MULTIFETAL PREGNANCY OB II | MIDTERMS (1st Sem)

Dr. Daisy Dulnuan

OUTLINE II. MULTIPLE ECTOPIC PREGNANCY

I. I. TYPES OF MULTIFETAL PREGNANCY  Combined intrauterine and extrauterine pregnancy; or
II. II. MULTIPLE ECTOPIC PREGNANCY
III. III.MECHANISM OF MULTIFETAL GESTATION
 Both embryos or fetuses can be extrauterine
A. Superfetation and Superfecundation
B. Determining Chorionicity and Zygosity III. MECHANISM OF MULTIFETAL GESTATION
C. Diagnosis of Multifetal Gestation
IV. IV. PREGNANCY COMPLICATIONS Genesis of Monozygotic Twin
V. V. COMPONENTS OF ANTEPARTUM MANAGEMENT  Increased two- to fivefold in pregnancies conceived
VI. VI. TWIN-TWIN TRANSFUSION SYNDROME
A. Diagnosis of TTTS
using assisted reproductive technology
B. Management of TTTS  Outcome of the monozygotic twinning process
VII. VII. DISCORDANT GROWTH OF TWIN FETUSES depends on when division occur:
A. Diagnosis of Discordant Fetuses
B. Principles of Management of Discordant Fetuses 72 hours Diamnionic
VIII. VIII. PREVENTION OF PRETERM DELIVERY Dichorionic
IX. IX. LABOR AND DELIVERY
X. X. TRIPLET OR HIGHER ORDER GESTATION 4th- 8th day Diamnionic
XI. XI. REDUCTION AND TERMINATION Monochorionic
XII. XII. DEATH OF A FETUS
* Those highlighted in red are the concepts discussed by Dr. Dulnuan during her 8th day Monoamionic
online discussion last 10-27-2020
Monochorionic

I. TYPES OF MULTIFETAL PREGNANCY

A. FRATERNAL, DIZYGOTIC, DOUBLE-OVUM TWINS A. Superfetation and Superfecundation
 Arises from the fertilization of two separate ova during Superfetation
a single ovulatory cycle  An interval as long as or longer than a menstrual

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cycle intervenes between fertilizations
 Influenced by race, heredity parity and age

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 Requires ovulation and fertilization during the course
 More common
of an established pregnancy

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 Result from markedly unequal growth and

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B. IDENTICAL, MONOZYGOTIC, OR SINGLE OVUM TWINS development of twin fetuses with the same gestational
 Arises from the fertilization of a single ovum which age

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early in its stage of development splits into two

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separate identical halves, each with the potential of Superfecundation
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developing into complete identical  Refers to fertilization of two ova within the same
 Frequency is more or less the same menstrual cycle but not at the same coitus, nor
necessarily by sperm from the same male
A. Classification  May occur with art, women should be advised to
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consider avoiding intercourse after embryo transfer

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Factors affecting twinning

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 Race (common among Blacks)

 Heredity
 Fertility treatment
 Parity
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 Maternal age -important risk factor

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o Frequency rises almost fourfold between the

ages of 15 and 37 years
o Paradox of declining fertility but increasing
twinning rates with advancing maternal age

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Maternal Size and Nutrition (obese)

 There may also be instances that one of the twins may be
 Induction of Ovulation
blighted and never develops significantly enough to be
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ever recognized.
B. Determining Zygosity and Chorionicity
 Fetal death up the end of the first trimester can lead to
 Twins of the opposite sex are almost always dizygotic
complete resorption of the involved product, and leave no
traces at delivery
Sonographic determination
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 Integral tool to assist in multifetal pregnancy

FETUS PAPYRACEOUS OR COMPRESSUS
management
 Fetal death at the end of first
 Recognized indication for first-trimester sonography
trimester can be retained up to the
end of pregnancy becoming
Four features assessed after 10th-14th wk AOG:
markedly shrunken and
1. number of placental masses
compressed between the uterine
2. thickness of the membrane dividing the sacs
wall and membraned of the loving
3. presence of an intervening membrane
twin
4. fetal gender

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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

IDENTIFICATION OF THICK DIVIDING MEMBRANE  Two fetal heart tones with a rate difference of at least 10
1. Dichorionic beats per minute
 Generally >2mm- supports presumed diagnosis of  Ultrasound
dichorionicity
 Composed of a total of four layers: Fundal Height:
 Two amnion  5cm greater than expected of singleton pregnancies
 Two chorion
Twin peak sign Ultrasonography:
 Also called lambda or delta sign; the point  Most accurate method
of origin of the dividing membrane on the  Separate gestational sacs can be identified early in
placental surface twin pregnancy
 Peak appears as a triangular projection of  Two fetal heads or two abdomens should be seen in
placental the same plane, to avoid scanning the same fetus
 Tissue extending a short distance between twice and interpreting it as twins
the layers of the dividing membrane

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Figure 3. Sonograms of first trimester twins. A. Dichorionic diamnionic twin. B.

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Monochorionic diamnionic twin.

IV. PREGNANCY COMPLICATIONS

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Figure 1.Sonographic image of the “twin-peak” sign also termed as “lambda
sign” in 24-wk gestation. 
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Spontaneous abortion
Congenital fetal malformations
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2. Monochorionic  Low birthweight
 Pregnancies have a dividing membrane that is so thin
 Hypertension (blood volume expansion up to 50 -60%)
 Generally <2 mm that it may not be seen until the
 Preterm birth
second trimester
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 Long term infant development

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T sign
A. Maternal Risks/Complications

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Relationship between the membranes and placenta

 Increased symptoms of early pregnancy (more
without apparent extension of placenta between the
pronounced nausea, vomiting)
dividing membranes
 Increased risk of miscarriage (greater likelihood of genetic
abnormality)

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Vanishing twin syndrome

 Minor disorders of pregnancy
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 Hypertension
 Preterm labor and delivery
 Anemia
 Antepartum Hemorrhage
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 Hydramnios
 Possible need for prenatal hospitalization
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Figure 2..Sonographic image of the “T” sign in a monochorionic diamnionic  Single fetal death in twins
gestation at 30 weeks.  Increased risk of an operative vaginal birth
 Increased likelihood of cesarean birth (most likely due to
Placental Examination: malpresentation)
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 Visual examination of placenta and membranes  Postpartum hemorrhage

 Placenta should be carefully delivered to preserve the  Postnatal problems
attachment of the amnion and chorion to the placenta  Maternal mortality
 Malpresentation
C. Diagnosis of Multifetal Gestation
 Family history B. Fetal Risks
 Assisted reproduction  Stillbirth or neonatal death
 A gravid uterus larger than the age of gestation  Single fetal death in twins
 Multiplicity of small parts as noted on palpation  Preterm labor and delivery
 Palpation of two heads and two buttocks  Intrauterine growth restriction
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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

 Congenital anomalies LABOR AND DELIVERY

 Congenital anomaly in one twin Hospital Delivery III B
 Twin reverses arterial perfusion sequence Experienced Obstetrician and other health III B
professionals
 Conjoined twins Await spontaneous labor if no complication Ia A
 Cord accident occur
 Zygosity Pediatrician neonatal nurse, and anesthetist III GPP
 Monoamniotic twins available at the time of delivery, with one
pediatrician at infant present if preterm delivery
 Hydramnios or operative delivery or fetal problems are
 Twin-twin transfusion syndrome anticipated
 Risks of asphyxia Continuous monitoring of all fetuses during labor III B
 Operative vaginal birth, especially for the second of twin IV access III GPP
Epidural analgesia recommended III B
 Twin entrapment
Aim for vaginal delivery unless the leading twin III B
 Cerebral palsy has a nonlongitudinal lie
Some advocate elective cesarean delivery if the III B
C. Management Options first of twin is not cephalic
PREPREGNANCY Quality of Strength of Vaginal delivery of the first of twin, if appropriate III B
Evidence Recommendation Synthetic oxytocin infusion for uterine inertia, - GPP
Counsel women about the risk III B especially after the first twin is delivered
of multiple pregnancy If the second twin has a longitudinal lie, III B
No data available to guide on Ia A amniotomy and delivery
“ideal” number of If an infant has a nonlongitudinal lie, convert to a III B
longitudinal lie by external version or internal

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embryos/oocytes
podalic version

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Pre-conceptional & peri- Ia A
conceptual folate Prophylactic oxytocin infusion after delivery to Ia A

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supplementation reduce risk of postpartum hemorrhage

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Some advocate elective cesarean delivery for IIB B
triplets and higher-order births
PRE-NATAL

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Specialized clinics may lessen adverse III B
POSTNATAL
outcomes
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Documentation of zygosity or chorionicity at 10- III B Extra support while in the hospital to assist with GPP
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14 weeks infant care
No prospective data on whether this IIb B Offer longer in-patient stay GPP
documentation improves outcome Arrange support at home GPP
Increased surveillance if twins are at increased IIb B Provide adequate contraceptive advice GPP
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risk for adverse outcome

Iron and Folate supplementation from second IIb B V.COMPONENTS OF ANTEPARTUM MANAGEMENT OF
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trimester TWIN GESTATION

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Screening for hypertension IIa B

Prenatal care
Conflicting evidence of the value of screening IIa B
for gestational diabetes  Primary goals aim to prevent or interdict complications
Nuchal translucency measurement of each fetus III B as they develop
identifies fetuses at risk for trisomy21,  Visits every 2wks beginning at 22wks AOG
cardiothoracic abnormalities, & Twin-Twin Diet
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Transfusion Syndrome
 Caloric requirement is increased (40-45kcal/kg/day)
Routine Anomaly Ultrasound scan at 18-20 wks III B
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 Iron supplement is doubled (*Normal - 27mg)

CONJOINED TWINS III B  Folic acid is increased to 1mg/day
 Careful ultrasonographic evaluation of  ASA 80mg OD (to prevent preeclampsia)
anatomy  Weight gain (37-54kgs)
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 Interdisciplinary discussion of therapeutic

options VI. TWIN-TWIN TRANSFUSION SYNDROME
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Vigilance for early symptoms of preterm labor; Ib A

 From a monochorionic placenta
Prompt self-referral if it is suspected
Possible ultrasound assessment of cervical IIa B  Blood is transfused from a donor twin to its recipient
changes and fetal fibronectin as part of preterm sibling
delivery screening  Presents in midpregnancy when the donor fetus becomes
Prenatal corticosteroids preterm birth before 34 Ia A
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oliguric from decreased renal perfusion

weeks is possible
o This fetus develops oligohydramnios, and the
No evidence that hospitalization to prevent Ia A
preterm labor and delivery is effective recipient fetus develops severe hydramnios
No evidence that prophylactic cervical cerclage Ia A
is effective to prevent preterm labor and delivery Chronic TTTS results from the unidirectional flow through
Regular fetal ultrasound assessment of growth Ib A deep arteriovenous anastomoses
and umbilical artery doppler
 Deoxygenated blood from a donor placental artery is
Hospitalization at the woman’s request or if Ia A
complications are detected pumped into a cotyledon shared by the recipient
Consider therapeutic amniocentesis for extreme IIb B  One oxygen exchange is completed in the chorionic
hydramnios and maternal distress villus, the oxygenated blood leaves the cotyledon via a
Prenatal education about possible modes of IV C placental vein of the recipient twin
delivery, analgesia, and care in labor
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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

Prognosis:
o Related to Quintero Stage and gestational age at
presentation
o Stage I: >3/4 remain stable or regress without
Figure 3..Anastomoses between twins intervention
maybe artery-to-vein, artery-to-artery or vein- o Stage III and higher: perinatal loss rate is 70-100%
to-vein without intervention

 If one twin of an affected pregnancy dies, cerebral

pathology in the survivor results from acute hypotension
Fetal brain damage:
due to an emboli of thromboplastic material originating
 Cerebral palsy, microcephaly, porencephaly and from the dead fetus
multicystic encephalomalacia are serious  This morbidity was related to the gestational age at the
complications associated with placental vascular death of the cotwin.
anastomoses
 If the death occurred: between 28 and 33 weeks’
o Donor twin- ischemia results from
gestation,
hypotension, anemia, or both
o Monochorionic twins – 8fold risk of
o Recipient twin- ischemia develops from
neurodevelopmental morbidity
blood pressure instability and episodes of
o After 34 weeks, the likelihood decreased –
profound hypotension
odds ratio 1.48
 Immediate delivery is not considered beneficial in the
A. Diagnosis of TTTS

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absence of another indication

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Based on 2 sonographic criteria
1. Monochorionic diamnionic pregnancy is Identified

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VII. DISCORDANT GROWTH OF TWIN FETUSES
2. Hydramnios (largest vertical pocket >8cm) in one sac and

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 Size inequality of twin fetuses
oligohydramnios (largest vertical pocket <2cm) in the
other twin sac  May reflect pathological growth restriction in one fetus

o.
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Stuck twin or polyhydramnios-oligohydramnios syndrome Causes:
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“polyoli” o Monochorionic twins
 Virtual absence of amnionic fluid in the donor sac  Attributed to placental vascular anastomoses
preventing fetal motion that cause hemodynamic imbalance between
o Associated with growth restriction, the twins
o

o Dizygotic twins
contractures, and pulmonary hypoplasia in
 Have different genetic growth potential
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the donor twin, and premature rupture of the

especially if they are of opposite genders
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membranes and heart failure in the recipient

 One placenta might have a suboptimal
Other ultrasonographic criteria: implantation site
1. Gender concordance
2. Growth discordancy >20% A. Diagnosis of discordant fetuses
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3. Umbilical cord size discrepancy % discordancy:

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4. Cardiac dysfunction in the recipient twin

5. Abnormal Doppler studies
 >20% is considered discordant twins
TTTS Quintero Staging System  As the weight difference within a twin pair increases,
Stage I perinatal mortality increases proportionately
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Discordant amnionic fluid volumes but urine is

still visible sonographically within the bladder of
the donor twin B. Principles of management of discordant fetuses
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Stage II Criteria of stage I, but urine is not visible within  IUGR is more predictive of poor perinatal outcome than
the donor bladder growth discordancy alone
Stage III Criteria of stage II and abnormal Doppler studies  Growth discordancy alone is not an indication of
of the umbilical artery, ductus venosus, or immediate delivery
sh

umbilical vein  Increased surveillance is warranted in cases of significant

Stage IV Ascites or frank hydrops in either twin
growth discordancy
Stage V Demise of either fetus.
Fetal Wellbeing Studies
B. Management of TTTS
1. Biometry every 2weeks
 Amnioreduction
2. NST/BPS twice weekly
o Laser ablation of vascular placental anastomoses
3. Weekly Doppler ultrasound (to diagnose IUGR)
 Selective feticide 4. Steroid at 24-34 weeks
 Septostomy

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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

Antepartum Surveillance XI. REDUCTION AND TERMINATION

1. Ultrasound at 10-13weeks (ideal time to determine Reduction
2. chorionicity) o May be chosen as a therapeutic intervention to
3. Congenital Anomaly Scan (CAS) at 18-22weeks enhance survival of the remaining fetuses
Biometry every 4weeks o Can be performed transcervically, transvaginally, or
4. Biophysical Profile Scoring (BPS)/ Non Stress transabdominally (easiest)
5. Test (NST) (starting at 28weeks) o Transabdominal fetal - typically performed between 1
6. Doppler studies in case of IUGR 0 and 1 3 weeks' gestation

VIII. PREVENTION OF PRETERM DELIVERY Termination

 Bed rest o Performed later in gestation than selective reduction
 Tocolytic therapy and entails greater risk
 Corticosteroids for lung maturation o Prerequisites to selective termination include:
 Cerclage – not been shown to improve perinatal outcome 1. Precise diagnosis for the anomalous fetus
 Twin gestation with preterm ruptured membranes 2. Absolute certainty of fetal location
 are managed expectantly much like singleton
 pregnancies Specific risks of selective termination or reduction:
1. Abortion of the remaining fetuses
IX. LABOR AND DELIVERY 2. Abortion or retention of the wrong fetus(es)
1. Timing of delivery: 3. Damage without death to a fetus
 Gestational age 4. Preterm labor

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 Fetal growth 5. Discordant or growth-restricted fetuses

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 Lung maturity 6. Maternal complications

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 Presence of maternal complications

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XII. DEATH OF A FETUS
2. Evaluation of fetal presentation
3. Labor induction or stimulation  “Vanishing twin”

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4. Analgesia and anesthesia  The prognosis for the surviving twin depends on the
5. Delivery route:
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o Cephalic-cephalic presentation
 If the first twin presents cephalic, delivery can Dichorionic Monochorionic
usually be accomplished spontaneously or with Pregnancies Pregnancies
forceps. Risk of Small Increased
o

o Cephalic-noncephalic presentation Complication

With neurologic
 Options include cesarean delivery of both twins
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abnormality
 Less commonly, vaginal delivery with
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intrapartum external cephalic version of the Delivery At 37 weeks If remote from

second twin term:
 Least desirable, vaginal delivery of the first but Expectant
cesarean delivery of the second twin may be Neonatal survival Likely with
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required due to intrapartum complications such immediate delivery

as umbilical cord prolapse, placental abruption,
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contracting cervix, or fetal distress

o Breech presentation of first twin References
 Cesarean delivery is often preferred with a th
William’s Obstetrics 25 Edition
viable-sized fetus Old ppt (2019)
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Dr. Dulnuan’s lecture & powerpoint presentation

X. TRIPLET OR HIGHER ORDER GESTATION
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 Pregnancies complicated by three or more fetuses should

undergo cesarean delivery
 Vaginal delivery
o Reserved for those circumstances in which survival is
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not expected because fetuses are markedly immature

or maternal complications make cesarean delivery
hazardous to the mother

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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

STUDY GUIDE QUESTIONS 45–9. What is the approximate risk of triplet or higher order
multifetal gestation if ovarian stimulation and intrauterine
45–1. Compared with singleton pregnancies, multifetal gestations insemination is used to achieve pregnancy?
have a higher risk of all EXCEPT which of the following a. 10% b. 20%
complications? c. 30% d. 40%
a. Preeclampsia b. Hysterectomy 45–10. What can be confirmed about the placenta being examined
c. Maternal death d. Postterm pregnancy in the image here?
45–2. Compared with singleton pregnancies, multifetal gestations
have an infant mortality rate that is how many times greater? a. Dizygosity
a. Twofold b. Threefold b. Monozygosity
c. Fivefold d. Tenfold c. One chorion, two amnions
45–3. Which of the following mechanisms may prevent d. Two chorions, two amnions
monozygotic twins from being truly “identical”?
a. Postzygotic mutation
b. Unequal division of the protoplasmic material
c. Variable expression of the same genetic disease
d. All of the above 45–11. Which of the following is true regarding the rate of
45–4. A patient delivers a twin gestation in which one infant has monozygotic twinning?
blood type A and one has type O. The patient and her husband a. It approximates 1 in 250 worldwide.
are both type O. A particular phenomenon is proposed as the b. It is increased with maternal age and parity.
etiology of the discordant blood types. How would you explain c. It is lower for Hispanic women than for white women.
this to the mother? d. It can be modified by FSH (follicle-stimulating hormone) treatment.
a. The proposed phenomenon does not spontaneously occur in 45–12. Which of the following statements is true regarding
humans. chorionicity in multifetal pregnancy?
c. It involves fertilization of two ova within the same menstrual cycle, a. Dichorionic pregnancies are always dizygotic.
but not at the same coitus. b. Monochorionic membranes should have four layers.

m
d. It involves fertilization of two ova separated in time by an interval as c. Monochorionic pregnancies are always monozygotic.

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long as or longer than a menstrual cycle. d. Chorionicity is accurately determined by measuring the thickness of
the dividing membranes during sonographic examination in the first

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45-5. When trying to establish chorionicity of the
pregnancy shown in the image here, which of the trimester.

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following statements is true? 45–13. Among the following choices, which is the strongest risk
factor for multifetal pregnancy?

o.
a. There are two placentas. a. Advanced maternal age

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b. The twins must be monozygotic.
c. The twins share the same
b. Use of clomiphene citrate
c. African American ethnicity
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amnion. d. Maternal history of being a twin herself
d. The twins must have arisen from 45–14. A patient presents for prenatal care at 12 weeks’ gestation
two separate and wants to know about specific risks to her pregnancy. She has
ova. spontaneously conceived a monochorionic twin gestation. Which
o

statement is false regarding these twins?

a. They have a higher risk of pregnancy loss than fraternal twins.
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b. Those born at term have a higher risk of cognitive delay than term
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singletons.
45–6. Which of the following factors increases the risk for c. They have twice the risk of malformations compared with singleton
monozygotic twinning? pregnancies.
a. Increased parity d. They have a lower risk of pregnancy loss than identical twins
b. Increased maternal age conceived with assisted reproductive technologies.
c. The father is an identical twin. 45–15. The differential diagnosis of clinically suspected twins
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d. None of the above includes all EXCEPT which of the following?

45–7. The first-trimester sonographic image here shows two fetal a. Obesity b. Hydramnios
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heads arising from a shared body. How many days after c. Leiomyomas d. Blighted ovum
fertilization must the division of this zygote have occurred to lead 45–16. Regarding maternal adaptations to multifetal pregnancy,
to the abnormality shown? which of the following is lower in twin pregnancy compared with
that in a singleton pregnancy?
a. Blood volume expansion
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b. Blood pressure at term

a. 0–3 days c. Blood loss at delivery
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b. 4–7 days d. Systemic vascular resistance

c. 8–12 days 45–17. A fetus that is part of a dichorionic twin pair is estimated to
d. More than 13 days weigh 2000 g at 33 weeks’ gestation. What can be said about its
growth?
a. The fetus already shows growth
restriction.
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b. The fetus will be growth restricted

45–8. A patient with twins is referred for prenatal care. At the at term.
referring clinic, she had several sonographic examinations that c. The fetal growth is adequate for
establish these to be monochorionic twins. Today, you see only gestational age.
one fetus sonographically. Which of the following statements is d. Growth differences will not be
false regarding the risk of a vanishing twin? apparent until delivery.
a. The risk exceeds 10% in multifetal gestations. 45–18. Among complications that
b. The risk is higher in monochorionic than in dichorionic pregnancies. may be seen in twin pregnancies, which of the following may be
c. This risk is increased if she used assisted reproductive technologies seen in dichorionic pregnancies?
to conceive. a. Acardiac twin
d. A vanishing twin does not affect first-trimester biomarker testing if it b. Fetus-in-fetu
occurs after 10 weeks’ gestation. c. Twin-twin transfusion syndrome
d. Complete mole with coexisting normal twin
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 Midterms (1st Sem) Multifetal Pregnancy
Dr. Daisy Dulnuan
OB II· October 27, 2020

45–19. What is the major cause of increased neonatal morbidity

rates in twins?
a. Preterm birth 45–29. With growing discordance, rates of which of the following
b. Congenital malformations neonatal complications are increased?
c. Abnormal growth patterns a. Neonatal sepsis
d. Twin-twin transfusion syndrome b. Necrotizing enterocolitis
45–20. When diagnosed at 20 weeks’ gestation, which of the c. Intraventricular hemorrhage
following statements is true regarding the twin vascular d. All of the above
complication seen in the image here? 45–30. Which of the following is the most important
predictor of neurological outcome of the survivor
after death of a cotwin?
a. It precludes vaginal delivery. a. Chorionicity
b. It implies the twins are b. Gestational age at time of demise
conjoined. c. Malformations present in the deceased twin
c. It has a 50% associated fetal d. Length of time between demise and delivery of
mortality rate. survivor
d. It can be monitored effectively 45–31. Which of the following methods of antepartum fetal
with daily sonography. surveillance has been shown to improve outcomes in twin
pregnancies?
45–21. Which are the most common vascular anastomoses seen a. Nonstress test
in monochorionic twin placentas? b. Biophysical profile
a. Deep vein-vein c. Doppler velocimetry of the umbilical artery
b. Deep artery-vein d. None of the above
c. Superficial artery-vein 45–32. Which of the following interventions has been shown to
d. Superficial artery-artery decrease the rate of preterm birth in twins?
45–22. Which of the following statements is true in twin reversed- a. Cerclage

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arterial-perfusion (TRAP) sequence? b. Betamimetics
a. It is caused by a large arteriovenous placental shunt. c. 17-Hydroxyprogesterone caproate

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b. The donor is at risk of cardiomegaly and high output heart failure. d. None of the above

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c. The most effective treatment is injection of KCl into the recipient 45–33. Which of the following findings can predict a lower risk of
twin. preterm birth in twins?
d. Placental arterial perfusion pressure in the recipient exceeds that of a. Closed cervix on digital examination

o.
the donor. b. Negative fetal fibronectin assessment

rs e
45–23. A pair of monochorionic twins presents at 20 weeks’
gestation with sonographic findings that suggest twin-twin
c. Normal cervical length measured by transvaginal sonography
d. All of the above
ou urc
transfusion syndrome. There is significant growth discordance, 45–34. Which is the most common presentation of twins in labor?
no bladder is visualized in the smaller twin, neither twin has a. Vertex/vertex b. Vertex/breech
ascites or hydrops, and umbilical Doppler studies are normal. c. Breech/vertex d. Vertex/transverse
What would be the assigned Quintero stage? 45–35. For twins in labor, risk factors for an unstable fetal lie
o

a. Stage I b. Stage II include all EXCEPT which of the following?

c. Stage III d. Stage IV a. Small fetuses
aC s

45–24. The recipient cotwin in a monochorionic twin gestation b. Polyhydramnios

vi y re

affected by twin-twin transfusion syndrome may experience all c. Increased maternal parity
EXCEPT which of the following neonatal complications? d. Vertex/vertex presentation
a. Thrombosis b. Hypovolemia 45–36. Which of the following scenarios presents the best
c. Kernicterus d. Heart failure opportunity for a vaginal trial of labor?
45–25. What percentage of Quintero stage I cases remain stable a. Nonvertex/vertex presentation
without intervention? b. Vertex/nonvertex presentation
ed d

a. 25% b. 50% c. Nonvertex second twin whose estimated fetal

c. 75% d. 90% weight is < 1500 g
ar stu

45–26. Which of the following therapies for severe twin-twin d. Vertex second twin whose estimated fetal weight
transfusion syndrome has been shown in a randomized trial to is > 20% larger than the presenting vertex twin
improve survival rates of at least one twin to age 6 months?
a. Septostomy
b. Amnioreduction
is

c. Selective feticide
d. Laser ablation of vascular anastomoses
Th

45–27. What is the calculated fetal growth discordance of a twin

pair where the estimated fetal weight of twin A is 800 g and that of
twin B is 600 g?
a. 10% b. 15%
c. 25% d. 33%
45–28. A second sonographic evaluation of the twin pair
sh

described in Question 45–27 shows 27% discordance. One fetus

is male and one is female. Which mechanism is not the likely
cause of their discordance?
a. Unequal placental sharing
b. Different growth potential
c. Histological placental abnormality
d. Suboptimal implantation of one placental site

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