Multiple Pregnancy and Births 2024 PDF

Multiple Pregnancy/Births NU3115 MOhaja & CKeegan 1 Learning outcomes Aim of Care Students will be able to Assess, diagnose and discus treat any complications the incidence of multiple that may arise...

Multiple Pregnancy/Births NU3115 MOhaja & CKeegan 1 Learning outcomes Aim of Care Students will be able to Assess, diagnose and discus treat any complications the incidence of multiple that may arise births Optimise physical and How twins arise and the psychological importance of chorionicity outcomes for the and zygosity mother babies and Additional information family and support required Support to parents to Risks of complications associated with twins adapt 2  Multiple Births The chances of conceiving twins with In Vitro Fertilisation (IVF) is 1 in 5. Increased monozygotic birth with ‘older’ mothers This technology has resulted in record numbers of multiple births, especially higher-order multiple involving 3 or more fetuses. (Cunningham et al, 2015) 3  Multiple Births  Over the last 40yrs, incidence of multiple births has increased.  In the United States it has increased from 9.5 twin deliveries per 1,000 deliveries in 1975 to 16.7 in 2015 (Martin and Osterman 2019) 9.9 to 16.1 (1975 to 16.7) in England and Wales from 9.2 to 18.4 in Germany, from 9.3 to 17.5 in France, from 9.6 to 16.7 in Denmark, from 5.9 to 9.9 in Japan (Torres et al. 2023) 4  Perinatal statistics https://www.hse.ie/eng/about/who/acute-hospitals-division/woman-infants/national-reports-on-womens- health/irish-maternity-indicator-system-national-report-2022.pdf accessed 16th Sept 2024 5 https://www.saolta.ie/sites/default/files/publications/Women%E2%80%99s%20%26%20Children%E2%80%99 s%20Managed%20Clinical%20%26%20Academic%20Network%20Annual%20Clinical%20Report%202022- 6 th compressed.pdf accessed 16 Sept 2024  Multiple pregnancies Can carry higher risks for Multiple births have the mother and babies considerable consequences Can impose greater burden for families, the health financially and emotionally service and society. Greater requirements for health services Early ultrasound scans have May be underestimated – shown that although there some foetuses will die in may be two or more fetal the first trimester. (Denton sacs in the first few weeks, & O’Brien, 2017, 2024) some fetuses may die during the first trimester (Denton & O'Brien 2017: 965, 2024). 7 Classification: Two Major Types Monozygotic (MZ) Dyzgotic (DZ) (non- (identical) identical) twins are binovular – increase Monozygotic twins are with advancing age and uniovular parity Caucasians about 30% In some families if twins are MZ and dyzygotic twinning is 70% are DZ probably inherited 8 How twins arise/Development Cause is unknown Monozygotic (MZ) – ‘identical’ Arise when Suggestive drugs used to fertilized egg divide into two stimulate ovulation identical halves – during the Incidence 3.5 per 1000 first 14 days after fertilization They will have the same genetic make-up therefore be of the same sex 9  How twins arise / Development Dizygotic or non-identical Associated with several factors: fertilization of two separate ova maternal parity, race, maternal height, weight and infertility (eggs). In such cases the treatment fetuses are genetically different, may or may not be the same sex Results from two separate ova (eggs), by two separate sperm. May be of the same or different sex and are no more genetically alike than any other siblings (Dento & O’Brien 2017) 10  Placentation - Choronicity Chorionicity refer to the number of chorionic (outer) Dichorionic Diamniotic membranes that babies in (DCDA) 2 chorions, 2 amnion. multiple pregnancy Twins (triplets or more) can be mono or dizygotic Amnionicity is the number of Monochorionic amnions (inner membranes) Diamniotic (MCDA) – one that surrounds babies in chorion, 2 amnion – twins are multiple pregnancy monozygotic Depending on the stage of Monochorionic embryogenesis at which the Monoamniotic (MCMA) – zygote splits four different one chorion, one amnion – MZ types of twins may result twins 11 Timing of Splitting When the splits occur within 3-4 days after fertilization, which occurs in one-third of monozygous twins have DCDA placentas (can be dizygotic or monozygotic). All dizygous twins have 2 amnions and 2 chorions. If the split occurs between 4-8 days – there will be one chorion but two amnions (70% - two-thirds) – (MCDA) If the split comes later between days 9-12 monoamniotic (MCMA) occurs (1%) Conjoined twins occur because the splitting of the embryo does not take place until after the primitive streak has differentiated 12 13 14  Chorionicity DZ & MZ All dizygotic - DZ ( non In MZ twins the zygote identical ) twins have splits early within 72 dichorioinc diamniotic placentas hours after fertilisation they can be fused or Each twin will lie in its separate own sac and the placenta will have separate chorions and amnions Dichorionic /diamniotic 15  Diagnosis of multiple pregnancy The "lambda sign" is also called the "twin peak sign". Early ultrasound >6 weeks most aware at 20 weeks At ultrasound at a gestational Chorionicity determined in the first age of 16-20 weeks, the trimester "lambda sign" is indicative of Palpation: fundal height greater than dichorionicity but its absence expected after 20 weeks especially does not exclude it. Foetal movement over a wide area When booking at ANC, a family history of twins should alert the midwife to the possibility of a multiple pregnancy 16 Care Pathways (NICE 2011) 17  Palpation Antenatal screening Fundal height may be NT fold preferably in greater than expected combination with biochemical screening ( not Foetal poles head and biochemical alone) breech may be felt Chorionic villus Smaller than expected sampling (CVS) can be performed from 11th week head for the size of the has 3-4% of miscarriage uterus Inform women about the 2 heartbeats with a complexity of decisions they may need to make variation of 10 beats depending on screening apart outcomes, including different options according to chorionicity. 18  Antenatal screening Monochorionic twin pregnancies: USS every 2 Ultrasound measures the wks from 16 -24 wks to thickness of the fluid build check fetal growth and up at the back of the signs of twin-to-twin developing baby's neck. If transfusion syndrome this area is thicker than (TTTS) normal, it can be an early sign of Down’s Syndrome Dichorionic twins: USS from or heart problems. 16wks, anomaly scan between 18 t 20+6 weeks Cardiac anomaly USS Nuchal translucency for - All monozygotic twins should Down’s syndrome is have echocardiography accurate only if performed performed at approx 20wks between 11-13 weeks gest as there is a higher risk of cardiac anomalies in these babies 19 Support for parents Parent education Early diagnosis and Early classes or chorionicity is specialist classes important for parents Twins club good source May be shocked of information disbelief Preparation for Support groups may be appropriate breastfeeding In touch with breastfeeding groups 20  Complication associated with multiple pregnancy Common disorders more Occasionally one fetus dies and severe e.g. ‘morning sickness’, becomes mummified heartburn. Increased oedema of ankles and varicose veins Higher order births increase As pregnancy progresses mortality dyspnoea, backache and exhaustion Increased risk of eclampsia, Higher mortality rates some miscarriage, anaemia, suggestion that 75% of one or haemorrhage, operative delivery both twins are miscarried and postnatal illness, acute Many due to congenital polyhydramnios, (Denton & malformations O’Brien 2017, 2024) 21  Complications of Multiple Pregnancy Acute Polyhydramnios: occur as early as 16 weeks, Preterm labour – major may be associated with risk. fetal abnormalities, with More than 50% of twins monochorionic twin and almost all tripplets are pregnancies born before 37weeks Approx. 15-20% admission to NICU are associated More likely to be attributed with twins to twin to transfusion Birth before 28weeks occur syndrome frequently Women complain of rapid HR (Denton & O’Brien 2017) 22  Fetal Complications during pregnancy - Twin to Twin Transfusion Syndrome (TTS) Acute or chronic occurs in about 15% of monochorionic diamniotic twin pregnancies Arises due to unequal blood flow through the placental anastomoses from one fetus to another The donor shares blood through arteriovenous anastamoses of the placenta of the recipient twin Risks; IUGR, oligohydramnios, anaemia in the donor twin, hyperperfusion, hypervoleamia and congestive hear failure of the recipient (Denton & O’Brien 2017) 23  Fetal Complications during pregnancy – Conjoined Twins Conjoined twins – extremely rare malformation of monozygotic twins Results from the incomplete division of the fertilised ovum after day 12 of conception. Occurs 1.47 per 100,000 births. Prognosis depends on the site and extent of conjoining, but in general, about 50% are stillborn and one third of those born alive have severe defects for which surgery is not possible Birth is by CS (Denton & O’Brien 2017) 24  Acardiac Twins (Twin Reversed Arterial Perfusion –TRAP) One twin presents without a well-defined cardiac structure Kept alive through placental anatomoses to the circulatory system of the healthy twin (RCOG 2016) Early diagnosis required Intra-fetal laser therapy can be carried out before 16 weeks 25  Other complications LBW IUGR Ante partum Birth asphyxia especially haemorrhage twin B PP - large placental site Malpresentations encroaching on lower Pre labour and preterm uterine segment rupture of membranes Anaemia Umbilical cord Placental abruption may accidents occur following rupture Operative delivery and PPH of the membranes and diminution of uterine size 26  Antenatal Care NICE 2011, 2019 Early diagnosis and chorionicity MDT - specialist obstetricians, Offer at least 9 AN specialist midwives and appointment for women with ultrasonographers with uncomplicated monochorionic experience and knowledge of twin managing twin and triplet pregnancies 8 AN appointment to be offered to women with an enhanced team for referrals (to include a perinatal mental health uncomplicated dichorionic professional, a women’s health twin physiotherapist, an infant feeding Information and emotional coordinator, and a dietitian). support Offer information and support Explain sensitively the aims specific to twin and triplet and possible outcomes of pregnancies at first contact and screening and diagnostic tests provide ongoing opportunities for to minimise anxiety. discussion covering: (NICE 2011, amended 2019) 27  Antenatal Care Provide ongoing opportunities Give the same advice about (AN education) to discuss the diet, lifestyle and nutritional following supplements as in routine the risks, symptoms and signs of antenatal care.‡ preterm labour and the potential need for Be aware of the higher corticosteroids for fetal lung incidence of anaemia in women maturation with twin and triplet likely timing and possible modes pregnancies. of delivery Perform a FBC at 20–24 weeks breastfeeding to identify a need for early Parenting supplementation with iron or (extensive information about each folic acid, and repeat at 28 visit in NICE guidelines 2011) weeks as in routine antenatal care. (NICE 2011, 2019, 2024) 28  Antenatal Care Hypertension Measure blood pressure and test Labour, pain relief and urine for proteinuria at each birth appointment, as in routine antenatal Possibilities of premature care. labour Advise women to take low dose Visit to the neonatal unit aspirin daily from 12 weeks until the birth of the babies if they have one or Breastfeeding and bottle more of the following risk factors for feeding hypertension: Equipment needed - first pregnancy (buggies, car seats, - age 40 years or older layette etc.) - pregnancy interval of more than 10 years Coping with newborn - BMI of 35 kg/m2 or more at first visit twins or more - family history of pre-eclampsia (NICE 2019) 29  Predicting the risk of IUGR preterm birth Estimate fetal weight Be aware that women with twin pregnancies have a higher risk of discordance using two spontaneous preterm birth if or more biometric they have had a spontaneous parameters at each preterm birth in a previous single scan from 20 weeks. pregnancy. Do not scan more Do not use cervical length (with or than 28 days apart. without fetal fibronectin) routinely Consider a ≥ 25% to predict the risk of preterm birth difference in size as Do not use the following to predict clinically important the risk of preterm birth: and refer woman to a fetal fibronectin testing alone tertiary level fetal home uterine activity monitoring medicine centre. (NICE 2011, 2019, 2024) 30  Do not use: abdominal palpation or To prevent preterm symphysis–fundal height birth measurements to predict bed rest at home or in intrauterine growth restriction hospital intramuscular or umbilical artery Doppler vaginal progesterone ultrasound to monitor for cervical cerclage intrauterine growth restriction or birth weight differences oral tocolytics not routinely targeted only (NICE 2011, 2019) 31  Timing of birth Inform women with twin Offer pregnancies that about 60% of Order/ elective birth twin pregnancies result in chorionicity from spontaneous birth before 37 weeks 0 days. Monochorionic 36 weeks 0 Inform women with triplet twins days* pregnancies that about 75% of triplet pregnancies result in spontaneous birth before 35 weeks Dichorionic 37 weeks 0 0 days. twins days Inform women with twin and triplet pregnancies that 35 weeks 0 Triplets spontaneous preterm birth and days* elective preterm birth are associated with an increased risk of admission to a special care baby unit. *after a course of corticosteroids has (NICE 2011, 2019, 2024) been offered 32 Presentations 33  Mode of birth Twin pregnancy: dichorionic diamniotic or monochorionic diamniotic uncomplicated twin pregnancy planning their mode of birth that planned vaginal birth and planned caesarean section are both safe choices for them and their babies if all of the following apply: the pregnancy remains uncomplicated and has progressed beyond 32 weeks there are no obstetric contraindications to labour the first baby is in a cephalic (head-first) presentation there is no significant size discordance between the twins. [NICE 2019] Offer caesarean section to women if the first twin is not cephalic at the time of planned birth [NICE 2019] Offer caesarean section to women in established preterm labour between 26 and 32 weeks if the first twin is not cephalic. [NICE 2019] 34  Twin pregnancy: monochorionic monoamniotic Triplet pregnancy Offer a caesarean section to Offer a caesarean section to women women with a triplet with a monochorionic pregnancy: monoamniotic twin pregnancy: at the time of planned birth at the time of planned birth (35 weeks) or (between 32+0 and 33+6 weeks) or after any complication is after any complication is diagnosed diagnosed in her pregnancy requiring earlier For women who decline delivery or elective birth, offer weekly if she is in established preterm appointments with the labour, and gestational age suggests specialist obstetrician. there is a reasonable chance of At each appointment offer an survival of the babies (unless the ultrasound scan, and perform first twin is close to vaginal birth and weekly a senior obstetrician advises continuing to vaginal birth). biophysical profile assessments and fortnightly fetal growth (NICE 2019) scans. 35  Prepare for birth Offer planned birth at 37 weeks to women with an uncomplicated Senior staff involved dichorionic diamniotic twin Anaesthetist paediatrics pregnancy. Offer planned birth as should be in attendance follows, after a course of antenatal Explained to parents who corticosteroids has been considered they are and why they are (see the section on maternal present corticosteroids in NICE's guideline on IV Access group and save preterm labour and birth): or cross matched if at 36 weeks for women with an indicated uncomplicated monochorionic Two resuscitaires diamniotic twin pregnancy prepared fully equipped labelled twin 1 and twin 2 between 32+0 and 33+6 weeks for triplet 1 etc. women with an uncomplicated Usually one team for each monochorionic monoamniotic twin more experienced pregnancy personnel ? Twin 2 (NICE 2019, 2024) 36  First stage Labour in the mother of twins is Uterine activity monitored considered high risk Pain relief: epidural Onset: the higher number of analgesia is the pain relief fetuses the earlier the labour is of choice offered to women likely to start (Denton and O’Brien 2017) Continuous fetal monitoring of Advantage that manoeuvres each twin is carried out forceps etc. can be carried out 3 way check 2nd Twin - more at risk - maternal pule compared with twin 1 If there are any signs of - maternal pulse compared with twin 2 foetal distress with either - Twin 1 compared with Twin 2 baby emergency caesarean (Denton & O’Brien 2017) section will be performed 37  When carrying out cardiotocography Use dual channel cardiotocography monitors to allow simultaneous monitoring of both fetal hearts Document on the cardiotocograph and in the clinical records which cardiotocography trace belongs to which baby Monitor the maternal pulse electronically and display it simultaneously on the same cardiotocography trace. Consider separating the fetal heart rates by 20 beats/minute if there is difficulty differentiating between them. Twin pregnancy should be considered a fetal clinical risk factor when classifying a cardiotocography trace as 'abnormal' versus 'non-reassuring' fetal scalp stimulation should not be performed in twin pregnancy to gain reassurance after a cardiotocography trace that is categorised as 'pathological‘ [NICE 2019] 38  Second stage If first (presenting) twin is cephalic presentation, labour is usually allowed to continue normally to a vaginal delivery If presenting twin is presenting other than cephalic, an elective caesarean section is carried out Obstetrician, anaesthetist and neonatologist should be present Labour room closer to operating theatre, with two resuscitation equipments Birthing trolley to include equipment for amniotomy, assisted birth, and extra cord clamp After birth of first twins, cord should be firmly clamped in two places & cut between the clamps If maternal side is not secure the 2nd twin may suffer exsanguination (in the case of monochorionic twins (Denton & O’Brien 2017) 39  Second Stage – 2nd Twin Once first twin is born – time of delivery and sex of baby are noted. Baby and cord must be labelled ‘twin 1’. Identity bracelets checked with parents before being applied to baby. Baby may be put to the breast immediately Following birth of twin 1, abdominal palpation to ascertain the lie, presentation and position of the second twin, confirmed by VE If lie is transverse or oblique an attempt may be made to correct the lie by External Version. If this is not possible an emergency CS will be performed USS performed FH and maternal pulse are recorded 40  Second Stage of Labour 2nd sac of Membranes are ruptured once presenting part in pelvis, and no cord presentation following the initial contraction after the birth of first twin. Further to outrule cord prolapse after ARM IV oxytocin may be required for birth of 2nd twin if no contraction Interval between births varies (up to 30 minutes) Once born, the baby and cord are labelled ‘twin 2’. ID bands checked with parents and applied to twin 2. If more than 2 babies – CS is performed After the birth of both babies, consider double clamping the cord to allow umbilical cord blood gases to be sampled (NICE 2019) 41  Undiagnosed twins Unusual Unbooked Large abdomen and small head raise suspicion Oxytocin withheld - Severe anoxia to second twin if given Shocked parents need extra support 42  Third stage By 28 weeks of pregnancy, discuss options for managing the third stage of labour with women with a twin or triplet pregnancy, include the potential for Blood Transfusion. Do not offer physiological management of the third stage to women with a twin or triplet pregnancy. Offer women with a twin or triplet pregnancy active management of the third stage. Explain that it is associated with a lower risk of postpartum haemorrhage and/or blood transfusion. Consider active management of the third stage with additional uterotonics for women who have 1 or more risk factors (in addition to a twin or triplet pregnancy) for postpartum haemorrhage. [NICE 2019, 2024] Consult local policy 43 44  Examination of placenta and membranes Usual examination If babies are of different sex they must be Dizygotic with either 2 separate placentas or one that has fused together – each will have its own amnion and chorion When babies are of the same sex they can be monozygotic or Dizygotic Used to be thought that a single chorion in all monozygotic twins 1/3 of monozygotic twins have a dichorionic placenta 45  2 amnions 2 chorions Two placentae Monochorionic twin placenta Separate placentas 46 Complications During Labour and Birth Cord entanglement Malpresentation Cord prolapse Prolonged labour Cord entanglement: common in monoamniotic twin as they share the same sac. Birth recommended between 32 Locked twins and 34 weeks (RCOG 2016) Locked twins Deferred birth of the 2nd twins – if the first twin is born very mature 47  Postnatal care AS for singleton May be tired Involution slower Lochia heavier Babies may be in SCBU One baby in SCBU Visits encouraged May breastfeed 48  Feeding babies Extra support Brestfeeding takes May prefer to feed separately to get to time know baby 4-6 weeks to Supportive pillows establish routine Bottle feeding – help also Twins can be fed separately or together Help with every feed initially 49 Multiples 50  Coming home Useful Videos Sources of help – twins Twin Birth and multiple groups https://www.youtube.c Family relationships – om/watch?v=Vj22xxh4 other children and partner Ohk https://www.youtube.c Individuality and identity om/watch?v=7hBibFM for each baby 1am8 (from 5 to 10 Postnatal depression mins) (accessed 16th Sept 2024) Bereavement and Disability if one baby died or one or both have a disability 51  References Cheong-See F., Schuit e., Arroyo-Manzano D., Khalil A., Barrett J. et al (2016) Prospective risk of stillbirth and neonatal complications in twin pregnancies: systematic review and meta-analysis. BMJ 2016;354:i4353 http://dx.doi.org/10.1136/bmj.i4353 Chol Y., Bishal D., Minkovitz C., (2009) Multiple Births are a risk factor for postpartum maternal depressive symptoms. Pediatrics. Vol 123. No.4 April 2009. Cunningham,F.Leveno, K. Bloom S. Hauth, J. gilstrap, L. Wenstrom, K. (2015) Williams Obstetrics, 22nd Ed. McGraw Hill Co. Inc.p.9 Da Silva Lopes K, Takemoto Y, Ota E, Tanigaki S, Mori R. (2017)Bed rest with and without hospitalisation in multiple pregnancy for improving perinatal outcomes. Cochrane Database of Systematic Reviews 2017, Issue 3. Art. No.: CD012031. DOI: 10.1002/14651858.CD012031.pub2. Davies M. (2014) in Marshall J and Raynor M. (eds) Myles Textbook for Midwives 16th ed. Churchill Livingstone, London. Pp.287-307 Denton, J. O’Brien W. (2017) Multiple Pregnancy in Macdonald, S and Johnson G.(eds) Mayes’ Midwifery. 15th ed. Elsevier, London. Mugford,M. Henderson,J. (1995) Resource implications of multiple births. In: Humphrey Ward, R., Whittle, M. (eds) Multiple Pregnancy. RCOG Press, London. pp.334-345 Nicolaides, K. Sebire, N. Snijders, R. Ximenes, R. (2008) Types of multiple pregnancy. http://www.centrus.com.br/DiplomaFMF/SeriesFMF/11-14weeks/chapter-05 National Institute for Health and Clinical Excellence (2011) Guideline Twin and Triplet Pregnancy https://www.nice.org.uk/guidance/ng137/resources/twin-and-triplet-pregnancy-pdf-66141724389829 National Institute for Health and Clinical Excellence (2019 update 2024) Guideline (NG137) Twin and Triplet Pregnancy Shub A, Walker SP. Planned early delivery versus expectant management for monoamniotic twins. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD008820.DOI:10.1002/14651858.CD008820.pub2. RCOG (2008) Green top no 51 Guidance for management of monchorioinc twin pregnancy https://www.rcog.org.uk/globalassets/documents/guidelines/t51managementmonochorionictwinpregnancy2008a.pdf Torres C., Caporali A. & Pison G. (2023) The Human Multiple Births Database (HMBD): An international database on twin and other multiple biths. https://www.demographic-research.org/Volumes/Vol48/4/DOI: 10.4054/DemRes.2023.48.4 52