Management Of Multiple Pregnancy

MANAGEMENT OF MULTIPLE PREGNANCY PRESENTER DR.IKOBHO E.H SENIOR REGISTRAR DEPT.OF OBSTETRICS AND GYNAECOLOGY U.P.T.H

INTRODUCTION HISTORY PHYSICAL EXAMINATION INVESTIGATION ANTEPARTUM MANAGEMENT MANAGEMENT IN LABOUR MANAGEMENT OF SOME COMPLICATIONS CONCLUSION

HISTORY. Family history Excessive fetal movement Exaggerated pregnancy symptoms. -Nausea -Hyperemesis gravidarum -Back ache -Abdominal distention -Difficulty in breathing -Constipation -Hemorrhoids -Varicose veins Early onset of complications Use of ovulation induction drugs History of assisted reproduction

CLINICAL EXAMINATION pallor Gross pedal oedema Excessive maternal weight gain Uterus may be larger than expected for date (> 4cm ) -Wrong dates -Uterine fibroid -Polyhydramnios -Ovarian cyst -Molar pregnancy -Urinary retention -fetal macrosomia Polyhydramnios (10 times commoner) Ballottement of more than two fetal poles Multiple fetal parts Simultaneous recording of different fetal heart rates Palpation of one or more fetuses at the fundus after delivery Abnormal lie and presentation

INVESTIGATIONS Packed cell volume Urinalysis-(possibly OGTT) Urine m/c/s Electrolytes urea and creatinine Grouping and cross matching VDRL and genotype Maternal serum alpha feto protein Ultrasound scan -Early confirmation of diagnosis -To determine chorionicity and zygosity -Congenital malformation -Discordant twins -Twin-twin transfusion syndrome -Vanishing twin -Abnormal lie and presentation -Death of one twin -Fetal surveillance

ANTENATAL MANAGEMENT Early booking -early diagnosis -optimal management Dietary advise -The requirements for calories, protein, minerals, vitamines -essential fatty acids are further increased - they require 300 kcal/day -Hematinics should be given Antenatal visits -More frequent antenatal visits -Detect complications early and admit when nessesary. Serial ultrasound scan -done 3-4 weekly till 28 weeks, then weekly till term to monitor: -Fetal growth and detect growth discordance -Intra uterine growth restriction -Twin-twin transfusion syndrome -Polyhydramnios Decision on mode of delivery -Lie and presentation of the leading twin -Contra-indication to vaginal delivery

MANAGEMENT DURING LABOUR conduct labour where services are optimal presence of obstetricians Trained obstetrics nurses 24 hour services for operative delivery presence of anaesthetist paediatrician (idealy two) special care baby unit Admit labour ward Detailed history Physical examination presentation of the leading twin contra indication to vaginal delivery

Management in labour Anticipate potential complications in labour Uterine dysfunction

pre-eclampsia Fetal distress

abruptio placenta cord prolapse retained second twin operative delivery post partum haemorrhage intravenous access with a wide bore needle. 2 units blood should be cross matched. Adequate analgesia( epidural anaesthesia.) Continuous fetal monitoring of both twins. Conduct labour and delivery of first twin normally as in singleton. No ergometrine after delivery of anterior shoulder of the first twin.

DELIVER Y OF THE 2ND TWIN Do abdominal examination for the lie and presentation of second twin if lie is longitudinal , deliver. If abnormal, correct to a longitudinal lie and preferably cephalic presentation by ECV. If unsuccessful do internal podalic version( success rate is higher but require anaesthesia) An assistant stabilizes the fetal head at the pelvic brim await uterine contractions for about 10 minutes, if none then use oxytocin infusion. Rupture fetal membranes when contractions are established and deliver. Active management of 3rd stage of labour to prevent PPH -give ergometrine at delivery of anterior shoulder -early cord clamping and controlled cord traction -maintain oxytocin infusion for about 2 hours post partum.

MANAGEMENT OF SOME COMPLICATIONS OF MULTIPLE PREGNANCY Retained second twin Retained if not delivered within 30 minutes Delivery is by caesarean section With continuous fetal monitoring,

-if there is no fetal distress or vaginal bleeding, -delivery could be delayed for about 2 hours. Delayed Delivery of Second Twin. In the circumstances where one of the fetuses has been expelled very preterm and uterine activity then ceased, The pregnancy has occasionally been allowed to continue With delivery of another fetus days to even many weeks later.

Preterm labour Duration of Gestation. Decresses with number of fetuses. Approximately 50 % of twins deliver at 36 weeks or less The average gestational age at delivery of twins is approximately 36 weeks 33weeks for triplets and 31weeks for quadruplets Preterm delivery before 37 weeks occurs in almost all higher-order multiple gestations. prevention bed rest tocolytic prophylactic cervical cerclage corticosteroids (L:S ratio is 2:1 at

Twin-Twin Transfusion Syndrome Occur in monochorionic twins Arise from vascular anaesthomosis Recipient twins become hypervolaemic, (cardiac Failure and polyhydramnios) Donor twin becomes anaemic, with Oligohydramnios Treatment is by-bed rest selective termination fetoscopic laser occlusion of communicating vessels

intra uterine fetal death of one twin Management depends on gestational age and chorionicity For dichorionic twins --manage conservatively till 37-38 weeks --close fetal surveillance --weekly monitoring of maternal coagulation profile --aim at vaginal delivery For monochorionic twins --Risk of ischemia of surviving twin --IUFD after34 weeks deliver --Before fetal viability, management is individualized

Discordant twins Unequal size of twin fetuses . may be due to growth restriction in one fetus. diagnosed when there is 25% difference in fetal weight Perinatal mortality increases in direct proportion with weight difference. Requires close fetal surveillance (CTG and ultrasound scan ) If one fetus is jeopardized at 34weeks, deliver Before fetal viability, individualize

Triplets and higher order pregnancies All of the problems of twin gestation are remarkably intensified . With vaginal delivery, the first infant is usually born spontaneously or with little manipulation. Subsequent infants are delivered according to the presention. This may require complicated obstetrical maneuvers, internal podalic version breech extraction, cesarean delivery. There is increased incidence of cord prolapse, Reduced placental perfusion and hemorrhage from separating placentas It’s difficult to monitor all the fetuses during labour High rate of prematurely Potential increase in perinatal mortality and morbidity There fore elective caesarean section is advocated by many obstetricians

CONCLUSION

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