Multiple Gestation

Clinical description

Multiple gestation refers to any pregnancy with more than one fetus and is a high risk pregnancy.

Maternal complications include: anaemia, hyperemesis gravidarum, hypertensive disorders of pregnancy, APH, thromboembolism, preterm labour (PTL), prolonged labour, caesarean delivery and PPH.

Fetal/neonatal complications include: twin-twin transfusion syndrome, twin reverse arterial perfusion sequence, miscarriage, IUGR, IUFD, hydrops fetalis, conjoined twins, polyhydramnios/oligohydramnios, cord entanglement, malpresentation, prematurity and death.

Signs and symptoms

History Increased symptoms of early pregnancy (i.e. nausea, vomiting), history of ovulation stimulation drug use, family history of multiple gestation Exam FH ≥ 3 cm than expected by dates, multiple fetal parts and/or > 2 fetal poles palpable, multiple fetal heart tones (difference ≥ 10 bpm) Investigations US with multiple fetal hearts or heads

Treatment

Antenatal management

• Order US for dating and chorionicity as early as possible
• Order US for anatomy and/or anomalies at 18-20 wks gestation
• Order US every 2-3 weeks after 28 wks gestation for growth, Doppler if discordant growth
• For growth discordance > 20%, refer to Central Hospital.
• Weekly NST with AFI (see IUGR) or BPP.
• Antenatal care visits: monthly up to 28 wks gestation, every 2 wks up to 36 wks gestation and then weekly

until delivery at 38 weeks (mono-di, di-di)

• Nutrition: extra daily caloric needs of 600 kcal (for twin gestation) more than a non-pregnant woman; eat

normal balanced diet

• No specific intervention to prevent preterm labour
• Plan delivery around 38 weeks gestational age unless earlier delivery is indicated or labor occurs.
• For monoamniotic (mono-mono) pregnancy, refer to Central Hospital
• Treat with steroids at 28 wks gestation, admit to inpatient ward for daily CTG, and caesarean

delivery between 32-34 wks gestation.

• Consider salvage course of steroids prior to delivery if ≥ 14 days has passed since initial course of steroids.

Intrapartum management

• Partograph to monitor labour progress
• Regular fetal heart rate monitoring for both fetuses, consider use of CTG/Moyo
• Prepare two delivery sets and prophylactic oxytocin IV
• Obstetrics and paediatrics registrars at delivery
• Low threshold for caesarean delivery, especially if primigravida, the woman should be participating in

decision making process

• For cephalic presentation of first twin and no complications, vaginal deliveryno later than at 39 wks

gestation; plan for caesarean delivery if earlier delivery is indicated (i.e. oligohydramnios, IUGR, maternal hypertension or other indications)

• For delay > 30 min between delivery of twins, assess lie and presentation and proceed accordingly
• For transverse lie of second twin, perform internal podalic version then breech extraction in OT
• For cephalic presentation of second twin, start oxytocin augmentation
• After delivery of second twin, perform AMTSL followed by oxytocin 20 IU/1L of NS IV at 30 dpm

Triplet gestation and beyond

• Treat with steroids at 28 wks gestation
• Caesarean delivery at 34 wks gestation or earlier if in labour

Clinical description

One antenatal fetal death in multiple gestation

• Admit to inpatient ward for expectant management
• Monitor for maternal complications of IUFD including infection or DIC (see Intrauterine Fetal Demise)
• Monitor fetal well-being of surviving twin