Multiple Pregnancy

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Multiple Pregnancy

• Reference WHO - Managing Complications in
  Pregnancy Childbirth S 89 91
• Slides adapted with permission Dr G Davis St
  George Hospital

2
Case Study - KP

• 28 years
• G1
• PMHx TB as child
• 10 weeks gestation
• Examination unremarkable
• USS twins ?Monochorionic

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Twins

• Incidence of twins about 1 -depends on age, race
  and ART (15)
• 1/3 are monozygous
• Can have
• dichorionic/diamniotic (30)
• Monochorionic/diamniotic (70)
• Monochorionic/monoamniotic (1)

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Twin-twin transfusion syndrome

• Only monozygous and monochorionic severe in 1
  (18-26wks)
• Discordant fetal size and amniotic fluid volume
• Donor twin anaemic, hypovolaemic,
  oligohydamniotic, growth restricted
• Recipient twin polycythaemic, hypervolaemic,
  polyhydramniotic, hydropic

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Twins Increased Risk

• Mother miscarriage, symptoms, anaemia, preterm
  delivery, hypertension, APH, assisted delivery,
  CS, PPH
• Baby stillbirth, IUGR, anomalies, cord
  prolapse, asphyxia, assisted delivery

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Case Study KP contd

• 2/52ly scans showed normal growth
• 27 wks
• Twin 1 759g (20th centile)
• Twin 2 1113g (50th centile)
• Liquor volume evenly distributed

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Measuring Growth in Twins

• Size/Estimated Fetal Weight
• Head Circumference
• Biparietal Diameter
• Femur Length
• Abdominal Circumference
• Amniotic Fluid Index
• Biophysical profile
• Umbilical Artery Dopplers

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Intrauterine Growth Restriction

• Due to decreased intervillous blood flow
• gt decreased transfer of gases and nutrients gt
  hypoxia and hypoglycaemia
• Fetus preserves supply to brain
• gt Asymmetrical IUGR
• Twins have larger placental mass and more likely
  to have inadequate supply

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KP - Antenatal Record

• 
  

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Case Study KP contd

• Diagnosis preeclampsia
• Hypertension
• Proteinuria
• IUGR
• Plan
• Admit
• PE Bloods/Spot Urine Protein/Creatinine ratio
• Steroids

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Definitions new onset hypertension after 20
weeks gestation

• GH
• BP gt 140/90
• Excellent prognosis for mother and baby
• PE
• Hypertension proteinuria (gt300 mg/day or spot
  prot/Cr ratio gt30mg/mmol)
• Increased perinatal and maternal mortality and
  morbidity

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Case Study KP contd

• Asymptomatic
• Bloods Platelets 137, others normal
• Spot urine protein/Cr ratio 1347 (lt30)
• Fetal growth as before
• Plan
• Steroids, oxprenolol
• 3hrly BP, daily urinalysis, repeat bloods am
• IOL after 24 hr

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Steroids

• Betamethasone 11.4 mg x 2, 12 hr apart
• Need at least 24 hr for effect
• Use 26 - 34 wks
• Effects reduce incidence of
• Hyaline membrane disease
• Intraventricular haemorrhage
• Necrotizing enterocolitis
• Perinatal mortality

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Case Study KP contd

• Induction at 0745 with PGE2 2mg
• Labour began 0945
• ARM 1230
• Epidural 1420
• Twin 1 delivered 1753, twin 2 1801
• Twin1 1753g,Twin 2 2495g (EFW 22.4.05 1667,
  2323g)

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Case Study KP contd

• Twin 1 LOP, asynclitic with ear at 2 oclock
• Vacumn applied and delivered with 4 contractions
• Twin II - pushed for 5 then Vacumn applied and
  delivered with 2 contractions
• Blood loss 800mL
• Second degree tear

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Case Study KP contd

• Initially in special care nursery
• Problems with feeding and jaundice
• Twin 1 VSD

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Twins I II Day 8