Although I love this topic of multiple gestations, scanning twins makes me nervous because it comes with twice the responsibility of checking the viability of these babies. Also, due to the 5x mortality rate in twins, I would go into the exam expecting an anomaly. Other than the normal anatomy we evaluate during a survey ultrasound (biometrics, maternal/fetal environment, etc..) we should thoroughly be assessing the chorionicity/amnionicity by looking for the thickness of the membrane near the placenta…. The “lambda/twin peak” sign or  “T” sign can help us identify if a twin pregnancy is Dichorionic/Diamniotic or Monochorionic/Diamniotic. This diagnosis is crucial because, as we learned today, there are more possibilities of anomalies with monochorionic twins because of the anastomosis of the vascular connections in the placenta. With this higher incidence of anomalies, I think that performing umbilical cord Dopplers would be beneficial to monitor blood flow in each of the twins. Making sure that we are labeling each fetus correctly, or following the labels from the previous sonographer, is essential. I couldn’t imagine mixing up the twins, especially if one had an anomaly. Another important parameter is to check amniotic fluid due to the fact that Poli-Oli and TTTS both have cases where one twin has an insufficient amount of fluid while the other has too much.

 *** Here’s where I have a question though, when doing AFI or DVP, would you do them separate for each twin’s gestational sac? I think this would make the most sense because it would tell you the fluid volume of each twin.***

I think the emotions of twin parents can vary, but I feel most would become exhausted having to get examined so often. I think this is important for us to remember as sonographers when scanning these mothers and realizing what they have to go through weekly. I think emotions may be heightened especially if this pregnancy is the first for a mother. Like Michelle said today, they probably go home and do their own research, like most patients do, and are aware of the risk factors of carrying twins rather than just carrying a singleton. I found a website called https://www.twiniversity.com/ that has resources for parents to access that help prepare them for pregnancy, delivery, post partum, and other factors after birth such as breastfeeding and stroller reviews. Of course, there are also many support groups on Facebook to assist mothers that are pregnant with twins. I always thought it would be nice to have twins, you know... two for the price of one! But after learning about the anomalies that can happen in singletons, just to find out they can happen more in twins, I think I’ll just be blessed with a healthy baby one day, no matter the number or gender!

Hello SonoSistas,

Before I got into this program I always seen pregnancy with triplets or twins as a blessing. I knew getting pregnant could be difficult. So when I saw a women carrying more than one baby in her stomach she stood out to me as a warrior. Now I know from lecture and reading multiple gestational pregnancy most commonly happen due to advanced maternal age, family history and assisted reproductive procedures. Also, the women that come in with multiple gestation pregnancys could have more anxiety than a woman with a singleton pregnancy because she is at risk for pre-eclampsia, prolapsed cord, and her babies having a congenital anomaly. She is probably also on edge about one of her babies not making it to term. 

As a sonographer, I would very much enjoy performing a survey on a multiple gestational pregnancy. I learn best by repetition, so if I had to scan a baby back to back three times in a row I image my images would show improvement. I would also be a bit nervous to scan a multiple gestational pregnancy because, if something is abnormal I would be the first to know. I would also be the first to know if there was a fetal demise because I would do a subjective assessment of the heart on each fetus before I began my exam. Then se if I can tell how the fetal demise happened was it twin to twin transfusion, trap syndrome (acardiac anomaly), or twin anemia polycythemia syndrome to name a few. Also determine which fetus is closer to the internal os (baby A).  When accessing a multiple gestation pregnancy, I think it is extremely important to be thorough and really see if you can evaluate chorionicity. 

 Here is something we probably won’t see in ultrasound but, just in case our patient has a history of some sort I think its good to be aware. Postpartum hemorrhage (PPH) I ran across it upon looking up differentials for multiple pregnancy concerns. The postpartum hemorrhage occurs when the uterus has grown extremely large (over distended) and the placenta is extremely large for the particular person (the mother) also the patient will bleed heavily after giving birth. 

https://www.aafp.org/afp/2017/0401/p442.html

Here is a couple of images of what these women can do for treatment if they face this complication after giving birth.

Reduction of uterine inversion (Johnson method). (A)The protruding fundus is grasped with fingers directed toward the posterior fornix. (B)The uterus is returned to position by pushing it through the pelvis and (C)into the abdomen with steady pressure toward the umbilicus.

I believe the topic itself about multiple gestations is a bit frightening let alone scanning it. The fact that multiple gestations run way more 5x more fatality risk compared to a singleton. You not only assessing the well being of one fetus but two or perhaps even more! Nowadays people google everything prior to their appointment and get a range of possibilities thus you are to most likely have a anxious and nervous family in your room examining your every expression and the monitor. Before diving in I believe it is important to obtain history and any other tools that may help you predict prior to scanning. Keep in mind the following anomalies can occur with multiple gestations: stuck twin, acardia anomaly and conjoined twins. Maternal complications may include preclampsia, bleeding, prolapsed cord and as for the fetus may have to be delivered premature. Sono we are to first look at what kind of twins we are assessing. By that I mean are we looking at twins that share both amnion and chorion versus twins that completely have their own "housing" or a mixture as certain conditions such as sharing everything in the "house" are higher at risk and may need to be monitored as they run a high risk of mortality. keeping all that in mind as it makes a huge impact in furthering providing service for our patients and their little  ones. I have here a picture that can maybe help some of us with identifying the " housing " in multiple gestations .I'd also like to include the importance of identifying the t and peak sign as this is a sono sign that can help identify the "housing " that way you can better access the patient and little ones. 

When scanning for multiple gestations definitely labeling the gestational sacs so there is no confusion of A versus B or C. We want to determine the chorionicity to figure out what type of pregnancy we are facing. Majority of pregnancies are dizygotic and under 1 % monozygotic. Whenever monochorionic we want to be detailed because anomalies are common with this type of pregnancy. My concern was confusing the babies along the way when they get bigger. However in class Michelle mentioned that they shouldn't move around to much. If they did, something was wrong. Also use reference whichever gest sac is closest to cx its labeled "AAA." Also with multiple gestations, being very alert with labs and the mothers clinical history. AFP is usually high with twins, but also AFP elevated is associated with anencephaly and spina bifida, so double check brain, spine and biometric measurements.  Also be aware of comparing gestational sacs. Eval if there is more fluid than the other. Is one bigger or smaller than the other fetus? The consistent evaluations of these multiple gestation pregnancies has the parents tense and anxious that something is wrong. A sonographer handling twin pregnancies will need to be more understanding with these parents because they're probably more emotional as well. It makes sense, if my babies were being evaluated frequently I would be panicking each visit that maybe this is the time when it all goes south. It's an emotional roller coaster.

When I showed up to clinicals Tuesday my lead was telling us she had scanned triplets the day before. She hadn't done one in years since often they are through IVF and are known and sent to a high risk center. She had to do some quick thinking about how to organizer her scan to answer any questions the doctors may have. It was difficult to tell the order based on proximity to the cervix since they were only about 8 weeks gestation so she did a sweep from rt to left and labeled them 1,2,3 from that order. She documented heart rate,CRL,yolk sac, and chorion for each. They appeared to each have their own chorion. These were also spontaneous triplets and the mother was sobbing during the entire exam. These were not tears of joy. She was worried and anxious. She was not expecting so many babies. It's unclear if she was unhappy about having too many or if it was also due to the high risk factor. I think simply because she didn't want three. With spontaneous multiples she may not be aware of the risk factors yet. 

That being said the pregnancy is at a much higher risk for fetal demise along with other complications with growth and moms health. Thankfully, because there didn't appear to be any shared chorion the risk factors are decreased since each fetus will have their own independent blood supply. This eliminates TTTS.