MULTIPLE PREGNANCY
➡️ Defitions:
Multiple pregnancy :
Is the term used to describe the development of fetus more than one in uterus.
(1) Twin- is developmement of two fetus in uterus.
(2) Triplet- is development of three fetus in uterus.
(3) Quintuplets- is development of more than three it can be 4 or more in uterus
🔷 Monozygotic type:
Monozygotic or uniovular twins:
Referred to as identical twins.
- Develop from fusion of one ovum and one spermatozoon, after fertilization splits into two.
- Have Two amniotic sacs.
- One placenta
- Usually one chorionic
- Occasionally two chorionic are found.
- Connection between the fetal circulations.
- Will have same sex genes, blood group and physical features such as eye and hair colour,ear shapes and palm creases.
- Similar palm and finger prints
🔷 Dizygotic or binovular twins:
- Develop from two ova and two spermatozoa
- More common than monozygotic.
- Two placenta which may fuse to have one.
- Two chorions
- Two amniotic sacs
- No connection between fetal circulations.
- May be of same sex ,but often of different sexes.
-Well known familial tendency.
- Genetic factor which cause double ovulation is carried by mother and passed on by the females in family.
Dizygotic twinning is a sign of fertility.
🔻Other terms related to twin pregnancy:
a) Super fecundation:
Term used when twins are conceived from sperm ,different men ,if a woman had sexual intercourse from different partner during ovulation period (DNA)
b) Superfertation:
Term used for twins conceived as a result of two coital acts in different menstrual cycles less (very rare).
📶 Diagnosis of twin pregnancy:
-May be difficult.
- Family history of twin should alert the midwife the possibility of twin pregnancy.
Diagnosis of twin pregnancy
-Ultrasound:
Used to detect pregnancy more than one
fetal sac from 8 weeks gestation.
Presence of more than two fetus may not be detected until 15 weeks when the heads will be noted.
- On Abdominal examination:
The following may be found:
a) On inspection:
The size of uterus may be larger than
expected for the period of gestation, particularly after 20th week.
The uterus may look broad or round.
Fetal movement may be seen over a wide area although this is not a diagnosis.
Fresh strae gravidurum may be apparent.
Excess of amniotic fluid may be expected.
Polyhydramnios may coexist with twin pregnancy,particularly in monozygotin twins.
(b) On palpation:
The fundal height may be greater than expected for the period of gestation.
Presence of fetal poles (head or breech ) in the fundus of the uterus may be revealed.
Multiple limbs may be palpable.
Size of head in relation of uterus may lead one to suspected that the fetus is small.
Lateral palpation may reveal two fetal backs or limbs on both sides.
Pelvic palpation may reveal similar results of those of fundal palpation.
(c) On auscultation:
Hearing of two fetal hearts is not diagnostic as one can often hear over a wide area in singleton.
Confirmed by simultaneous comparison of heart rates that reveals a difference of at least 10 beats per minute.
🔷 Effects of pregnancy:
a) Exacerbation of minor disorders:
Presence of more than one fetus and higher level of circulating hormones lead to exacerbation of minor disorders such as morning sickness, nausea, and heart burn.
b) Anaemia:
Iron deficiency and folic acid deficiency anemia's are common in twin pregnancies.
Early growth and development of the uterus and its contents make greater demands on maternal iron stores.
In later pregnancy after 28 th week fetal demands for iron depletes those stores further.
Pregnancy induced hypertension:More common in twin.
Associated with the larger placental site or the increased hormonal output.
Incidence is greater in monozygotic twin pregnancies.
d) Polyhydramnious:
Associated monozygotic twins with fetal abnormality.
Acute polyhydramnious leads to abortion.
Leads to discomfort.
e) Pressure symptoms:
Increased weight and size of uterus and its content may be troublesome.
Impaired venous return from lower limbs increases the tendency to varicose veins and oedema of the legs.Backache,Marked dysponea and indigestion
🔻Management of twin pregnancy:
During antenatal:
a) Early diagnosis:
prevention of anemia
Advice on diet
Regular checking of HB
Detection of pregnancy induced hypertension.
Women to be under supervision of obstetrician.
Relief of discomfort in later pregnancy:
Woman to wear light support tights.
May require extra pillow at night to prop her up in bed or support the weight of uterus.
c)Parenthood preparation:
prepare for twins by discussing with them any problems or worries about caring for two babies.
d) Admission to hospital:
If complications arises may be admitted to hospital around 20-32 weeks for rest and observations.
Labour and delivery:
Effects of twin pregnancy in labour:
Labour occurs spontaneously before term due to overstretching of the uterus.
May be induced early if complication arises.
In addition to being preterm babies may be light for dates.
Prone to complications.
It is unusual for a twin pregnancy to last more than 40 weeks.
If pregnancy continues beyond term induction of labour will be considered.
Malpresentation are common and in small number.
The first twin presents by breech,this may have an adverse effect on length of labour.
During Labour and delivery in twin pregnancy:
Woman adopt whichever position she finds most comfortable.
Prevent supine hypertensive syndrome by keeping her on semi prone position.
Give analgesia when required
Monitor both fetuses continuously
If fetal distress occurs cesarean section is done.
If the uterine activity is poor,oxyctocin is started after membranes are ruptured.
Preparations to be done if you expect how birth weight baby.
Physical and psychological support.
Presence of partner is important.
Inform the pediatrics team.
Confirm second stage by per vaginal examination.
Continue to monitor and record heart rates.
Elective episiotomy if there is complications.
Note the time for delivery and sex of first twin.
Label the baby as twin one immediately.
Abdominal examination is done to check the lie, presentation and position of the second fetus and to ascultate the fetal heart.
If the lie is not longitudinal an attempt is made to correct it by external cephalic version.
If is longitudinal per vaginal examination is done to confirm the presentation.
If the presentation is not engaged it should be pushed into pelvis by fundal pressure before second of membrane ruptured.
If uterine activity does not commence, intravenous syntocinon may be used to stimulate it.
When the presenting part is visible the mother is encouraged to push with contractions.
Label the baby twin two, note delivery time and sex.
Delivery of the placenta:
Controlled traction is applied to both cords simultaneously
Examine the placenta ,note the number of chorions, sacs and placenta plus the length of the cord.
Complications associated with Twin pregnancy:
1 abortions:
If abnormality is present, pregnancy will end in abortion quite early.
Over distension of the uterus may lead to late abortion.
One twin is lost at an early stage and the remaining fetus continues to develop.
2 polyhydramnious:
May occur at around 26-30 weeks.
May be associated with fetal abnormality also in monozygotic twins.
Outcome is abortion
Chronic polyhydramnious is possible.
May occur in one or both sacs.
3 fetal abnormality:
Associated monozygotic twins.
4 malpresentations:
Fetus can restrict each others movements, this may result in malpresentations, particularly of the second twin.
After delivery of first twin the presentation of the second twin may have changed.
5 premature of rupture of membrane:
This may be due to malpresentations or polyhydramnious.
6. prolapsed of the cord :
Associated with malpresentations and polhydramnious this is most likely if there is poor fitting presenting part.
Second twin is at risk of prolapsed of cord.
7. Prolonged labour:
Malpresentations are poor stimulus to good uterine action.
Distended uterus is likely to lead to poor uterine activity and consequent prolonged labour.
8. locked twin:
Rare but serious complication.
Occurs when the first twin presents by breech and the second by vertex
The other when both are vertex presentation.
In both the second twin presents the continued of the first by the position of its head.
MIDWIFERY COURSE PDF NOTES
11. Cord Prolapse and Presentation
13. Pre-eclampsia and Eclampsia
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