multiple pregnancy

nursing

1. Multiple Pregnancy Mittal College Of Nursing Ajmer

2. Introduction When more then one foetus simultaneously develops in the uterus, it is called Multiple pregnancy. Simultaneously develop of two foetuses ( TWINS) is the most common. Although rare , development of three foetuses (TRIPLETS), four foetuses (QUADRUPLETS), Five foetuses (QUINTUPLETS) or six foetuses (SEXTUPLETS) may also occur.

3. twins Simultaneous development of two foetus in the uterus is the most common variety of multiple pregnancy. Varieties – i) Dizygotic (DZ) twins – It is most common (80%) and results from the fertilization of two ova. ii) Monozygotic(MZ) twins- (20%) results from the fertilization of a single ovum.

4. Twins

5. Incidence It is highest in Nigeria being 1 in 20. and lowest in far Eastern Countries being 1 in 200 pregnancies. In India, the incidence is about 1 in 80. According to Hellins Rules(1895):- The mathematical frequency of multiple birth is , twins 1 in 80 pregnancies , triplets 1 in 80², quadruplets 1 in 80³and so on.

6. etioliogy The cause of twinning is not known . The frequency of monozygotic twins remains constant throughout the globe and is probably related to maternal environmental factors. Prevalence of dizygotic twins is related to:- Race :- Highest in Negroes , lowest in Mongols. Hereditary :- Transmitted through maternal side.

7. cont... Advancing age of mother :- The max. Being between the age of 30 yrs and 35 yrs. Influence of parity :- Especially from 5 th gravida onword . Iatrogenic :- Drugs used for induction of ovulation may produce multiple foetuses to the extent of 20-40% following gonadotropin therapy, although to a lesser extent (5-6%) following clomiphene citrate.

8. Superfecundation :- fertilization of two diff. Ova released in the same cycle, by separate acts of coitus within a short period of time. Superfetation:- fertilization of two ova released in different menstrual cycles the development of one foetus over another foetus theoretically possible untill the decidual space is obliterated by 12 weeks. Foetus compresses:- It is a state which occurs if one of the foetuses dies early.The dead foetus is compressed b/w the membranes of the living foetus and the uterine wall . It may occur in both varities of twins.

9. Foetus Compressus

10. Foetus Acardiacus:- It occurs only in monozygotic twins. Vanishing Twins:- serial USG imaging in multiple pregnancy since early gestation has revealed occasional death of one foetus and continuation of pregnancy with the surviving one. The dead foetus (if within 14 weeks) simply vanishes by resorption. Hydatidiform mole (from one placenta):- A normal foetus and placenta(from the other conceptus) have been observed by USG.

11. Maternal physiological change (1)There is increase in weight gain and cardiac output . (2)Plasma volume is increase by an addition of 500ml .there is no corresponding increase in red cell volume resulting in exaggerated hemodilution and anemia . (3)There is increase α -fetoprotein level,tidal volume and GFR rate.

12. diagnosis (1) History : - (a)history of ovulation inducing drugs. (b)Family history of twinning . ( 2) Symptoms:- (a)increased nausea and vomiting in early months. (b)Cardiorespiratory changes such as palpitation or SOB. (c)Swelling of the legs and hemorrhoids is greater. (d)Unusual rate of abdominal enlargement.

13. (3.)General examination :- a. prevalence of anemia is more than in singleton pregnancy. b. unusual weight gain , not explained by pre – eclampsia or obesity. (4.) Abdominal examination :- a. Inspection b. Palpation c. Auscultation (5.) Investigations :- a. Sonography b. Bio-chemical test

14. Complications Maternal 2 . Fetal . Nausea , vomiting . Abortion . Anemia . Vanishing twin . Pre- eclampsia . Preterm birth . Malpresentation . LBW babies . Preterm labor . Cord prolapse . Prolonged labor . Asphyxia . PPH . Locked twins

15. PROGNOSIS Maternal mortality – is increased in twins than in singleton pregnancy . Death is mostly due to hemorrhage , pre – eclampsia and anemia . Increased maternal morbidity is due to the prevalence of complications . Prenatal outcome : prenatal mortality is markedly increased mainly due to prematurity. It is 4-5 times higher than in a singleton pregnancy .

16. Antenatal management The essence of successful outcome of a twin pregnancy is to make an early diagnosis and through USG examination are the keys to the diagnosis . ADVICE :- . Diet .Increased rest . Supplement therapy . Interval of antenatal visit HOSPITALIZATION :- . Routine hospital admission only for bed rest is not essential . Emergency : development of complicating factors .

17. Management during labor Place of delivery : As the twin pregnancy is considered a high risk , the patient should be confined in an equipped hospital prefrably having an intensive neonatal care unit . Vaginal delivery is allowed when both the twins are atleast the first twin is with vertex presentation FIRST STAGE :- . A skilled obstetrician should be present . . Neonatologists (two)

18. . Presence of USG in the labor ward . The patient should be in bed . Use of analgesics drugs . Careful fetal monitoring . Internal examination should be done . An intravenous line prepaired . One unit of compatible and cross match blood Delivery of the first baby : the delivery should be conducted in the same guidlines as mentioned in normal labor . . E xtended episiotomy . Forceps delivery , if needed . Not to give IV ergometrine

19. Conduction of labor after the delivery of the first baby ( delivery of second twin ) Principles : The principle is to expedite the delivery of the second baby . The second baby is put under strain due to placental insufficiency caused by uterine retraction following the birth of the first baby . Steps of management : Step 1 – following the birth of the first baby . Lie . Presentation . Size of the second baby

20. Scheme of management of twins during labor .Both twins vertex 50% .Twin A vertex 40% .Twin B non vertex 40% .Analgesia .Careful foetal monitoring .Conduct delivery of first baby as usual Deliver of the first baby vaginally .Cord is divided in b/w two clamps . No methergine is given To note the lie of the second baby clinically or by USG Interval b/w twin A and B should ideally be 15 mins.

21. Transverse lie Longitudinal lie External version ARM+ Oxytocin if necessary Fails If delay Vertex Breech Breech extraction Delivery: To guard against PPH, presence of neonatologist

22. Indication of cesarean section : a. Obstetric indications b. for twin . Placenta previa . Twins with complications IUGR . Sever pre – eclampsia . Monoamniotic twins . Previous cesarean section . Monochorionic twins with TTTS . Cord prolapse of first baby . Abdominal uterine contraction

23. Management of difficult cases of twins:- Interlocking:- The most common one being the after coming head of the first baby getting locked with the forecoming head of the second baby. Occasionally, two heads of both vertex twins get locked at the pelvic brim preventing engagement of either of the head. The possibility should be kept in mind and the diagnosis is confirmed by intranetal sonography.

24. Triplets, quadruplets, etc.:- Triplets may develop from fertilization of a single ovum or two or even three ova. Similarly with Quadruplets and Quintuplets . Female foetus usually out number the male one. The diagnosis is confirmed by USG or during births. Pre term delivery is common (50%) and usually delivery occurs anytime between 35 and 36 weeks . Management is similar to that outline in twins. Average time for delivery in quadruplets is 30 -31 weeks.

25. Triplets

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