Assisted Reproduction Techniques and Multiple Births – The Obstetric Challenge
Globally, the incidence of twins and higher order multiple pregnancies have increased astronomically as a result of assisted reproductive techniques. This poses a lot of challenge to the care givers as a result of increased number of complications and exerts significant physical, emotional and financial burden to the parents and family members.
Complications of Twins and higher order multiple gestation are by far more than singletons. Higher order multiple gestation i.e three or more fetuses are by far the ones that have most complications.
Early in the first trimester, pregnancy symptoms are exaggerated such as vomiting. Hyperemesis gravidarum, a condition of excessive vomiting with electrolyte imbalance necessitating hospital admission is infact associated with multiple pregnancies. Bleeding per vagina as part of the symptoms and signs of miscarriage is also common.
Of importance also,in the first trimester, is the phenomenon called vanishing twin syndrome where there is an arrest of development of one or more embryos or fetuses with the continuing development of the other. In other words, an apparent singleton in 2nd trimestermay infact started as multiple.
Other obstetric challenges associated with multiple and higher order multiple pregnancies include increased incidence of pre eclampsia, gestational diabetes, preterm labour and delivery, placenta praevia, placental abruption, anaemia, difficulty in breathing, malpresentation, intra uterine growth restriction, intra uterine fetal death, increased operative delivery, postpartum haemorrhage. The list is not exhaustive.
The vast majority of the problems associated especially with higher order multiple pregnancies is preterm birth with its attendant consequencies.
There is increased perinatal morbidity and perinatal mortality from prematurity as a result of preterm birth. On the average, twins, triplets and quadruplets are delivered 36-37 weeks, 33-34 weeks and 30-31 weeks respectively. Fetal Lung matures by 34 weeks, hence the increased respiratory difficulties experienced by these fetuses born before this gestational age.
Of importance, is the emotional and financial burden associated with period of pregnancy? This poses a lot of stress to the mother, spouse and family members considering the cost of admission if need be as well as the cost of delivery and neonatal intensive care unit cost for the babies if they are delivered preterm.
With all of these obstetric and neonatal challenges highlighted above, it is important to constitute an obstetric/ neonatal team to ensure prompt and efficient service delivery so as to manage these recognized complications as they arise.
With an adequately staffed and equipped obstetric and neonatal facility, the myriads of problems highlighted above can be reduced to the barest minimum. Essentially, a neonatal intensive care unit with an absolute zero tolerance to infection, a ventilator to support the respiratory difficulty often encountered in these babies and use of surfactant will greatly improve neonatal outcome. More importantly is dedicated neonatal nurses who take care of these neonates.
Below,is a case Report and a 3 year review of ART and multiple births in Medical Art Center/ Mart Medicare – A world class maternity suites in Lagos, Nigeria.
Graph showing incidences of Multiple births in Medical Art.
Table showing multiple births in Mart Medicare.
MrsA.O , 32 year old Nigerian, who had ivf + ET. Early Ultrasound revealed 3 gestational sacs at 4 weeks gestation. She was subsequently enrolled in our early pregnancy and obstetric monitoring unit where a weekly transvaginal scan was done. At 9 weeks gestation, she had an episode of bleeding per vagina. She was reviewed and brought in for a bed rest. Ultrasound on admission revealed 3 viable fetuses with marginal bleed at the placenta edge. She was advised to continue progesterone support till 13 weeks. Bleeding however, subsided completely after a few weeks on admission and subsequently discharged home to be seen forthnightly in antenatal clinic.
She had a prophylactic cervical cerclage at 15 weeks. No complication was recorded.
Antenatal care was uneventful, she was placed early on folic acid 5mg daily, iron gluconate 300mg thrice daily. She had 2 doses of tetanus toxoids at 20 weeks and 24 weeks. Also had sulphadoxine and pyrimethamine at 18 weeks and 24 weeks.
She was admitted for bed rest till delivery from 24 weeks. She wore a TED stockingsthrough out the admission period to prevent blood clots in the legs. On admission, complete blood count was done every 4 weeks so as to identify any form of abnormal blood parameter prevalent with higher order multiple gestation. At 28 weeks, Haemoglobin was found to be 8g/dl. Blood film revealed a dimorphic feature of hypochromic microcytic and megaloblasticanaemia. Stool for ova and parasite done for any worm infestation was negative.
She was also found to have difficulty in breathing at this time. However, her chest was clinically clear. She was subsequently transfused with 2 pints of packed cells. She also had 2 doses of 12mg dexamethasone 12 hourly.
Ultra sound scan was subsequently done fortnightly and fetal weights and growths were satisfactory. She had an emergency caesarian section at 33 weeks on account of preterm prelabour rupture of membrane. Twin 1 was 2.1kg, twin II 2. 1kg, Twin III 1.8kg
The babies were delivered to the mother and there was no need to admit in neonatal intensive care unit.
Mother was discharged home on 5th day post operative day. She had 5 days course of thromboprophylaxis with low molecular weight heparin.
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