Podcast Beta
Questions and Answers
Which of the following describes an acardiac twin condition?
Interlocking of twins occurs in the second twin.
False
What is the typical management for conjoint twins?
C-section at 32-34 weeks
Fetal weight in IUGR is defined as less than the __________ percentile of a normal fetus.
Signup and view all the answers
Match the type of twin complication with its description:
Signup and view all the answers
What does PTL stand for in medical terms?
Signup and view all the answers
The beginning of preterm labor occurs after 37 weeks of gestation.
Signup and view all the answers
What is the primary characteristic of preterm labor?
Signup and view all the answers
Preterm labor is defined as when the process of labor begins at __________ weeks of gestation.
Signup and view all the answers
Match the following terms related to labor with their definitions:
Signup and view all the answers
What does fetal fibronectin act as between the fetal membrane and decidua?
Signup and view all the answers
Fetal fibronectin is usually present in cervicovaginal secretions before 22 weeks of gestation.
Signup and view all the answers
What are the two conditions associated with the presence of fetal fibronectin between 22-35 weeks?
Signup and view all the answers
Four contractions in 20 minutes or eight contractions in 60 minutes are part of the current definition of __________.
Signup and view all the answers
Match the following definitions with their associated symptoms:
Signup and view all the answers
What is the primary purpose of Doppler studies in twin pregnancies?
Signup and view all the answers
Oligohydramnios refers to an excessive amount of amniotic fluid.
Signup and view all the answers
What is the recommended treatment for twin pregnancies diagnosed before 28 weeks?
Signup and view all the answers
The condition known as TAPS is a milder, chronic form of ________.
Signup and view all the answers
Match the following conditions with their descriptions:
Signup and view all the answers
Which of the following is a maternal complication associated with twin pregnancy?
Signup and view all the answers
Intrahepatic cholestasis is a known complication that can occur in twin pregnancies.
Signup and view all the answers
What is the recommended prophylaxis for pre-eclampsia in twin pregnancy?
Signup and view all the answers
The risk of preterm labor is increased in twin pregnancies due to __________.
Signup and view all the answers
Match the following fetal complications with their characteristics:
Signup and view all the answers
What is the maximum time gap allowed between the deliveries of twins?
Signup and view all the answers
Vaginal delivery is always possible for both twins.
Signup and view all the answers
What delivery method is indicated if the second twin is in a transverse position and there is a prior history of C-section?
Signup and view all the answers
Methyl ergometrine is contraindicated after the delivery of the __________ twin.
Signup and view all the answers
Match the delivery presentations with their corresponding delivery methods:
Signup and view all the answers
What is the primary method for assessing amniotic fluid in a twin pregnancy?
Signup and view all the answers
Oligohydramnios refers to increased amniotic fluid in one twin.
Signup and view all the answers
What condition is indicated when bladder visualization is normal in a twin with oligohydramnios?
Signup and view all the answers
The _____ system is activated in the donor twin during TTTS to maintain blood pressure and volume.
Signup and view all the answers
Match the stages of TTTS to their characteristics:
Signup and view all the answers
What is the optimal timing for cervical cerclage surgery during pregnancy?
Signup and view all the answers
Progesterone can prevent preterm labor once uterine contractions have started.
Signup and view all the answers
What cervical length measured by transvaginal ultrasound is an indication for cervical cerclage?
Signup and view all the answers
Hydroxyprogesterone caproate is administered via __________ injections, starting at 16-20 weeks gestation.
Signup and view all the answers
Match the medication to its method of administration:
Signup and view all the answers
What is a complication that occurs specifically in monochorionic twins?
Signup and view all the answers
TTTS is more prevalent in DCDA twins compared to MCDA twins.
Signup and view all the answers
What is the primary physiological change in the donor twin affected by TTTS?
Signup and view all the answers
In Selective IUGR, the affected twin is typically known as the __________ twin.
Signup and view all the answers
Match the following characteristics with the appropriate twin in TTTS:
Signup and view all the answers
What is a common complication for twin pregnancies?
Signup and view all the answers
Vanishing twin syndrome occurs more commonly in singleton pregnancies than in twin pregnancies.
Signup and view all the answers
What complications can arise due to vascular anastomosis in surviving monochorionic twins?
Signup and view all the answers
In monochorionic twin pregnancies, congenital anomalies are more prevalent due to __________.
Signup and view all the answers
Match the following conditions related to twin pregnancy with their descriptions:
Signup and view all the answers
Study Notes
Fetal Fibronectin Protein
- Present between fetal membrane and decidua
- Acts as glue and present in cervicovaginal secretions
- Normal after 35 weeks
- Suggests PTL or PROM between 22-35 weeks
Preterm Labor (PTL) Definition
- Uterine contraction defined as 4 contractions in 20 mins/ 8 contractions in 60 mins
- One of the following criteria must be met:
- Progressive dilatation and effacement of cervix
- Cervical dilatation at initial presentation
Acardiac Twin Outcome
- Acardiac acephalus: Only the lower body of twin develops
- Acardiac amorphous: No parts develop, forming an amorphous mass
Selective IUGR
- Normal twin is represented by circle "A" in the diagram
- IUGR twin represented by circle "B" in diagram
- Fetal weight < 10th percentile of normal fetus
-
25% discordance in weight compared to normal twin
Monoamniotic Twin Complications
-
Cord entanglement:
- Cause: Formation of true knots
-
Conjoint twins: :
- Management: C-section at 32-34 weeks
Twin Pregnancy Delivery
- First twin is closer to internal os during pregnancy
- First twin comes out first during delivery
- Most common presentation: Both twins vertex
- 1st twin vertex & second twin breech can result in interlocking of twins
- Interlocking of twins seen in first twin and managed via C-section
Doppler Studies
- Performed at 16-20 weeks
- Include umbilical artery, vein, and ductus venosus
- PSV of MCA
Ultrasound in Twin Pregnancy
- Fetal biometry for growth assessment
- Diagnose oliguria/polyhydramnios
- Diagnose hydrops fetalis
Recipient Twin Echocardiography
- Assess for pulmonary atresia/stenosis
- Hypertrophy
- Right side dysfunction
- Left side dysfunction
Interventions for Twin-to-Twin Transfusion Syndrome (TTTS)
- ≤ 28 weeks: Fetoscopic laser ablation of vascular anastomosis
- > 28 weeks: Serial amnioreduction
Twin Anemia Polycythemia Syndrome (TAPS)
- Atypical, milder, chronic form of TTTS
- Caused by slow transfusion of RBCs via few, small vessels
- Hemoglobin levels:
- Donor twin: ≤ 1.5 mom (months)
- Recipient twin: < 0.8 mom (months)
Twin Reversed Arterial Perfusion (TRAP)
- Rare monochorionic twin complication
- Deoxygenated blood flows from normal twin (Twin A) to acardiac twin (Twin B)
- Flow via aberrant arterio-arterial anastomosis
Maternal Complications of Twin Pregnancy
- Pronounced haemodynamic changes
- Pre-eclampsia
- Abruptio Placenta
- Placenta previa
Other Maternal Complications
- ↑ Placenta size
- Intrahepatic cholestasis and acute fatty liver of pregnancy
- ↑ Human placental lactogen
- Polyhydramnios:
- ↑ risk of: Preterm labor, PROM, Postpartum hemorrhage, Cord prolapse, malpresentations
- Hyperemesis gravidarum
- Gestational diabetes
- ↑ hCG
Fetal Complications
- Most common in:
- Monochorionic vs. dichorionic twins
- Monozygotic vs. dizygotic twins (Exception: Cumulative risk of chromosomal anomalies)
Testing for Aneuploidy
- Monozygotic: Sample from any twin
- Dizygotic: Sample from both twins
Fetal Reduction
- DOC: Intracardiac KCl injection
- Given to fetus with least chance of survival
- Timing: 10 - 13 weeks
- Does not affect survival of the other fetus
Amniotic Fluid Assessment
- Single largest vertical pocket on ultrasound is best method for assessing amniotic fluid.
TTTS Diagnostic Criteria
- MCDA: Monochorionic diamniotic twins with TTTS
- Polyhydramnios in one twin
- Oligohydramnios in the other twin
- Early marker: Increased nuchal translucency
- Stuck twin: Activation of RAAS in donor twin
Quintero Staging for TTTS
Stages | One Twin | Other Twin | Doppler Findings |
---|---|---|---|
Stage 1 | Polyhydramnios | Oligohydramnios: Bladder visible (oliguria) | Normal |
Stage 2 | Polyhydramnios | Oligohydramnios: Bladder not visible (anuria) | Normal |
Stage 3 | Abnormal doppler study | ||
Stage 4 | Hydrops fetalis in one/both twins | ||
Stage 5 | Death of one/both twins |
Delivery Options Based on Presentation
1st Twin | 2nd Twin | |
---|---|---|
Presentation | Vertex | Vertex |
Breech | Transverse | |
Delivery | Vaginal delivery | Vaginal delivery |
Vertex | ||
Breech | Assisted breech delivery | |
Shift to OT Internal podalic version + breech extraction | ||
Transverse | ||
C-section | C-section |
Additional Notes
- After delivery of 1st twin: methyl ergometrine is contraindicated (causes uterine contractions)
- Maximum time gap between twin deliveries: 30 minutes
- If time gap exceeds 30 minutes, immediate C-section for second twin is performed
- Internal podalic version: Performed if the 2nd twin is in transverse lie
- Only indication if there’s a previous history of a C-section
- Method of delivery is under general anesthesia
- External cephalic version: Only performed if the membranes are intact
General Twin Pregnancy Complications
- Preterm labor
- IUGR
- Congenital anomalies
Cervical Cerclage
- Not recommended in primigravida
- Not recommended if no history of preterm labor or 2nd trimester abortion in twin pregnancy
-
Indications:
- History of preterm birth
- Cervical length ≤ 2.5 cm
- Singleton pregnancy
- Timing: 14-24 weeks gestation
- Additional: Progesterone given with the cerclage.
Progesterone
- Indications: History of preterm labor
-
Medications:
- Hydroxyprogesterone caproate: Intramuscular (IM) weekly injections, start 16-20 weeks, stop at 36 weeks
- Micronised progesterone: Per vaginally daily
- Function: Smooth muscle relaxant
PTL: Important Note
- Progesterone cannot prevent PTL once uterine contractions have started
PTL: Additional Considerations
-
Symptoms: Uterine contractions (4 contractions in 20 minutes / 8 contractions in 60 minutes) AND any of the following:
- Cervical length ≤ 2 cm
- Cervical dilation ≥ 3 cm
- Positive fetal fibronectin protein test (≥50 ng/mL) in cervicovaginal secretions.
Diagnostic Procedures
- Pelvic Exam (speculum): Rule out premature rupture of membranes (PROM)
-
Pelvic Exam (vaginal):
- If cervical dilation is ≥ 3 cm → refer to labor and delivery
Congenital Anomalies
- Twin > singleton pregnancy
- Monochorionic > dichorionic twins
- Heart defects: TTTS (Twin-to-twin transfusion syndrome) - monochorionic twins
- Diagnosis methods:
- Echocardiography (18-22 weeks)
- Targeted/Anomaly/Level II scan
- Diagnosis methods:
Vanishing Twin
- Early spontaneous reduction in twin pregnancy
- Common in IVF pregnancies
- Effect on other twin: Normal survival ± LBW (low birth weight)/SGA (small for gestational age)
Death of One Twin
- Surviving monochorionic twin: Complications d/t vascular anastomosis
- Surviving dichorionic twin: Complications d/t absence of vascular anastomosis
Monochorionic Twin Complications
- High pressure system: Twin A
- Hypotension
- Anemia
- Exsanguination
- Low pressure system: Twin B
Death of Twin A
- Diagram Description: A diagram depicts the pathway of blood flow from the healthy twin (Twin A) to the dying twin (Twin B) in a monochorionic pregnancy. It shows the consequence of this blood flow, such as the high blood pressure in Twin A and low blood pressure in Twin B.
Management
- Immediate delivery: Not indicated
- Note: Pregnant female with USG showing impending death of 1st twin
Specific Monochorionic Twin Complications:
- TTTS (Twin to twin transfusion syndrome)
- TAPS (Twin anemia polycythemia sequence)
- Immediate delivery of both twins
- TRAP (Twin reverse arterial perfusion)
- Selective IUGR
IUGR vs Selective IUGR
IUGR | |
---|---|
Related to number of twins | |
A | |
IUGR | |
- Selective IUGR:*
- Complication of monochorionic twins.
Twin to Twin Transfusion Syndrome (TTTS)
- Etiopathogenesis: Occurs due to deep vascular anastomosis between artery and vein.
- Prevalence: MCDA: Most common (due to deep anastomosis)
- MCMA: Less common (due to superficial anastomosis)
- DCDA: Not seen (vascular connections Θ)
TTTS: Factors
Donor | Recipient | |
---|---|---|
Renal blood flow | ↓ (↑ risk of renal failure) | ↑ |
GFR | ↓ | ↑ |
Amniotic fluid | Oligohydramnios | Polyhydramnios |
Hemoglobin levels | Anemia | Polycythemia |
Peak systolic volume (PSV) of middle cerebral artery (MCA) |
TTTS: Complications
Donor | Recipient | |
---|---|---|
Heart failure | Congestive heart failure | |
≥1.5 mom | < 0.8 mom | |
Hydrops fetalis | ||
Death |
Measures to Prevent Preterm Labor (PTL)
Cervical Cerclage Surgery
-
Indications:
- History of preterm birth (H/O PTL)
- Cervical length ≤ 2.5 cm (measured by transvaginal ultrasound (TVS))
- Singleton pregnancy
- Timing: 14-24 weeks gestation
- Additional: Progesterone should be given with the cerclage.
Progesterone
- Indications: H/O PTL
-
Medications:
- Hydroxyprogesterone caproate: IM weekly injections, start 16-20 weeks, stop at 36 weeks
- Micronised progesterone: Per vaginally daily
- Function: Smooth muscle relaxant
Important Note
Progesterone cannot prevent PTL once uterine contractions have started
Other Considerations
- Symptoms: Uterine contractions (4 contractions in 20 minutes / 8 contractions in 60 minutes) AND any of the following
- Cervical length ≤ 2 cm (measured by TVS)
- Cervical dilation ≥ 3 cm
- Positive fetal fibronectin protein test (≥50 ng/mL) in cervicovaginal secretions.
Diagnostic Procedures
- Pelvic Exam (speculum): Rule out premature rupture of membranes (PROM)
- Pelvic Exam (vaginal): If cervical dilation is ≥ 3 cm → refer to labor and delivery
Studying That Suits You
Use AI to generate personalized quizzes and flashcards to suit your learning preferences.
Description
This quiz covers essential topics in obstetrics, specifically focusing on fetal fibronectin, preterm labor definitions, acardiac twins, selective IUGR, and complications of monoamniotic twins. Test your understanding of these concepts and their implications for pregnancy management.