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Wiki.multiples for review class 2011


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OB multiple gestation

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Wiki.multiples for review class 2011

  1. 1. MULTIPLE GESTATION Peggy Foster, RNC-OB, MSN Sandy Warner RNC-OB, MSN
  2. 2. MULTIPLE GESTATION Definition—Pregnancy with more than 1 Fetus
  3. 3. 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
  4. 4. 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
  5. 5. Monozygotic vs. Dizygotic
  6. 6. 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
  7. 7. 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
  8. 8. Monozygotic twins occur independently Cause is unclear
  9. 9. 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 !!
  10. 10. What we do know for Sure !! Different sex—always dizygous Different blood types—always dizygous If Monochorionic—always monozygous
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. Multiple tracing
  17. 17. 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
  18. 18. 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
  19. 19. Multiples Average Gestational Age at Birth Singletons 40 weeks Twins 35 weeks Triplets 33 weeks Quadruplets 29 weeks Prevention: Don’t do this 
  20. 20. 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
  21. 21. Twin-Twin Transfusion cont’d Recipient develops: Polycythemia Hypervolemia Hypertension Enlarged Heart Increased Renal perfusion and excessive voiding Polyhydraminous
  22. 22. Twin-Twin Transfusion cont’d Donor develops: Hypovolemia Anemia Decreased Renal perfusion Oligohydramnious “Stuck twin”
  23. 23. Donor and Recipient
  24. 24. 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
  25. 25. 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
  26. 26. Interventions Nutrition: ↑ Calories 300 > Singleton ↑ weight gain to 40-60 # ↑ Folic acid ↑ Iron 60-100 mg/day ↑ Protein from 40 to 74 gms/day
  27. 27. 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)
  28. 28. 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
  29. 29. 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
  30. 30. NURSING IMPLICATIONS Antepartum  Emotional support of woman and significant others  Teaching  Monitoring each fetus
  31. 31. 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
  32. 32. 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
  33. 33. NURSING PP cont’d May feel overwhelmed Feeding and Caring for 2 (+) Assistance with Breastfeeding Shock/Inadequacy/Guilt/Sadness
  34. 34. 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
  35. 35. 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.