1. Which of the following is/are true about chorionicity in twin pregnancies?

• a)
  

  It can be reliably determined in the first trimester of pregnancy.

  
  
• b)
  

  It can be reliably determined by measuring the thickness of the inter-twin membrane.

  
  
• c)
  

  It is accomplished by identifying the Lambda (λ) sign in monochorionic pregnancies and T signs in dichorionic pregnancies.

  
  
• d)
  

  It can be determined only if the placentas are separated.

  
  
• e)
  

  Discordant genders are diagnostic of dichorionicity.

2. Which of the following is/are true about dating twin pregnancies?

• a)
  

  Twin pregnancies cannot be dated accurately.

  
  
• b)
  

  They are dated best by first day of the last menstrual period.

  
  
• c)
  

  Singleton crown–rump length (CRL) charts cannot be used to date twin pregnancies, and charts specific to twins should be used.

  
  
• d)
  

  Dating twin pregnancy by the CRL of the larger twin or by the mean CRL of the two is reasonably accurate.

  
  
• e)
  

  CRL of the smaller twin should not be used to date twin pregnancy because it might underlie the presence of a chromosomal abnormality in the fetus.

3. Which of the following is/are true about twin labelling in twin pregnancies?

• a)
  

  It is only possible in dichorionic twin pregnancies.

  
  
• b)
  

  It is based on the relationship between the inter-twin membrane and the cervix.

  
  
• c)
  

  It can only be accomplished reliably when the two twins are of opposite sex.

  
  
• d)
  

  It is not possible in structurally normal mono-amniotic twins of similar size.

  
  
• e)
  

  It reliably reflects the order of the twins at delivery.

4. Which of the following is/are true about a discrepancy in CRL measurements in twins?

• a)
  

  It is associated with fetal loss in 50% of cases.

  
  
• b)
  

  It is not predictive of fetal outcome once chromosomal and structural anomalies are ruled out.

  
  
• c)
  

  Is a much more common in monochorionic pregnancies compared with dichorionic pregnancies.

  
  
• d)
  

  It is highly suggestive of preterm delivery and birth-weight discordance.

  
  
• e)
  

  It is only a weak indicator of adverse fetal and neonatal outcome.

5. Which of the following is/are true about twin-to-twin transfusion syndrome (TTTS)?

• a)
  

  Discrepancy in CRL is a not a particularly good predictor.

  
  
• b)
  

  It is evident in the first trimester of pregnancy.

  
  
• c)
  

  It might be anticipated by a discrepancy in nuchal translucency discordance or abnormal flow in the ductus venosus.

  
  
• d)
  

  It is most commonly diagnosed in the third trimester of pregnancy.

  
  
• e)
  

  It is predicted by the presence of cord entanglement.

6. Which of the following statements about single intrauterine fetal demise (sIUFD) is/are true?

• a)
  

  Timing and chorionicity are important factors in determining the outcome of a co-twin.

  
  
• b)
  

  Monochorionic survivor twins are at five times higher risk of death after sIUFD compared with dichorionic survivor twins.

  
  
• c)
  

  The risk of fetal death in dichorionic twin pregnancies with selective intrauterine growth restriction (IUGR) doubles that of IUGR in singleton pregnancies.

  
  
• d)
  

  Among the types of selective IUGR in monochorionic twin pregnancies, type II has the highest rate of severe fetal deterioration.

  
  
• e)
  

  A surviving co-twin is at higher risk of preterm delivery after sIUFD.

7. Which of the following is/are true about the consequences of a sIUFD?

• a)
  

  Monochorionic survivor twins are at double the risk of neurological sequelae compared with dichorionic twins.

  
  
• b)
  

  Less neurological morbidity was observed in monochorionic survivor twins in cases in which sIUFD had occurred after a vascular occlusion treatment than in those where sIUFD had occurred spontaneously.

  
  
• c)
  

  Immediate delivery of the survivor co-twin is advised after sIUFD, regardless of gestation.

  
  
• d)
  

  Magnetic resonance imaging (MRI) of the brain of the survivor twin should be carried out at least 3 weeks after sIUFD.

  
  
• e)
  

  There is no increased risk of maternal complications after sIUFD.

8. A monochorionic twin pregnancy showed a discordant crown–lump length (CRL) at 12 weeks gestation, and a discordant amniotic fluid volume at 15 weeks with a deepest vertical pocket of 1.8 cm in the smaller twin and 6.3 cm in the larger twin. Both bladders are visible. Which of the following is/are likely diagnosis(es)?

• a)
  

  Unequal placental sharing.

  
  
• b)
  

  Twin-to-twin transfusion syndrome Quintero Stage I.

  
  
• c)
  

  Complicated monochorionic twin pregnancy, suspected to develop either selective fetal growth restriction or twin–twin transfusion syndrome (TTTS).

  
  
• d)
  

  Velamentous cord insertion in one twin.

  
  
• e)
  

  Physiological variation.

9. In monochorionic twins with discordant growth, measuring the blood flow waveforms by Doppler plays an important role in both identifying the cause and predicting the outcome. Which description(s) of how to measure these waveforms is/are correct?

• a)
  

  The Doppler sample volume should be placed in the intra-fetal part of the umbilical artery, close to the bladder.

  
  
• b)
  

  The Doppler sample volume should be enlarged to capture both arteries in one image.

  
  
• c)
  

  The Doppler sample volume should be placed in the umbilical artery at a zero degree angle, assisted by colour, close to the placental surface.

  
  
• d)
  

  The Doppler sample volume should be placed in a free loop of the cord, about half way between the fetus and the placenta, at 90°.

  
  
• e)
  

  The Doppler sample volume should be placed in a free loop of the cord, about half way between the fetus and the placenta, at 30°.

10. In evaluating a pregnancy with twin reversed arterial perfusion sequence, the following parameters should be interpreted as follows:

• a)
  

  A normal cardiac function in the pump twin is associated with a more than 80% survival with expectant management.

  
  
• b)
  

  An acardiac twin with a total volume that is less than the volume of the pump twin does not require intervention to improve the chances of survival of the pump twin.

  
  
• c)
  

  A low a-wave in the ductus venosus of the pump twin is an indication for at least weekly ultrasound and Doppler examination.

  
  
• d)
  

  A pregnancy with twin reversed arterial perfusion sequence should be referred to a fetal echocardiography specialist.

  
  
• e)
  

  When finding an acardiac twin with reversed perfusion, and a normal, healthy looking co-twin, urgent referral to a centre where interventions are offered is indicated.

11. Which of the following statements is/are true about multiple pregnancies after assisted reproductive technology (ART) treatment?

• a)
  

  Women carrying multiple pregnancies have the same risk of complications as those who are pregnant with singletons.

  
  
• b)
  

  Neonatal mortality is increased in multiple births.

  
  
• c)
  

  Prematurity is the main cause of neonatal morbidity in twins.

  
  
• d)
  

  Three-quarters of triplets require neonatal admission.

  
  
• e)
  

  The mean gestational age for twin and high-order pregnancies is the same.

12. Which of the following is/are true about measures for reducing multiple pregnancies after ART treatment?

• a)
  

  A marked reduction occurs in multiple pregnancies after double embryo transfer (DET) compared with triple embryo transfer.

  
  
• b)
  

  Elective single-embryo transfer is the most effective way to reduce multiple pregnancies after ART treatment.

  
  
• c)
  

  Pregnancy rates per fresh in-vitro fertilisation cycle after elective single-embryo transfer are lower compared with DET.

  
  
• d)
  

  Multiple pregnancy rates are similar after single-embryo transfer and DET.

  
  
• e)
  

  An effective cryopreservation programme is essential for widespread use of single-embryo transfer.

13. Which of the following is/are true about serial ultrasound scanning in twin and triplet pregnancy?

• a)
  

  Twin-to-twin transfusion syndrome (TTTS) may present early and be diagnosed at early first-trimester scan.

  
  
• b)
  

  In screening for fetal abnormalities, second-trimester ultrasound is less effective in twin and triplet pregnancies compared with singleton pregnancies.

  
  
• c)
  

  In screening for TTTS in monochorionic twins, it is recommended that scans are carried out more often if membrane folding or liquor discordance occurs.

  
  
• d)
  

  In screening for fetal growth problems, scans should be carried out every 2 weeks from 20 weeks gestation.

  
  
• e)
  

  No evidence supports screening for fetal growth problems using umbilical artery Doppler blood flow routinely.

14. Which of the following is/are true about prediction and prevention of preterm labour in twin and triplet pregnancies?

• a)
  

  Women should be advised to abstain from sexual intercourse.

  
  
• b)
  

  A cervical length of less than 25 mm in a twin pregnancy at 20–24 weeks gestation is a good predictor of preterm labour and delivery.

  
  
• c)
  

  Bed rest in hospital is more effective at preventing preterm labour compared with bed rest at home.

  
  
• d)
  

  Although vaginal progesterone has been shown to prevent preterm delivery in singleton pregnancy where there is a short cervix, it has not been shown to be effective in twin pregnancy where there is a short cervix.

  
  
• e)
  

  Although cervical cerclage has been shown to be ineffective in preventing preterm labour in twin pregnancy, it has been shown to be effective in triplet pregnancy.

15. Which of the following is/are true about maternal complications in multiple pregnancy?

• a)
  

  Maternal mortality is higher in multiple pregnancy.

  
  
• b)
  

  Given the risk of haemorrhage, women with multiple pregnancy should routinely be given iron and folic acid supplements.

  
  
• c)
  

  Good evidence shows that women with multiple pregnancy should be screened for gestational diabetes.

  
  
• d)
  

  Specialist care reduces the incidence of postnatal depression.

  
  
• e)
  

  If hypertensive disorders occur, they are likely to present earlier and be more severe.

16. Which of the following is/are true about twin–twin transfusion syndrome (TTTS)?

• a)
  

  It is a unique complication in most monochorionic twins.

  
  
• b)
  

  It is always caused by an imbalance in amniotic fluid amounts of each fetus.

  
  
• c)
  

  It is best treated by fetoscopic laser coagulation of the placental vascular anastomoses.

  
  
• d)
  

  It is severe if polyhydramnios of the recipient exceeds 8 cm deepest vertical pocket (DVP) after 20 weeks gestation, and the donor twin shows less than 2 cm DVP.

  
  
• e)
  

  It is characterised by an anaemic donor twin who has transfused blood to a plethoric recipient twin.

17. Which of the following is/are true about using the Quintero staging system?

• a)
  

  In a case presenting in week 21 with polyhydramnios of 8.5 cm DVP in the recipient and 3 cm DVP in a donor with bladder filling, laser therapy is indicated.

  
  
• b)
  

  In monochorionic twins presenting at 23 weeks with 8 cm DVP in the recipient and a stuck donor twin, laser therapy should be considered if the recipient shows signs of advanced heart failure, including ascites, holosytolic tricuspid regurgitation, and a reverse flow in the ductus venosus.

  
  
• c)
  

  Cases presenting with stage I TTTS will progress to higher stages and weekly follow up is therefore mandatory.

  
  
• d)
  

  An arrested or reversed end-diastolic flow in the umbilical artery in the donor twin classifies TTTS into stage III, and increases its risk for intrauterine fetal demise.

  
  
• e)
  

  After single fetal demise in severe TTTS, fetoscopic laser coagulation of placental anastomoses is no longer indicated, as the surviving twin in no longer protected.

18. In the treatment of severe TTTS with fetoscopic laser coagulation, which of the following factors is/are of key importance?

• a)
  

  All vessels crossing the inter-twin membrane insertion line have to be followed in both directions to make sure they do not run to the vascular equator as communicating vessels.

  
  
• b)
  

  During fetoscopy, it is especially important to coagulate thick arterio-venous anastomosis from donor to recipient to stop blood transfusion, and other anastomoses may be left open.

  
  
• c)
  

  The insertion site for the fetoscope should be opposite to the expected vascular equator to achieve optimal access to the anastomoses.

  
  
• d)
  

  To prevent the development of TAPS after a laser procedure, it is mandatory to dichorionise the placenta at the insertion line of the inter-twin membrane.

  
  
• e)
  

  The direction of blood flow can be identified, as arteries cross over veins and are darker than veins.

19. Which of the following is/are true about asymptomatic twin pregnancies?

• a)
  

  Cervical length remains stable throughout pregnancy.

  
  
• b)
  

  The cut-off for short cervix is 25 mm in mid-trimester compared with 15 mm in singleton pregnancies.

  
  
• c)
  

  Cervical length shorter than 25 mm at mid-trimester is still associated with less than 2% risk for birth before 28 weeks.

  
  
• d)
  

  Fetal fibronectin cannot be used to predict preterm birth.

  
  
• e)
  

  Cervical length is best measured during the first trimester.

20. Which of the following is/are true about twin pregnancies with symptoms of preterm birth?

• a)
  

  Most women will deliver within a week.

  
  
• b)
  

  Insufficient data are available to make evidence-based recommendations.

  
  
• c)
  

  Cervical length measurement is an accurate predictor.

  
  
• d)
  

  The accuracy of cervical length measurement is higher than for asymptomatic women.

  
  
• e)
  

  Fetal fibronectin has high negative predictive value.

21. Which of the following is/are true about progesterone treatment in twin pregnancies?

• a)
  

  Progesterone treatment prevents preterm delivery before 34 weeks in unselected twin pregnancies.

  
  
• b)
  

  Progesterone treatment prevents preterm delivery before 34 weeks in high-risk twin pregnancies.

  
  
• c)
  

  Results from progesterone treatment in singletons is likely to be even more effective in twins as the incidence of PTD is higher.

  
  
• d)
  

  Progesterone treatment reduces perinatal mortality and morbidity in unselected twin pregnancies.

  
  
• e)
  

  Progesterone treatment reduces perinatal mortality and morbidity in high-risk twin pregnancies.

22. Which of the following statements is/are true about progesterone administration and side-effects?

• a)
  

  Progesterone supplementation may be administered orally, intramuscularly, or vaginally.

  
  
• b)
  

  Oral progesterone has a significant first pass metabolism

  
  
• c)
  

  Longer-term follow up has not suggested harmful effects of progesterone treatment in infants born to mothers treated with progesterone.

  
  
• d)
  

  Long term follow up studies have followed up progesterone exposed children for more than 10 years

  
  
• e)
  

  Progesterone treatment increases the risk of gestational diabetes but does not affect the maternal liver.

23. Which of the following statements is/are true about cervical cerclage in twin pregnancies?

• a)
  

  Cervical cerclage increases the rate of preterm delivery in twin pregnancy.

  
  
• b)
  

  Cervical cerclage increases the perinatal mortality rate in twin pregnancy.

  
  
• c)
  

  In women with twin pregnancies and a short cervical length, cervical cerclage has no effect.

  
  
• d)
  

  Data regarding cervical cerclage in women with twin pregnancies and a short cervical length is based on large numbers

  
  
• e)
  

  Cervical cerclage is technically more difficult to perform in twin pregnancies compared to singletons

24. Which of the following statements is/are true about treatment with a cervical pessary in twin pregnancies?

• a)
  

  The sole mechanism of action of a cervical pessary is to close the cervical canal.

  
  
• b)
  

  Non-change of cervical canal angle with a cervical pessary may be associated with preterm delivery.

  
  
• c)
  

  Insertion of a cervical pessary in women with twin pregnancies increases gestational age at delivery.

  
  
• d)
  

  Treatment of twin pregnant women with a cervical pessary has no effect on neonatal outcome.

  
  
• e)
  

  Significant maternal adverse effects have been reported with cervical pessaries

25. Which of the following is/are true about twin pregnancies?

• a)
  

  Term should be calculated as 38 weeks.

  
  
• b)
  

  Twin pregnancies have a higher rate of still birth after 38 weeks than singleton pregnancies.

  
  
• c)
  

  Respiratory distress syndrome in twin pregnancies is more common than in singleton pregnancies at the same gestation.

  
  
• d)
  

  The first twin is usually presented non-vertex at term.

  
  
• e)
  

  Twin pregnancies should be allowed to progress to 40 weeks before delivery is planned.

26. Which of the following is/are true about planned vaginal birth between 32 and 38 weeks with the first twin vertex?

• a)
  

  It is associated with a similar fetal outcome as planned caesarean section.

  
  
• b)
  

  If a planned caesarean section is carried out, the maternal outcome will be worse than planned vaginal birth.

  
  
• c)
  

  It will be associated with at least a 15% risk of vaginal birth of the first twin but caesarean section for the second.

  
  
• d)
  

  It is of higher risk in primigravidae.

  
  
• e)
  

  It is of higher risk in monochorionic twins.

27. Which of the following is/are true about delivery of the second twin?

• a)
  

  It is safer if the second twin is vertex presentation.

  
  
• b)
  

  It is best carried out by external cephalic version rather than breech extraction if the second twin is in non-vertex presentation.

  
  
• c)
  

  The second twin can be relied upon to maintain its pre-labour presentation.

  
  
• d)
  

  The second twin is usually delivered more than 30 minutes after the first twin in experienced hands.

  
  
• e)
  

  If the second twin is delivered by Caesarean section it is at increased risk of adverse outcomes.

28. Which of the following is/are true about conducting a twin delivery?

• a)
  

  It can be safely carried out in a delivery room if both are vertex presentation.

  
  
• b)
  

  It may be monitored by intermittent auscultation.

  
  
• c)
  

  Epidural may be useful in allowing anesthesia for operative delivery of the second twin.

  
  
• d)
  

  A high rate of vaginal birth occurs for the first and caesarean sections for the second.

  
  
• e)
  

  It may require the use of oxytocin after delivery of the first twin.

29. Which of the following is/ are true about twin pregnancy?

• a)
  

  Pregnancy outcome is determined by the chorionicity.

  
  
• b)
  

  Early complications of monochorionic twins are caused by vascular anastomoses in the placenta.

  
  
• c)
  

  Selective fetal growth restriction complicates 10% of monochorionic twins.

  
  
• d)
  

  Anaemia–polycytheamia sequence is an early complication of monochorionic twins.

  
  
• e)
  

  Discordant fetal weight of over 25% is an independent predictor of poor pregnancy outcome in dichorionic twins.

30. Which of the following is/are true about timing of delivery in twins?

• a)
  

  Maturity of singleton pregnancy at 40 weeks equates to that of twins at 38 weeks.

  
  
• b)
  

  Uncomplicated dichorionic twins should be delivered after 38 weeks.

  
  
• c)
  

  Monochorionic twins carry higher stillbirth rates than dichorionic twins.

  
  
• d)
  

  Uncomplicated monochorionic twins should be delivered at 34 weeks.

  
  
• e)
  

  Frequent antenatal fetal monitoring is justifiable in monochorionic twins.