTS- twin to twin transfusion syndrome
only in monochorionic-
Sx- suddent abdo increase size, SOB
why USS every 2weeks

Mx-
used to be amnioreduction
New- <26w- foetoscopic laser ablation or vascular anastamosis
>26w -delivert

Selective growth restriction-
selective reduction may be option if earlyy
surveillance scan 2w
abnormal doppler- indication for delivery