multiple gestation

Multiple GestationMultiple Gestation

Authored by:Authored by:

Susan Bishop, RNC-OB, MNSusan Bishop, RNC-OB, MNPerinatal Outreach Coordinator

MultiCare Regional Perinatal Outreach Program

[email protected]

Incidence of Incidence of MultiplesMultiples

Currently 3% of all births (95% twins)Currently 3% of all births (95% twins)

Naturally occurring twins 1 in 80 Naturally occurring twins 1 in 80 pregnanciespregnancies

Naturally occurring triplets 1 in 8000 Naturally occurring triplets 1 in 8000 pregnanciespregnancies

incidence in African descentincidence in African descent

incidence in Asian descentincidence in Asian descent(7 – Mandy & Weisman)

Between 1980-2004 Incidence of Between 1980-2004 Incidence of Twins Increased by 70%Twins Increased by 70%

(8 – Simpson & Creehan)

HOM* increased by 500%HOM* increased by 500%

*HOM=Higher Order Multiples


Factors Associated with Multiple Factors Associated with Multiple GestationGestation

Delayed childbearing: AMA Delayed childbearing: AMA 75% increase75% increase Higher levels of Follicle Higher levels of Follicle

Stimulating HormoneStimulating Hormone Greater use of fertility Greater use of fertility

servicesservices

ART (assisted reproductive ART (assisted reproductive technology)technology)OI (ovulation induction) OI (ovulation induction) 400% triplets/HOM400% triplets/HOM

(1 – ACOG, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

Physiology of TwinningPhysiology of Twinning

Monozygotic (MZ) Monozygotic (MZ) – fertilization of a single – fertilization of a single ovum that subsequently divides into 2 or more ovum that subsequently divides into 2 or more zygotes zygotes (31% incidence)(31% incidence) Cell splits between day 4-day 12Cell splits between day 4-day 12 Genetically the same: physical characteristics, sex, Genetically the same: physical characteristics, sex,

blood type hair & eye colorblood type hair & eye color

Dizygotic (DZ) Dizygotic (DZ) – fertilization of multiple ova – fertilization of multiple ova (67% incidence)(67% incidence) Two separate eggs/two separate spermTwo separate eggs/two separate sperm No more alike than other siblings born to the same No more alike than other siblings born to the same

parentsparents


Monozygotic TwinsMonozygotic Twins


Dizygotic TwinsDizygotic Twins


TripletsTriplets


Diagnosis of Multiple GestationDiagnosis of Multiple Gestation11stst trimester ultrasound trimester ultrasound >5weeks chorionicity>5weeks chorionicity >6weeks fetal number>6weeks fetal number >8weeks amnionicity>8weeks amnionicity Highly accurate at 10-14 weeksHighly accurate at 10-14 weeks

Clinical ExamClinical Exam Fundal height 2-4 cm > estimated GAFundal height 2-4 cm > estimated GA Leopolds/FHRLeopolds/FHR

Subjective symptomsSubjective symptoms Fatigue, hyperemesis, increased appetite/wt gain, Fatigue, hyperemesis, increased appetite/wt gain,

FM, exaggerated pregnancy discomforts, “feel FM, exaggerated pregnancy discomforts, “feel different”different”


Maternal ChangesMaternal ChangesGIGI

Hyperemesis/N&V; refluxHyperemesis/N&V; reflux

HematologicHematologic Plasma volume Plasma volume by 50-100%=dilutional anemia/iron deficiency by 50-100%=dilutional anemia/iron deficiency

anemiaanemia

CardiovascularCardiovascular HR/stroke volume; HR/stroke volume; risk pulmonary edema; supine aortocaval risk pulmonary edema; supine aortocaval

compressioncompression

RespiratoryRespiratory >tidal volume and oxygen consumption; more alkalotic arterial pH; > >tidal volume and oxygen consumption; more alkalotic arterial pH; >

dyspnea and SOBdyspnea and SOB

MusculoskeletalMusculoskeletal Symptoms earlier in pregnancy; back/ligament painSymptoms earlier in pregnancy; back/ligament pain

DermatologicDermatologic PUPPP (Pruritic urticarial papules and plaques of pregnancy) 3% PUPPP (Pruritic urticarial papules and plaques of pregnancy) 3%

twins/14% tripletstwins/14% triplets


Maternal ComplicationsMaternal ComplicationsPreterm Labor – 50% twins, 76% triplets, 90% Preterm Labor – 50% twins, 76% triplets, 90% quadsquads Education important!Education important! Serial U/S with assessment of cervical lengthSerial U/S with assessment of cervical length Fetal fibronectin testingFetal fibronectin testing Tocolytics, corticosteriod therapy, bedrestTocolytics, corticosteriod therapy, bedrest

HypertensionHypertension Preeclampsia develops earlier and is more severePreeclampsia develops earlier and is more severe HELLP may present with atypical signs/symptomsHELLP may present with atypical signs/symptoms ART multiple pregnancies at higher riskART multiple pregnancies at higher risk

(1 – ACOG, 6 – Jones, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

Maternal Complications Maternal Complications (continued)(continued)

PPROM – increased rate; shorter latency PPROM – increased rate; shorter latency to birth timeto birth time

Gestational Diabetes Gestational Diabetes

Intrahepatic Cholestasis – 2-5 x greaterIntrahepatic Cholestasis – 2-5 x greater

Abruptio PlacentaAbruptio Placenta

Pulmonary Embolism Pulmonary Embolism

Acute Fatty LiverAcute Fatty Liver


Fetal Risks/ComplicationsFetal Risks/ComplicationsMortality increased with plurality and late GA Mortality increased with plurality and late GA

(Jones, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

Fetal Risks/Complications Fetal Risks/Complications (continued)(continued)

MZ twin mortality 3-10x than DZ twinsMZ twin mortality 3-10x than DZ twins Intrauterine demise is usually cord Intrauterine demise is usually cord

entanglemententanglement Greater incidence of congenital anomolies Greater incidence of congenital anomolies

such as:such as:Neural tube defectsNeural tube defects

Urinary tract malformationsUrinary tract malformations

Discordant birth weight (20%)Discordant birth weight (20%)

Twin to Twin Transfusion SyndromeTwin to Twin Transfusion Syndrome

(7 – Mandy & Weisman)

Discordant GrowthDiscordant GrowthWeight of one multiple differs Weight of one multiple differs significantly from that of the other(s) by significantly from that of the other(s) by 25% 25%

More common in Mono chorionic twinsMore common in Mono chorionic twins

Twin to Twin Transfusion SyndromeTwin to Twin Transfusion Syndrome

Also effected by maternal age, parity, Also effected by maternal age, parity, sex discordance and gestational age.sex discordance and gestational age.

Discordance ranging from 15-40% has Discordance ranging from 15-40% has been considered predictive of an been considered predictive of an adverse outcomeadverse outcome


Twin-to-Twin Transfusion Twin-to-Twin Transfusion SyndromeSyndrome

Almost exclusively occurs in monochorionic (1 Almost exclusively occurs in monochorionic (1 placenta) diamniotic (2 amniotic sacs) pregnanciesplacenta) diamniotic (2 amniotic sacs) pregnancies

Unequal balance of blood flow between the two Unequal balance of blood flow between the two fetuses due to placental vascular anastomoses fetuses due to placental vascular anastomoses within the placenta allowing one twin to transfuse within the placenta allowing one twin to transfuse the otherthe other

20% growth discordance, poly/oligo, discrepancy 20% growth discordance, poly/oligo, discrepancy in cord size, cardiac dysfunction &/or abnormal in cord size, cardiac dysfunction &/or abnormal cord Doppler studiescord Doppler studies

Staging: I-VStaging: I-V(5 – Jackson & Mele, 7 – Mandy & Weisman)

TTTSTTTS

TTTS Management TTTS Management

Treatment options: Treatment options: AmnioreductionAmnioreduction SeptostomySeptostomy PhotocoagulationPhotocoagulation Umbilical cord occlusionUmbilical cord occlusion

Maternal dietary managementMaternal dietary management

Patient education, supportPatient education, support

(5 – Jackson & Mele, 7 – Mandy & Weisman)

Reduction AmniocentesisReduction Amniocentesis SeptostomySeptostomy

Selective Vessel Laser AblationSelective Vessel Laser Ablation Umbilical Cord Occlusion/AblationUmbilical Cord Occlusion/Ablation

Fetal Risks/Complications Fetal Risks/Complications (continued)(continued)

Intrauterine Growth Restriction (IUGR)Intrauterine Growth Restriction (IUGR) Due to placental insufficiency and competition Due to placental insufficiency and competition

for nutrientsfor nutrients Fetal growth rates Fetal growth rates at: at:

30-32 weeks (twins) 29 weeks (triplets)


Fetal LossFetal LossSpontaneous loss early in multiple Spontaneous loss early in multiple pregnancy associated with bleedingpregnancy associated with bleeding

““Vanishing Twin”Vanishing Twin”

Fetal death Fetal death 20 weeks gestation 20 weeks gestation Surviving twin at Surviving twin at risk of fetal death, risk of fetal death,

neonatal death and severe long-term neonatal death and severe long-term morbidity.morbidity.

Survival is inversely related to time death Survival is inversely related to time death occurred and survivors of opposite-sex twin occurred and survivors of opposite-sex twin pairs more likely to survive than same-sex pairs more likely to survive than same-sex twin pairs.twin pairs.


( Fuller & Fuller)

Fetal SurveillanceFetal Surveillance

Fetal Activity Fetal Activity AssessmentAssessment

Serial NSTs – BPP Serial NSTs – BPP if nonreactiveif nonreactive

Doppler Doppler velocimetryvelocimetry

Close assessment Close assessment for possible for possible complicationscomplications


Laboring with MultiplesLaboring with Multiples

Must occur in facility capable of emergent Must occur in facility capable of emergent C/S and neonatal resuscitationC/S and neonatal resuscitation

Capability of monitoring all fetuses Capability of monitoring all fetuses simultaneously and continuouslysimultaneously and continuously

Qualified personnel in numbers required to Qualified personnel in numbers required to care for all neonatescare for all neonates

Ultrasound at bedsideUltrasound at bedside

VBAC possibleVBAC possible


Management of Multiple BirthManagement of Multiple Birth

Route: Vaginal or C/SRoute: Vaginal or C/SDependant on presentation and number!Dependant on presentation and number! Twin: VV/ VB/ BBTwin: VV/ VB/ BB HOM=C/SHOM=C/S

(2 – Chasen & Chervenak)(2 – Chasen & Chervenak)

Management of Multiple Birth Management of Multiple Birth (continued)(continued)

Timing of delivery Timing of delivery is controversial. is controversial. Lowest fetal Lowest fetal

death rates of death rates of twins 36-37 twins 36-37 weeksweeks

Lowest fetal Lowest fetal death rates for death rates for triplets 34-35 triplets 34-35 weeksweeks

FLM testing may FLM testing may be requiredbe required

Dependant on Dependant on pregnancy pregnancy course and course and type of twin type of twin pairingspairings (6 – Jones, 7 – Mandy & Weisman, 8 – Simpson & Creehan)

Management of Multiple BirthManagement of Multiple BirthIV access, Type & ScreenIV access, Type & Screen

Prepare for PP Hemorrhage BEFORE Prepare for PP Hemorrhage BEFORE delivery!delivery!

Continuous monitoring of allContinuous monitoring of all

Bedside U/S on admission to Bedside U/S on admission to determine/confirm fetal liedetermine/confirm fetal lie

Delivery in OR for all twins and HOMsDelivery in OR for all twins and HOMs 6-25% C/S for B after vaginal delivery of A6-25% C/S for B after vaginal delivery of A

(1 – ACOG, 2 – Chasen & Chervenak,Chasen & Chervenak, 8 – Simpson & Creehan)

Delivery of MultiplesDelivery of MultiplesEach must have own bed, own team, own Each must have own bed, own team, own identifier (bracelets)identifier (bracelets) Double check bands before, during and after delivery!Double check bands before, during and after delivery!

Prepare to differentiate cords and send Prepare to differentiate cords and send placentas to pathologyplacentas to pathologyVag Del: After delivery of Twin A be prepared Vag Del: After delivery of Twin A be prepared with U/S to confirm lie and stabilize Twin B.with U/S to confirm lie and stabilize Twin B.Twin B at higher risk of perinatal mortality when Twin B at higher risk of perinatal mortality when delivered vaginallydelivered vaginally When > 36 weeks gestation and most likely due to When > 36 weeks gestation and most likely due to

mechanical problems (compound presentation, cord mechanical problems (compound presentation, cord prolapse, abruption)prolapse, abruption)

Continue to monitor Twin B!Continue to monitor Twin B! May need pitocin, C/S if problems developMay need pitocin, C/S if problems develop

(2 – Chasen & Chervenak, 8 – Simpson & Creehan)(2 – Chasen & Chervenak, 8 – Simpson & Creehan)

Delivery of Multiples Delivery of Multiples (continued)(continued)

Nonreassuring FHR Twin BNonreassuring FHR Twin B VE – assess dilatation and check for VE – assess dilatation and check for

presence of cord!presence of cord! Bedside U/SBedside U/S Prepare for forceps or vacuum assistPrepare for forceps or vacuum assist External version/internal rotation/extraction for External version/internal rotation/extraction for

transverse or footling breechtransverse or footling breech Interval >30 minutes associated with poorer Interval >30 minutes associated with poorer

outcomesoutcomes C/S via general anesthesia for deteriorationC/S via general anesthesia for deterioration

(2 – Chasen & Chervenak, 8 – Simpson & Creehan)(2 – Chasen & Chervenak, 8 – Simpson & Creehan)

PostpartumPostpartumHemorrhage – count on it!Hemorrhage – count on it! Twin EBL avg 1000 mLTwin EBL avg 1000 mL Twice as likely to need Twice as likely to need

transfusiontransfusion Fundal checks!Fundal checks! Uterine Atony -> act quicklyUterine Atony -> act quickly

Physical & Emotional Physical & Emotional StressStress

Muscle Atrophy/EnduranceMuscle Atrophy/Endurance

BreastfeedingBreastfeeding


Triplets and HOMTriplets and HOM

Increased Gestational Diabetes, pre-Increased Gestational Diabetes, pre-eclampsia, PTL, Pregnancy Associated eclampsia, PTL, Pregnancy Associated HTNHTNCommon discordant growthCommon discordant growthIncreased risk of velamentous insertion of Increased risk of velamentous insertion of cordcordBPPs weekly from 30 weeks onBPPs weekly from 30 weeks onIncreased risk of PP Hemorrhage (10-Increased risk of PP Hemorrhage (10-35%)35%)

(2 – Chasen & ChervenakChasen & Chervenak 6 – Jones, 7 – Mandy & Weisman)

Resources & Resources & ReferencesReferences

1.1. American College of Obstetricians & Gynecologists (2004) Multiple Gestation: Complicated Twin, American College of Obstetricians & Gynecologists (2004) Multiple Gestation: Complicated Twin, Triplet, and High-Order Multifetal Pregnancy, ACOG Practice Bulletin Number 56. Triplet, and High-Order Multifetal Pregnancy, ACOG Practice Bulletin Number 56.

2.2. Chasen, ST & Chervenak, FA (2009) Delivery of twin gestations, UpToDate online Chasen, ST & Chervenak, FA (2009) Delivery of twin gestations, UpToDate online www.uptodate.comwww.uptodate.com

3.3. Creasy, RK & Resnick, R (2004) Creasy, RK & Resnick, R (2004) Maternal-Fetal Medicine: Principles and Practice (5Maternal-Fetal Medicine: Principles and Practice (5thth ed.) ed.) Philadelphia: Saunders.Philadelphia: Saunders.

4.4. Gilbert, ES (2007) Gilbert, ES (2007) Manual of High Risk Pregnancy & Delivery (4Manual of High Risk Pregnancy & Delivery (4thth ed.) ed.) St. Louis: Mosby. St. Louis: Mosby.

5.5. Jackson, KM & Mele, NL (2009) Jackson, KM & Mele, NL (2009) Nursing for Women’s HealthNursing for Women’s Health,, Twin-to-twin transfusion syndrome: Twin-to-twin transfusion syndrome: what nurses need to knowwhat nurses need to know, 13 (3), p224-233., 13 (3), p224-233.

6.6. Jones, D (2008) Triplet pregnancy: Mid and late pregnancy complications and management, Jones, D (2008) Triplet pregnancy: Mid and late pregnancy complications and management, UpToDate online www.uptodate.comUpToDate online www.uptodate.com

7.7. Mandy, GT & Weisman, LE (2009) Multiple Births, UpToDate online www.uptodate.comMandy, GT & Weisman, LE (2009) Multiple Births, UpToDate online www.uptodate.com

8.8. Simpson, KR & Creehan, PA (2008). Simpson, KR & Creehan, PA (2008). AWHONN Perinatal Nursing (3AWHONN Perinatal Nursing (3rdrd ed). ed). Philadelphia: Wolters Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins.Kluwer/Lippincott Williams & Wilkins.

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