MRCOG PART 2 SBAs and EMQs
Course PAID | ||
notes | 336 | |
EMQ | 1502 | |
SBA | 2115 |
MRCOG Part 2 Essay 273: Multiple pregnancy
multiple pregnancy |
Posted by Ghida R. |
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A healthy 33 year old woman attends the antenatal clinic at 12 weeks gestation. She is known to have a dichorionic diamniotic twin pregnancy. (a) She wishes to know whether or not her babies have Down’s syndrome. Discuss your management [10 marks]. I will start by checking what does she know about down's syndrome and what it implies as regard to health of those who have it e.g. this will result in mental retardation and growth retardation and might predispose the child to have some diseases e.g risk of heart anomalies, childhood leukemia. If she does not have much knowledge I will explain in simple terms explaining what is down's syndrome i.e.when a baby is being made, the information needed to create it comes from his parents in equal parts. this info is written on chromosomes which are tiny bits that each carries a information eg what the colour of the eye will be etc... there are 23 chromosomes from the father and 23 from the mother. these come together to form the complete make up of human being 46 chromosomes which are also known as karyotype. During this process something might go wrong and the baby will get an extra set of chromosome from one of his parents and thus will have a 47 chromosome and this will interfere with his body's proper functioning. then I will tell her that her age related risk of down 's syndrome is around 1 in 350, but the overall risk for this pregnancy to have one twin with down's syndrome is double that of a single pregancy i.e. 1 in 175, because each twin has its own risk. screening for down's syndrome in twin gestation is best performed by use of ultrasound to measure nuchal translucency which measures the maximal thickness between the skin over the neck of the baby till the neck bone. this measure if increased it will point out to increased risk of chromosomal or cardiac abnormalities. It has a high detection rate of 85%, meaning that it will detect 85 babies with down syndrome out of 100 babies with down syndrome, but if the NT is thick this has false positive rate of 20% thus necessitating further test to confirm down's syndrome. Other ultrasound markers of the first trimester scan include looking for the fetal nasal bone and check for tricuspid regurge. blood test are not reliable in twin gestation as they have low detection rate of down's syndrome in twin gestation. So if we measure first the nuchal translucency and it is thick, further testing to confirm can include more invasive testings like amniocentesis which involves introducing a needle into the belly of the mom to get fluid from around the baby. this will test for fetal chromosomes abnormalities such as in the case of down's syndrome. this test has miscarriage rate of 1-2%, it is done at around 15 weeks, and is performed by a maternofetal specialist. Another test called CVS chorionic villus sampling can be performed earlier, usually after 10wks and is done by taking cells from the cells from the placenta (organ which attaches the baby to his mother's womb and through it gets his nutrients and sheds his waste matter). This is also done via a needle inserted through the belly or the neck of the womb. It has the risk of contamination of the sample by the co-twin material in 4% of cases meaning if one of the twins has down's syndrome we might not be sure which twin is it. This test has a 3-4% risk of miscarriage. there are other new investigation, expensive not not available blood test for the mother that will detect cell free fetal DNA which means we can sample the maternal blood and know if fetus has chromosomal abnormalities. Patient should be counselled about her decisions in the event of having one or more affected baby, and whether she will want to terminate the pregnancy or carry the pregnancy till term and delivery of both babies. patient should be supplied with pamphlets to read at home about Down syndrome and about prenatal testing. She should be encourage to ask questions and will be provided with contact numbers in case she needed more clarifications. (b) Discuss the additional antenatal interventions that you would recommend to optimize pregnancy outcome [10 marks]. this is a high risk pregnancy , it should be followed in a consultant led antenatal care. Follow up should be every two weeks. Screening ultrasound including fetal echocardiography should be offerred at around 20wks as twin pregnancies are at higher risk of congenital anomalies especially midline anomalies: cardiac, cleft lip, spine.Ultrasound can detect only 60%of anomalies. Also there is increased risk of preterm birth and an ultrasound for cervical length of 25mm at 23 weeks will detect 80% of spontaneous preterm deliveries at <30weeks with false positive rate of 11%. home uterine monitoring, cervical cerclage, progesterone supplementation and bed rest have not shown proof of efficency in preventing preterm delivery and has been abandoned. This pregnancy is at increased risk growth restriction of one of the twins and this should be followed up every 4 weeks by a growth scan starting at 24 weeks, follow up will occur at intervals of two weeks if growth restriction is detected with doppler studies. this pregnancy is also at risk of developing high blood pressure as in preeclampsia, thus patient should be screened at each visit by taking blood pressure and check for proteinuria by dipsticks. screening for gestational diabetes should be undertaken due to higher risk. If anticipating a preterm delivery, steroids should be administered in order to benefit the newborns from accelerated lung maturity as this has shown to decrease the incidence of repiratory distress syndrome. Delivery should be planned in a tertiary care center with well equipped NICU especially in the event of a preterm delivery or in the event of maternal complications. They should be cared by a team including neonatologists, obstetrician, perinatologist, paediatric surgeon. specialized nurse. |
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Essay 373-multiple pregnancy |
Posted by Reena G. |
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a)Firstly I will ask what she knows about down syndrome(DS) and will explain DS is the baby born with mental retardation and with multiple birth defects . Their life span is short and need support throughout their life.This condition occurs due to extra chromosome 21. Chromosomes are thread like structures that carry genetic information from each parent and in a child 23 chromosomes comes from each parent to make a total of 46 in each normal one , If there is extra transfer of 21 chromosome the total will be 47 which is abnormal one and that is linked to DS. The risk of DS increases with advance maternal age and the likelihood is more in twin pregnancy.I will tell her that in her case there are two separate placenta for each twin so need to calculate separate risk for each twin .I will discuss the options of screening test first and its sensitivity in predicting risks of DS , its false positive rate and that if positive need diagnostic test like biopsy from placenta( CVS) at this gestation age or extracting fluid around baby(amniocentesis ) later after 15 weeks gestation . The best screening test is combined test that include blood test and ultrasound . In ultrasound we measure thickness of skin fold at the fetal neck , between skin and spine of the neck .This is highly predictive of DS if increased .This together with blood test for specific protein like PAPPA and Hormone level BHCG we calculate the risks along with your age which has high predictability(85 out of 100 if test +) and small false positive risks(5 out of 100 if test negative)and if risks exceeds 1:150 then you need to refer to fetal medicine centre for further invasive testing(According to FASP) so that if selctive fetal reduction is needed then it can be undertaken by the same specialist who has an expertise in doing such procedures. In Fetal medicine centre the specialist will map the fetuses and then do invasive testing i.e. putting the needle through your tummy or mouth of the cervix and will take some placental(organ connection between fetus and mother where exchange of nutrient and waste occurs ) material through special instruments . The risks of fetal loss is higher as compare to singleton pregnancy as double invasive technique and risk of fetal contamination while drawing the sample is high.I will discuss the physical risks and psychological implications of selective reduction. .She can also go for cell free fetal DNA which is new test where fetal information could be drawn from maternal blood samples but is not widely available and she can also have an option later to do in 2nd trimester by maternal blood screening but which is not that reliable as combined screening.The options of amniocentesis i.e. drawing fluid from her tummy by needle insertin in the fluid sac around her babies after 15 weeks gestation should be discussed and that the risks are less as compare to CVS but still more than singleton pregnancy . She should be provided with written information and leaflets about DS and methods of CVS and amniocentesis indicating all risks and benefits.She should be supported throughout this process by special counsellor. b)Twin pregnancy is a high risk pregnancy as there is more likelihood of maternal(anemia, preelampsia, APH, PPH, preterm labour and postpartum depression) as well as fetal complication (IUGR, Still birth, prematurity, congenital anomalies). She should be seen under consultant led unit by MDT including specialist obstetrician, specialist midwife, ultrasonographers, perinatal mental health professional , dietician , infant feeding specialist, women’s specialist physiotherapist. If she is uncomplicated pregnancy , I will offer at least eight appointment with at least 2 with specialist obstetrician. At each appointment blood pressure and urine analyses to be checked as high risks for Preeclampsia. I will give her advice about lifestyle (Stopping smoking and alcohol if she is taking) and dietician will provide information about diet .They are at increase risks of anemia so at booking ,20-24 weeks and at 28 weeks her FBC and red cell Antibody to be checked to know the need of iron supplement to know her red cell AB status . Her appointment to be merge with the scan schedule so as to avoid her visits. Anomaly scan to be done between 18-21 weeks + 6 days and minimum 45 minutes to be devoted . Growth scan to be done 3-4 weekly from 20-34 weeks and discordant growth to be detected by checking at lest 2 growth parameters with a difference of 25% and time spent should be 30 minutes.If any discordant growth or congenital anomalies then she should be referred to fetal medicine centre. She is at high risks of preterm labour so should be advised about benefits of corticosteroid . Use of cervical screening and fetal fibronectin is assessing risk is not recommended. Use of home monitoring of contractions , bed rest , Im or vagina progesterone, cervical cerclage and tocolysis are not recommended. Use of single or multiple untargeted(routine) steroid not recommended. I will discuss timing and mode of delivery at 28 weeks gestation and offer her birth at 37 weeks gestation as risk of still birth increases at 38 weeks in multiple pregnancy. If the woman denies then her follow up should be weekly for appointment and scan for BPS(biophysical score) weekly and growth scan 2 weekly. |
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Posted by amina . |
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A healthy 33 year old woman attends the antenatal clinic at 12 weeks gestation. She is known to have a dichorionic diamniotic twin pregnancy. (a) She wishes to know whether or not her babies have Down’s syndrome. Discuss your management [10 marks]. (b) Discuss the additional antenatal interventions that you would recommend to optimize pregnancy outcome [10 marks]. 1. rountine down syndrome screening should be offered to all antenatal women.she should receive pre test counselling about the benfeits and risk associated with it. she may need to go for termination of pregnancy , if she is not considering termination of pregnancy for down syndrome, she may choose not to go for screening tests. her age related risk is 1/350 , which means at this age 1 in 350 women will have down syndrome fetus. she should be offered nuchal translucency mesurement with PAPPA and HCG. PREGNANCY ASSOCIATED plasma protein will be lower and hcg will be higher value in down syndrome pregnancies. nuchal translucency is measurement of tissue fluid , made at 11-13+6wks. there is no strict cut off value . as down syndrome fetuses have delay in lymphatic maturation , so more fliud, more value of nuchal translucency.it has associations with cardiac anomalies and chromosomal anomalies. detection rate is 72% with 5% false +ve rate. threshould for invasive screening is 1/150. if after combined screening with NT and HCG + PAPPA , her risk is 1/150 , she will be offered CVS / amniocentesis DEPENDING UPON GESTATIONAL AGE.invasive screenings are diagnostic . need specialist with expertise in selective termination of pregnancy if needed. risk of miscarriage is 1-2% , that may be higher in twin pregnancy. she should be given written information leaflets about down syndrome screening and invasive screening.
2. she should be booked in consultant led unit with appropriate neonatal facilities available. ideally she should be seen in specialized dedicated multiple preg units with specialized midwifery support and expert health care professionals. advice about folic acid supplementation , vit D supplementation should be give. she should be offered 5mg folic acid and 10mg vit D. ADVICE about immunization should be given. if she is smoker , advice about quitting smoking should be a part of consultation. advice about life stlye modification should be given. she should not use over the counter drugs. ask for domestic abuse and be alert for signs of domestic abuse. advice about recreational drugs if she is using. assess risk for pre eclampsia . assess risk for VTE. she should be given dietary advice. weight management is important issue nowadays. advice against high impact excercises . she should have anomaly scan done at 21-22wks. twins are at high risk of congenital anomalies. growth scans from 24wks should be done every 4wks . this will help in detection of FGR . gestational diabetes screening should be offered. if she has risk factors like previous macrosomic baby , previous gestational diabetes, previous stillbirth , she may be offered early screening at 16wks. there is some debate about cervical assessment in multiple pregnancies. she may be offered cervical assessment using TVS at 24wks.if cervical length less than 25mm , it is powerful predictor of preterm delivery before 32wks. there is no proven benfits of treatments and strategies like cervical cerclage, progesterone , bed rest and tocolytics in preventing preterm birth , hence cervical assessment in twin pregnancies may not be of clinical significance. inform about corticosteriods value in preterm birth , its benefits . discuss about risks associated with labour and delivery.may need caesarian section. she may need operative delivery. there is risk of single twin death . mangement and decisions may be complex . inform about postnatal care , parenting skills and mamnaging twin in postpartum period. she will need social /partner support. vigilant monitoring for detecting pre eclampsia should be the routine part of multiple pregnancies. delivery plan should be made at 36wks, documented in notes. offer elective birth at 37wks. |
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373-multiple pregnancy |
Posted by D M. |
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We would discuss the difficulties of prenatal diagnosis associated with twin pregnancy. Serum screening for aneuploidy in twins has a poor detection rate because the level of serum markers is double the level expected in a singleton pregnancy.In dichorionic pregnancy it can be even more complex where one twin is chromosomally normal.The normal twins’ biochemistry masks the abnormal result,reducing the sensitivity of the test. We offer measurement of nuchal translucency as a screening tool for Downs syndrome in twins which is a measurement of the thickness of the back of the fetal neck.This is done between 10-14 weeks of gestation and it is noninvasive. The sensitivity of NT in detecting downs is similar to that of singletons,which is approximately 85%,with false positive rate more than 6%(false positive rate is higher in twins than singletons). False positive rate means that the baby does not have Downs syndrome but the test shows it does and we will only know this if we perform diagnostic tests on the baby. If the test shows positive or if the patient wishes to know then a diagnostic tests can be done: chorionic villus sampling (sample from the placenta) done between 11-14 weeks or amniocentesis(sample from fluid around the baby) from 15 weeks onwards. It is adviced by RCOG that these procedures be done at a tertiary centre in twins,we would therefore refer the patient to a fetal medicine centre.They are done under ultrasound guidance.The person that performs the CVS or amniocentesis should also be experienced enough to carry out selective fetocite of the abnormal twin,if desired.There is a 5-10% risk of loss of a healthy dichorionic twin if selective fetocite of an abnormal twin is performed in the second trimester. I would also offer written info and leaflets regarding the above procedures ,the reason for offering(mentioned above) and the type of the procedure. I would advice the risk of miscarriage for amniocentesis is 1% above the background risk and CVS 1-2%. I will also explain the time it takes for the results to come back,the type of cytogenetic tests being done and the method of communicating the results to the patient. Patient will need Anti-D if rhesus negative. We would also need a infection screen status before the procedures carried out. (b) In order to optimise this patients pregnancy outcome we need to identify the maternal and fetal risks in twin pregnancy and monitor those closely antenatally in consultant led antenatal clinics throughout pregnancy and for delivery she would be on consultant led unit with experienced staff on multiple pregnancies. The maternal risks are Pre-eclampsia,pregnancy induced hypertension and gestational diabetes mellitus. We would therefore organise regular and frequent BP and urinalysis check every 3 -4 weeks initially and every 2 weeks in 3rd trimester.We would also educate patient regarding symptoms of headache,visual disturbances or epigastric pain. We would organise glucose tolerance test at 26-28 weeks or 16-18 weeks if history of gestational DM and repeat again at 28 weeks if initial test is normal. For fetal surveillance we would organise serial growth scans starting from 24 weeks every 4 weeks unless there is a suspicion of IUGR,then we would repeat it every 2 weeks with umbilical artery dopplers. I would advice patient regarding the risks of preterm labour (5 fold higher) in twins. There is no clinical method of predicting preterm labour. There is no indication of performing either fetal fibronectin electively or cervical length measurement in low risk twin pregnancies. There is no indication of electively giving corticosteroids in twins unless there are clinical indications of threatened labour or preterm delivery (prior to 35 weeks).I would also discuss the increased risk of operative vaginal delivery and postpartum haemorrhage. We would use oxytocin 10u in 500ml N/Saline as infusion as well as the bolus (10u) as a preventative measure –active 3rd stage of labour. We would advice that around 34-36 weeks we will decide on the mode and time of delivery which is usually around 38-39 weeks of gestation to reduce the risk of placental insufficiency and stillbirth which is higher in twins. We also discuss the mode of delivery, vaginal delivery if presenting twin is cephalic. In labour,we would advice continuous fetal monitoring and epidural anaesthesia. |
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373-multiple pregnancy-additional info! |
Posted by D M. |
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sorry failed to mention in (b) anomaly scan with a detailed 4 chamber view of the heart as twins have a higher risk of structural anomalies.This is done by an experienced sonographer or fetal medicine . |
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Posted by saini K. |
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a) I will enquire about patient understanding about role of screening test which allows identification of high risk group for diagnostic take (more expensive, invasive and high complication rate). I will explain to her that risk of Down syndrome in multiple pregnancies is 3% higher as compared to singleton pregnancy. I will further explain that serum screening for aneuploidy has poor detection rate in twin pregnancy. I will offer her screening by measurement of nuchal translucency (skin fold at nape of neck) between 12 to 13 weeks. It has detection rate similar to singleton pregnancy (85%) but high false positive rate (20%). The other alternative is anomaly scan at 18 to 21 weeks of gestation. Duodenal atresia, atrioventricular septal defect etc. are typical anomalies associated with Down syndrome. It can detect upto 60% of Down syndrome but in >40% no anomalies are detected. If women falls in high risk offer diagnostic test including CVS at 11-14 weeks and amniocentesis after 16 weeks. I will explain nature of procedure (done under ultrasound guidance), risk of procedure including ~ 1% risk of miscarriage and rhesus isoimmunisation. FISH provides result within 48-72 hours with confirmation karyotype result available by 2-3 weeks later. CVS/amniocentesis in multiple pregnancies should be done by someone who has expertise to perform selective termination of pregnancy if required. Normal result is reassuring. If Down syndrome confirmed, ensure that she understand long term implication of having Down syndrome baby. Discuss about her attitude towards affected baby, she may wish to continue pregnancy, selective or whole pregnancy termination. Discuss options of TOP if keen. Provide written information leaflet and support group details.
b) Manage in consultant led unit as it is high risk pregnancy. I will explain her maternal and fetal risk. Maternal risk including aggravated symptoms of nausea and vomiting in pregnancy, risk of preeclampsia/eclampsia, gestational diabetes mellitus, anaemia, polyhydramnios, PPH, postnatal depression. Fetal risk includes risk of congenital anomaly, IUGR, polyhydramnoios, IUD, premature delivery, fetal distress, operative delivery etc. Continue Folic acid as it reduces risk of NTD. Start iron supplementation if laboratory evidence of anaemia. I will arrange for anomaly scan at 18- 22 weeks along with cardiac scan as high risk of congenital anamoly.I will do OGTT at 24-28 weeks as high risk of GDM or earlier if high risk, repeat FBC and atypical antibodies at 28 weeks. Her BP and urinalysis for proteinuria should be checked at each visit as high risk of developing PIH or preeclampsia. I will do serial growth scan for fetal growth and amount of liquor (risk of IUGR/hydramnois).Advise her to contact early if contraction pain or vaginal loss as high risk of going into premature labour. Discuss mode and timing delivery with patient by 36 weeks and clearly documented in her notes. Offer induction of labour or caesarean section at 37+0 weeks of gestation. Vaginal delivery if 1sttwin is cephalic, recommend caesarean section if 1sttwins non vertex presentation. Explain the need for continuous fetal monitoring during labour. Ensure anaesthetist review as epidural analgesia is recommended during deliver especially if 2ndtwin is non-cephalic anticipating need for potential manoeuvre for delivery. Offer corticosteroid cover if elective caesarean section before 39+0 weeks of gestation to reduce risk of respiration morbidity.
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373 ans to multiple pregnancy |
Posted by sowba B. |
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I will first talk to her and find out if she understands what ‘Downs syndrome ‘is.If not ,I will explain to her that a chromosome is a thin strand which carries the genes deciding various characteristics and fetus inherits 23 pairs of chromosomes equal contribution from mother and father.When there is an extra chromosome in the 21st pair it is 21TRISOMY or DOWNS.Affected babies will have mental retardation,structural anamolies,with a maximum life expectancy of 50-55years and will need to be specially cared for in their life. She has an age related risk of downs 1:350 and also in dichorionic twins risk per twin equals that of a singleton,so risk for this pregnancy is twice that of a singleton pregnancy for the same age.As she is at 12 weeks,screening tests can be offered as a first part of a 2step screening program designed by the NHS.I will explain a screening test does not give a definite diagnosis,also there is no risk of miscarriage.ACombined test is appropriate now as she is 12 weeks.For this a fetal medicine trained sonologist will measure the fluid in the nape of the fetal neck called “nuchal Trnsluscency” .Pregnancy associated plasma protein –A(PAPP-A) is a substance measured in mothers blood , increased in downs,and a programmed software calculates the risk for downs for her taking into account her age and gestational age(ideal time is when CRL Is 39-84mm).If the cut off is lower than the national recommended cutoff 1:150,then downs is ruled out but if higher ,she should be referred ta fetal medicine centre for further invasive testing.NT alone using a cut off>3.5mm has a20% false positive while that of combined test is 6.1% at a 85%detection rate..Nasal bone is a soft marker on scan,when absent suggests downs but should be interpreted with other screening results.Chorion villus sampling is an invasive test done at 12 weeks,where using usg guidance,a bit of the conceptus is taken for genetic testing,miscarriage risk being1 to2% sampling error1to5%.Amniocentesis is aspirating some fluid from around the fetus using ultrasound guidance,at15to18weeks,miscarriage risk 1%.These results take two weeks but if PCR(polymerase chain reaction)is done it comes in 2to3 days. I will also tell about CELL FREE FETAL DNA from mothers blood ,a noninvasive prenatal diagnosis,not widely available.If screen positive she should know the options are selective foeticide of affected twin (may kill the normal twin in 5to 10%) or non-interference . I will provide details of support groups like www.arc.org.uk,www.CAFAMILY.org.uk, www.downs-syndrome.org.uk and FASP NHS Website. She should be antenatally managed in a dedicated multiple pregnancy clinic comprising of a consultant obstetrician,specialist midwife,a fetalmedicine specialst,a trained sonologist,a dietician and a specilalist physiotherapist. Because of twins she is at increased risk of complications namely,hyperemesis,anemia due to increased demand of iron or poor intake,preeclampsia 5times more,gestational diabetes mellitus,poly or oligohydramnios and increased operative interference. Complications for the foetuses ara increased risk of aneuploidy,congenital anamolies three times more,intrauterine growth restriction,fetal asphyxia,prematurity,increased operative interference and hence more morbidity,mortality. Most of these are preventable.She should be given an optimum dietary advice by dietician her rubella,hep B,HIV status must be checked.A full blood count to identify need for iron supplementation and blood grouping and typing including atypical antibodies to be done.Ultrasound at 12 to 13+6 weeks to be done for viability,number of foetuses,chorionicity and aneuploidy screen.Scan for structural anamolies is to be done at 18 to 20+6weeks,fetal echo at24 weeks.A full blood count to be repeated at 28 weeks.Antenatal visits must be minimum 8,atleast 2 to be seen by consultant.Blood pressure check,urine analysis to be done at every visit .Growth scans are to be done every 4 weeks till 32 weeks then every 2-4 weeks.There is no role for routine cervical length screening to predict preterm labour ,prophylactic cerclage, bed rest,progestogen therapy, home uterine activity monitoring or prophylactic steroids in all cases. The womans/family’s needs towards twin pregnancy must be identified and addressed.Discussion regarding time ,place and mode of delivery done at 34weeks. In view of increased risk of stillbirths in late pregnancy,a planned delivery by induction at 37 to38 weeks is recommended,but if she denies then followed up with weekly Biophysical profile and 2 weekly growth scans. She should be offered counselling by a neonatologist explaining fetal risks and need for probable NICU care.Contact details of support groups like www.tamba.org.uk, www.twinsclub.co.uk are to be given.Advice regarding postnatal care(hospital or community based),breast feeding and contraceptive advice given .Appropriate patient information leaflets are to be given.
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Essay 273: Multiple pregnancy |
Posted by A A. |
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