OBG PRACTICAL EXAMINATION PREPARATION

TOPIC: MULTIPLE PREGNANCY (TWIN PREGNANCY)

(Reference: Hepsibah Kirubamani Practical OBG + Creasy & Resnik's MFM)

SECTION 1: CASE SHEET (PROFORMA)

Name: Mrs. ___________           Age: ___ years
IP No: ___________               Date: ___________
Ward: ___________                Bed No: ___________

OBSTETRIC SCORE: G___ P___ L___ A___

PRESENTING COMPLAINTS:
1. Amenorrhea for ___ months
2. Abdominal distension more than expected for period of amenorrhea
3. (Any other: breathlessness / leg swelling / vomiting / bleeding PV)

MENSTRUAL HISTORY:
- LMP: ___________  EDD: ___________
- Cycle: Regular/Irregular, ___/28 days
- Flow: Normal/Heavy/Dysmenorrhea

OBSTETRIC HISTORY:
[Table: G, date, sex, birth weight, mode of delivery, complications, outcome]

PAST HISTORY: DM / HTN / Thyroid / Cardiac / Surgical

PERSONAL HISTORY: Diet / Habits / Occupation

FAMILY HISTORY: History of twins in family (maternal side especially)

TREATMENT HISTORY: Ovulation induction / ART / IVF

GENERAL EXAMINATION:
Build: ____________   Nourishment: ____________
Pallor: +/−         Icterus: +/−         Cyanosis: +/−
Clubbing: +/−       Lymphadenopathy: +/−
Edema: bilateral pitting pedal edema +/−
BP: ___/___mmHg    Pulse: ___/min    Temp: ___°F
RR: ___/min        SpO2: ___%

SYSTEMIC EXAMINATION:
CVS: S1 S2 heard, no murmur
RS: Clear air entry bilaterally
CNS: Conscious, oriented

OBSTETRIC EXAMINATION:
INSPECTION:
- Abdomen is enlarged, MORE than expected for period of amenorrhea
- Linea nigra / striae gravidarum present
- Umbilicus: everted / flat
- Visible fetal parts: yes/no

PALPATION:
- Fundal height: ___ weeks (more than dates)
- Uterine girth: ___ cm
- Fundal grip (1st): _____ (twin 1 pole)
- Lateral grips (2nd & 3rd): Multiple fetal parts / Small parts palpable on BOTH sides
- Pawlik's grip (4th): _____
- Presenting part: vertex/breech (Twin 1) / vertex/breech (Twin 2)
- Fetal movement: active/sluggish in multiple quadrants

AUSCULTATION:
- FHR 1: ___ bpm at _______ area
- FHR 2: ___ bpm at _______ area
- Simultaneous auscultation at two different sites - different rates with "silent zone" between them

VAGINAL EXAMINATION (if appropriate): 
- Cervix: Posterior/Mid/Anterior, Long/Effaced, Closed/___cm
- Presenting part: Vertex / Breech / Floating

PROVISIONAL DIAGNOSIS: 
Mrs. ___, G_P_L_A_, with ___ weeks / months of amenorrhea, diagnosed as MULTIPLE PREGNANCY (TWIN), with _______ (complication if any), in _____ stage of labour.

INVESTIGATIONS ORDERED: [See Management section]

MANAGEMENT PLAN: [See Management section]

SECTION 2: CASE PRESENTATION WITH "WHY" OF EVERY HISTORY & DIFFERENTIAL DIAGNOSIS

A. HISTORY TAKING - WITH REASONS

1. Age of the Patient

• Ask: "How old are you?"
• Why:
  • Older women (>35 yrs) have higher rates of dizygotic twinning due to elevated FSH levels causing multiple follicle recruitment
  • Younger age (<20 yrs) is associated with lower twinning rates
  • Age also determines risk stratification for ART-related multiple pregnancy

2. Gravidity and Parity

• Ask: "How many times have you been pregnant? How many deliveries?"
• Why:
  • Higher parity increases dizygotic twinning rate (each successive pregnancy mildly increases FSH)
  • Prior twins in obstetric history increases recurrence risk (fraternal twins are hereditary; identical twins are not)
  • Parity determines risk of complications (grand multipara + twins = very high risk)

3. Chief Complaint - Amenorrhea Duration vs. Abdomen Size

• Ask: "How many months since your last period? When did you first notice your abdomen growing?"
• Why:
  • In multiple pregnancy, uterine size is larger than expected for gestation (key clinical feature)
  • A 25-week twin uterus is equal in volume to a term singleton uterus (Creasy & Resnik)
  • Excessive uterine enlargement prompts clinical suspicion

4. Excessive Nausea and Vomiting

• Ask: "Did you have severe vomiting in early pregnancy?"
• Why:
  • Multiple pregnancies produce exaggerated levels of hCG (all pregnancy hormones are significantly elevated)
  • This leads to hyperemesis gravidarum more commonly
  • Elevated hCG also means higher AFP, hPL, estradiol, progesterone - all exaggerated

5. Fetal Movements

• Ask: "Do you feel movements? Where? Are movements from multiple areas?"
• Why:
  • In singleton, movements are felt in one area predominantly
  • In twins, patients often report simultaneous movements from different quadrants
  • Reduced movement in one twin while other is active may suggest fetal compromise (TTTS)

6. Breathlessness / Pressure Symptoms

• Ask: "Do you have difficulty breathing? Heartburn? Urinary frequency?"
• Why:
  • Large uterus causes splinting of diaphragm - breathlessness
  • Increased uterine pressure on bladder causes urinary frequency
  • Acid reflux from upward displacement of stomach
  • These are exaggerated due to the larger uterus in twin pregnancy

7. Leg Swelling

• Ask: "Do you have swelling of feet and legs?"
• Why:
  • Physiologic plasma volume increases 50-100% in multiple gestation (vs ~45% in singleton)
  • Greater uterine compression of IVC causes dependent edema
  • Edema also signals possible preeclampsia - risk is 26% in twins (vs ~5% in singletons)

8. Hypertension / Headache / Visual Disturbances

• Ask: "Do you have headaches? Blurred vision? Was your BP raised at any visit?"
• Why:
  • Preeclampsia risk: 26% in twins vs ~5% in singletons
  • HELLP syndrome risk: 9% in twins
  • Preeclampsia occurs earlier, is more severe, and may have atypical presentation in multiple gestations
  • Essential to screen at every visit

9. Vaginal Bleeding / Discharge

• Ask: "Any bleeding per vaginum? Any watery discharge?"
• Why:
  • Twins have 24% risk of PPROM (preterm premature rupture of membranes)
  • Uterine overdistension is the mechanism
  • Placenta previa and abruption are more common (larger placental surface area)
  • Placental abruption risk is significantly higher in twins

10. Pelvic/Abdominal Pain

• Ask: "Any lower abdominal tightening? Backache?"
• Why:
  • 78% risk of preterm labor in twin pregnancy
  • Uterine overdistension triggers premature uterine contractions
  • Regular contractions before 37 weeks = threatened preterm labor

11. Menstrual History (LMP/EDD)

• Ask: "When was your last normal period?"
• Why:
  • Fundal height always more than dates in multiple pregnancy - this discrepancy is a key clinical clue
  • Accurate dating crucial for management decisions (delivery timing differs: DI twins at 38 wks, MC twins at 36-37 wks)

12. Family History of Twins

• Ask: "Is there a history of twins on either side of your family?"
• Why:
  • Dizygotic twinning has a genetic basis - maternal genetics particularly important
  • Familial tendency is due to hereditary tendency toward multiple ovulations
  • Monozygotic twinning occurs at a constant rate (~3-4/1000 worldwide) - NOT familial
  • Family history of DZ twins on mother's side significantly raises probability

13. Treatment for Infertility / ART / IVF

• Ask: "Did you take any fertility drugs? Did you undergo IVF or any fertility procedure?"
• Why:
  • Ovulation induction (clomiphene, gonadotropins) causes multiple follicle recruitment - DZ twins
  • ART/IVF - multiple embryo transfer is the commonest iatrogenic cause of higher-order multiples
  • IVF also increases monozygotic twinning 3.2% (vs background 0.4%)
  • Knowing the cause helps predict chorionicity and risk

14. Socioeconomic Status / Race / Ethnicity

• Ask: "Where are you from? What do you eat?"
• Why:
  • DZ twinning: 6/1000 in Asia, 40/1000 in sub-Saharan Africa (huge regional variation due to diet, FSH levels)
  • Race influences baseline risk of complications
  • Higher rates of maternal mortality in lower-resource settings

B. DIFFERENTIAL DIAGNOSIS (Why the Uterus is Large for Dates)

SECTION 3: SUMMARY WITH POSITIVE HISTORY AND EXAMINATION FINDINGS

SECTION 4: EXAMINATION PROCEDURE (OBSTETRIC EXAMINATION FOR TWINS)

Step-by-Step Abdominal Examination

• Position: Patient supine, slightly tilted to left
• Note: Is the abdomen disproportionately large for dates?
• Look for: linea nigra, striae gravidarum, visible fetal parts, umbilical eversion (due to overdistension)
• Note the shape: More globular, wider than singleton at same gestation

• Using a tape measure from the top of the symphysis pubis to the fundus
• In twins: fundal height is typically 2-4 cm MORE than the gestational weeks from ~20 weeks
• At 25 weeks twin gestation: uterus size equals a 36-week singleton uterus

• Face the patient's head
• Cup both hands over the fundus
• In twins: Often a breech (soft, irregular) of one twin occupies the fundus
• Sometimes BOTH poles felt - one in fundus, one in pelvis with unusual fullness

• Face the patient's feet, place hands on lateral sides of uterus
• Classic twin finding: Small parts (limbs) felt on BOTH sides of the uterus, OR a back on one side and a back on the other side (back-to-back twins)
• Uterine girth is significantly increased
• Three poles may be felt: two heads and a breech, or two breeches and a head (pathognomonic of twins)

• Face the patient's feet, place fingers on either side of the lower uterine segment
• Identify the presenting part of Twin 1
• In twins: presenting part may be less well-engaged due to the presence of Twin 2

• Use a Pinard stethoscope or fetoscope
• Listen at the usual areas for the presenting part
• Critical maneuver: Have an assistant simultaneously count another FHR at a different site
• Positive finding: Two distinct FHR at two different locations, with:
  • A rate difference of >10 bpm between the two, OR
  • A clear "silent zone" (area of no FHR) between the two auscultation points
• Rule: Both FHR are counted for one full minute SIMULTANEOUSLY (not sequentially)
• One observer counts FHR1 while another counts FHR2, or count both with stopwatch method

• Ballottement: Multiple ballottable masses
• Fluid thrill: May be positive if associated polyhydramnios
• Fetal movement: Feel for simultaneous movements in different quadrants

SECTION 5: DIAGNOSIS WITH EXPLANATION

Clinical Diagnosis: TWIN PREGNANCY (MULTIPLE PREGNANCY)

1. Uterus larger than dates - The fundal height exceeds the gestational age by more than 4 cm, suggesting a larger than expected uterine volume.
2. Palpation of more than 3 fetal poles - Feeling three or more distinct fetal poles (e.g., two heads + one breech, or two poles and unusually full lower segment) strongly suggests twins.
3. Small parts on BOTH flanks - When limbs are felt on both lateral sides simultaneously, it implies two fetuses back-to-back.
4. Two distinct FHR - The hallmark clinical finding. Two separate fetal hearts beating at different rates, heard at two different sites with a silent zone between them.
5. History of predisposing factors - Family history of twins, ART, ovulation induction, advanced maternal age, multiparity.

• Monochorionic twins (MC) have significantly higher perinatal morbidity and mortality than dichorionic twins (DC)
• MC twins are at risk for: Twin-to-Twin Transfusion Syndrome (TTTS), Twin Anemia-Polycythemia Sequence (TAPS), selective fetal growth restriction, cord entanglement (MCMA)
• TTTS occurs in ~10-15% of MCDA twins - one donor twin becomes anemic, small; recipient becomes polycythemic, large with hydrops

SECTION 6: CASE DISCUSSION

A. Etiology / Predisposing Factors

• Hereditary: Maternal family history (FSH gene variants - tendency to multiple ovulation)
• Advanced maternal age (>35 yrs): Higher FSH stimulates multiple follicle development
• Multiparity: Each pregnancy slightly raises baseline FSH
• Race: Sub-Saharan African women 40/1000 vs Asian 6/1000
• Nutrition: Adequate folic acid and diet (Yoruba tribe in Nigeria - yam consumption hypothesis)
• Ovulation induction: Clomiphene, gonadotropins - most common iatrogenic cause
• ART/IVF: Multiple embryo transfer

• Spontaneous, occurs at constant rate (~3-4/1000) worldwide
• NOT genetic/hereditary
• Slightly higher after IVF (3.2% vs 0.4% background)
• Possibly related to zona pellucida manipulation

B. Pathophysiology of Complications

C. Classification of Multiple Pregnancy

• Dichorionic-Diamniotic (DCDA) - 70% of twins
• Monochorionic-Diamniotic (MCDA) - 28%
• Monochorionic-Monoamniotic (MCMA) - 1-2%
• Conjoined - <1:100,000

D. Maternal Physiological Changes in Multiple Pregnancy

• Plasma volume increases 50-100% (vs 45% in singleton)
• Cardiac output increases 20% more than singleton
• Uterine volume at 25 weeks twin = singleton at term
• All pregnancy hormones (hCG, hPL, AFP, progesterone, estradiol) significantly elevated
• Systolic/diastolic BP drops more in 2nd trimester but is significantly higher at term vs singleton

SECTION 7: INVESTIGATIONS

A. To Confirm Diagnosis

B. Routine Investigations

C. Fetal Monitoring Investigations

D. Antenatal Screening

SECTION 8: MANAGEMENT

A. Antenatal Management

• Register early and more frequently (fortnightly visits from 20-32 wks, weekly from 32 wks)
• Adequate rest - avoid strenuous activity from second trimester
• Nutritional supplementation: Iron (60 mg elemental iron daily), Folic acid (5 mg/day), Calcium 1g/day
• Adequate caloric intake (add 300 kcal/day for each fetus beyond singleton)
• Avoid long travel

• Serial BP monitoring at every visit (preeclampsia risk 26%)
• Urine protein at every visit
• Serial Hb checks and correction of anemia
• Fetal growth scan every 2-4 weeks (DC twins from 24 wks; MC twins from 16 wks)
• MC twins: Cervical length check every 2 weeks from 16-24 wks + TTTS surveillance
• Doppler studies as clinically indicated

• Preterm labor: Education on warning signs; tocolysis if needed (nifedipine, atosiban); corticosteroids (betamethasone 12 mg IM x 2 doses, 24 hours apart) if delivery <34 weeks expected
• Preeclampsia: Low-dose aspirin 150 mg/day from <16 weeks in high-risk cases; manage as per severity
• Anemia: Iron + folate supplementation; parenteral iron if oral not tolerated
• GDM: Dietary modification, insulin if required

B. Intrapartum Management

1. Continuous EFM with two separate transducers (electronic fetal monitoring)
2. IV access with two large-bore cannulas
3. Oxytocin augmentation as needed
4. Deliver Twin 1 in usual manner
5. After Twin 1 delivery: Check lie/presentation of Twin 2 immediately by palpation/USG
6. If Twin 2 is vertex - allow spontaneous labor (usually delivers within 30 mins)
7. If Twin 2 is breech - experienced obstetrician performs internal podalic version or breech extraction
8. Interval between twins: Should not exceed 30 minutes; prolonged interval increases risk to Twin 2
9. Active management of third stage - oxytocin immediately after delivery of Twin 2
10. Type and crossmatch blood; PPH risk is 9%

• Non-vertex presenting twin (Twin 1 is breech)
• MCMA twins (cord entanglement risk)
• Conjoined twins
• Higher-order multiples (triplets and above)
• Fetal compromise during labor
• Failed internal version after delivery of Twin 1

C. Postpartum Management

• Active management of third stage (oxytocin 10 IU IV)
• Misoprostol if needed for uterine atony
• Monitor for PPH closely for 24 hours
• Continue iron supplementation
• Breastfeeding support (both twins can breastfeed)
• Contraception counseling

SECTION 9: POSSIBLE VIVA QUESTIONS AND ANSWERS

A: Approximately 1 in 80 spontaneous pregnancies (Hellin's rule: twins 1/80, triplets 1/80², quadruplets 1/80³). With ART, the incidence has increased significantly. In the US, twin births were ~120,000 in 2019. DZ twinning ranges from 6/1000 in Asia to 40/1000 in sub-Saharan Africa; MZ twinning is constant at 3-4/1000 worldwide.

A: If the incidence of twins is 1/n, then the incidence of triplets is 1/n², quadruplets is 1/n³, etc. Since twin incidence is ~1/80 spontaneously: triplets = 1/6400, quadruplets = 1/512,000. This applies to spontaneous conceptions only.

A: Dizygotic (fraternal, ~70%): arise from fertilization of two separate ova by two sperm; share ~50% genes; always DCDA; influenced by genetics, age, parity, race, ART. Monozygotic (identical, ~30%): arise from splitting of one fertilized ovum; share ~100% genes; chorionicity depends on timing of split; NOT hereditary; constant rate worldwide.

A:

• Best time: 11-14 weeks (first trimester - most accurate)
• Twin Peak / Lambda sign: Triangular wedge of placental tissue insinuating between the two chorionic layers at the placental insertion - indicates DICHORIONIC placentation
• T-sign: Right-angle junction of the membrane with the placenta without placental tissue insinuation - indicates MONOCHORIONIC placentation
• After first trimester: Sex discordance (different sexes = DC); two placental masses (DC); thickness of dividing membrane (>2mm = DC)
• Clinical: Cannot reliably determine chorionicity

A: (Using mnemonic - HAPARTDG-PP):

• Hypertension / Preeclampsia: 26%
• Anemia: 24%
• Preterm labor: 78%
• Abruption: increased risk
• Rupture of membranes (PPROM): 24%
• Thromboembolism: increased
• Diabetes (GDM): 14%
• Gestational cholestasis / PUPPP / Acute fatty liver
• Postpartum hemorrhage: 9%
• Psychological morbidity: stress, postnatal depression

A:

• Prematurity (mean gestation 35.1 weeks; 20% deliver before 34 weeks)
• Low birth weight (risk of <1500g is 10x that of singletons)
• TTTS (10-15% of MCDA twins) - donor: anemia, oligohydramnios, IUGR; recipient: polycythemia, polyhydramnios, hydrops
• TAPS (Twin Anemia-Polycythemia Sequence) - small placental anastomoses causing chronic slow transfusion
• TRAP sequence (Twin Reversed Arterial Perfusion) - acardiac twin
• Selective IUGR
• Conjoined twins
• Increased congenital anomalies (cardiac defects, neural tube defects in MZ twins)
• Cord entanglement (MCMA twins)
• Fetal death and co-twin complications
• Cerebral palsy: 4-6x higher than singletons

A: TTTS occurs in 10-15% of monochorionic-diamniotic (MCDA) twins. Mechanism: arteriovenous anastomoses in the shared monochorionic placenta create unidirectional net blood flow from one twin (donor) to the other (recipient).

• Donor twin: Anemia, oligohydramnios/anhydramnios ("stuck twin"), IUGR, cardiomegaly
• Recipient twin: Polycythemia, polyhydramnios, hydrops fetalis, cardiac dysfunction
• Staging: Quintero staging (I-V) based on amniotic fluid discordance, absent/reversed diastolic flow, hydrops, demise
• Treatment: Fetoscopic laser photocoagulation of anastomotic vessels is the treatment of choice for Stage II-IV; amnioreduction for selected cases

A:

• Stage I: Discordant amniotic fluid (DVP <2cm in donor, >8cm in recipient), bladder visible in both twins
• Stage II: Absent bladder in donor twin (no urine production)
• Stage III: Critically abnormal Doppler (absent/reversed end-diastolic flow in UA, reversed flow in DV, pulsatile UV)
• Stage IV: Hydrops fetalis in either twin
• Stage V: Demise of one or both twins

A: The Lambda sign (also called the Twin Peak sign) is a triangular, wedge-shaped projection of placental tissue that insinuates into the base of the inter-twin membrane. It is seen on ultrasound in the first trimester (optimally 11-14 weeks) at the site where the membrane meets the placenta. It indicates DICHORIONIC placentation. The triangular echogenicity represents villous tissue from the chorion frondosum growing into the potential space between the two fused chorions. The T-sign, in contrast, is a right-angle insertion of the membrane into the placenta without placental tissue insinuation, indicating MONOCHORIONIC placentation.

A: Presentations in twin pregnancy:

• Vertex-Vertex: ~40-45% - vaginal delivery possible
• Vertex-Breech / Vertex-Transverse: ~35% - controversial; internal podalic version for Twin 2 possible
• Breech-Vertex: Non-vertex first twin - cesarean recommended
• Breech-Breech: ~10% - cesarean
• Other: Transverse-any - cesarean

A:

1. Uterus disproportionately large for gestational age (SFH > dates by ≥4 cm)
2. Three or more fetal poles palpable (two heads + breech, or two breeches + head)
3. Small parts palpable on BOTH flanks
4. Two distinct FHR heard simultaneously at two sites with different rates and a silent zone between them
5. Increased uterine girth
6. Excessive fetal activity felt simultaneously in different quadrants
7. Ballottement of multiple masses

A: Two observers are needed. Each listens with a Pinard fetoscope or Doppler device at different sites - one at the right lateral area (for Twin 1, if presenting part is on the right), the other at the left lateral area or above the umbilicus (for Twin 2). Both count FHRs simultaneously for one full minute. For a positive diagnosis of twin pregnancy:

• Two separate rates must be heard
• Rates differ by >10 bpm, AND/OR
• A silent zone (area with no FHR) exists between the two auscultation sites
• Simple counting sequentially is not sufficient - simultaneous counting is required

A: Ultrasonography is the gold standard. It shows:

• Two separate gestational sacs (early 1st trimester)
• Two embryonic poles with two distinct heartbeats
• Dividing membrane (if present)
• Lambda/T-sign for chorionicity determination (best at 11-14 weeks)
• Biometry of both fetuses
• Amniotic fluid volume for each sac

A:

• Uncomplicated DCDA twins: 38 weeks (37+0 to 38+6 per ACOG)
• Uncomplicated MCDA twins: 36-37 weeks (individualized; ACOG allows 34-37+6)
• Uncomplicated MCMA twins: 32-34 weeks by elective cesarean

A: Growth discordance is defined as a difference in estimated fetal weight of ≥20% between the two twins, calculated as: [(Larger EFW - Smaller EFW) / Larger EFW] × 100.

A: Twin Reversed Arterial Perfusion (TRAP) sequence - also called acardiac twin. It is a complication of MC twins where one twin is structurally normal (pump twin) and the other (acardiac twin) has absent or rudimentary cardiac structures. The pump twin's heart maintains perfusion of both twins through artery-to-artery anastomoses - the acardiac twin receives reversed, deoxygenated blood. The pump twin is at risk of high-output cardiac failure. Treatment: radiofrequency ablation of the umbilical cord of the acardiac twin.

A:

• Onset: Usually preterm; mean gestation 35.1 weeks
• First stage: Often prolonged due to uterine overdistension and malpresentation
• Second stage: After Twin 1 delivers, Twin 2 may change lie - requires urgent assessment
• Third stage: Higher risk of PPH (uterine atony from overdistension, larger placental site)
• Complications during labor: cord prolapse (after ROM, especially if Twin 2 is non-vertex), fetal distress (continuous dual EFM essential), locking of twins (chin-to-chin in breech-vertex presentation - rare)

A: Collision of twins during delivery - occurs when Twin 1 presents as breech and Twin 2 as vertex. The chin of the aftercoming head of Twin 1 (breech) becomes interlocked with the chin of the descending head of Twin 2. This is a very rare but life-threatening complication. Management: disimpaction under GA with upward pressure on Twin 2's head; Zavanelli maneuver; emergency cesarean.

A: An extension of Hellin's law, it states that the frequency of multiple pregnancies in a population can be expressed as: if the frequency of twins = n, then the frequency of triplets = n², quadruplets = n³, etc. It helps estimate expected rates of higher-order multiples in a population.

A: MCMA twins (1-2% of MC twins) share both chorion and amnion - no dividing membrane. Risks:

• Cord entanglement - occurs in virtually all MCMA twins, causing variable FHR decelerations
• Cord knots - can cause acute fetal compromise or death
• Perinatal mortality is 10-40%
• Management: Intensive surveillance from 26 weeks; inpatient monitoring from 26-32 weeks at tertiary center; planned cesarean delivery at 32-34 weeks

A: The normal cardiovascular adaptations of singleton pregnancy are exaggerated:

• Plasma volume increases 50-100% (vs ~45% in singleton)
• Cardiac output increases 20% more than singleton (stroke volume +15%, heart rate +4%)
• Increased myocardial contractility
• Greater fall in BP in second trimester, but significantly higher mean BP at term vs singleton
• These changes increase risk of: pulmonary edema (if other risk factors present), hypertension, cardiac strain in women with pre-existing cardiac disease

A: Counsel on:

1. Higher risk pregnancy - more frequent antenatal visits
2. Timing of delivery (36-38 weeks depending on chorionicity)
3. Mode of delivery - if both vertex, vaginal delivery is safe; cesarean if non-vertex first twin
4. Preterm birth risk - recognize warning signs (regular contractions, PV discharge, pressure)
5. Hospital delivery is mandatory - tertiary center for MC twins
6. Neonatal ICU availability for preterm twins
7. Iron and folic acid supplementation
8. Feeding: Both twins can breastfeed; adequate nutrition for mother

What's Included:

1. Case Sheet (Proforma)

2. History Taking with "WHY"

• Age, parity, family history of twins, ART/ovulation induction, nausea, breathlessness, fetal movements from multiple quadrants, leg swelling, hypertension symptoms, PV bleeding, amenorrhea vs size discrepancy

3. Differential Diagnosis

4. Summary with Positive Findings

5. Examination Procedure

6. Diagnosis with Explanation

7. Case Discussion

• Etiology of DZ vs MZ twinning
• Pathophysiology of each complication (preterm labor, preeclampsia, anemia, TTTS, PPROM, etc.) with mechanism explained

8. Investigations

9. Management

10. 22 Viva Questions and Answers