Twins and APH

Question 1

When the fundal height reaches the umbilicus what gestation is the fetus?

Answer 1

20 weeks

Question 2

When the fundal height is at the symphysis pubis how many weeks gestation?

Answer 2

12 weeks

Question 3

When the fundal height is at the xiphysternum how many weeks gestation?

Answer 3

36 weeks

Question 4

Causes of baby being large for dates at 12 weeks?

Answer 4

wrong dates, twins, hydatiform mole, fibroids, full bladder, ovarian cyst

Question 5

How do you check the gestational age of the fetus below 14 weeks and above 14 weeks?

Answer 5

Below = CRL
Above = HC and BPD

Question 6

What does dichorionic and diamniotic mean?

Answer 6

Dichorionic = have their own placentas
Diamniotic = have their own sacs

Question 7

If monozygotic twins occur before day 3 after fertilisation, what type of pregnancy will form (30% of cases)?

Answer 7

Dichorionic Diamniotic

Question 8

If monozygotic twins occur between day 3-9 after fertilisation then what pregnancy will form (70% of cases)

Answer 8

Monochorionic Diamniotic

Question 9

If monozygotic twins occur between day 9-12 after fertilisation then what pregnancy will form (less than 1%)

Answer 9

Monochorionic Monoamniotic

Question 10

If monozygotic twins occur after day 12 of fertilisation then what pregnancy will form?

Answer 10

Conjoined twins

Question 11

What is the lambda sign on USS of a twin pregnancy?

Answer 11

Thich V shaped echogenic area at the edge of the placental membrane to represent the thick dividing membrane made up of 2 chorions and 2 amnions

Question 12

What is the T sign on USS of a twin pregnancy?

Answer 12

Representing the thing dividing membrane seen on USS of the 2 amnions and no chorion present in MCDA twins?

Question 13

How much higher is perinatal mortality in twin pregnancies?

Answer 13

10 times higher

Question 14

What are twin pregnancy risks of twins?

Answer 14

Stillbirth, premature rupture of membranes, IUGR, congenital abnormalities, Prematurity, fetal death, Cord accident, cerebral palsy in babies, low apgar scores

Question 15

During the first trimester carrying a twin pregnancy, what are the potential maternal risks assocaited?

Answer 15

Vanishing twin syndrome, increased risk of miscarriage, increased pregnancy symptoms and potentially hyperemesis gravidarum

Question 16

What maternal risks are associated with a twin pregnancy in the second and third trimester?

Answer 16

Hypertension and preeclampsia, Pressure symptoms and back ache, breathlessness, UTI, anaemia, preterm labour and delivery, APH,polyhydramnios

Question 17

What do you need to monitor for development of within a twin pregnancy?

Answer 17

PIH

Question 18

What supplementation is given from second trimester in twin pregnancy?

Answer 18

Folic acid and iron

Question 19

When are growth scans started during a twin pregnancy?

Answer 19

Serial growth scans 24 weeks onwards

Question 20

Difference between arterioarterial and venovenous anastomoses in TTTS compared to arteriovenous

Answer 20

Arterioarterial and venovenous are both bidirectional and superficial whereas arteriovenous is unidirectional and deep allow blood to directly pour from one twin to the other

Question 21

Unidrectional vs bidirectional TTS?

Answer 21

unidirectional is dangerous (arteriovenous anastomoseS) compare to bidirectional which is protective (AA or VV)

Question 22

What happens to the donor twin in TTTS?

Answer 22

Anaemia, hypovolaemia, growth restriction, oligouria, oligohydramnios

Question 23

What happens to the recipient twin in TTTS?

Answer 23

Polycythaemia, hypervolaemia, polyuria, polyhydramnios, hydrops fetalis

Question 24

How is TTTS diagnosed and monitored for its development during a MCDA/MCMA pregnancy?

Answer 24

2 weekly USS scan between 16-24 weeks

Question 25

In minor placenta pravia detected at the anomaly scan, how is it managed?

Answer 25

Another scan at 36 weeks to check for placental migration

Question 26

In major placenta praevia detected at the anomaly scan, how is it managed?

Answer 26

Another scan at 34 weeks and management plan

Question 27

What are the 4 grades of placenta praevia and which are major and minor classified?

Answer 27

Grade 1 is placenta doesn't reach cervical os but is low lying - minor Grade 2 is placenta reaches cervical os but doesn't cover - minor Grade 3 is placenta covers part of cervical os - major Grade 4 is cervical os is completely covered by placenta - major

Question 28

Risk factors for placenta praevia?

Answer 28

Previous CS, parity, age, smoking, cocaine, history of, history of miscarriage

Question 29

Maternal risks caused by placenta praevia?

Answer 29

PPH, CS risks, surgical risks, placenta accreta, post partum sepsis

Question 30

Risks to fetus caused by placenta praevia?

Answer 30

preterm birth, growth restriction, congenital malformation

Question 31

Who needs to be informed in cases of placenta praevia?

Answer 31

Blood bank

Question 32

Questions to ask about in case of PV bleeding during known placenta praevia?

Answer 32

Quantity of blood, character of bleeding (are they still bleeding? sudden or gradual onset?), has this happened before during the pregnancy, any pain associated with the bleeding, any uterine contractions, Initiatin factors (any trauma? coitus?)

Question 33

How do you initially manage a patient who has PV bleeding during placenta praevia?

Answer 33

2 IV wide bore cannulas inserted, take bloods - FBP, U&E, coag screen, keihauer, cross match. IV fluids, consider group o neg transfusion if taking to long with the crossmatch. Anti D if she is rh neg (plus more if kleihauer is positive)

Question 34

4 Ts that can cause APH?

Answer 34

Tone - uterine laxity due to multiparity or overdistension of uterus Tissue - retained placenta Thrombus - retained placenta Trauma - episiotomy, lacerations, tears, cervical injury

Question 35

What monitoring does the mother need if she is experiencing PV bleeding during pregnancy?

Answer 35

Obs, shock symptoms - clammy hands, cold peripheries, decreased skin turgor, restless, lie and presentation of fetus, vaginal exam with speculum (not in placenta praevia) USS to see placental site and any retroplacental clots

Question 36

Fetal monitoring required when PV bleeding is evident?

Answer 36

CTG, USS of fetal heart, fetal movements

Question 37

Differentials of placenta praevia?

Answer 37

Placental abruption, cervical lesions, premature labour, infection, trauma

Question 38

What signs suggest the mother is experiencing placental abruption and not placental praevia?

Answer 38

Shock more than BP suggests or less bleeding than BP drop suggests, marked pain, decreased fetal movements

Question 39

What signs suggest the mother is experiencing placenta praevia PV bleeding rather than placental abruption?

Answer 39

Large amount of blood passed in keeping with BP drop, painless, normal fetal movements, if shock is present it is in keeping with blood loss

Question 40

What is vasa praevia? symptoms? key sign?

Answer 40

umbilical cord blood vessels passing by internal cervical os, bleeding can be variable, not usually in shock but painless and key feature is decreased/absent fetal movements

Question 41

Initial management of heavy PV bleeding during pregnancy?

Answer 41

admit for obs, steroids in case, no tocolytics, anticoagulation if high risk VTE, stockings regardless

Question 42

How do you confirm placenta accreta? what do you need to inform and prepare with the patient?

Answer 42

MRI, colour doppler, potential hysterectomy, uterine artery embolization, internal iliac artery ligation

Question 43

Placenta praevia what are you expecting?

Answer 43

Massive obstetric haemorrhage

Question 44

How does a CS placenta accreta delivery differ to a normal CS?

Answer 44

Different consent, potential for hysterectomy, senior anaethetist/obstetrician/gynaecologist, cross matched blood, HDU informed, neonatologist, radiologist

Question 45

Mechanical methods of labour induction?

Answer 45

artificial rupture of membranes, cervical sweep, membrane sweep

Question 46

What pharmacological methods of labour induction are there?

Answer 46

Oxytocin (after membrane sweep), prostaglandins