Multiple Pregnancy

1. MULTIPLE
PREGNANCY
Presented by:-
Leima Sapam
2nd Year M.Sc.Nsg
AINE

2. INTRODUCTION
• When more than one fetus
simultaneously develop in the uterus, it
is called multiple pregnancy.

3. TWINS
DEFINITION:
Simultaneous development of two
fetuses in the uterus is known as twins.

4. TYPES
1. Dizygotic twins:
- Results from the fertilization of two ova.

5. 2. Monozygotic twins:
- Results from the fertilization of a single
ovum.

7. EXAMINATION OF PLACENTA AND
MEMBRANES
DIZYGOTIC TWINS:
-Two placentae
-No anastomosis
-Intervening membranes consist of 4 layers.

9. MONOZYGOTIC TWINS:
-Single placenta
-Free anastomosis
-Separate amniotic sac
-Common chorionic layer
-2 Intervening membranes

11. TABLE: SUMMARY OF DETERMINATION OF
ZYGOSITY
Pla-
centa
Commu
nicating
vessels
Intervening
membrane
s
Sex Genetic
features
Skin
grafting
Follow-
up
Monozygotic One Present 2(amnions) Always
identical
Same Acceptance Usually
identical
Dizygotic Two
(most
often
fused
)
Absent 4
(2 amnions
2 chorions)
May
differ
Differ Rejection Not
identical

12. INCIDENCE
Highest in Nigeria being 1 in 20 and lowest in
Far Eastern countries being 1 in 200
pregnancies.
In India, it is 1 in 80.
Incidence is much higher due to Assisted
Reproductive Techniques.

13. ETIOLOGY
oNot known
oProbably related to maternal
environmental factors.

14. Race
Hereditary
Advancing age of the mother
Influence of parity
Iatrogenic
RISK FACTORS

15. CLINICAL MANIFESTATIONS
Rapid increase in weight
Increase in cardiac output
Increase plasma volume
Increase in fetoprotein level, tidal volume and
glomerular filtration rate
Anaemia
Evidence of pre-eclampsia
Barrel shape uterus

16. LIE AND PRESENTATION
• The commonest is longitudinal (90%).
• Possible combinations are:
-both vertex (60%)
-first vertex and second breech (20%)

17. -first breech and second vertex (10%)
-both breech (10%)

18. -first vertex and second transverse
-the rarest is being both transverse

19. DIAGNOSTIC TESTS
Internal examination
Abdominal examination
Ultrasonography
Biochemical tests
History collection
General examination

20. DIFFERENTIAL DIAGNOSIS
• Hydramnios
• Big baby
• Fibroid or ovarian tumour with
pregnancy
• Ascites with pregnancy

21. COMPLICATIONS
Maternal
During Pregnancy,
Nausea
and
vomiting
Anaemia
Pre-
eclampsia
Malpresentation
Antepartum
haemorrhage
Hydramnios
Preterm
labour
Mechanical
distress
Placenta
praevia

22. During labour,
Early rupture
of membranes
Prolonged
labour
Increased
operative
interference
Intrapartum
bleeding
Postpartum
haemorrhage

23. During Puerperium,
Subinvolution
Infection
Lactation failure

24. FETAL COMPLICATIONS
Increased
miscarriage rate
Increased
premature rate
Discordant
twin growth
Intrauterine death
Increased fetal
anomalies
Asphyxia and
stillbirth

26. PROGNOSIS
Increased
Maternal
Mortality
Increased
Maternal
Morbidity
Increased
Perinatal
Mortality

27. COMPLICATIONS OF
MONOCHORIONIC TWINS
1. Twin-twin Transfusion Syndrome (TTTS)
- One twin appears to bleed into the other
through some kind of placental vascular
anastomosis.
- Difference of haemoglobin concentration
between the two, usually exceeds 5gm%.

29. Management:
- Repeated amniocentesis to control
polyhydramnios in the recipient twin.
- Septostomy
- Laser photocoagulation to interrupt the
anastomotic vessels on the chorionic plate.
- Selective reduction
• Perinatal mortality in TTTS is about 70%.

30. 2. Dead fetus syndrome
3. Twin reversed arterial perfusion
4. Monoamniocity
5. Conjoined twin

32. ANTENATAL MANAGEMENT
Advice:
- Diet
- Increased rest at home
- Early cessation of work
- Supplement therapy
- Frequent antenatal visits
- Fetal growth assessment
- Preparation for breastfeeding
Hospitalization
- Elective
- Emergency

33. MANAGEMENT DURING LABOUR
• Place of delivery
• Vaginal delivery is allowed if the first twin is
with vertex presentation.

34. FIRST STAGE
• A skilled obstetrician
• Presence of ultrasound in the labour ward
• Patient should be in bed
• Limited use of analgesic drugs
• Careful fetal monitoring
• Internal examination
• Intravenous line
• One unit of blood
• Neonatologist

35. DELIVERY OF THE FIRST
BABY

36. CONDUCTION OF LABOUR AFTER THE
DELIVERY OF THE FIRST BABY
Principles:
-To expedite the delivery of the second baby.
-The second baby is put under strain due to
placental insufficiency caused by uterine
retraction following the birth of the first baby.

37. Steps of Management
• Step-I:
- Ascertain the lie, presentation, size and FHS by
abdominal examination.
- It can also be done by ultrasound.
- Vaginal examination

38. LIE LONGITUDINAL
Step-I:
-Low rupture of the membrane
-Syntocinon may be added.
-Internal examination
Step-II:
-If poor uterine contraction, Oxytocin 5 units to
be added.
Step-III:
- Interference to be done if delayed for 30
minutes.

39. VERTEX
• Low down: Forceps are applied.
• High-up :
-The first baby is too small and the second one
seems bigger.
- Internal version followed by breech extraction
is performed under general anaesthesia.
- Ventouse may be an effective alternative.

40. LIE TRANSVERSE
• Corrected by External version into a
longitudinal lie.
• Internal version under GA if external version
fails.
• It is the only accepted indication of internal
version in present day obstetric practice.

41. Indications of urgent delivery of the
second baby
1. Severe vaginal bleeding
2. Cord prolapse of the second baby
3. Inadvertent use of intravenous ergometrine
with the delivery of the anterior shoulder of
the first baby.
4. First baby delivered under GA.
5. Appearance of fetal distress.

42. MANAGEMENT
A. Head
- If low down, delivery by forceps
- If high up, delivery by internal version under GA
B. Breech should be delivered by breech extraction.
C. Tranverse lie
- Internal version followed by breech extraction
under GA.

43. MANAGEMENT OF THE THIRD STAGE
• Routine administration of 0.2mg methergin IV
or oxytocin 10IU IM
• Controlled cord traction
• Oxytocin drip for at least one hour
• Watched carefully for about 2 hours.
• Additional support to the mother at home.

44. INDICATIONS OF CAESAREAN SECTION
Obstetric Indications:-
1. Placenta previa
2. Severe pre-eclampsia
3. Previous Caesarean Section
4. Cord prolapse
5. Abnormal uterine contractions
6. Contracted pelvis

45. For twins:-
1. Both the fetuses or even the first fetus with
noncephalic presentation
2. Twins with complications
3. Monoamniotic twins
4. Monochorionic twins with TTS
5. Collison of both the heads at brim preventing
engagement of either head

46. MANAGEMENT OF DIFFICULT CASES
OF TWINS
• Interlocking
• Vaginal manipulation
• Intranatal sonography
• Decapitation of the first baby if already dead
• Caesarean section

47. CONJOINED TWINS
 Extremely rare
 Incidence varies from 1:100,000 to 1:50,000
births
 In twin pregnancies, 1:900 to 1:650
Diagnosis:
- Diagnosed during delivery when there is
obstruction in the second stage
- Failure of traction to deliver the first twin in
the second stage.

48. ANTENATAL DIAGNOSIS is important because it-
• reduces maternal trauma and morbidity
• improves fetal survival
• helps to plan the method of delivery
• allows time to organize the paediatric surgical
team

49. Management depends on-
 Extent and site of union
 Possibility of surgical separation
 Size of the fetuses and possibility of the
survival

50. TRIPLETS, QUADRUPLETS, ETC....
• Fertilization of single ovum or two or even
three ova
• Similar with quadruplets and quintuplets
• Female fetus usually outnumber the male one
• Accidental diagnosis following sonography,
radiography or during births
• Clinical course and complications are
intensified compared to twins.

51. • Preterm delivery is common.
• Delivery occurs by 32-34 weeks.
• Perinatal loss is inversely related to birth
weight.
• Management is similar to twins.
• Average time for delivery in quadruplets is 30-
31 weeks.
• Caesarean section to improve the fetal
salvage.

52. SELECTIVE REDUCTION
o 4 or more fetuses
o To improve outcome of
the co-fetuses.
o Intracardiac injection of
potassium chloride
between 11 and 13
weeks under ultrasonic
guidance.
o Transabdominally

53. o Occlusion of umbilical cord of the targeted
twin by fetoscopic ligation or by laser or by
bipolar coagulation, to protect the co-twin
from adverse drug effect.
o Improves perinatal outcome in women with
triplets or more.
o Selective termination of a fetus with structural
or genetic abnormality.

54. NURSING DIAGNOSIS
1. Acute pain related to descend of the gravid
uterus.
2. Knowledge deficit related to lack of
knowledge about the labour process and her
diagnosis.
3. Impaired sleeping pattern related to pain in
the abdomen.
4. Anxiety related to fear of losing the baby and
increased operative interference.