Multiple pregnancy

Dr Sanaa Abujilban, RN,RM, PhD

Objectives

• Describe types of multiple pregnancy
• Consider the diagnoses and management of MP
• Identify the problems associated with MP
• Explain the special need of parents of twins

Incidence

• incidence increased in the last years because of treatment of infertility
• Triplets: 3 fetuses
• Quadruplets: 4 fetuses

Types of twin pregnancy

1. Monozygotic (identical twins);
1. one spermatozoon and one oocyte
2. Same sex, same genes, same physical features
3. May be different sizes
4. Often different personalities and characters
2. Dizygotic (non-identical)
• two sperms and two oocyte
• Different sex, genes, physical features

Relationship between zygosity and chorionicity

Placentation of twins

Diagnosis of twin pregnancy

• Through U/S examination
• Abdominal examination:
• inspection
• Larger size of uterus according to GA
• More and fresh striae gravidarum
• Up to twice amniotic fluid amount
• Palpation:
• Greater than expected fundal ht
• Two heads into fundus
• Two back into lateral palpation
• Auscultation:
• Two FHR WITH 10 b/min differences between them

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Effects of multiple pregnancy on mother

• Increase the common disorders:
• N&V, heartburn…
• anemia:
• common in twins, need supplements
• Polyhydramnios:
• common, may cause abortion or premature labor
• Pressure symptoms:
• varicose veins and edema, backache, dyspnea and ingestion
• Other:
• increase complications of pregnancy

Antenatal screening

• Nuchal translucency (back neck fluid collection)
• Chorionic villus sampling
• Amniocentesis
• Chorionicity by U/S
• Check for cardiac anomaly

Nuchal translucency

Ultrasound examination�(Chorionicity by U/S

• Monochorionic:
• Should scanned every 2 wks to check if there is a twin-to-twin transfusion syndrome
• Dichorionic:
• scanned every 4 wks

Antenatal preparation

• Need parent education
• Written information
• Contacts of support organizations
• Special antenatal classes
• Preparation for breast feeding
• Possible to breast feed the two
• Need more time for BF

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Labor and birth

• Onset:
• The more babies the shorter GA will be
• 50% preterm
• Should receive tocolytic agent if labor begin before 37 wks
• Treat any UTI to prevent preterm labor
• Most likely spontaneous labour
• If the 1^st twin is cephalic: vaginal delivery
• If the 1^st is not cephalic: C/S DELIVERY
• C/S is recommended for:
• monochorinic (twin –to-twin transfusion ) and
• abruptio placenta risk

Presentation of twins before birth

Management of labor

• Induction for free complication women:
• At 38 weeks for the twins of two chorions and two amnions
• At 36-37 weeks for Monochorionic diamniotic placenta
• Need continuous fetal monitoring
• Put in comfortable position
• Precautions for supine hypotension

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Management of labor cont.

• Anathsthesia:
• Epidural blocks is preferred or others
• May need C/S for fetuses compromise
• May require oxytocin for poor uterine activity
• Send premature babies to NICU
• Pediatric team need to attend birth
• Support the women all the time during labor

Management of birth

• Obstetrician and anasthetist and pediatric team should attend birth
• Operating room should be ready for emergency C/S
• Monitor the two fetuses
• First baby labeled “twin one”
• Then: Abdominal palpation to ascertain the lie, presentation and position of the 2^nd twin and FHR

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Management of birth cont.

• May need external cephalic version to correct the lie
• Then: vaginal examination to check the presenting part
• May need fundul pressure to help the engagement of the presenting part before the rupture of the 2^nd sac
• FHR again
• May give oxytocin

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Management of birth cont.

• Then: encourage the woman to push with contraction
• If the 2^nd twin is breech, need doctor’s assistance
• Time for the 2^nd twin: 45 min or longer
• Then: give oxytocin or methergine to enhance contractility after the birth of anterior shoulder
• Label the baby “twin two”

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Management of birth cont.

• 2^nd twin: have high risk for asphyxia
• Then: controlled cord traction is applied to both cords simultaneously
• Then: check placenta (two), cords and membranes for completeness and number

Complications associated with multiple pregnancy

1. Polyhydramnios
1. May occur at 16 weeks
2. Most likely due to twin-to-twin transfusion syndrome

Complications cont.

2. Twin-to-twin transfusion syndrome (TTTS)
1. Acute:
• Happen during labor;
• blood transfuse from one baby (donor) to another (recipient) through the monochorinic placental vascular anastomosis (connection of arteries)
• Fatal: Need urgent treatment

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Complication cont.

• 2. Twin-to-twin transfusion syndrome (TTTS)

2. Chronic:

• Occurs in 15 % of monochorionic twin
• Blood transfuse from one twin to the other through the placenta
• Cause:
1. anemia and growth restriction in the donor twin and
2. circulatory overload with the recipient
• Need early diagnosis and treatment
• Treatment:
• Amnio-reduction of fluids (for Polyhydramnios)
• Laser ablation therapy for the placenta

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Complications cont.

3. Fetal abnormality:
• Associated with monochorionic twins
4. Conjoined twins
• Result from:
• incomplete division of the fertilised oocyte
• C/S delivery
• May separate them if alive
• Ethical dilemma: save one only

Complication cont.

5. Twin reversed arterial perfusion:
• One twin presents without a well-defined cardiac structure
6. Fetus-in-fetu
• Parts of one fetus may be lodged within another fetus

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Complication cont.

6. Malpresentations:
• Unlikely during pregnancy
• Most likely the 2^nd twin after the 1^st will born
7. Premature rupture of membranes
• Caused by malpresentation as a result from polyhydromions
8. Prolapse the cord:
• for the 2^nd twin
• Caused by:
• malpresentation as a result from polyhydromions
• Poorly fitting presenting part

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Complications associated with multiple pregnancy cont.

9. Prolonged labour
• Caused by:
• Malpresentation and
• over distened uterus (hypoactive)
10. Monoamniotic twins
• Share the same sac (1%)
• risk for cord entanglement (occlude blood supply)
• Treatment:
• reduce amniotic fluid
• Deliver at 32-34 weeks by C/S

Complication cont.

11. Locked twins:
• Very rare but very dangerous
• The 2^nd twin prevents the continued descent of the 1^st

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Complication cont.

12. Delay in the birth of the second twin
• Caused by:
• poor uterine activity as a result of malpresentaion
• Risk for:
• hypoxia and asphyxia due to placenta separation
• sepsis: ascending bacteria by the umbilical cord
• Not fully dilated cervix after the 1^st twin

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Complication cont.

13. Premature expulsion of the placenta:
• Placenta (shared) may be expelled after the 1^st twin
• Risks:
• Hypoxia of the 2^nd twin
• Hemorrhage

Complication cont.

14. Postpartum hemorrhage:
• Caused by
• over distension of the uterus
• Hypotonic activity
• Large placenta
15. Undiagnosed twins
• Expect it if:
• Large abdomen
• Smaller baby than expected
• Risks:
• Hypoxia as the methergine given in anterior shoulder

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Complications cont.

16. Delayed interval delivery of the second twin:
• 1^st baby premature
• Some times it takes Days or weeks before the 2^nd baby to be born
• Give betamethasone to mature the 2^nd baby lungs

Postnatal period: infant care

• Immediate care: same as single baby
• Maintain body temperature (use overhead heaters)
• ID band
• May need neonatal unit
• Breast feeding (separately specifically at the beginning or simultaneously) or bottle feeding as the mother want
• Monitor the weight gain

Breastfeeding positions

Postnatal Care for the mother

• Slower involution because of uterine increased bulk
• Afterpain may need analgesia
• High protein, high calorie diet for breast feeding mother
• Need main meals and snacks
• Exercise
• Teaching parenting skills

Postnatal Care for the mother�cont.

• Psychologically:
• May feel “in the way” (interfere) if the babies in the NICU
• Feelings of guilt: as having premature baby
• Isolation: a precipitant for depression
• Keep the up-to-date about babies condition
• Better to have rooming-in policy: keep mother in hospital with babies
• Need help at home for 2-3 weeks

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Triplets and higher order births

• May need hospitalization before the babies born
• Almost certainly born premature
• Perinatal mortality rates are higher for triplet than twins
• More incidence for cerebral palsy
• Almost always Need C/S
• pediatric team should attend C/S

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Triplets and higher order births cont.

• Complications associated with births:
• Asphyxia
• Intracranial injury
• Perinatal death

Triplets and higher order births cont.

• Family problems:
• Practical and financial help
• Professionals’ lack of awareness of family problems
• Need extra help at home after birth
• May experience:
• Stress and anxiety
• A mother should never be expected to manage by herself

Disability and bereavement

• Perinatal mortality is 4 times for twins and 12 for triplets than singletons
• The grief of Family who one of the twins died is Underestimated as the focus will be on the alive one
• Their needs poorly met

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Multi-fetal pregnancy reduction (MFPR)

• Reduction of an apparently healthy higher order multiple pregnancy down to two or even one embryo to increase the chance of survival
• Between 10^th -12^th weeks of pregnancy
• All embryo remain in the uterus until delivery
• Parents need education about:
• risks,
• benefits,
• their feelings,
• organizations, and
• support

Multi-fetal pregnancy reduction (MFPR) cont.

• Technique:
• Insert a needle via vagina or abdomen under the guidance of U/S
• Inject saline or potassium chloride into the fetal thorax

Selective feticide

• One of the babies has a serious abnormality
• Same procedure of MFPR
• Delayed to a later time
• parents need counseling
• Need to understand the parents' bereavement (loss by death)

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