Multiple Gestations

Question 1

What are the types of twin that we have?

Answer 1

• dizigotic (two eggs & two sperms)

- monozygotic (1 egg & 1sperm)

Question 2

In dizygotic twins the only option we have regarding placenta and sac is

Answer 2

2 sac and 2 placenta (wither close or far)

Question 3

In monozygotic twins the options we have regarding placenta and sac is

Answer 3

• 2 sac 2 placenta
• 2 sac 1 placenta
• 1 sac 1 placneta

Question 4

From day 
1-3 
4-8
9-13 
>13
What do we expect the sac and placenta to be?

Answer 4

• 2 sac & 2placenta
• 2sac 1 placenta
• 1 sac 1 placenta
• risk of congoined

Question 5

MC monozygotic twin sac and placenta

Answer 5

2 sacs & 1 placenta

Question 6

Which type of monozygotic twins carry the highest risk of complication?

Answer 6

The later 9-13

1 sac and 1 placenta

Question 7

MC twins are (mono or dizygotic)

Answer 7

Dizygotic

Question 8

Which one is influnced by family hx, ethnicity & maternal age
(MZ or DZ)

Answer 8

DZ

Question 9

What is the relation between maternal age and twinning

Answer 9

With increase there’s increase in twining

Question 10

What can be contrirbuting factor to twinning (DZ)

Answer 10

• use of clomiphene

- gonadotropic therapy

Question 11

What could give you a clue of MZ or DZ in early fetal US

Answer 11

• monochornioc: MZ

- dichorionic & different sex: DZ

Question 12

What does lambda sign indicate in US

Answer 12

DC twins

Question 13

What does T sign indicate in US

Answer 13

Monochrionic

Question 14

Name abn of the twinning process

Answer 14

• conjoined twins
• interplacental vascular anastomosis
• TTTS
• fetal malformation
• umbilical cord abnormalities
• retained dead fetus syndrome

Question 15

What is the majority of cases of conjoined twin

Answer 15

Thoracopagus

Question 16

What is the mode of delivery in conjoined twin

Answer 16

CS

Question 17

Interplacental vascualr anastomoses commonly occur in

MZ or DZ

Answer 17

Monochorionic

Question 18

What is the MC type of interplacental vascular anastomses

Answer 18

Arterial-arterial

Question 19

When do we start seeing compliactions in interplacental vascular anastomoses?

Answer 19

Twin-twin: unbalanced interplacental vascular anastomoses (arterial-venous)

Question 20

What is twin-twin transfusion

Answer 20

Donor transfuse recepient

Question 21

What is the outcome for the donor in TTTS?

Answer 21

• anemia
• IUGR\IUGD
• oligohydraminos
• hypovoulemia & hypotension

Question 22

What is the outcome for the recipient in TTTS?

Answer 22

• Hypervoluemia, hyperviscosity, Polycythemia
• HF & Hydrops fetalis
• cardiomegaly
• thrombi

Question 23

If one twin dies, the other will follow, why is this?

Answer 23

Hypovolemia

Question 24

How to treat TTTs?

Answer 24

• serial amniocentesis
• laser photocoagulation of anastomotic vessels
• delivery

Question 25

Which of the two treatments for TTTs is definitive

Answer 25

Photocoagulation

Question 26

Name an important complication of TTTS

Answer 26

Acardiac twin

Question 27

When is umbilical artery abn of great significance?

Answer 27

If the baby is small

Question 28

What to screen in baby in case of umbilical cord abnormalitis?

Answer 28

Heart and renal system

Question 29

With multiple gestations, there’s an increased risk of: (maternal)

Answer 29

- preterm labor & C\s - anemia - pre-eclampsia - orthostatic hypotension - compromised renal function - post-partum uterine atony

Question 30

How to clinically suspect multiple gestations

Answer 30

- worsening symptoms of morning sickness | - fundal height is larger than expected

Question 31

How to confirm multiple

Answer 31

US

Question 32

With multiple gestations, there’s an increased risk of: (fetal)

Answer 32

- Malpresentation - placenta peevia & abruption - PROM - umbilical coed prolapse - IUGR - congenital anomalies - morbidity & mortality

Question 33

What is the antepartum management of multiple gestations?

Answer 33

- 1st\2nd: frequent visit, optimize diet, assess cervix | - 3rd: prevent preterm, follow growth & wellbeing, pre-eclampsia & DM.

Question 34

How to prevent preterm labor

Answer 34

Vaginal progestrone

Question 35

For a mother with multiple gestation who’s at risk of developing pre-eclampsia, we give her .... as prophylaxis

Answer 35

Asprin before 16 weeks

Question 36

What are the pre-requisits for intrapartum management in multiple gestations

Answer 36

- secondary tertiary hospital - equipped delivery room w\ C-s - fluid & blood & large bore IV - monitor 2 HR simontanously - US for presentation - 2 obstetrician - 2 pediatrician - enough nurses

Question 37

What if the mother with multiple gestations was to deliver preterm, how will you manage the baby?

Answer 37

1- steroid for lung maturity 2- MgSO4 for neuroprotection 3- EONGBS prophylaxis if unkown status 4- tocolysis if need for transportation

Question 38

What are teh contrainidcations of tocolysis?

Answer 38

GA > 34 - preeclampsia - IUGR - abnormal fetal testing - chorioaminitis

Question 39

When we can do vaginal delivery and when we must do C\S in multiple gestations

Answer 39

1- monoamniotic: C\S at 32-34 | 2- diamniotic: VD if first or both twin are cephalic

Question 40

What are the causes of morbidity and mortality in twins

Answer 40

- RDS - Cerebral hemorrhage - birth aspyhxia & anoxia - still birth - prematurity - conginital anomalies