Presentation on multiple pregnancy

1. Presented by
NCdt Bhawana Yadav
4th yr BBSc Nursing
Guide
Maj Shivapriya S
Assistant prof
College of nursing AFMC
Pune 1

2. Multiple Pregnancy
• “When more than one fetus simultaneously
develops in the uterus then it is called multiple
pregnancy”
D C Dutta’s , Textbook of Obstetrics 9th edition
• 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.

3. Few terms..
ZYGOSITY
• Genetic make up of the twin pregnancy
CHORIONISITY
• Placenta’s membrane status
• Determined by the timing of embryo division

4. Twins pregnancy
Varieties:
• Dizygotic twins: is
the
commonest(two-
third) and
results from the
fertilization of two ova.
(Biovular)
• Monozygotic
twin
s (one-third)
resul
ts from the

5. Diagnosis of Jaipur city can be made by
• Examining fetal genders (different genders = dizygotic)
• Placenta (mono chorionic = monozygotic and
• genetic testing
Determination of Zygosity

6. Examination of placenta and
membranes
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.

7. Determination of Zygosity cont...
ZYGOSITY Monozygotic twins Dizygotic twins
Placenta One Two (separate or most
often fused )
Communicating vessels Present Absent
Intervening membrane
and thickness
Two( aminons)
<2mm
Four(2 aminons 2 chorions)
>2mm
Sex Always identical May differ
DNA fingerprinting Same Different
Reciprocal skin grafting Acceptance Rejection
Follow up Usually identical Not-identical

8. Determination of
CHORIONISITY in
Monozygotic
Pregnancy

9. Cont...
• 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 4th and 8th day
after the formation of inner cell mass when chorion has
already developed diamniotic monochorionic twins
develop (D/M)
• If the division after 8th day of fertilization, when the
amniotic cavity has already formed, a monoamniotic
monochorionic twins develop (M/M)

10. 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)

11. THORACOPAGUS
CRANIOPAGUS
ISCHIOPAGUS OMPHALOPAGUS
PYOPAGUS RACHYPAGUS

12. INCIDENCE
• Highest in Nigeria ( 1 in 20)
• Lowest in far eastern countries (1 in 200)
• In India- 1 in 80
• Hellin’s Law:
Twins: 1:80
Triplets: 1:80^2
Quadruplets: 1:80^3
Quintuplets: 1:80^4
• Conjoined twins: 1 : 60,000

13. Factors that Influence Twinning
• 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: Twinning peaks at
age 37 years
• Increasing parity: 5th gravid onwards.
• Nutritional Factors: Taller, heavier
women—twinning rate 25 to 30 % greater.
• Pituitary Gonadotropin
• Assisted Reproductive Technology

14. Terms
• Superfecundation is fertilisation of two ova produced in
the same menstrual cycle by two spermatozoa deposited
in two separate acts of coitus
• Superfetation is fertilisation of two ova produced in two
different menstrual cycles by two separate spermatozoa.
The development of one foetus over another foetus is
possible theoretically until the decidual space is
obliterated until 12 weeks of pregnancy.

15. Terms Cont...
• Foetus papyraceous or compressus is a state which
occurs if one of the foetus dies early. The dead foetus is
flattened, mummified and compressed between the
membranes of the living foetus and the uterine wall.
Usually discovered at delivery or earlier USG.

16. Terms cont..
• Fetus acardius occurs only in monozygotic twins. Part of
one foetus remains amorphous and becomes parasitic
without a heart.

17. Terms cont...
• Vanishing twin 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 reabsorption. The rate of
disappearance could be to the extent of 40%.

18. Diagnosis
History
• Recent administration of ovulation inducing drugs esp.
gonadotropins for infertility or pregnancy accomplished
by ART are much stronger associates.
• Family history of twinning specially on maternal side.

19. Diagnosis cont…
Symptoms
• Minor symptoms of normal pregnancy are often
exaggerated.
• Increased nausea and vomiting in early months
• Cardio-respiratory embarrassment
• Tendency of swelling in the legs, varicose veins and
hemorrhoids is greater
• Unusual rate of uterine enlargement and excessive fetal
movements

20. Diagnosis cont…
20
General examination
• Prevalence of anemia is more
• Unusual weight gain, not explained by
preeclampsia or obesity
• Evidence of preeclampsia is a common
association.

21. Diagnosis cont…
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.

22. Diagnosis cont…
Investigations
Sonography
• separate gestational sacs identified early
• Confirmation of diagnosis as early as 10th week of
pregnancy
• Variability of fetuses, vanishing twin in second trimester
• Chorionicity (twin peak sign/ lambda sign)
• Pregnancy dating, Fetal anomalies
• Fetal growth monitoring, Presentation and lie of fetuses
• Twin transfusion, placenta localisation, Amniotic fluid
volume

23. Twin peak sign for
dizygotic twins

24. T sign for mono chorionic twins

25. Diagnosis cont…
Biochemical Tests:
• Levels of hCG in plasma and in urine are higher
• Maternal serum alpha-fetoprotein level: Elevated
• Unconjugated oestriol: approximately double

26. Diagnosis cont…
26
• 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)

27. Complications
Maternal
During pregnancy
Nausea and vomiting
Anaemia
Pre-eclampsia (25%)
Hydramnios (10%)
Antepartum haemorrhage
Malpresentation
Preterm labour (50%)
Mechanical distress

28. Complications cont…
• During labour
Early rupture of membranes and
cord prolapse
Prolonged labour
Increased operative interference
Bleeding after the birth of first
baby
Postpartum haemorrhage

29. Complications cont…
• During puerperium
Sub involution
Infection Lactation
failure
• Foetal
Miscarriage
Prematurity (80%)
Growth problem (25%)
Intrauterine death Asphyxia and
still birth
Foetal anomalies

30. Complications of mono chorionic twins
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.

31. Complications of monochorionic twins
contd…
TTTS contd..
Management
• Antenatal diagnosis: ultrasound with doppler flow study
in the placental vascular bed.
• Repeated amniocentesis to control 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%.

33. Complications of monochorionic twins
contd…
Dead fetus syndrome
• Death of one twin (2-7%) is 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.
• This is due to thromboplastin liberated from the dead
twin that crosses via placental anastomosis to the living
twin.

34. Complications of monochorionic twins
contd…
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.
• Major cardiovascular anastomosis leads to high
mortality.

35. Fetal acardius

36. Complications of monochorionic twins
contd…
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.

37. Antepartum Management of Twin Pregnancy
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.

38. Management contd…
• 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.

39. Management during labour
First stage:
• A skilled obstetrician, presence of ultrasound machine and
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.

40. Management during labour contd..
Delivery of the first baby:
• Delivery: Same guidelines as in normal labour with
liberal episiotomy.
• Forceps delivery: if needed, should be done 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.

41. Management during labour contd..
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.

42. Lie & Presentation

43. Management during labour contd...
Lie longitudinal:
• Step I: Low rupture of membranes, syntocinon, internal
examination to exclude cord prolapse.
• Step II: If the uterine contraction is poor, 5 units of
oxytocin is added.
• Step III: Is there is still a delay, interference is to be
done.

44. Management during labour contd...
1. Vertex: Low down—forceps are applied.
• High up—CPD should be ruled out.
• The possibility of hydrocephalic head should also 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.

45. Management during labour contd...
45
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.

46. Management during labour contd...
Delay in the birth of second twin
within 45
• Birth of second twin should be completed
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

47. Management during labour contd...
methergin IV with
Management of third stage
• Routine administration of 0.2mg
delivery of anterior shoulder.
• Deliver placenta by CCT
• Continue oxytocin drip for at least one hour, following
delivery of second baby.
• The patient is to be carefully watched for about 2 hours
after delivery.

48. Indications of caesareansection
twins;
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,
• Twins with complications: IUGR, conjoint
Monoamniotic twins, monochorionic twins with TTS

49. 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, followedby 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: Under general
anesthesia, If fails, caesarean section is the alternative

50. Management of difficult cases of
twins contd..
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.

51. Postnatal period
Care of the babies
• Immediate care
• Maintenance of body temperature,
• Use of overhead heaters,
• Parents given the opportunity to check the identity tag
and cuddle them.
Breastfeeding
regarding different
• Provide knowledge to mother
positions for breastfeeding, along with advantages,
attachment, positioning timing.

52. Postnatal period contd..
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 involution of uterus, increased ‘After pains’ so analgesia
should be offered.
• High calorie diet.
• Teach extra support to handle twin babies

53. Management and Nursing Interventions
• Nutrition counseling
• Fetal evaluation
• Evaluate woman for signs and symptoms of obstetrical
complications
• Preterm labor prevention: explain for hospitalization
– Encourage bed rest and hydration.
– Institute fetal monitoring and assist with tocolytic therapy, if
ordered.
• Explain to the woman that mode for delivery depends on
the presentation of the twins, maternal and fetal status,
and gestational age

54. 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.
• Neonatal team for each neonate present at birth for neonatal
resuscitation.
– Pitocin induction/augmentation may be required secondary to
hypotonic labor.
– Postpartum hemorrhage may occur due to uterine atony.
• Emotional support.

55. Nursing diagnoses
• 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.

56. Nursing diagnosescontd…
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

57. THANK
YOU