Multiple pregnancy

[Link]
[Link]
Multiple pregnancy
• Definition
• When more than one fetus simultaneously
develops in the uterus it is called multiple
pregnancy
• Twins-2 fetuses
• Triplets- 3 fetuses
• Quadruplets- 4 fetuses
• Quintuplets -5 fetuses
• Sextuplets- 6 fetuses
Multiple pregnancy
• Twins
• 1. Monozygotic twins - 20% results from the
fertilization of a single ovum
• 2. Dizygotic twins- 80% - most common and
results from fertilization of two ova
Multiple pregnancy
 Multiple pregnancy
• Incidence
• High- Nigeria, 1:20
• Low- Japan, 1:250
• India- 1:80
Multiple pregnancy
Multiple pregnancy
• Etiology
• Cause unknown
• Race: high in Africa, low in eastern countries
• Family history: maternal side
• Advanced maternal age: 30 to 35 yrs
• ART procedure: drugs used for ovulation high-
gonodotrophin and low in clomiphene citrate and
letrozole
• Influence of parity: 5th gravida onward
Multiple pregnancy
• Other issues
• Superrfecundation- fertilization of 2 different ova
released in the same cycle by seprate acts of coitus
within a short period of time
• Superfetatio -fertilization of 2 ova released in
different menstrual cycles
• Fetus pqpyraceus or compressus- is a state which
occurs if one of the fetuses dies early. The daed
fetus is flattened mummified and compressed
between the membranes of the living fetus and the
uterine wall
Multiple pregnancy
• Fetus acardicus- occurs only in monozygotic
[Link] of fetus remains amorphous and
becomes parasitic without a heart
• Hydatidiform mole
• Vanishing twin- serial ultrasound imaging in
multiple Pregnancy ,dead of one fetus and
continuation of pregnancy with the surviving one.
The dead fetus simply vanishes by resorption
Multiple pregnancy
Multiple pregnancy
• Maternal physiological changes
• Increase in weight gain and cardiac output
• Plasma volume increased by addition 500ml
• Increased alpha fetoprotein level and GFR
• Lie and presentation
• Both vertex( 50%)
• First vertex and second breech(30%)
• First breech and second vertex(10%)
• Both breech(10%)
Multiple pregnancy
• Diagnostic evaluation
• History - ovulation induction drugs,family history
• Symptoms
• Increased nausea and vomiting
• Cardiorespiratory embarrassment ( palpitation,
SOB)
• Swelling of legs,varicose veins and hemorrhoids
• Unusual abdominal enlargement
Multiple pregnancy
• General examination
• Anemia is more than singleton pregnancy
• Unusual Wt gain
• Evidence of preeclampsia
• Abdominal examination
• Inspection -barrel shape
• Palpation- height of uterus is more than the
period of amenorrhea
• Girth of abdomen > 100cm
• Fetal bulk seems
• Palpation- height of uterus is more than the
period of amenorrhea
• Girth of abdomen > 100cm
• Fetal bulk seems disproportionately larger in
relation to the size of fetal head
• Palpation of too many fetal parts
• Auscultation -2 district FHS located at separate
spots with a silent area in between. 2 observers
Twin peaks sign or
lambda sign
Multiple pregnancy
• Internal examination
• One head is falt deep in pelvis while the other is
located by abdominal examination
Multiple pregnancy
• Investigation
• Sonography -confirmation of diagnosis -10th wk of pregnancy
• Viability of fetus
• Vanishing twin in 2nd trimester
• Chorionocity( lambda or twin peaks sign)
• Pregnancy dating
• Fetal growth monitoring
• Fetal anomalies
• Presentation and lie
• Twin transfusion
• Placental localisation
• Amniotic fluid volume
Multiple pregnancy
• Biochemical test
• Maternal serum chorionic gonadotrophin
• Alpha fetoprotein
• Unconjugated estriol
• Differential diagnosis
• Hydramnios
• Big baby
• Fibroid or ovarian tumor
• Ascites with pregnancy
Multiple pregnancy
• Complications
• Maternal ( during pregnancy)
• Nausea nad vomiting
• Anemia
• Preeclampsia
• Hydramnios
• APH
• Malpresentation
• Preterm labor
• Mechanical distress
Multiple Pregnancy
• During labor
• Early ROM
• Cord prolapse
• Prolonged labor
• Increase operative interference
• Bleeding
• PPH
Multiple pregnancy
• During puerperium
• Subinvolution ( big size of uterus)
• I fevyoon( operative interference)
• Lactation failure
• Thromboembolism
Multiple pregnancy
• Fetal complications
• Miscarriage rate is increased
• Premature rate increased
• Discordant twin growth
• Vanishing twin
• IUD of fetus
• Appearing twin
• Fetal anomalies
• Asphyxia and stillbirth
Multiple pregnancy
• Prognosis
• Maternal mortality rate is increased
• Preeclampsia
• Maternal morbidity
• During delivery 2nd baby is more at risk than the
first one
Multiple pregnancy
• Antenatal management
• Diet- 300kcal,increased energy requirements
• Rest
• Supplement therpay- iron therapy is increased to
the extent of 100-200 mg per day
• Interval of antenatal visit
• Fetal surveillance- maintained by sonography at
every 3-4 weeks
• Hospitalization
Multiple pregnancy
Multiple pregnancy
• First stage
• Skilled obstetrician
• Neonatologist
• Presence of ultrasound in labor
• Pt should be in bed
• Use of analgesics drugs
• Careful fetal monitoring
• Internal examination should be done
• IV- RL
• One unit compatible and cross matched blood should bedae
Available
• Oxytocin
Multiple pregnancy
• Delivery of first baby
• Extended episiotomy under 1% lignocaine
• Forceps delivery
• Not to give iV ergometrine with the delivery of
first baby
• Clamp the cord at two places and cut in between
• Atleast 8-10cm of cord is left behind
Multiple pregnancy
• Lie longitudinal: cephalic - LROM, spontaneous forceps
delivery
• Breech presentation - RoM, assisted breech delivery
• Transverse lie-ECV, internal pofalic version
• Head- low down delivery by forceps
• Urgent delivery of second baby
• Severe vaginal bleeding
• Cord prolapse
• IV ergometrine
• First baby delivered by GA
• Featl distress
Multiple pregnancy
• Indications of cesarean section
• Obstetric condition
• Placenta previa
• Severe preeclampsia
• Previous cesarean section
• Cord prolapse
• Abnormal uterine contractions
 Multiple pregnancy
• For twins
• Both fetuses or even the first fetus with non
cephalic
• Twins with complications: IUGR, conjoined twins
• Mono horoic twins
• Monochorionic twins with TTS
Conjoined twins

• Depends upon the site of union

• Thoracophagys- chest
• Omphalophagus- abdominal wall
• Pyopagus- buttocks
• Ischiopagus- ischium
• Cephalopagus- head
Conjoined twins
Nursing diagnosis

• Risk for preterm labor

• Risk for gestational diabetes
• Risk for preeclampsia and
• Risk for postpartum hemorrhage.
• Knowledge deficit
• Imbalaced Nutrition less than body requirement
Thank you