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MRCOG PART 2 SBAs and EMQs

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Essay 347

ans to essay 347 Posted by anupama M.

A,

The first and foremost part of management is educating the patient about the diagnosis and its implications in the management in a non alarming manner.counsel her regarding the need of care in a consultant led obstetric unit,with good neonatal facilities Tell her that multiple pregnancy is a high risk pregnancy and needs extra surveillance in view of the greater chances of PIH,preterm labour,IUGR,PPROM,induction of labour,operative delivery and PPH.

AN ultrasound scan between 11-13w to be done,though it is already diagnosed as DCDA,ultra sound should also see for NT,because of the less reliabiliy of the serum markers of aeuploidy.

In case an invasive test is required amiocentesis is the only invasive test available from this gestational age and take care to sample from both sacs

An anomaly scan around 18-20 wks as routine

Monitor for blood pressure and proteinuria at every visit.

Serial growth scans from 24 wks,repeat at 28 weeks and 32 wks,then2-4 wkly as clinically indicated

The role of cervical length measurement routinely to detect preterm labour is controversial,educate the patient regarding the features of preterm labour and ask to seek obstetric care if any develops,corticosteroids should be given in such cases

Mode of delivery and timing should be discussed with the patient and decided by 36 weeks

Elective delivery at  37-38 weeks,route depending on other obstetric  indications

B,

First alert the unit and involve more staff in the care

Inform neonatologist,theatre staff,anaesthetist should a need for CS arise

Arrange for grouing and save blood

In labour continous electronic fetal monitoring is  done since this is a high risk pregnancy

Labour augmentation can be done if needed

Monitor progress of labour with partogram

Epidural analgesia is preferable due to chance of operative deliveries

After deliver of the fist baby which is cephalic,stop oxytocin if it was on flow,assess the second baby for presentation and FHS,clinically and radiologically if there is a clinical suspicion

If the second baby is non cephalic,ECV can be done provided membranes are intact

Once the presentation is confirmed,ECV done,allow labour to proceed as usual

Once engaged,ARM can be done to accelerate labour

Active managment of third stage  with oxytocics,early cord clamping and cord traction is essential

Neonatologist should be involved.

Posted by JMY R.

a) Chorionicity should be confirmed by present of lambda sign,and dating should be done. Crown rump lenght of the largest fetus should be used. Nuchal translucency of both twin should be measured as biochemical markers of aneuploidy is inaccurate in twin pregnancy. There is high risk of Pre eclampsia, and since she is nulliparous with twin pregnancy,T.aspirin 75mg daily should be started at 12weeks till deliveries. She should be reassed at next antenatal visit for risk of pre eclampsia where blood pressure and urinary protein is measured. She is at higher risk of Gestational diabetes mellitus,thus Modified glucose tolerance test should be taken. The risk of congenital anomaly is increase 2 fold thus detailed scan to be done at 20-22weeks of gestation. Risk of preterm delivery is increased 4-5fold thus urinary tract infection should be treated and screened at each antenatal visit. Fetal growth does not correspond well with symphysiofundal height,thus 2weekly growth scan need to be done from 24weeks onwards.

b) there is higher risk of postpartum haemorrhage,thus 2 large bore brannula 16gauge at least should be set and group screen and hold dispatched. This is high risk deliveries,thus consultant obstetrician should be informed. Senior midwife assign to monitor the progress of labour. Judicious use of oxytocin reduce the risk of PPH and uterine rupture. Fetal monitoring is difficult,thus internal CTG should be used for the presenting twin and external CTG for the second twin. Provision of epidural is important as possibilities of performing an internal podalic version should abnormal lie for second twin present . There is high risk of aorta caval compression due to twin pregnancy, thus parturient is encourage to be in left lateral position. Prolong labour should be avoided and partogram adherence is important to prevent PPH due to uterine atony. IV oxytocin 10iu should be made ready to initiate contraction after the delivery of first twin. Accoucher may be needed to stabilize the lie to longitudinal during Artificial rupture of membrane of second twin. Active 3rd stage of labour with cord clamping after 1 minute of life,and ergometrine injection should be initiated to prevent PPH. Neonatologist,p-referably 2 should be on standby to manage the babies,as well as provision of 2 neonatal cots and open hood.

Posted by miss T.

(a)

She need to be followed up in a dedicated multiple pregnancy clinic with a lead clinician. Multidisciplinary care will be implemented based on any added risks during her pregnancy. I will tell her about the implications of multiple gestation on her and her fetus for which she will need to be seen more frequently.

She will be given iron supplements for rest of her pregnancy and will be informed of expected increased pregnancy symptoms such as vomiting/nausea now, back ache, abdominal discomfort and breathlessness in late pregnancy and when to report to hospital.

She will be offered aneuploidy screening by nuchal translucency in next two weeks, as serum screening in twin gestation has poor sensitivity. And although there are more false positive cases with nuchal translucency in multiple gestation yet this is the best option for her because the sensitivity to detect Down’s is equal to that in singletons. If she need amniocentesis, she will be referred to tertiary care setting for appropriate mapping of twins before sampling and she will be informed that procedure-related miscarriage rate is not increased being multiple.

I will start for her aspirin 75 mg from mext week to continue till the end of her pregnancy as she is at moderate rosk of pre-eclampsia. The available evidence has proved that this is significantly associated with fewer incidences of pre eclampsia, pre term labour, fetal and neonatal mortality. She will be screened for Bp and proteinuria each visit and will be referred for specialist care should need arise. Also she will be screened for gestational diabetes with 75gm glucose tolerance test at 24-28 weeks. A detailed anomaly scan will be done at 20-22 weeks. If it is normal serial growth scan will be done 2-4 weeks from 24 weeks gestation.

She is at high risk of pre-term delivery but there is no reliable test that predicts it. She will be informed of warning signs to report like lower abdominal pain and tightenings, vaginal discharge. In event of threatened pre term labour corticosteroids will be given as singleton gestation, as there is no evidence to prove that their efficacy is limited and a higher dose is needed in multiple.

Mode of delivery and intrapartum care plan will be discussed, decided and documented in her case notes between 34-38 weeks by senior obstetrician.

 

(b)

Being a high risk labour (increase risk of PPH, asphyxia and operative delivery) she should deliver in a hospital with multidisciplinary care involving senior obstetrician, midwife, anesthetist and neonatologist. Continuous fetal monitoring should be applied and if there is difficulty tracing fetal scalp electrode for twin 1 and abdominal trace for twin 2 can be used. She should have venous access with blood taken for group and save. There is no contraindication to the use of epidural analgesia and it should be offered as there is more chance of operative delivery. Vaginal delivery will be recommended in her case with early re-course to emergency cesarean if there is evidence of fetal compromise or a difficulty tracing fetal heart for twin 2. Delivery should be conducted in operating theatre with facilities to do emergency cesarean if needed.

After delivery of twin 1, lie and presentation of twin 2 will be determined by abdominal pelvic examination or ultrasound. Options for abnormal lie are external or internal podalic version. External version has more chance to fail and internal podalic version with breech extraction has higher success. After lie is turned to longitudinal and oxytocin 5/10 IU in 500ml will be commenced and membranes will be ruptured once presenting part (vertex/breech) settles in the pelvis. If lie determination or correction to longitudinal lie is not possible, cesarean will be done. The delay of up to 30 minutes is acceptable between delivery of 1st and 2nd twin provided fetal heart is normal.

Active management of third stage will be done with oxytocin drip to continue for 6-8 hours.

ANS: essay 347 Posted by DCR R.

A.  At her first booking visit I would ensure that she has had a dating Uss, viability and chorionicity ( DCDA in her case )confirmed and that she has her routine antenatal blood tests done. I would councel the woman regarding twin pregnancy, pregnancy may be more challenging than a singleton pregnancy, need for more frequent antenatal visits and delivery in a consultant led unit. I would also explain the need for close surveilance as her pregnancy is at a higher risk of anemia, pre-eclampsia, IUGR, preterm labour & caesarean delivery. I will organise for her to have an aneuploidy screening by nuchal translucency measurement as soon as possible. This is more accurate in twin pregnancies as serum markers are not reliable. Also I will ensure that she has her anomaly Uss at 20 weeks and a growth scan every 4 weeks from then on to detect any IUGR.I will prescribe oral iron supplements if her Hb is less than 10.5g/dl and at every visit ensure that her BP and urine dipstick are normal. At 34-36 weeks of gestation I will discuss the mode of delivery with her and document it in her notes. She can be offered a vaginal delivery if the presentation of twin 1 is cephalic and if there are no other obstetric indications for a caesarean section. Delivery is usually planned at 38 weeks.

B. At 37 weeks if she presents in active labour I will confirm the presentation of the first twin is cephalic by examination and if in doubt by doing a presentaion scan. I would go through her notes and rule out any other complications, note the plan of delivery and inform the neonatologists. I would discuss analgesia with her (entonox, opiates, epidural ) and ensure that she is  comfortable. She will need continuous electronic foetal monitoring for both foetuses. Labour progress should be recorded on a partogram and if there is any delay in progress she should be assessed thoroughly and decision to start syntocinon for augmentation must be discussed with a consultant as she is at high risk of uterine rupture. After delivery of the first twin, syntometrine is witheld and the presenting part of the second twin is confirmed by USS. If the contractions are not strong syntocinon can be started with continuous monitoring. If cephalic ARM can be done and the baby delivered vaginally. If breech or transverse lie, internal podlic version can be done with intact membranes and the baby delivers by breech extraction. Indications for caesarean section are bradycardia with high presenting part, abruption and cord prolapse. Active management of the third stage is recommended as she is at high risk of PPH.

sofia Posted by sofia  S.

 

Ansa; modification in her antenatal care would include  multideciplinary care involving lead clinician with expertise in ultrasound and intrapartum care of  multiple pregnancy, specialist midwife and neonatologist. Ultrasound  between 11-13 wks for determination of major congenital anomaly and nuchal translucency for aneuploidy screen as serum screening is unreliable.if a definitive test is required like cvs or amniocentesis it should be carried out in fetal medicine centre.scan between 20-22 wks for structural anamoly.regular growth scan at 24, 28,32 wks and then 2-3 weekly thereafter.  BP  and urine analysis at 20,24,28 and then 2 weekly to screen for preecclampsia.iron supplementation would be required as these mothers are increased risk of anemia.educate about signs of preterm labour.dicussion regarding womans and family need relating to care of twin babies.mode of delivery and intrapartum care should be discussed at 34-36 wks. Elective delivery should be planned by 37-38 wks to avoid  late still antepartum still birth .place of delivery in hospital setting with facility for emergency LSCS, advanced neonatal resuscitation and blood transfusion.

 

 

 Ans b:options for mode of delivery will depend on the presentation of second twin which should be confirmed by ultrasound scan. If both cephalic  recommendation is to proceed for vaginal delivery. She would require one to one midwifery care. Room should be equipped with 2 neonatal resucsitare and ultrasound machine and delivery tray with extra clamps two oxytocin drips one with 10-15u in 500 ml to be used after delivery of first twin and other with 40 u in500ml for managmant of third stage..consultant obstetrician and neonatologist should be informed and supervised or delivered by personell experienced in managmant of twin delivery.. Iv access early in labour andFBC, group and save should be send as increased risk of pph.  Continous electronic monitoring and scalp electrode  for 1st twin as external monitor alone for both babies may be unreliable. emergency cesarean would be required if difficulty in monitoring FHR of second baby. regional analgesia  should be encouraged as higher risk for operative delivery.after delivery of 1st baby confirmation of presentation of second twin by internal examination or if doubtful by usg. No recommended time limit between two deliveries. Oxytocin can be started if contraction inadequate. Increased risk of cord prolapse if membrane rupture with presenting part still high up. Amniotomy can be done once head is engaged.  After delivery of second twin active management of third stage with 5 u oxytocin injection im followedby infusion as she is increased risk of pph.

Mode of delivery for vertex/nonvertex twin pregnancy is controversial.options should be discussed with the women depending on clinical scenario. First option to go for LSCS which is safer form the infants perspective but assosciated with risk of major surgery and anesthesia and implications for future pregnancy for mother.

Second option includes vaginal delivery of first followed by breech vaginal delivery.patient should be explained about risk of increased perinatal morbidity and mortality with breech vaginal delivery. Or 1st vaginal delivery followed by internal podalic version and breech extraction in case of transverse lie.expertise required with this,increased risk of cord prolapse,trauma to baby ,anoxia and uterine rupture. If unsuccessful a second stage cesarean section which itself is associated with higher morbidity. Role of external cephalic version after delivery of 1st twin is limited as success rate are low.

Postpartum assessment&  provision of thromboprohylaxis, contraceptive advise, support for breastfeeding and education on formula feed should be provided. Support groups like TAMBA and multiple birth foundation be provided.

 

ANS TO 347 Posted by SARO K.

 

Ans to essay 347:

(a)Modification to Antenatal care:

I will advise her multiple pregnancy needs frequent antenatal visits with the consultant led unit .I will offer Nuchal translucency between 11-13 weeks instead of serum screening for Down s syndrome screening as it has poor sensitivity in multiple pregnancy whereas detection rate of aneuploidy by  NT is similar to singleton pregnancy. Chance of false positive rate of NT is higher in multiple pregnancy.The procedure related miscarriage rate with amniocentesis and CVS is not increased but advised to be done in a Tertiary care center(RCOG).  I will get a anomaly scan done between 18+0 to 20+6 weeks by an EXPERT  as chances of congenital anomaly is high . I will offer iron supplementation if HB found to be less than 10.5 gm I will screen for gestational hypertension by assessing BP and proteinuria from 20 weeks every 4 weeks till 32 weeks and then fortnightly till delivery.I will offer screening for gestational diabetes by 24 -28 weeks by 75 gm OGTT .I will offer serial  ultrasound for growth assessment  from 24 weeks every 2 -4 weeks as SFH(singleton) is not useful due to overdistended abdomen .I will teach about the symptoms of preterm labour and report as early as possible.Role of predictors of preterm labour includes fetal fibronectin,cervical lengthmeasurement is not sensitive in detecting in case if multiple pregnancy.I will discuss about the implications of twins on social, financial and occupation at 32-34 weeks.I will discuss abt delivery and plan of care by 36 weeks.I will advise delivery  37 -38 weeks to prevent unexpected still birth whereas we can wait till 41 weeks in singleton pregnancy.I will offer sweeping of membaranes if she is not getting spontaneous onset if labour by 38 weeks.I  will discuss induction of labour if no spontaneous onset by 38-39 weeks.I will assess for risk for  venousthromboembolism and advise thromboprophylaxis as and when needed.I will ask her to attend anesthesia consult to plan type of analgesia  and neonate consult to discuss abt the neonatal care. I will plan her delivery in consultant lead unit with SCBU  facilities

Intrapartum:I will offer continuous electronic fetal monitoring  and  epidural analgesia. Early decision about fetal scalp monitoring if external CTG is not marking properly.Venous access early in labour with FBC ,group and save as chance of Post partun hemorrahage is high.I will inform experienced neonatologist and anesthetist.I will plan one to one midwifery care throughout pregnancy.I will get ready with two neonatal care sets to receive the baby .I will get usg machine ready for presentation of second twin.I will get oxytocin drip ready  with 10 u /500 ml of saline to use after delivery if second twin and 40u oxytocin to use after third stage.I will  confirm presentation after delivery of first twin by doing abdomen examination,p/v if still doubt confirm by scan.I will discuss the external cephalic version and internal podalic version  with the patient if second twin is non cephalic . If contraction are inadequate, I will start oxytocin and do ARM  after engagement  to prevent cord prolapse.I will plan operative vaginal delivery in the operation theatre  done by consultant.I will plan cs if fetal heart rate abnormalities or unable to achieve version.Active management of third stage  followed by oxytocin infusion with 40u for 6hrs postpartum to prevent PPH.

Posted by Samira  K.

a-Her antenatal care should be in hospital.She should be advised to take iron supplement together wth folic acid.Should be offered NT Scan at 13 wks and if  amniocentesis or CVS is indicated should be reffered to tertiary centre as it is challenging in twins .Offer detailed anomaly scan at 18-20wks and look for any sign of TTTS.More frequent antenatal visits.Growth Scans should be offered from 24 wks every 2-4 wks.If IUGR is suspected perform BPP and umblical artery dopplers every 2 wks.Screen for gestational HTN and gestational diabetes.Check presentation from 36 wks and discuss about mode of delivery,need to deliver in hospital .Inform that in case of noncephalic 1st twin,abnormal FHR of 2nd twin or if unable to correct lie of 2nd twin might need to go for emergency c-section.Inform about increase incidence of pretarm labour in twins and in case of any sign of preterm labour to report to hospital.Induction of labour can be performed at 38-39 wks to avoid antenatal still birth but its role is contraversial.Encourage her to take antenatal classes.In case of any complication like TTTS,IUGR or death of cotwin reffer to tertiary centre.

supprt women as with twins her symptoms of pregnancy like nausea ,vomiting,abdominal discomfort and backache will be exaggerated.

b-In labour patient should be admitted in hospital under supervision of senior obstetrician.Senior paediatrician and anaesthetist should be involved in patient care.Secure venous access and take blood sample for FBC,Type and save.Continous CTG monitoring and FSE applied as soon as possible for 1st twin.Deliver in Operation theatre.After delivery of 1st twin check fetal lie of second twin by palpation and ultrasound scan .If second twin is cephalic start oxytocin 10 units in 500ml of normal saline and allow desent of presenting part.If second twin is non cephalic perform ECV,internal podalic version or breech extraction.If failed proceed for C-Section after informed consent.Keep membranes intact as much as possible as there is possibility of cord prolapse.Active management of 3rd stage start 40-50 units of oxytocin in 500ml of normal saline for 6-8 hrs.

Support women during labour .

   

Posted by Muthu M.

She will need referral to antenatal clinic for her antenatal care under a Consultant.  She should continue to take the folic acid and could stop at 14weeks.  She will have booking investigations: serological tests such as rubella, syphilis, hepatitis, HIV and other tests like FBC, Blood Group save and antibody screen, haemoglobinopathies, random glucose level, MSU to have a baseline level as well as screen for any underlying risks which may require further management plan of care.  According to her BMI and BP, she is low risk apart from twin pregnancy finding.  We also need other booking history to rule out any other medical problems, smoking history, previous abdominal operations which might put her under high risk pregnancy.  The ultrasound finding with lambda sign which confirms the chorionic status should be kept in USG records for future reference.  She will nuchal translucency scan between 11 and 13weeks, 6days.  If she is found to be high risk for aneuploidy with 1st trimester screening and needs invasive procedures such as amniocentesis or chorionic villus sampling; it needs to done at fetal medicine unit; where there facilities for selective feticide available.  She is high risk for developing, pre-eclampsia, IUGR and pre-term labour.  She should be counseled properly and advised to contact labour ward with regard to any concern which may need immediate review like bleeding in pregnancy, abdominal pain, SROM.  She needs GTT at 24weeks of pregnancy to rule out gestational diabetes.  During her visit to every antenatal clinic she needs urine analysis for glucose, protein and BP check to rule out raising BP.  If urine analysis is positive for protein, leucocytes, nitrates – she needs MSU and treated appropriately to avoid pre-term labour.  In addition to detailed anomaly scan at 20 weeks, she needs regular growth scans at 24, 28, 32 and 36 weeks to monitor fetal growth and liquor volume to rule out IUGR.  We will discuss with her the mode of delivery during her antenatal visits.  She will be counseled for vaginal birth provided the first twin is cephalic presentation.  She may develop iron deficiency anaemia, she will have repeat FBC at 28 weeks and will need iron tablets if Hb is low.

She will have IV access and bloods for FBC and Blood G&S, at admission as she is high risk for PPH.  If the BP is raised she needs PET bloods, PCR value and regular blood pressure monitoring in labour.  She needs basic assessment at admission, urine analysis for protein, BP, CTG to check both fetus well-being and further plan of care should be documented by either by registrar on-call or senior obstetrician in labour ward.  The NNU should be informed.  She needs continuous monitoring and need a midwife to care for her through out labour as one to one care.  The pain relief in labour should be discussed and documented in the notes.  If patient agrees, early epidural could be given.  The progress in labour is monitored closely and reviewed by Obstetric registrar on-call at regular interval.  Any delay in progress should be reviewed and dealt appropriately.  If the labour progress well and the fetal monitoring shows both fetus are well; at 2nd stage of labour, we need 2 midwives, 2 paediatricians and labour ward registrar on-call to be present at the labour.  The delivery can be conducted at labour ward theatre or in a labour ward room depends on the unit’s preference and the protocol.  We should have a portable scanner available ready to check the lie and presentation of 2nd twin.  She need syntocinon 10units in 500ml of Normal saline for the delivery of 2nd twin, it may need to be started if the contractions stops after the delivery of the first twin.  We have to keep it ready, 40 units syntocinon in 500ml Normal saline for 3rd stage of labour as she is high risk for PPH. 

Once the twin one is delivered vaginally, after card clamping, the twin two’s presenting part – head should be stabilized at the pelvis (by ECV) and will have ARM with contraction; USG should be used in this process.  If no contractions occur 30minutes since delivery of the 1st twin, after ARM of 2nd twin membrane; start the 2nd stage syntocinon, and labour is allowed to progress accordingly.  However, the 2nd twin presents as either breech or transverse and not successful with ECV; will need delivery by emergency LSCS.  At the delivery of the 2nd twin, needs syntometrine and the placenta willl then be delivered.  Needs 40 units syntoinfusion for 3rd stage.  Patient needs Perineum, pervaginal and per rectal examination and needs suturing if necessary.

H H Posted by H H.

a) Proper and sensitive explanation of dichorionic diamniotic twin pregnancy. Seen in consultant led unit. Twin clinic would be optimal. If any doubt about chorionicity ,ultrasound photos to be seen by experts in fetal medicine unit ,chorionicity is best detected by ultrasound between 11 to 14 weeks.Nuchal translucency thickness(NT) is best seen at 13wk ,and is more valuable than serum screening tests in twin pregnancy for screening for trisomy. If there is abnormality in NT will refere her to fetal medicine unit for diagnostic tests( CVS Amnicentesis). Will do fetal anomaly scan at 20wk. Will start fetal growth scan from 24wk and repeat every 2-4 weeks. Patient will have more frequent antenatal visits.Patient is nulliparous and has twin pregnancy,so low dose aspirin given from 12wk till delivery,to reduce her risk of developing pre eclampsia and pre term delivery. BP monitoring weekly in the third trimester. Risk assessment for venous thromboembolism and thromboprophylaxis. Measures taken if has pre term labour( corticosteroids, neonatologist, place in SCBU,tocolytics used till corticosteroids have an effect and neonatal bed available). Scan for presentation late in pregnancy. Delivery plan, aim for vaginal delivery if first twin is cephalic, Cesarean if it is not. Give written information regarding twins and their care after delivery.

b)Patient will deliver in consultant led unit,with consultant informed. Intravenous line secured and group and save for possibility of post partum hemorrhage.Aim for vaginal delivery ,Cesaerean for obstetric complications. Epidural analgesia is offered ,as will make manipulation for delivery of second twin bearable. Continuous electronic fetal monitoring of both twins,with fetal scalp electrode applied after rupture of membranes for first twin. Avoid augmentation of labour. Partogram with assessment of cervical dilatation every 4 hr. Neonatologist available ,who can ask for help from collegues for care of both babies. Clamp cord after delivery of 1st twin.Feel presentation of 2nd twin, scan will aid in this and observe the CTG. Set an oxytocin drip if 2nd twin is is cephalic allowing vaginal delivery . Timing between both twins should not exceed 30 min ,despite there is cotroverse regarding this. Should the 2nd twin be breech or transverse, external podalic version done and allow for vaginal delivery. Should there be fetal compromise of 2nd twin or cord prolapse, internal podalic version and breech extraction done provided expertise in it present,other wise cesarean would be safer. Active management of third stage ,to reduce risk of post partum hemorrhage.

Srinivas Posted by Srinivas  A.
She should be managed in specialized twin clinic. Ultrasound between 11 -13 weeks is done for the measurement of nuchal translucency for screening of aneuploidy which has got similar sensitivity but high false positive rate compared to singletons. Serum screening for aneuploidy in twins has poor detection rate. If amniocentesis is planned, it should be undertaken in a tertiary centre. She needs frequent antenatal visits for close monitoring, as twins is high risk pregnancy with maternal risks ( hypertension, increased pregnancy symptoms, and hydramnios) and  fetal risks (prematurity, growth restriction) Structural anomaly scan is advised at 20-22 weeks as twin pregnancy is associated with increased risk of congenital anomalies. Screening for preeclampsia should be carried out by measuring blood pressure and urinalysis for protein at each antenatal visit. Screening for diabetes is undertaken by performing hourly oral glucose tolerance test at 24-28 weeks. Twin pregnancy is at risk of preterm delivery. The risks factors like UTI and bacterial vaginosis should be identified and treated. The presence of fetal fibronectin on cervical swab is less predictive of preterm delivery of twins compared to singletons. Serial growth scans are required at an interval of 2-4 weeks to monitor fetal growth and liquor volume. Corticosteroid administration for lung maturity in case of threatened preterm may be associated with limited efficacy. She may require iron supplementation as she at risk of anaemia due increased fetal demands. B) Twins is a high risk pregnancy and advised hospital confinement. As the first twin is cephalic, vaginal delivery is aimed. The presence of experienced obstetrician, neonatalogist, anesthetist is ensured  Early venous access is advised. Blood is sent for group and save as she may require operative intervention , due to increased risk of PPH. Delivery is planned preferably in the operation theatre with ultrasound immediately available. Epidural anesthesia is recommended to facilitate maneuvers to deliver the non vertex second twin and also to provide immediate anesthesia for intrapartum CS. Continuous fetal monitoring of both the fetuses is done and FSE monitoring of the first twin is undertaken as early as possible. If the monitoring of the second twin is inadequate CS is considered. Following the delivery of the first twin lie of the second twin is identified with the help of abdominal , vaginal examination and US scanning. second twin should ideally be delivered  within 30 minutes  after the first twin due to the risk of acidosis. External cephalic version is tried in case of non cephalic second twin. Success of external version is poor compared to internal podalic version and breech extraction which have a higher success rate with no increase in neonatal morbidity but require an experienced operator. CS is indicated if version fails or in the event of complications abnormal fetal heart rate or cord prolapse.
ANSWER TO ESSAY 347 Posted by DHARSHITHA J.

 

(a)Counsel the patient regarding the risks during the antenatal period(preterm labour, fetal anomalies, growth retardation, anaemia, PIH) and in labour(increased risk of interventions,PPH)

Early registration and referral to consultant led care and plan the delivery in hospital obstetric unit, and documentation of the birth plan in her notes are important aspects to arrange in eary pregnancy.

Nutritional advice and supplementation of folic acid (5mg daily)and ferrous sulphate throughout the pregnancy as there is a risk of nutritional deficiencies in multiple pregnancies,due to increased demand.

Perform the u/ssscan between 10- 13weeks to confirm the viability , to exclude gross fetal anomalies and more importantly to assess Nuchal Translucency.There is no place for serum screening for aneuploidies as invariably high serum markers present in multiple pregnancies. Measures should be arranged to refer to the nearest regional fetal medicine unit if the NT is increased in either of twins to consider and discuss amniocentasis and risks/ benefits.Amniocentasis is performed under direct u/s guidance to prevent the risk of injury to fetuses.

This mother requires frequent regular antenatal clinic visits and should be seen by a consultant with experience in management of twin pregnancy and its' complications.

BP and urinalysis should be performed in every ANC visit, due to risk of PIH / PET and should be assessed for any signs and symptoms of anaemia(pallor and tachycardia) and FBC needs to be performed regularly,in addition to the booking visit and 28weeks and more frequently if suspected anaemia and on treatment of anaemia.Patient is advised to admit to the hospital if any signs of preterm labour(tighetenings, bleeding PV) also sudden increase of the fundal height asosciated with abdominal pain to exclude acute polyhydroamniosis.

In addition to the routine anomaly scan , detailed fetal cardiac scan can be performed to exclude heart anomalies, around 20- 22wks as increased risk of fetal anomalies, in multiple pregnancies.

Fetal growth should be monitored by serial u.sscans since 24 weeks, every 2-4 weeks,to assess the growth and liquor, as abdominal palpation in twin pregnancy is unreliable.

Steroids can be considered if any signs of preterm labour, however according to the evidence, the routine dose seems inadequate.

Psycho-social support throughout the pregnancy to cope with 2 babies.

The delivery plan should be discussed at 34-36 weeks by the consultant obstetrician and early delivery is arranged in a hospital obstetric unit at 37- 38weeks due to increased risk of perinatal mortality and morbidity assosciated with multiple pregnancies.

(b)Needs delivery in an obstetric unit in the presence of the senior obstetrician at the time of the delivery.

Needs u/ s scan confirmation of the presentation of the first twin and exclusion of complications such as growth restriction of either of the twins prior to decide mode of delivery.

If the first twin is cephalic , and if no growth descrepancies the vaginal delivery can be considered despite of the presentation of the second twin. Otherwise emergency caesarian section is safer( eg . To prevent cord accidents and cord prolapse, locked twins)

Multidesciplinary involvement including the senior midwife, informing the anaesthetist and paediatrician and the theatre staff is required.

Dual monitoring of babies with continuous intrapartum CTG. Also needs to allocate two midwives for the intrapartum care.

Early IV access is established and blood is taken for FBC and group and save as higher risk of PPH.

Effective pain relief is provided with epidural, also this may helpful for various internal manouvres at the time of delivery of the second twin(internal podalic version).

Delivery ideally should take place in the theatre as risks to second twin may warrant for an emergency LSCS-catergory -1. Senior obstetrician and 2 paediatricians should be present in theatre.

U/S scan should be availaible in the theatre to ascertain the presentation of the second twin after the delivery of the first baby. If it is cephalic presentation can wait for nearly 20 minutes for spontaneous onset of contractions, if not oxytocin augmentation can be considered after the rupture of membranes as in a singleton pregnancy.

If it is transverse or breech presentation ECV or internal podalic version or emergency caesarian section can be considered depending on the expertise of the obstetrician.

The success of the ECV is less , however internal podalic version may assosciate with increased morbidity such as fetal trauma, uterine rupture, endometritis.

Active management of the third stage is carried out with using syntocinon 10unit as bolus and 30-40 units as infusion to prevent PPH.

Psychosocial support and breast feeding advice given in early pueperium to cope up with 2 babies, as postpartum psychiatric disorders and breast feeding problems are higher in multiple pregnancies.

Detailed documentation of the events and debreifing also important.

Posted by BHAWANA  P.

As she is DCDA twins, she is high risk pregnancy. I will make her aware that there is increase in all pregnancy symptoms like hyperemesis, anaemia, abdominal discomfort and she is high risk of developing high blood pressure, pre-eclampsia, diabetes and she needs close monitoring and frequent visits to hospital.

 Serum screening for Down's syndrome is inaccurate in twins so I will offer her nuchal translucency scan. This needs to be done by an expert or foetal medicine consultant. She needs to understand difficulties if there is raised NT for one of the twins and she goes for amniocentesis- risk of sampling errors and what will she do if one of them is diagnosed with aneuploidy.

As there is risk of Intrauterine growth retardation, discordant growth I will offer her regular growth scans- 4weekly from 24 weeks onwards and then 2 eekly from 32 week onwards. I will ascertain that she needs regular B.P and urine dipstick in all these antenatal visits as she is at risk of pre-eclapmsia, hypertension.I will make her aware of signs and symptoms of pre-term labour and advise her to seek help appropiately as twins have high risk of pre-term labour.At 34 weeks I will discuss about mode of delivery. The standard practice is to offer induction of labour at 37-38weeks if first twin is cephalic and to offer caeserean section if first twin is breech.

B) She will classed as high risk pregnancy in labour needing a experienced midwife to look after her in labour. I will inform anaesthesist, consultant obstetrician and involve neonatatogist as well is in labour so that appropiate preparatio can be made from neonatal side.She will be having continuous CTG monitoring. There can be difficulty in monitoring  so once membranes are ruptured , Fetal scalp electrode can be applied to first twin and appropiate monitoring can be done.

labour should be allowed to progress as per intrapartum guidelines and avoid unnecessary delay. I will advise her that regional anaesthesia could be better mode of pain relief especially if 2nd twin needs any intervention like turning the baby or instrumental delivery.

I will ensure that she has Iv access and G&s done in view of high risk for Post-partum haemorrhage.During delivery of twins experienced staff like team co-ordinator and senior obstetrician should be around. During delivery of 1st twin I will ask midwife to stabilize the lie of 2nd twin (if cephalic)as if there is  more space second twin can change  its lie.

She can be given around an hour to deliver after 2nd twin . If progress is slow, oxytocin augmentation can be done. If there is any signs of fetal distress- safest mode of delivery should be opted as per expertise of the obstetrician- instrumental delivery for cephalic, vaginal breech delivery, internal podalic version and breech extraction or emergency caserean section.There is increased perinatal mortality associated with internal podalic version and breech extraction like cord prolapse,fetal trauma and death and it is dying practice among obstetricians because of limited opportunitis for training. immediate caserean section is most favourite route adopted generally and theatre staff need to be aleted appropiately.

I will be aware of risk of post-partum haemorrhage and will do active management of second stage- early cord clamping,controlled cord traction, 5-10 iu of  syntocin or 5iu of ergometrine according to local protocol.

 

Answer to Essay 347 Posted by Colin M.

(a) Modifications to antenatal care

 I would explain to her that her type of pregnancy, dichorionic diamniotic pregnancy, is the lower-risk type of twin pregnancy (compared with monozygotic) but nonetheless it is associated with a higher risk of complications than singleton pregnancy such as anaemia, hyperemesis, musculoskeletal pain, miscarriage, stillbirth, pre-term labour, pre-eclampsia, post-partum haemorrhage and a higher chance of requiring a caesarean section, and that because of this she would require consultant-led care with frequent monitoring.

I would discuss the limitations for mid-trimester screening, that serum screening with AFP to assess risks of chromosomal disorders and neural tube defects is unreliable in multiple pregnancy, and would therefore offer her a nuchal translucency scan to assess the risk of Down syndrome at no later than 13+6 weeks (with or without the offer of amnioscentesis depending on the result that should be performed in a tertiary fetal medicine centre with facilities and staff to terminate an affected fetus) and a detailed anomaly scan at 20 weeks to assess for neural tube defects. She should also be offered a seperate scan for fetal echocardiography at 22 weeks. In addition serial growth scans, every four weeks, should be arranged from 24 weeks gestation to monitor growth. Regular antenatal appointments should be made and she should have regular monitoring of her blood pressure and urinalysis to detect pre-eclampsia.

She should be routinely commenced on iron replacement therapy (ferrous sulphate 200mg three times daily)at booking due to her higher risk of develoing anaemia.

At 34-36 weeks I would arrange to discuss delivery with her. I would recommend delivery (if not spontaneous) by 37-38 weeks as per RCOG guidelines, and the importance of knowing the presentation of the first twin beforehand in order to help decide the appropriate mode of delivery. I would emphasise that delivery must be in a consultant-led obstetrics unit.

 

(b) Modifications to her intra-partum care given that she presents in spontaneous labour at 37 weeks with cephalic presentation of twin 1

Due to the first twin being cephalic, the goal should be vaginal deliveries of both twins in the presence of a consultant obstetrician and experienced midwives. Continuous fetal monitoring for both twins is necessary and ideally a fetal scalp electrode should be used for twin 1 to ensure that two seperate fetal hearts are heard. If there is any concern regarding the CTG of twin 2 then an emergency caesarean section should be preformed. An early epidural anaesthetic should be recommended due to the high chance of obstetric intervention, internal manouvres, and discomfort. Due to the high risk of postpartum haemorrhage, she should have IV access with a wide bore cannula, and blood sent for full blood count and group and save.

Delivery should be in the operating theatre in the presence of a consultant obstetrician and anaesthetist and senior midwifery staff. After delivery of the first twin, the lie of the second twin should be stabilised to longitudinal, and a portable scan present to confirm the lie and position (cephalic or breech). Syntocinon (as per protocol) should be commenced to produce better contractions to aid descent of the second twin, If cephalic and low enough down then the membranes should be ruptured and an FSE applied, and spontaneous delivery awaited or instrumental delivery if any maternal or fetal compromise. If non-cephalic then the options would include external cephalic version,  breech extraction, internal podalic version (ideally with intact membranes for twin 2) and breech extraction (with recognised increased complication rate including cord prolapse, uterine rupture, fetal trauma) or caesarean section of the second twin if neither method successful and delivery necessary. Ideally the interval between delivery of the 2 twins should not exceed 1 hour and continuous CTG monitoring throughout is mandatory. Active management of the third stage of labour with 10 units of IV syntocinon and controlled cord traction is needed to reduce the risk of postpartum haemorrhage. One person should be designated to keep a written record of events and times for the casenotes.

 

 

 

essay 347 Posted by Sherif N.

a) this patient antenatal care should be done in an obstetric asessment unit, not midwifery unit, as her pregnancy is high risk with increased possibility of complications as increase risk of PIH, gestational diabetes, oligohydramnios/ polyhydramnios, IUGR, congenital anomalies.

UUS should be done at 11 weeks to measure NT, then at 16weeks to detect twin to twin transfusion and its management by laser ablation if occured and causes manifestations in the form of oligohydramnios, oliguria, decreased weight of donor twin, and polyhydramnios, heart failure, increased weight of recepient twin

after 16weeks, the possibility of twin to twin transfusion is limited, so USS to detect cardiac anomalies is to be done at 20weeks, then serial growth scans starting from 24weeks

more frequent ANC visits (every 3weeks in 1st and 2nd trimester, every 2weeks from 28-32weeks, then weekly) to measure her BP, Body weight, urine dip stick for proteinuria for early PIH detection. also 75gm GTT at 16 and 20weeks for early gestational diabetes detection, FBC monthly to detect anemia

advice the patient about proper and adequate fod intake both quality and quantity, and nutritional supplementation by multivitamins, calcium and iron to avoid any deficiency

explain to her that she should have hospital and not home delivery as her pregnancy and labour are high risk, also she should be taught about the importance of going to hospital as son as ROM occurs due to high risk of cord prolapse

abdominal, PV and USS at 36weeks to detect presentation of 1st twin and if cephalic, allow for vaginal delivery, but if not, so option of elective CS should be discussed with the patient

b) patient should be under continuous electronic fetal monitoring

active management of 1st stage of labour to allow vaginal delivery of the 1st cephalic twin, then examin the presentation and position of 2nd twin, if it is cephalic, then do ROM, give oxytocin IV drip and allow delivery of 2nd twin vaginally. if it is non-cephalic (breech or transverse) then try ECV (don't do IPV) if succeeded and baby becomes cephalic, then vaginal delivery should be proceeded quickly to avoid return of the abnormal presentation, if head is still high, instrumental delivery is tried, if ECV failed, or if arm prolapse, or uterus contract and cx reform over the 2nd twin, then emergency grade I cesarean section is done

active management of 3rd stage of labour with administration of methergine IM, oxytocin IV drip or syntometrine to avoid the occurence of postpartum haemorrhage (due to increase risk of atonic uterus from overdistension)

close observation of vital sighns, uterine contraction and vaginal bleeding in the early post partum period for early detection of any sign of atonic postpartum haemorrhage and so early management

 

a) this patient antenatal care should be done in an obstetric asessment unit, not midwifery unit, as her pregnancy is high risk with increased possibility of complications as increase risk of PIH, gestational diabetes, oligohydramnios/ polyhydramnios, IUGR, congenital anomalies.

UUS should be done at 11 weeks to measure NT, then at 16weeks to detect twin to twin transfusion and its management by laser ablation if occured and causes manifestations in the form of oligohydramnios, oliguria, decreased weight of donor twin, and polyhydramnios, heart failure, increased weight of recepient twin

after 16weeks, the possibility of twin to twin transfusion is limited, so USS to detect cardiac anomalies is to be done at 20weeks, then serial growth scans starting from 24weeks

more frequent ANC visits (every 3weeks in 1st and 2nd trimester, every 2weeks from 28-32weeks, then weekly) to measure her BP, Body weight, urine dip stick for proteinuria for early PIH detection. also 75gm GTT at 16 and 20weeks for early gestational diabetes detection, FBC monthly to detect anemia

advice the patient about proper and adequate fod intake both quality and quantity, and nutritional supplementation by multivitamins, calcium and iron to avoid any deficiency

explain to her that she should have hospital and not home delivery as her pregnancy and labour are high risk, also she should be taught about the importance of going to hospital as son as ROM occurs due to high risk of cord prolapse

abdominal, PV and USS at 36weeks to detect presentation of 1st twin and if cephalic, allow for vaginal delivery, but if not, so option of elective CS should be discussed with the patient

b) patient should be under continuous electronic fetal monitoring

active management of 1st stage of labour to allow vaginal delivery of the 1st cephalic twin, then examin the presentation and position of 2nd twin, if it is cephalic, then do ROM, give oxytocin IV drip and allow delivery of 2nd twin vaginally. if it is non-cephalic (breech or transverse) then try ECV (don't do IPV) if succeeded and baby becomes cephalic, then vaginal delivery should be proceeded quickly to avoid return of the abnormal presentation, if head is still high, instrumental delivery is tried, if ECV failed, or if arm prolapse, or uterus contract and cx reform over the 2nd twin, then emergency grade I cesarean section is done

active management of 3rd stage of labour with administration of methergine IM, oxytocin IV drip or syntometrine to avoid the occurence of postpartum haemorrhage (due to increase risk of atonic uterus from overdistension)

close observation of vital sighns, uterine contraction and vaginal bleeding in the early post partum period for early detection of any sign of atonic postpartum haemorrhage and so early management

 

can we have another 2 SQE's please Posted by H H.

Dear Paul, can we have another 2 essays with model answers please

Posted by HAnaa B.

A

Modification of her antenatal care should include, booking in a unit lead by consultant with special interest in multiple pregnancy. Folic acid with iron is to be used, explain the diagnosis and the risk accompanied with twins in an easy way without threatening, support her increased symptoms of pregnancy prescribe anti emetics in severe cases .explain that she has to do NT at 13 weeks which is superior to maternal serum in predication of anopleudy, although low sensitivity. in case of abnormality amniocenteses to be done in tertiary centre under us guide. Selective feticide can be done with risk of miscarge and 2ndtwin death, detailed us at 18-20 weeks should be done to exclude anomalies by experienced physician for both twins , risk of congenital anomalies is doubled than singleton, patient should knowthat her risk of preterm labor is increased treatment of asymptomatic bacteruria is very important, fibrinectn from the cervical discharge is considered good negative for suspected cases of preterm labor. Controversies about circulage of the cervix , didn’t show much benefit than doing nothing in low risk cases where cervical length is more than 3 cm.bed rest has no role in decrease preterm labor

Patient is at increased risk for diabetes and preeclampsia. She should be screened against them frequent, regular visits to the antenatal clinic is very important. Twins is at increased risk of discordant growth so 2-4 weeks growth scans till 34 weeks is highly indicated. Steroids after 24 weeks should be considered. Neonatologist should be involved in the team of her care.

Mode of delivery should be discussed according to her wishes and the position of the first twin. Vaginal delivery is considered if 1stis cephalic.

Social worker and breast feeding specialist should be also involved to insure good maternal and fetal care latter with prospect to breast feeding latter on.

B

Intrapartum care at 37 weeks with cephalic 1sttwin, vaginal delivery should be the aim, unless any abnormality in the fetal tracing.

Hospital delivery is to be considered, senior stuff should handle her case,. Save serum, iv line from the 1ststage, epidural should be considered risk of operative delivery in high.

Progress of labor is monitored until the delivery of the first twin in double sitting inside the OR. Assessment of the lie of the 2ndtwin by abd , vaginal and us , ECV is tried 48% success rate. 30 minutes is allowed after the delivery of the 1sttwin if succeeded ECV oxytocin is started and rupture of the membrane of the 2ndtwin if the pp is in the pelvis. internal podalic version with breech extraction can be tried if experienced physician is available or delivery by cs if failed  or any abnormality of the fetal heart, risk of asphyxia ,cord prolapsed ,fetal trauma , wrong delivery of hand or shoulder and  endometritis is increased. Active management of the 3rdstage of labor to decrease blood loss. start  oxytocin 40-50 units after delivery. Or stuff should be alerted throughout labor process. Social patient should be motivated and psychologically supported and reassured all through labor. 

EssaY Posted by j  .

J reply

a.I will ensure patient has aneuploidy screening by NT scan since serum screening is not  reliable in multiple pregnancy.Patient care will  be consultant lead in a multiple  pregnancy clinic.Structural anomaly  scan is done at 20 -22 weeks because of increased eisk of anomalies in multiple pregnancy.Growth san will be done from 24 weeks every 4 weeks because of increased growth discrepancies and difficulties in clinical assessment.I will be vigilant for PET and anaemia.Bp monitoring and urine dipstick for protein will be done  from 20 weeks.Plan for delivery and intrapartum care will be discussed  with the woman around 34 weeks.

b.Patient needs iv access in labour because of increased risk of PPH.Continuous monitoring of both the babies will be done.Adequate pain relief including epidural will be discussed with the patient because of increased operative morbidity  if 2 nd twin not cephalic.Aim for vaginal delivery since first twin is cephalic.As soon as fisrt twin is delivered I will confirm the presentation  with USS.If second twin is transverse ,will try external cephalic version or internal podalic version.After stabilisation of cephalic presentation oxytocin will  be started.If this fails caessarean section  willbe advocated.In case of second twin as breech ECV,or delivery as breech can be done .If fetal distress present and delivery is not imminent caessarean section will be done.Delivery can be conducted in LWS or theatre depending on hospital protocol.Paediatrician presence will be ensured  because of risks of twin delivery.Active managent of third stage of labor will be done to prevent PPH. 

ash Posted by anuradha N.

A healthy 27 year old nulliparous woman attends the antenatal clinic at 11 weeks gestation. She has a dichorionic diamniotic twin pregnancy. Her BMI is 24 kg/m2 and her BP is 110/60 mmHg with no proteinuria. (a) Discuss your modifications to her antenatal care [8 marks].

she requires care under a multidisciplinary team involving, specialist obstetrician, specialist midwife, ultrasonographer having knowledge and experience in multiple pregnancy. she would also require enhanced care referrals to, womens health physiotherapist, infant feeding coordinator, dietician and perinatal mental health specialist. i will offer her aspirin 75mg starting from 12 weeks to birth for reducing the risk of preeclampsia. i will offer screening for chromosomal abnormalities in the form of combined test between 11wks to 13-6wks after counselling that she is at a higher risk of false positive test and a higher possibility of requiring an invasive test. there is no role of triple or quadruple testing in midtrimester. i would suggest at least 8-10 antenatal visits with at least 3 visits at the obstetric clinic. symphysiofundal height charting is unreliable in twin pregnncy. in view of twin gestation she is at a higher risk of anemia hence i will offer and additional screening for anemia(FBC) at 20 wks(in adiition to 12wks and 28wks).  In addition to the structural anomaly  ultrasound at 20 wks i will offer serial growth ultrasound scans at 24,28,32,36 wks of gestation. in view  of multiple pregnancy she is at a higher risk of preterm labour, hence i would council and provide written information regarding identifying symptoms of preterm labour.  no evidence to support the role of cervical assessment or untargetted corticosteroids. Referal to a fetal medicin e specialist would be considered in the presence of discordent fetal growth (>25% differance using 2 parameters), anomaly in one fetus, death of single fetus. i will consider delivering her at 37wks of gestation. 

(b) Discuss your modifications to her intra-partum care given that she presents in spontaneous labour at 37 weeks with cephalic presentation of twin 1 [12 marks].

Labour and delivery should be in an obstetric unit where immediate acces to caesarean section is available if necessary., since there can be difficulty in delivering the second of the twin and she is at high risk of post partum hemorrhage. continuous electronic fetal monitoring is indicated. If monitoring of fetal heart of twin 2 is doubtful, caesarean section should be offfered. fetal scalpe electrode should be cited as early as possible for monitoring of the leading twin. Iv access obtained and group and save blood. Epidural anesthesia should be offered since this will also fecilitate, manouvers in the second stage of labor. ensure availability of ultrasound in second stage, for confirming the lie of second of the twin after the delivery of 1st twin. deliver in the operating theatre and ensure the presence of consultant obstetrician, anesthetist and pedistrician during delivery. Progress of labour is monitored in the same way as for  a singleton  pregnancy. the delivery of the first baby is conducted in the same way as a singleton vertex delivery. after that ultrasound is performed to identify the lie of the second twin. if vertex, oxytocin augmentation is started with continuous monitoring of fetal heart. once uterine contractions are well establised and the fetal head is descended, membranes are ruptured and delivery expedited. if the second twin is transverse or breech, options are external cephalic version and delivery by vertex presentation. however ECV in labor has a higher failure rate and eventually may require caesarean delivery for the second twin. in the presence of adequate expertise, one may consider internal podalic version and breech extraction, however this procedure  carries significant risks like, cord prolapse, inadvertant hand or shoulder delivery, fetal trauma. Caesarean section for the second of the twin is indicated in cord prolapse, acute fetal compromise with a high head, non vertex presentation with fetal compromise. Active management of third stage of labor should be done. 40IU oxytocin in 500ml infusion continued post third stage for at least 6 hours, to counter atonic post partum hemorrhage

Posted by Bee Fong C.

I am sorry this is a bit late.

(A)  This is a high risk pregnancy and the patient needs to be under consultant led care in a multiple pregnancy clinic. The risk of this pregnancy needs to be explained to her as it is associated with increased risk of pre-eclampsia, fetal growth restriction, preterm rupture of membrane and labour, abruption and postpartum haemorrhage. The woman's and family's needs relating to twin pregnancy should be discussed as well early in the pregnancy.

       She should be offered nuchal transluency as biochemical screening is not accurate. If it is abnormal, she should be referred to the fetal maternal medicine department for karyotyping with choriovillus sampling at 10 to 13 weeks or amniocentesis at 15 weeks onwards. After 20 weeks anomaly scan, 4 weekly scan should be offered from 24 weeks to monitor growth acceleration, liqour volume and umbilical arteries dopplers. This is because of the risk of fetal growth restriction and not identifiable with measuring symphysial fundal height. 

      75mg aspirin should be given from 12 weeks to delivery to reduce the risk of pre-eclampsia as this is her first pregnancy and mutliple pregnancy. Blood pressure and urine dip for proteinuria should be performed 20, 24, 28 weeks and then fortnightly to identify pre eclampsia at an early stage.

     The patient should be informed of this symptoms and signs of preterm rupture of membrane and labour. Information on contacting the hospital should be provided in case of emergency.

     The delivery should be directed to the presentation and lie of the twin 1. Discussion about delivery should take place around 34-36 weeks. Elective delivery should be planned for 37-38 weeks. Induction of labour and vaginal delivery is not contra indicated in uncomplicated twins where twin 1 is cephalic. 

(B) Early intravenous access with bloods taken for full blood count and group and save of her blood group should be performed. Adequate pain relieve should be offered. This includes epidural as she may require interventions in the deliveries of the babies. Continuous electronic fetal monitoring should be used throughout the labour. It may be difficult to differentiate the heart beats separately and a fetal scalp electrode may need to be used. Dedicated midwife should be allocated to ensure continuing care and support. 

       Progress of labour should be adequate and syntocinon infusion may need to be started if there is inadequate contractions. Two midwives should be present at delivery. The most senior obstetrician should be a standby because delivery of twin 2 may be difficult. The anaesthetist and consultant obstetrician oncall should be informed. Theatre staffs should be at a standby if there is a need for emergency caesarean, in particular after the delivery of twin 1. 

       Once twin one is delivered, syntocinon infusion should be started to build up the contractions again. The lie and presentation of twin 2 is confirmed with ultrasound scan and vaginal examination. Twin 2 should be stabilised in longitudinal lie.

      Membrane is ruptured only when the presenting part is in the pelvis. If there is oblique or transverse lie, an experienced obstetrician can perform a internal podalic version with breech extraction. External cephalic version can also performed at this stage according to the experience of the obstetricians.

       As there is high risk of postpartum haemorrhage, active 3rd stage should be advocated.

      

Essay 347 Posted by Reena G.

a)As she is high risk pregnancy  she requires multidisciplinary care with lead clinician senior obstetrician, anesthetist, neonatologist and midwife.Dating and chorionicity is already confirmed as given dichorionic and diamniotic and I would go for nuchal translucency for aneuploidy screen as serum screening is unreliable in multiple pregnancy.I would educate her that if definitive test is required then it should be carried in Tertiary centre and will tell her that procedure related loss is not increased. All booking investigations includind Fbc, haemoglobinopathies, viral screen , blood group , LFT , RFT  for baseline to be done. Iron and folic acid to be started as increase risk of anemia. Educate about increase risks of nausea vomiting and backache and to treat accordingly.Multiple pregnancy has 2 fold increase risks of congenital anomaly so a scan between 20-22 weeks  for structure anomaly to be done . She needs regular growth scan from 24 weeks every 2-4 weeks as symphyseal fundal height measurement  is no more reliable. Blood pressure and urine protein  to be done every visit to screen for Preeclampsia as increase chances in multiple pregnancy. To start aspirin 75 mg  from 12 weeks till delivery to decrease the risk of preeclampsia , preterm labour , neonatal and fetal morbidity.To educate about symptoms of preterm labour and to  treat Urinary tract infection  as can be a cause of preterm labour, also to discuss need of corticosteroids and in utero transfer  in case of unavailability of beds. I will also discuss with the woman and her partner regarding mode of delivery and intrapartum care at 34-36 weeks  and also place of delivery in hospital setting with facility for emergency cesarean , blood transfusion and neonatal resuscitation. I will also discuss regardingelective delivery at 37-38 weeks to avoid late still birth  and will discuss regarding care of  twin babies after delivery

b)As she presented in labour at 37 weeks  with 1st twin in cephalic presentation , in view of PPh, asphyxia and operative delivery I will involve senior obstetrician , midwife, neonatologist ( preferably 2) and anesthetist  in her intrapartum care.Venous access  with group and save  to be done as early as possible . continuos Fetal monitoring  to be done if difficulty then 1st twin by fetal scalp electrode  can be done. Labour closely monitored by partogram. Use of epidural analgesia as more chances of operative delivery, delivery to be conducted in O.T. with all necessary preparation for cesarian should the need arise. Arm to be done  and labour can be augmented with oxytocin , deliver the 1st baby by vertex , stop oxytocin and hold methergin , check the presentation and lie of 2nd twin by abdominal ,Vaginal examination and by scan, correct the lie by ECV , start syntocinon and deliver by vertex, if ruptured membranes then deliver by IPV if have expertise in it otherwise if any fetal compromise, cord prolapse and placental abruption deliver by cesarean section. Active management of third stage labour with  early cord clamping, CCT and oxytocin and methergin . Postpartum education about early breast feeding, thromboprophylaxis assessment, ambulation, hydration and to encourage to pass urine.

Posted by Yingjian C.

a) Dichorionic diamniotic twin pregnancy has increased risks compared to that of a singleton pregnancy hence closer surveillance in pregnancy is required with increased number of antenatal visits. This may be undertaken at a unit with specialists in this field. Confirmation of chorionicity is important and should be undertaken between 10 to 13wks gestation by identification of the lambda sign at the placenta membrane interface as monochorionic twins have a higher complication rate. At the same time, viability can be confirmed and any major fetal abnormalities identified. First trimester screening for Down’s Syndrome will be done by nuchal translucency screening only as the serum tests would not be as accurate. NT screening would be more challenging as the false positive rates are higher. A fetal anomaly screening scan would be offered at 20 weeks as there is higher rate of congenital malformation in twins. I would also offer serial growth scans comprising of head and abdominal circumference, amniotic fluid levels and umbilical artery Doppler studies every 2 to 4 weekly from 24 weeks to screen for discordant growth in twins, which may need more intensive monitoring. In view of her being at moderate risk for developing pre eclampsia (this being her first pregnancy and a twin pregnancy), I would offer her aspirin at 100mg daily from 12 weeks until the birth of the babies. She would also be at higher risk for venous thromboembolism in view of her twin pregnancy. I would enquire about other risk factors of VTE and administer thromboprophylaxis according to the guidelines. Her risk for VTE would need to be reassessed if she gets admitted to hospital or if she develops any concurrent illness. During her antenatal follow up visits, I would enquire about pregnancy symptoms such as nausea and vomiting in early pregnancy and backache, shortness of breath and abdominal discomfort as these can be more marked in twin pregnancies. I would also offer her an oral glucose tolerance test to screen for gestational diabetes mellitus between 24 to 28 weeks gestation. I would counsel her about the increased risks associated with her pregnancy and to alert her regarding symptoms of preterm delivery so that she can seek prompt medical attention.    

 

b) She would be advised to deliver at a consultant led obstetric unit in hospital. She would be allowed to deliver vaginally if twin 1 is cephalic and there are no contraindications to a vaginal delivery. She would be encouraged to have epidural analgesia in labour and continuous fetal heart rate monitoring for both twins. Venous access would be established and blood investigations taken for full blood count, group and save. An experienced obstetrician, anesthetist and paediatrics team would need to be available for delivery. Delivery is best undertaken in the operating theatre so that Caesarean delivery can be performed swiftly if indicated. Fetal scalp electrode monitoring should be considered for twin 1. After delivery of twin 1, the lie of twin 2 should be determined by abdominal palpation and confirmed by ultrasound examination. If twin 2 is not in a longitudinal lie or cephalic presentation, the lie/ presentation can be corrected either by external cephalic version or internal podalic version. ECV has a higher failure rate than IPV, but IPV and breech extraction need to be performed by an experienced operator as there can be serious complications such as cord prolapse, delivery of hand or shoulder, associated with fetal hypoxia and placental abruption. Upon correction to longitudinal lie, oxytocin can be commenced according to protocol and the presenting part allowed to descent. Membranes are ruptured once regular contractions are present and the presenting part is engaged. The fetal heart rate of twin 2 should be monitored continuously throughout, the interval between delivery of twins 1 and 2 should not be longer than 30 minutes in general. Caesarean delivery should be done if there are signs of fetal compromise  or inability to correct the abnormal lie/ presentation. Active management of the third stage of labour should be undertaken after delivery of twin 2 in view of higher risks of postpartum hemorrhage. An oxytocin infusion should be commenced after delivery of twin 2 and maintained for 6 to 8 hours post delivery. 

Mohanad Posted by vanosch M.

 

a)

This patient is still high risk patient, despite normal BP. I will explain to her in lay man language the finding and all risks and potential complications of twin pregnancy which may include preterm delivery, PET,FGR,  possible need for caesarean section and PPH.I will advice her for regular follow up, During each follow up visit her BP should be checked with urine dipsticks and weight.  Blood work up should be drawn for blood type and Rh status  FBC, U&E, thyroid function test, fasting glucose and antenatal screening tests including hepatitis B virus and offer her HIV screening test.

Anomaly ultrasound scan should offer at 18-20 weeks gestation, then ultrasound for growth every 4 weeks or less with or without UA Doppler if there is suspicion of FGR.

Folic acid is advised for the first trimester and iron supplementation as indicated by lab results. Screening for GDM is preferred at 20 weeks. Patient should be educated about symptoms and signs if PTL & PPROM as these are increased with twin pregnancy. If she has PTL  and /or PPROM before 34 weeks, corticosteroids should be given to enhance fetal lung maturity and tocolysis medications if indicated and referred to a hospital with NICU facilities. 

b)

Aim for vaginal delivery.  After explaining the possibility of caesarean section for the second twin if he/she has abnormal presentation. However, if patient requests to have caesarean section, this should be respected and supported.

If she opts vaginal delivery, she should have continuous fetal monitoring  for each twin during labour.

Labour augmentation is not contra-indicated if needed. Neonatologist should be informed and should attend the delivery. Epidural is offered for the management of labour pain and it should be recommended as it is suitable for caesaren section if needed by top- up.

 After the delivery of the first twin, second twin presentation should be assessed. If the second twin is non-cephalic ECV should be offered and if this was not successful caesarean section or vaginal breech delivery will be the options which should be given to the woman to choose.

If vaginal delivery is performed active third stage management of the second twin is recommended as it will reduce the risk of PPH. After delivery patient should be monitored and vigilance should be maintained as there is risk of PPH.

Breast feeding is encouraged and contraception advice is given.

 

Mohanad Posted by vanosch M.

Dear Dr Paul could you please mark my essay 344 &345 as I uploaded them late because there was a proplem with internet in my area and I could not send them earlier.

thanks you

NA Posted by naila A.

 

  1. Twin pregnancy is associated with increased risk for the mother and fetuses therefore she need booking in obstetric clinic with multidisciplinary management including obstetrician, neonatologist, specialist midwife and ultrasonologist. I’ll discuss with her the implications of this diagnosis .I’ll inform her that she is at increased risk of developing pregnancy induced hypertension, gestational diabetes, iron deficiency anemia and preterm labor. The fetuses are at increased risk of having congenital anomalies as compared to singleton pregnancy and increased neonatal mortality and morbidity due to preterm labor and delivery. I’ll inform her about signs and symptoms of preterm labor and advice her to take light work if it is possible to prevent chances of preterm labor. Other interventions to prevent preterm labor like prophylactic cervical circlage , measurement of vaginal fetal fibrinoectin or serial ultrasound assessment of length of cervix are not recommended. I’ll advice NT for both twins to assess the risk of aneuploidy .Serum screening will no be advised as it is less reliable in twin pregnancy. I’ll request an anomaly scan at 18 to 20 weeks .I’ll ask for serial growth scan at 2 to 3 weeks interval from 24 weeks onwards as twins are at increased risk of developing growth restriction. I’ll put an agreed upon plan of delivery between mother and obstetrician by 32 to 34 wks in her file. The delivery will be planned by 37 to 38 wks in case of a smooth and uncomplicated pregnancy.
  2. She need multidisciplinary management. Senior obstetrician, pediatrician, and anesthetist should be informed.Epidural should be offered due to increased risk of intervention. IV access should be taken .CTG need to be started for both twins and internal electrode should be started as soon as possible. At the time of delivery a senior obstetrician should be present. Two resuscitators should be available. After delivery 10 to 15 units of syntocinon in 500 ml solution should be started .Presentation of second twin is assessed .In case of longitudinal lie normal vaginal delivery is planned .CTG is continued and if CTG is normal a normal delivery is anticipated without an upper limit of time.ARM is conducted as soon as presenting part is engaged and delivery is conducted. If the lie is transverse ECV is performed and fetus is brought to a longitudinal lie either cephalic or breech which ever is possible and ARM is performed when suitable and delivery is conducted. Internal podalic version for transverse lie is an option if a senior obstetrician with experience in this type of version is present as it associated with an increased risk of cord prolapse, hand prolapse, fetal compromise and fetal trauma. In case of fetal compromise or cord prolapsed operative vaginal delivery or c/s may be needed for second twin. Active management of third stage is required by early cord clamping and oxytocics  due to increased risk of PPH. 30 to 40 units syntocinon in 5oo ml solution should be started.
Posted by Ana B.

  

1) Screening for aneuploidy  : nuchal transluscency is method of choice as serum screening for Down syndrome is unreliable in multiple pregnancies. The risk of pregnancy loss with amniocentesis considered similar to singletons. CVS is also possible in twin pregnancy, can be performed earlier; however it carries a higher miscarriage rate.

Before an invasive procedure for karyotyping  is undertaken  careful ultrasound mapping of the different placenta and gestational sac is mandatory. Amniocentesis or CVS should be undertaken in a tertiary centre. Referral to tertiary centre in case of complications such as : hydramnios , death of co-twin etc.

Multiple pregnancies are associated with an increase in fetal and neonatal mortality. The majority of perinatal deaths are associated with preterm bith and IUGR. Therefore frequency of antenatal visits should be increased with shared primary and secondary care. Serial growth scans should be performed to evaluate fetal growth velocity and to detect any abnormalities in umbilical artery Doppler. Sensible policy is to monitor twins with 4 weekly scans from 24 weeks with more frequent scans (2weekly) if there suboptimal growth.

Prediction of preterm labour is difficult, but cervical length of 25 mm at 23 weeks gestation predicts about 80% of women who deliver spontaneously at less than 30 weeks of gestation with false positive rate of approximately of 11%. Women should be counselled about the risks. However, there is currently not enough evidence to support a policy of routine hospitalisation for bed rest, indeed there is a suggestion in uncomplicated pregnancy bed rest may increase preterm birth.

In preterm labour the efficacy of antenatal steroids in twin pregnancies is uncertain; however some benefit is apparent.

2)

The patient should be admitted to delivery suit. The most obstetricians would recommend IOL at 38-39 weeks in dichorionic twins.
Vaginal delivery is the option as the first twin is cephalic with recommended continuous electronic fetal monitoring and epidural analgesia. The patient should be counselled about caesarean section in case fetal heart rate abnormalities or if difficult delivery of the second twin is anticipated. During delivery experienced obstetrician , anaesthetist / paediatrician should be present and if difficult delivery is anticipated, delivery should be performed in operating theatre.

Measures for potential PPH should be undertaken such IV access and Group and Save and stand by Oxytocin 10 iu in 500 mls for delivery and 40 iu in 500 mls of Normal Saline for use on the third stage.

After the delivery of second twin the position of the second twin needs to be determined , then  corrected by external cephalic version of a non-vertex second twin, Internal cephalic version and breech extraction to be performed by experienced obstetrician. Oxytocin infusion is helpful to establish regular contractions and to allow descent of presenting part. Rupture membranes performed once regular contractions and presenting part is in the pelvis providing FHR is satisfactory. The risks associated with internal podalic version should be discussed with mother beforehand and consent obtained; otherwise delivery by caesarean section. The third stage manage actively and oxytocin infusion advised over 6 hours postpartum.
 

Dr Mohanad Posted by vanosch M.

Dear Dr Pual can you comment on my answer

ans please Posted by anupama M.

Dear Paul,

can you just give what all points to be written in this essay.

More EMQS and Essay Posted by Reena G.

I wish to sit in sept2011 and my subscription will  finish in april 2011