Multiples Flashcards
Define a multiple pregnancy?
When there are 2 or more fetus
Dizygotic - when two ova are fertilised, no more the same as any other siblings
Monozygotic- when one fertilised embryo splits - the degree of separation is dependant on when developmental stage at which they split
What are the incidences of multiples?
occur in 1 in 90 pregnancies and make up 3% of live births in the UK
Dizygotic twins are fairly constant
Monozygotic vary - recent increase due to IVF- 24% of successful IVF pregnancies
Perinatal mortality in twin pregnancies is 5 time more likely
What are the 5 predisposing factors ?
Maternal age Maternal height and weight Ethnicity IVF increased parity
What are the 6 fetal risk of multiple pregnancy?
ALL: FGR
congenital abnormalities
- cardiac
- neural tube
neonatal seizures
increased respiratory morbidity
cerebral palsy x4
MC only:
Cord entanglement
Feto-fetal transfusion TTF
What are the 6 Maternal risk factors of multiple pregnancy?
PPH Cord prolapse Malpresentation GDM Pre-eclampsia Preterm 50%
What is TTF?
Twin to Twin feto-fetal transfusion
occurs in 20% of MC twins
cause 15-17% of perinatal death
if untreated 80-100% of IUD
causes-
recipient - polycythaemia, circulatory overload, polyhrdramnios
- anaemia, oedema, IUGR, oligohydramnios
What is the antenatal management for multiple pregnancy- diagnosis?
around 11-13 weeks by USS
- viability
- chorionicity
- nuchal translucency
Discuss:
-diagnosis sensitively
-screening and diagnostic test aims and outcomes
-vanishing twin 20%
-risk associated with twins relevant to chroinoicity
provide info sign post local and national support
- care plan
-exaggerated pregnancy symptoms
-nutrient
-discuss preterm 50% and corticosteroid steriods
What is routine AN care for all twin?
GTT BP and urinalysis Routine bloods auscultate discuss mode of delivery
Explain Appt for twins ..
All: 11-13+6
- viability
- chorionicity
- nuchal translucency
MC: 16 weeks
- TTS
- EFW - if discoradance of 20% increased perinatal risk
ALL: 18-20+6
-Anomaly
ALL: 32weeks -discuss mode of delivery - analgesia morbidity of twin 2 stabilising twin 2 risk of C/s - potential use of oxytociin between twins
IN ADDITION:
4 weekly DCDA
- growth
- if falls 2 weekly uss
2weekly MC
- TTS
- growth
- if signs of TTS 1 weekly USS consider intervention
MC: Echocardiogram 20/40 (32/1000)
Describe timing of birth
DCDA 37-38 weeks
MCDA 36
MCMA 32-24
Rates of stillbirth increase after 38 weeks with twins
What happens in First stage non- clinical? X4
one to one care experienced MW
r/v obstetrician
anaesthetist, neonatalogist, theatre team on stand by
Discuss and document birth plan for both twins
Prep Rm - 2x resusitare
What happens clinically in first stage? X6
Routine obs IV access - FBC G&S CTG Clear fluids from active labour and ranitidine 6hrly confirm presentation by USS analgesia
Who should be in attendance for 2nd stage of labour?
2 MW
obstetrician
2 neonatal team
anaesthetist and theatre team on stand by
How should twin birth be managed?
Twin one should deliver as singleton
- stabilise twin 2 ? ECV
- if CTG normal continue as natural delivery (if abnormal expedite)
- if contractions stop/become irregular ? oxytocin infusion - 3units/50mls normal saline 4mls/hr double every 5 mins until contraction regular
- ARM only when PP is fixed in pelvis
- Aim for delivery <30mins twin one
- if delay ? internal podalic version
How do you manage third stage?
Delayed cord clamping not recommended double clamp - use identifier cord gases bolus oxytocin immediately after twin 2 Prophylactic oxytocin infusion Monitor PPH Documentation pro forma
