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% Document Info
\author{Teas}
\pdfinfo{
  /Title (multifetal-pregnancy.pdf)
  /Creator (Cheatography)
  /Author (Teas)
  /Subject (MULTIFETAL PREGNANCY Cheat Sheet)
}

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\noindent
\begin{multicols}{3}
\begin{tabulary}{5.8cm}{C}
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    \vspace{-7pt}
    {\parbox{\dimexpr\textwidth-2\fboxsep\relax}{\noindent
        \hspace*{-6pt}\includegraphics[width=5.8cm]{/web/www.cheatography.com/public/images/cheatography_logo.pdf}}
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\columnbreak
\begin{tabulary}{11cm}{L}
    \vspace{-2pt}\large{\bf{\textcolor{DarkBackground}{\textrm{MULTIFETAL PREGNANCY Cheat Sheet}}}} \\
    \normalsize{by \textcolor{DarkBackground}{Teas} via \textcolor{DarkBackground}{\uline{cheatography.com/181443/cs/37794/}}}
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\noindent
\begin{multicols}{3}
\begin{tabulary}{5.8cm}{LL}
  \SetRowColor{FootBackground}
  \mymulticolumn{2}{p{5.377cm}}{\bf\textcolor{white}{Cheatographer}}  \\
  \vspace{-2pt}Teas \\
  \uline{cheatography.com/teas} \\
  \end{tabulary}
\vfill
\columnbreak
\begin{tabulary}{5.8cm}{L}
  \SetRowColor{FootBackground}
  \mymulticolumn{1}{p{5.377cm}}{\bf\textcolor{white}{Cheat Sheet}}  \\
   \vspace{-2pt}Not Yet Published.\\
   Updated 21st March, 2023.\\
   Page {\thepage} of \pageref{LastPage}.
\end{tabulary}
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  \vspace{-5pt}
  %\includegraphics[width=48px,height=48px]{dave.jpeg}
  Measure your website readability!\\
  www.readability-score.com
\end{tabulary}
\end{multicols}}




\begin{document}
\raggedright
\raggedcolumns

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\begin{multicols*}{2}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{MECHANISMS OF MULTIFETAL GESTATION}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Dizygotic or fraternal twin }} - twin fetuses result from fertilization of two separate ova} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Monozygotic or identical twin }} - twins arise from a single fertilized ovum} \tn 
% Row Count 4 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Genesis of Monozygotic Twins}}} \tn 
% Row Count 5 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{First 72 hours→ {\bf{diamnionic, dichorionic}}} \tn 
% Row Count 6 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{4th-8th day → {\bf{diamnionic, monochorionic}}} \tn 
% Row Count 7 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{8th-12th day → {\bf{monoamnionic, monochorionic}}} \tn 
% Row Count 8 (+ 1)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{\textgreater{}13 day→ {\bf{conjoined twin}}} \tn 
% Row Count 9 (+ 1)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Superfetation}} - requires ovulation and fertilization during the course of an established pregnancy} \tn 
% Row Count 12 (+ 3)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Superfecundation}} - refers to fertilization of two ova within the same menstrual cycle but not at the same coitus, nor necessarily by sperm from the same male} \tn 
% Row Count 16 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{Mechanism of monozygotic twinning}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/teas_1679210274_1.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{RISK FACTORS}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{ART (2-5 fold increase) - Monozygotic twins} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Different races and ethnic groups} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Maternal age} \tn 
% Row Count 3 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Increasing parity} \tn 
% Row Count 4 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Family history - maternal \textless{} paternal} \tn 
% Row Count 5 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Greater nutritional status reflected by maternal size} \tn 
% Row Count 7 (+ 2)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Pituitary gonadotropin in amount greater than usual} \tn 
% Row Count 9 (+ 2)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Ovulation induction with FSH plus hCG or clomiphene citrate} \tn 
% Row Count 11 (+ 2)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{In vitro fertilization (IVF)} \tn 
% Row Count 12 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{MATERNAL PHYSIOLOGICAL ADAPTATIONS}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Higher serum B-hCG levels → nausea and vomiting} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Blood volume expansion is greater (50-60\%)} \tn 
% Row Count 2 (+ 1)
% Row 2
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\mymulticolumn{1}{x{8.4cm}}{Greater blood loss with vaginal delivery} \tn 
% Row Count 3 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Greater iron and folate requirements} \tn 
% Row Count 4 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Augmented cardiac output} \tn 
% Row Count 5 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Lower vascular resistance} \tn 
% Row Count 6 (+ 1)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Uterine growth is greater} \tn 
% Row Count 7 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
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\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{DIAGNOSIS OF MULTIFETAL GESTATION}}  \tn
% Row 0
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\mymulticolumn{1}{x{8.4cm}}{{\bf{Clinical evaluation}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Uterine size is larger during the second trimester} \tn 
% Row Count 3 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Palpating two fetal heads in different uterine quadrants} \tn 
% Row Count 5 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Palpating two fetal heads in different uterine quadrants} \tn 
% Row Count 7 (+ 2)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Sonography}}} \tn 
% Row Count 8 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Used to determine fetal number, estimated gestational age, chorionicity, and amnionicity} \tn 
% Row Count 10 (+ 2)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Separate gestational sacs} \tn 
% Row Count 11 (+ 1)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Other diagnostic aids}}} \tn 
% Row Count 12 (+ 1)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Abdominal radiography} \tn 
% Row Count 13 (+ 1)
% Row 9
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- MRI} \tn 
% Row Count 14 (+ 1)
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Serum and urine B-hCG and maternal serum AFP} \tn 
% Row Count 15 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{SONOGRAPHY}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/teas_1679210739_3.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Sonograms of first-trimester twins. A. Dichorionic diamnionic twin pregnancy at 6 weeks' gestation. Note the thick dividing chorion (yellow arrow). One of the yolk sacs is indicated (blue arrow). B. Monochorionic diamnionic twin pregnancy at 8 weeks' gestation. Note the thin amnion encircling each embryo, resulting in a thin dividing membrane (blue arrow).}  \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{DIZYGOTIC BOYS - SUPERFECUNDATION}}  \tn
\SetRowColor{LightBackground}
\mymulticolumn{1}{p{8.4cm}}{\vspace{1px}\centerline{\includegraphics[width=5.1cm]{/web/www.cheatography.com/public/uploads/teas_1679210304_2.png}}} \tn 
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{PRENATAL CARE}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Prevent preterm delivery of markedly immature neonates} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Prenatal visit every 2 weeks beginning at 22 weeks} \tn 
% Row Count 3 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{ Diet:}}} \tn 
% Row Count 4 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- 37-57 lbs weight gain – normal BMI} \tn 
% Row Count 5 (+ 1)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- 40-45 kcal/kg/d - daily recommended augmented caloric intake} \tn 
% Row Count 7 (+ 2)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Sonography}}} \tn 
% Row Count 8 (+ 1)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Serial sonographic examinations} \tn 
% Row Count 9 (+ 1)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{- Oligohydramnios → uteroplacental pathology}}} \tn 
% Row Count 10 (+ 1)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Single deepest vertical pocket is measured} \tn 
% Row Count 11 (+ 1)
% Row 9
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ - \textless{}2cm = oligohydramnios}}} \tn 
% Row Count 12 (+ 1)
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{- \textgreater{}8 cm hydramnios}}} \tn 
% Row Count 13 (+ 1)
% Row 11
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Antepartum fetal surveillance}}} \tn 
% Row Count 14 (+ 1)
% Row 12
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Biophysical profile} \tn 
% Row Count 15 (+ 1)
% Row 13
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Nonstress test} \tn 
% Row Count 16 (+ 1)
% Row 14
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Umbilical artery doppler velocimetry} \tn 
% Row Count 17 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{PRETERM BIRTH}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Prediction of preterm birth}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Cervical length} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ - \textless{}20mm most accurate for predicting birth before 34 weeks}}} \tn 
% Row Count 4 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Closed internal os by examination was found to as predictive of postponed delivery} \tn 
% Row Count 6 (+ 2)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Fetal bronectin levels also may predict preterm birth} \tn 
% Row Count 8 (+ 2)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{ Prevention}}} \tn 
% Row Count 9 (+ 1)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Limited physical activity, early work leave, more frequent health-care visits, serial sonographic examinations, and structured maternal education regarding preterm delivery risks have been advocated to reduce preterm birth rates in women with multiple fetuses} \tn 
% Row Count 15 (+ 6)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Prophylactic Tocolysis} \tn 
% Row Count 16 (+ 1)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ treatment did not reduce the rate of twins delivering before 37 or before 34 weeks' gestation}}} \tn 
% Row Count 18 (+ 2)
% Row 9
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{oral terbutaline}}*} \tn 
% Row Count 19 (+ 1)
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Progesterone Therapy} \tn 
% Row Count 20 (+ 1)
% Row 11
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{17-alpha-hydroxyprogesterone caproate (17-OHPC) injections are not effective for multifetal gestations}}} \tn 
% Row Count 23 (+ 3)
% Row 12
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{*Vaginal micronized progesterone - ineffective for preterm birth prevention before 34 weeks} \tn 
% Row Count 25 (+ 2)
% Row 13
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Cervical Cerclage} \tn 
% Row Count 26 (+ 1)
% Row 14
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Prophylactic cerclage - does not improve perinatal outcome in women with twin pregnancies}}} \tn 
% Row Count 28 (+ 2)
% Row 15
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Physical examination–indicated cerclage in women with a second-trimester twin gestation and a dilated cervix may be beneficial}}} \tn 
% Row Count 31 (+ 3)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{PRETERM BIRTH (cont)}}  \tn
% Row 16
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Pessary} \tn 
% Row Count 1 (+ 1)
% Row 17
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ not recommended}}} \tn 
% Row Count 2 (+ 1)
% Row 18
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Treatment}}} \tn 
% Row Count 3 (+ 1)
% Row 19
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- Tocolytic therapy to help halt preterm labor in multifetal pregnancy} \tn 
% Row Count 5 (+ 2)
% Row 20
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{does not measurably improve neonatal outcomes}}} \tn 
% Row Count 6 (+ 1)
% Row 21
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{entails higher maternal risk than in singleton pregnancy}}} \tn 
% Row Count 8 (+ 2)
% Row 22
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{augmented pregnancy-induced hypervolemia, which raises cardiac demands and increases the susceptibility to iatrogenic pulmonary edema}}} \tn 
% Row Count 11 (+ 3)
% Row 23
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{nifedipine}}} \tn 
% Row Count 12 (+ 1)
% Row 24
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Antenatal corticosteroids} \tn 
% Row Count 13 (+ 1)
% Row 25
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ for fetal lung maturation}}} \tn 
% Row Count 14 (+ 1)
% Row 26
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{betamethasone}} - reduced rates of periventricular hemorrhage} \tn 
% Row Count 16 (+ 2)
% Row 27
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Preterm Prelabor Membrane Rupture}}} \tn 
% Row Count 17 (+ 1)
% Row 28
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- PPROM after 24 weeks' gestation, the median number of days to subsequent delivery was 4 days for twins compared with 7 days for singletons} \tn 
% Row Count 20 (+ 3)
% Row 29
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Delayed Delivery of Second Twin}}} \tn 
% Row Count 21 (+ 1)
% Row 30
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- If delayed delivery is attempted, counseling should include the potential for serious maternal complications.} \tn 
% Row Count 24 (+ 3)
% Row 31
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- The range of gestational age for which benefits outweigh the risks for delayed delivery is likely narrow, and gestations of 22 to 24 weeks would seem the most probable to benefit} \tn 
% Row Count 28 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{FETAL DEMISE}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{At any time during multifetal pregnancy, one or more fetuses may die, either simultaneously or sequentially} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Causes and incidence of fetal death are related to}}} \tn 
% Row Count 5 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{1) fetal anomaly} \tn 
% Row Count 6 (+ 1)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{2) chorionicity - monochorionic twins suffer higher rates of sFGR, TTTS or TAPS from unequal vascular anastomoses; monoamnionic pairs can die from cord entanglement} \tn 
% Row Count 10 (+ 4)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Early death - {\bf{vanishing twin}}} \tn 
% Row Count 11 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Fetus compressus}} - in a more slightly advanced gestation, the dead fetus may become compressed appreciably} \tn 
% Row Count 14 (+ 3)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{fetus papyraceus}} - flattened dead fetus through desiccation} \tn 
% Row Count 16 (+ 2)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{MANAGEMENT}}} \tn 
% Row Count 17 (+ 1)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- decisions should be based on gestational age, the cause of  death, and the risk to the surviving fetu} \tn 
% Row Count 20 (+ 3)
% Row 9
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{- If  the loss occurs after the first trimester, the risk of death or damage to the survivor is largely limited to monochorionic twin gestations.  Morbidity in the monochorionic twin survivor is  almost always due to vascular anastomoses, which often cause  the demise of one twin followed by sudden hypotension in the  other.} \tn 
% Row Count 27 (+ 7)
% Row 10
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{- Single fetal death during the late second and early third  trimesters presents the greatest risk to the surviving twin.} \tn 
% Row Count 30 (+ 3)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{FETAL DEMISE (cont)}}  \tn
% Row 11
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ If death of one dichorionic twin is due to a discordant congenital anomaly in the first trimester, it should not affect the surviving twin}}} \tn 
% Row Count 3 (+ 3)
% Row 12
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ If one fetus of a monochorionic twin gestation dies after the first trimester but before viability, pregnancy termination can be considered}}} \tn 
% Row Count 6 (+ 3)
% Row 13
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Delivery generally occurs within 3 weeks of diagnosis of fetal  demise, thus antenatal corticosteroids for survivor lung maturity should be considered. Regardless, unless  the intrauterine environment is hostile, the goal is to prolong  the preterm pregnancy.} \tn 
% Row Count 12 (+ 6)
% Row 14
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Dichorionic twins can probably be safely delivered  at term}}} \tn 
% Row Count 14 (+ 2)
% Row 15
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Monochorionic twin gestations are more difficult to  manage and are often delivered between 34 and 37 weeks' gestation}}} \tn 
% Row Count 17 (+ 3)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{EVALUATION OF FETAL PRESENTATION}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Fetal presentations are best described sonographically} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Possible presentation combinations:} \tn 
% Row Count 3 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ -most common: cephalic-cephalic,  cephalic-breech, and cephalic-transverse}}} \tn 
% Row Count 5 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{ROUTE OF DELIVERY}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Vaginal vs CS}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Cephalic-cephalic}} - vaginal birth} \tn 
% Row Count 2 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Cephalic-noncephalic}} - caesarean section or vaginal} \tn 
% Row Count 4 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Breech first twin}} - caesarean section} \tn 
% Row Count 5 (+ 1)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{VAGINAL BIRTH AFTER CESAREAN DELIVERY}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{No evidence currently suggests an  increased risk of uterine rupture, and women with twins and  one previous cesarean delivery with a low transverse incision  may be considered candidates for trial of labor} \tn 
% Row Count 5 (+ 5)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{VAGINAL DELIVERY OF SECOND TWIN}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Following delivery of the first twin, the presenting part of the second  twin, its size, and its relationship to the birth canal should be quickly  and careully ascertained by combined abdominal, vaginal, and at  times, intrauterine examination} \tn 
% Row Count 5 (+ 5)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{- Sonography is a valuable aid}}} \tn 
% Row Count 6 (+ 1)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{- If the fetal head or the breech is fixed in the birth canal,  moderate fundal pressure is applied and membranes are ruptured}}} \tn 
% Row Count 9 (+ 3)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{- Immediately afterward, digital examination of the cervix is  repeated to exclude cord prolapse}}} \tn 
% Row Count 11 (+ 2)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{- Labor is allowed to resume}}} \tn 
% Row Count 12 (+ 1)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{- If contractions do not begin within approximately 10  minutes, dilute oxytocin may be used to stimulate  contractions}}} \tn 
% Row Count 15 (+ 3)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{The safest interval between delivery of the first and  second twins was frequently cited as \textless{}30 minutes} \tn 
% Row Count 18 (+ 3)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{If the occiput or breech presents immediately over the pelvic inlet,  but is not fixed in the birth canal, the presenting part can often be  guided into the pelvis by one hand in the vagina, while a second hand  on the uterine fundus exerts moderate pressure caudally. A  presenting shoulder may be gently converted into a cephalic  presentation. Alternatively, with abdominal manipulation, an assistant can guide the presenting part into the pelvis} \tn 
% Row Count 27 (+ 9)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{ - Sonography can aid guidance and allow heart rate  monitoring. Intrapartum external version of a noncephalic  second twin has also been described.}}} \tn 
% Row Count 30 (+ 3)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{VAGINAL DELIVERY OF SECOND TWIN (cont)}}  \tn
% Row 9
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{If the occiput or breech is not over the pelvic inlet and cannot be so positioned by gentle pressure or if appreciable uterine bleeding develops, delivery of the second twin can be problematic.} \tn 
% Row Count 4 (+ 4)
% Row 10
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{To take maximum advantage of the dilated cervix before the uterus contracts and the cervix retracts, delay should be avoided} \tn 
% Row Count 7 (+ 3)
% Row 11
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Prompt cesarean delivery of the second fetus is preferred if no one present is skilled in the performance of internal podalic version or if anesthesia that will provide effective uterine relaxation is not immediately available.} \tn 
% Row Count 12 (+ 5)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{LABOR AUGMENTATION OR INDUCTION}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Active labor with twins progresses more slowly in both nulliparas and multiparas compared with that in singleton} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{Second-stage labor of the first twin also is longer} \tn 
% Row Count 5 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{labor augmentation}} - {\emph{oxytocin}} may be used provided that women with twins  meet all criteria for its administration} \tn 
% Row Count 8 (+ 3)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{labor induction}} -{\emph{oxytocin alone or in combination with cervical ripening}} can  safely be used in twin gestations} \tn 
% Row Count 11 (+ 3)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Augmentation or induction of labor is not recommended in multifetal pregnancy}}} \tn 
% Row Count 13 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{ANALGESIA AND ANESTHESIA}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Epidural anesthesia}} - ideal because it provides excellent pain relief and can be rapidly extended cephalad if internal podalic version or cesarean delivery is required.} \tn 
% Row Count 4 (+ 4)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{General anesthesia}} - necessary for intrauterine manipulation during vaginal birth (underliverd twin), uterine relaxation can be accomplished rapidly with halogenated inhalation agent} \tn 
% Row Count 8 (+ 4)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{nitroglycerin (IV/sublingual) or  terbutaline (IV)}} - for uterine relaxation} \tn 
% Row Count 10 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{TRIPLET OR HIGHER-ORDER GESTATION}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Fetal heart rate monitoring during labor with triplet pregnancies is  challenging} \tn 
% Row Count 2 (+ 2)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{-With vaginal delivery, the first neonate is usually born with  little or no manipulation}}} \tn 
% Row Count 4 (+ 2)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{-Subsequent fetuses, however, are delivered according to the presenting part}}} \tn 
% Row Count 6 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{-{}-often requires complicated obstetrical maneuvers such as total breech extraction with or  without internal podalic version or even cesarean  delivery} \tn 
% Row Count 10 (+ 4)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{-Associated with malposition of fetuses is an increased  incidence of cord prolapse}}} \tn 
% Row Count 12 (+ 2)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{-{}-reduced placental perfusion and hemorrhage from separating placentas are more likely during  delivery} \tn 
% Row Count 15 (+ 3)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{Pregnancies  complicated by three or more fetuses should undergo cesarean  delivery} \tn 
% Row Count 17 (+ 2)
% Row 7
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{-vaginal delivery was associated with a higher perinatal  mortality rate}}} \tn 
% Row Count 19 (+ 2)
% Row 8
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{-recommended prelabor cesarean delivery for triplets}}} \tn 
% Row Count 21 (+ 2)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{PREGNANCY COMPLICATIONS}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Spontaneous Abortion and Vanishing Fetus}} - monochorionic twins have significantly higher early fetal loss rates than dichorionic pairs} \tn 
% Row Count 3 (+ 3)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Congenital Malformations}} - monochorionic twins was almost twice that of dichorionic twin gestations. The occurrence risk and concordance were substantially higher among monochorionic twins} \tn 
% Row Count 7 (+ 4)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Low Birthweight}} - Multifetal gestations are more likely to be low birthweight than singleton pregnancies due to restricted fetal growth and preterm delivery. Birthweights in twins closely paralleled those of singletons until 28 to 30 weeks' gestation. Beginning at 35 to 36 weeks' gestation, twin birthweights clearly diverge from those of singletons. Thus, abnormal growth should be diagnosed only when fetal size is less than expected for multifetal gestation. To confirm suitable growth in dichorionic pairs, perform sonography every 4 weeks, starting at 16 to 20 weeks. Monochorionic twins are imaged every 2 weeks for twin-twin transfusion syndrome.} \tn 
% Row Count 21 (+ 14)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Hypertension}} - those with multifetal gestations are more likely to develop a pregnancy-associated hypertensive disorder, and the incidence further rises with advancing fetal number} \tn 
% Row Count 25 (+ 4)
\hhline{>{\arrayrulecolor{DarkBackground}}-}
\end{tabularx}
\par\addvspace{1.3em}

\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{UNIQUE FETAL COMPLICATIONS}}  \tn
% Row 0
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Monoamnionic Twins}}} \tn 
% Row Count 1 (+ 1)
% Row 1
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Fetal loss}} - fetuses alive before 16 weeks' gestation, less than half survive to the neonatal period. Fetal abnormalities and spontaneous miscarriage contribute to most loss. High perinatal death is attributable to preterm birth, twin-twin transfusion syndrome, cord entanglement, birth weight discordance, and congenital anomalies.} \tn 
% Row Count 8 (+ 7)
% Row 2
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Congenital anomaly}} - concordance anomalies - fetal echocardiography is indicated} \tn 
% Row Count 10 (+ 2)
% Row 3
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Twin-twin transfusion syndrome}} - lower in monoamnionic twins than in monochorionic diamnionic pregnancies} \tn 
% Row Count 13 (+ 3)
% Row 4
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Umbilical cord entanglement}} - a frequent event. Mothers with monoamnionic twins are often admitted at 24-28 weeks gestation to begin 1 hour of daily fetal heart rate monitoring. Betamethasone is given to promote pulmonary lung maturation. If fetal testing remains reassuring and no other intervening indications arise, CS is performed at 32-34 weeks gestation.} \tn 
% Row Count 21 (+ 8)
% Row 5
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Unique and Aberrant Twinning}}} \tn 
% Row Count 22 (+ 1)
% Row 6
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Conjoined Twins}} - referred to as Siamese twins, joining of the twins may begin at either pole and produce characteristic forms depending on which body parts are  joined or shared, {\bf{thoracopagus}} is the most common. Frequently identified using sonography (fetal poles are seen to be closely associated and do not change relative position from one another, more than 1 three vessels in the umbilical cord, fewer limbs than expected, spine hyperflexion, bifid fetal pole, and increased nuchal thickness) at midpregSurgical separation of an almost completely joined twin pair may be successful if essential organs are not shared.  Viable conjoined twins should be delivered by cesareannancy.} \tn 
% Row Count 36 (+ 14)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{UNIQUE FETAL COMPLICATIONS (cont)}}  \tn
% Row 7
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{External Parasitic Twins and Fetus-in-fetu}} - attached to a relatively normal twin, an external parasitic twin is grossly defective fetus or merely fetal parts. Usually consists of supernumerary limbs, often with some viscera. A functional heart or brain is absent. Parasitic twins are believed to derived from a dead defective twin, whose surviving tissue attached to and receives vascular support from the normal co-twin.} \tn 
% Row Count 9 (+ 9)
% Row 8
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Fetus-in-fetu}} - one embryo may enfold early within its co- twin  and mainly intraabdominally. Vertebral or axial bones are found in the fetiform mass, whereas a heart and brain are absent.} \tn 
% Row Count 13 (+ 4)
% Row 9
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\bf{Monochorionic Twins and Vascular Anastomoses}} -  All monochorionic placentas likely share some anastomotic  connections (exceptions: anastomoses between twins are unique to monochorionic twin placentas, number, size, and direction of these seemingly haphazard connections vary markedly. \{\{nl\}\} Artery-to-artery anastomoses are most frequent. \{\{nl\}\} Deep artery-to-vein  communications can extend  through the capillary bed of a  given villus -\textgreater{} create a common  villous compartment  or "third circulation"  that has been  identified in  approximately half  of monochorionic  twin placentas \{\{nl\}\}This chronic fetofetal transfusion may result in several clinical syndromes that  include twin-twin transfusion syndrome (TTTS), twin anemia  poycythemia sequence (TAPS), and acardiac twinning} \tn 
% Row Count 29 (+ 16)
% Row 10
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Twin-Twin Transfusion Syndrome}} \{\{nl\}\} - blood is transfused from a donor twin to its recipient sibling such that the donor may eventually become anemic and its growth may be restricted. \{\{nl\}\} The recipient becomes polycythemic may develop circulatory overload with heart failure manisfest as hydrops. \{\{nl\}\} - donor twin is smaller and pale, recipient twin is larger and has volume excess. \{\{nl\}\} - recipient may suffer from hyperviscosity and occlusive complications, polycythemia may lead to hyperviscosity and occlusive complications. \{\{nl\}\} - Chronic TTS: unidirectional arteriovenous anastomoses.  \{\{nl\}\} -TTTS typically presents in midpregnancy when the donor fetus becomes oliguric from hypovolemia and decreased renal perfusion. \{\{nl\}\} - Donor develops oligohydramnios; recipient develops severe hydramnios (due to inc. urine production) \{\{nl\}\}  - absent amnionic fluid in the donor sac = prevents fetal movement refereed to as {\emph{"stuck twin or \seqsplit{polyhydramnios-oligohydramnios} syndrome - poly-oli"}}} \tn 
% Row Count 50 (+ 21)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{UNIQUE FETAL COMPLICATIONS (cont)}}  \tn
% Row 11
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Fetal Brain Damage}} \{\{nl\}\} Cerebral palsy, microcephaly, porencephaly, and multicystic  encephalomalacia are serious complications associated with placental vascular anastomoses in multifetal gestation. \{\{nl\}\} -{}-\textgreater{} likely caused by ischemic necrosis leading to cavitary brain  lesions \{\{nl\}\} donor twin (hypotension, anemia, or both -{}-\textgreater{} ischemia) o recipient twin (blood pressure instability and  episodes of profound hypotension -{}-\textgreater{}ischemia)} \tn 
% Row Count 9 (+ 9)
% Row 12
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Diagnosis}} \{\{nl\}\} TTTS is diagnosed based on two sonographic criteria: \{\{nl\}\} 1) a monochorionic diamnionic pregnancy is identified \{\{nl\}\}  2) hydramnios (defined by a largest vertical pocket \textgreater{}8cm) in  one sac and oligohydramnios (defined by a largest vertical  pocket \textless{}2cm) in the other twin is found \{\{nl\}\} Sonographic surveillance of pregnancies at risk for TTTS is  recommended: \{\{nl\}\} -begin at approximately 16 weeks AOG \{\{nl\}\} - subsequent studies are considered every 2 weeks \{\{nl\}\}  {\bf{ {\emph{Quintero (1999) Staging System}} }} \{\{nl\}\} Stage I - discordant amnionic fluid volumes as described in the earlier paragraph, but urine is still visible  sonographically within the bladder of the donor twin \{\{nl\}\} Stage II - criteria of stage I, but urine is not visible within the donor bladder \{\{nl\}\} Stage III - criteria of stage II and abnormal Doppler studies of the umbilical artery, ductus venosus, or umbilical vein \{\{nl\}\} Stage IV - ascites or frank hydrops in either twin \{\{nl\}\} Stage V - demise of either fetus \{\{nl\}\} -myocardial performance index (MPI) or Tei index -{}-\textgreater{} a Doppler index of ventricular function calculated  for each ventricle} \tn 
% Row Count 32 (+ 23)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{UNIQUE FETAL COMPLICATIONS (cont)}}  \tn
% Row 13
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Management and Prognosis}} \{\{nl\}\} Prognosis is related to Quintero stage and gestational age at  presentation. \{\{nl\}\} Several therapies are available for TTTS and include amnioreduction,  laser ablation of vascular placental anastomoses, selective feticide,  and septostomy \{\{nl\}\} - amnioreduction - needle drainage of excess amnionic fluid \{\{nl\}\} - Septostomy - intentionally creating a hole in the dividing  amnionic membrane \{\{nl\}\} laser ablation of anastomoses is preferred for severe TTTS  (stages II-IV) \{\{nl\}\} - Selective fetal reduction has generally been considered if severe  amnionic fluid and growth disturbances develop before 20 weeks -{}-\textgreater{}  both fetuses typically will die without intervention \{\{nl\}\} -} \tn 
% Row Count 15 (+ 15)
% Row 14
\SetRowColor{white}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Twin Anemia-Polycythemia Sequence}} \{\{nl\}\} This form of chronic fetofetal transfusion is characterized by  significant hemoglobin differences between donor and recipient  twins. \{\{nl\}\}  It is diagnosed antenatally by MCA peak systolic velocity (PSV) \textgreater{}1.5  multiples of the median (MoM) in the donor and \textless{}1.0MoM in the  recipient twin. \{\{nl\}\}  Spontaneous TAPS usually occurs after 26 weeks' gestation, and  iatrogenic TAPS develops within 5 weeks of a procedure.} \tn 
% Row Count 25 (+ 10)
% Row 15
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Twin \seqsplit{Reversed-Arterial-Perfusion} Sequence}} aka {\bf{acardiac  twin}} \{\{nl\}\}  a rare but  serious complication of monochorionic multifetal  gestation where there is a  normally formed donor twin  that shows features of heart  failure and a recipient twin that lacks a heart  (acardius) and other  structures. \{\{nl\}\} - caused by a large  artery-to-artery placental shunt,  often also  accompanied by a  vein-to-vein shunt \{\{nl\}\}  - failed head growth is called {\bf{acardius acephalus}} \{\{nl\}\} - failed head growth is called {\bf{acardius acephalus}} \{\{nl\}\} - failure of any recognizable structure to form is  {\bf{acardius amorphous}} \{\{nl\}\} - Radiofrequency ablation (RFA) of the umbilical  cord is the preferred modality of therapy \{\{nl\}\} Median gestational age at delivery was 37 weeks and the average gestational age at the time of the  RFA was 20 weeks \{\{nl\}\} - Major complications were prematurely ruptured  membranes and preterm birth.} \tn 
% Row Count 44 (+ 19)
\end{tabularx}
\par\addvspace{1.3em}

\vfill
\columnbreak
\begin{tabularx}{8.4cm}{X}
\SetRowColor{DarkBackground}
\mymulticolumn{1}{x{8.4cm}}{\bf\textcolor{white}{UNIQUE FETAL COMPLICATIONS (cont)}}  \tn
% Row 16
\SetRowColor{LightBackground}
\mymulticolumn{1}{x{8.4cm}}{{\emph{Hydatidiform Mole with Coexisting Normal Fetus}} \{\{nl\}\} This unique gestation contains one normal fetus, and its cotwin is a  complete molar pregnancy \{\{nl\}\} - must be differentiated from a partial molar pregnancy, in  which an anomalous singleton fetus (usually triploid) is  accompanied by molar tissue \{\{nl\}\} Diagnosis is usually made in the first half of pregnancy \{\{nl\}\} - Sonographically, a normal-appearing twin is accompanied  by its cotwin (a large placenta containing multiple small anechoic cysts). \{\{nl\}\} Often, these pregnancies are terminated, but pregnancy continuation  is increasingly adopted. \{\{nl\}\} 1) the pregnancy prognosis is not as poor as previously  thought \{\{nl\}\} 2) the risk of persistent trophoblastic disease is similar  whether the pregnancy is terminated or not \{\{nl\}\} Complications of expectant management include vaginal bleeding,  hyperemesis gravidarum, thyrotoxicosis, and early-onset  preeclampsia.} \tn 
% Row Count 19 (+ 19)
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