Early Identification of Multiple Pregnancies - Essay Example

Generally, unusual weight gain during the first trimester, increased size of the uterus, and severe morning sickness may be witnessed during multiple pregnancies. An inconsistency during the 2nd trimester between the measured fundal height and gestational age of the fetus usually presents a case of twin or multiple pregnancies. Clinical presentation of these pregnancies elicits the size of the fetus greater than the date by exam, fetal motion not detected until 18-20 weeks, and elevated AFP results (Tharpe, 2006). Confirmation of such pregnancies is made through ultrasonographic examination.

Complications:

Several risks and complications are associated with multiple gestations including early pregnancy loss, low birth weight along with the occurrence of intra-uterine fetal demise, preterm labor, and delivery (Levene and Chervenak, 2009). There is an increased prevalence of congenital anomalies in monozygotic twins. Brain anomalies like hydrocephaly and microcephaly are found to be associated with multiple pregnancies. Also, the risk for intrapartum asphyxia is increased in the second-born due to frequent fetal mal-presentation leading to traumatic delivery.

The risk of maternal morbidity is also enhanced in these pregnancies. Other maternal complications include induced hypertension, gestational diabetes, anemia, urinary tract infections, pre-eclampsia, antepartum hemorrhage, post-partum hemorrhage, and endometriosis (Littleton and Engebreston, 2002).  

According to Avery et al., (2005) in multiple births, an increased risk of intra-uterine growth retardation is reported which may be due to unequal sharing of placenta among fetuses. Consequently, usual problems associated with intra-uterine growth retardation like intrapartum asphyxia, polycythemia, hypoglycemia, and pulmonary hemorrhage are witnessed.  In 5% of the multiple pregnancies, twin-to-twin transfusion syndrome is observed which is due to vascular anastomosis between the circulations of monozygotic twins sharing the same placenta. The transfusions taking place in a single direction may render the donor fetus anemic, while the recipient fetus becomes polycythemic. Eventually, either of the twin fetuses may become hydropic due to volume overload or anemia. In some severe cases, the donor twin may expire.          

Management:

Patients with multi-fetal pregnancies are followed closely with ultrasonographic examination to assess fetal growth and development throughout their pregnancy. The patient may be hospitalized if she develops signs of preterm labor or other complications. Delivery room management of multiple births requires a larger number of trained personnel for resuscitation/CPR in case of preterm delivery and availability of blood as multi-fetal pregnancies experience frequent blood loss and may lead to post-partum hemorrhage (Gilstrip et al., 2002).

Multiple births offer a challenge to nurses and health paramedics in the delivery room. Where the majority of multiple pregnancies should be delivered normally a cesarean section is suggested as a preferred mode of delivery (Levene and Chervenak, 2009). For a vaginal delivery, continuous electronic monitoring of the fetal vital signs, tolerance to labor (attained by fetal electronic heartbeat monitor), and uterine activity should be done (Cruickshank and Shetty, 2009).

Delivery should be done during the 40th week of gestation because of the increased risk of perinatal morbidity after the due date. In the labor management of twin gestation prostaglandins or oxytocin can be administered to induce vaginal delivery (Creasy et al., 2004). Vaginal delivery should be prompted in vertex-vertex twins if no symptoms of obstetric complications are present. Yet, after the birth of the first twin, the patient is assessed for the possible delivery of the second twin which may take minutes to hours after the first one (Littleton and Engebreston, 2002). However, in the case of vertex-non-vertex twins (breech presentation), if the first twin is non-vertex, a cesarean section is necessary on the other hand if the second twin is non-vertex, a cesarean is recommended depending upon the fetus's weight and maternal choice (Tharpe, 2006).

Management of the delivery of twins suffering from twin-to-twin transfusion syndrome is extremely complicated. Diagnosis in the mother should lead to regular ultrasonographic observation and prenatal recognition of transfusion direction. Further, the hematocrit of the polycythemic twin should be reduced while that of the anemic twin should be enhanced through partial exchange transfusion of packed cells (Avery et al., 2005).   

In some special circumstances, where the twins share the same amniotic sac, cord entanglement may take place causing double fetal death or single fetus death and brain damage to the other. In such cases, elective preterm caesarian delivery at 32-34 weeks is done (Levene and Chervenak, 2009).  Sequential cervical examination of the fetuses should be a part of management strategies starting from 16-18th week (Guha, 2005).