OB multiple gestation

1. MULTIPLE GESTATION
Peggy Foster, RNC-OB, MSN
Sandy Warner RNC-OB, MSN

2. MULTIPLE GESTATION
 Definition—Pregnancy with more than 1
Fetus

3. Diagnosis of multiple gestation
 Size greater than dates
 Greatly elevated hCG levels
 Elevated alpha-fetoprotein (MSAFP)
 More than one audible heart beat
 U/S confirmation
 ART

4. Multiple Gestation
 Twins are most common form of multiples
 Monozygotic twins - 25%
 One sperm and one ova
 “identical”
 Can separate into more than 2 (identical triplets etc)
 Dizygotic twins are majority
Includes twins and higher order multiples
 “fraternal” or nonidentical
 Two ova and two sperm

5. Monozygotic vs. Dizygotic

6. Monozygotic vs. Dizygotic
 Amnion layer inside Chorion
 Dizygotic twins always have 2 amnions and 2
chorions
 Monozygotic twins can be
Mono Chorionic - Mono Amnionic
Mono Chorionic - Di Amnionic
OR Di Amnionic - Di Chorionic

8. Associated factors for dizygotic
twins
 ART (assisted reproductive technology)
 Age
 Ovarian follicicle stimulation
 Parity > 4
 Race—More common in Blacks—Less common
in Oriental populations
 Family history
 Coital frequency

9. Monozygotic twins occur
independently
 Cause is unclear

10. Monozygotic twins can be:
 Diamnionic/dichorionic—Occur<72 hours after
conception
 Monochorionic/diamnionic (MOST !!)—Occur 3-7
days after conception
 Conjoined twins >7 days after conception—
incomplete separation of developing embryonic
cell masses
 Monochorionic/monoamnionic –RARE !!

11. What we do know for Sure !!
 Different sex—always dizygous
 Different blood types—always dizygous
 If Monochorionic—always monozygous

12. Pregnancy Outcomes
 85% of multiple gestation mothers have
antepartal complications—compared with
only 32% of singleton pregnancies
 Perinatal morbidity and mortality is TWICE
that of singleton pregnancies—In these
women 4% of all maternal deaths are
related to vascular problems

13. Antepartum complications with
multiple gestation
 “Vanishing twins” may occur< 12 weeks
gestation
 “Fetal Papyraceous” > 12 weeks
 ↑ Spontaneous abortions
 ↑ Nausea and Vomiting
 ↑ Anemia
 ↑ uterine size and ↑ placental hormones—
explains minor discomforts of pregnancy—both
chemically and pressure related

14. Antepartum complications cont.
 ↑ PIH (20% of twin pregnancies)
 ↑ Hydraminous (Polyhydraminous)
 ↑ Blood Volume 500 ml > than singleton
 ↑ Uterine size causes ↑ Vena Cava Syndrome
 ↑ SOB
 ↑ Varicosities, VTEs, PEs
 Cholestasis

15. Ante & Intrapartum complications
cont.
 ↑ Edema
 ↑ Placenta Previa and ↑ Abruption
 ↑ Labor dystocia—secondarily to an over-
stretched myometrium-- ↑ PP Hemorrhage
 ↑ Preterm labor and deliveries (12 X that of
Singleton pregnancies)
 ↑ Cesarean rates
 ↑ Emotional adjustments and stress on family
relationships—both partner and siblings

16. Intrapartum complications
 Maternal  Fetal
 Acute fatty liver  Cord accidents
 Difficulty of fetal
 Malpresentation
monitoring
 Cardiac issues  Congenital anomalies
 ENVIRONMENTAL
 Availability of
necessary equipment
 Availability of
necessary personnel

17. Multiple tracing

18. Postpartum Complications
 PPH
 Pulmonary edema
 Lack of bonding/breastfeeding
 Feelings of being overwhelmed
 Delayed return to normal activity if long periods
of bed rest
 Fatigue
 Grief – acknowledging individuality

19. Risks to fetus (es)
 The 2 major causes of Neonatal M&M are:
PREMATURITY AND IUGR—50% of twins
weigh < 2500 gms at birth
 Monozygotic twins have 2-3 X PM&M rates as
Dizygotic
 ↑ Congenital Anomalies 2-3 X that of Singletons
and is more common in Monozygous twins
 Preterm Delivery is 5-10 X that of Singletons

20. Multiples Average Gestational
Age at Birth
 Singletons 40 weeks
 Twins 35 weeks
 Triplets 33 weeks
 Quadruplets 29 weeks
Prevention: Don’t do this 

21. TWIN TO TWIN
TRANSFUSION SYNDROME
 In Monozygotic twins the vessels may
develop vessel-vessel anastamosis
 Most common Artery-Vein
 Increase pressure of one vessel causes
transfusion to the lower pressure vessel
 Results in 1 twin (Recipient)--over-
perfused and other twin (Donor) under-
perfused

23. Twin-Twin Transfusion cont’d
 Recipient develops:
Polycythemia
Hypervolemia
Hypertension
Enlarged Heart
Increased Renal perfusion and excessive voiding
Polyhydraminous

24. Twin-Twin Transfusion cont’d
 Donor develops:
Hypovolemia
Anemia
Decreased Renal perfusion
Oligohydramnious
“Stuck twin”

25. Donor and Recipient

26. Common problems with Twins
 If twins share same sac
(Monoamnion/Monochorion) is ↑ chance
for Cord Entanglement
 Stillbirthrate ↑ to 50%
 These babies have ↑ developmental issues,
↓ IQ levels, and ↓ physical growth
 In all Multiple births there is ↑ Fetal
distress and ↑ Cesarean deliveries

27. Goals for Care of Multiples
 Promote Normal Development of all
fetuses
 Prevent Preterm Birth
 Decrease Fetal Trauma at Birth
 Support Mother’s needs throughout
Pregnancy

28. Interventions
 Nutrition: ↑ Calories 300 > Singleton
 ↑ weight gain to 40-60 #
 ↑ Folic acid
 ↑ Iron 60-100 mg/day
 ↑ Protein from 40 to 74 gms/day

29. Interventions cont.
 Monitor for Discordance—defined as >25%
difference in weight at birth—occurs in 9% of all
twins—When discordance occurs Neonatal
mortality ↑ 4X
 ↑ Prenatal Visits
 ↑ Teaching about Kick counts
 ↑ Teaching about Signs of PTL
 ↑ Teaching about Danger signs in pregnancy
(bleeding, Headaches, etc)

30. Interventions cont.
 Serial U/S to assess for Growth and
Development, IUGR, or discordance
 At 34 Weeks weekly NST’s
 ↑ Biophysical Profiles
 ↑ Bed rest ??? Benefit--controversial
 Arrange Pediatric/Neonatal Consult
 Discuss plans/options for delivery

31. Interventions cont.
VAGINAL DELIVERY if:
 Both are Vertex, if are Vtx/Breech/ or if
Vtx/Trans and both are > 1500 gms
 If fetuses are non-viable
CESAREAN DELIVERY if:
 1st fetus if Breech
 2nd twin is breech and weighs < 1500
 Unable to adequately monitor the 2nd
 Multiples > twins
 Mother requests

32. NURSING IMPLICATIONS
 Antepartum
 Emotional support of woman and significant
others
 Teaching
 Monitoring each fetus

33. NURSING IMPLICATIONS--IP
 INTRAPARTUM
 IV
 Type and Screen
 Monitoring
 Anesthesia always present and aware
 SCN/NICU/Neonatology aware
 Staffing to accommodate labor/Cesarean and
Neonatal outcomes

34. NURSING IMPLICATIONS--PP
Postpartum
Mom prone to PP hemorrhage
Many changes in Body systems back to Non-
pregnant state
Emotional changes—weary—
Needs ↑ Sleep
Humans are Monotropic—difficult to bond with 2
people at same time
Moms focus on concrete factors

35. NURSING PP cont’d
 May feel overwhelmed
 Feeding and Caring for 2 (+)
 Assistance with Breastfeeding
 Shock/Inadequacy/Guilt/Sadness

36. NURSING NEONATAL
 ↑ Birth Trauma
 ↑ Hyperbilirubinemia
 ↑ Respiratory problems
 Size Discrepancy
 Rx infections
 Effect of tocolytics given to mother
 ↑ Nutritional needs
 ↑Bonding needs of entire family
 ↑ Risks for Late Preterm infant

37. References
 AWHONN (2009) POEP
 Gilbert, E. S., (2011) 5th edition Manual of
High Risk Pregnancy and Delivery.
 Mattson, S. & Smith, J.E., (2011) 4th
edition Core Curriculum for Maternal-
Newborn Nursing.