3.2 Multiple Pregnancy / Pregancy Loss Flashcards
Multiple pregnancy - fraternal/dizygotic
Fraternal (dizygotic) - ovaries release 2 separate eggs simultaneously (hyperovulation - excess follicle stimulating hormone) that are fertilised individually and have different genetic makeups (10 in 1000 births). Increase with advanced maternal age due to increased FSH
Multiple pregnancy - identical/monozygotic
Identical (monozygotic) - a single zygote that quickly splits into two separate embryos within the first 13 days of development. Identical DNA (4 in 1000 births)
- Split occurs 2-3 days after fertilisation (dichorionic-diamniotic) - separate placentas and amniotic sacs
- Split occurs 3-8 days after fertilisation (monochorionic-diamniotic) - single placenta, separate amniotic sacs
- Split occurs 8-13 days after fertilisation (monochorionic-monoamniotic) - single placenta, single amniotic sac
Multiple pregnancy - abdominal palpation
Fundal height may be greater than expected for the period of gestation
Potential presence of 2 foetal poles
Multiple limbs palpated
Smallness of foetal head in relation to size of uterus (later clue)
Two foetal backs
Multiple pregnancy - potential fetal complications
Abortion (miscarriage) due to foetal abnormality or overdistension of the uterus
Single foetal demise - will not cause issue for surviving foetus before 14 weeks but may be problematic after 14 weeks
Congenital malformations - can be lethal for monozygotic twins (cleft lip, CNS defects, cardiac defects)
Monochoriomnic twins - umbilical cord entanglement, twin-to-twin transfusion syndrome (TTTS)
TTTS: there is an unequal transfer of blood between the twins (unbalanced artery-vein connections), leaving one with less blood in the exchange, resulting in malnourishment, anaemia, and organ failure (donor twin) and potential overwork of the heart and cardiac complications (recipient twin)
Stage 1: TTTS can find the donor twin (anaemic) does not urinate as much and has oligohydramnios (<2cm), whereas the recipient twin (overloaded) urinates frequently and has polyhydramnios (>8cm)
Stage 2: Donor twin bladder not visible
Stage 3: Recipient twin has strain on heart
Stage 4: Recipient twin has heart failure - hydrops
Stage 5: One foetus has died
Treatment options - amnioreduction, fetoscopic laser photocoagulation (create two chorions)
Polyhydramnios
Intrauterine growth retardation - one twin obtains more nourishment than the other
Multiple pregnancy - potential maternal complications
Exacerbation of minor symptoms of pregnancy due to increased hormones and pressure from growing uterus - nausea, morning sickness, heartburn
Anaemia - iron deficiency and folic acid deficiency due to increased foetal demand
Pregnancy-induced hypertension - increased
blood volume (can take aspirin from 12 weeks)
Antepartum haemorrhage - placenta praevia due to large placenta site, abruptio placentae due to polyhydramnios
Elevated levels of HCG - signs of pregnancy present earlier and more intensely than for singles
Multiple pregnancy - potential labour complications
Foetal malpresentations - vertex, breech, transverse
Locked twins - breech-vertex presentation
Umbilical cord problems - prolapse, entanglement
Preterm onset of labour
Mode of delivery
PPH
Undiagnosed twins
Multiple pregnancy - unique challenges
Lack of access to early parenting education that is specific to their needs - things like feeding on demand, rest when baby rests can be difficult for parents of multiples.
Clinical practice: multiple-specific early parenting education
Increased tendency for surgical birth/obstetric intervention
Clinical practice: accommodate for maternal birth preferences where possible (e.g., skin-to-skin)
Parental maternal health
Improving parents’ mental health strengthens their ability to respond to their infant cues, promotes communication between parents/babies, improves early childhood developmental thinking, language, behaviour
Multiple pregnancy - Midwife’s role
Care of the babies - premature or SGA, breastfeeding help, skin-to-skin
Care of the mother - analgesia, treat any anaemia, PN services, pelvic floor exercises, referrals to local support groups
MC - plan for delivery at 36 weeks, DC plan for 37 weeks
Birth suite
Immediately after birth of twin 1, perform abdominal and vaginal examination to determine lie and presentation of the second twin (confirm with US)
FSE for twin 1, CTG for other if can’t get FHR for both with CTG, withhold syntocinon for third stage, withhold cord clamping until second baby is born
Try birth twin 2 in 30 minutes - potential IV oxytocin infusion if inadequate contractions
40 iu oxytocin infusion (500 ml 0.9% SC at 125ml / hour) for PPH prophylaxis as indicated after birth of babies and placenta
Active management of 3rd stage, IV access established
Bedside US
Postnatal care
Breastfeeding in tandem
Organise social support
Monitor PV loss due to increased risk of PPH
Vitals, fundus, pain
DIet and sleep support (nutrition/caloric intake)
LC referral and family education
SIDS education, DRAM assessment, contraception education
FDIU - prevention & diagnosis
Diagnosing:
Stats probe on
CTG or bedside US with Obstetrician (be weary of woman seeing screen - potentially turn it away)
Abdo palp and FHR
Try not to leave the woman alone - if you need In charge to come in use the call bell
Following diagnosis:
Reassurance / consolation
Discuss birth options when appropriate (Obstetrician will do this) - vaginal or caesarean, induction of labour through misoprostol oral or suppository (over a 6 hour period). Don’t have to birth immediately (woman dependent)
Preparation for how baby will look
FDIU - intrapartum care
Discuss timing and options for birth with parents - provide written information
Vaginal birth is preferable
Consider method of induction relevant to gestation and clinical circumstances
Ensure adequate analgesia
Consider active third stage management
Discuss how the woman wants to have their labour - use name, feel or see baby, if they want epidural
Let the ward know to minimise disruptions through butterfly on wall (catering, midwives, students)
Can encourage taking pictures during the process - don’t have to look at them if they don’t want to (can be stored for a few years)
FDIU - immediate PN care
Investigations (maternal, foetal, cord)
FDIU checklist paperwork
Autopsy considerations - discuss reasons/location for autopsy, offer to all parents, obtain consent
Facilitate the creation of memories (photos, footprints/handprints, cot card, first clothes in memory box)
Provide advice on lactation suppression/milk donation
Provide information on funeral planning, potential cuddle/cold cot
Arrange follow-up referral
FDIU - follow up care
Consider pre-conception advice/genetic counselling
Offer COC
Detailed history (obstetric, medical, previous stillbirth, family tree)
Lifestyle advice
USS - dating and anomaly screening
Discuss awareness of foetal movement
