Multifetal gestations have increased significantly in the past 30 years, mostly due to the increase in fertility treatments. Diagnosis can be made as early as 5 weeks gestation. Determination of both chorionicity and zygosity is most accurate early in pregnancy. Maternal and fetal complications are elevated in multifetal gestations, and such patients should receive specialized prenatal care [1].

Recommended resource—ACOG Practice Bulletin 169: Twin, Triplet, and Higher-Order Multifetal Pregnancies [2].

Q1::

What is the most common complication encountered in multifetal gestations?

A.:

Neonatal death

B.:

Stillbirth

C.:

Preeclampsia

D.:

Spontaneous preterm birth

Q2::

Multifetal gestations are associated with all the following, EXCEPT:

A.:

Increased prevalence of cerebral palsy

B.:

Higher costs

C.:

Increase in short-term morbidity neonatal morbidity

D.:

Increase in long-term infant morbidity

E.:

All of the above are true

Q3::

Excluding ART use, the likelihood of a multifetal gestation increases with maternal age.

A.:

TRUE

B.:

FALSE

Q4::

Which of the following ART techniques may have the most significant effect on the increase of multifetal pregnancies?

A.:

In vitro fertilization

B.:

Ovulation induction with clomiphene

C.:

Controlled ovarian hyperstimulation with gonadotropins

D.:

A and C

E.:

All of the above

Q5::

A woman presents to your office with quadruplets and requests information about multifetal reduction. How would you counsel her?

A.:

She would have a decreased risk of IUGR and decreased risk of cesarean section, but an increased risk of preterm delivery

B.:

She would have an increased risk of IUGR, decreased risk of cesarean section, and no change in her risk of preterm delivery

C.:

She would have a decreased risk of IUGR, decreased risk of cesarean section, and a decreased risk of preterm delivery

D.:

She would have an increased risk of IUGR, decreased risk of cesarean section, and an increased risk of preeclampsia

Q6::

Further review of this patient’s records reveals that she has one monochorionic pair. What would you recommend in terms of reduction?

A.:

Reduction of one of the non-monochorionic fetuses

B.:

Reduction of one of the monochorionic fetuses

C.:

Reduction of both monochorionic fetuses

D.:

Recommend against reduction given the increased risks associated with it

Q7::

Another woman with triplets voices interest in selective fetal termination. How would you counsel her on the difference?

A.:

Selective fetal termination refers to reduction based on desired sex of live-born children

B.:

Selective fetal termination refers to reduction of an abnormal fetus

C.:

Selective fetal termination is associated with higher risks compared to multifetal reduction

D.:

B and C

E.:

All of the above

Q8::

How can dichorionicity be established?

A.:

Sex discordance

B.:

Two placentas

C.:

IVF with documentation of two embryos transferred

D.:

Twin peak sign

E.:

A, B, and D

F.:

All of the above

Q9::

Given risk for preterm delivery, all women with multifetal gestations should be screened using the following method:

A.:

Serial cervical lengths

B.:

Cervical length at growth US

C.:

Fetal fibronectin at visits between 24 and 34 weeks gestational age

D.:

All of the above

E.:

B and C

F.:

None of the above

Q10::

Which of the following interventions have been shown to prolong pregnancy in women with multifetal gestations without a history of cervical insufficiency?

A.:

Bed rest

B.:

Prophylactic cerclage

C.:

Prophylactic tocolysis

D.:

Vaginal progesterone in setting of a shortened cervix

E.:

Prophylactic pessary

F.:

None of the above

Q11::

How should preterm labor with multifetal gestations be managed?

A.:

Hold tocolysis regardless of gestational age, give betamethasone if 23–34 weeks gestation, and hold magnesium sulfate for neuroprotection

B.:

Give tocolysis for steroid benefit, give betamethasone if 23–34 weeks gestation, and hold magnesium sulfate for neuroprotection

C.:

Give tocolysis for steroid benefit, give betamethasone if 23–34 weeks gestation, and give magnesium sulfate for neuroprotection up to 32 weeks gestation

D.:

Give magnesium for tocolysis and for neuroprotection up to 32 weeks gestation, and give betamethasone if between 23 and 34 weeks gestation

Match the following tests with the current knowledge of their use in multiple gestations:

A. Not as sensitive because average of values can mask abnormal values

B. Can be technically challenging, but is equally as sensitive in singletons and multiples

C. Insufficient evidence to recommend its use

D. Can be performed for definitive diagnosis, higher risk of sampling error

E. Can be performed for definitive diagnosis, lower risk of sampling error

Q12::

CVS

Q13::

Nuchal translucency

Q14::

Amniocentesis

Q15::

Cell-free fetal DNA

Q16::

Serum screening

Q17::

How is discordance calculated?

A.:

(Larger twin − smaller twin) × 100/smaller twin

B.:

(Larger twin − smaller twin) × 100/larger twin

For questions 18–22—True or False:

Q18::

Twins are considered discordant when there is a 25% difference in fetal weight between larger and smaller fetus.

Q19::

Twins with isolated growth discordance are at no increased risk for morbidity or mortality.

Q20::

IUGR twins have equivalent outcomes to singleton IUGR babies once gestational age is controlled for.

Q21::

Dichorionic-diamniotic twin gestations should undergo growth ultrasounds every 46 weeks.

Q22::

Dichorionic-diamniotic twin gestations should undergo antenatal testing starting at 32 weeks gestational age.

Q23::

Which of the following is FALSE regarding twin-twin transfusion syndrome?

A.:

Ultrasounds should be performed to monitor for twin-twin transfusion syndrome starting at 20 weeks gestational age

B.:

Twin-twin transfusion syndrome occurs in 10–15% of monochorionic-diamniotic twin gestations

C.:

Twin-twin transfusion syndrome is generally diagnosed in the second trimester

D.:

Twin-twin transfusion syndrome results from AV anastomoses in the placenta

Q24::

Which of the following is the correct sequence for the progression of twin-twin transfusion?

A.:

Absent bladder in the donor, abnormal Doppler ultrasonography, oligohydramnios/polyhydramnios, hydrops, and death

B.:

Oligohydramnios/polyhydramnios, absent bladder in the donor, abnormal Doppler ultrasonography, hydrops, and death

C.:

Oligohydramnios/polyhydramnios, abnormal Doppler ultrasonography, absent bladder in the donor, and death

D:

Absent bladder in the donor, oligohydramnios/polyhydramnios, abnormal Doppler ultrasonography, hydrops, and death

E.:

Oligohydramnios/polyhydramnios, absent bladder in the donor, abnormal Doppler ultrasonography, and death

Q25–27: In uncomplicated pregnancies, choose the latest recommended gestational age to deliver at: A, 34 weeks; B, 35 weeks; C, 36 weeks; D, 37 weeks; E, 38 weeks; F, 39 weeks.

Q25::

Dichorionic-diamniotic twin gestations.

Q26::

Monochorionic-diamniotic twin gestations.

Q27::

Monochorionic-monochorionic twin gestations.

Q28::

Which of the following factors are necessary to attempt a vaginal delivery in dichorionic-diamniotic twin gestations?

A.:

No prior cesarean sections

B.:

Gestational age at 32 weeks or greater

C.:

Presenting twin is vertex

D.:

A and C

E.:

B and C

F.:

All of the above

Q29::

If all criteria are met, planned vaginal delivery compared to planned cesarean section in dichorionic-diamniotic twin gestations is associated with:

A.:

Increased risk of fetal death

B.:

Increased risk of serious neonatal morbidity

C.:

Increased risk of cerebral palsy

D.:

B and C

E.:

None of the above

FormalPara Answers

Q1: D, Q2: E, Q3: A, Q4: D, Q5: C, Q6: C, Q7: D, Q8: E, Q9: F, Q10: F, Q11: C, Q12: D, Q13: B, Q14: E, Q15: C, Q16: A, Q17: B, Q18: False, Q19: True, Q20: False, Q21: True, Q22: False, Q23: A, Q24: B, Q25: E, Q26: D, Q27: A, Q28: E, Q29: E.