Antenatal Care for Multiple Pregnancies

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Questions and Answers

What is a key component of antenatal care for women with twin and triplet pregnancies?

Frequent testing for high blood pressure only

Awareness of higher incidence of anaemia (correct)

Increased dietary recommendations without monitoring

Immediate corticosteroid treatment for all pregnancies

At what stage of pregnancy should a Full Blood Count (FBC) be performed to check for the need for iron or folic acid supplementation?

At the first appointment only

Between 12-16 weeks

At 20–24 weeks and again at 28 weeks (correct)

During the last trimester only

What should be included in discussions during antenatal care regarding lifestyle?

Information on postnatal care options

General advice on diet, lifestyle, and nutritional supplements (correct)

Recommendations for specific medication use

Assessment of family medical history only

Which procedure should be performed at every appointment during antenatal care?

Testing for proteinuria and measuring blood pressure Signup and view all the answers

What potential intervention is indicated for fetal lung maturation in cases of preterm labour?

Administration of corticosteroids Signup and view all the answers

What does early ultrasound scanning reveal regarding multiple pregnancies?

Some fetuses may die during the first trimester Signup and view all the answers

What misconception might exist regarding the outcomes of multiple pregnancies?

All multiple pregnancies result in healthy deliveries Signup and view all the answers

What is the approximate chance of conceiving twins through In Vitro Fertilisation (IVF)?

1 in 5 Signup and view all the answers

What factor is associated with an increased likelihood of monozygotic twins?

Older maternal age Signup and view all the answers

What has contributed to the rising incidence of multiple births over the last 40 years?

Advancements in fertility technology Signup and view all the answers

Which aspect of care aims to optimize outcomes for mothers and families in the context of multiple births?

Enhance psychological and physical support Signup and view all the answers

What is a significant risk associated with multiple births that healthcare providers need to address?

Complications arising during pregnancy Signup and view all the answers

What is the recommended daily low dose aspirin intake for pregnant women with risk factors for hypertension?

From 12 weeks until birth Signup and view all the answers

What is an important consideration for estimating fetal weight discordance in twin pregnancies?

Using two biometric parameters at each scan Signup and view all the answers

What factor is NOT advisable for predicting the risk of preterm birth?

Fetal fibronectin testing alone Signup and view all the answers

Which of the following women has increased risk factors for hypertension during pregnancy?

A woman pregnant for the first time at 39 years Signup and view all the answers

What condition is considered clinically important for measuring fetal weight discordance?

A difference of ≥ 25% Signup and view all the answers

What is a critical action to take if there are signs of fetal distress during a twin pregnancy?

Perform an emergency caesarean section Signup and view all the answers

What is recommended to help differentiate between the fetal heart rates in a twin pregnancy?

Separate the fetal heart rates by 20 beats/minute Signup and view all the answers

Which situation mandates an elective caesarean section during twin delivery?

First twin has a non-cephalic presentation Signup and view all the answers

What procedure should be followed immediately after the birth of the first twin?

Clamp the cord firmly in two places and cut between the clamps Signup and view all the answers

Which of the following is NOT a recommended action when using dual channel cardiotocography monitors?

Perform amniotomy before monitoring Signup and view all the answers

In the context of twin pregnancies, what risk does monochorionic twins pose during delivery?

Potential exsanguination of the second twin if maternal side is not secure Signup and view all the answers

What must be noted immediately after the first twin is born?

The time of delivery and sex of the baby Signup and view all the answers

What is a key feature of monitoring in a twin pregnancy?

Simultaneous visual display of both fetal hearts Signup and view all the answers

What type of twins may have either two separate placentas or a fused placenta with individual amnion and chorion sacs?

Dizygotic twins Signup and view all the answers

What is a common complication during labor for monoamniotic twins?

Cord prolapse Signup and view all the answers

Which statement correctly describes the feeding routine for twins?

Extra support may be needed to establish a breastfeeding routine. Signup and view all the answers

What is a recommended time frame for the birth of monoamniotic twins?

32 to 34 weeks Signup and view all the answers

Which of the following options indicates an important consideration for postnatal care of twins?

Involution may be slower for mothers of twins. Signup and view all the answers

Identifying individuality among twins can be important for what aspect of their care?

Establishing family relationships Signup and view all the answers

What common misconception exists regarding monozygotic twins and their placentas?

Monozygotic twins only have a single chorion. Signup and view all the answers

Why might families of twins consider joining support groups?

To build relationships and deal with challenges of parenting multiples. Signup and view all the answers

What is the approximate chance of conceiving twins without any fertility assistance?

1 in 30 Signup and view all the answers

Which factor is most closely associated with an increased incidence of monozygotic twins?

Older maternal age Signup and view all the answers

Over the past 40 years, what trend has been observed regarding multiple births?

Increase in multiple births Signup and view all the answers

Which approach is essential for optimizing outcomes for families involved in multiple births?

Comprehensive support addressing both physical and psychological needs Signup and view all the answers

What is one of the risks associated with multiple pregnancies that healthcare providers should be aware of?

Higher likelihood of complications during delivery Signup and view all the answers

Which sign in ultrasound at 16-20 weeks suggests dichorionicity in a pregnancy?

Lambda sign Signup and view all the answers

What should prompt a midwife to consider the possibility of a multiple pregnancy during an antenatal booking?

Positive family history of twins Signup and view all the answers

What is a common outcome to communication about antenatal screening for twins?

Women need to make complex decisions based on screening outcomes Signup and view all the answers

Which condition requires ultrasounds every 2 weeks from 16 to 24 weeks in monochorionic twin pregnancies?

Fetal growth and signs of TTTS Signup and view all the answers

What is a characteristic finding when palpating a uterus of a woman with multiples after 20 weeks?

Fundal height greater than expected Signup and view all the answers

Which screening method is suggested for assessing the risks in twin pregnancies?

Combined NT fold with biochemical screening Signup and view all the answers

What is a potential risk associated with chorionic villus sampling (CVS)?

Miscarriage risk between 3-4% Signup and view all the answers

What could be an indication of potential heart problems or genetic concerns in a fetus during ultrasound assessments?

Thicker NT fold than average Signup and view all the answers

Under which condition is a planned vaginal birth safe for women with uncomplicated twin pregnancies?

The pregnancy has progressed beyond 32 weeks Signup and view all the answers

What is the recommended action if the first twin is not in a cephalic presentation at the time of planned birth?

Offer a caesarean section Signup and view all the answers

A caesarean section should be offered to women with a monochorionic monoamniotic twin pregnancy under which circumstance?

If complications arise during the pregnancy Signup and view all the answers

At what gestational age should a woman with a triplet pregnancy be offered a caesarean section?

35 weeks or later Signup and view all the answers

What is a recommended action for women who decline elective birth for a triplet pregnancy?

Offer weekly appointments with a specialist obstetrician Signup and view all the answers

What indicates that a caesarean section is necessary in cases of established preterm labour with twin pregnancies?

The first twin is not cephalic Signup and view all the answers

What is the significance of a senior obstetrician’s advice during labor when a woman with twins is close to vaginal birth?

To guide the continuation of vaginal birth Signup and view all the answers

Which of the following is NOT a factor for assessing mode of birth in uncomplicated twin pregnancies?

Maternal age over 35 Signup and view all the answers

What is a potential psychological risk factor for mothers of twins?

Increased likelihood of postpartum depression Signup and view all the answers

What is a recommended intervention for expectant management of monoamniotic twins?

Increased frequency of ultrasound monitoring Signup and view all the answers

Which complication is commonly associated with multiple pregnancies during labor?

Higher chance of postpartum hemorrhage Signup and view all the answers

What is the significance of the Human Multiple Births Database (HMBD)?

It functions as a research tool for studying multiple births. Signup and view all the answers

What is a critical consideration when managing monochorionic twin pregnancies?

Monitoring for twin-to-twin transfusion syndrome is essential. Signup and view all the answers

What is the primary focus of guidelines for twin and triplet pregnancies?

Optimizing maternal and fetal outcomes Signup and view all the answers

What is a known benefit of planned early delivery for monoamniotic twins?

Reduced chances of fetal injury during delivery Signup and view all the answers

Which type of delivery is typically recommended for twins that share a single placenta?

Elective cesarean section Signup and view all the answers

What procedure is indicated if the lie of the second twin is transverse or oblique and cannot be corrected?

Conduct an emergency cesarean section Signup and view all the answers

Which of the following should NOT be offered to women with a twin or triplet pregnancy for managing the third stage of labor?

Physiological management of the third stage Signup and view all the answers

What is the maximum recommended interval between the births of twins?

30 minutes Signup and view all the answers

What should be done immediately after the birth of twin 2?

Label the baby and cord 'twin 2' Signup and view all the answers

What is a potential risk of administering oxytocin in cases of undiagnosed twins?

Severe anoxia to the second twin Signup and view all the answers

Which of the following is a common implication of having more than two babies during delivery?

Emergency cesarean section is performed Signup and view all the answers

What key feature is essential to ensure after the birth of both twins?

Checking ID bands with parents Signup and view all the answers

Which statement accurately reflects the management recommendation for the third stage of labor in women with twin or triplet pregnancies?

Offer active management to lower postpartum hemorrhage risk Signup and view all the answers

Which statement accurately describes the monitoring of fetal heart rates during a twin pregnancy?

The fetal heart rates must be documented separately on the cardiotocograph. Signup and view all the answers

What is the most appropriate action if there are signs of fetal distress in a twin pregnancy?

Perform an emergency caesarean section. Signup and view all the answers

What should be done immediately after the birth of the first twin?

Label the baby as 'twin 1' and clamp the cord in two places. Signup and view all the answers

In a twin pregnancy, what is a significant risk factor associated with monochorionic twins?

Increased risk of exsanguination for the second twin. Signup and view all the answers

What should be avoided during cardiotocography in a twin pregnancy?

Performing fetal scalp stimulation post-pathological traces. Signup and view all the answers

What is essential for the team present during the delivery of twins when the first twin is in cephalic presentation?

An anesthetist and neonatologist should also be present. Signup and view all the answers

Which precaution is necessary for twin pregnancies, especially when differentiating fetal heart rates?

Fetal heart rates should be separated by at least 20 beats/minute. Signup and view all the answers

What should be included in the birthing trolley for the delivery of twins?

Amniotomy equipment, assisted birth tools, and an extra cord clamp. Signup and view all the answers

Study Notes

Multiple Pregnancy/Births

Multiple pregnancies are on the rise over the past 40 years.
In the US, the incidence of multiple births increased from 9.5 twins per 1,000 deliveries in 1975 to 16.7 in 2015.
Multiple births are affected by factors like maternal age, race, weight/height, and infertility treatment.
IVF increases the likelihood of twins to 1 in 5.
Monozygotic (identical) twins arise when a single fertilized egg divides into two identical halves within the first 14 days after fertilization. They have the same genetic makeup and are always the same sex.
Dizygotic (fraternal) twins arise from two separate eggs fertilized by separate sperm. They may be the same or different sexes and are not genetically more alike than other siblings.
Chorionicity refers to the number of outer membranes (chorions) in multiple pregnancies.
Amnionicity refers to the number of inner membranes (amnions) in multiple pregnancies. These interactions result in different types of twins:
- Dichorionic diamniotic (DCDA): 2 chorions, 2 amnions. Common in dizygotic twins (fraternal).
- Monochorionic diamniotic (MCDA): 1 chorion, 2 amnions. Common in monozygotic twins (identical).
- Monochorionic monoamniotic (MCMA): 1 chorion, 1 amnion. Rare.
Splitting of the zygote during the first few days of conception is a defining factor in determining chorionicity.
Multiple pregnancies carry a higher risk for the mother and babies due to increased financial and emotional burden, and greater health service requirements.
Some foetuses may die in the first trimester. Early ultrasound scans may show two or more fetal sacs, but some may still die.
Multiple births have noteworthy consequences for families, the healthcare system, and society.
Higher-order multiples (involving 3 or more fetuses) are increasing with assisted reproductive technologies.
Common complications associated with multiple pregnancies include:
- Higher risk of complications in mother and babies with higher numbers of fetuses.
- Severe morning sickness.
- Heartburn.
- Edema of ankles.
- Varicose veins.
- Dyspnea.
- Backache.
- Exhaustion.
- Miscarriage.
- Anemia (in the donor twin).
- IUGR (intrauterine growth restriction).
- Oligohydramnios.
- Increased risk of eclampsia.
- Postnatal illness.
- Acute polyhydramnios.
- Twin-to-twin transfusion syndrome (TTS): unequal blood flow between fetuses in monochorionic pregnancies. One fetus receives more blood than the other, causing problems like IUGR (intrauterine growth restriction), fetal anaemia, and/or other abnormalities in the recipient twin.
Acardiac twins (TRAP): one twin lacks a fully formed heart (and is often smaller) and relies on the other twin for blood supply, which can lead to complications.

Learning Outcomes

Students will be able to discuss the incidence of multiple births.
Students will be able to discuss how twins arise and the importance of chorionicity and zygosity.
Students will be able to discuss additional information and support required for families dealing with multiple pregnancies.
Students will be able to discuss risks of complications associated with twins.
Students will learn about the aim of care in multiple pregnancies including assessing and treating pregnancy complications, maximizing the physical and psychological outcomes for the mother, babies, and family, and supporting parents in adapting to the situation.

Aim of Care

Assess, diagnose and treat any complications that may arise.
Optimize physical and psychological outcomes for the mother, babies and family.
Support parents to adapt.

Diagnosis of Multiple Pregnancies

The "lambda sign" (twin peak sign) is a crucial ultrasound indicator of dichorionicity. Its absence doesn't definitively exclude dichorionicity.
Early ultrasound scans (6+ weeks) are essential for pregnancy detection in multiple pregnancies; however, chorionicity is often determined earlier in the first trimester.
Increased fundal height, palpation of fetal parts, and fetal movement patterns are physical indicators but are not conclusive and may be associated with a range of factors.

Antenatal Screening

Ultrasound measures the thickness of fluid buildup behind the developing baby's head provides crucial information about various fetal abnormalities.
Screening techniques, particularly for monochorionic twins, can detect fetal abnormalities earlier in pregnancy.

Support for Parents

Early diagnosis of chorionicity and related risks is vital to reassure and support parents.
Support groups can be helpful for parents facing the realities of multiple pregnancies.

Complications Associated with Multiple Pregnancies

Severe morning sickness, heartburn, ankle edema, and varicose veins are common, albeit possibly more severe, for pregnant women with multiple fetuses.
Higher mortality rates in multiple pregnancies are often associated with congenital malformations.
Complications such as placental abruption, premature labor, and birth asphyxia are potential risks for mothers and babies.
Twin-to-twin transfusion syndrome (TTTS) is a potentially serious complication impacting monochorionic twin pregnancies.

Postnatal Care

The care considerations for mothers and babies are the same as those associated with singleton pregnancies
Post-birth, support for mothers is similar whether their pregnancy was with one or multiple babies
Care in the postnatal period will differ and will vary depending on the complexity and resources available.

Feeding Multiple Babies

Extra support during breastfeeding for mothers of multiple babies is crucial and helpful.
Babies can be fed separately or together.
Mothers may prefer to feed babies separately to be closer to understanding and bonding with them.
Breastfeeding support, supplementary feeding support, and advice are recommended for mothers of multiples.
Consideration of feeding methods that work for mothers and newborns.

Coming Home

Multiple families need support from sources like support groups, family relations, and individualized help and care plans.
Post-natal depression is a common concern for families who have multiples and should be addressed promptly.
Bereavement also plays a crucial part and should be addressed.
If babies have a disability, these families require individual support.

Timing of Birth

Planned birth timing varies according to chorionicity:
Monochorionic twins are often delivered slightly earlier (around 36 weeks), dichorionic twins around 37-38 weeks and triplets/higher-order multiples earlier.

Presentations

Twins/triplets may present in different positions.

Mode of Birth

Planned vaginal deliveries and planned C-sections, including when twins are cephalic, are safe options.
Caesarean delivery may be required when the first twin is in a non-cephalic presentation.
When there is significant size discrepancy between twins, caesarean delivery is recommended.
The mode of birth is dependent on the situation, maternal well-being, and the status of both/all babies.

Third Stage of Labour

Active management of the third stage of labor in women carrying multiples is recommended to lower postpartum haemorrhage risk.

Examination of Placenta

Examining placentas and membranes provides essential information for determining the type of multiple pregnancy (e.g., dizygotic or monozygotic).
Placental abnormalities/problems can indicate a higher-risk pregnancy.

Complications During Labour and Birth

Malpresentation.
Cord prolapse.
Prolonged labour.
Locked twins.
Deferred birth for one or more of the babies.
Entanglement of the umbilical cord is a possibility and requires careful management.

Undiagnosed Twins

Unusual situations, such as an enlarged abdomen or delayed birth, must be evaluated by a healthcare professional.
Undiagnosed twins can lead to potential complications for both the mother and babies (e.g., severe anoxia).

Second Stage of Labour

Detailed information on the second stage of labor in a multiple pregnancy, including procedures to assess and manage the second presenting twin during birth; implications for fetal/neonatal outcomes, such as potential problems for the second baby, including:

Assessing lie and presentation
Managing a transverse/oblique fetus
Avoiding damage to fetal tissues
Interventions for delayed birth

First Stage of Labour

Detailed information on the first stage of labor in a multiple pregnancy, including procedures to assess and manage labor; implications for fetal/neonatal outcomes, such as issues for either twin, and procedures like monitoring fetal heart rates.

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Description

This quiz will test your knowledge on antenatal care specifically for women expecting twins or triplets. Learn about the key components, procedures, and risks associated with multiple pregnancies. It covers essential topics like blood tests, fetal development, and lifestyle discussions.