PROBLEM BASED LEARNING

TWINS
STEP 1: GROUP SETTING
1.1 BIODATA
YEE HON KIT (Presenter)
ONG SHWU CHYN (Researcher)
PUI WAN TING (Researcher)
YAASHINI SELVARAJAH (Designer)
KRISNAVIMALA KRISHUAN (Presenter)
1.2: GROUP ROLES

1.3: ROLES OF TUTOR AND STUDENTS

 TUTOR
 STUDENTS
STEP 2.0: PROBLEM IDENTIFICATION
Pregnant mothers often suspect that they are carrying more than one
baby (or more). Suddenly your pregnancy is filled with double delight,
and probably a double dose of anxiety also. People are very fascinated
with twins and other multiples. It seems mysterious how one
pregnancy can result in more than one baby.
One day, Pn. Laila received the surprise of her life. She is having
pregnant! Her mind is whirring with questions. Am I having more
than one? It is twins? Could you be having more than one? How do I
know its twins? What are some of the signals of a multiple
pregnancy? How twins are made? How did this happen? If I’ve twins,
how can I find out whether my babies are identical or non-identical?
You as a doctor, what would you tell Pn. Laila regarding to twins
pregnancy?
2.1 PROBLEMS
Pn. Laila is pregnant and suspects that she is having
more than one baby.
How many pregnancies can result in more than one
baby?
How does Pn. Laila know if she is having twins?
How twins are made?
What are some if the suspects of a multiple pregnancy?
How can Pn. Laila know whether her babies are
identical or non-identical if she was having twin?
 Regarding on the problems that she faced during
her pregnancy, she needs to look for a gynecology
doctor for a good advice. Plus, she has to clarify all her
doubt about her problem from the professional. A
good explanation and understanding can give her best
solution about what she is going through now.
STEP 3: IDEA GENERATION
Pn. Laila maybe looking huge for eight weeks or having
severe nausea and vomiting, due to the high level of
hormone present.
Possible multiple egg are released, more than one ovulation
and fertilizations.
One egg is released but split into two
Pn. Laila will know that she is having twins if she is
showing the sign or symptom of multiple pregnancy or run
test.
Pn.Laila can knowwhether her baby are identical or not
through ultrascan sound
There are at least ten sign or symptoms of multiple pregnancies.
 Ultrasound confirmation
 Doppler Heartbeat Count
 Elevated HCG Levels
 Abnormal AFP test result
 Measuring large for gestational age
 Weight gain
 Excessive morning sickness
 Early / frequent fetal movement
 Extreme fatique
 History/ hunches
STEP 4 : LEARNING ISSUE
How one pregnancy can result in more than one baby?
 Could she be having more than one?
 How to know whether it is a twin?
What are the some of the signals of a multiple
pregnancy?
How twins are made?
 How to find out whether the babies are identical or
non-identical?
STEP 5 : SELF-DIRECTED LEARNING
5.1 PN LAILA IS PREGNANCY AND SUSPECT THAT
SHE IS HAVING MORE THAN ONE BABY?
easily feel extremely fatigue or exhaustion.
 her body weight has an obviously increasing during
her pregnancy.
experiences the morning sickness (nausea and
vomiting) more seriously.
 The result of alphfeprotein (AFP) test is abnormally
high compare with the can mother which has
singleton pregnancy.
5.2 HOW CAN PREGNANCY RESULT IN MORE THAN ONE
BABY (HOW TWINS ARE MADE)?
The multiple eggs are released in one monthly cycle or in other
word is more than 1 ovulation. Then, the both eggs are fertilized
by two spermatozoids and two embryos are made.
Besides that, one egg is released during ovulation and has been
fertilized by only one sperm. But the egg splits into two
embryos, therefore the identical twins are made.
In the case of IVF (in-vitro fertilization), there are usually 3 or
more fertilized eggs will put back into the uterus. Sometimes all
of the fertilized eggs will be implanted and developing into
embryos
5.3 HOW DOES PN LAILA KNOW IF SHE IS HAVING TWINS?
Through the ultrasound scan, Pn Laila can discover that she is
having twins. This is because ultrasound scan is the most
foolproof at diagnosing twins.
The sign of multiple heartbeats detected during test also can
diagnosis that the pregnancy mother is having twins or more
than that.
Besides that, pregnancy mother which is carrying twins also
will have higher-than-usual level of hormone hGG, this
because the more babies the faster the rate of increasing
hormone hGG.
5.4 WHAT ARE SOME OF THE SIGNALS OF A
MULTIPLE PREGNANCY?
The multiple pregnancy mothers will feel several
morning sickness symptoms seriously such as nausea
and vomiting than singleton pregnancy mothers.
Multiple pregnancies easily feel extremely fatigue or
tiredness this is because that mother has to provide
more energy to embryos to develop in every stage.
One of the appearances signals of the multiple
pregnancies is body weight increasing dramatically.
The result of alphfeprotein (AFP) is abnormally high.
This is because the ATP test measures a protein
secreted by the fetal liver. More than one baby
increases the amounts of this protein to release to
mothers’ blood, thus a high level of AFP.
The measuring of large for gestational age is the strong
indicator of multiple pregnancies.
5.5 HOW CAN PN LAILA KNOW WHETHER HER
BABIES ARE IDENTICAL OR NON-IDENTICAL IF SHE
WAS HAVING TWINS?
According to the ultrasound scan, the babies can be
diagnosis as identical or non-identical. An identical
twins is from the same egg that fertilized by one sperm
which is divided into two embryos; while the non-
identical twins is from two eggs and both of it
fertilized by other two sperms to develop to embryos.
STEP 6: SYNTHESIS AND APPLICATION
Do women who are pregnant with twins, triplets or more exhibit
special "symptoms"? Just as individual women experience a wide
range of symptoms with a singleton pregnancy, so the conditions
vary with multiples. It's true that the morning sickness, exhaustion
and weight gain can be intensified in proportion to the number of
babies twice as sick, three times as tired, or four times as many
pounds! But, some lucky mothers experience only mild discomfort,
so mild that they never even suspect they are carrying multiples.
People are very fascinated with twins and other multiples. It seems
mysterious how one pregnancy can result in more than one baby.
Multiple pregnancies are on the rise in recent years with more and
more twins and other types of multiples being born. The majority
of the reason for this rise is the increased use of fertility drugs.
How one pregnancy can result in
more than one baby?
There are a couple of ways that multiples are conceived:
Multiple eggs are released or there is more than one
ovulation
One egg is release but splits in two
In cases of IVF, there are usually 3 or more fertilized
eggs put back into the uterus
Could she be having more than
one?

Yes, there are possibilities for her to have more babies

at one birth
How to know whether it is a twin?

early ultrasound
find a rapid rate of grow in their uterus
abnormally high levels on the AFP test -with
serial hCG levels
What are the some of the signals of
multiple pregnancies?
is a thorough ultrasound performed by a trained
professional in the second trimester. Listening for dual
heartbeats is tricky even for the most experienced
obstetricians, even with Doppler technology.
And an early sonogram isn't conclusive either. My
seven-week sonogram showed one perfect bean-sized
bubble.
How twins are made?
Heredity
Race
Number of prior pregnancies
Delayed childbearing
Infertility treatment
How to find out whether the babies
are identical or non-identical?
on an ultrasound scan,
-the sonogram can see that your babies share an inner
sac chorionic with no dividing membrane called
monochromic or monoamniotic.
- carries the same genetic package(boy/boy or girl/girl)
If the sonogram detects two sacs dichorionic or
diamnoti, your babies may or may not be identical.
About one third of dichorionic or diamnotic identical
twins are in separate sacs, too.
• Although sharing a placenta may be a sign that your
twins are identical, the placenta itself isn't a guide, as
the placentas of non-identical twins can fuse together.
And in a few cases identical twins can have a placenta
• other markers (include blood groups, eye and hair
colour, the shape of feet, hands and ears, and the
pattern of tooth eruption)
• The most accurate way= DNA test
~ Zygocity determination
STEP 7.0: REFLECTION AND FEEDBACK
7.1 GROUP FUNCTIONING
~started with analyzing and understanding the problem
scenario
~diagnose the problem scenario accordingly to the FILA
chart
~divided work into two parts
 drafting for the PBL report based on the 7 steps given
 preparation of power point presentation slides
~finally, final editing and 2 of us prepared for presenting
our work
 7.2 INDIVIDUAL PROBLEM SOLVING
PROCESS
find the information (books and internet)
discuss and summarize our information based on the
PBL scenario
 7.3 KNOWLEDGE LEARN
have learn about multiple pregnancy, signs and
symptoms of multiple pregnancies, identical and non-
identical twins, and how multiple twins are make.
 7.4 SOLUTION
When another woman faces the same problem, we as
doctor in gynaecology department will check the symptoms
she have during her pregnancy.
Her chance to have multiple pregnancies will increase if
there have such cases happen in her family before.
Heredity is also one of the factors causing multiple
pregnancies.
But the only way to know for sure is through ultrasound
performed in the second trimester of her pregnancy.
If there have more than 1 fetus, it means she is having
multiple pregnancies.
7.5 TUTOR’S FACILITATION
Consult Dr.Norhayati for advise and further
understanding about outcome of PBL.
FACTS IDEAS LEARNING ISSUES ACTION PLAN

1.Pn.laila is pregnant 1.Pn.laila maybe looking 1. How one pregnancy 1. Info about multiple
  huge for eight weeks or can result in more than pregnancy such as sign
2.Pn.laila suspects that having severe nausea one baby? and symptoms on
she is having more than and vomiting, due to the   internet
one baby high level of hormone 2. Could she be having  
  present more than one? 2.Consult gynaecologist
3.Her mind is whirring    
with questions 2.Possible multiple eggs 3. How to know whether 3.Ask opinion or advise
are released, more than it is a twin? from other parents who
4. She is going to get one ovulation and   are also having twins
treatment from the fertilisation 4. What are the some of  
doctor the signals of a multiple 4. Search for book about
  3.One egg is released pregnancy? multiple pregnancies.
5. She is very anxious but split into two    
about her pregnancy 5. How twins are made?
4. Pn. Laila will know  
that she is having twins 6. How to find out
if she is having the signs whether the babies are
and symptoms of identical or non-
multiple pregnancies or identical?
via run tests.
5. There are at least 10
signs or symptoms of
multiple pregnancies.

6Pn.Laila can know

whether her identical or
not through ultrasound
scan.