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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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