1 / 34

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

eloise
Télécharger la présentation

Multiple Gestation

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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.

More Related