Mrs. Iresha 40 year old Management assistant attending her antenatal booking visit at POA of 12 weeks. This is her 3rd pregnancy and she is otherwise healthy. Her previous two pregnancies were uncomplicated and delivered vaginally without complications. Dating scan was performed and her dates were confirmed. It was diagnosed as a MCDA twin pregnancy and there is no obvious fetal anomalies.
- How will you diagnose the chorionicity in twin pregnancy?
- Appearance of ‘T’ sign / ‘λ’ sign
- Thickness of inter-twin membrane
- Number of layers in inter-twin membrane
- Number of placental masses
- Discordant fetal sex
- What special intervention you will do at her booking visit?
- Arrange for Aneuploidy screening- NIPT
- Arrange for Early OGTT
- Start O. Aspirin 150mg daily
- Counsel her regarding possible complications
- Miscarriage / Fetal anomaly
- GDM/ PIH/ Pre-eclampsia/Anemia
- TTTS/ TAPS
- sFGR
- Preterm labour à
- 60% deliver <37 weeks
- Arrange USS 2 weekly from 16weeks for fetal complications
She was followed up 2 weekly with USS and also had a detailed anomaly scan and were said to be normal. She is at POA of 28 weeks now and she came to the clinic with the scan report
|
- What is the diagnosis? What further details you need to know?
- Selective fetal growth restriction
- Need further information of doppler studies
- How will you classify sFGR in Monochorionic twins?
- Type I – UA PI > 95th centile
- Type II – Absent or reverse end diastolic velocity
- Type III- Cyclical Absent or reverse end diastolic velocity
- UA Doppler studies shows normal values in Twin I but PI > 95th centile in Twin II. Liquor amount is normal in both.
What is your management plan for the rest of the pregnancy? - Explain the condition to the mother
- Arrange multi-disciplinary team meeting including Obstetrician / Fetal medicine specialist / Neonatologist
- Plan for fetal monitoring and plan for delivery should be decided
- Weekly monitoring of EFW, every 3rd day doppler studies
- Do routine OGTT and FBC
- Check for BP and proteinuria in each visit
- Time of delivery – between 34 to 36 weeks or earlier if indicated
- Mode of Delivery – LSCS is preferred as fetal compromise is seen
- Give antenatal maternal corticosteroid – around 34weeks
- She was followed up weekly USS and twice weekly Dopplers. At 31 weeks of POA Doppler shows absent end diastolic velocity of Twin II and growth on the same centile.
- What will your management plan?
- Admit the mother to the antenatal ward
- Discuss with the neonatologist – availability of neonatal facility, outcome
- Assess with CTG +/- biophysical profile
- Start course of IM dexamethasone 12mg 12hourly – 2 doses
- If facilities available can go for delivery via elective LSCS
- If not delivered now, monitor with ductus venosus doppler daily or twice daily
- Delivery should be arranged after 32 weeks as the morbidity and mortality is high if pregnancy progressed further
- Give IV MgSO4 atleast 4 hours before delivery for fetal neuro-protection
About the Author
