multiple pregnancy – management
TRANSCRIPT
APARNA P2009 MBBS
Multiple Pregnancy –
Management
Antepartum Management
1.Prenatal care
More frequent antenatal visits.
prophylactic iron 60-100mg and folic acid 1mg daily should be given.
Nutritional advice-calorie req is 300kcal/day more than that recommended for uncomplicated pregnancy.
Restriction of activity and increased rest at home.
Prophylactic steroids – risk for preterm labour or IUGR.
2.Ultrasound scan
At 9-11 wks : confirmation, chorionicity determination, assessment of gestational age and nuchal translucency.
anomaly scan at 20 wks
4 weekly scans in 3rd trimester to assess fetal growth, diagnose complications like TTS
3.Prenatal diagnosis
Screening for aneuploidy
Mid trimester amniocentesis
Chorionic villous sampling
Serum screening
Management of anomalies-
Selective feticide kcl injection
Ultrasound guided doppler coagulation
4.Multifetal and selective pregnancy reduction
Selective fetal reduction-one fetus in a multiple gestation is abnormal
Multifetal reduction-in higher order pregnancy
Iatrogenic fetal death –us guided fetal heart puncture or inj kcl
One member of monochorionic pair should never be selected
Intrapartum Management
1.Place of delivery- Fully equipped hospital having intensive neonatal care unit.
2.Timing of delivery
RCOG recommends elective termination of pregnancy at 37-38 weeks
Monochorionic pregnancy best delivered at 36-37 weeks
Indications For Elective Cs
Maternal indications
Placenta previa
Severe preeclampsia
Previous cs
Cord prolapse is baby
Abnormal uterine contractions,CPD
Fetal indications
Ist fetus noncephalic
Twins with complications IUGR
Monoamniotic twins
Monochorionic twins with severe
TTTS
Vaginal Delivery-prerequisites
First twin presents as vertex,no other indications for CS.
Facilities for operative delivery, careful fetal monitoring,neonatal unit available.
Portable US & preferably a cardiotocography machine with dual channel monitoring.
Second obstetrician(atleast one obstetrician should be experienced in breech extraction)
Anesthetist, Neonatologist
Internal examination soon after rupture of membranes to r/o cord prolapse.
Women should be counseled about chances of operative interference.
She is restricted to taking sips of clear fluids and antacids can be given.
All precautions to combat PPH should be ready like cross matched blood and oxytocics.
Delivery Of First Baby
Liberal episiotomy under local infiltration with 1% lignocaine.
First baby delivered in the usual manner as if it were a singleton.
Cord is clamped immediately at both fetal & placental ends to prevent acute intrapartum transfusion.
IV oxytocics shouldn’t be given at this point as it can cause entrapment and asphyxia of second twin.
Delivery Of Second Twin• Palpate abdomen
immediately to ensure lie,presentation.
• If required-ultrasound examination done.
• Vaginal examination is also done to exclude cord prolapse.
• Acceptable interval between deliveries – 30 mins
Longitudinal LieVertex or breech is presenting,& is in pelvis,good contractionsARM done,second fetus descends rapidly.
If contractions are inadequate,oxytocin given for augmentation, then amniotomy done.
IF VERTEX is low donforceps can be appliedHigh up-r/o CPD, hydrocephalusafter excluding these,internal version & breech extcn under GA
BREECH-delivery compltd by breech extraction
Rapid Delivery Indications are : -
Severe vaginal bleeding
Cord prolapse of second baby
Inadvertent use of iv ergometrine with the delivery of anterior shoulders of first baby
Appearance of fetal distress
Transverse Lie : 2 options
External version
Internal podalic version and breech extraction
Steps Of External Version
Internal Podalic Version Internal podalic version is used
only for second twin when it is lying transversely.
Useful when immediate delivery of second fetus is needed as in cord prolapse or abruption.
Performed in operation theatre under GA
Prerequisites-1. Membranes intact2. Uterus relaxing between pains3. Cervix completely dilated4. Under GA
Contraindications Obstructed labour Membranes ruptured with
all liquor drained Previous CS Contracted pelvisComplications Rupture uterus Anaesthetic risks Atonic pph due to use of
uterine relaxants Birth asphyxia & birth
trauma
ProcedureGen anaesthesia-hand ruptures membranes & introduced into uterine cavity
This hand identifies and grasps the foot and gives traction
Other hand kept on the uterine fundus to provide assistance from above
Manual removal of placenta, iv ergometrine, episiotomy suturing
Twin
1st twin non vertex 1st twin vertex
Caesarean section vaginal delivery of first twin
assess lie of second twin
Vertex breech transverse lie
Vaginal delivery assisted breech external version
delivery
Vertex breech unsuccessful
Vaginal assisted breech intact membrane ruptured
delivery delivery membrane
IP version & breech
extraction CS
Third Stage Cross matched blood should
be readily available.
Risk of atonic PPH is more.
Oxytocin infusion & i/v ergometrine 0.25mg or methergine 0.2mg given following delivery of anterior shoulder of second baby.
Prostaglandins-15 methyl PG F2alpha can also be used.
Placenta examined for completeness, confirm chorionicity.
Thank you!