Multiple pregnancy

1. Multiple Pregnancy Presentation by Prativa Dhakal M.Sc. Nursing Maternal Health Nursing Batch 2011

2. Contents Definition Varieties of twin pregnancy Incidence Factors influencing twinning Maternal physiological changes Diagnosis History and clinical examination Symptoms General examination Abdominal examination Investigations Complications Prognosis Management Nursing interventions References

3. Multiple pregnancy When more than one fetus simultaneously develops in the uterus then it is called multiple pregnancy. Simultaneous development of two fetuses (twins) is the commonest; although rare, development of three fetuses (triplets), four fetuses (quadruplets), five fetuses (quintuplets or six fetuses (sextuplets) may also occur.

4. Twins pregnancy Varieties: Dizygotic twins : is the commonest (two-third) and results from the fertilization of two ova. Monozygotic twins (one-third) results from the fertilization of single ovum.

5. Genesis of twins Imonozygotic twins (syn. identical, uniovulvar ) Dizygotic twins ( syn : fraternal, binovular

6. On rare occasion, the following possibilities may occur If the division takes place within 72 hours after fertilization the resulting embryos will have two separate placenta, chorions and amnions (D/D) If the division takes place between the 4 th and 8 th day after the formation of inner cell mass when chorion has already developed diamniotic monochorionic twins develop (D/M) If the division after 8 th day of fertilization, when the amniotic cavity has already formed, a monoamniotic monochorionic twins develop (M/M)

7. Diamniotic Dichorionic   Separate placenta Frequency: 35% Mortality: 13% Diamniotic DiChorionic   fused placenta Frequency 27% Mortality 11% Diamniotic Monochorionic  single placenta Frequency 36% Mortality 32% Monoamniotic Monochorionic   single placenta Frequency 2% Mortality 44%

8. Multiple pregnancy contd … On extreme rare occasions, division occurs after 2 weeks of the development of embryonic disc resulting in the formation of conjoined twins called-Siamese twins. Four types of fusion may occur Thoracopagus (commonest) Pyopagus (Posterior fusion) Craniopagus (cephalic) Ischiopagus (caudal)

9. Examination of placenta and membranes Dizygotic Twin Monozygotic twin Two placenta, either completely separated or more commonly fused at the margin appearing to be one. No anastomosis between the two fetal vessels. Placenta is single. Varying degrees of anastomosis between the two fetal vessels. Each fetus is surrounded by a amnion and chorion Each fetus is surrounded by a separate amniotic sac with the chorionic layer common to both. Intervening membranes consist of 4 layers-amnion, chorion , chorion and amnion. Intervening membrane consists of two layers of amnion only.

10. Anastomosis between placenta

11. Sex: while twins having opposite sex are almost always binovular and twins of the same sex are not always uniovular but the uniovular twins are always of the same sex. If the fetuses are of the same sex and have the same genetic features (dominant blood groups), monozygosity is likely. A test skin graft: Acceptance of reciprocal skin graft—proof of monozygosity . DNA microprobe technique is more definitive. Follow-up study between 2-4 years—showing almost similar physical and behavioral features suggestive of monozygosity .

12. Incidence Varies widely. Highest in Nigeria being 1 in 20 and lowest in Far Eastern countries being 1 in 200 pregnancies. Monozygotic twins 1 in 250 in the world. According to Hellin’s rules, the mathematical frequency of multiple birth is twins 1 in 80 pregnancies, triplets 1 in 80 2 , quadruplets 1 in 80 3 and so on.

13. Factors that Influence Twinning The causes of twin pregnancy is not known. Race: Highest amongst Negroes (once in every 20 births), lowest amongst Mongols and intermediate among Caucasians Heredity: Family history in mother. Maternal Age and Parity : T winning peaks at age 37 years Increasing parity: 5 th gravid onwards. Nutritional Factors : Taller, heavier women—twinning rate 25 to 30 % greater. Pituitary Gonadotropin Infertility Therapy Assisted Reproductive Technology

14. Terms Superfecundation Superfetation Fetus papyraceous or compressus Fetus acardius Hydatidiform mole Vanishing twin

15. Diagnosis History and Clinical Examination Recent administration of either clomiphene citrate or gonadotropins or pregnancy accomplished by ART are much stronger associates. Clinical examination with accurate measurement of fundal height.

16. Diagnosis contd … In women with a uterus that appears large for gestational age, the following possibilities are considered: Multiple fetuses Elevation of the uterus by a distended bladder Inaccurate menstrual history Hydramnios Hydatidiform mole Uterine leiomyomas A closely attached adnexal mass Fetal macrosomia (late in pregnancy)

17. Diagnosis contd … Symptoms Minor symptoms of normal pregnancy are often exaggerated. Increased nausea and vomiting in early months Cardio-respiratory embarrassment Tendency of swelling in the legs, varicose veins and hemorrhoids is greater Unusual rate of uterine enlargement and excessive fetal movements

18. Diagnosis contd … General examination Prevalence of anemia is more Unusual weight gain, not explained by preeclampsia or obesity Evidence of preeclampsia is a common association.

19. Diagnosis contd … Abdominal examination Inspection : Barrel shaped and the abdomen is unduly enlarged Palpation Height of uterus > period of amenorrhoea Girth of abdomen> normal average at term (100 cm) Fetal bulk disproportionately larger in relation to the size of the fetal head. Palpation of too many fetal parts Finding of two fetal heads or three fetal poles Auscultation Two distinct FHS at separate spots, difference in heart rates is at least 10 beats/minute.

20. Diagnosis contd … Investigations Sonography separate gestational sacs identified early Confirmation of diagnosis as early as 10 th week of pregnancy Variability of fetuses, vanishing twin in second trimester Chorionicity (twin peak sign) Pregnancy dating, Fetal anomalies Fetal growth monitoring, Presentation and lie of fetuses Twin transfusion localization, Amniotic fluid volume

21. Twin peak sign

22. Diagnosis contd … Biochemical Tests: Levels of hCG in plasma and in urine are higher Maternal serum alpha-fetoprotein level: Elevated Unconjugated oestriol : approximately double Radiological examination

23. Complications Maternal During pregnancy

24. Complications contd … During labour

25. Complications contd … During puerperium Fetal

26. Complications of monochorionic twins Twin twin transfusion syndrome (TTS ) one twin appears to bleed into other through placental vascular anastomosis . Receptor twin becomes larger with hydramnios , polycythemic , hypertensive and hypervolemic Donor twin which become smaller with oligohydramnios , anemic, hypotensive and hypovolemic . Donor may appear stuck due to severe oligohydramnios . Difference of hemoglobin concentration between the twin usually exceeds 5 gm% and estimated fetal weight discrepancy is 25% or more.

27. Complications of monochorionic twins contd … TTTS contd.. Management Antenatal diagnosis: ultrasound with doppler flow study in the placental vascular bed. Repeated amniocentesis to control polyhydramnios in recipient twin. prevent preterm labour and placental abruption. Selective reduction of one twin is done when survival of both the fetuses is at risk. Smaller twin generally have got better outcome. Plethoric twin: risk of CCF and hydrops . Perinatal mortality: 70%.

28. Complications of monochorionic twins contd … Dead fetus syndrome Death of one twin (2-7%) is associated with poor outcome of the Co-twin (25%) specially in monochorionic placenta. The surviving twin runs the risk of cerebral palsy, microcephaly , renal cortical necrosis and DIC. This is due to thromboplastin liberated from the dead twin that crosses via placental anastomosis to the living twin.

29. Complications of monochorionic twins contd … Twin reversed arterial perfusion (TRAP): Characterized by an acardiac perfused twin having blood supply from a normal co-twin via large arterio -arterial anastomosis . Conjoint twin: Rare. Perinatal survival depends upon the type of joint. Major cardiovascular anastomosis leads to high mortality.

30. Fetal acardius

31. Research evidence Twin, acardiac , outcome ( GrabD , Schneider V, Keckstein J, Terinde R) 26-year-old G2P1 was initially seen in the 16th week of a twin gestation. An acardiac-acranial twin was present. There were spontaneous movements of the lower extremities. Chromosomal analysis of amniotic fluid showed two normal females. Several ultrasonographic examinations showed lack of growth of the malformed twin but appropriate growth of the normal twin . Spontaneous labor developed at 40 weeks and a normal female, 3270g, with Apgar 9/10/10, was delivered. The acardiac twin was approximately 10 cm long and was spontaneously delivered out of a second amniotic cavity. Pathologic findings The female acardiac acephalic twin (31g, 10 cm) showed no heart or lung development; liver, intestine, and urogenital tract appeared normal. Spleen, pancreas and stomach were absent. The placenta was monochorionic diamniotic , and the two umbilical cords were interconnected by a direct anastomosis .

32. Complications of monochorionic twins contd … Monoamniocity : Monochorionoc twins leads to high perinatal mortality due to cord problems. Prostaglandin synthase inhibitor used to reduce fetal urine output, creating borderline oligohydramnios and to reduce the excessive movements.

33. Antepartum Management of Twin Pregnancy To reduce perinatal mortality and morbidity rates in pregnancies complicated by twins, it is imperative that: Delivery of markedly preterm neonates be prevented Fetal-growth restriction be identified and afflicted fetuses be delivered before they become moribund Fetal trauma during labor and delivery be avoided, and Expert neonatal care be available.

34. Management contd … Diet: increased requirement of calories, protein, minerals, vitamins, and essential fatty acids. Caloric should be increased by another 300 kcal/day. Supplementation with 60 to 100 mg/day of iron and1 mg/day of folic acid. Bed Rest Antepartum Surveillance: sonographic examinations Tests of Fetal Well-Being Prevention of Preterm Delivery Hospitalization Use of corticosteroids to accelerate fetal lung maturation.

35. Management during labour First stage: A skilled obstetrician, presence of ultrasound machine and experienced anesthetist Bed rest to prevent early rupture of membrane. Limit use of analgesic drugs Careful monitoring Internal examination soon after the rupture of membranes An intravenous line with ringer’s solution Availability of one unit of compatible and cross matched blood Neonatologist:Present at the time of delivery.

36. Management during labour contd.. Delivery of the first baby : Delivery: Same guidelines as in normal labour with liberal episiotomy. Forceps delivery: if needed, should be done preferably under pudendal block anaesthesia . Do not give intravenous ergometrine with delivery of the anterior shoulder of the first baby. Clamp the cord at two places and cut it between. At least 8-10 cm of cord is left behind for administration of any drug or transfusion, if required. The baby should be labeled one.

37. Management during labour contd.. Conduction of labour after the delivery of the first baby: Steps of management: Step I: Ascertain lie, presentation, size and FHS of the second baby. Vaginal examination: To confirm the abdominal findings and to exclude cord prolapsed, if any to note the status of membrane.

38. Management during labour contd... Lie longitudinal: Step I: Low rupture of membranes, syntocinon , internal examination to exclude cord prolapse . Step II: If the uterine contraction is poor, 5 units of oxytocin is added. Step III: Is there is still a delay, interference is to be done.

39. Management during labour contd... Vertex: Low down—forceps are applied. High up—CPD should be ruled out. The possibility of hydrocephalic head should also be kept in mind and excluded by ultrasonography . If these are excluded, internal version followed by breech extraction is performed under general anesthesia. Ventouse : effective alternative. 2. Breech: Breech extraction. 3. Lie transverse : Correct by external version or internal version to cephalic or podalic .

40. Management during labour contd... Indication of urgent delivery of second baby : Severe vaginal bleeding, Cord prolapse Inadvertent use of IV ergometrine with the delivery of anterior shoulder of the first baby, First baby delivered under general anesthesia, Appearance of fetal distress.

41. Management during labour contd... Delay in the birth of second twin Birth of second twin should be completed within 45 minute of the first twin being born but with close monitoring can be extended if there are no signs of fetal compromise. The risk of delays: intrauterine hypoxia, birth asphyxia, sepsis

42. Management during labour contd... Management of third stage Routine administration of 0.2mg methergin IV with delivery of anterior shoulder. Deliver placenta by CCT Continue oxytocin drip for at least one hour, following delivery of second baby. The patient is to be carefully watched for about 2 hours after delivery.

43. Indications of caesarean section Obstetric causes: Placenta previa Severe preeclampsia Previous caesarean section Cord prolapse of the first baby Abnormal uterine contractions Contracted pelvis For twins: Both fetuses or even first fetus with non-cephalic presentation, Twins with complications: IUGR, conjoint twins; Monoamniotic twins, monochorionic twins with TTS

44. Management of difficult cases of twins Interlocking Commonest: Aftercoming head of first baby getting locked with forecoming head of second baby. Vaginal manipulation to separate chins of the fetuses Decapitation of first baby (dead), pushing up decapitated head, followed by delivery of second baby and lastly, delivery of decapitated head. Occasionally, two heads of both vertex get locked at the pelvic brim preventing engagement of either of the head. Disengagement of the higher head: Under general anesthesia, If fails, caesarean section is the alternative

45. Management of difficult cases of twins contd.. Conjoined twins Extremely rare. Often diagnosed during delivery Presence of a bridge of tissue between the fetuses on vaginal examination confirms the diagnosis. Antenatal diagnosis is important. Benefits are: reduces maternal trauma and morbidity, improves fetal survival, helps to plan method of delivery, allows time to organize pediatric surgical team.

46. Postnatal period Care of the babies Immediate care Maintenance of body temperature, Use of overhead heaters, Parents given the opportunity to check the identity tag and cuddle them. Breastfeeding Provide knowledge to mother regarding different positions for breastfeeding, along with advantages, attachment, positioning timing.

47. Postnatal period contd.. Nutrition Expressed breast milk is best (for small babies), they may need to be fed intravenously or by nasogastric tube or cup-fed, depending on their size and general condition. Careful monitoring of weight gain, regular capillary blood glucose estimations Reassure her that lactation responds to the demands made by babies sucking at the breast. At feeding times, mother must be provided support and advised on positioning and fixing babies. Care of the mother Slow involution of uterus, increased ‘After pains’ so analgesia should be offered. High calorie diet. Teach extra support to handle twin babies

48. Management and Nursing Interventions Nutrition counseling Fetal evaluation Evaluate woman for signs and symptoms of obstetrical complications PTL prevention: explain for hospitalization Encourage bed rest and hydration. Institute fetal monitoring and assist with tocolytic therapy, if ordered. Explain to the woman that mode for delivery depends on the presentation of the twins, maternal and fetal status, and gestational age

49. Management and nursing interventions contd … Intrapartum management Establish I.V. access Provide for electronic fetal monitoring for each fetus. Double setup is recommended for delivery. Availability of two units of crossmatched whole blood. I.V. access with large bore catheter. Surgical suite immediately available. An obstetrician and assistant experienced in vaginal births of twins. Best choice of anesthesia: epidural. Anesthesia provider capable of administering general anesthesia. Neonatal team for each neonate present at birth for neonatal resuscitation. Pitocin induction/augmentation may be required secondary to hypotonic labor. Postpartum hemorrhage may occur due to uterine atony . Emotional support.

50. Nursing diagnoses Anxiety Deficient Knowledge Regarding High-risk Situation/Preterm Labor Risk for Imbalanced Nutrition: Less/More than Body Requirements Risk for Fetal Injury Risk for Maternal Injury Risk for Deficient Fluid Volume Risk for Impaired Gas Exchange Risk for Activity Intolerance Risk for Ineffective/Compromised Family Coping Risk for Interrupted Family Process.

51. Nursing diagnoses contd … For Cesarean Delivery Deficient Knowledge Regarding Surgical Procedure, and Postoperative Regimen Anxiety (Specify Level) Powerlessness Risk for Acute Pain Risk for Infection Risk for Impaired Fetal Gas Exchange Risk for Maternal Injury Risk for Decreased Cardiac Output

52. References Fraser DM, Cooper MA.Myles Textbook for Midwives.15th edition. Philadelphia:Churchill livingstone elsevier;2009 Dutta DC.Textbook of obstetrics. 6th edition.Calcutta:New central book agency;2004 Pillitteri A. Maternal and child health nursing. Care of the childbearing and childrearing family. Sixth edition. Philadelphia; Lippincott Williams & Wilkins: 2010. Cunningham, Leveno , Bloom. William’s obstetrics. 23 rd edition. United states of America; Mcgraw Hill companies: 2010. Nettina S.M, Mills E.J. Lippincott Manual of Nursing Practice. 8th Edition. Philadelphia: Lippincott Williams and Wilkins; 2006 Multiple Pregnancy and Birth: Twins, Triplets, and High-order Multiples: A Guide for Patients. Patient information series. American Society for Reproductive Medicine. 2012

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