Complications associated with multiple pregnancy

The higher perinatal mortality associated with twinning is largely due to complications of pregnancy, such as the premature onset of labour, intrauterine growth restriction and complications at birth. -The management of multiple pregnancy is concerned with the prevention, early detection and treatment of these complications.

Polyhydramnios Acute polyhydramnios may occur as early as 16 weeks. -It may be associated with fetal abnormality but is more likely to be due to TTTS -which can also be known as fetofetal transfusion syndrome (FFTS).

Twin-to-twin transfusion syndrome -Twin-to-twin transfusion syndrome (TTTS) can be acute or chronic. -The acute form usually occurs during labour - the result of blood transfusing from one fetus (donor) to the other (recipient) through vascular anastomosis in a monochorionic placenta. - Both fetuses may die of cardiac failure if not treated urgently. -Chronic TTTS occurs in about 15% of monochorionic twin pregnancies -

The placenta in TTTS transfuses blood from one twin fetus to the other. -This results in anaemia and growth restriction in the donor twin (the term ‘stuck twin’ may be used) - polycythaemia with circulatory overload in the recipient twin (hydrops). -The fetal and neonatal mortality is high but infants may be saved by early diagnosis and prenatal treatment - amnioreduction, which may have to be repeated regularly as fluid can reaccumulate rapidly. - or laser ablation therapy of communicating placental vessels, or septostomy

-The midwife should always be alerted to the mother who complains of a rapid increase in her abdominal girth in the second trimester - a uterus that feels hard and uncomfortable continuously, due to polyhydramnios and if not treated urgently can cause premature labour. - This usually occurs in women who have a monochorionic pregnancy

Fetal abnormality -associated with monochorionic twins. 1-Conjoined twins -rare malformation of monozygotic twinning - results from the incomplete division of the fertilized oocyte; -it occurs once in births and over half the cases are stillborn. -Delivery has to be by caesarean section. - Separation of the babies is sometimes possible and will depend on how they are joined and which internal organs are involved.

Thoracopagus is the commonest form of fusion (over 70% of cases). -Many conjoined twins can now be successfully separated. -Others pose major ethical dilemmas – particularly if one can be saved at the expense of the other.

2-Twin reversed arterial perfusion Twin reversed arterial perfusion (TRAP) -In TRAP, one twin presents without a well-defined cardiac structure and is kept alive through placental anastomoses to the circulatory system of the viable fetus

3-Fetus-in-fetu -In fetus-in-fetu (endoparasite) - parts of a fetus may be lodged within another fetus - this can happen only in MZ twins Malpresentations - malpresentations, particularly of the second twin. - After the birth of the first twin, the presentation of the second twin may change.

Premature rupture of the membranes -Malpresentations due to polyhydramnios may predispose to pre-term rupture of the membranes. Prolapse of the cord -associated with malpresentations and polyhydramnios, with a poorly fitting presenting part. - The second twin is particularly at risk of cord prolapse. Prolonged labour -Malpresentations are a poor stimulus to good uterine action - a distended uterus is lead to poor uterine activity and prolonged labour.

Monoamniotic twins -Approximately 1% of twins share the same sac. -(MCMA) twins risk cord entanglement with occlusion of the blood supply through the umbilical cords to one or both fetuses. - treated with sulindac taken by the mother to reduce amniotic fluid levels - delivered at around 32–34 weeks -by elective caesarean section

Locked twins -a very rare but serious complication. -There are two types 1- the first twin presents by the breech and the second by the vertex 2- when both are vertex presentations In both instances, the head of thesecond twin prevents the continued descent of the first. -Primigravidae are more at risk than multiparous women.

Delay in the birth of the second twin -After the birth of the first twin, uterine activity should recommence within 5 min. -Ideally the birth of the second twin should be completed within 45 min of the first twin being born - Poor uterine action as a result of malpresentation may be the cause of delay.

-The risks of such delay are 1-intrauterine hypoxia 2- birth asphyxia 3- premature separation of the placenta 4- sepsis as a result of ascending infection from the first umbilical cord, which lies outside the vulva. - After the birth of the first twin the lower uterine segment begins to reform and the cervical canal may have to dilate fully again.

-The midwife may need to ‘rub up’ a contraction - put the first twin to the breast to stimulate uterine activity. - a caesarean section may be necessary if obstructed labor occur -If there is no obstruction, oxytocin infusion may be commenced or forceps delivery considered.

Premature expulsion of the placenta -The placenta may be expelled before the birth of the second twin. - In dichorionic twins with separate placentae, -in monochorionic twins the shared placenta may be expelled. - The risks of severe asphyxia and death of the second twin are very high. -Haemorrhage is also likely if one twin is retained in utero as this prevents adequate retraction of the placental site.

Postpartum haemorrhage -Poor uterine tone as a result of over distension or hypotonic activity is likely to lead to postpartum haemorrhage. -There is also a much larger placental site to contract down. Undiagnosed twins -The possibility of an unexpected, undiagnosed second baby (though this is unlikely with ultrasound scanning) should be considered if the uterus appears larger than expected after the birth of the first baby or if the baby is surprisingly smaller than expected.

-If an uterotonic drug has been given after the birth of the anterior shoulder of the first baby - the second baby is in great danger of birth asphyxia and his birth should be expedited. -The midwife must break the news of undiagnosed twins gently to the parents. - These parents will require special support and guidance during the postnatal period.

Delayed interval delivery of the second twin can be used to give betamethasone to the mother to help mature the lungs of the second twin. Careful observations of the mother's condition must be made during this time for signs of infection and fetal compromise. The mother will need additional support from the midwives to cope with her anxieties for her premature baby, time to grieve if the baby has died.

Postnatal period Care of the babies is the same as for a single baby. Maintenance of body temperature is vital use of overhead heaters will help to prevent heat loss. Identification of the babies should be clear The babies may need to be admitted to the neonatal unit -transferred to the postnatal ward with their mother

Temperature control -Maintenance of a thermo neutral environment is essential, particularly for babies in the neonatal unit. Nutrition -The mother may choose to feed her babies by breast or with formula milk - may be breastfed separately or simultaneously. -In the immediate postnatal days, it is recommended the mother breastfeeds her twins separately,

-this give her time to get to know each baby and to feel confident in her ability to cope. -If the babies are small for gestational age or pre-term, the paediatricians may recommend that the babies be ‘topped up’ after a breastfeed. -Expressed breast milk is best for these babies. -If the babies are not able to suck,the mother should be encouraged to express her milk regularly. - human milk bank can be used; this is preferable for pre-term babies,and reduces the risk of necrotizing enterocolitis (NEC)

-As twin babies are more likely to be pre-term or small for gestational age, their ability to coordinate the sucking and swallowing reflexes may be poor. -need to be fed intravenously or by nasogastric tube, or cup-fed,depending on their size and general condition. -Careful monitoring of weight gain is required. - Hypoglycemia may occur and regular capillary blood glucose estimations may be needed.

mother think of insufficient milk, the midwife should reassure her that lactation responds by the babies sucking. - At feeding times, the midwife must be with the mother to offer support and advice on positioning and fixing the babies - encouraging her to breastfeed two babies.

Breastfeeding -The advantages of breastfeeding are the same as for single babies - twins have a higher tendency to be born prematurely and small for gestational age, it is even more important that they should be breastfed.

-advantages of breast milk -It is cheaper - breast milk is available 24 hrs a day - at the correct temperature. -There are no bottles to wash, no sterilizing to organize or feeds to make up, - less take time. -Twins can be breastfed together or separately.

- If the babies are to be fed together, then the feeds will take only a little longer than with a single baby. -Mothers of twins always complain that there is never enough time for cuddling. -breastfeeding together is the only way for her to hold and feed both babies together at the same time. - to coping with two or more babies. It may take 4–6 weeks for a feeding to get established

Mother–baby relationships it more difficult to bond with both babies equally. the mother should be encouraged to spend as much time as possible with the baby on the NNU and to visit as soon after the birth as she feels able. help the mother to divide her attention between both babies and to give plenty of reassurance that she is not the first mother to feel the same way

Mother–partner relationships In some cases her partner may feel that she is devoting too much time to the babies and not enough to him, thus making him feel excluded. The midwife should always encourage the father to be involved in the daily care of the babies, either in hospital or at home.

Care of the mother -involution of the uterus will be slower - ‘After pains’ is more so analgesia should be offered. -A good diet is essential - a high protein, high calorie diet. - It is quite common for breastfeeding mothers to feel hungry between meals and they should be encouraged to keep snacks to hand for such times. -A dietician may be able to offer help. -The physiotherapist or midwife should instruct the mother in her postnatal exercises. - The mother may feel ‘in the way’ if the babies are in the neonatal unit

-She may also have feelings of guilt - let her to express her feeling -keep her up-to-date with the care and condition of her infants. -If one infant is very ill or dies, the mother will experience additional psychological problems. -included partner,relatives & friends in support. -The community midwife will contact the mother after discharge from hospital to arrange home visits. - encouraged to rest and sleep during the day

- eat a well-balanced diet - discourage visitors in the first week at home -The father should be encouraged to help as much as possible. -Isolation can be a real problem for new mothers. - the incidence of postnatal depression to be significantly higher in mothers of twins

Stress, isolation and exhaustion are all significant precipitants of depression; mothers of twins are therefore more vulnerable.