Wiki.multiples for review class 2011
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Wiki.multiples for review class 2011

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OB multiple gestation

OB multiple gestation

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  • Increased nausea due to hormones
  • Sometimes tell by u/s – often placental pathology
  • Ovarian follicicles stimulated by drugs, not necessarily ART
  • Monoamniotic twins are delivered at 32 wks to prevent cord entanglement
  • Papyraceous – rare condition where one fetus dies, atrophies and mummifies - very unusual
  • Pulmonary edema Gallbladder due to increased progesterone
  • Emotional/social isolation if on hospitalized bed rest, especially during flu season
  • Increased progesterone - cholestasis
  • Synchronous FHR patterns – hard to distinguish b/w fetus –may need to get U/S to distinguish Asychronous patterns – able to tell
  • Threatens fetal life and maternal well being. Almost always in pregnancies with one placenta/2 amniotic sacs. Mortality rates as high as 80-100% if untreated (Cromblehome and Harkness – 05). Numerous theories as to why it occurs, but no definitive answer (renin – angiotension and brain peptides all areas of current study).
  • Stuck when no urine visible in donor twin’s bladder. Amniotic sac appears on U/S to be adhered to fetus, leaving no room for movement. Centers that perform various treatments: amnioreduction – most common; amniotic septosomy (perforation of intertwin membrane so fluid volumes equal); fetal laser coagulation of vascular anastomoses; finally fetoscopic cord coagulation occludes umbilical cord of twin with severe cardiomyopathy who had no chance of survival. Any of these methods can cause fetal death of both.
  • Monoamniotic twins usually hsopitalized and monitored TID. Challenge to monitor. Delivery at 32 wks – ACOG recommendation
  • Emotional/social needs with hospitalization. Importance of support groups. TriState multiple and Mothers of Twins clubs
  • In order to support normal growth of fetus. Supplements. Increased risk of GDM due to multiple placentas secreting HPL and other insulin antagonistic hormones. Small frequent meals.
  • Social needs and networking with other multiple moms Don’t rub abdomen – stimulate ctxs

Wiki.multiples for review class 2011 Wiki.multiples for review class 2011 Presentation Transcript

  • MULTIPLE GESTATION Peggy Foster, RNC-OB, MSN Sandy Warner RNC-OB, MSN
  • MULTIPLE GESTATION Definition—Pregnancy with more than 1 Fetus
  • Diagnosis of multiple gestation Size greater than dates Greatly elevated hCG levels Elevated alpha-fetoprotein (MSAFP) More than one audible heart beat U/S confirmation ART View slide
  • Multiple Gestation Twins are most common form of multiples Monozygotic twins - 25%  One sperm and one ova  “identical”  Can separate into more than 2 (identical triplets etc) Dizygotic twins are majority Includes twins and higher order multiples  “fraternal” or nonidentical  Two ova and two sperm View slide
  • Monozygotic vs. Dizygotic
  • Monozygotic vs. Dizygotic Amnion layer inside Chorion Dizygotic twins always have 2 amnions and 2 chorions Monozygotic twins can be Mono Chorionic - Mono Amnionic Mono Chorionic - Di Amnionic OR Di Amnionic - Di Chorionic
  • Associated factors for dizygotic twins ART (assisted reproductive technology) Age Ovarian follicicle stimulation Parity > 4 Race—More common in Blacks—Less common in Oriental populations Family history Coital frequency
  • Monozygotic twins occur independently Cause is unclear
  • Monozygotic twins can be: Diamnionic/dichorionic—Occur<72 hours after conception Monochorionic/diamnionic (MOST !!)—Occur 3-7 days after conception Conjoined twins >7 days after conception— incomplete separation of developing embryonic cell masses Monochorionic/monoamnionic –RARE !!
  • What we do know for Sure !! Different sex—always dizygous Different blood types—always dizygous If Monochorionic—always monozygous
  • Pregnancy Outcomes 85% of multiple gestation mothers have antepartal complications—compared with only 32% of singleton pregnancies Perinatal morbidity and mortality is TWICE that of singleton pregnancies—In these women 4% of all maternal deaths are related to vascular problems
  • Antepartum complications with multiple gestation “Vanishing twins” may occur< 12 weeks gestation “Fetal Papyraceous” > 12 weeks ↑ Spontaneous abortions ↑ Nausea and Vomiting ↑ Anemia ↑ uterine size and ↑ placental hormones— explains minor discomforts of pregnancy—both chemically and pressure related
  • Antepartum complications cont. ↑ PIH (20% of twin pregnancies) ↑ Hydraminous (Polyhydraminous) ↑ Blood Volume 500 ml > than singleton ↑ Uterine size causes ↑ Vena Cava Syndrome ↑ SOB ↑ Varicosities, VTEs, PEs Cholestasis
  • Ante & Intrapartum complications cont. ↑ Edema ↑ Placenta Previa and ↑ Abruption ↑ Labor dystocia—secondarily to an over- stretched myometrium-- ↑ PP Hemorrhage ↑ Preterm labor and deliveries (12 X that of Singleton pregnancies) ↑ Cesarean rates ↑ Emotional adjustments and stress on family relationships—both partner and siblings
  • Intrapartum complications Maternal  Fetal  Acute fatty liver  Cord accidents  Difficulty of fetal  Malpresentation monitoring  Cardiac issues  Congenital anomalies ENVIRONMENTAL  Availability of necessary equipment  Availability of necessary personnel
  • Multiple tracing
  • Postpartum Complications PPH Pulmonary edema Lack of bonding/breastfeeding Feelings of being overwhelmed Delayed return to normal activity if long periods of bed rest Fatigue Grief – acknowledging individuality
  • Risks to fetus (es) The 2 major causes of Neonatal M&M are: PREMATURITY AND IUGR—50% of twins weigh < 2500 gms at birth Monozygotic twins have 2-3 X PM&M rates as Dizygotic ↑ Congenital Anomalies 2-3 X that of Singletons and is more common in Monozygous twins Preterm Delivery is 5-10 X that of Singletons
  • Multiples Average Gestational Age at Birth Singletons 40 weeks Twins 35 weeks Triplets 33 weeks Quadruplets 29 weeks Prevention: Don’t do this 
  • TWIN TO TWIN TRANSFUSION SYNDROME In Monozygotic twins the vessels may develop vessel-vessel anastamosis Most common Artery-Vein Increase pressure of one vessel causes transfusion to the lower pressure vessel Results in 1 twin (Recipient)--over- perfused and other twin (Donor) under- perfused
  • Twin-Twin Transfusion cont’d Recipient develops: Polycythemia Hypervolemia Hypertension Enlarged Heart Increased Renal perfusion and excessive voiding Polyhydraminous
  • Twin-Twin Transfusion cont’d Donor develops: Hypovolemia Anemia Decreased Renal perfusion Oligohydramnious “Stuck twin”
  • Donor and Recipient
  • Common problems with Twins If twins share same sac (Monoamnion/Monochorion) is ↑ chance for Cord Entanglement  Stillbirthrate ↑ to 50%  These babies have ↑ developmental issues, ↓ IQ levels, and ↓ physical growth In all Multiple births there is ↑ Fetal distress and ↑ Cesarean deliveries
  • Goals for Care of Multiples Promote Normal Development of all fetuses Prevent Preterm Birth Decrease Fetal Trauma at Birth Support Mother’s needs throughout Pregnancy
  • Interventions Nutrition: ↑ Calories 300 > Singleton ↑ weight gain to 40-60 # ↑ Folic acid ↑ Iron 60-100 mg/day ↑ Protein from 40 to 74 gms/day
  • Interventions cont. Monitor for Discordance—defined as >25% difference in weight at birth—occurs in 9% of all twins—When discordance occurs Neonatal mortality ↑ 4X ↑ Prenatal Visits ↑ Teaching about Kick counts ↑ Teaching about Signs of PTL ↑ Teaching about Danger signs in pregnancy (bleeding, Headaches, etc)
  • Interventions cont. Serial U/S to assess for Growth and Development, IUGR, or discordance At 34 Weeks weekly NST’s ↑ Biophysical Profiles ↑ Bed rest ??? Benefit--controversial Arrange Pediatric/Neonatal Consult Discuss plans/options for delivery
  • Interventions cont.VAGINAL DELIVERY if: Both are Vertex, if are Vtx/Breech/ or if Vtx/Trans and both are > 1500 gms If fetuses are non-viableCESAREAN DELIVERY if: 1st fetus if Breech 2nd twin is breech and weighs < 1500 Unable to adequately monitor the 2nd Multiples > twins Mother requests
  • NURSING IMPLICATIONS Antepartum  Emotional support of woman and significant others  Teaching  Monitoring each fetus
  • NURSING IMPLICATIONS--IP INTRAPARTUM  IV  Type and Screen  Monitoring  Anesthesia always present and aware  SCN/NICU/Neonatology aware  Staffing to accommodate labor/Cesarean and Neonatal outcomes
  • NURSING IMPLICATIONS--PPPostpartumMom prone to PP hemorrhageMany changes in Body systems back to Non- pregnant stateEmotional changes—weary— Needs ↑ SleepHumans are Monotropic—difficult to bond with 2 people at same timeMoms focus on concrete factors
  • NURSING PP cont’d May feel overwhelmed Feeding and Caring for 2 (+) Assistance with Breastfeeding Shock/Inadequacy/Guilt/Sadness
  • NURSING NEONATAL ↑ Birth Trauma ↑ Hyperbilirubinemia ↑ Respiratory problems Size Discrepancy Rx infections Effect of tocolytics given to mother ↑ Nutritional needs ↑Bonding needs of entire family ↑ Risks for Late Preterm infant
  • References AWHONN (2009) POEP Gilbert, E. S., (2011) 5th edition Manual of High Risk Pregnancy and Delivery. Mattson, S. & Smith, J.E., (2011) 4th edition Core Curriculum for Maternal- Newborn Nursing.