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Chapter 4: Obstetrics 77
https://t.me/med1917
Other maternal disease in pregnancy
Thromboembolic disease
EPIDEMIOLOGY
• Risk of VTE is increased ×6
• Greatest risk is postpartum
• PE = important cause of maternal
death
SIGNS/SYMPTOMS
• Calf tenderness
• Cough
• Chest/abdo/groin pain
Anaemia
→ Hb drops to 11g/dl (symptoms if <9g/dl)
PROPHYLAXIS:
• Dietary advice
• Folic acid 5mg OD
• Iron supplements
PROPHYLAXIS: with LMWH*
Antenatally: only if high risk
Postnatally: if >1 moderate risk factor
INVESTIGATIONS
PE: CXR, ABG, CT
DVT: Doppler USS
d-dimer not useful in pregnancy
*warfarin contraindicated in pregnancy
Risk factors for thromboembolic disease:
assess at booking & postpartum
High risk:
• previous VTE
• prolonged immobility/hospitalisation
Moderate risk:
• BMI >30
• age >35
• IVDU/smoker
• immobility
• thrombophilia
• varicose veins
• C-section
• pre-eclampsia
DIETARY ADVICE:
Iron-rich: kidney, liver, eggs, green vegetables
Folate-rich: fish, raw green vegetables
Thrombophilias
→ antiphospholipid syndrome, protein S/C deficiency, factor V Leiden
COMPLICATIONS
• VTE • IUGR
• Miscarriage • Pre-eclampsia
• Placental abruption • Fetal death
MANAGEMENT: as high-risk pregnancy
• Aspirin & LMWH
• LMWH continued postnatally
Cardiac disease
PATHOPHYSIOLOGY: During pregnancy HR & SV to CO by 40%
IMPACT
• Major cause of maternal mortality: pre-existing cardiac condition may mean
heart cannot cope with increased demand during pregnancy
• Problems usually occur >28w or during labour
• Fetal cardiac abnormalities occur in 3%
blood flow causes
in 90%
MANAGEMENT
1. Treat conditions before pregnancy if possible e.g. valve disease
2. Stop contraindicated drugs: warfarin, ACEi
3. Regular checks: of BP, anaemia, fetal abnormalities
78 Chapter 4: Obstetrics
https://t.me/med1917
Reassure that 9 out of 10 women with
epilepsy have a healthy baby
Epilepsy
IMPACT
• Significant cause of maternal mortality:
▶ seizure control reduced: in labour, if sleep-deprived, during
morning sickness
• Increased risk of congenital defects (NTDs) – mainly due to drug therapy
• 3% risk of fetus developing epilepsy
Safest drugs: carbamazepine, lamotrigine
Contraindicated drugs: sodium valproate
MANAGEMENT4:
1. Seizure control: with as few drugs as possible at lowest dose
2. Folic acid supplementation 5mg OD pre-conception
3. Vitamin K for baby at birth: 1mg IM
4. Offer high resolution USS abnormality scan at 18–20w + serial growth scans
→ involve neurology team → DO NOT CHANGE MEDS without their advice
Obesity
20% pregnant women have BMI >30
MATERNAL RISKS
• Thromboembolism
• Pre-eclampsia
• GDM
• C-section
• Postpartum haemorrhage
• Wound infection
ANTENATAL MANAGEMENT
1. Preconceptual advice: weight, diet, exercise
2. Supplementation: 5mg folic acid & vit D
3. Thromboprophylaxis
4. Prophylactic aspirin: 75–150mg OD to prevent HTN
5. Monitor: blood glucose, BP
• OGTT at 28w
• Serial growth scans from 24w
5
FETAL RISKS
• Congenital abnormalities
• Mortality ×2.5
• Miscarriage/stillbirth
• NTDs
• Macrosomia (shoulder dystocia)
LABOUR/POSTNATAL MANAGEMENT
1. IOL if large baby (elective C-section may be discussed)
2. Continuous CTG in labour
3. Thromboprophylaxis: clexane, stockings, up & moving
4. risk of haemorrhage: IV syntocin for 4h
5. risk of infection: regular checks, expose to air if possible
4
RCOG (2016) Epilepsy in pregnancy [GTG 68]
5
RCOG (2018) Care of women with obesity in pregnancy [GTG 72]
Early pregnancy problems
https://t.me/med1917
↱ 15% pregnancies
Miscarriage
→ fetus dies or delivers dead before 24 completed weeks of pregnancy
↳
CAUSE: Significant chromosomal abnormality in 60% cases
SYMPTOMS: Lower abdo pain (crampy/ ‘period-like’) & vaginal bleeding
↳ Bleeding before pain
INVESTIGATIONS: in order
1. Speculum – open os is suggestive of miscarriage
2. TV USS – shows if fetus is intra-uterine & viable / any RPOC
3. 48h serum hCG – rise >66% in viable pregnancies, remains low in miscarriage
4. Check FBC, CRP, Rhesus status, G&S
↳ CRP often raised
Interpreting USS results
CRL <7.2mm on 1st scan
= very early pregnancy OR miscarriage
→ rescan in 7–10d to be sure
CRL >7.2mm + no cardiac activity
= miscarriage diagnosed
→ at this size heartbeat should be present
Chapter 4: Obstetrics 79
TYPES OF MISCARRIAGE
Type Symptoms On examination Mx
Threatened Pain, bleeding – fetus still alive (only 25% miscarry) Os closed, uterus normal for date Home
Inevitable Pain, heavy bleeding – fetus may/may not be alive Os open 1, 2 or 3
Incomplete Pain, bleeding – some fetal parts passed Os open, some RPOC* 1, 2 or 3
Complete Slowed bleeding – all fetal parts passed Os closed, uterus not enlarged, no RPOC* Home
Missed May be asymptomatic – fetus dead/not developed Os closed, uterus small for date
Septic Pain, offensive vaginal loss ± fever Uterine tenderness, endometritis ABX & 3
MANAGEMENT
1. Conservative/expectant: wait to see if miscarriage occurs naturally → 80%
successful
• R/V at 14d
▶ no bleeding/pain = pregnancy test at 3w to confirm miscarriage
▶ still bleeding/pain = re-scan & consider medical/surgical management
2. Medical: give medication to cause completion of miscarriage → 80% successful
• PO/PV misoprostol (prostaglandin) ± mifepristone (anti-progesterone)
• + Analgesia & anti-emetics PRN
• Pregnancy test at 3w to confirm miscarriage
• Risks: bleeding*, infection, failure
6
*RPOC: retained products of conception
1, 2 or 3
(often picked up on 1st dating scan)
Additional management considerations
1. Give anti-D prophylaxis if Rh –ve & >12w
2. Give PV progesterone BD for pregnant
SEs of misoprostol = diarrhoea & fever
*Risk of excess bleeding
gestation AND are having SURGICAL
MANAGEMENT
women with vaginal bleeding & history of
miscarriage
3. Surgical: remove tissue surgically under local or general anaesthetic
• Vacuum aspiration + histological examination to exclude molar pregnancy
• Complications: partial removal of endometrium, perforation/scarring of uterus
Recurrent miscarriage
→ 3 or more miscarriages in succession
CAUSES
• Antiphospholipid antibodies – cause thrombosis → Tx: aspirin & LMWH
• Chromosomal defects – refer to geneticist & consider IVF/PGS (rare)
• Uterine abnormalities, e.g. LLETZ, fibroid – USS to identify → Tx depends
oncause
• Hormonal: thyroid problems
• Other: obesity, smoking, higher maternal age, PCOS
6
NICE (2019, updated 2021) Ectopic pregnancy and miscarriage [NG126]
All have approx. 3% risk of infection
↲
1% couples
Emotional support/counselling = very
important in these cases
80 Chapter 4: Obstetrics
Tubal
Ovarian
https://t.me/med1917
↱ 1% pregnancies
Ectopic pregnancy
In a woman of child-bearing age,
abdominal pain + abnormal PV bleed =
ectopic until proven otherwise.
→ Must do a URINE PREGNANCY TEST!
*RED FLAGS
→ embryo implants outside of the uterine cavity
RISK FACTORS: particularly things that scar tubes
• Advanced maternal age
• Previous ectopic pregnancy
• IVF pregnancy
• PMHx chlamydia/pelvic infection/PID
• Previous abdo/tubal surgery
• Use of progesterone-only pill or IUD (the coil)
SIGNS & SYMPTOMS: can be
variable & vague!
• Lower abdominal pain
▶ initially colicky then constant
▶ rebound tenderness
▶ uterine & adnexal tenderness
• Abnormal vaginal bleeding –
scanty, dark
• Signs of intraperitoneal blood
loss
▶ dizziness & *shoulder-tip pain
(referred)
▶ *syncope/collapse in extremes
• Amenorrhoea 4–10w
▶ may be unaware of pregnancy &
interpret bleed as period
• Uterus small for date & closed
cervical os
↱ Pain before bleeding
INVESTIGATIONS:
1. Urine hCG pregnancy test: will
show +ve in ectopics
2. TV USS to exclude intrauterine
pregnancy
• BUT won’t show very early
uterine pregnancies
• May show clot / free fluid in tubes
3. Serum βhCG to distinguish early &
ectopic pregnancies
• Early pregnancy: by >60% in 48h
• Ectopic = slower or decrease
• If already >1000IU/ml would
see pregnancy in uterus unless
it is ectopic
4. Laparoscopy: most sensitive but
invasive*
Interstitial
Cervical
Fig. 4.1 Locations of
ectopic pregnancy.
Side-effects of methotrexate
• Mouth ulcers
• Liver dysfunction
MANAGEMENT7:
1. Admit to hospital: ABCDE, IV access, X-match, Anti-D if Rh –ve
2. Medical: If unruptured AND no cardiac activity AND hCG <1500 IU/L
• Single dose IM methotrexate → 15% need 2nd dose, 10% need surgical
escalation
• Followed by serial hCG level monitoring
3. Surgical:
• Laparoscopic salpingectomy (tube removal)
→ consider salpingostomy (remove ectopic & leave tube) if other tube is
damaged – allows future conception
→ Risks: bleeding, infection, damage to other structures, hernia from
incisions, DVT/PE, anaesthetic risks
Counselling points
1. If medical management or salpingostomy: explain possibility ectopic remains
→ need for serial hCG levels
→ know warning signs of rupture: severe abdo pain, pale/clammy, tachycardic, LOC/collapse
2. Information about increased risk of ectopic in future BUT reassure 70% go on to have
future successful pregnancy
3. Emotional support/counselling
7
NICE (2019, updated 2021) Ectopic pregnancy and miscarriage [NG126]
Chapter 4: Obstetrics 81
https://t.me/med1917
Hyperemesis gravidarum
↳ 1 in 750 women
= Severe N&V in early pregnancy causing dehydration, electrolyte
disturbances, 5% weight loss, ketosis
• starts at 4–7w, resolves by 16w
Severity Prevalence Symptoms Treatment
Mild NVP* 50% Nausea, occasional vomiting No treatment needed
Moderate NVP 5% More persistent vomiting Often need admission
Severe NVP (hyperemesis gravidarum) 0.15% Vomiting causing systemic Sx Hospital admission
INVESTIGATIONS: Physical exam for signs of dehydration
• BP & pulse – for hypovolaemia
• Urine dip/urinalysis – for ketonuria & exclude UTI
• FBC – raised haematocrit if dehydrated
• U&Es – raised urea & Cr if dehydration causes AKI, hyponatraemia, hypokalaemia
• Calcium – exclude hypercalcaemia as cause of vomiting
• Pelvic USS – check viability of pregnancy & RFs for hyperemesis gravidarum
COMPLICATIONS
• DVT/PE – TED stockings ± LMWH prophylaxis
• Wernicke’s encephalopathy – due to thiamine deficiency
• Hypokalaemia – IV/PO potassium replacement
• Mallory–Weiss tear – due to excessive vomiting
• Oesophageal rupture/pneumothorax – very rare!
MANAGEMENT
Dehydration: IV fluids (Hartmann’s/saline) → may need added K+ if hypokalaemia
N&V: antiemetics (IV/IM/SL if oral intake not tolerated)
Close monitoring: BP, pulse, renal function
Complications: TED stockings/LMWH, thiamine/Pabrinex, Gaviscon, folic acid
8
Feel dizzy/faint
Oliguria
Gestational trophoblastic disease
→ trophoblastic tissue proliferates more aggressively than normal
TYPES:
1. Hydatidiform mole: localised & non-invasive proliferation
• Complete: sperm fertilises empty oocyte = mitosis of 46XX tissue → no
fetal tissue
• Partial: two sperms fertilise oocyte = forms triploid zygote (69XXX/XXY/
XYY) → variable evidence of fetus
2. Invasive mole: invasion localised to within the uterus
3. Choriocarcinoma: invasion followed by metastases
Malignant: need
further Ix/Tx
outside of the uterus
SYMPTOMS
• Vaginal bleeding –
may be heavy
• Severe vomiting
• Uterus large for date
• Early pre-eclampsia &
hyperthyroidism
INVESTIGATIONS
• USS – swollen
villi = ‘snowstorm
appearance’
• Serum hCG – very
high
• Histology = diagnostic
MANAGEMENT
• Suction curettage –
removes
trophoblastic tissue
• Serial hCG levels –
persistent/rising
suggests malignancy*
excess hCG
Risk factors
• Multiparous
• Multiple pregnancy
• Molar pregnancy
Differential diagnosis
• UTI
• Gastroenteritis
• Trophoblastic disease
Possible antiemetics
• Promethazine
• Cyclizine
• Metoclopramide
• Ondansetron
RARE: 1 in 700 pregnancies
Gestational trophoblastic neoplasia:
persistently elevated hCG resulting from
persistence of any form of trophoblastic tissue
*Malignancy
Diagnosed if: persistent/rising hCG OR
persistent vaginal bleeding OR blood-borne
metastases
Mx: chemotherapy
8
RCOG (2016) The management of nausea and vomiting of pregnancy and hyperemesis gravidarum
[GTG 69]
82 Chapter 4: Obstetrics
https://t.me/med1917
Late pregnancy problems
Antepartum haemorrhage (APH)
Give anti-D if Rh –ve
Kleihauer test: estimates fetal Hb & therefore
amount of anti-D to give
Classification of placenta praevia
Minor: placenta not covering os
Major: partially/fully covering os
90% low-lying placentas will move upwards after
20w with growth of the uterus in the 3rd trimester
Delivery of placenta praevia
Elective C-section at 36–37w
• Earlier if severe bleeding
If placenta accreta/percreta
• Rusch balloon compression/total
hysterectomy after C-section to bleeding
↳
*Blood ≠ severity. Pain without bleed = ‘concealed’
abruption
Delivery in placental abruption
• No fetal distress >37w: IOL with
amniotomy
• No fetal distress <37w: monitor on
antenatal ward, steroids if <34w
• Fetal distress = urgent C-section
• Fetus is dead: IOL with amniotomy + blood
& FFP transfusion
↳
→ bleeding from the genital tract after 24 weeks’ gestation
Common causes
• Undetermined
• Placental abruption
• Placenta praevia
Rarer causes
• Genital tract pathology
• Uterine rupture
• Vasa praevia
PLACENTA PRAEVIA – placenta implants in lower section of uterus
→ Complicates 0.4% pregnancies
Risk factors
• Twins
• High parity
• Increased maternal age (>40)
• Scarred uterus, e.g. previous C-section/surgery, previous placenta praevia
↳ Placenta accreta: implantation so deep into scar that placental separation
is prevented
↳ Placenta percreta: implantation so deep into scar that it penetrates
uterine wall into surrounding structures e.g. bladder
Symptoms
• Intermittent, painless bleeds → increase in frequency & intensity
• Breech presentation, transverse lie, fetal head not engaged
Investigations: avoid vaginal examination → can provoke massive bleed
• Ultrasound scan
▶ detects low-lying placenta at 20w → safety-net: straight to hospital if
bleed occurs
▶ repeat at 32w to exclude praevia
Management
• Presentation without bleeding: delay admission until delivery
• Presentation with bleeding: admit & keep until delivery
▶ FBC, clotting studies, cross-match
▶ monitor fetal and maternal wellbeing: CTG, IV access
▶ IV steroids if <34 weeks’ gestation
▶ anti-D if woman is Rhesus –ve
9
PLACENTAL ABRUPTION – part or all of placenta separates before delivery
of the fetus
→ Complicates 1% pregnancies
Risk factors
• Hx of placental abruption (6%)
• Pre-eclampsia / pre-existing HTN
• IUGR
• Multiple pregnancy
• High parity
• Autoimmune
• Smoking / cocaine use
Investigations
USS: exclude placenta praevia
→ may not show abruption
9
RCOG (2011) Antepartum haemorrhage [GTG 63]
Symptoms
• Painful, dark bleeds*
• Tender, contracting uterus → labour
often ensues
• If severe = ‘woody-hard’ uterus,
hypotension, HR
• Decreased fetal movements
Management: admit
• FBC, clotting studies, cross-match
• Monitor fetal and maternal
wellbeing: CTG, CVP, IV access
• IV steroids if <34w gestation
• Anti-D if woman is Rhesus –ve
VASA PRAEVIA – fetal blood vessels run in the membranes in front of the
https://t.me/med1917
presenting part
→ when membranes rupture, fetal vessels do too = MASSIVE FETAL BLEED
Chapter 4: Obstetrics 83
Symptoms
• Moderate, painless vaginal bleed
when membranes rupture
• Severe fetal distress
Management
URGENT C-SECTION
UTERINE RUPTURE
→ occasionally occurs before labour in women with scarred / congenitally
abnormal uterus but very rare
BLEEDING OF GYNAECOLOGICAL ORIGIN
Causes
• Cervical carcinoma → suspect if small recurrent or post-coital bleeding
• Cervical polyps
• Ectropions
• Vaginal lacerations
↳
BLEEDING OF UNKNOWN ORIGIN
→ Small, painless bleeds in absence of placenta praevia → likely minor
placental abruptions
Prolonged pregnancy
DEFINITION: >42w
RISKS
To fetus/neonate
• Meconium aspiration
• Macrosomia: prolonged labour,
shoulder dystocia
• Neonatal seizures/encephalopathy
• IUGR (due to placental insufficiency)
• Stillbirth / neonatal death
To mother
• Prolonged labour
• Instrumental delivery/C-section
• Perineal damage
• PPH
• Infection
usually too slow to save
fetus if not in hospital
Risk factors for prolonged pregnancy
• Hx post-term pregnancy
• Primigravidity
• High BMI
• Higher maternal age
• Genetics
MANAGEMENT
Offer IOL after 41w
If IOL declined, increased monitoring: CTG 2× per week
Chorioamnionitis
↳
DEFINITION: acute inflammation of the amniotic fluid/membranes 2° to
ascending bacterial infection
RISK FACTOR: Prelabour ROM
INVESTIGATIONS
• FBC, CRP
• High vaginal swab – culture &
sensitivities
• CTG
SYMPTOMS
• Uterine tenderness
• Maternal signs of infection: fever,
tachycardia, leucocytosis
MANAGEMENT: Medical emergency
• Prompt delivery under IV ABX
→ may need C-section
84 Chapter 4: Obstetrics
https://t.me/med1917
Risk factors for preterm delivery
General
• Hx of preterm labour
• Younger/older mothers
• Lower socioeconomic status
• Short inter-pregnancy interval
Fetal survival response
Biggest risk factor
• Maternal disease, e.g. renal, thyroid, DM
• Pregnancy complications – IUGR,
pre-eclampsia
• Antepartum haemorrhage
Damage to uterus/cervix
• STIs/UTIs/vaginal infections
• Hx cervical surgeries
• Uterine abnormalities/fibroids
Not enough space
• Multiple pregnancy
• Polyhydramnios
Infection
indicated
in 60%
Preterm delivery
↳
DEFINITION: delivery between 24w & 37w (if <24w = miscarriage)
CAUSES
• Spontaneous preterm labour (50%)
• Iatrogenic – IOL by doctor due to fetal/maternal risk or PPROM
COMPLICATIONS
For neonate:
• Prematurity = 80% NICU occupancy
• Chronic morbidity
• Death
Lung disease, blindness/hearing loss, cerebral
palsy, neurological impairment
For mother:
• Infection (endometritis = common)
• Increased need for C-section
SYMPTOMS
• Painful contractions → 50% resolve & no preterm delivery
• Dull suprapubic ache & increased discharge if cervical incompetence
• Antepartum haemorrhage
• Fluid loss → suggests ROM
↳
Predicting preterm labour
1. Hx & VE
2. Transvaginal USS:
Serial cervical length
3. Fetal fibronectin
Levels rise shortly before labour
4. QUiPP app10 to calculate risk
Prevention: only high-risk women, e.g. previous preterm labour
10
• Offer cervical cerclage: sutures to strengthen cervix & keep it closed
▶ elective at 12–14w if recurrent early loss
▶ cervical length scans at 16w, 18w, 20w & offer sutures if <25mm
▶ ‘rescue suture’ of dilated cervix can be performed if first presentation
• Progesterone supplementation: suppositories from early pregnancy
• Treatment of maternal medical disease
• Avoid unnecessary ABX: treat UTIs, STIs, bacterial vaginosis but caution for
other infections
• Multi-fetal reduction: of higher order multiples
• Treatment of polyhydramnios: needle aspiration (amnioreduction) or
NSAIDs (reduce fetal urine output)
MANAGEMENT11: <27w transfer to NICU
1. Steroids & tocolysis:
infection present
• Steroids if <34w to promote pulmonary maturity
• Take 24h to work so delay delivery with tocolysis → e.g. nifedipine
2. IV ABX: only given antenatally if PPROM
3. MgSO4 if <32w: reduces risk of intraventricular haemorrhage and cerebral
palsy
4. Delivery: VAGINAL WHERE POSSIBLE – ensure in optimal environment
(neonatal unit)
• C-section if breech or other obstetric indications → increases risk of fetal
respiratory distress
• No artificial rupture of membranes if <34w
• Forceps only if necessary
• Antibiotics* – given intrapartum as GBS prophylaxis (regardless of mum’s
GBS status)
10
QUiPP version 2.0, released Oct 2017, © King's College London
11
NICE (2015, updated 2019) Preterm labour and birth [NG25]
Preterm pre-labour rupture of membranes (PPROM)
https://t.me/med1917
DEFINITION: membranes rupture before labour at <37w
CAUSES
• Often unknown
• Any of the causes of preterm labour
COMPLICATIONS
• Preterm delivery – occurs within 48h in 50%
• Infection of fetus, placenta, or cord (chorioamnionitis/funisitis)
• Prolapse of umbilical cord
• Pulmonary hypoplasia / postural deformities (due to lack of liquor)
SYMPTOMS
• Gush of clear fluid + further leaking
• Chorioamnionitis Sx:
▶ contractions
▶ abdominal pain / uterine tenderness
▶ fever, tachycardia
▶ offensive liquor
Chapter 4: Obstetrics 85
INVESTIGATIONS
• Speculum: pool of fluid in posterior fornix
• USS: may show reduced liquor BUT normal liquor volume doesn’t exclude
PPROM
• Point of care tests*: ILGF binding protein / placental alpha microglobulin
• Infection screen: high vaginal swab, FBC, CRP ± amniocentesis & culture
• Assess fetal wellbeing: CTG
Management12: balance risks of infection vs. risks of preterm delivery
No signs of infection
• Admit & monitor for signs of infection
• Corticosteroids if <34w (promote lung maturity of fetus)
• Prophylactic erythromycin (for maximum of 10d)
• IOL if reach 37w
Signs of infection
• Immediate IV ABX & delivery
• IV ABX & septic screen in baby when born
remember
12
RCOG (2019) Care of women presenting with suspected preterm prelabour rupture of membranes
[GTG 73]
86 Chapter 4: Obstetrics
Embryonic Disc
Conjoined Twins
Monochorionic/Monoamniotic
https://t.me/med1917
Multiple pregnancies
↳ Twins: 1/80 pregnancies
Risk factors
• Assisted conception
• Increasing maternal age
• Higher parity
• Genetics
↳ Triplets: 1/1000 pregnancies
Definitions
Dizygotic twins (2/3) – fertilisation of 2 different oocytes by 2 different sperm
Monozygotic twins (1/3) (identical) – meiotic division of a single oocyte
↳ Division before day 3 = dichorionic
diamniotic (DCDA) 2 placentas, 2 amnions (30%)
↳ Division in days 4–8 = monochorionic
diamniotic (MCDA)
↳ Division in days 9–13 = monochorionic
monoamniotic (MCMA) 1 placenta, 1 amnion (rare)
↳ Incomplete division = conjoined twins
1 placenta, 2 amnions (70%)
Biggest risk
MC twins
of complications is in
*All obstetric risks increased!
Complications*
MATERNAL
• Gestational diabetes, preeclampsia, anaemia = more
common
• Spontaneous miscarriage – one
fetus dies in 50% cases
• Preterm labour – 40% twins, 80%
triplets
• Malpresentation of 1st twins at
labour – 20%
• Postpartum haemorrhage –
atonic uterus is common
FETAL
• ×6 mortality/stillbirth →
prematurity = big cause of
mortality
• ×5 handicap (e.g. cerebral palsy)
• Congenital abnormalities more
common in MC twins
• IUGR – ⁄ cases: especially in MC twins
but can occur in any twin pregnancy
due to placental insufficiency
↳
Morula
Blastocyst
Implanted
Blastocyst
Formed
Cleavage
Days 1–3
Dichorionic/Diamniotic
Cleavage
Days 4–8
Monochorionic/Diamniotic
Cleavage
Days 8–13
Cleavage
Days 13–15
Fig. 4.2
Outcomes of TTTS
• Severe preterm delivery
• IUFD
Prognosis of TTTS
• Both survive: 50%
• One survives: 80%
Specific complications of monochorionicity
TWIN–TWIN TRANSFUSION SYNDROME (TTTS) – in MCDA only (15%)
• Unequal blood distribution through anastomoses in placenta
• Donor twin: volume depletion, anaemia, IUGR, oligohydramnios
• Recipient twin: volume overload, polycythaemia, cardiac failure, polyhydramnios
Management
→ complete laser photocoagulation of placental interface via USS & fetoscopy
(seal blood supply between twins)
→ USS amnioreduction (draw out some amniotic fluid)
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