7.1 - Multple Pregnancy - Exam Flashcards
‘=Describe the unique physiology of multiple pregnancy
- Monozygotic twins
- Dizygotic Twins
Multiple pregnancy - Intrapartum management
- labour at 36 weeks
- CTG monitoring for twins continous
- Diamnionic dichorionic (Fused or unfused) - low risk iol after 37 weeks
- Diamnionic Monochorionic - IOL at 36 weeks (prophylactic corticosteriods has ben offered)
- Monoamnionic Monochorionic - IOL 36 weeks but also when clinically indicated
- commonly IOL by 38 weeks placental function decreases
- Birth plan
- epidural - manipulation of second twin - breech extractions
- epidural - for c-section
- fetal scalp electrode (35 weeks)
- under 32 weeks increases risk of bleeding, skull soft increased risk of damage
- external U/S for twin two
- up twin one on ctg - increase by 20 beats
- monitor for identical monitoring on ctg
- identify scn
Dizygotic Twins
Both refered to as Dizygotic Twins One - two sperms & two eggs fertilized - two types of implantation - implantation separately into the uterus - separate amnio & choriona
Two One - two sperms & two eggs fertilized - implantation together into the uterus - fused Amnio & choriona
Incorporating a woman centred approach, explain the midwifery care for woman with a multiple pregnancy across the continuum, as part of the multi disciplinary team
Early counselling
- body image
- support groups
- discuss birth vaginal v c-section
- increase visits
- challenges for multiple
- scan
- attend antenatal education
factors - IVF & ART - birth control long term use - family hx - increased maternal age - increased parity pregnancy symptoms - GDM - increase uterine size -- increase gain - increased circulating blood volume - increased N&V - Constipation - diet
Incorporating a woman centred approach, explain the midwifery care for woman with a multiple pregnancy across the continuum, as part of the multi disciplinary team
- increased u/s
- growth scan
- OGTT
- Doppler studies
- low dose aspirin
- time of delivery
- mode of delivery
- allied health
- LC antenatally - early expressing/feeding multiple babies
- feeding options
- refer to multiple birth society
- reassurance and support
Multiple pregnancy - pregnancy management
- unable to do fundal size
- u/s
- maternal screening
- obstetric care
Multiple pregnancy - Postpartum care
- feeding support - feeding plan
- mother crafting
- Australia multiple birth association
- developmental care
- bgl if small or premature - feeding plan
- AC obs
- clinically
- routine
- fundal checks
- PV Loss - PPH -
- sync infusion 40 units
- higher risk PPH
TWIN - CTG
Twin one up by 20 beats
- darker line twin one
Describe the potential complications of multiple pregnancy
- perterm birth
- IUGR
- Pre-eclampsia
- TTTS - risk diamniotic monochorionic
- antepartum death of one of the twins
- increased N&V in early pregnancy
- respiratory discomfort in late pregnancy
- miscarriage
- Anaemia
- Polyhydramnios
- placental abruptions
- Cord intanglement - monoamniotic monochorionic
- GDM
- congenital anomalies (more common in monozygotic twins)
- malpresentation
- Cord accident (presentation and prolapse)
- Post partum haemorrhage
- post partum depression
- long term adverse infant outcome - cerebral palsy
Explain the maternal and fetal surveillance undertaken to monitor multiple pregnancy
early ultrasound
U/S in monochorionic twins (after 24 weeks)
- amniotic fluid volume in each sacs 5-25ml is normal
- Bladder volume
- umbilical artery
- middle cerebral artery doppler wave form
Maternal abdominal girth - rapid accumulation of polyhydramnios
Nuchal translucency measurement
Normal antenatal screening as well
definition of Zygosity & Chrionicity
Dizygotic twins - can only be Diamniotic dichorionic
monzygotic - can be > Diamniotic dichorionic
> Diamniotic monochroinic
> monoamniotic monochorionic
What is the underlying physiology that leads to twin to twin transfusion
TTTs occurs in pregnancies where twins share one placenta and a network of blood vessels that supply oxygen and nutrients essential for fetal development
Describe twin to twin transfusion and the potential impact on each of the fetuses
- progressive order
- one twin transfers to the other twin through abnormal or imbalanced blood vessel
connections shared in the placenta - Donor twin - an artery branches off into the placenta. the corresponding view that
would normally bring the nutrient rich blood back the same fetus however in the
case the blood is directed toward the other twin via abnormal arterio-venous
connection - Twin two is overloaded with blood and volume
Potential impact - donor twin
- risk of developing failure of the kidneys and other organs because of the inadequate blood flow
- oligohydramnios
- kidney failure
- IUFGR
- anaemia
- diversion of blood flood to heart and head (head sparing)
- death
Potential impact - recipient twin
- fluid overloaded
- blood can become thick and difficult to pump around thebody
- polyhydramnios
- Heart failure
- generalised soft tissue swelling (“Hydrops”)
- if donor twin dies the other twin faces significate risk of death, damage to vital organs
- 40% risk of some form of brain injury
Is all twin to twin transfusion bad? describe the protective v pathological differences .
share one placenta
- 90% of the time equal transfusion
- artery
- AA Connections
- allows for blood flow back and forth
- bidirectionally
Five stages of TTTS
Stage 1:
- there is an imbalanced of amniotic fluid
- donor twin (<2cm)
- recipient twin (>8cm)
- 20% more in difference of size
Stage 2:
- Donor twin bladder is not visible
- Does not fill with urine during U/S
Stage 3:
- imbalance blood flow starts to effect the heart function of one or both fetuses
- abnormal blood flow in the umbilical cords or hearts
Stage 4:
- The imbalance of blood flow causes signs of heart failure in on the twins
Stage 5:
- one or both twins pass away
Monozygotic twins
- one egg and one sperm
- fertilized ovum
Diamniotic dichorionic (Fused or unfused) wedge shape protrusion (lambda sigs)
2 x Amnionic
2 x chorion
-0-4 days becomes two morula
- becomes two blastocysts (separate)
- lower risk can be IOL at 37 weeks
Diamnionic Monochorionic (ammoniac separates the fetus)
- one morula
- 4-7 days - one blastocysts -twins attached in different areas of the blastocyst
2 x amnionic
1 x chorion
- delivered at 36 weeks
Monoamnionic Monochorionic (no membrane between the fetus)
- one morula & blastocysts
-7-14 days
- embryonic disk division
