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Multiple Pregnancy - Coggle Diagram
Multiple Pregnancy
Antenatal care:
- ALL MULTIPLE PREGNANCIES are HIGH RISK and care should be consultant led.
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- Routine use of iron & folate supplements
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- Advise aspirin 75mcg od (if additional risk factors for PE)
- Serial growth scans @ 28, 32 & 36 weeks for DC twins
- More frequent antenatal checks because of increased risk of PE
- Discuss mode, timing and place of delivery
- Establish presentation of leading twin by 34 weeks
- Offer delivery @ 37-38 weeks (IOL or LSCS)
- Surveillance needs to be more intensive for MC twins particularly <24 weeks or higher multiples (referral to specialist fetal medicine team is advisable)
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Aetiology:
- Previous multiple pregnancy
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- Ethnicity (Nigeria - 40:1000; Japan 7:1000)
- Assisted reproduction (clomiphene - 10%, IUI - 10-20%, IVF w/ 2 embryo transfer - 20-30%)
Labour:
- The 2nd twin is at increased risk of perinatal mortality, but it is not currently the case that all twins are delivered by CS.
- For labour, the leading twin should be cephalic (~80%), and there should be no absolute contraindication (e.g.: placenta praevia)
- Triplets and higher-order multiples are usually delivered by CS.
- Some authorities advise CS for MC twins.
- Intrapartum risks associated w/ multiple pregnancy:
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MCDA Twins Problems:
- Twin-to-twin transfusion syndrome:
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c) MC twins require intensive monitoring, usuallly in the form of serial USS every 2 weeks from 16-24 weeks and every 3 weeks until delivery.
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a) Growth discordance, even w/o TTTS
b) Very variable pattern of umbilical artery Doppler signals (increased AREDF - Intermittent absent/reversed end diastolic flow) indicates a high risk of sudden demise)
c) Treatment:
i. If >28 weeks, delivery is safest
ii. If <28 weeks, selective termination or laser ablation should be considered
- Termination of pregnancy issues:
a) Requires closure of the shared circulation so is normally performed using diathermy cord occlusion
- Twin Reversed Arterial Perfusion (TRAP)
a) One of the twin pair is structurally very abnormal with no or a rudimentary heart and receives blood from the other (umbilical artery flow direction is reversed), which is called the ""pump twin"
b) The normal twin may die of cardiac failure and unless the abnormal twin is very small or flow to it ceases, selective termination using radiofrequency ablation or cord occlusion is indicated.
- Intrauterine Death of a twin:
a) DC:
i. Death of one twin in 1st trimester / early part of the 2nd does not appear to adversely affect the remaining fetus.
ii. Loss in late part of 2nd / 3rd usually precipitates labour, with 90% having delivered within 3 weeks.
b) MC:
i. Because of shared circulation, subsequent death or neurological damage from hypovolaemia follows in up to 25%, where one of the pair dies.
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Diagnosis:
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- Uterus is larger than expected for dates
- Three or more fetal poles may be palpable at >24 weeks
- Two fetal hearts may be heard on auscultation
Chorioinicity:
- Obsviously widely separated sacs or placentae - DC
- Membrane insertion showing the lambda sign - DC
- Absence of lambda sign <14 weeks diagnostic of MC
- Fetuses of different sex - DC (dizygotic)
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Types:
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a) Division into 2 of a single, already developing, embryo.
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c) Whether they share the same amniotic membrane and/or chorion depends on the stage of development when the embryo divides.
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