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Multiple Gestation

Multiple Gestation. Authored by: Susan Bishop, RNC-OB, MN. Perinatal Outreach Coordinator MultiCare Regional Perinatal Outreach Program. susan.bishop@multicare.org. Incidence of Multiples. Currently 3% of all births (95% twins) Naturally occurring twins 1 in 80 pregnancies

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Multiple Gestation

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  1. Multiple Gestation Authored by: Susan Bishop, RNC-OB, MN Perinatal Outreach Coordinator MultiCare Regional Perinatal Outreach Program susan.bishop@multicare.org

  2. Incidence of Multiples • Currently 3% of all births (95% twins) • Naturally occurring twins 1 in 80 pregnancies • Naturally occurring triplets 1 in 8000 pregnancies •  incidence in African descent •  incidence in Asian descent (7 – Mandy & Weisman)

  3. Between 1980-2004 Incidence of Twins Increased by 70% (8 – Simpson & Creehan)

  4. HOM* increased by 500% *HOM=Higher Order Multiples (8 – Simpson & Creehan)

  5. Factors Associated with Multiple Gestation • Delayed childbearing: AMA • 75% increase • Higher levels of Follicle Stimulating Hormone • Greater use of fertility services • ART (assisted reproductive technology) • OI (ovulation induction) 400% triplets/HOM (1 – ACOG, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

  6. Physiology of Twinning • Monozygotic (MZ) – fertilization of a single ovum that subsequently divides into 2 or more zygotes (31% incidence) • Cell splits between day 4-day 12 • Genetically the same: physical characteristics, sex, blood type hair & eye color • Dizygotic (DZ) – fertilization of multiple ova (67% incidence) • Two separate eggs/two separate sperm • No more alike than other siblings born to the same parents (8 – Simpson & Creehan)

  7. Monozygotic Twins (8 – Simpson & Creehan)

  8. Dizygotic Twins (8 – Simpson & Creehan)

  9. Triplets (8 – Simpson & Creehan)

  10. Diagnosis of Multiple Gestation • 1st trimester ultrasound • >5weeks chorionicity • >6weeks fetal number • >8weeks amnionicity • Highly accurate at 10-14 weeks • Clinical Exam • Fundal height 2-4 cm > estimated GA • Leopolds/FHR • Subjective symptoms • Fatigue, hyperemesis, increased appetite/wt gain, FM, exaggerated pregnancy discomforts, “feel different” (8 – Simpson & Creehan)

  11. Maternal Changes • GI • Hyperemesis/N&V; reflux • Hematologic • Plasma volume  by 50-100%=dilutional anemia/iron deficiency anemia • Cardiovascular • HR/stroke volume;  risk pulmonary edema; supine aortocaval compression • Respiratory • >tidal volume and oxygen consumption; more alkalotic arterial pH; > dyspnea and SOB • Musculoskeletal • Symptoms earlier in pregnancy; back/ligament pain • Dermatologic • PUPPP (Pruritic urticarial papules and plaques of pregnancy) 3% twins/14% triplets (8 – Simpson & Creehan)

  12. Maternal Complications • Preterm Labor – 50% twins, 76% triplets, 90% quads • Education important! • Serial U/S with assessment of cervical length • Fetal fibronectin testing • Tocolytics, corticosteriod therapy, bedrest • Hypertension • Preeclampsia develops earlier and is more severe • HELLP may present with atypical signs/symptoms • ART multiple pregnancies at higher risk (1 – ACOG, 6 – Jones, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

  13. Maternal Complications (continued) • PPROM – increased rate; shorter latency to birth time • Gestational Diabetes • Intrahepatic Cholestasis – 2-5 x greater • Abruptio Placenta • Pulmonary Embolism • Acute Fatty Liver (1 – ACOG, 6 – Jones, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

  14. Fetal Risks/Complications Mortality increased with plurality and late GA (Jones, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

  15. Fetal Risks/Complications (continued) • MZ twin mortality 3-10x than DZ twins • Intrauterine demise is usually cord entanglement • Greater incidence of congenital anomolies such as: • Neural tube defects • Urinary tract malformations • Discordant birth weight (20%) • Twin to Twin Transfusion Syndrome (7 – Mandy & Weisman)

  16. Discordant Growth • Weight of one multiple differs significantly from that of the other(s) by  25% • More common in Mono chorionic twins • Twin to Twin Transfusion Syndrome • Also effected by maternal age, parity, sex discordance and gestational age. • Discordance ranging from 15-40% has been considered predictive of an adverse outcome (7 – Mandy & Weisman)

  17. Twin-to-Twin Transfusion Syndrome • Almost exclusively occurs in monochorionic (1 placenta) diamniotic (2 amniotic sacs) pregnancies • Unequal balance of blood flow between the two fetuses due to placental vascular anastomoses within the placenta allowing one twin to transfuse the other • 20% growth discordance, poly/oligo, discrepancy in cord size, cardiac dysfunction &/or abnormal cord Doppler studies • Staging: I-V (5 – Jackson & Mele, 7 – Mandy & Weisman)

  18. TTTS

  19. TTTS Management • Treatment options: • Amnioreduction • Septostomy • Photocoagulation • Umbilical cord occlusion • Maternal dietary management • Patient education, support (5 – Jackson & Mele, 7 – Mandy & Weisman)

  20. Reduction Amniocentesis Septostomy Selective Vessel Laser Ablation Umbilical Cord Occlusion/Ablation

  21. Fetal Risks/Complications (continued) • Intrauterine Growth Restriction (IUGR) • Due to placental insufficiency and competition for nutrients • Fetal growth rates  at: 30-32 weeks (twins) 29 weeks (triplets) (7 – Mandy & Weisman)

  22. Fetal Loss • Spontaneous loss early in multiple pregnancy associated with bleeding • “Vanishing Twin” • Fetal death  20 weeks gestation • Surviving twin at  risk of fetal death, neonatal death and severe long-term morbidity. • Survival is inversely related to time death occurred and survivors of opposite-sex twin pairs more likely to survive than same-sex twin pairs. (7 – Mandy & Weisman)

  23. ( Fuller & Fuller)

  24. Fetal Surveillance • Fetal Activity Assessment • Serial NSTs – BPP if nonreactive • Doppler velocimetry • Close assessment for possible complications (8 – Simpson & Creehan)

  25. Laboring with Multiples • Must occur in facility capable of emergent C/S and neonatal resuscitation • Capability of monitoring all fetuses simultaneously and continuously • Qualified personnel in numbers required to care for all neonates • Ultrasound at bedside • VBAC possible (1 – ACOG, 6 – Jones, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

  26. Management of Multiple Birth Route: Vaginal or C/S Dependant on presentation and number! • Twin: VV/ VB/ BB • HOM=C/S (2 – Chasen & Chervenak)

  27. Management of Multiple Birth (continued) Timing of delivery is controversial. Lowest fetal death rates of twins 36-37 weeks Lowest fetal death rates for triplets 34-35 weeks FLM testing may be required Dependant on pregnancy course and type of twin pairings (6 – Jones, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

  28. Management of Multiple Birth • IV access, Type & Screen • Prepare for PP Hemorrhage BEFORE delivery! • Continuous monitoring of all • Bedside U/S on admission to determine/confirm fetal lie • Delivery in OR for all twins and HOMs • 6-25% C/S for B after vaginal delivery of A (1 – ACOG, 2 – Chasen & Chervenak, 8 – Simpson & Creehan)

  29. Delivery of Multiples • Each must have own bed, own team, own identifier (bracelets) • Double check bands before, during and after delivery! • Prepare to differentiate cords and send placentas to pathology • Vag Del: After delivery of Twin A be prepared with U/S to confirm lie and stabilize Twin B. • Twin B at higher risk of perinatal mortality when delivered vaginally • When > 36 weeks gestation and most likely due to mechanical problems (compound presentation, cord prolapse, abruption) • Continue to monitor Twin B! • May need pitocin, C/S if problems develop (2 – Chasen & Chervenak, 8 – Simpson & Creehan)

  30. Delivery of Multiples (continued) • Nonreassuring FHR Twin B • VE – assess dilatation and check for presence of cord! • Bedside U/S • Prepare for forceps or vacuum assist • External version/internal rotation/extraction for transverse or footling breech • Interval >30 minutes associated with poorer outcomes • C/S via general anesthesia for deterioration (2 – Chasen & Chervenak, 8 – Simpson & Creehan)

  31. Postpartum • Hemorrhage – count on it! • Twin EBL avg 1000 mL • Twice as likely to need transfusion • Fundal checks! • Uterine Atony -> act quickly • Physical & Emotional Stress • Muscle Atrophy/Endurance • Breastfeeding (8 – Simpson & Creehan)

  32. Triplets and HOM • Increased Gestational Diabetes, pre-eclampsia, PTL, Pregnancy Associated HTN • Common discordant growth • Increased risk of velamentous insertion of cord • BPPs weekly from 30 weeks on • Increased risk of PP Hemorrhage (10-35%) (2 – Chasen & Chervenak 6 – Jones, 7 – Mandy & Weisman)

  33. Resources & References • American College of Obstetricians & Gynecologists (2004) Multiple Gestation: Complicated Twin, Triplet, and High-Order Multifetal Pregnancy, ACOG Practice Bulletin Number 56. • Chasen, ST & Chervenak, FA (2009) Delivery of twin gestations, UpToDate online www.uptodate.com • Creasy, RK & Resnick, R (2004) Maternal-Fetal Medicine: Principles and Practice (5th ed.) Philadelphia: Saunders. • Gilbert, ES (2007) Manual of High Risk Pregnancy & Delivery (4th ed.) St. Louis: Mosby. • Jackson, KM & Mele, NL (2009) Nursing for Women’s Health,Twin-to-twin transfusion syndrome: what nurses need to know, 13 (3), p224-233. • Jones, D (2008) Triplet pregnancy: Mid and late pregnancy complications and management, UpToDate online www.uptodate.com • Mandy, GT & Weisman, LE (2009) Multiple Births, UpToDate online www.uptodate.com • Simpson, KR & Creehan, PA (2008). AWHONN Perinatal Nursing (3rd ed). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.

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