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!