Multiple Pregnancy1

8/17/2019 Multiple Pregnancy1

1/57

Powerpoint Templates

Page 1

Multiple Pregnancy

Presentation by

Prativa Dhakal

M.Sc. NursingMaternal Health

Nursing

Batch 2011

http://www.powerpointstyles.com/http://www.powerpointstyles.com/


2/57


Page 2

Contents• Definition

• Varieties of twin pregnancy

• Incidence• Factors influencing twinning

• Maternal physiological changes

• Diagnosis

– History and clinical examination

– Symptoms

– General examination

– !dominal examination

– In"estigations

• #omplications

• Prognosis

• Management

• $ursing inter"entions

• %eferences



3/57


Page 3

Multiple pregnancy

• &hen more than one fetus simultaneously de"elops in

the uterus then it is called multiple pregnancy'

• Simultaneous de"elopment of two fetuses (twins) is the

commonest* although rare+ de"elopment of three fetuses

(triplets)+ four fetuses (,uadruplets)+ fi"e fetuses

(,uintuplets or six fetuses (sextuplets) may also occur'



4/57


Page 4

Twins pregnancy

Varieties:

• Dizygotic twins: is the commonest (two-third) and

results from the fertili.ation of two o"a'

• Monozygotic twins (one-third) results from thefertili.ation of single o"um'



5/57


Page 5

Genesis of twins

• Imono.ygotic twins (syn' identical+ unio"ul"ar)

• Di.ygotic twins (syn/ fraternal+ !ino"ular



6/57


Page 6

On rare occasion, the following

possibilities may occur

• If the di"ision ta0es place within 72 hours afterfertili.ation the resulting em!ryos will ha"e two separate

placenta+ chorions and amnions (D/D)

•

If the di"ision ta0es place between the 4th

and 8 th

dayafter the formation of inner cell mass when chorion has

already de"eloped diamniotic monochorionic twins

develop (D/M)

• If the di"ision after 8 th day of fertili.ation+ when theamniotic ca"ity has already formed+ a monoamniotic

monochorionic twins develop (M/M)



7/57

Powerpoint Templates Page 7



8/57

Powerpoint Templates Page



9/57

Powerpoint Templates Page !

Diamniotic

Dichorionic

Separate placenta

Fre,uency/ 123

Mortality/ 413

Diamniotic

Di#horionic

fused placenta

Fre,uency 563

Mortality 443

Diamniotic

Monochorionic single

placenta

Fre,uency 173

Mortality 153

Monoamniotic

Monochorionic

single placenta

Fre,uency 53Mortality 883



10/57

Powerpoint Templates Page 1"

Multiple pregnancy cont#$

• 9n extreme rare occasions+ di"ision occurs after 5 wee0sof the de"elopment of em!ryonic disc resulting in the

formation of con:oined twins called-Siamese twins'

• Four types of fusion may occur – Thoracopagus (commonest)

– Pyopagus (Posterior fusion)

– #raniopagus (cephalic)

– Ischiopagus (caudal)



11/57


!amination of placenta and

membranes%i&ygotic Twin Mono&ygotic twin

Two placenta+ either completelyseparated or more commonly fused atthe margin appearing to !e one'$o anastomosis !etween the two fetal

"essels'

Placenta is single'

Varying degrees of anastomosis

!etween the two fetal "essels'

;ach fetus is surrounded !y a amnionand chorion

;ach fetus is surrounded !y a separateamniotic sac with the chorionic layercommon to !oth'

Inter"ening mem!ranes consist of 8layers-amnion+ chorion+ chorion andamnion'

Inter"ening mem!rane consists of twolayers of amnion only'



12/57


'nasto(osis )etween placenta



13/57


• Sex: while twins ha"ing opposite sex are almost always!ino"ular and twins of the same sex are not always unio"ular

!ut the unio"ular twins are always of the same sex'

• If the fetuses are of the same sex and ha"e the same genetic

features (dominant !lood groups)+ mono.ygosity is li0ely'

• A test skin graft: cceptance of reciprocal s0in graft


14/57


"ncidence

• Varies widely' Highest in $igeria !eing 4 in 5= and lowest

in Far ;astern countries !eing 4 in 5== pregnancies'

Mono.ygotic twins 4 in 52= in the world'

• ccording to Hellin>s rules+ the mathematical fre,uency

of multiple !irth is twins 4 in ?= pregnancies+ triplets 4 in

?=5+ ,uadruplets 4 in ?=1 and so on'



15/57


*actors t+at ,nfluence Twinning

•The causes of twin pregnancy is not 0nown'

• Race: Highest amongst $egroes (once in e"ery 5= !irths)+

lowest amongst Mongols and intermediate among #aucasians

• Heredity: Family history in mother'

• Maternal Age and arity : ! winning pea0s at age 16 years

• "ncreasing parity: 2th gra"id onwards'

• #utritional $actors/ Taller+ hea"ier women


16/57


Ter(s

• Superfecundation

• Superfetation

•

$etus papyraceous or compressus

• $etus acardius

• Hydatidiform mole

• 'anishing twin



17/57


%iagnosis

#istory and $linical !amination• %ecent administration of either clomiphene citrate or

gonadotropins or pregnancy accomplished !y %T are

much stronger associates'

• #linical examination with accurate measurement of

fundal height'



18/57


%iagnosis cont#$

• In women with a uterus that appears large for gestationalage+ the following possi!ilities are considered/

– Multiple fetuses

– ;le"ation of the uterus !y a distended !ladder

– Inaccurate menstrual history

– Hydramnios

– Hydatidiform mole

– @terine leiomyomas

– closely attached adnexal mass

– Fetal macrosomia (late in pregnancy)



19/57

Powerpoint Templates Page 1!

%iagnosis cont#$

-y(pto(s• Minor symptoms of normal pregnancy are often

exaggerated'

•

Increased nausea and "omiting in early months• #ardio-respiratory em!arrassment

• Tendency of swelling in the legs+ "aricose "eins and

hemorrhoids is greater • @nusual rate of uterine enlargement and excessi"e fetal

mo"ements



20/57


%iagnosis cont#$

%eneral e!amination• Pre"alence of anemia is more

• @nusual weight gain+ not explained !y

preeclampsia or o!esity

• ;"idence of preeclampsia is a common

association'



21/57


%iagnosis cont#$

&bdominal e!amination

"nspection/ Aarrel shaped and the a!domen is unduly enlarged

alpation

– Height of uterus B period of amenorrhoea

–

Girth of a!domenB normal a"erage at term (4== cm) – Fetal !ul0 disproportionately larger in relation to the si.e of the

fetal head'

– Palpation of too many fetal parts

– Finding of two fetal heads or three fetal poles

Auscultation

• Two distinct FHS at separate spots+ difference in heart rates is

at least 4= !eatsCminute'



22/57


%iagnosis cont#$

,n.estigations

Sonography

• separate gestational sacs identified early

• #onfirmation of diagnosis as early as 4=th wee0 of

pregnancy• Varia!ility of fetuses+ "anishing twin in second trimester

• #horionicity (twin pea0 sign)

•

Pregnancy dating+ Fetal anomalies• Fetal growth monitoring+ Presentation and lie of fetuses

• Twin transfusion locali.ation+ mniotic fluid "olume



23/57


Twin pea0 sign



24/57


%iagnosis cont#$

(iochemical !ests: • e"els of h#G in plasma and in urine are higher

• Maternal serum alpha-fetoprotein le"el/ ;le"ated

• @ncon:ugated oestriol/ approximately dou!le

Radiological examination



25/57


Co(plicationsMaternal

D'ring pregnancy $ausea and "omiting$ausea and "omiting



26/57


Co(plications cont#$• D'ring labo'r

;arly rupture of mem!ranes and cord;arly rupture of mem!ranes and cord



27/57


Co(plications cont#$

• D'ring p'erperi'm

• etal

Su!in"olutionSu!in"olution

MiscarriageMiscarriage



28/57




29/57


Co(plications of (onoc+orionic twins

win twin transf'sion syndrome (* )

• one twin appears to !leed into other through placental

"ascular anastomosis'

• Receptor twin !ecomes larger with hydramnios,

polycythemic, hypertensi&e and hyper&olemic • )onor twin which !ecome smaller with oligohydramnios,

anemic, hypotensi&e and hypo&olemic*

•

Donor may appear stuc0 due to se"ere oligohydramnios'• Difference of hemoglo!in concentration !etween the twin

usually exceeds 2 gm3 and estimated fetal weight

discrepancy is 523 or more'



30/57



cont#$

!!!S contd**

Management

• ntenatal diagnosis/ ultrasound with doppler flow study

in the placental "ascular !ed'

•

%epeated amniocentesis to control polyhydramnios inrecipient twin' – pre"ent preterm la!our and placental a!ruption'

• Selecti"e reduction of one twin is done when sur"i"al of

!oth the fetuses is at ris0'

• Smaller twin generally ha"e got !etter outcome'

• Plethoric twin/ ris0 of ##F and hydrops'

• Perinatal mortality/ 6=3'



31/57




32/57



cont#$

Dead fet's syndrome

• Death of one twin (5-63) is associated with poor

outcome of the #o-twin (523) specially in monochorionic

placenta'

•

The sur"i"ing twin runs the ris0 of cere!ral palsy+microcephaly+ renal cortical necrosis and DI#'

• This is due to throm!oplastin li!erated from the dead

twin that crosses "ia placental anastomosis to the li"ing

twin'



33/57



cont#$

win reversed arterial perf'sion (+&,)-

• #haracteri.ed !y an acardiac perfused twin ha"ing !lood

supply from a normal co-twin "ia large arterio-arterial

anastomosis'

$on.oint twin-

• %are'

•

Perinatal sur"i"al depends upon the type of :oint'• Ma:or cardio"ascular anastomosis leads to high

mortality'



34/57


*etal acar#ius



35/57


/esearc+ e.i#ence

Twin0 acar#iac0 outco(e Gra!D+ Schneider V+ Eec0stein + Terinde %)

• 57-year-old G5P4 was initially seen in the 47th wee0 of a twin gestation' n

acardiac-acranial twin was present' There were spontaneous mo"ements of the

lower extremities' #hromosomal analysis of amniotic fluid showed two normal

females' Se"eral ultrasonographic examinations showed lac0 of growth of the

malformed twin !ut appropriate growth of the normal twin' Spontaneous la!or

de"eloped at 8= wee0s and a normal female+ 156=g+ with pgar C4=C4=+ wasdeli"ered' The acardiac twin was approximately 4= cm long and was

spontaneously deli"ered out of a second amniotic ca"ity'

athologic findings

• The female acardiac acephalic twin (14g+ 4= cm) showed no heart or lung

de"elopment* li"er+ intestine+ and urogenital tract appeared normal' Spleen+pancreas and stomach were a!sent' The placenta was monochorionic

diamniotic+ and the two um!ilical cords were interconnected !y a direct

anastomosis'



36/57



cont#$

Monoamniocity-• Monochorionoc twins leads to high perinatal mortality

due to cord pro!lems'

•

Prostaglandin synthase inhi!itor used to reduce fetalurine output+ creating !orderline oligohydramnios and to

reduce the excessi"e mo"ements'



37/57


'ntepartu( Manage(ent of Twin

Pregnancy

To reduce perinatal mortality and mor!idity rates inpregnancies complicated !y twins+ it is imperati"e that/

• Deli"ery of mar0edly preterm neonates !e pre"ented

• Fetal-growth restriction !e identified and afflicted fetuses

!e deli"ered !efore they !ecome mori!und

•

Fetal trauma during la!or and deli"ery !e a"oided+ and

• ;xpert neonatal care !e a"aila!le'



38/57


Manage(ent cont#$

•

)iet: increased re+uirement of calories+ protein+ minerals+"itamins+ and essential fatty acids' #aloric should !e

increased !y another 1== 0calCday' Supplementation with 7=

to 4== mgCday of iron and4 mgCday of folic acid'

• (ed Rest

• Antepartum Sur&eillance: sonographic examinations

• !ests of $etal ell-(eing

•

re&ention of reterm )eli&ery

• Hospitali.ation

• @se of corticosteroids to accelerate fetal lung maturation'



39/57


Manage(ent #uring la)our

First stage/

• s0illed o!stetrician+ presence of ultrasound machine and

experienced anesthetist

• Aed rest to pre"ent early rupture of mem!rane'

• imit use of analgesic drugs

• #areful monitoring

• Internal examination soon after the rupture of mem!ranes

• n intra"enous line with ringer>s solution

• "aila!ility of one unit of compati!le and cross matched !lood

• $eonatologist/Present at the time of deli"ery'



40/57


Manage(ent #uring la)our cont#

)eli&ery of the first baby /

•Deli"ery/ Same guidelines as in normal la!our withli!eral episiotomy'

• Forceps deli"ery/ if needed+ should !e done prefera!ly

under pudendal !loc0 anaesthesia'

• Do not gi"e intra"enous ergometrine with deli"ery of the

anterior shoulder of the first !a!y'

• #lamp the cord at two places and cut it !etween'

• t least ?-4= cm of cord is left !ehind for administration

of any drug or transfusion+ if re,uired'

• The !a!y should !e la!eled one'



41/57



/onduction of labour after the deli&ery of the first baby:Steps of management:

Step ":

• scertain lie+ presentation+ si.e and FHS of the second

!a!y'• Vaginal examination/ To confirm the a!dominal findings

and to exclude cord prolapsed+ if any to note the status

of mem!rane'



42/57



0ie longitudinal:

• Step ": ow rupture of mem!ranes+ syntocinon+ internal

examination to exclude cord prolapse'

• Step "": If the uterine contraction is poor+ 2 units of

oxytocin is added'

• Step """: Is there is still a delay+ interference is to !e

done'



43/57



1* 'ertex: ow down


44/57



"ndication of urgent deli&ery of second baby / – Se"ere "aginal !leeding+

– #ord prolapse

– Inad"ertent use of IV ergometrine with the deli"ery of

anterior shoulder of the first !a!y+

– First !a!y deli"ered under general anesthesia+

– ppearance of fetal distress'



45/57



)elay in the birth of second twin• Airth of second twin should !e completed within 82

minute of the first twin !eing !orn !ut with close

monitoring can !e extended if there are no signs of fetal

compromise'

• The ris0 of delays/

– intrauterine hypoxia+

– !irth asphyxia+

– sepsis



46/57



Management of third stage

• %outine administration of ='5mg methergin IV with

deli"ery of anterior shoulder'

• Deli"er placenta !y ##T

• #ontinue oxytocin drip for at least one hour+ following

deli"ery of second !a!y'

• The patient is to !e carefully watched for a!out 5 hours

after deli"ery'



47/57


"ndications of caesarean section

9!stetric causes/

– Placenta pre"ia – Se"ere preeclampsia

– Pre"ious caesarean section

– #ord prolapse of the first !a!y

– !normal uterine contractions

– #ontracted pel"is

• $or twins: Aoth fetuses or e"en first fetus with non-

cephalic presentation+

• !wins with complications: I@G%+ con:oint twins*

Monoamniotic twins+ monochorionic twins with TTS

Management of diffic lt cases of



48/57


Management of diffic'lt cases of

twins"nterlocking

• #ommonest/ ftercoming head of first !a!y getting loc0ed

with forecoming head of second !a!y'

• Vaginal manipulation to separate chins of the fetuses

• Decapitation of first !a!y (dead)+ pushing up decapitatedhead+ followed !y deli"ery of second !a!y and lastly+ deli"ery

of decapitated head'

• 9ccasionally+ two heads of !oth "ertex get loc0ed at the pel"ic

!rim pre"enting engagement of either of the head'

• Disengagement of the higher head/ @nder general

anesthesia+ If fails+ caesarean section is the alternati"e



49/57


Management of diffic'lt cases of

twins contd

/on4oined twins

• ;xtremely rare'

• 9ften diagnosed during deli"ery

• Presence of a !ridge of tissue !etween the fetuses on

"aginal examination confirms the diagnosis'

• ntenatal diagnosis is important'

• Aenefits are/ reduces maternal trauma and mor!idity+

impro"es fetal sur"i"al+ helps to plan method of deli"ery+

allows time to organi.e pediatric surgical team'



50/57


Postnatal perio#

/are of the babies

• Immediate care

• Maintenance of !ody temperature+

• @se of o"erhead heaters+

•

Parents gi"en the opportunity to chec0 the identity tagand cuddle them'

(reastfeeding

• Pro"ide 0nowledge to mother regarding different

positions for !reastfeeding+ along with ad"antages+

attachment+ positioning timing'



51/57


Postnatal perio# cont#

#utrition

•

;xpressed !reast mil0 is !est (for small !a!ies)+ they may need to!e fed intra"enously or !y nasogastric tu!e or cup-fed+ depending

on their si.e and general condition'

• #areful monitoring of weight gain+ regular capillary !lood glucose

estimations

•

%eassure her that lactation responds to the demands made !y!a!ies suc0ing at the !reast'

• t feeding times+ mother must !e pro"ided support and ad"ised on

positioning and fixing !a!ies'

/are of the mother • Slow in"olution of uterus+ increased fter pains> so analgesia

should !e offered'

• High calorie diet'

• Teach extra support to handle twin !a!ies

M t # i



52/57


Manage(ent an# ursing

,nter.entions

•

$utrition counseling• Fetal e"aluation

• ;"aluate woman for signs and symptoms of o!stetrical

complications

• PT pre"ention/ explain for hospitali.ation – ;ncourage !ed rest and hydration'

– Institute fetal monitoring and assist with tocolytic therapy+ if

ordered'

• ;xplain to the woman that mode for deli"ery depends on

the presentation of the twins+ maternal and fetal status+

and gestational age



53/57


54/57


ursing #iagnoses

• nxiety

• Deficient Enowledge %egarding High-ris0 SituationCPreterm

a!or

• %is0 for Im!alanced $utrition/ essCMore than Aody

%e,uirements

• %is0 for Fetal In:ury• %is0 for Maternal In:ury

• %is0 for Deficient Fluid Volume

• %is0 for Impaired Gas ;xchange

• %is0 for cti"ity Intolerance• %is0 for Ineffecti"eC#ompromised Family #oping

• %is0 for Interrupted Family Process'

i #i t#



55/57


ursing #iagnoses cont#$

*or Cesarean %eli.ery

• Deficient Enowledge %egarding Surgical Procedure+ and

Postoperati"e %egimen

• nxiety (Specify e"el)

• Powerlessness

• %is0 for cute Pain• %is0 for Infection

• %is0 for Impaired Fetal Gas ;xchange

• %is0 for Maternal In:ury

•%is0 for Decreased #ardiac 9utput



56/57


/eferences

• Fraser DM+ #ooper M'Myles Text!oo0 for Midwi"es'42th edition'

Philadelphia/#hurchill li"ingstone else"ier*5==

• Dutta D#'Text!oo0 of o!stetrics' 7th edition'#alcutta/$ew central

!oo0 agency*5==8

• Pillitteri ' Maternal and child health nursing' #are of the

child!earing and childrearing family' Sixth edition' Philadelphia*ippincott &illiams J &il0ins/ 5=4='

• #unningham+ e"eno+ Aloom' &illiam>s o!stetrics' 51rd edition'

@nited states of merica* Mcgraw Hill companies/ 5=4='

•

$ettina S'M+ Mills ;'' ippincott Manual of $ursing Practice' ?th;dition' Philadelphia/ ippincott &illiams and &il0ins* 5==7

• Multiple Pregnancy and Airth/ Twins+ Triplets+ and High-order

Multiples/ Guide for Patients' Patient information series' merican

Society for %eproducti"e Medicine' 5=45



57/57

Date post:	06-Jul-2018
Category:	Documents
Upload:	muhammad-abeesh
View:	221 times
Download:	0 times

Multiple Pregnancy1

Documents