Multiple pregnancy management protocol

Introduction:

The presence of two or more foetuses co-existing in a pregnant uterus.The commonest variety is twin pregnancy;triplets,quadruplets and higher order multiple pregnancies are rare.

The incidence of multiple pregnancies has increased recently;maternal and perinatal morbidity and mortality rates are higher than for singleton pregnancies

A. Problems

Maternal

1. Exaggerated early morning sickness

2. Miscarriages

3. Anaemia

4. Preterm labour

5. APH

6. UTI

7. Pregnancy induced hypertension

8. Previous PPH

Foetal

1. High still birth rate

2. chromosomal anomalies

3. prematurity

4. hypoxia

5. trauma

6. Cord accidents

7. urogenital anomalies

8. Abnormal lie&presentation

DIAGNOSIS

Early diagnosis to prevent complication

Clinical diagnosis possible in about 75% of cases

High index of suspicion[our environment where high twin rates occur]

Diagnostic indices:

1. Uterus larger than date by 4wks[4cm]

2. Excessive maternal weight gain

3. Exaggerated pregnancy symptoms/signs[threatened abortion,APH,DIC if one foetus dies,pre-eclampsia/eclampsia,excessive anaemia,glycosuria,OGTT anomalies]

4. Polyhydramnios

5. Family history of twinning

6. History of assisted reproduction

7. Elevated MSAFP

8. Ballotment of more than one foetus

9. Multiple small parts

10. Recording of different heart rates simultaneously using electronic foetal monitoring that are asynchronous with maternal pulse with each varying about 8beats/minute

11. Palpation of one or more foetuses in the fundus after delivery of one infant

Ultrasound diagnosis is preferred and highly accurate from early pregnancy,monitor growth of foetuses,detect anomalies

The incidence of undiagnosed twins before labour with ultrasound is less than 10% in developed countries

Differential diagnosis

1. Inaccurate date

2. Polyhydramnios from single pregnancy

3. Molar pregnancy

4. Fibroid,ovarian tumour

5. Distended bladder or full rectum

6. Complicated twins-conjoined twins

Reducing complications of multiple pregnancy

1. Early diagnosis

2. Enhanced antenatal care:iron,folic acid,vitamin supplements,high protein diet[no evidence for routine hospitalization,no evidence for prophylactic cerclage improving outcome]

3. Frequent follow-up visits-sonographic measurement of cervical length with emergency cerclage offered by 24wks if short cervix or funnel shaped membranes noted

4. Early and prompt treatment of vaginal infections,pre-eclampsia and eclamsia

5. Tocolytic drugs for 48hrs to allow for steroid effect to be realised.Terbutaline[maternal hypotension];indomethacine contraindicated after 32wks due to premature closure of the ductus arteriosus

6. APH:delay delivery till at least 34wks as much as possible

LABOUR AND DELIVERY

Prerequisite :

adequate assistance:personnel[paediatricians,senior obstetric resident,midwives,anaesthesiologist]

On admission:

Evaluation to include:

physical exam-mother’s CVS,Respiratory

obstetric:presentation of each foetus especially the leading twin.Sonographic aid desirable for this and estimate of foetal weight

routine,continuous electronic foetal monitoring

IV line is mandatory

Induction of labour is controversial[decision by consultant]

Hb,group and crossmatch 2pints of blood

Indication for C/S

1. Foetal compromise,locked twins,cord prolapsed

2. Placenta praevia

3. Triplets and higher order

4. Previous C/S

5. Other complications of pregnancy e.g. pre-eclampsia,DM etc

Categories of twin delivery

Twin 1 VxA-VxB:vaginal birth,exception if any other complication

Twin-VxA-non VxB:vaginal birth of first twin+external version of second twin.If this fails,then C/S

Twin-non vertexA-TwinB:primary C/S

Prompt clamping of cord at delivery of first twin to prevent ex-sanguination of second twin

After delivery of first twin,

-conduct a vaginal examination to note presentation of second twin,presence of second sac and absence or presence of cord presentation or prolapse

-do external version to convert breech to vertex and guide same into pelvic inlet

-rupture membrane of second sac if no cord presentation

-Time of delivery between twin A and B for optimum foetal wellbeing remains controversial[30minutes used to be suggested]

Augment labour if return of contraction is delayed beyond 10minutes of delivery of first twin

-Locked twins:twin A is breech and twin B vertex;both heads impacted in the pelvis

-liberal use of oxytocics for 2hrs after delivery of second twin and placentae,fundal massage to prevent PPH

-Neonatologist care of infant especially if low birth weight baby,preterm delivery etc.

Examine placenta(e) for zygosity