MULTIPLE GESTATION

Peggy Foster, RNC-OB, MSN

Sandy Warner RNC-OB, MSN

MULTIPLE GESTATION

Definition—Pregnancy with more than 1 Fetus

Diagnosis of multiple gestation

Size greater than dates Greatly elevated hCG levels Elevated alpha-fetoprotein (MSAFP) More than one audible heart beat U/S confirmation ART

Multiple Gestation

Twins are most common form of multiples

Monozygotic twins - 25% One sperm and one ova “identical” Can separate into more than 2 (identical triplets etc)

Dizygotic twins are majorityIncludes twins and higher order multiples “fraternal” or nonidentical Two ova and two sperm

Monozygotic vs. Dizygotic

Monozygotic vs. Dizygotic

Amnion layer inside Chorion Dizygotic twins always have 2 amnions and 2

chorions Monozygotic twins can be

Mono Chorionic - Mono Amnionic

Mono Chorionic - Di Amnionic

OR Di Amnionic - Di Chorionic

Associated factors for dizygotic twins

ART (assisted reproductive technology) Age Ovarian follicicle stimulation Parity > 4 Race—More common in Blacks—Less common

in Oriental populations Family history Coital frequency

Monozygotic twins occur independently

Cause is unclear

Monozygotic twins can be:

Diamnionic/dichorionic—Occur<72 hours after conception

Monochorionic/diamnionic (MOST !!)—Occur 3-7 days after conception

Conjoined twins >7 days after conception—incomplete separation of developing embryonic cell masses

Monochorionic/monoamnionic –RARE !!

What we do know for Sure !!

Different sex—always dizygous Different blood types—always dizygous If Monochorionic—always monozygous

Pregnancy Outcomes

85% of multiple gestation mothers have antepartal complications—compared with only 32% of singleton pregnancies

Perinatal morbidity and mortality is TWICE that of singleton pregnancies—In these women 4% of all maternal deaths are related to vascular problems

Antepartum complications with multiple gestation

“Vanishing twins” may occur< 12 weeks gestation

“Fetal Papyraceous” > 12 weeks Spontaneous abortions Nausea and Vomiting Anemia uterine size and placental hormones—

explains minor discomforts of pregnancy—both chemically and pressure related

Antepartum complications cont.

PIH (20% of twin pregnancies) Hydraminous (Polyhydraminous) Blood Volume 500 ml > than singleton Uterine size causes Vena Cava Syndrome SOB Varicosities, VTEs, PEs Cholestasis

Ante & Intrapartum complications cont.

Edema Placenta Previa and Abruption Labor dystocia—secondarily to an over-

stretched myometrium-- PP Hemorrhage Preterm labor and deliveries (12 X that of

Singleton pregnancies) Cesarean rates Emotional adjustments and stress on family

relationships—both partner and siblings

Intrapartum complications

Maternal Acute fatty liver Difficulty of fetal monitoring Cardiac issues

ENVIRONMENTAL Availability of necessary equipment Availability of necessary personnel

Fetal Cord accidents Malpresentation Congenital anomalies

Multiple tracing

Postpartum Complications

PPH Pulmonary edema Lack of bonding/breastfeeding Feelings of being overwhelmed Delayed return to normal activity if long periods

of bed rest Fatigue Grief – acknowledging individuality

Risks to fetus (es)

The 2 major causes of Neonatal M&M are: PREMATURITY AND IUGR—50% of twins weigh < 2500 gms at birth

Monozygotic twins have 2-3 X PM&M rates as Dizygotic

Congenital Anomalies 2-3 X that of Singletons and is more common in Monozygous twins

Preterm Delivery is 5-10 X that of Singletons

Multiples Average Gestational Age at Birth

Singletons 40 weeks Twins 35 weeks Triplets 33 weeks Quadruplets 29 weeks

Prevention: Don’t do this

TWIN TO TWIN TRANSFUSION SYNDROME

In Monozygotic twins the vessels may develop vessel-vessel anastamosis

Most common Artery-Vein Increase pressure of one vessel causes

transfusion to the lower pressure vessel Results in 1 twin (Recipient)--over-

perfused and other twin (Donor) under-perfused

Twin-Twin Transfusion cont’d

Recipient develops:Polycythemia

Hypervolemia

Hypertension

Enlarged Heart

Increased Renal perfusion and excessive voiding

Polyhydraminous

Twin-Twin Transfusion cont’d

Donor develops:Hypovolemia

Anemia

Decreased Renal perfusion

Oligohydramnious

“Stuck twin”

Donor and Recipient

Common problems with Twins

If twins share same sac (Monoamnion/Monochorion) is chance for Cord EntanglementStillbirth rate to 50%These babies have developmental issues,

IQ levels, and physical growth In all Multiple births there is Fetal

distress and Cesarean deliveries

Goals for Care of Multiples

Promote Normal Development of all fetuses

Prevent Preterm Birth Decrease Fetal Trauma at Birth Support Mother’s needs throughout

Pregnancy

Interventions

Nutrition: Calories 300 > Singleton weight gain to 40-60 # Folic acid Iron 60-100 mg/day Protein from 40 to 74 gms/day

Interventions cont.

Monitor for Discordance—defined as >25% difference in weight at birth—occurs in 9% of all twins—When discordance occurs Neonatal mortality 4X

Prenatal Visits Teaching about Kick counts Teaching about Signs of PTL Teaching about Danger signs in pregnancy

(bleeding, Headaches, etc)

Interventions cont.

Serial U/S to assess for Growth and Development, IUGR, or discordance

At 34 Weeks weekly NST’s Biophysical Profiles Bed rest ??? Benefit--controversial Arrange Pediatric/Neonatal Consult Discuss plans/options for delivery

Interventions cont.

VAGINAL DELIVERY if: Both are Vertex, if are Vtx/Breech/ or if

Vtx/Trans and both are > 1500 gms If fetuses are non-viableCESAREAN DELIVERY if: 1st fetus if Breech 2nd twin is breech and weighs < 1500 Unable to adequately monitor the 2nd

Multiples > twins Mother requests

NURSING IMPLICATIONS

AntepartumEmotional support of woman and significant

others

Teaching

Monitoring each fetus

NURSING IMPLICATIONS--IP

INTRAPARTUM IV Type and Screen Monitoring Anesthesia always present and aware SCN/NICU/Neonatology aware Staffing to accommodate labor/Cesarean and

Neonatal outcomes

NURSING IMPLICATIONS--PP

PostpartumMom prone to PP hemorrhageMany changes in Body systems back to Non-

pregnant stateEmotional changes—weary— Needs Sleep Humans are Monotropic—difficult to bond with 2

people at same timeMoms focus on concrete factors

NURSING PP cont’d

May feel overwhelmed Feeding and Caring for 2 (+) Assistance with Breastfeeding Shock/Inadequacy/Guilt/Sadness

NURSING NEONATAL

Birth Trauma Hyperbilirubinemia Respiratory problems Size Discrepancy Rx infections Effect of tocolytics given to mother Nutritional needs Bonding needs of entire family Risks for Late Preterm infant

References

AWHONN (2009) POEP

Gilbert, E. S., (2011) 5th edition Manual of High Risk Pregnancy and Delivery.

Mattson, S. & Smith, J.E., (2011) 4th edition Core Curriculum for Maternal-Newborn Nursing.