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
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
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
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
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
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
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--PPPostpartumMom 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.