Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
INTRODUCTION
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
1
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
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
Race. Black women have the highest rate of natural multiple pregnancy. Asian
women have the lowest.
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
Suggestive findings :
a.
Familial history.
b.
The uterus and abdomen seem larger than expected for the period of
amenorrhea.
2.
c.
d.
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.
d.
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
Hydramnios;
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,
10
2.
3.
4.
11
12
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
16
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
Situation
A
B
C
PRESENTATION OF TWINS
Twin A
Twin B
Vertex
Vertex
Vertex
Nonvertex
Nonvertex
Other (any)
%
40
40
20
17
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.
18
exercise programs). Frequent rest periods are initiated after the 24th week (e.g.,
1 week of bedrest at 26 weeks and again at 3233 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.
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.
19
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 1012%
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.
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
and the recipient twin is often plethoric with hemoglobin differences greater
than 5 g/dL.
Conjoined twins.
21
22
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
Religion
Islam
Ethnic
Java
Occupation
Education
Entry date
3 desember 2009
PATIENTS HUSBAND
Name
Mr.S
Age
28 years
Ethnic
Betawi
Occupation
Ojeg
Education
I. ANAMNESIS
(Autoanamnesa, Desember 3 th 2009, 11.15 a.m )
1. Main complaint
Patients referred from the midwife came with G2P1A0 Pregnant at 40
weeks with multiple pregnancy.
2. History of present illness
24
2.
Presence pregnancy
6. History of contraception
Pill contraception
7. History of Past Disease
Hipertension (-), DM (-), Heart disease (-), Asthma (-), Allergies (-)
25
: 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
Pulmo
Abdomen
Ekstremity
B. Obstetrics status
Abdomen
Inspection : longitudinal shape, striae gravidarum (+)
Palpation
1st Leopold
2nd Leopold
right
left
3rd Leopold
4th Leopold
: 2/5
26
: 4000 gr
Auscultation
Anogenital
I
: v / u calm,
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
85/13/32
: 63 mg/dl
27
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
Eritrosit
Silinder
(-)
Kristal
(-)
Bakteri
(-)
Lain-lain
(-)
3. CTG
Desember 3, 2009
Fetal I :
Frekuensi dasar
155 bpm
Variability
5-20 bpm
Acceleration
(+)
Deceleration
(-)
Fetal movement
(+)
Contraction
(+)
28
Impression
reassuring
Fetal II :
Frekuensi dasar
150 bpm
Variability
5-15 bpm
Acceleration
(+)
Deceleration
(-)
Fetal movement
(+)
Contraction
(+)
Impression
reassuring
Fetal
V. PROGNOSIS
Mother
: Dubia
Fetal
: Dubia
VI. MANAGEMENT
Dx/
-
Th/
adequate contraction.
-
29
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
: BP : 110/80 mmHg
HR : 88x/menit
RR : 18x/ menit.
T : 36,7
v/u calm,
Vaginal toucher
membranes
A
05.00 p.m
S
HR : 98x
RR : 20x/m.
T : 36,6
30
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
contraction (+)
Ku/Kes : Baik / CM
BP : 120/90 mmHg
HR : 100x/menit
RR : 20x/ menit.
T : 37
: open v/u
Vaginal toucher :
Complete dilatation, fetus head I in H III, UUK right anterior,
A
: 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
22.00
110/70
92
18
good
2 jbpst
22.15
110/70
92
19
good
2 jbpst
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
32
23.45
110/70
88
17
bgood
2 jbpst
(+)
11.45 p.m
S
spontaneously BAK
RR : 20x/m
HR: 88/
T:36,5
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
- Palpable large part of more than 1 fetus
- Palpable 2 heads, 2 ass and one / two backs
34
- 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
insufficiency. However, eventually the second baby was born with Apgar scores good
enough (8 / 9).
35
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
3. Harry, Oxorn B.A, Oxorn- Foote Human Labor and Birth. 5 th . 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 Dewhurts 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
37