Multiple gestation - NYSORA

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Multiple gestation

Multiple gestation

Learning objectives

  • Define the signs and symptoms of multiple gestation pregnancies
  • Describe the complications associated with multiple gestation pregnancies
  • Management of multiple gestation pregnancies

Definition and mechanisms

  • Multiple gestation is pregnancy with more than one fetus at a time, occurring in approximately 3% of all pregnancies
  • Examples include pregnancy with twins, triplets, and quadruplets
  • High-risk pregnancy requiring extra care
  • Most women have multiple births via caesarean section
  • Babies are often born prematurely and with a low birth weight → need to spend some time in the NICU
  • The goal is to complete 37 weeks in twin pregnancies (considered term) → increases the chance that both babies will be born healthy and at a good weight

Signs and symptoms

  • Exaggerated signs of pregnancy (e.g., extreme nausea and fatigue, severe vomiting)
  • Faster than usual weight gain in the first semester of pregnancy
  • Sore or very tender breasts
  • Higher than normal levels of pregnancy hormones (i.e., human chorionic gonadotrophin)
  • Higher than normal levels of protein alpha-fetoprotein in the mother’s blood
  • Larger than usual belly compared to most women at a similar stage of pregnancy
  • More than one fetal heartbeat

Causes

  • One fertilized egg (ovum) splits before it implants in the uterine lining → monozygotic or identical twins
  • Two (or more) separate eggs are fertilized by different sperm at the same time → dizygotic or fraternal twins
  • Fraternal twins are more common than identical twins
  • In a pregnancy with triplets or more, the babies could all be identical, all fraternal, or a mixture of both

Complications

Maternal

Fetal

  • Preterm delivery
  • Low birth weight
  • Congenital anomalies (e.g., cerebral palsy)
  • Polyhydramnios
  • Cord entanglement
  • Umbilical cord prolapse
  • Fetal growth restriction, intrauterine growth restriction (IUGR), or small for gestational age
  • Malpresentation (e.g., breech presentation)
  • Increased mortality (i.e., miscarriage, stillbirth)
  • Monochorionic twins (one placenta) risks that are unique to them
    • Twin-twin transfusion syndrome
    • Twin anemia polycythemia sequence 
    • Selective IUGR

Risk factors

  • Family history of twins, triplets, or more increases the chance of multiple gestation pregnancy
  • Fertility treatments 
  • Age ≥35 years (women are more likely to release more than one egg per cycle)

Management

All obstetric patients are considered to have a full stomach and be at risk for pulmonary aspiration, regardless of the time of last oral intake

multiple gestation, vaginal delivery, caesarean section, epidural, large bore IV, general anesthesia, nitroglycerine, uterine relaxation, breech extraction, internal version, spinal, aortocaval compression, rapid desaturation, postpartum hemorrhage, resuscitation, uterotonics, neonatal resuscitation

See also caesarean section considerations

See also premature infant considerations

See also postpartum hemorrhage considerations

Suggested reading

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