Multiple pregnancy: management

Patients with multiple pregnancies should visit the antenatal clinic more often than when they are singleton: 2 times a month until 28 weeks (when the disability certificate for pregnancy and childbirth is issued), after 28 weeks - 1 time every 7-10 days. Consultation of the therapist should be done 3 times during pregnancy.

Given the increased need for caloric content of food, protein, minerals, vitamins in multiple pregnancies, special attention should be given to training pregnant mothers with a balanced diet. Optimal for multiple pregnancy, in contrast to single-pregnancy, consider a total increase of 20-22 kg.

Pregnant women with multiple pregnancies from 16-20 weeks are prescribed anti-anemia therapy (ingestion of iron-containing drugs in a dose of 60-100 mg / day and folic acid at 1 mg / day for 3 months).

To prevent premature births, pregnant women with multiple births are recommended to restrict physical activity, increase the duration of daytime rest (three times for 1-2 hours). Expand the indications for the issuance of a sick leave sheet.

For the prediction of premature births, it is necessary to examine the state of the cervix. In this case, the method of choice - transvaginal cervicography, which, in addition to evaluating the length of the cervix, determine the state of the internal pharynx, which is impossible with manual examination. The terms of gestation from 22-24 to 25-27 weeks are considered "critical" for pregnant women with multiple births regarding the risk of premature birth. With a cervical length ≤34 mm at 22-24 weeks, the risk of preterm delivery to 36 weeks is increased; criteria for the risk of preterm delivery at 32-35 weeks - the length of the cervix ≤27 mm, and the criterion for the risk of "early" preterm labor (up to 32 weeks) is ≤19 mm.

For early diagnosis of delayed fetal / fetal growth, careful dynamic ultrasound monitoring is necessary.

For the development of tactics for the management of pregnancy and childbirth, in addition to fetometry, in multiple pregnancies, as in single-pregnancy, evaluation of the state of the fetuses is important (cardiotocography, dopplerometry in the mother-placenta-fetus system, biophysical profile). Of considerable importance is the determination of the number of amniotic fluid (many aridity) in both amnions.

[1], [2], [3], [4], [5]

Treatment of feto-fetal blood transfusion

The method of choice in the treatment of feto-fetal high-grade hemotransfusion is endoscopic laser coagulation of the anastomosing vessels of the placenta under echographic control ("sonoendoscopic" technique). The effectiveness of endoscopic laser coagulation therapy SFFG (the birth of at least one live child) is 70%. This method involves the transabdominal introduction of the fetoscope into the amniotic cavity of the recipient fetus. The combination of ultrasound observation and direct visual inspection through the fetoscope allows the examination of the chorionic plate along the entire interstitial septum, to detect and produce coagulation of the anastomosing vessels. The surgical intervention ends with drainage of the amniotic fluid before the normalization of their quantity. With the help of endoscopic laser coagulation, prolongation of pregnancy on average by 14 weeks is possible, which leads to a decrease in fetal death from 90 to 29%.

Alternative management tactics for pregnant women with severe SFFG in the absence of the possibility of laser coagulation of anastomosing vessels of the placenta - amniodraination of excess amniotic fluid from the amniotic cavity of the fetus-recipient. This palliative method of treatment, which can be used repeatedly in the dynamics of pregnancy, although it does not eliminate the cause of SFFG, but contributes to a decrease in intra-amniotic pressure and thereby - compression, as a rule, of the membrane-attached cord and surface vessels of the placenta, which to some extent improves the condition as a fetus -donor, and the recipient fetus. To the positive effects of amniodraination, prolongation of pregnancy should be attributed as a result of a decrease in the intrauterine volume.

The effectiveness of amniodrainage, conducted under ultrasound control, is 30-83%. The main and most important difference in perinatal outcomes in endoscopic laser coagulation and repeated amniodrainage is the incidence of neurologic disorders in surviving children (5 versus 18-37%, respectively).

Reverse arterial perfusion

Reverse arterial perfusion in twins is a pathology inherent only in monochorionic pregnancy and is considered the most pronounced manifestation of SFFG. At the heart of this pathology is a violation of vascular perfusion, as a result of which one fetus (recipient) develops due to the donor fetus due to the presence of umbilical arterio-arterial anastomoses. In this case, the donor fetus ("pump"), as a rule, does not have structural anomalies, but there are signs of dropsy. The recipient fetus ("parasitizing") is always with multiple anomalies incompatible with life: the head and heart can be missing or significant defects of these organs (rudimentary heart) are revealed. The prognosis for the donor fetus is also unfavorable: in the absence of intrauterine correction, the mortality rate reaches 50%. The only way to save the life of the donor fruit is the fetocid of the recipient fetus (umbilical cord ligation).

Intrauterine death of one of the fetuses

Intrauterine death of one of the fetuses in case of multiple pregnancy can occur at any gestation period, the result may be the "withering away" of one fetal egg in the first trimester (20% of observations) and the development of the so-called "paper fetus" in the second trimester of pregnancy. The average frequency of death of one or both of the fetuses in early gestation is 5% (2% for single-fetal). The frequency of late (in the II and III trimesters of pregnancy) of the intrauterine death of one of the fetuses is 0.5-6.8% for twins and 11-17% for triplets. The main reasons for late intrauterine death are in monochorionic placentation of SFFG, and in bichorial - delay in fetal / fetal growth and membrane attachment of the umbilical cord. The frequency of intrauterine fetal death with monochorionic double is 2 times higher than that of a bichoric multiple pregnancy.

With the death of one of the fetuses in the first trimester of pregnancy, a second fetus may be killed in 24% of the observations or a miscarriage occurs. However, in most cases, there may be no adverse effects on the development of the second fetus.

With the death of one of the fetuses in the II-III trimesters of pregnancy, premature termination of pregnancy is possible due to the isolation of the "dead" placenta of cytokines and prostaglandins. A large risk for the fetal survivor is also damage to the brain, which is due to severe hypotension due to redistribution of blood ("bleeding") from the live fetus to the fetoplacental complex of the deceased.

When fetal death of one of the fetuses with bihorionic double optimal tactics consider the prolongation of pregnancy. In the monochorionic type of placentation, the only way to save a viable fetus is by a cesarean section, performed as soon as possible after the death of one of the fetuses, when the brain of the surviving fetus has not yet occurred. When fetal death of one of the fruits from monochorionic twins at an earlier time (before reaching viability), the method of choice is the immediate occlusion of the umbilical cord of the dead fetus.

Congenital malformations of the fetus

The tactics of conducting a multiple pregnancy discordant in relation to congenital malformations of the fetus depends on the severity of the defect, the gestational age of the fetus at the time of diagnosis and, most importantly, the type of placentation. With bihorial double, a selective fetocid of a diseased fetus is possible (intracardiac introduction of potassium chloride under ultrasound control), but considering the insecurity of the invasive procedure, with an absolute lethality of the defect (eg anencephaly), the issue of expectant management should also be considered in order to reduce the risk of the procedure for the second the fetus.

With monochorionic placentation, the presence of interplanar transplacental anastomoses excludes the possibility of selective fetocid with the use of potassium chloride because of the danger of its entry from the circulation of a diseased fetus or bleeding into the vascular bed of a live fetus.

In monochorionic twins, other methods of fetocid of a diseased fetus are used: injection of pure alcohol into the intra-abdominal part of the umbilical artery, umbilical cord banding during fetoscopy, endoscopic laser coagulation, administration of a thrombotic spiral under the echographic control, embolization of a diseased fetus. The optimal tactic of conducting monochorionic twins with discordance in relation to congenital developmental anomalies is the occlusion of the umbilical cord of the diseased fetus.

[6], [7], [8], [9], [10], [11], [12], [13], [14],

Fused twins

This pathology is typical for monochorion monoamniootic pregnancy. Its frequency is 1% of monochorionic twins.

The most common types of fusion are thoracopagi (fusion in the thoracic region), omphalopagia (fusion in the navel and cartilage of the xiphoid process), craniopagi (fusion with homologous parts of the skull), pygopagi and ishiopagi (connection of the lateral and inferior parts of the coccyx and sacrum), and also incomplete discrepancy: bifurcation in only one part of the body.

The prognosis for intergrown twins depends on the location and extent of the connection, as well as on the presence of concomitant malformations. In this regard, in order to more accurately establish the potential for the survival of children and their separation, in addition to ultrasound, it is necessary to conduct additional methods of research, such as echocardiography and magnetic resonance imaging (MRI).

The management of pregnancy in utero-diagnosed fused twins is the termination of pregnancy, if the diagnosis is established in the early gestation. With the possibility of surgical separation of newborns and consent, mothers adhere to expectant tactics until the fruits reach vitality.

Chromosomal pathology in double-fetal pregnancy (in each fetus) is observed with the same frequency as in single-fruited pregnancy, and thus the possibility of damage to at least one of the fetuses is doubled.

In identical twins, the risk of chromosomal pathology is the same as in single-pregnancy, and in most cases both fetuses are affected.

If the tactics of managing pregnant women with twins in diagnosed trisomy of both fetuses is unambiguous - abortion, then with discordance of fetuses in relation to chromosomal pathology, either a selective fetocid of a diseased fetus or prolongation of pregnancy without any intervention is possible. The tactics are completely based on the relative risk of selective fetocid, which can cause miscarriage, premature birth, and the death of a healthy fetus. The issue of prolonging pregnancy with the carrying of a knowingly ill child should be decided taking into account the desire of the pregnant woman and her family.

The course and management of labor

The course of labor in multiple pregnancies is characterized by a high incidence of complications: primary and secondary weakness of labor, premature discharge of amniotic fluid, prolapse of umbilical cord loops and small parts of the fetus [18]. One of the serious complications of the intranatal period is the premature detachment of the placenta of the first or second fetus. The cause of placental abruption after the birth of the first fetus is a rapid decrease in the volume of the uterus and a decrease in intrauterine pressure, which is particularly dangerous in monochorionic twins.

Rare (1 in 800 pregnancies of twins), but a severe intranatal complication - a collision of fetuses with pelvic presentation of the first fetus and head presentation of the second. In this case, the head of one fetus clings to the head of the second and they simultaneously enter the entrance of the small pelvis. With the collision of twins, the method of choice is an emergency cesarean section.

In the postpartum and early postpartum period, due to overgrowth of the uterus, hypotonic bleeding may develop.

The method of delivery in a double depends on the presentation of the fruit. The optimal method of delivery in the head presentation of both fruits is considered to be delivery through the natural birth canal, with the transverse position of the first fetus - the caesarean section. Pelvic presentation of the first fetus in primiparas is also attributed to indications for cesarean section.

With the head presentation of the first and the pelvic presentation of the second method of choice - the birth through the natural birth canal. In childbirth, an external turn of the second fetus is possible, with a transfer to the head presentation under the supervision of an ultrasound examination.

The transverse position of the second fetus is now considered by many midwives as an indication to the caesarean section on the second fetus, although with sufficient physician qualification the combined rotation of the second fetus on the stem and its subsequent extraction is not particularly difficult.

A clear knowledge of the type of placentation is important for determining the tactics of giving birth, since in monochorionic twins, in addition to the high frequency of antenatal fetal and fetal blood transfusion, there is a high risk of acute intranatal transfusion, which may be fatal to the second fetus (severe acute hypovolemia followed by brain damage , anemia, intrapartum death), therefore, the possibility of delivery of patients with monochorional twin by caesarean section is not excluded.

The greatest risk with respect to perinatal mortality is the birth of a monochorion monoamniosic twin, which requires a particularly careful ultrasound monitoring of the growth and condition of the fetuses, in which, in addition to the specific complications inherent in monochorionic twins, umbilical cord torsion is often observed. The optimal method of delivery in this type of multi-fetus is considered to be cesarean section at 33-34 weeks of gestation. Caesarean section is also performed by delivery with fused twins at late diagnosis of this complication.

In addition, the indication for the planned caesarean section in double is expressed by the expressed overgrowth of the uterus at the expense of large children (total weight of the fruit is 6 kg or more) or polyhydramnios. In pregnancy, three or more fetuses are also shown by cesarean delivery within 34-35 weeks.

When conducting labor through the natural birth canal, careful monitoring of the patient's condition and continuous monitoring of the heart activity of both fetuses must be carried out. It is preferable to have childbirth in multiple births in the position of the parturient woman on the side in order to avoid the development of the syndrome of compression of the inferior vena cava.

After the birth of the first child, external obstetric and vaginal examinations are performed to clarify the obstetric situation and the position of the second fetus. It is also advisable to conduct an ultrasound study.

In the longitudinal position of the fetus, a fetal bladder is opened, slowly releasing amniotic fluid; further childbirth is conducted as usual.

The question of caesarean section during delivery in case of multiple pregnancy can arise for other reasons: persistent weakness of labor, loss of small parts of the fetus, umbilical cord at the head presentation, symptoms of acute hypoxia of one of the fruits, placental abruption, etc.

During multiple births, it is mandatory to prevent bleeding in the consecutive and postpartum periods.

Training of Patients

Each patient with multiple pregnancies should be aware of the importance of a full-fledged rational diet (3,500 kcal per day), and special attention must be paid to the need for the preventive use of iron preparations.

Patients with multiple pregnancies should know that the total weight gain for pregnancy should be at least 18-20 kg, while it is important to increase weight in the first half of pregnancy (at least 10 kg) to ensure the physiological growth of the fruit.

All patients with multiple pregnancy should be informed of the main possible complications, primarily about miscarriages. It is necessary to explain to the woman the necessity of observing the protective regime, which includes the reduction of physical activity, obligatory daytime rest (three times for 1-2 hours).

Pregnant women with monochorionic twins should undergo a systematic examination, including ultrasound, more often than with bichorial, to identify early signs of feto-fetal blood transfusion syndrome. These patients should be informed of the possibility of surgical correction of this complication.