Multiple pregnancies

Question 1

Types of twins pregnancy.

Answer 1

1. Number of conceptions Zygosity
   (monozygotic/dizygotic)
   • 2. Number of placenta Chorionicity
   (monochorionic/dichorionic)
   Number of amniotic cavities Amnionicity
   (monoamniotic/diamniotic)

Question 2

2 type of zygotes

Answer 2

1. (DIZYGOTIC/ FRATERNAL /BINOVULAR ) : Twins resulting from ovulation and subsequent fertilization of more than one oocyte.
2. (MONOZYGOTIC/IDENTICAL/MONOVULAR): Splitting of one embryonic mass to form two or more genetically identical fetuses.

Question 3

If the fetus share of the placenta what type of the zygotes

Answer 3

Monozygous

Question 4

The characteristic of the dizygotic twins 5.

Answer 4

1. 2/3rd of all
2. May/may not be of the same sex
3. Genetically similar to other siblings
4. Always have separate placentae &
   amniotic membranes (dichorionic
   diamniotic …DCDA)
5. Incidence varies by factors like age,
   parity& ethnicity, etc.

Question 5

What’s the characteristic of the monozygotic twins? 5

Answer 5

1. 1/3rd of all
2. Same sex
3. Genetically identical
4. Sharing of placenta and amniotic cavity depend on the time of splitting
5. Incidence is relatively fixed i.e. 1/250

Question 6

How much placenta and amniotic in the di-chorionic?

Answer 6

2 placenta , 2 amniotic

Question 7

How much placenta and amniotic in mono chorionic?

Answer 7

Single placenta
2 amniotic
1 amniotic

Question 8

If monozygotic twins, splitting within three days, what’s the results?

Answer 8

DCDA

Question 9

If monozygotic twins, splitting within 4 to 8 days, what’s the results?

Answer 9

MCDA

Question 10

Monozygotic twins, splitting with the 9 to 12 days what’s the results?

Answer 10

MCMA

Question 11

If monozygotic twins, splitting with that more than 12 days, what’s the result?

Answer 11

Conjoined twins.

Question 12

The longer the time between fertilization & splitting, what’s the result?

Answer 12

more structures the fetuses will share.

Question 13

How to determine chorionicity ?

Answer 13

By US in late 1st and early 2nd (10-14 weeks )

Question 14

By the ultrasound, if you see triangular projection of the chorion projecting between the two layer of the inter-twin membrane, what’s the type of placenta mono or di ?
What’s the name of the sign ?

Answer 14

Dichorionic.
Lambda sign.

Question 15

If you see by the ultrasound The intertwin membrane ends
abruptly at the edge in a T
configuration.
what does it mean?
What’s the name of the sign?

Answer 15

Monochorionic
T sign

Question 16

What’s the factors affecting dizygotic twins?

Answer 16

1. Race Nigeria > Japan
2. Increases maternal age. :
   <20 (( 6:1000 ))
   >35 (( 22 :1000 ))
   >45 (( 57 : 1000 ))
3. Assistant reproduction:
   IUI 10-20%
   IVF 20-30%
4. Parity > in multipara
5. Heredity +ve maternal family history
6. Nutritional status
7. Conception after stopping OCP

Question 17

Maternal Complications ?

Answer 17

1. Hyperemesis gravidarum
2. Pre-eclampsia
3. Gestational diabetes
4. Anemia (iron & folate)
   5.Thromboembolic disease 6.Antepartum hemorrhage – placenta previa and placental abruption
   7.Cholestasis of pregnancy
5. Malpresentations
   9.Mechanical distress such as palpitation, dyspnea, varicosities, and
   hemorrhoids
6. Preterm labor (50%)
   twins –37 weeks, triplets –34 weeks, quadruplets –30 weeks • Pre-labour rupture of the membranes • Cord prolapse • Increased cesarean delivery (50%) • Postpartum hemorrhage

Question 18

What are the 2 obstetrical complications that are never seen in
multiple pregnancy?

Answer 18

Postpartum
Macrosomia

Question 19

Fetal Complications

Answer 19

1. Spontaneous Miscarriages
2. Congenital Anomalies
3. Conjoined twins
4. IUGR
5. Twin-twin Transfusion Syndrome
6. Twin Anemia Polycythemia Sequence
7. Twin Reversed Arterial Perfusion Sequence
8. Monoamniotic Twin Pregnancy

Question 20

Spontaneous Miscarriages more in

Answer 20

monochorionic twins

Question 21

Spontaneous Miscarriages
Types

Answer 21

➢VanishingTwinSyndrome/FetalResorption during first10weeks(anabortedfetus
absorbedcompletely,sonosigns/remainsvisibleinlaterscans)
➢Fetus Papyraceous/Compressus during early (12-20 weeks) 2nd trimester
(a dead flattened fetus compressed against the uterine wall by the second
alivetwin)

Question 22

Fetus Papyraceous/Compressus

Answer 22

12-20wks

Question 23

VanishingTwinSyndrome/FetalResorption

Answer 23

during first10weeks

Question 24

Congenital Anomalies
What’s the classification?

Answer 24

Chromosomal like Down syndrome
• Structural : Neural tube defects – anencephaly, microcephaly, hydrocephaly, cardiac anomalies
etc
Because of over crowding of uterine space like talipes, hip dislocation etc) Unique to twins : acardiac twin, conjoined twins

Question 25

Conjoined twins What’s the treatment?

Answer 25

CS

Question 26

What’s the complication of Dichorionic Twins

Answer 26

preterm labor

Question 27

What’s the complication of Monochorionic Twins

Answer 27

immediate death or neurological deficit.

Question 28

Twin-twin Transfusion Syndrome what’s the cause?

Answer 28

Monochorionic twin vascular anastomoses exist between two fetal circulations • Vascular anastomoses, A-V, V-A, A-A, V-V. Mostly, these are balanced • In About 10-15% of monochorionic twins, an imbalance

Question 29

Twin-twin Transfusion Syndrome Management

Answer 29

• Serial amnioreduction from the recipient sac • Septostomy • Selective feticide by umbilical cord occlusion • Selective laser ablation of abnormal vascular connections

Question 30

Diagnostic markers for TTTS

Answer 30

• Ø both fetuses of the same gender • Ø polyhydramnios/oligohydramnios • Look for the bladder size and liquor volume of each twin (Quintero Staging)

Question 31

Management of labour • First stage: 4

Answer 31

• Same as in singleton pregnancy but with more vigilance • Avoid supine hypotension • Blood to be cross-matched and ready • Intrapartum fetal monitoring separately for both fetuses

Question 32

Management of labour SECOND STAGE– Delivery of the first baby 6

Answer 32

• As in singleton pregnancy • maintain an IV line • No oxytocic (AMTSL) after delivery of the first baby*** • Secure cord clamping • Ensure labeling of 1st baby*** • 2 separate neonatal resuscitation teams

Question 33

Management of labour Second stage Delivery of second twin

Answer 33

• FHS of second baby • Lie and presentation of the second twin • Wait for uterine contractions • Oxytocin infusion to ensure adequate uterine contraction Transverse lie - external cephalic version/internal podalic version Breech presentation - breech extraction Cephalic presentation – amniotomy once the head is in the pelvis complete the delivery

Question 34

Management of the labor third stage

Answer 34

-Continue oxytocin drip -Carboprost250 gm/ Oxytocin 10 units IM -Delivery of placenta following delivery of both twins, by controlled cord traction (CCT) method - Monitor for at least 2 hours -Exam of placenta & membranes

Question 35

Indications for c-section twins:👯

Answer 35

• Non cephalic presentation of first twin • Monoamniotic twins • Conjoined twins • Locked twins • Other obstetric conditions like placenta previa • Second twin –closure of cervix (rarely)

Question 36

Antenatal management twins

Answer 36

✓Aim is to early detection & management & prevention (where possible) ✓More frequent A/N visits ✓Advice regarding diet, rest, physical activity ✓Folic acid, iron & calcium supplements ✓Ultrasound: ✓ 1st trimester for dating, no of fetuses, viability & chorionicty ✓ 2nd trimester for congenital anomalies ✓ 3rd trimester for serial growth ✓Corticosteroids when preterm labor is suspected

Question 37

INVESTIGATION

Answer 37

(ultrasound) • 1st trimester-no of fetuses, viability, chorionicity, nuchal translucency • 2nd trimester-congenital anomalies • 3rd trimester- serial growth scan, fetal complications like TTTS etc.

Question 38

Monoamniotic Twin Pregnancy how you can diagnosed

Answer 38

Ultrasound, no divide membrane

Question 39

Monoamniotic Twin Pregnancy What’s the management?

Answer 39

Frequent antenatal visits and ultrasound scans with Doppler study • Give corticosteroids • CTG to detect bradycardia or deceleration. • Delivery by caesarean section at 32 to 34 weeks.