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MRCOG PART 2 SBAs and EMQs

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ESSAY 155 - MULTIPLE PREGNANCY

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		Posted by uma M. Sat Jul 9, 2005 06:52 am
Triplet pregnancies are assosiated with increased maternal & fetal complications.Perinatal mortality rate due to triplet pregnancy is high (13%) compared to singelton preganancies mainly due to prematurity, low birth weight, congenital anomalies and so is morbidity. Maternal complications include increased risk of hyperemesis miscarriage ,preeclampsia, antepartum haemorrhage, GDM ,preterm labour & it\'s attendant problems due to tocolysis, anaemia, IUD. In this woman, triplets after IVF cycle during which 2 embryos were transferred means that there is division in one embryo after transfer leading to monozygosity of 1 pair of fetuses among triplets.It means that there is chance of monochorionicity for 2 fetuses among 3 of them.If there is monochorionic placentation then additional risks include TTTS, risk of monoamnionicity which carries very high perinatal mortality, increased congenital anomalies Perform USG early to confirm viability, determine chorionicity and this can most accurately be done before 13 weeks. Taking all these into consideration it is appropriate to explain woman the risks assosiated with this pregnancy.She needs appropriate counselling and management of this pregnancy in tertiary center where expertise for fetal medicine are available. Multi fetal pregnancy reduction is not advisable for triplet pregnancies as overall prognosis in reduced pregnancies is not significantly different from that of those managed expectantly. She should be managed in consultant lead care ,at tertiary centre. It is prefferable that a single consultant will take care of her entire pregnancy. Screening for aneuploides is difficult. serum screening is not reliable and is ineffective. Nuchal translucency is reliable, sensitivity of which is unaltered due to triplet .Invasive testing should be done in tertiary centre ,where expertise is also available for selective termination of pregnancy .uTERINE CONTENTS need to be mapped with great care durin g invasive procedures to ensure seperate samples are taken as dictated by chorionicity. She requires frequent AN visits, surveillance every 2 weeks till 24-26,then every week till delivery. She requires additional nutritional supplementation, especially iron and folic acid, as these women are at increased risk of anaemia , APH,PPH. USG is done at 18-20 weeks for anomalies , cardiac scans are advisable as there is increased risk of congenital abnormalities. Frequent growth monitoring is recommended,from 20 weeks to detect any IUGR, Chronic TTTS, discordant growth. USG is likely to be difficult because of over crowding of fetuses. In event of IUGR, fetal monitoring must be more intense with frequent CTG, Doppler,BPP. Routine use of tests for fetal wellbeing ? Doppler studies and BPP may identify impending fetal demise and allow earlier elective delivery She should be screened for Diabetes at 28 -30weeks. Be vigilant for development of Preeclampsia as there is 25% chance of she developing Preeclampsia. Preterm labour is likely in 75% of triplet pregnancies. But there is right now no reliable test for predicting preterm labour.However close monitoring on US of cervical length may provide an oppurtunity for interventions like encirclage. She should be educated regarding symptoms and signs of preterm and advised to report early for medical assistanse. No role for prophylactic encirclage in triplets - it has not been shown that it improves out come.No role for prophylactic steroids. No role for routine tocolysis, bed rest, admission.any .If women presents with threatened preterm labour there is a place for tocolysis and steroids .Tocolysis will cover inutero transfer if necessary to tertiary centre and steroids to be administered. Admission is required is there is maternal discomfort, coping problems at home, develops complications like preeclampsia . Any complications like TTTS, single fetal death , discordant growth, discordant anomalies identified are managed appropriately. Disscuss regarding mode of delivery. preferred mode of delivery is Caessarean section planned one ,as it allows the relevant neonatal staff and equipment to be gathered, and obviates the difficulties assosiated with intrapartum fetal monitoring. Antenatally she should be prepared to cope with managing these babies. Specific information and support to help them caring there babies is provided.Joinning local twin club offer many oppurtunities and support to the family.Provide information leaf lets with all relavent information.
		Posted by Sreekala S. Sat Jul 9, 2005 07:09 pm
Triplet pregnancy comes under \"high risk\" category and therefore should be dealt by the consultant led team. Once the diagnosis of triplet pregnancy is made, possibility of an early fetal loss should be carefully explained to the couple. The maternal risks of miscarriage, preterm labour, Anemia, Pre eclampsia, antepartum haemorrhage, increased maternal discomfort, glucose intolerance, polyhydramnios, PPH, increased operative delivery and fetal risks of IUGR, LBW & VLBW babies,IUD, fetal anomalies may need to be discussed. They should be prepared for close follow up in the 3rd trimester, need for hospitalization and risks of preterm labour or operative delivery. Assistance may be given in planning for the caring of 2 or more premature babies. Although only 2 embryos were transferred, there are 3 embryos developing indicating the possibility of a monozygous twinning in one of the two transferred embryos, with an increased probability of monochorionic fetuses developing along side another embyo. Ultrasound scanning is mandatory to determine the chorionicity and should be preferably performed in the 1st trimester as it is 100% accurate now to determine the chorionicity. Determination of chorionicity is important for counselling and management issues as Monochorionic twins are at a higher risk of late miscarriages, genetic / structural abnomalities and high perinatal mortality. chorionicity also needs to be known before invasive testing, management of discordant growth or for selective fetal reduction if desired. Serum Screening may be offered, but has a poor detection rate in multiple pregnancy. Nuchal translucency thickness for detecting trisomy 21 is similar to that of singleton pregnancies. Amniocentesis and CVS carry similar fetal loss rates as that of singletons but amniocentesis may be preferable as CVS is associated with the risk of feto-fetal contamination and failure to obtain a sample. Multifetal pregnancy reduction may be offered at 11-12 weeks after the main risk of miscarriage, when Nuchal translucency mearurement identifies fetuses with the lowest risk of aneuploidies to the left intact. Multifetal reduction reduces the chances of miscarriage and preterm labour while increasing the take home baby rate. A careful assessment for the development of maternal complications should be done at every antenatal visit with measurement of BP, weight, Hb%estimation, urinalysis for protein and sugars. It may be reasonable to prescribe Iron and Folic acid to build up stores and prevent anemia. Frequent scans to monitor fetal growth to detect IUGR, twin-twin transfusion syndrome and measurement of cervical length to detect preterm labour are worthwhile. If Dichorionicity is present then 4 weekly scans from 24weeks should be done and if monochorionicity is present, then fortnightly scans from 18 weeks should be considered because of higher risk of IUGR in monochorionic fetuses. Doppler studies may be needed if there is discordant growth, IUGR or suspicion of TRAP or twin-twin transfusion syndrome. Referral to tertiary level fetal medicine centers is indicated if such conditions are detected. Home uterine monitoring to detect uterine contractions may be done to predict preterm labour, but it is associated with a higher chance of unscheduled hospital visits. Detection of fetal fibronectin in cervical swabs at 28 weeks predicts only 50% of those who will deliver before 35 weeks compared to 80-90% in singleton pregnancies. The pregnancy may have to be intervened depending on the development of any maternal or fetal complications. Antenatal classes should be given to the parents to give specific inormation and advice about feeding, equipment and parenting skills . Contat with organizations like Multiple births foundation should be encouraged at an early stage. Opitmal results can be expected in the presence of good fetal suveillance with serial growth scans, biophysical assessments and psychological supportive counselling in experienced hands.
		Posted by Mangala sundari R. Sat Jul 9, 2005 07:32 pm
Higher order multiple pregnancy as in this patient carries more perinatal morbidity and mortality. Though she had only IVF-ET of only 2 embryos, one has further divided into two. So it is monochorionic twins added to the singleton. The surveillance and outcome will be like that of the monochorionic diamniotic twins. The patient will be explained about the ultrasound findings and the triplet pregnancy. And the associated complications and outcome associated with triplets,If she wishes to have to go for fetal reduction she will be referred to fetal medicine centre for furthur counseling and procedure. If she wishes to continue with the pregnancy she will be followed up as a high risk patient by the consultant care. In the first trimester she will undergo all the booking investigations, ( CBC, Gr/Rh/antibodies/VDRL,Hepatitis B,Rubella,) and folic supplementation given. She can be prescribed cyclogest (progestogins) p/r or oral tablets for endometrial support or HCg injections till 12 to 14 weeks till placenta takes over the function. She is more likely to have exaggerated hyperemesis gravidarum, threatened miscarriage or bleeding or miscarriage.She will be advised to have more frequent AN checkups and admissions as and when required. The shorter cervical length ( less than 3.5 cms or coning of the internal os is an indication for cervical cerclage. In the second trimester, she will have an anomaly scan at 18 to 20 weeks,. The serum narkers are not reliable for anomalies in multiple pregnancy. If found to be abnormal , should refer to fetal medicine centre for furthur evaluation. Otherwise she should de advised adequate rest, iron folic acid supplementations. They may have early onset pregnancy induced htpertension, lower limb edema, backache due to lordosis, frequent UTI, vaginal infections due to poor perineal hygiene,Respiratory embarrassment due to enlarging abdomen, varicose veins and venous stasis in the lower limbs . Twin to twin transfusion syndrome, acute hydramnios, discordant growth, IUGR, death of one twin are complications of monochorionic twins and should be looked for and managed accordingly. She will undergo screening for Gestational diabetes between 28 ? 32 weeks. Patients with triplets will go into preterm labour 4 to 6 weeks earlier than the twins and the perinatal morbidity and mortality are more due to prematurity and its complications. In the earliest sign of labour she should be admitted , and steroids given. Though there is no confirmed study about their efficacy in triplets it is given before 34 weeks of gestation. The administration of tocolytics should be with caution, ( mag sulph preferable to B sympathomomietics ) till the steroids take effect. She will be planned for elective C section after consultaion with anesthesiologists nd neonatologists. Active management of third stage with oxytocics done since PPH is more coomon.Thromboprophylaxis done as per protocol , especially if she was not mobile well or hospitalized for long time. Partner and family support for the new borns should be assured before discharge. Contraceptive advise given and to come for postnatal followup. MANGALA Bahrain
		Posted by Mangala sundari R. Sat Jul 9, 2005 07:55 pm
Higher order multiple pregnancy as in this patient carries more perinatal morbidity and mortality. Though she had only IVF-ET of only 2 embryos, one has further divided into two. So it is monochorionic twins added to the singleton. The surveillance and outcome will be like that of the monochorionic diamniotic twins. The patient will be explained about the ultrasound findings and the triplet pregnancy. And the associated complications and outcome associated with triplets,If she wishes to have to go for fetal reduction she will be referred to fetal medicine centre for furthur counseling and procedure. If she wishes to continue with the pregnancy she will be followed up as a high risk patient by the consultant care. In the first trimester she will undergo all the booking investigations, ( CBC, Gr/Rh/antibodies/VDRL,Hepatitis B,Rubella,) and folic supplementation given. She can be prescribed cyclogest (progestogins) p/r or oral tablets for endometrial support or HCg injections till 12 to 14 weeks till placenta takes over the function.Early fetal loss is common in multiple pregnancy. She is more likely to have exaggerated hyperemesis gravidarum, threatened miscarriage or bleeding or miscarriage.She will be advised to have more frequent AN checkups and admissions as and when required. The shorter cervical length ( less than 3.5 cms or coning of the internal is an indication for cervical cerclage.US done for chorionocity and fetal viability. In the second trimester, she will have an anomaly scan at 18 to 20 weeks,. The serum narkers are not reliable for anomalies in multiple pregnancy. If found to be abnormal , should refer to fetal medicine centre for furthur evaluation. Otherwise she should de advised adequate rest, iron folic acid supplementations. They may have early onset pregnancy induced htpertension, lower limb edema, backache due to lordosis, frequent UTI, vaginal infections due to poor perineal hygiene,Respiratory embarrassment due to enlarging abdomen, varicose veins in the lower limbs . Twin to twin transfusion syndrome, acute hydramnios, discordant growth, IUGR, death of one twin are complications of monochorionic twins and should be looked for and managed accordingly. She will undergo screening for Gestational diabetes between 28 ? 32 weeks. In the third trimester she will have more frequent US and growth scan and doppler studies for IUGR and TTTS. Patients with triplets will go into preterm labour 4 to 6 weeks earlier than the twins and the perinatal morbidity and mortality are more due to prematurity and its complications. In the earliest sign of labour she should be admitted , and steroids given. Though there is no confirmed study about their efficacy in triplets it is given before 34 weeks of gestation. The administration of tocolytics should be with caution, ( mag sulph preferable to B sympathomomietics ) till the steroids take effect. She will be planned for elective C section after consultaion with anesthesiologists nd neonatologists. Active management of third stage with oxytocics done since PPH is more coomon.Thromboprophylaxis done as per protocol , especially if she was not mobile well or hospitalized for long time. Partner and family support for the new borns should be assured before discharge. Contraceptive advise given and to come for postnatal followup. MANGALA Bahrain
		Posted by jyoti D. Sat Jul 9, 2005 08:50 pm
multiple pregnancies are at high risk of perinatal mortality and morbidity and maternal complications.the aim of antenatal care is to prevent ,identify and manage complications. women should be ex[plained about the fact how 3 fetus if 2 embroys were transferred that one embryo would have undergone division so monozygous twin and one singleton. the maternal complications include hyperemesis gravidarum,pregnancy induced hypertension so regular blood pressure and urine for proteins and sugar tested and accordingly glucose tolerance test as at increased risk of geatational diabetes mellitus.physiological anaemia is common hence regular fullblood count and advice regarding folic acid and diet should be given , she might experience discomfort and backach because of averdistention and more if associated polyhydramnions.check for rubella status,rhesusstatus and accordingly anti d prescribed , advice against smoking and alcohol. the fetal complications include misscarrige,congenital anamolies so dating scan done for chorionicity as monochorionic are at increased risk of complications.serum screening is not reliable and nuchal tranclucency is sensitive in multiple pregancies and hence if decised for fetal reduction or amnioncentesis its important to explain the risk of misscariage and carried out at the tertiary centers.fetal surviellance in form of subsequent scans fortnightly for cervical length as increased risk of preterm labour ,cervical cerclage its role is not clear and fetal fibronectin in predic`ting preterm labour is low in multiple pregnancies.role of steroids in multiple pregnancies is still debatable if comes in preterm labour can consider tocolytics till administration of steroids and intrauterine transfer. if the complications like intrauterine growth restriction ,very low birth weight babies ,twin to twin transfusion syndrome conjoint twins,one fetal demise occurs a multidisciplinary team involving the fetal medicine expert,paediatrician ,radiologist is important in a tertiary center,the mean age of delivery in triplets is around 33 weeks so risk of neonatal admission and neurodevelopmental problems should be explained . parents should be encouraged to attend parenteral classes as multiple pregnancies are at increased risk of social,psychological and have financial implications.leaflets with phone numbers of the multiple pregancies organiosation should be provided.
		Posted by jyoti D. Sat Jul 9, 2005 09:00 pm
susequent scans for growth and liquor .vaginal delivery is not a contraindication but usually caesarian section is practised.
		Posted by Shakira B. Sun Jul 10, 2005 07:42 am
A) Triplet pregnancy ia a high risk pregnancy with risk to mother and foetus. Due to increasing use of ART, multiple pregnancy are also incrasing. For mother the risks are:- Hyperemesis, anemia, polyhydraminios, abdominal discomfort, pre- eclampsia, APH, increasing use of operative delivary and CS. For the foetus the risks are:- increase in miscarriage, preterm labour, IUGR, Congenital anamolies. LBW and VLBW. Triplet pregnancy occuring afterreplacement of 2 embryos, means one of them is duplicated, so there is one set of monochorionic twins in them. This is associated with higher morbidity and mortalitydue to shared circulation between them. US screening in first trimester is important:- to find out chorionicity as this has an important rule later for detecting any structural / genetic abnormality and in invasive testing / feotal reduction / to moniter growth. As discordant growth, TTS is quite common in monochorionic twins. AN screening test based upon bio- chemical test are not very helpful in triplets, so nuchal translucency by US is helpful in finding out chromosomoally abnormal foetus. Invasive testing in the form of amnio/CVS can be done to confirm chromosomal abnormality in foetus if screening test are positive. Amnio preffererd as in CVS there is risk of contamination. Both the women and her partner should be involved in the decision of treatment. Options include non - intervention and TOP. parity, ease of conception, nature of subfertility treatment and the couple\'s religious and moral stance will influence couples decision. With non intervention there is chance of loss of all three feotuses. This is unlikely to be accepted in a women with long history of infertility. A women who has responsibility of other children to care or may find the prospect of long inpatient stay and huge impact of multiple births on the family unit unacceptable. If transfer to a distant unit is required due to inadequate facilities locally. If premature delivary occurs there is increase risk of cerebral palsy and sequalae of extreem prematurity are significant. Couple should be informed of frequent AN visits and there care will be hospital consaltant led care. At AN visit BP, wt, HB, urine are checked. Advised to take folicacid and iron supplements, as incidence of anemia is high. growth scans to detect IUGR, TTS should be every 4 weeks for 24 weeks and much earlierin MC twins. As these pregnancies are prone for preterm labour, patient advised about its symptoms and to report to hospital early. No evidence of benifit from complete bed rest / tocolysis / cerclage. Cervical length measurement and funnelling of membranes at internal os are predictors of preturm labour. Fetal fibronectin in cervical secretion can predict preterm labour. For IUGR, Doppler studies helps patients should have antenatal classes and advises how to cope with multiple birth, they should be put in touch with multiple birth foundation. These patients have mixed emotional felings with guilt if they opt for TOP. In such cases counselling must be continued.
		Posted by Shakira B. Sun Jul 10, 2005 07:42 am
A) Triplet pregnancy ia a high risk pregnancy with risk to mother and foetus. Due to increasing use of ART, multiple pregnancy are also incrasing. For mother the risks are:- Hyperemesis, anemia, polyhydraminios, abdominal discomfort, pre- eclampsia, APH, increasing use of operative delivary and CS. For the foetus the risks are:- increase in miscarriage, preterm labour, IUGR, Congenital anamolies. LBW and VLBW. Triplet pregnancy occuring afterreplacement of 2 embryos, means one of them is duplicated, so there is one set of monochorionic twins in them. This is associated with higher morbidity and mortalitydue to shared circulation between them. US screening in first trimester is important:- to find out chorionicity as this has an important rule later for detecting any structural / genetic abnormality and in invasive testing / feotal reduction / to moniter growth. As discordant growth, TTS is quite common in monochorionic twins. AN screening test based upon bio- chemical test are not very helpful in triplets, so nuchal translucency by US is helpful in finding out chromosomoally abnormal foetus. Invasive testing in the form of amnio/CVS can be done to confirm chromosomal abnormality in foetus if screening test are positive. Amnio preffererd as in CVS there is risk of contamination. Both the women and her partner should be involved in the decision of treatment. Options include non - intervention and TOP. parity, ease of conception, nature of subfertility treatment and the couple\'s religious and moral stance will influence couples decision. With non intervention there is chance of loss of all three feotuses. This is unlikely to be accepted in a women with long history of infertility. A women who has responsibility of other children to care or may find the prospect of long inpatient stay and huge impact of multiple births on the family unit unacceptable. If transfer to a distant unit is required due to inadequate facilities locally. If premature delivary occurs there is increase risk of cerebral palsy and sequalae of extreem prematurity are significant. Couple should be informed of frequent AN visits and there care will be hospital consaltant led care. At AN visit BP, wt, HB, urine are checked. Advised to take folicacid and iron supplements, as incidence of anemia is high. growth scans to detect IUGR, TTS should be every 4 weeks for 24 weeks and much earlierin MC twins. As these pregnancies are prone for preterm labour, patient advised about its symptoms and to report to hospital early. No evidence of benifit from complete bed rest / tocolysis / cerclage. Cervical length measurement and funnelling of membranes at internal os are predictors of preturm labour. Fetal fibronectin in cervical secretion can predict preterm labour. For IUGR, Doppler studies helps patients should have antenatal classes and advises how to cope with multiple birth, they should be put in touch with multiple birth foundation. These patients have mixed emotional felings with guilt if they opt for TOP. In such cases counselling must be continued.
		Posted by Shakira B. Sun Jul 10, 2005 07:42 am
A) Triplet pregnancy ia a high risk pregnancy with risk to mother and foetus. Due to increasing use of ART, multiple pregnancy are also incrasing. For mother the risks are:- Hyperemesis, anemia, polyhydraminios, abdominal discomfort, pre- eclampsia, APH, increasing use of operative delivary and CS. For the foetus the risks are:- increase in miscarriage, preterm labour, IUGR, Congenital anamolies. LBW and VLBW. Triplet pregnancy occuring afterreplacement of 2 embryos, means one of them is duplicated, so there is one set of monochorionic twins in them. This is associated with higher morbidity and mortalitydue to shared circulation between them. US screening in first trimester is important:- to find out chorionicity as this has an important rule later for detecting any structural / genetic abnormality and in invasive testing / feotal reduction / to moniter growth. As discordant growth, TTS is quite common in monochorionic twins. AN screening test based upon bio- chemical test are not very helpful in triplets, so nuchal translucency by US is helpful in finding out chromosomoally abnormal foetus. Invasive testing in the form of amnio/CVS can be done to confirm chromosomal abnormality in foetus if screening test are positive. Amnio preffererd as in CVS there is risk of contamination. Both the women and her partner should be involved in the decision of treatment. Options include non - intervention and TOP. parity, ease of conception, nature of subfertility treatment and the couple\'s religious and moral stance will influence couples decision. With non intervention there is chance of loss of all three feotuses. This is unlikely to be accepted in a women with long history of infertility. A women who has responsibility of other children to care or may find the prospect of long inpatient stay and huge impact of multiple births on the family unit unacceptable. If transfer to a distant unit is required due to inadequate facilities locally. If premature delivary occurs there is increase risk of cerebral palsy and sequalae of extreem prematurity are significant. Couple should be informed of frequent AN visits and there care will be hospital consaltant led care. At AN visit BP, wt, HB, urine are checked. Advised to take folicacid and iron supplements, as incidence of anemia is high. growth scans to detect IUGR, TTS should be every 4 weeks for 24 weeks and much earlierin MC twins. As these pregnancies are prone for preterm labour, patient advised about its symptoms and to report to hospital early. No evidence of benifit from complete bed rest / tocolysis / cerclage. Cervical length measurement and funnelling of membranes at internal os are predictors of preturm labour. Fetal fibronectin in cervical secretion can predict preterm labour. For IUGR, Doppler studies helps patients should have antenatal classes and advises how to cope with multiple birth, they should be put in touch with multiple birth foundation. These patients have mixed emotional felings with guilt if they opt for TOP. In such cases counselling must be continued.
		Posted by hassan M. Sun Jul 10, 2005 11:12 am
News of triplet pregnancy to a woman undergoing treatment of infertility would be assocated with joy as well as anxiety .Patient should be informed that though she was transferred 2 embryos one zygote has split into 2 resulting in triplet .There is a25%chance of having monochorionic pregnancy among mz twins. .Triplet are asscociated with increased risk of perinatal morbidity and mortality due to prematurity , birth of extremely preterm babies, iud ,& congenital anomalies..Maternal morbidities are due to anemia ,preeclampsia .diabetes, PPH,risk of operative deliveries and its associated risks. Antenantal At 6 weeks of pregnancy there is chance of perishing of one baby as 50%of twins pregnancy at conception progresses to single viable fetus to term and this pregnancy may progress as twins. Mother should be counceled in detail regarding risk of early miscarriage ,hyperemesis ,and anemia of pregnancy.appropriate care of nutition iron suuplement and anti emetics should be adviced during first trimester .At booking all routine investigationseg Bloodgroup ,Rh .,FBC ,Rubella ,VDRL,MSU,GCT and Hepatitus screening is done.Folic acid is given . Early Uss is done to establish fetal viability,dating and chorionicity as biochemical screening can not be interperated corectly in multiple pregnancy .NT uss is done at 11 weeks .In case of need for invasive diagnostic test as CVS or Amniocentecis arise patient should be reffered to tertiary Fmunit where expertise are available.Selective fetal reduction should be discussed with mother with risk of miscarriage in case abnormality is diagnosed and procedure is carried out at tertiary center .If all the fetuses are normal fetal reduction to twins can still be discussed but may not be an easy decission for the mother as there is a chance that she may abort all the fetuses .Incase mother wishes to continue it is considered a high risk pregnancy and will need close surveillance of mother and fetus both .Cervical measurement if less then 2.5 cm or cervix is found incompetent with membrane funnelling cervical cerclage can be offered although there is very little evidence to support the need of prophylactic cerclage.Fetal fibronectin has 95%negative predictive value and its absence is a good indicator to reassure mother and clinician both.It can be checked regularly after 22weeks of pregnancy.Bed rest may predispose to preterm labour . Patient should be seen in ANC every 2 weeks, Bp and dipstick urine tested for sugar albumin and bacteriurea as uti can predispose to preterm labour.Hb to be checked at 4 weeks intervals to exclude anemia.Serial USS is done every 2 weeks if MC twins and monthly if DC to measure fetal parameters ,Doppler of Umblical arteries is carried out to exclude IUGRfrom 28 weeks onwards . Incase of MC twins there is increased risk of TTTsyndrome,Trap syndrome,IUGR and death of co twin. Placenta previa in multiple pregnancy should be excluded by USS at 34 weeks.Measurement of amniotic fluid volume is important as there is risk of polyhydramnios with Mc twins .Triplet pregnancy is associated with increased maternal discomfort fatigue and backache and prmature contractions.If there are signs of preterm labour single course of Betamethasone to be given 12 mg im 2 doses in 24 hours .Role of tocolytics in multiple pregnancy is not clear as yet .Local protocol should be followed if need of tocolytics arises.Atosiban has been tried in twins pregnancy but no RCTs are available yet. Triplet pregnancy should be delivered by elective LSCs in a tertiary center with NICU facelties available .Neonatoligist consultent should be ionformed to make sure of the availability of cots and other facilities eg ventilators for babies.LSCS should be done by senior obstetrician ,senior anesthetist should be present at time of LSCS. Blood should be cross matched and saved as there is increased risk of PPH and placenta should be deliverd with controlled cord traction.and methergen to be given followed with synticinion infusion to maintain good uterine tone&antibiotics to give at induction of anesthsia. In case patient present in spontaneous labour seniors counsultant anesthetist,neonataologist and obstettricain informed and emergency lscs is carried out . Post natal care should include earlymobilisation ,thrombodeterant stockings,and thromboprophylaxis .breast feeding is incouraged but may not be suuficient and mother may be exausted by it .financial implications of taking care of three babies are an important issues asweell.patient and partner to be given addresses of support groups .lack of sleep and rest in mother may predispose her post partum psychological morbidity.
		Posted by Farzana N. Mon Jul 11, 2005 02:21 am
Multiple pregnancy is a major complication of assisted reproduction, which contributes to10% of all perinatal mortality. This triplet pregnancy is the result of division of one of the embryos, which would lead to formation of identical, monochorionic twins. Perinatal mortality rate in these cases is52/1000 and a 47-fold increase in the risk of cerebral palsy. There is high incidence of maternal complications such as increased nausea, vomiting, miscarriage anemia, preterm labor/delivery, hydramnios and APH. Fetal complications include vanishing twin syndrome, IUD, risk of congenital anomalies and preterm delivery. Monochorionic twins in this case are at risk of IUGR, TTTS, TRAP sequence, Hydramnios. Antenatal management should aim at early detection and treatment of maternal and fetal complications and thus improving the perinatal outcome. This is a high risk pregnancy, and it should be closely monitored by consultant led lead team. Having a triplet pregnancy puts parents under anxiety and stress. Careful information and counseling of parents will not only release their anxiety, but also ensure their compliance during pregnancy and delivery. USG repeated to ensure viability and growth of all the fetuses due to the risk of miscarriage in early pregnancy and vanishing twin syndrome. There is no clinical method of preventing idiopathic miscarriage. Folic acid should be given in early pregnancy to reduce NTD.Biochemical screening for prenatal diagnosis of aneuploidy has poor sensitivity in multiple preg. Scan should be done at 10-14 weeks for measurement of NT, which is sensitive but less specific. Suspected cases should be referred to tertiary center for amniocentesis. This would also confirm the chorionicity. Iron and folic acid is given to mother in the second trimester to prevent anemia. screening is done for HTN and gestational diabetes. Patient should be advised for more frequent antenatal visits to permit early detection and treatment of these complications. Anomaly scan done at 18-20 wks will detect structural anomalies especially CVS and neural tube.Monochorionicity in this case would require serial scans every 2wks,for identification and treatment of following complications- TTTS ?4-35% risk, associated with arteriovenous anastomosis between circulations and detected by discordant fetal size and AF volume. Treatment options include serial amnioreduction, amniotic septostomy, selective feticide and laser ablation of communicating vessels. Twin reverse arterial perfusion (TRAP) sequence-occurs in 1% of MC twins. Treatment is by ultrasonically guided diathermy occlusion of acardiac twin. Hydramnios-management is expectant in. asymptomatic cases with simple analgesics. Amnioreduction may be required in severe cases IUGR or discordant growth, prognosis will depend on gestational age at diagnosis, umbilical artery doppler velocimetry. MC twins are at high risk of preterm delivery before 32wks.Cervical swab done at 28wks for the presence of fetal fibronectin may predict 50% of twin pregnancies that deliver before 35wks.as compared to 80-90% of singletons. Corticosteroids can be given for fetal lung maturation, in cases of threatenened preterm labor., although their efficacy in multiple pregnancy may be limited. Admission for bed rest may be associated with increased risk of preterm delivery. Parents should be counseled that caesarian section is the recommended mode of delivery in cases of triplet pregnancy.
		Posted by jyoti D. Tue Jul 12, 2005 08:17 am
kindly do check my answer as it will be helpful for improvement. thanking you.
		Posted by Vandana D. Wed Jul 13, 2005 05:41 pm
I TYPED THIS ANSWER & when i submit it shows -welcome guest,please use the above forums to navigate.Same problem occured when I sent the reply of Syphilis,at last i sent it in parts.Its so much waste of time.
		Posted by Vandana D. Wed Jul 13, 2005 08:36 pm
To have conceived after IVF is good news but having Triplets is not a desirable outcome of conception.MP -is a high risk pregnancy due to increased risks of perinatal,maternal ,neonatal &infant morbidity & mortality.The risks & complications are directly proportional to the no. of fetuses. The woman & her partner should be informed about the Triplets.Counsel them regarding the possibilities -there are 50 to 80% chances of spontaneous loss of 1 OR 2 fetus/es.In that case ,she would continue with twin /singleton preg.If this does not occur then she would have triplets . Triplet pregnancy has 10 times higher perinatalmortality as compared to singleton;& twice as compared to twin pregnancy.Chance of Cerebral palsy is 47 times in triplet & 8 times in twins as compared to singleton.Causes of perinatal morb. & mort. in MP are prematurity,LBW,IUGR,IUD,Chromosomal &/or structural anomaly.Monochorionic fetuses are at high risk of complications-TTTS,TRAP.~75% OF MONOZYGOTIC pregnancies are monochorionic.This woman if she continues with triplets has high risk of monochorionic preg with its attendant risks. Counsel the parents reg.increased maternal risks.Hyperemesis,miscarriage,anaemia,APH,PIH,preeclampsia,cholestasis,hydramnios,discomfort,premature labour & delivery,PPH,post partum depression.Greater financial & emotional burden. Need to manage MP in high risk pregnancy unit .Refer to expert in fetal medicine/fetal med centre.Need frequent antenatal checkups-every 2/3 weeks as appropriate. To minimise the risks & improve the outcome ,option is to have selective fetal reduction at fetal medicine centre.Counsel reg the procedure.US Scan to assess chorionicity,NT, Instillation of intracardiac/thoracic kcl in dichorionic twin .In monochorionic twin occlusion of umblical cord with occlusive agent..Risks of proce.-miscarriage,infection,psychological impact.It may pose ethical dilemma to some.Take informed consent prior to procedure. If she is not willing ,to continue as triplet preg with approp[rite management. Antenatal check ups -bp wt pallor. US Scans -1ST Trimester-chorionicity,no. of viable fetus/es,NT. 2nd tri:invasive tests if req.;anomaly scan ,fetal echo if appropritate,discordant growth. Routine A.N investigations-CBC(anaemia,) MSU(AILUMINURIA,INFECTION)blood sugar etc. 3rd tri.assess risk of preterm delivery(hydramnios,preeclampsia,APH ,severe IUGR,UTI) TVS to measure cervical length-though low senstivity.HVS for fetal fibronectin-senstivity ~80%,PPV ~80%,high negative pred. value.Give steroids arrange for delivery at tertiary care centre with good neonatal facilities. Treat anaemia,high B.P ,Infection. Plan delivery-triplet-el. CS.If she goes in premature labour emergency CS.Availability of Senior Obs. neonatologist,anaesthetist.Arrange blood .Consider prophylactic oxytocin infusion. Transfer of one good quality embryo with back up of cryopreserved embryos is a better approach in IVF.
		Posted by Vandana D. Thu Jul 14, 2005 11:51 pm
please mark my answer. Thank you.