multiple pregnancy

1. MITTAL COLLEGE OF NURSING,AJMER Multiple pregnancy SUBMITTED TO: SUBMITTED BY: Mrs.SnehlataParasharAvdhesh Singh (Lecturer,OBG) (BSc.Nsg.4th Yr.)

2. When more than one foetus simultaneously developes in the uterus ,called MULTIPLE PREGNANCY. • Two foetuses – Twins (most common) • Three foetuses - Triplets • Four foetuses - Quadruplets • Five foetuses – Quintuplets • Six foetuses - sextuplets

3. Monozygotic (Mz) or uniovular twins or identicle twins • Dizygotic (Dz) or biovular twins or non-identicle twins • Monozygotic (Mz) twins :-Monozygotic twins develop from fusion of one ovum and one spermatozoa. • after fertilization it split into two • it is found cases (20%) • Most often division occur’s between 04 - 08 days after fertilization • These twins will be of the same sex and have same gene’s blood group and physical feature’s such as eye’s,hair’scolour,ear shape

4. Dizygotic (Dz) twins :- Dizyggotic twins develop from two separate ova that are fertilized by two differnt spermatozoa. • Most common (80% cases ) • There is 50-50 chances of agirl or a boy. It may found both girls and boys.

5. In india and bangladesh is generally 01 casess into 70-100 pregnancies.

6. A multiple pregnancy is shorter than a single pregnancy. The average gestational period is ....... • Twins is 37 weeks • Triplets is at 34 weeks • Quadruplets is at 33 weeks

7. The cause of twin is not known. But the frequency of uniovular twins is related to: • Maternal environmental factors and the prevelence of biovular twins is related to: • Race : highest among negros • Hereditory : most transmitted through maternal side • Advancing age of mother : (30-35 years) • Influence of parity :- specially from 5thgravida • Iatrogenic :- drugs used for induction of ovulation may produce multiple fetuses to the extent of 20 – 40%

8. Super fecundation :- it is the fertilization of two different ova released in the same cycle by separate act of coitus within a short period of time. • Superfetation :- it is the fertilization of two ova release in different menstrual cycle • Fetuspapyraceouas or compressus:- it is a state which occrs if one of the fetus dies early. The dead fetus is flattened and compressd between the membrane’s of the living fetus and the uterine wall • Fetusacardiacus:- it occur,s in uniovular twins • Vanishing twins :- it includes death of one fetus and continuation of pregnancy with the surviving one. The dead fetus simply “vanishes” by resorption.

9. LIE :- commonest lie of the fetus is longitudinal ( 90%) but malpresentation are quite common. • PRESENTATION :- • Both vertex (commonest) – 50% • First vertex & second breech – 30% • First breech & second vertex – 10% • Both breech – 10% • First vertex & second transverse – 5% • Both transverse – (Rare)

10. Weight gain • Increase cardiac output • Increase plasma volume by an additional of 500 ml. • Increase alpha fetoprotein level • Increase tidal volume • Increase GFR Rate

11. History taking :- family history of twinning • Noting symptoms :- enlargement of uterus. – nausea & vomiting in early month. - cardio- respiratory – palpitation & SOB - swelling in legs , vericose vein and hemorrhoids - fetal movement may be noticed • General examination : - - anemia is more prevalent. - unusual weight gain - evidence of pre- eclampsia

12. 4. Abdomonal examination :- - Inspection :- Elongated shape of a normal pregnant uterus is changed to a more “ Barrel” shape – palpation:-fundal height may be greater. - multiple fetal limbs may be felt. - the girth of the abdomen at the level of umblicus is more than the normal average at term ( 100 cm. ) - Auscultation :- hearing of two distinct fetal heart sounds located at separate spots with a silent area. - different heart rate is at least 10 beats / min. 5. Investigations :- (a) sonography :- it is confirmation test. - pregnancy date. - fetal anomalies.

13. Presentation & lie’s of foetuses • placental localization • Amniotic fluid volume (b) Biochemical test – maternal serum chorionic gonadotrophin - alpha foetoprotein

14. Maternal complication – • During pregnancy • During labour • During puerperium During pregnancy- Nausea & vomiting - Anemia – more common in twin preggnancy - pre – eclampsia - Hydramnious is more common - Antipartumhemorrhage - Preterm labour - malpresentation – more common in second baby

15. During labour – • Early rupture of membrane & cord prolapse • Prolong labour • Increase operation interferences • Bleeding • Post – partum hemorrhage • During puerperium- • Subinovulation • Infection • Failing lactations

16. (2) Fetal complication – • Abortion rate is increase • Prematurity is seen • Growth problem appear like IUGR • Intra uterine death of one fetus • Fetal anomalies (Eg. Hydrocephalus, down syndrome,encephaly etc.) • Asphyxia and still birth

17. Proper care and advice • Hospitalization • Management during labour • Indication for cesarean section

18. Indication’s for cesarean section/LSCS • Associated causes :- - contracted pelvis - placenta praevia - sever pre – eclampsia - previous history of LSCS - cord prolapse of 1st baby - abnormal uterine contraction’s • For twins :- - both babies / first born with transverse lie - Non – vertex twins with weight 2 kg or less - Conjoined twins

19. Management during labour :- Place of delivery – as the twin pregnancy is considered a high risk the patient should be confined in an equiped hospital prefarably having an intensive neonatal care unit. Vaginal delivery is allowed – when both the twins are atleast the first twin is with vertex presentation.

20. FIRST STAGE :- A skilled obstetrician should be present. • Neonatologist • Presence of USG machine in labour room • Use of analgesic drugs • Careful foetal monitoring • Internal examination should be done • An I/V line prepared • Arranged 01 unit blood (if needed).