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

2. Powerpoint Templates Contents Page 2 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. Powerpoint Templates Multiple pregnancy Page 3 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. Powerpoint Templates Twins pregnancy Page 4 ( t w o - third) and Varieties: Dizyg o t i c twins : i s the comm on e st results from the fertilization of two ova. M onozygot i c twins (on e - third) results f r om t h e fertilization of single ovum.

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

6. Powerpoint Templates On rare occasion, the following possibilities may occur Page 6 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. Powerpoint Templates Diamniotic Dichorionic Separate placenta Frequency: 35% Mortality: 13% Page 9 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. Powerpoint Templates 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) Page 10

9. Powerpoint Templates Examination of placenta and membranes Page 11 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. Powerpoint Templates Anastomosis between placenta Page 12

11. Powerpoint Templates 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. Page 13

12. Powerpoint Templates Incidence Page 14 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. Powerpoint Templates Factors that Influence Twinning Page 15 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. Powerpoint Templates Terms Page 16 Superfecundation Superfetation Fetus papyraceous or compressus Fetus acardius Hydatidiform mole Vanishing twin

15. Powerpoint Templates Diagn o sis Page 17 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. Powerpoint Templates Diagnosis contd… Page 18 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. Powerpoint Templates Diagnosis contd… o f normal pregn a ncy are o f ten Page 19 Symptoms Minor symptoms exaggerated. Increased nausea and vomiting in early months Cardio-respiratory embarrassment Te n d ency o f sw e lling i n the l e gs, varicose ve i ns and hemorrhoids is greater Unusual rate of uterine enlargement and excessive fetal movements

18. Powerpoint Templates Diagnosis contd… Page 20 e x p l a i n e d by is a common General examination Prevalence of anemia is more Unu s u a l wei g ht g a i n , not preeclampsia or obesity Evi d e n ce o f p r e e c l am p s ia association.

19. Powerpoint Templates Diagnosis contd… Page 21 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. Powerpoint Templates Diagnosis contd… Page 22 Investigat i ons Sonography 10 th separate gestational sacs identified early Confirmati o n o f diagnosis a s early a s w e ek 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. Powerpoint Templates Twin peak sign Page 23

22. Powerpoint Templates Diagnosis contd… Page 24 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. Powerpoint Templates Complications Maternal During pregnancy Nausea and vomiting Anemia Pre-eclapmsia (25%) Hydramnios (10%) Antepartum hemorrhage Malpresentation Preterm labour (50%) Mechanical distress Page 25

24. Powerpoint Templates Complications contd… During labour Early rupture of membranes and cord prolapse Prolonged labour Increased operative interference Bleeding Postpartum hemorrhage Page 26

25. Powerpoint Templates Page 27 Complications contd… During puerperium Subinvolution Infection Lactation failure Fetal Miscarriage Prematurity (80%) Growth problem (25%) Intrauterine death Asphyxia and still birth Fetal anomal ies

26. Powerpoint Templates Page 28

27. Powerpoint Templates Complications of monochorionic twins Page 29 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.

28. Powerpoint Templates Complications of monochorionic twins contd… Page 30 TTTS contd.. Management A n tenatal diagn o s is: u l tras o und with d o pp l er flow study in the placental vascular bed. Rep e ated amniocentesis to c o ntrol 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%.

29. Powerpoint Templates Page 31

30. Powerpoint Templates Complications of monochorionic twins contd… Dead fetus syndrome Death of one twin (2-7%) is associated Page 32 w i th 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.

31. Powerpoint Templates Complications of monochorionic twins contd… Page 33 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. Ma j or cardiovascular an a stom osis l e ads to hi g h mortality.

32. Fetal acardius

33. Powerpoint Templates Research evidence Page 35 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.

34. Powerpoint Templates Complications of monochorionic twins contd… Page 36 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.

35. Powerpoint Templates Antepartum Management of Twin Pregnancy Page 37 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.

36. Powerpoint Templates Management contd… Page 38 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.

37. Powerpoint Templates Management during labour Page 39 First stage: A s k illed ob s tetri c ian, pres e n c e of ultra s ou n d ma c hine a nd 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.

38. Powerpoint Templates Management during labour contd.. Page 40 with Delivery of the first baby : De l iv e r y : S a me guidelines a s i n norm a l lab o ur liberal episiotomy. Forceps d eliver y: i f n eeded, shou l d b e do n e 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.

39. Powerpoint Templates Management during labour contd.. Page 41 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.

40. Powerpoint Templates Management during labour contd... Page 42 Lie longitudinal: Step I : Lo w rupture o f mem branes, synt o cinon , i n tern a l examination to exclude cord prolapse. Step I I : I f the uterine contraction i s p oo r, 5 un i ts of oxytocin is added. Step II I : Is there i s still a del a y , i n terfere n ce i s to be done.

41. Powerpoint Templates Management during labour contd... Page 43 1. Vertex: Low down—forceps are applied. High up—CPD should be ruled out. Th e p o ssibi l ity o f hy d rocephal i c hea d sh o uld a l s o 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. Breech: Breech extraction. Lie transverse : Correct by external version or internal version to cephalic or podalic.

42. Powerpoint Templates Management during labour contd... Page 44 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.

43. Powerpoint Templates Management during labour contd... Page 45 Delay in the birth of second twin B i r t h o f s econd twin should b e com p le t ed w i t h in 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

44. Powerpoint Templates Management during labour contd... Page 46 met herg i n IV with Management of third stage Routine administ r ation o f . 2 mg delivery of anterior shoulder. Deliver placenta by CCT Continue o x ytoc i n dr i p for a t l e ast on e ho ur, foll o wi n g delivery of second baby. The patient is to be carefully watched for about 2 hours after delivery.

45. Powerpoint Templates Indications of caesarean section Page 47 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, tw i n s ; Twins with complications: IUGR, conjoint Monoamniotic twins, monochorionic twins with TTS

46. Powerpoint Templates 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: U nder gen e ral anesthesia, If fails, caesarean section is the alternative Page 48

47. Powerpoint Templates Management of difficult cases of twins contd.. Page 49 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.

48. Powerpoint Templates Postnatal period Page 50 Care of the babies Immediate care Maintenance of body temperature, Use of overhead heaters, P a rents given the op p ortunity t o check t h e i d entity t a g and cuddle them. Breastfeeding rega r ding different Provide knowledge to mother positions f o r breas t f e eding, al o ng with advantages, attachment, positioning timing.

49. Powerpoint Templates Postnatal period contd.. Page 51 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 involu t i on of uterus, increased ‘After pains’ so analgesia should be offered. High calorie diet. Teach extra support to handle twin babies

50. Powerpoint Templates Management and Nursing Interventions Page 52 Nutrition counseling Fetal evaluation Evaluate woman for signs and symptoms of obstetrical complications PTL prevention: explain for hospitalization Encourage bed rest and hydration. Insti t u t e f etal monit o ring and assist with t o c o l y tic th e rap y , if ordered. Explain to the woman that mode for delivery depends on the presentation of the twins, maternal and fetal status, and gestational age

51. Powerpoint Templates Page 53 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. N e onatal team for e a ch n e o n ate p r es e nt a t b i rth for n e o n atal resuscitation. Pi t o c in ind u c t ion/au g me n t ation may b e requ i red sec o nd a ry to hypotonic labor. Postpartum hemorrhage may occur due to uterine atony. Emotional support.

52. Powerpoint Templates Nursing diagnoses Page 54 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.

53. Powerpoint Templates Nursing diagnoses contd… Page 55 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

54. Powerpoint Templates Refer e nces Page 56 Fraser DM, Cooper MA.Myles Textbook for Midwives.15th edition. Philadelphia:Churchill livingstone elsevier;2009 Dut t a DC . T e x t book of o b ste t rics. 6 t h edition . Calcu t t a : New cen t r al book agency;2004 Pillitteri A. Maternal a n d child he a lth n u r s i n g. Care of t he c h ildbe a ring and childre a ring f a mil y . Sixth edition. Philadelphia; Lippincott Williams & Wilkins: 2010. Cunningham, Leveno, Bloom. William’s obstetrics. 23 rd edi t io n . 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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