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MULTIPLE PREGNANCY – COMPLICATION AND MANAGEMENT

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MULTIPLE PREGNANCY – COMPLICATION AND MANAGEMENT

COMPLICATIONS:
Maternal:
During pregnancy:
  • Nausea and vomiting 
  • Anemia 
  • Pre-eclapmsia (25%) 
  • Hydramnios (10%) 
  • Antepartum hemorrhage 
  • Malpresentation Preterm labour (50%) 
  • Mechanical distress

During labour :

  • Early rupture of membranes and cord prolapse 
  • Prolonged labour 
  • Increased operative interference 
  • Bleeding Postpartum hemorrhage

During puerperium:

  • Subinvolution 
  • Infection 
  • Lactation failure 
  • Miscarriage 

Fetal 

  • Prematurity (80%) :main cause of increased mortality and morbidity
  • Growth problem (25%) 
  • Intrauterine death Asphyxia and still birth 

Fetal anomalies

  • Twin twin transfusion syndrome (TTS) 
  • Dead fetus syndrome
  • Twin reversed arterial perfusion (TRAP)
  • Conjoint twin
  • Fetal acardius
  • Monoamniocity
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 : 

  • Become smaller with oligohydramnios, anemic, hypotensive and hypovolemic.
  • Appear stuck
  • Difference of hemoglobin concentration:> 5 gm% 
  • Estimated fetal weight discrepancy: 25% 

Management :

  • Antenatal diagnosis
  • Repeated amniocentesis
  • Prevent preterm labour and placental abruption.
  • Selective reduction of one twin is done when survival of both the fetuses is at risk.
  • Plethoric twin: risk of CCF and hydrops.
  • Perinatal mortality: 70%
Dead fetus syndrome:
  • Death of one twin (2-7%) 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. 
  • Thromboplastin liberated from the dead twin that crosses via placental anastomosis to the living twin.
Twin reversed arterial perfusion (TRAP):
  • Characterized by an acardiac perfused twin having blood supply from a normal co-twin via large arterio-arterial anastomosis.
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
MANAGEMENT:
 
Antepartum Management:
  • Delivery of markedly preterm neonates be prevented
  • Fetal-growth restriction identified and afflicted fetuses be delivered before they become moribund
  • Fetal trauma during labor and delivery be avoided, 
  • Expert neonatal care be available.

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 (50% incidence)
  • Hospitalization 
  • Use of corticosteroids to accelerate fetal lung maturation
Management during labour:

DELIVERY OF THE FIRST BABY:

  • In an uncomplicated twin pregnancy :Vertex delivery
  • Forceps delivery: if needed, under pudendal block anaesthesia.
  • Clamp the cord at two places and cut it between.
  • 8-10 cm of cord is left behind for administration of any drug or transfusion
  • The baby should be labeled one

DELIVERY OF SECOND TWIN:

  • In an uncomplicated twin pregnancy :second baby transverse lie
  • Lie, presentation, size and FHS of the second baby ascertained

Lie longitudinal: 

  • Step I: Low rupture of membranes, syntocinon, internal examination to exclude cord prolapse.
  • Step II: IPoor contraction → 5 units of oxytocin
  • Step III:Still delayed, interference done.

Vertex: 

  • Low down—forcep delivery
  • High up—CPD  ruled out
  • Internal version followed by breech extraction under GA or Ventouse
  • Breech: Breech extraction
  • Lie transverse: Correct by external version or internal version to cephalic or podalic.

Indication of urgent delivery of second baby:

  • Severe vaginal bleeding
  • Cord prolapse
  • Inadvertent use of IV ergometrine 
  • First baby delivered under general anesthesia
  • Appearance of fetal distress.

The risk of delays:

  • Intrauterine hypoxia 
  • Birth asphyxia
  • Sepsis

Indications of caesarean Section:

Obstetric causes:

  • Placenta previa
  • Severe preeclampsia
  • Previous CS 
  • Cord prolapse
  • Abnormal uterine contractions
  • Contracted pelvis 

For twins: 

  • Noncephalic presentation:First baby is in transverse lie
  • IUGR
  • Conjoint twins
  • Monoamniotic twins
  • Monochorionic twins with TTS
  • Weight less than 1500 gm

Exam Important

  • Prematurity is the main cause of increased mortality and morbidity in twins.
  • Primigravida with twin pregnancy may develop Hydramnios, Pregnancy induced hypertension & Malpresentation
  • To say twin discordance the differences in the two twins should be 25% with the larger twin as index
  • Incidence of preterm delivery in twin pregnancy  is 50%
  • Important factor for discordant growth between twins is  Twin to twin transfusion
  • In an uncomplicated twin pregnancy normal delivery should be attempted in First baby – Vertex and second baby transverse lie
  • In twin pregnancy, treatment of choice when first baby is in transverse lie is Cesarean section
  • In twin pregnancy delivery by cesarean section is advocated in Monoamniotic twins & Weight less than 1500 gm.
  • Oligohydramnios is Not associated with twin pregnancy
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