T2 L15 Multiple pregnancy

Question 1

Describe the incidence of twin pregnancies across the world

Answer 1

2-7 per 1000 in far east
9-20 per 1000 in Europe
20-45 per 1000 in Nigeria

Question 2

Why is the incidence of twin pregnancies rising?

Answer 2

Due to increasing maternal age and IVF

Question 3

Why did the incidence of triplets decrease after 2002?

Answer 3

Law was introduced so only 1 embryo could be implanted during IVF

Question 4

What is super ovulation?

Answer 4

More than 1 egg is released per menstrual cycle and all are then fertilised

Question 5

What are the risk factors for super ovulation?

Answer 5

Ethnicity
Increasing maternal age
Increasing parity 
Family history
Fertility treatment

Question 6

What is the definition of monozygous?

Answer 6

1 egg
Twins are identical
1/3 of all twin pregnancies

Question 7

What is the definition of dizygous?

Answer 7

2 eggs
Non identical
2/3 of twin pregnancies

Question 8

Definition of dichorionic?

Answer 8

Each twin has its own chorionic sac and separate circulation

Must be diamniotic

Question 9

How many monozygous twins are dichorionic?

Answer 9

1 in 3 monozygous twins

Question 10

Definition of monochorionic?

Answer 10

Have vascularly joined placentae

Question 11

How many monozygous twins are monochorionic?

Answer 11

2 in 3 monozygous twins

Question 12

How are twin pregnancy diagnosed?

Answer 12

Uterine size
Diagnosed at delivery
Ultrasound

Question 13

How many twin pregnancies are diagnosed at delivery?

Answer 13

50%

Question 14

What is worse in multiple pregnancies?

Answer 14

Symptoms of pregnancy
Anaemia
Hypertension
Intrauterine growth restriction
Pre-term labour
Delivery problems
Perinatal mortality

Question 15

Why are you likely to have an earlier due date with multiple pregnancies?

Answer 15

Going overdue increases the risk of stillbirth and the risks are already higher so the pregnancy is delivered earlier

Question 16

Definition of stillbirth

Answer 16

Death after 24 weeks

Question 17

Definition of early neonatal death

Answer 17

Death in first 7 days

Question 18

Definition of neonatal death

Answer 18

Death in first 28 days

Question 19

Definition of perinatal death

Answer 19

Combined numbers of stillbirth and early neonatal deaths

Question 20

Definition of infant death

Answer 20

Death within 1st year

Question 21

What is the first trimester management for a twin pregnancy?

Answer 21

Discuss screening for chromosomal anomalies
Determine chorionicity
Discuss foetal reduction if triplets or more

Question 22

What is the management in the second trimester for a twin pregnancy?

Answer 22

Detection of foetal abnormality
Serial scans for growth for all
Serial scans for TTTS
Maternal complications

Question 23

How often are dichorionic given scans?

Answer 23

Monthly from 24 weeks to check for growth restriction

Question 24

How often are serial scans for TTTS done for monochorionic twins?

Answer 24

Fortnightly scans between 16-24 weeks and then monthly scans after this

Question 25

When does twin to twin transfusion occur?

Answer 25

Occurs when identical twins share a placenta

Question 26

Describe twin to twin transfusions

Answer 26

Unbalanced placental vascular anastomoses so blood flows unevenly. Donor twin has decreased blood volume which restricts twin's growth Retrieving twin has increased blood volume which can cause heart failure

Question 27

What is the management for twin to twin transfusion?

Answer 27

Treat with laser treatment or amnio-reduction | Early delivery by caesarean

Question 28

What is the management for a twin pregnancy in the third trimester?

Answer 28

Scanning as in 2nd trimester Monitor blood pressure Pre-term labour Delivery planning

Question 29

Describe delivery planning for a twin pregnancy

Answer 29

37-38 weeks for dichorionic twins (vaginal or caesarean) Presentation of twin 36-37 weeks for monochorionic twins (all by caesarean) Pregnancy complications

Question 30

Why are triplets always delivered by caesarean?

Answer 30

It is too difficult to monitor them for a vaginal delivery

Question 31

What factors need to be managed during labour of twins?

Answer 31

Monitor both twins Problems delivering twin II Risk of postpartum bleeding

Question 32

What should be considered if high order multiples?

Answer 32

``` Consider foetal reduction Determine chorionicity High risk of preterm labour Deliver preterm by caesarean Postpartum haemorrhage Difficult puerperium and after ```