BAB I

INTRODUCTION

Twin pregnancy is a pregnancy with two or more fetuses. It is a pregnancy

that get attention and often becomes a joyous occasion for the parents of the fetus and

society in general. But women who are pregnant without their baby will realize a

greater risk of very serious for the health.

In recent years, the number of multiple births has increased greatly. The birth

rate for twins in the United States has increased about 65 percent since 1980,

according to the National Center for Health Statistics. Other multiple births have

increased at an even higher rate for several reasons. Various factors affect the

frequency of twin pregnancies, as a nation, heredity, age, and maternal parity Second,

when the medical and technological methods used to treat infertility are successful,

they frequently result in multiple pregnancy.

In developed countries, two of the major causes of multiple gestation are

cessation of oral contraception and artificial ovulation induction. The latter is of

particular concern for higher-order multiple gestations (triplets and above) are

increasingly common as a result of assisted reproductive technologies (ART).

Although these pregnancies are not at significantly increased risk from the ART, they

are at exceptional risk for immature or premature delivery and other morbidity and

mortality associated with higher-order multiple gestations.

Maternal morbidity and mortality are much higher in multiple than in

singleton pregnancy. There is increased frequency and severity of anemia; increased

occurrence of urinary tract infection; more preeclampsia-eclampsia, hydramnios, and

uterine inertia (overdistention); and a greater chance of hemorrhage (before, during,

and after delivery).

The perinatal mortality rate of twins is 4 – 6 times higher and for triplets much

higher again than for singletons because of prematurity and associated difficulties.

Indeed, as the number of fetuses rises, their average size and length of gestation

decrease. Moreover, intrauterine growth retardation (IUGR) is more common in all

multiple gestations (as opposed to singletons). Congenital abnormalities of all organ

systems are as high as 18% among twins . Other perinatal risks of multiple gestations

include abnormal presentation and position, hydramnios, hypoxia because of cord

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prolapse ( 5 times more common in multiple pregnancy), placenta previa, and

premature separation of the placenta after the first twin or operative manipulation.

Because of maternal and perinatal risk, many authorities recommend that no less than

qualified obstetricians care for twins and that maternal fetal consultation be utilized.

Additionally, triplet and higher birth order risk is such that maternal–fetal specialists

should be involved in, or provide their care.

Therefore, diagnosis of early twin pregnancy early is right way, which needs

to be done. If the diagnosis of twin pregnancy was established, so many things and

aspects that need attention needs to be addressed.

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BAB II

LITERATURE REVIEW

II.1 DEFINITION

Multiple pregnancy involves more than one embryo (fetus) in any one

gestation. Two independent mechanisms may lead to multiple gestation:

segmentation of a single fertile ovum (identical, monovular, or monozygotic) or

fertilization of separate ova by different spermatozoa (fraternal or dizygotic)

multiple pregnancy.1

II.2 ETIOLOGY of MULTIPLE FETUSES

Twin fetuses commonly result from fertilization of two separate ova and are

termed double-ovum, dizygotic, or fraternal twins. About a third as often, twins

arise from a single fertilized ovum that subsequently divides into two similar

structures, each with the potential for developing into a separate individual. These

twins are termed single-ovum, monozygotic, or identical twins. Either or both

processes may be involved in the formation of higher numbers of fetuses.

Quadruplets, for example, may arise from as few as one to as many as four ova.2

Picture 1. placental variation in twinning.

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Dizygous : Double Ovum

About 75 % of twins are binovular. Two fetuses develop from the fertilization

or two ova liberated during the same menstrual cycle. The incidence of double

ovum twins is influenced by hereditary, race, maternal age, and parity. Each twin

has its own placenta, chorion and amniotic sac. When the ova are implanted near

each other, the two placentas may seem to fuse. The circulation, however, remain

completely separate. This children are fraternal twins. They resemble each other

only to the extent that siblings of the same age would. They maybe of different

sex and sometimes look entirely dissimilar. Wein-birg’s role states that the

number of dizigous twin in any population is twice the number of twin of different

sex ; the reminder are monozigous. Dizigous twinning is the result of multiple

ovulation which maybe caused by high level of gonadotropic hormones over

stimulating the ovari. The artificial induction of ovulation by clomipenth or

gonadotropin in creases the chance of multiple pregnancy.3

Genesis of Monozygotic Twins

Evidence regarding the physiological basis of monozygotic twinning now

suggests that the division of the fertilized ovum may result from a delay in the

timing of normal developmental events. In humans, delayed ovum transport

through the fallopian tube increases the risk of twinning. Because progestational

agents and combination contraceptives decrease tubal motility, delayed tubal

transport and implantation are believed to increase the risk of twinning in

pregnancies conceived in close temporal proximity to contraceptive use . Minor

trauma to the blastocyst during assisted reproductive technology (ART) may

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possibly lead to the increased incidence of monozygotic twinning observed in

pregnancies conceived in this manner.2

The outcome of the twinning process depends on when the division occurs.

Dichorionic diamniontic twins : In this case the division occurs at the

blastomere stage, no later than 2 to3 days after fertilization. The iner cell mass

has not yet been delineated. Separate embryos develop, undistinguishable at

birth from dizygous twins. Each twin has its own chorion, amnion, and

placenta. The latter may be separete or fused depending on the site of

implantation.

picture 2. Diamniotic, dichorionic placentation.

Monochorionic diamniotic twins : The split takes place at the blastocyst stage

between 4 and 6 days. The inner cell mass, which has been formed, divide in

two. The placenta has one chorion, but two amnions. Each twin lies in its own

sac.3

Picture 3. Diamniotic, monochorionic placentation.

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Monochorionic monoamniotic twins : the division takes place in the primitive

germ disc at between 7 and 13 days. The amnion has already formed. The

twins lie in the same amniotic sac. Monoamniotic twins are rare

Picture 4. Monoamniotic, monoamniotic placentation.

Conjoined twins—monochorionic monoamniotic : After the primitive streak

of the embryo has appeared and the cells of the germ disc have assumed an

axial arrangement (arround 14 days), complete separation does not occurs,and

conjoined twins can develop.

Because the fetuses are not separated by membranes, there is great possiblility

of knotting, tangling and strangulation of the umbilical cords. The resultant

anoxia may lead to fetal death. 3

Superfetation and Superfecundation

In superfetation, an interval as long as or longer than a menstrual cycle

intervenes between fertilizations. Superfetation requires ovulation and

fertilization during the course of an established pregnancy, which would

theoretically be possible until the uterine cavity is obliterated by the fusion of

the decidua capsularis to the decidua vera. Although known to occur in mares,

superfetation is as yet unproven to occur in humans. Most authorities believe

that the alleged cases of human superfetation result from marked inequality in

growth and development of twin fetuses of the same gestational age.

Superfecundation refers to the fertilization of two ova within the same menstrual

cycle but not at the same coitus, nor necessarily by sperm from the same male. 2

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An instance of superfecundation, documented by Harris (1982), is

demonstrated in Figure 39–5. The mother was sexually assaulted on the 10th day

of her menstrual cycle and had intercourse 1 week later with her husband. She was

delivered of a black neonate whose blood type was A and a white neonate whose

blood type was O. The blood type of both the mother and her husband was O.

Terasaki and co-workers (1978) described the use of HLA typing to establish that

a specific set of dizygotic twins were sired by different fathers. 2

Risk factors for multifetal pregnancy can be divided into natural and induced.

Risk factors for natural multifetal pregnancy include advanced maternal age,

family history of dizygotic twins, and race. Induced multifetal pregnancies occur

following infertility treatment via the use of ovulation-inducing agents or

gamete/zygote transfer.4

Some of the factors that are associated with multiple pregnancy include:

Race. Black women have the highest rate of natural multiple pregnancy. Asian

women have the lowest.

Age. Older women are more likely to have a multiple pregnancy.

Family history. Women with multiple pregnancies in their families are more

likely to have a multiple pregnancy.

Prior pregnancy. Women who have given birth four or more times are more

likely to have a multiple pregnancy.

Fertility drugs. Some of these drugs cause a woman to ovulate more than one

egg a month, which increases the likelihood of multiple pregnancy.

Pregnancies of triplets, quadruplets and higher orders have increased

dramatically as a result of the use of fertility drugs.

Assisted reproductive technology (ART). Measures that implant more than

one embryo are more likely to produce a multiple pregnancy. These measures

have also increased the number of higher order pregnancies. 5

II.3 FREQUENCY of TWINS

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The birth rate of monozygotic twins is constant worldwide (approximately 4

per 1000 births) and is largely indepentent of race, heredity, age, and parity. The

frequency was once thought to be independent of infertility theraphy, however,

there is now evidence that the incidence of zygotic splitting is increased

following ART. The incidence of dizygotic twinning, however, is influenced

remarkably by race, heredity, maternal age, parityand especially, fertility drugs.

Birth rates of dizygotic twins vary by race. The highest birth rate of dizygotic

twinning occurs in African nations, and the lowest birth rate of dizygotic

twinning occurs in Asia. The Yorubas of Western Nigeria have a frequency of

45 twins per 1000 live births, and approximately 90 percent are dizygotic.4

II.4 DIAGNOSIS of MULTIPLE PREGNANCY

1. Suggestive findings :

a. Familial history.

b. The uterus and abdomen seem larger than expected for the period of

amenorrhea.

c. Uterine growth is more rapid than normal

d. There is unexplainably excessive weight gain 3

2. Positive signs :1,3

a. Palpation of two heads or two breeches.

When uterine palpation leads to the diagnosis of twins, it is

most often because two fetal heads have been detected, often in

different uterine quadrants. In general, however, before the third

trimester it is difficult to diagnose twins by palpation of fetal parts.

Even late in pregnancy it may be difficult to identify twins by

abdominal palpation, especially if one twin overlies the other, if the

woman is obese, or if hydramnios is present.

b. Two fetal heart auscultated at the same time by two observers and

differing in rate by at least 10 beats per minute.

c. X-ray of the abdoment shows two skeletons. These may appear by the

18th week or sooner, but a second skeleton cannot be ruled out until

the 25th week.

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d. Ultrasonography demonstrates the presence of two or more fetal skulls.

3. The diagnosis of twins is not easy unless there is ahigh index of suspicion. The

frequency of preterm labor makes the diagnosis before the onset of labor even

less frequence.3

Another clinical suggestions of multiple pregnancy include the following:

Excessive maternal weight gain not explained by eating or edema;

Hydramnios;

Iron deficiency anemia;

Maternal reports of increased fetal activity.3

Laboratory findings

Commonly encountered laboratory findings in multiple pregnancy include:

abnormal elevation of maternal hCG and/or alphafetoprotein, moderate reduction

in Hct (also Hgb and RBC count, i.e., iron deficiency anemia), blood volume

increased over normal pregnancy values, and an increased incidence of glucose

intolerance. Cervicovaginal secretion of fetal fibronectin (Ffn) is a sensitive

predictor of preterm delivery in twins, but has low specificity. Thus, Ffn is best

used in conjunction with other criteria (e.g., sonographic evaluation of cervical

length). Currently, there is little Ffn data for higher-order multiples.1

Ultrasonografy

Sonography is vital in modern management of multiple gestations. Areas of

utility include: assisting in zygosity determination, detecting and assessing fetal

anomalies, determination of growth, assessing amniotic fluid, determining well

being, management of antenatal testing, and caring for uncommon complications.

Therefore, a standardized approach to sonographic evaluations is useful.

By careful ultrasonographic examination, separate gestational sacs can be

identified early in twin pregnancy. Subsequently, each fetal head should be seen in

two perpendicular planes so as not to mistake a cross section of the fetal trunk for

a second fetal head. Ideally, two fetal heads or two abdomens should be seen in

the same plane, to avoid scanning the same fetus twice and interpreting it as twins.

Ultrasonographic examination should detect practically all sets of twins. Indeed,

one argument in favor of ultrasonographic screening is earlier detection of

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multiple fetuses.. Higher-order multiple gestations are more difficult to evaluate.

Even in the first trimester it can be difficult to determine the correct number of

fetuses and their position, which is important for nonselective pregnancy reduction

and essential for selective termination. Ultrasonographic examination should

detect practically all sets of twins. Indeed, one argument in favor of

ultrasonographic screening is earlier detection of multiple fetuses.

Multiple pregnancy may be demonstrated by vaginal ultrasonography before 6

weeks, and multiple pregnancy should be routinely detected by other scanning

methods at 8 weeks. A pitfall of multiple gestation sonography, particularly those

done at 6 weeks, is both undercounting and overcounting fetuses. Sonographic

visualization of the chorion(s) can be assessed as early as 6–7 weeks (after LMP),

with dichorionic being visualized earlier. Although reliable imaging of the amnion

is not usually possible before the 9–10th week. This determination is important

because of the disproportionate outcomes related to chorionicity and amnionicity.

Differential findings include: placental masses, septal thickness, “twin peak” sign,

as well as fetal gender. At 16–20 weeks, a detailed sonographic anatomic survey

screens for congenital anomalies and provides a baseline for further testing.1

II.5 PRESENTATION and POSITION

With twins, all possible combinations of fetal positions may be encountered.

The most common presentations at admission for delivery are cephalic–cephalic,

cephalic–breech, and cephalic–transverse. Importantly, these presentations,

especially those other than cephalic–cephalic, are unstable before and during labor

and delivery. Compound, face, brow, and footling breech presentations are

relatively common, especially when the fetuses are small, amnionic fluid is

excessive, or maternal parity is high. Prolapse of the cord is also common in these

circumstances. The presentation can often be ascertained by ultrasonography. If

any confusion about the relationship of the twins to each other or to the maternal

pelvis persists, a single anteroposterior radiograph of the abdomen may be

helpful.2

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II.6 ANTEPARTUM MANAGEMENT OF TWIN PREGNANCY

To reduce perinatal mortality and morbidity in pregnancies complicated by

twins, it is imperative that:

1. Delivery of markedly preterm infants be prevented.

2. Failure of one or both fetuses to thrive be identified and fetuses so afflicted be

delivered before they become moribund.

3. Fetal trauma during labor and delivery be avoided.

4. Expert neonatal care be available. 1

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Additional Needs in a Multiple Pregnancy

Nutrition

Women with a multiple pregnancy need more food, calories, protein, and

vitamins and minerals than women with a singleton pregnancy. Women who are

well nourished and of normal weight should be encouraged to consume 3,000 to

3,500 calories a day for twin gestations, 4,000 calories a day for triplets, and 4,500

or more for quadruplets. Iron is particularly important for blood volume expansion

to support multiple fetuses and placentas. Any pregnancy results in a measurable

increase in blood volume from increases in both plasma volume and red blood

cells. A 22% increase occurs as early as 8 weeks, with progressive increases seen

until 32–34 weeks. The proportional increase in a multiple pregnancy is directly

related to the number of fetuses present. The vast majority of pregnant women in

the United States are prescribed a prenatal vitamin. Because of the increased

physiological demands and the additional nutrients required by multiple fetuses,

women with a multiple pregnancy almost always need to supplement their diet

with a multivitamin. Women can achieve the recommended higher calorie diets by

eating more of the same types of healthy food and by eating often. Women should

also be encouraged to drink plenty of water.

Weight Gain

Weight gain during pregnancy comes from the fetus, increased maternal blood

volume, uterine size, amniotic fluid, the placenta, colostrum, and fat storage.

recommends that women of normal weight should gain approximately 35–45

pounds for twin gestations. Weight gain is increased and generally occurs earlier

and more rapidly in women with a multiple pregnancy. Some women report

weight gains as early as 8 weeks. Women considered underweight should gain 1

pound each week through 20 weeks gestation and 1–2 1/2 pounds per week for the

remainder of the pregnancy. Inadequate weight gain early in pregnancy is

associated with complications even if compensatory weight is gained later. Ideal

weight gains for triplets and higher-order pregnancies have not been well

researched. However, anecdotal evidence indicates that a 36-pound gain by week

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26 is associated with higher birth weights and optimal outcomes in triplet

gestation .5

Monitoring for Potential Risks and Complications

Women pregnant with multiple fetuses are at an increased risk for numerous

problems during the antepartum period. Multiple gestations account for 10–12%

of fetal deaths. Death can be caused by abnormal fetal or placental development,

cord compression, or other accidents. Although not all multiple births have

complications, women should be familiar with the warning signs of problems.

Below is a discussion of the most common complications of a multiple

pregnancy, the expected medical management, and the implications for the

childbirth educator and childbearing family.5

II.7 DELIVERY

Timing

The antepartum stillbirth rate in twins exceeds that of singletons, both per

fetus and, in particular, per pregnancy. Thus while awaiting the results of a

randomized trial in progress , it seems prudent to recommend elective delivery

at 37–38 weeks when neonatal morbidity is lowest.

The large rise in stillbirths seen in population data at 38 weeks is artifactual,

reflecting gestational age at delivery not at intrauterine death. There is an

argument for delivering MC twins earlier, based on their high rate of

unexplained death rate in utero and the desire to avoid the consequences of fetal

death to its co-twin. Twins are not a contraindication to induction .6

Vaginal delivery

Mode of delivery has traditionally been decided on the presentation of the

first twin (cephalic in 70%, breech in 30%), and fetal growth and well-being.

Caesarean section has been advised where the first twin is breech, based on

extrapolation from the term breech trial, and the desire to avoid the rare

interlocking with head entrapment of a presenting breech above a second

cephalic twin. The presentation of the second twin is of little relevance until

after the birth of the first. Parturients with a previous Caesarean section are

probably best delivered by repeat Caesarean, because of greater risks of

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scardehiscence/rupture due both to uterine distension and to intrauterine

manipulation of the second twin.6

For vaginal delivery, continuous cardiotocography (CTG) of both twins is

facilitated by use of a dual channel recorder and/or a combination of internal and

external electrodes. Anintravenous line is sited, antacids given and blood drawn

for cross matching, in view of the increased incidence of Caesarean section and

post-partum haemorrhage. Augmentation may be used as in singletons. An

epidural is strongly advised in case internal manipulation of the second twin is

needed; if one is not sited, an anaesthetist will be required at delivery in case

general anaesthesia is required. The delivery of the first twin proceeds as for a

singleton. Its cord is clamped to prevent haemorrhage from the second twin along

any placental anastomoses. An experienced obstetrician discerns the presentation

of the second twin, either by abdominal and vaginal examination or increasingly

by transabdominal ultrasound. Oblique or transverse lies are then converted to

longitudinal. The membranes should be left intact to facilitate version.

External cephalic version may be used to manipulate the fetal head over the

pelvic inlet. However, internal podalic version and breech extraction is preferred

as the primary procedure as observational studies show that it is associated with a

higher chance of success and lower rate of fetal distress. One or preferably both

feet are grasped and brought down into the vagina followed by assisted breech

delivery with contractions and maternal effort. Although historical series

suggested that the risk to he second twin increased the greater the delay until its

delivery, intervals of >30 min are acceptable providing the CTG is satisfactory

and the presenting part is descending. Uterine inertia with a longitudinal-lying

second twin is corrected by oxytocin infusion. Fetal distress can be managed by

vento use delivery even if the head is high or breech extraction if podalic. The

already stretched vaginal tissues after birth of the first twin allow these procedures

in circumstances where they are normally contraindicated.

Caesarean section for a second twin is rarely indicated for disproportion,

usually only where the second twin is unexpectedly much bigger than the first,

and is associated with an increased complication rate compounding the

complications of vaginal and abdominal delivery .An oxytocin infusion is given

prophylactically in the third stage.6

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Vaginal Delivery of the Second Twin

As soon as the presenting twin has been delivered, the presenting part of the

second twin, its size, and its relationship to the birth canal should be quickly and

carefully ascertained by combined abdominal, vaginal, and at times intrauterine

examination. Ultrasonography is also valuable in some cases. If the fetal head or

the breech is fixed in the birth canal, moderate fundal pressure is applied and

membranes are ruptured. Immediately afterward, digital examination of the

cervix is repeated to exclude prolapse of the cord. Labor is allowed to resume,

and the fetal heart rate is monitored. With reestablishment of labor there is no

need to hasten delivery unless a nonreassuring fetal heart rate or bleeding

develops. Hemorrhage may indicate placental separation, which can be harmful

to both the fetus and the mother. If contractions do not resume within

approximately 10 minutes, dilute oxytocin may be used to stimulate

contractions.2

If the occiput or the breech presents immediately over the pelvic inlet but is

not fixed in the birth canal, the presenting part can often be guided into the

pelvis by one hand in the vagina while a second hand on the uterine fundus

exerts moderate pressure caudally. Alternatively, an assistant can maneuver the

presenting part into the pelvis using ultrasonography for guidance and to

monitor heart rate. Intrapartum external version of the noncephalic second twin

has also been described (Chervanak and co-workers, 1983).2

A presenting shoulder may be gently converted into a cephalic presentation.

If the occiput or the breech is not over the pelvic inlet and cannot be so

positioned by gentle pressure, or if appreciable uterine bleeding develops,

delivery of the second twin can be problematic.2

It is essential to have an obstetrician skilled in intrauterine fetal manipulation

and an anesthesiologist skilled in providing anesthesia to effectively relax the

uterus for vaginal delivery of a noncephalic second twin to obtain a favorable

outcome. To take maximum advantage of the dilated cervix before the uterus

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contracts and the cervix retracts, delay must be avoided. Prompt cesarean

delivery of the second fetus is preferred if no one present is skilled in the

performance of internal podalic version (described in the following section) or if

anesthesia that will provide effective uterine relaxation is not immediately

available.2

Caesarean section

Essentially the risks of vaginal delivery are increased in twins compared to

singletons, as are the risks of Caesarean section. A large international randomized

trial is underway to resolve the optimal mode of delivery in twins. In the interim,

it seems reasonable to offer women Caesarean section where otherwise suitable

for vaginal delivery. This is based on a high intrapartum section rate in twins,

with evidence from other trials suggesting that maternal morbidity from elective

section is comparable where the emergency rate exceeds one in three and

increasing recognition that the second twin has a chance of intrapartum related

death some five-fold higher than first twin or singletons .6

Cesarean section is recommended for monoamniotic twins because of the 10%

delivery loss from cord entanglement. Caesarean section has been advised where

the first twin is breech, based on extrapolation from the term breech trial, and the

desire to avoid the rare interlocking with head entrapment of a presenting breech

above a second cephalic twin. The presentation of the second twin is of little

relevance until after the birth of the first. Parturients with a previous Caesarean

section are probably best delivered by repeat Caesarean, because of greater risks

of scar dehiscence/rupture due both to uterine distension and to intrauterine

manipulation of these second twin.1

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Locked twins

Other standard indications for cesarean include: any birth number exceeding

twins (e.g., triplets), twins ,2500 g, or if the first twin is nonvertex . It is

recommended that all twin gestations be delivered in an operating room with full

preparation (including maternal abdominal preparation), equipment, and

personnel in attendance for cesarean section. The first twin may be delivered

vaginally if it presents by the vertex (situation A and situation B). A

significantly shorter first stage of labor (compared to singletons) may be

anticipated.1

DELIVERY SITUATIONS ACCORDING TO

PRESENTATION OF TWINS

Situation Twin A Twin B %

A Vertex Vertex 40

B Vertex Nonvertex 40

C Nonvertex Other (any) 20

A generous episiotomy reduces fetal cranial compression. With delivery of

the first fetus, clamp the cord promptly. Should there be twin-to-twin vascular

communication, a second monozygotic twin can exsanguinate through the first

cord. A vaginal examination immediately after the first delivery is performed to

identify a possible forelying or prolapsed cord and establish the position of the

second fetus. If B has continued as a vertex (situation A), a second vaginal

delivery may be performed.1

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If the second fetus is anything but vertex (situation B), there are three

alternatives.

● Bringing the head into the inlet by external guidance (version), if successful,

allows labor to proceed for another vertex vaginal delivery.

● Perform cesarean section immediately if external version is unsuccessful or if

the fetus is not a candidate for a vaginal breech delivery.

● Complete a vaginal breech delivery if the external version is unsuccessful and

the fetus is a candidate for a vaginal breech delivery.

Rupture of the second sac (if present) is accomplished as late as possible to

avoid prolapse of the cord. Continuous electronic fetal monitoring of the second

twin is employed. Should fetal compromise supervene (e.g., persistent cord

compression or premature separation of the placenta) and the second twin cannot

be delivered easily or immediately, an immediate cesarean section is

recommended. The three major preventable causes of morbidity in twins are

immaturity, trauma, and manipulative delivery (with associated asphyxia), and

preventing their occurrence is a primary goal. To assist with care of the newborns,

a neonatologist or pediatrician should be in attendance.1

II.8 TREATMENT

AVOIDING MATERNAL COMPLICATIONS IN MULTIPLE

PREGNANCY

A thoughtful approach is necessary for the mother with multiple gestations.

This plan begins with early diagnosis of multiple pregnancy. This goal may be

achieved by obtaining sonography (ideally on all and certainly on questionable

pregnancies) no later than 12–16 weeks. A high-protein, high-vitamin diet; with

no limitation of weight gain assists in prevention of fetal intrauterine growth

retardation. Dietary supplements demonstrated to be useful in multiple

gestations include: a prenatal vitamin per day, folic acid of 1.0 mg per fetus per

day, supplemental iron preparations as indicated by hemogram and calcium to a

total intake of 1500 mg/day beneficially influences birth weight.

Because of the number of potential problems, it is common to examine the

patient with multiple pregnancy more often than most during pregnancy

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(individualized, but in most cases at least twice as often). Physical activity is

usually limited to ensure adequate uterine blood flow (e.g., cancel regular

exercise programs). Frequent rest periods are initiated after the 24th week (e.g.,

1 week of bedrest at 26 weeks and again at 32–33 weeks). Ultrasound

examinations and blood counts are obtained more frequently. Ultrasound

examinations for growth progress may be useful monthly from diagnosis until

the 32nd week, when both ultrasonography and BPP on each fetus may be useful

on a weekly basis. Cervical length sonography may be performed as often as

every other week in the latter half of pregnancy.1

Given the risk, consideration is given to deliver all patients with multiple

pregnancy in a tertiary medical facility if possible. Psychoprophylaxis is often

stressed, and the patient introduced to a support group. Additionally, patients

find literature concerning multiple gestation and preterm birth prevention

education helpful. At the time of delivery, increased blood loss may be

anticipated (hemorrhage is 5 times increased over singletons). Thus, seeking

donors acceptable to the patient in advance may be worthwhile. In cases where

one fetus delivers untenably early (e.g., 22 weeks), some now recommend

delaying delivery of the remaining fetuses (especially if membranes are intact)

in an attempt to decrease morbidity and mortality in the remaining fetuses.

Although the delayed delivery of remaining fetuses improves prognosis, there is

no consensus regarding technique or enough cases to demonstrate true statistical

relevance. In sum, care of the mother with a multiple pregnancy requires

enhanced sensitivity to, as well as frequent assessment of, maternal symptoms

and cervical status.1

PREVENTION OF FETAL COMPLICATIONS OF MULTIPLE GESTATION

Details concerning identifying congenital anomalies are noted previously

as are techniques to maximize fetal growth. Preventing early preterm delivery is

an objective best realized through maximizing maternal antenatal care. The

utilization of fetal fibronectin screening may be useful in detection of preterm

labor. Utilization of home uterine activity monitoring, salivary estriols, and

other modalities may be considered.

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Cervical cerclage may delay preterm birth in selected cases. Indeed, some

now recommend this in triplet and higher-order gestations. Further study is

necessary, however, prior to recommending this approach.

Tocolytic drugs to prevent early birth may be effective , however, these

agents must be used with great care in multiple gestation because of possible

maternal pulmonary edema. Appropriate fetal therapy is initiated if early

delivery is anticipated.1

II.9 TRIPLET or HIGHER – ORDER GESTATION

Fetal heart rate monitoring during labor is challenging. A scalp electrode

can be attached to the presenting fetus, but it is difficult to ensure that the other

two triplets are each being monitored separately. With vaginal delivery, the first

infant is usually born spontaneously or with little manipulation. Subsequent

fetuses, however, are delivered according to the presenting part. This often

requires complicated obstetrical maneuvers such as total breech extraction with or

without internal podalic version or even cesarean delivery. Associated with

malposition of the fetuses is an increased incidence of cord prolapse. Moreover,

reduced placental perfusion and hemorrhage from separating placentas are more

likely during delivery.

For all these reasons, many clinicians believe that pregnancies complicated

by three or more fetuses are best delivered by cesarean delivery. Vaginal delivery

is reserved for those circumstances in which survival is not expected because the

fetuses are markedly immature or maternal complications make cesarean delivery

hazardous to the mother. Other clinicians believe that vaginal delivery is safe

under certain circumstances. For example, Alamia and colleagues (1998)

evaluated a protocol for vaginal delivery of triplet pregnancies in which the

presenting fetus was cephalic. A total of 23 sets of triplets were analyzed, and a

third of these were delivered vaginally. Neonatal outcomes were the same in the

vaginal and cesarean groups, with no morbidity and 100 percent fetal survival.

Grobman and colleagues (1998) and Alran and co-workers (2004) reported

vaginal delivery completion rates of 88 and 84 percent, respectively, in women

carrying triplets who underwent a trial of labor. Neonatal outcomes did not differ

20

from those of a matched group of triplet pregnancies delivered by elective

cesarean. As in any obstetrical procedure, the safety of vaginal triplet delivery

depends on the skill and experience of the operator.2

II.10 COMPLICATION

Multiple pregnancies are generally considered high-risk pregnancies.

Women pregnant with multiple fetuses are at an increased risk for numerous

problems during the antepartum period. Multiple gestations account for 10–12%

of fetal deaths. Death can be caused by abnormal fetal or placental development,

cord compression, or other accidents.

Some of the complications are : 4,7

Preeclampsia

Gestational diabetes.

Gestational diabetes is defined as the abnormal metabolism of

carbohydrates during pregnancy, wherein the pancreas is unable to produce

enough insulin to move glucose into the cells for the production of energy.

The end result is hyperglycemia.

Uterine and placental abnormalities.

Iron deficiency anemia

The symptoms of iron deficiency anemia are similar to many of the

common complications associated with pregnancy, including fatigue,

lightheadedness, pale skin, and shortness of breath.

Preterm labor and premature birth

. Prevention of Preterm Delivery : Several techniques have been applied

in attempts to prolong multifetal gestations. These include bed rest,

especially through hospitalization, prophylactic administration of beta-

mimetic drugs, and prophylactic cervical cerclage.

Twin-to-twin transfusion.

Twin-to-twin transfusion syndrome (TTTS) is the result of an

intrauterine blood transfusion from one twin (donor) to another twin

(recipient). TTTS only occurs in monozygotic (identical) twins with a

monochorionic placenta. The donor twin is often smaller with a birth weight

20% less than the recipient's birth weight. The donor twin is often anemic

21

and the recipient twin is often plethoric with hemoglobin differences greater

than 5 g/dL.

Conjoined twins.

Incomplete late division of monozygotic twins produces conjoined twins.

Conjoined twins are connected at identical points and are classified

according to site of union.

o Thoracopagus - Joined at chest (40%)

o Xiphopagus/omphalopagus - Joined at abdomen (34%)

o Pygopagus - Joined at buttocks (18%)

o Ischiopagus - Joined at ischium (6%)

o Craniopagus - Joined at head (2%)

Hyaline membrane disease

Twins born at fewer than 35 weeks' gestation are twice as likely to

develop hyaline membrane disease (HMD) as single birth infants born at

fewer than 35 weeks' gestation are.

Birth asphyxia/perinatal depression

Newborns from multiple gestation pregnancies have an increased

frequency of perinatal depression and birth asphyxia from a variety of

causes.

Vanishing twin syndrome

Early ultrasound diagnosis has revealed that as many as one half of all

twin pregnancies result in the delivery of only a single fetus. The second

twin vanishes. Intrauterine demise of one twin can result in neurologic

sequelae in the surviving twin. Acute exsanguination of the surviving twin

into the relaxed circulation of the deceased twin can result in intrauterine

CNS ischemia

Congenital anomalies/acardia/twin reversed arterial perfusion sequence

Acardia is a rare anomaly unique to multiple gestation. In this

condition, one twin has an absent or rudimentary heart. Twin reversed

arterial perfusion (TRAP) sequence occurs when an acardiac twin receives

all of the blood supply from the normal "pump" twin. This only occurs in

monochorionic twins. Blood enters the acardiac twin in a reversed perfusion

22

manner. Blood enters this fetus via an umbilical artery and exits via the

umbilical vein. The excessive demands on the normal "pump" twin can

cause cardiac failure in that twin.

Intrauterine growth retardation

It can occur because of inadequate nutrients, poor placental perfusion,

and unknown factors. Multiple fetuses do not grow at the same rate in utero

as singletons. In later pregnancy, differences in growth rates may be

attributed to fetal crowding. Also, one fetus may receive more nutrients

while the other fetus gets a smaller portion and grows more slowly.

II.11 DIFFERENTIAL DIAGNOSIS

Single large pregnancy, hydramnios, hydatidiform mole, abdominal or pelvic

tumors complicating singleton pregnancy, and complicated multiple gestation

(e.g., triplets) must all be considered in the diagnosis of multiple gestation.3.

II.12 PROGNOSIS

The prognosis of infants born from multiple gestations depends upon the

complications that develop. Some studies have reported that the risks of death,

chronic lung disease, and grade III/IV intracranial hemorrhage were similar in

twins and singletons. Other studies have reported a higher prevalence of

complications such as necrotizing enterocolitis, retinopathy of prematurity, and

patent ductus arteriosus in infants from multiple gestation versus singletons. 4

23

BAB III

CASE REPORT

I. IDENTITY

PATIENT IDENTITY

Name : Ms. N

Age : 22 years

Address : Jl. Salak II no.18 RT/RW 04/011, Pamulang, Kab.

Tangerang

Religion : Islam

Ethnic : Java

Occupation : -

Education : Junior High School

Entry date : 3 desember 2009

PATIENT’S HUSBAND

Name : Mr.S

Age : 28 years

Ethnic : Betawi

Occupation : Ojeg

Education : Junior High School

I. ANAMNESIS

(Autoanamnesa, Desember 3 th 2009, 11.15 a.m )

1. Main complaint

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Patients referred from the midwife came with G2P1A0 Pregnant at 40

weeks with multiple pregnancy.

2. History of present illness

Patients admitted 9 months pregnant. First Day of Last Menstrual

February 24th, 2009. Estimated day of confinement November 31st 2009.

Patients regular ANC at the health center midwives. Patients have had a

one-time ultrasound examination at 7 months gestation, when It was

considered normal.

Patients feel the contraction since 10 hours before came the hospital.

Contraction more and more frequently. Mucus blood (+). According

to this pregnancy patients were higher compared with the first

pregnancy. This is felt more or less since the age of 5 months of

pregnancy Patient weight 40 kg before pregnancy, whereas patient

weight 52 kg now. No twin offspring

According to the patient, he often felt fetal movement not only in one

place, but in places different at the same time. The patient never

experienced shortness of breath during pregnancy older age, history of

swelling in the legs (-). History nausea and excessive vomiting in early

pregnancy denied.

3. Menstrual History

menarche at the age of 13 years, 28 days cycle, while 5 day period,

patients changing pads 2 – 3 times a day. No menstrual pain.

4. Marital Status

Marriage, Marriage in 2006

5. History of Previous Pregnancy

1. Normal, ♂ , 3 years old, 3000 gr, midwives , RB, healthy

2. Presence pregnancy

6. History of contraception

Pill contraception

25

7. History of Past Disease

Hipertension (-), DM (-), Heart disease (-), Asthma (-), Allergies (-)

8. History of Family Disease

Hipertension (-), DM (-), Heart disease (-), Asthma (-),

II. PHISYCAL EXAMINATION

General Status

General condition : moderate illness

Degree of consciousness : Compos Mentis

Vital sign

Blood pressure : 110/80 mmHg

Heart rate : 100x/menit

Temperature : 36,7 oC

RR : 20 x/m

Eyes : CA -/-, SI -/-.

Cor : Regular S1-S2 , murmurs (-), gallop (-)

Pulmo : Vesicular, Rh -/-, Wh -/-

Abdomen : see the obstetric status.

Ekstremity : warm exstremity, Edema -/-,

B. Obstetrics status

Abdomen

Inspection : longitudinal shape, striae gravidarum (+)

Palpation

1st Leopold : Fundal height 40 cm, palpable a large part, round,

not bouncy and one part hard, round and bounce.

2nd Leopold :

right : palpable hard part as a board

left : palpable hard part as a board

3rd Leopold : palpated a large part, round, soft, not bouncy, and a

largepart, a round hard bouncy

26

4th Leopold : 2/5

Fetal movement (+), Contraction 1x/10’/15”

EFW : 4000 gr

Auscultation : FHR 140 bpm dan 138 bpm

Anogenital

I : v / u calm,

Io : portio livid, ostium open, fluor (-), fluxus (-)

VT : soft potsio , axial, 3cm thick, Ø 4 cm,

membranes (+), head of the H I

III. PEMERIKSAAN PENUNJANG

1. USG

Gemelli fetal presentation looks head-breech both life.

Fetal I : DBP = 8,8 cm , AC = 27 cm, FL = 6,37, EFW : 2100 gram.

Fetal II : DBP = 8,5 cm, AC = 29,3 cm, FL = 6,2 cm, EFW : 2200 gram

Placenta in the fundus, ICA 3, fetal movement (+) active, insulation (+)

Impression : pregnant 35 – 36 weeks , Gemelli, presentation head –breech,

both live.

2. Laboratorium Desember 3,2009

Hb : 13,2 g/dl

Ht : 42 %

Leucocytes : 7500 uL

Platelets : 186.000 uL

Erythrocytes : 5,06 millions uL

27

VER/HER/KHER/RDW : 82,4 / 26,1 / 31,7 /13,4

Netrofil / Lmfosite / Monosite : 85/13/32

Spot glucose blood : 63 mg/dl

Tipe of blood : A +

URYNALISIS

Urobilinogen : 0,2

Protein : (+)

BJ : 1,010

Bilirubin : (-)

Ketones : 2+

Nitrite : 6,5

Leukosit : +1

Glukosa : (-)

Color : yellow

Sedimen Urine

Epitel : +1

Leukosit : 40-50 / magnified view field

Eritrosit : 6-8 / magnified view field

Silinder : (-)

Kristal : (-)

Bakteri : (-)

Lain-lain : (-)

3. CTG

Desember 3, 2009

Fetal I :

Frekuensi dasar : 155 bpm

Variability : 5-20 bpm

Acceleration : (+)

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Deceleration : ( - )

Fetal movement : (+)

Contraction : (+)

Impression : reassuring

Fetal II :

Frekuensi dasar : 150 bpm

Variability : 5-15 bpm

Acceleration : (+)

Deceleration : ( - )

Fetal movement : (+)

Contraction : (+)

Impression : reassuring

IV. WORKING DIAGNOSE

Mother : G2P1A0 pregnancy 40 weeks

PK 1 active

Fetal : Gemelli Presentation head –breech, both live intrauterine.

V. PROGNOSIS

Mother : Dubia

Fetal : Dubia

VI. MANAGEMENT

Dx/

- Observation vital sign, FHR, Contraction / hours.

Th/

- Initial vaginal delivery re value 8 hours again (19.15)

29

- Augmentation with oksitosin 5 Iu/500 RL titration until

adequate contraction.

- Re value 3 hours again after adequate contraction

FOLLOW-UP

3 Desember 2009

08.00 a.m :

Attached oksitosin 5 IU/500 cc RL, titration started 8 dpm until adequate

contraction

09.00 a.m

Achieved adequate contraction with oksitosin 12dpm re value 4 hours later

01.00 p.m

S : Contraction (+) , fetal movement (+)

O : BP : 110/80 mmHg HR : 88x/menit

RR : 18x/ menit. T : 36,7

Obstetric Status : contraction : 3 x / 10’/ 40” SRB ;

DJJ I : 140 bpm ; DJJ II : 145 bpm

Inspection : v/u calm,

Vaginal toucher : Portio thin, anterior, t 1 cm, dilatation 5 cm,

membranes (+), head of the fetus I Hodge I-II

A : active I period of Gravidity in G2P1A0 40 weeks pregnancy, gemelli

cephalic –breech presentation, both live intrauterine

P : - Observe vital sign, contraction, FHR / hours

- Re value 4 hours again

05.00 p.m

S : contraction more often, fetal movement (+)

30

O : general status in normal condition

BP : 110/80 mmHg HR : 98x

RR : 20x/m. T : 36,6

St. Obs : contraction : 4X/10’/45” ; DJJ I : 140 bpm; DJJ II :146 bpm

I : v/u calm

Vaginal toucher :

Soft Portio , axial, thick = 1 cm, dilatation 6 cm, membranes (+) / no

breaks, the head of the fetus I Hodge II, right anterior occiput

A : Active I period of Gravidity in G2P1A0 40 weeks pregnancy, gemelli

cephalic –breech presentation, both live intrauterine

P : - Observe vital sign, contraction, FHR / hours

- Plan vaginal delivery → re value of labor progress 4 hours again

09.00 p.m

S : contraction (+)

O : Ku/Kes : Baik / CM

BP : 120/90 mmHg HR : 100x/menit

RR : 20x/ menit. T : 37

St. Obs : contraction : 4X/10’/45”

DJJ I : 140 dpm;,DJJ II:148 dpm

I : open v/u

Vaginal toucher :

Complete dilatation, fetus head I in H III, UUK right anterior,

A : 2nd period labor of gravidity

P : help in labour

31

09.00 p.m

Spontaneously born baby boy 2100gr / 45 cm A.S.: 8 / 9

Baby covered and dried

Umbilical cord is clamped and cut

Do check in:

In VT: Opening full, membranes (+) outstanding, palpable fetal breech II H I

performed external fixation with the baby still in position lengthwise

Spontaneous rupture of the membrane

Helping in labour

Pukul 09.40 p.m

the baby was born spontaneously bracht II: Men 2000gr / 45 cm U.S.: 8 / 9

Umbilical cord is clamped and cut

Babies dried and covered

Mother Oxytocin 10 IU was injected IM

Nice contraction

Do stretch the cord of control

Complete spontaneous birth of the placenta

Do massage fundus, contractions both

In exploration I found the perineum RG

Done hemostasis and perineorafi

Bleeding time III and IV 300 cc.

Observasi 2 jam PP :

TD FN RR Contraction TFU Bleed. BAK spt

22.00 110/70 92 18 good 2 jbpst - -

22.15 110/70 92 19 good 2 jbpst - -

32

22.30 110/80 88 20 good 2 jbpst - -

22.45 110/70 80 21 good 2 jbpst - -

23.15 110/70 84 18 good 2 jbpst - -

23.45 110/70 88 17 bgood 2 jbpst - (+)

11.45 p.m

S : spontaneously BAK

O : general condition : CM/Baik

BP: 120/80 RR : 20x/m

HR: 88/’ T:36,5

Stat generalis DBN

Stat. Obs.: TFU 2 jbpst, kontraksi baik

I: V/U calm, active bleeding (-)

A: P2 PP Spt Gemelli 2 hours ago, stable hemodynamil

P: Rdx/ Observe vital sign Mother

Observe sign of vagina bleeding.

Rth/ -diet TKTP

-higiene V/P

-motivasi KB dan ASI eksklusif

-mobilisasi dini

33

BAB IV

ANALISA KASUS

In this case upheld Aterm pregnant G2P1A0 diagnosis, fetal presentation Gemelli

cephalic - breech life intrauterine based on anamnesis, physical examination and

investigation.

Anamnesa

Anamnesis obtained from the patient is referred by health centers with G2P1A0 H

aterm with Gemelli. Information from the referral is important to know what the

problem is happening to patients. But such information must be sharpened again. So

on further anamnesa found that the pregnancy is felt by the mother is greater than the

first pregnancy and fetal movements felt more than one. This is consistent with

literature which states that "The amount exceeds the duration of amenorrhea of the

uterus, the uterus grows faster than the gestational age (> 4cm) and on repeated

examination (because there 10 times more common in twin pregnancy)".is

polihidramnion However, patients have abdominal enlargement is not suitable during

pregnancy was caused by the hidramnion.

Anamnesa of risk factors in these patients clearly have not obtained, the patient did

not have a twin family descendants and contraceptive histories obtained from patients

were taking contraceptive injection from the clinic. But the menstrual history obtained

from the regular menses and may think that the ovulatory cycle has proven the patient

has a son. So the use of birth control injection to patients only for spacing pregnancies

and not to induce ovulation.

Physical examination

Obtained from physical examination at the examination of fetal Leopold impression

gained 2 double and fetal heart sounds. This is consistent with the literature:

- Many small part palpable

34

- Palpable large part of more than 1 fetus

- Palpable 2 heads, 2 ass and one / two backs

- There were two heart beats, which were located far from the speed difference of at

least 10 pulse permenit

Examination Support

In laboratory tests found no anemia which is a complication of most normal and twin

birth. This happens probably because the patient's intake of good nutrition and

activities that routine pregnancy testing performed by the patient.

Of ultrasound investigation of the impression obtained G2P1A0 H Aterm, gemelli

fetal presentation cephalic-breech intrauterin both life. These checks can ensure the

existence of multiple pregnancies and can estimate the weight of the fetus. So that it

can predict whether there is a discrepancy fetal growth. Widespread use of imaging

has ultrasonografik greatly reduce the incidence of twin gestation detection not before

delivery.

Procedure

In these patients planned vaginal partus because fetuses in length with a presentation

cephalic-breech. As in the literature "When I was treated as usual when the first child

lying lengthwise. After the first baby was born, soon carried out and a vaginal

examination to determine the location and condition of the second fetus. When the

fetus in the location of elongated, broken membranes and amniotic fluid flowed

slowly to avoid prolapse funikuli. Patients recommended or performed meneran

controlled pressure on the fundus uteri, to the bottom of the fetus into the pelvis. The

second fetus rapidly descending to the bottom of the pelvis and was born

spontaneously due to impassable roads have been born first child. "

Both spontaneous vaginal birth with an Apgar score of good, but at the time of

delivery of the placenta, the amniotic membrane and chorion was not examined.

Membranes should be examined to determine this from the baby so zigositas known

risks that may occur in the fetus.

By the time the second baby intervals with the first baby was 25 minutes this is not in

accordance with the literature that says that birth spacing should be the first and

second baby was 5-15 minutes, because it was feared would happen uteroplasenter

35

insufficiency. However, eventually the second baby was born with Apgar scores good

enough (8 / 9).

BAB V

CONCLUSSION

Twin pregnancy today there are about 3% of all pregnancies, and twin two

fetuses found in approximately 25-30% of labor resulting from assisted reproductive

technologies . Maternal morbidity and mortality was higher in twin pregnancies than

singleton pregnancies because of preterm labor, bleeding, and pregnancy Induced

hypertension.

Disorders in infants is more common in twin pregnancies, especially in

monozygotic twins. Therefore, more attention needs to overcome the twin

pregnancies during antenatal, delivery and postnatal mothers and babies.

ANC in pregnant women should be done regularly so that if there complication the

mother and baby can be resolved early. Ultrasound during pregnancy at least 3X, 1X

in each trimester to detect abnormalities early in pregnancy and to monitor the welfare

of the fetus and to determine the birth process.

36

DAFTAR PUSTAKA

1. Pernol, Martin L. Multiple pregnancy. In Benson & Pernoll’S Handbooks of

Obstetri and Gynecologi. 10Th ed. New York : Medical Publishing Division ;

2006. P 367 – 378

2. Cunningham FG, Gant NF, Leveno KJ, Gilstrap LC, Hauth JC, Wenstrom KD, et al ,

editors. Williams obstetrics, 21st ed. New York: McGraw-Hill; 2001

3. Harry, Oxorn B.A, Oxorn- Foote Human Labor and Birth. 5th . New York :

Mcgraw-Hill ; 2000

4. Zach T, Pramanik A. Multiple birth : emedicine. May 2006 [diakses pada 9

Feb2007]:[1hal.].diunduh dari: http://www.emedicine.com/med/topics342.htm

5. http//: Multiple Pregnancy - iVillage Your Total Health2.htm

6. Keith, Edmons. Multiple Pregnancy. In Dewhurt’s Textbooks of Obstetric &

Gynecology. 7 Th. London : Blackwell Publishing ; 2007. P : 166 – 176.

7. R. Pinglli, V. bomigboye, K. Jegede. Multiple Pregnancy a Blessing or a

Curse ?. The Internet Journal of Gyn & Ob.2008 ; vol. 9 : No.2

8. Kristen S. Monogery, Sabrina Cubera, Christine Blecher, et all. Childbirth

Education For Multiple Pregnancy.2005 ;14 : 26 -35

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