Obstetrics Marrow Pg 465-474 (Obstetrics Complications)
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Questions and Answers

Which of the following describes an acardiac twin condition?

  • Both twins developed normally.
  • An amorphous mass with no developed parts. (correct)
  • Only the lower part developed. (correct)
  • Both twins are acephalous.

    • 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.

    <p>10th</p> Signup and view all the answers

    Match the type of twin complication with its description:

    <p>Cord entanglement = Formation of true knots Selective IUGR = Unequal placental sharing or cell mass splitting Acardiac amorphous = An amorphous mass with no parts developed Management for conjoint twins = C-section at 32-34 weeks</p> Signup and view all the answers

    What does PTL stand for in medical terms?

    <p>Preterm Labour</p> Signup and view all the answers

    The beginning of preterm labor occurs after 37 weeks of gestation.

    <p>False</p> Signup and view all the answers

    What is the primary characteristic of preterm labor?

    <p>Labor begins prematurely before 37 weeks of gestation.</p> Signup and view all the answers

    Preterm labor is defined as when the process of labor begins at __________ weeks of gestation.

    <p>before 37</p> Signup and view all the answers

    Match the following terms related to labor with their definitions:

    <p>Preterm Labor = Onset of labor before 37 weeks Full-term Labor = Onset of labor between 39 and 40 weeks Post-term Labor = Onset of labor after 42 weeks Pre-labor = The period leading up to labor onset</p> Signup and view all the answers

    What does fetal fibronectin act as between the fetal membrane and decidua?

    <p>A glue</p> Signup and view all the answers

    Fetal fibronectin is usually present in cervicovaginal secretions before 22 weeks of gestation.

    <p>False</p> Signup and view all the answers

    What are the two conditions associated with the presence of fetal fibronectin between 22-35 weeks?

    <p>Preterm labor (PTL) or preterm premature rupture of membranes (PPROM)</p> Signup and view all the answers

    Four contractions in 20 minutes or eight contractions in 60 minutes are part of the current definition of __________.

    <p>preterm labor</p> Signup and view all the answers

    Match the following definitions with their associated symptoms:

    <p>Progressive dilatation = Involves the cervix changing during labor Effacement of cervix = Thinning of the cervix Dilatation at initial presentation = Cervix opens before labor begins Normal presence of fetal fibronectin = After 35 weeks of gestation</p> Signup and view all the answers

    What is the primary purpose of Doppler studies in twin pregnancies?

    <p>Evaluate blood flow in fetal vessels</p> Signup and view all the answers

    Oligohydramnios refers to an excessive amount of amniotic fluid.

    <p>False</p> Signup and view all the answers

    What is the recommended treatment for twin pregnancies diagnosed before 28 weeks?

    <p>Fetoscopic laser ablation of vascular anastomosis</p> Signup and view all the answers

    The condition known as TAPS is a milder, chronic form of ________.

    <p>TTTS</p> Signup and view all the answers

    Match the following conditions with their descriptions:

    <p>Twin Anemia Polycythemia Sequence (TAPS) = Chronic form of TTTS Twin Reversed Arterial Perfusion (TRAP) = Flow of blood from a normal twin to an acardiac twin Doppler Studies = Evaluate blood flow in the fetal vessels Echocardiography = Assesses cardiac issues in the recipient twin</p> Signup and view all the answers

    Which of the following is a maternal complication associated with twin pregnancy?

    <p>Gestational diabetes</p> Signup and view all the answers

    Intrahepatic cholestasis is a known complication that can occur in twin pregnancies.

    <p>True</p> Signup and view all the answers

    What is the recommended prophylaxis for pre-eclampsia in twin pregnancy?

    <p>Low dose aspirin</p> Signup and view all the answers

    The risk of preterm labor is increased in twin pregnancies due to __________.

    <p>polyhydramnios</p> Signup and view all the answers

    Match the following fetal complications with their characteristics:

    <p>Monozygotic twins = Higher risk of complications Dichorionic twins = Lower risk of complications Fetal reduction = Intracardiac KCl injection at 10-13 weeks IUGR = Related to the number of twins</p> Signup and view all the answers

    What is the maximum time gap allowed between the deliveries of twins?

    <p>30 minutes</p> Signup and view all the answers

    Vaginal delivery is always possible for both twins.

    <p>False</p> 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?

    <p>internal podalic version</p> Signup and view all the answers

    Methyl ergometrine is contraindicated after the delivery of the __________ twin.

    <p>first</p> Signup and view all the answers

    Match the delivery presentations with their corresponding delivery methods:

    <p>First Twin Vertex, Second Twin Vertex = Vaginal Delivery First Twin Breech, Second Twin Breech = Assisted Breech Delivery First Twin Transverse = C-section First Twin Vertex, Second Twin Transverse = C-section</p> Signup and view all the answers

    What is the primary method for assessing amniotic fluid in a twin pregnancy?

    <p>Single largest vertical pocket on ultrasound</p> Signup and view all the answers

    Oligohydramnios refers to increased amniotic fluid in one twin.

    <p>False</p> Signup and view all the answers

    What condition is indicated when bladder visualization is normal in a twin with oligohydramnios?

    <p>Stage 1 TTTS</p> Signup and view all the answers

    The _____ system is activated in the donor twin during TTTS to maintain blood pressure and volume.

    <p>renin-angiotensin-aldosterone</p> Signup and view all the answers

    Match the stages of TTTS to their characteristics:

    <p>Stage 1 = Polyhydramnios: Bladder visible (oliguria) Stage 2 = Polyhydramnios: Bladder not visible (anuria) Stage 3 = Abnormal doppler study Stage 4 = Hydrops fetalis in one/both twins Stage 5 = Death of one/both twins</p> Signup and view all the answers

    What is the optimal timing for cervical cerclage surgery during pregnancy?

    <p>14-24 weeks gestation</p> Signup and view all the answers

    Progesterone can prevent preterm labor once uterine contractions have started.

    <p>False</p> Signup and view all the answers

    What cervical length measured by transvaginal ultrasound is an indication for cervical cerclage?

    <p>≤ 2.5 cm</p> Signup and view all the answers

    Hydroxyprogesterone caproate is administered via __________ injections, starting at 16-20 weeks gestation.

    <p>intramuscular</p> Signup and view all the answers

    Match the medication to its method of administration:

    <p>Hydroxyprogesterone caproate = Intramuscular injections Micronised progesterone = Vaginal administration Cervical cerclage = Surgical procedure Progesterone = Hormonal treatment</p> Signup and view all the answers

    What is a complication that occurs specifically in monochorionic twins?

    <p>Twin to Twin Transfusion Syndrome (TTTS)</p> Signup and view all the answers

    TTTS is more prevalent in DCDA twins compared to MCDA twins.

    <p>False</p> Signup and view all the answers

    What is the primary physiological change in the donor twin affected by TTTS?

    <p>Decreased renal blood flow</p> Signup and view all the answers

    In Selective IUGR, the affected twin is typically known as the __________ twin.

    <p>donor</p> Signup and view all the answers

    Match the following characteristics with the appropriate twin in TTTS:

    <p>Donor Twin = Anemia and oligohydramnios Recipient Twin = Polycythemia and polyhydramnios</p> Signup and view all the answers

    What is a common complication for twin pregnancies?

    <p>Preterm labor</p> Signup and view all the answers

    Vanishing twin syndrome occurs more commonly in singleton pregnancies than in twin pregnancies.

    <p>False</p> Signup and view all the answers

    What complications can arise due to vascular anastomosis in surviving monochorionic twins?

    <p>Hypotension, anemia, exsanguination</p> Signup and view all the answers

    In monochorionic twin pregnancies, congenital anomalies are more prevalent due to __________.

    <p>shared placental circulation</p> Signup and view all the answers

    Match the following conditions related to twin pregnancy with their descriptions:

    <p>Twin-to-twin transfusion syndrome = Occurs in monochorionic twins leading to congenital heart defects Vanishing twin syndrome = Early spontaneous reduction in a twin pregnancy Intrauterine growth restriction = Fetal growth that is less than expected for gestational age Congenital anomalies = Abnormalities that are present at birth</p> 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

    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:

    1. TTTS (Twin to twin transfusion syndrome)
      • TAPS (Twin anemia polycythemia sequence)
    2. Immediate delivery of both twins
    3. TRAP (Twin reverse arterial perfusion)
    4. 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

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    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.

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