Lecture of multiple pregnancies (multiple pregnancies)

2021-03-20 12:00 AM

The rate of monocular twins is relatively constant worldwide, regardless of race, genetics, age, and number of births. In contrast, the rate of twin ovules is influenced by many factors

General perception

Multiple pregnancy is the simultaneous development of multiple pregnancies in the uterus. This is an abnormality in the number of pregnancies that is not a disease. It is possible to have two pregnancies, three pregnancies, four pregnancies ... but the most common one is two pregnancies that we often call twins.

Because multiple pregnancies cause negative consequences for the fetus and mother, multiple pregnant women often experience early miscarriage, the rate of multiple pregnancies decreases gradually compared with gestational age. When the fetus is over 20 weeks old, the rate of multiple pregnancies accounts for about 1% of the total number of pregnancies.

In 1993, there were more than 100,000 cases of multiple births in the US (Ventura et al.). In particular, there are more than 96,000 cases of live twins, 3834 triplets, 277 private births, 57 births. The rate of multiple births varies significantly among ethnic groups. Myrianthopoulos (1970) found that the birth rate of twins for white women is 1/100 compared to black women is 1/80. In some special regions of Africa, the rate of multiple births is very high. Research by Knox and Morley (1960) conducted in Nigeria showed that the rate of twins is 1/20. In Asia the rate of twins is 1/155.

In the late 1960s, people used oocyte stimulants and assisted reproductive techniques in use since the 1970s, leading to an increasing incidence of multiple pregnancies.

The rate of monocular twins is relatively constant worldwide, regardless of race, genetics, age, and number of births. In contrast, the rate of two oocyte twins is influenced by many factors: ethnicity, genetics, mother's age, number of births, and especially the use of oocyte stimulants in infertility treatment has increased The rate of multiple fetuses is significantly more fertile.

Multiple pregnancies can also be seen in ectopic pregnancy. These cases of multiple ectopic pregnancies are as well as mixed pregnancies with intrauterine and ectopic pregnancies.

Many statistics show that in multiple pregnancies, the rate of pregnant women is higher than that of boys.

The infant mortality rate of twins accounts for 11% of the total neonatal mortality and 10% of the perinatal mortality due to multiple pregnancies. In multiple pregnancies, the rate of preterm birth, poor fetal development in the uterus, and birth defects is higher than that of a single fetus. High perinatal mortality in multiple pregnancies is caused by:

Miscarriage.

Đẻ not.

Birth defects.

Underdeveloped pregnancy in the uterus.

Two fetuses circulate together, leading to the situation of giving and receiving, causing a fetus to atrophy and an edematous fetus.

Pregnancy toxicity and hypertension.

Striker vegetables, young vegetables.

Vegetable fiber, pregnant placenta.

Poly amniotic fluid.

Abnormal pregnancy.

Classify

Based on the origins of the generation, people divide the single-oocyte multi-fetus and the poly-oocyte multiple. Two pregnancies have a different origin for fertilization of two ovules, that is twins two ovaries. If the twins are bivalve, the sex may be the same or different, two separate amniotic fluid, one vegetable cake or two separate vegetable cakes. About a third of twins develop from a fertilized ovule and divide into two identical parts, each capable of developing into a separate fetus, the monocort.

If due to division before the inner cell layer is formed and the outer layer of the embryonic sac has not formed the mesothelioma, it will be the twin one ovule, two endothelium, two mesotheliomas. This twins rate is between 18 and 36%. It is possible to encounter two separate vegetable cakes or a joint vegetable cake, in terms of how long the division occurs during the first 72 hours after fertilization.

If division occurs between days 4 and 8, after the inner cell layer has formed and the cells have differentiated into the mesothelioma but the amniotic membrane has not yet formed. The two pregnancies will develop in two separate amniotic fluid chambers, but with only one outer mesothelioma. They are twins with one ovule, one mesothelioma and two endothelium.

If division occurs after eight days, when the endothelium has formed, two fetuses will develop in a common amniotic fluid, that is, twins one ovule, one mesothelioma, one endometrium.

If cleavage occurs later, after the embryo plate has formed. The division of the two fetuses is not complete and the two will stick together.

Reason

Ethnicity

In white women, the rate of twins is about 1%. This rate is higher in Africa, and lower in the East.

Genetic

It has been found that mothers with monocytes are more likely to conceive of twins than fathers who are monocytes.

Mother's age and number of births

Maternal age over 40, giving birth many times, the rate of multiple pregnancies increases.

Multiple ovulation placenta

Common in tall women, this has more to do with the diet than the mother's stature.

Endogenous Gonadotropin

Multiple ovarian placenta is more common in women one month after stopping oral contraceptive pills. In the following months, this phenomenon rarely happened. This may be due to an increase in pituitary hormone release during the first natural menstrual cycle after birth control is stopped.

Medications that stimulate ovulation

Multiple pregnancies are common in high rates in women treated for infertility with oocyte-stimulating drugs such as clomiphen citrate, Humegon, Pregnyl, Puregon ... These drugs can cause both monocytes and twins. two ovules.

In Vitro Fertilisation

Attempts to transfer more than one embryo into the uterus or into the oviduct significantly increase the rate of multiple pregnancies.

Pregnant women with multiple pregnancies require special care before, during and after childbirth. In general, the events that happen to the mother and the fetus are more and more severe the higher the number of pregnancies.

Symptoms and diagnosis

Mechanical symptoms

Prehistoric:

Ask if your wife's family history or: if your husband has given birth to multiple pregnancies. If you are a pregnant woman giving birth, ask if you have had multiple pregnancies. If the baby is a comparison, ask if she used birth control pills before getting pregnant. If the patient is being treated for infertility, ask if this pregnancy is taking oocyte stimulants.

Morning symptoms:

Multiple pregnancies often cause poisoning in early pregnancy. Pregnant women are pregnant more than last time or compared with people of the same gestational age.

The cabinet grows quickly:

Pregnant women feel their stomach enlargement faster than in previous pregnancies. Examination will find the uterus larger for gestational age. There are cases where the uterus grows quickly, making it difficult for pregnant women to rabbits because the bottom of the uterus pushes the diaphragm up. Pregnant women have difficulty walking.

The tubers of pregnancy:

Pregnant women feel more pregnant, many places throughout the abdomen.

Edema:

Often premature swelling of the legs due to compression of the uterus obstructs peripheral circulation.

Physical symptoms

Look:

Body: tired figure, blue skin, difficulty breathing.

The abdomen is stretched, the abdominal wall has many stretch marks. In humans, the cracks are usually brown and the moon cracks in the moon. If accompanied by poly amniotic abdominal skin stretch, shiny and may be accompanied by complete collateral system. The legs are white and soft, sometimes spreading to the abdomen.

Touching:

Measurement of uterine height shows that the uterus is larger than the gestational age, waist circumference is also larger than normal, at the second trimester of pregnancy if the uterus is larger than the gestational age, possibly due to

Multiple pregnancy.

The uterus is pushed up because the bladder is full of urine.

Wrongly remember the first day of your last period.

Poly amniotic fluid.

Pregnant eggs.

Pregnant with uterine fibroids.

Ovarian tumor and pregnancy.

Thai is too big.

Touch for the poles of the fetus:

In multi-fetus palpable one can see many poles or buttocks. As in twins one can feel the four poles: the first and the buttock poles, but it is rarely possible to fully manipulate all four poles. Three poles can be palpable: the first and the buttocks or vice versa. It is also possible to feel two poles of the same name (head - head or butt - butt) adjacent to each other, or two poles with different names (one head, one buttock) adjacent. Sometimes we do not clearly define which pole, but we only see a lot of things.

During labor, when there is a contraction of the uterus, manipulating the abdomen to find the fetal poles is sometimes difficult.

Listening to fetal heart:

Hear many fetal sockets, but the fetal sockets must be at least 1 inch apart. The frequency between the fetal hubs can vary by 10 cycles per minute. The distance between the fetal hearts must be a silent space.

Vaginal visit

It is an additional examination method that helps us confirm the external examination results. When not in labor, uterus contraction is still closed, through the pocket and vagina we can determine the fetal tip or buttocks. When the uterus has been opened it is possible to feel the fetal poles, the parts of the fetus often smaller than the size of the uterus.

Other exploration methods

Doppler tim thai:

During the first trimester, multiple fetal hubs can be detected with doppler.

Supersonic:

It is a convenient method that does not harm the fetus and mother, giving accurate and fast results. Ultrasound can detect multiple pregnancies early:

6 weeks gestation: amniotic sacs are visible.

10 weeks gestation: see the activity of the fetal heart.

13 weeks gestation: measured the length of the buttock.

Pregnancy from 17 weeks: measuring the dipole diameter of each head of the fetus and the development of the fetus can be monitored.

As the number of pregnancies increases, the ability to accurately diagnose ultrasound decreases.

Abdominal x-ray:

Can see images of many heads, many spines of the fetus on abdominal x-ray film. This method can easily infect the fetus with radiation. In some cases, the X-ray to diagnose fetal skin can be mistaken:

When taking X-ray before 18 weeks gestation because at this age fetal bone is not fully contrasted.

The shooting technique is not good, does not capture images of all fetuses, or the quality of the film is poor.

Fat mother.

When there is poly amniotic fluid.

Nowadays, the appointment of X-ray to diagnose multiple pregnancies has been replaced by ultrasound indications because of the effectiveness and harmlessness of ultrasound.

Biochemical test:

The amount of hCG in serum and urine in multiple pregnancies is higher than in single pregnancy, but not enough to determine definite. Sometimes it is also difficult to distinguish between pregnancy and multiple pregnancies based solely on the determination of hCG.

Placenta lactogen concentrations are also higher in multiple pregnancies than in single pregnancy.

Maternal serum feto-protein concentrations were also higher during multiple pregnancies.

In serum, the concentration of estrogen: alkaline phosphatase; leucine aminopepti- dase and in domestic concentrations of estrion and pregnandion are also higher. In general, all biochemical tests cannot clearly distinguish the presence of one or more pregnancies in the uterus.

.Implementing the quadrants

Based on physical, physical symptoms, ultrasound and the tests in which ultrasound plays the most important role.

Legs guess differentiation

Thai to:

Only see where the two poles and the buttocks, between the two poles is the back area connecting the two poles together. Only a fetal heart socket is heard.

Single pregnancy and poly amniotic fluid:

The uterine wall is usually tight and soft, making it difficult to manipulate the fetal poles. The fetal heart sounds small far away.

In twins, the rate of amniotic fluid is about 10%. Palpation shows that the poles and parts of the fetus are small relative to the uterus and show signs of "floating". Often relying on ultrasound to make the differential guess.

A pregnancy and hit-chamber cyst:

In the normal history a woman has been examined and diagnosed with an ovarian cyst. When the goat munches the cyst with the extreme or buttocks of the fetus. The exclusion of an ovarian cyst must stimulate the uterus to contract, if the uterus still has contractions, it is usually a cyst, and if the mass is not clearly manipulated in which the uterus contractions, it is a fetal pole.

A pregnancy and fibroids:

Uterine fibroids usually exist before pregnancy. The aneurysm during examination should stimulate the uterus to contract.

Pregnant eggs:

In the first trimester of pregnancy, multiple pregnancies and pregnancies are easily confused with each other, because the same symptoms of fetal poisoning, multiple pregnancies and pregnancy are easily confused, due to the same symptoms of poisoning early pregnancy, uterus. are larger than the fetus, the density is soft.

During pregnancy, there are often signs of abnormal bleeding, the blood is usually black, and the bleeding is persistent. The whole body may show signs of anemia. The uterus is large, unable to manipulate parts of the fetus. Can't hear the fetal heart. There is also a possibility to manipulate the glandular cysts one or two sides.

Diagnosis is confirmed based on ultrasound.

To solve

While pregnant

Monitoring and evaluating the development of the fetus by periodic pregnancy check-up every two weeks. Ensuring the hygiene regime during pregnancy, labor regime and appropriate nutritional regimen.

Early detection of late pregnancy toxicity in the last three months for timely and active management.

Fight premature birth. Pregnant women need to have appropriate rest and labor regime right from the time of detecting multiple pregnancies, need early detection and prompt treatment when there is a phenomenon of preterm labor with rest, medicine: using drugs reducing uterine contractility such as papaverin, buscopan, salbutamol ... especially, it is necessary to consider the use of corticosteroids to help the fetus mature early if it is not able to control preterm birth.

During labor

Well-organized team for midwifery and newborn care. In centers with conditions, it is advisable to arrange a midwifery team with 3 people and newborn resuscitation team and 3 staff.

In the process of labor must always closely monitor the state of the pregnant woman and the fetus to detect early events and promptly manage them.

In multiple pregnancies, labor is usually prolonged because of a weak uterine contraction.

First delivery: if the first is a pivot, it will be treated like a normal treadmill. After pregnancy, the umbilical cord must be clamped on both sides (mother and first fetus) to prevent the second fetus from having the same circulation as the first. Immediately after finishing the first pregnancy, the midwife gives this child to the woman to take care of to deliver the second pregnancy.

If the first fetus is in reverse, then treatment is the same as for cases of normal birth reverse. But it should be noted that the fetus is usually small, so it is susceptible to trauma during childbirth and if the second fetus is a crown, there is a possibility that the two fetuses will have each other.

Prepare and deliver a second pregnancy. After the first pregnancy is completed, the second pregnancy must be checked immediately. If the throne is horizontal, then it must be rancid and follow the internal rotation and then pull out the pregnancy immediately. If it is a conical or inverted throne, there are two handling attitudes:

Respect the period of physiological rest. Usually after 10 to 15 minutes, the uterine contraction reappears, at which point the amniotic fluid will be pressed to fix the second pregnancy. After that, the delivery will proceed as usual.

Amniocentesis immediately does not wait for uterine contractions to appear to fix the second fetus. If more than 20 minutes but the second fetus does not come down, they must intervene. Often the uterine contraction is weak, weak, so it is slow intravenous drip oxytocin.

The third and fourth pregnancy ... continue to treat like the second pregnancy.

Vegetable book: after the second maternity is finished, there is a short period of physiological rest, vegetables will be out at the same time, or two vegetable cakes will be written out in succession. Because the uterus is overly stretched, the uterine muscle is weak, so it is easy to have uterine sputum after childbirth, so oxytocin should be given intravenously drip and ergometrin intramuscularly after checking that the herb has not been burned to prevent lethargy. uterus. Currently, the use of prostaglandins to prevent bleeding due to sputum of the uterus has been shown to be very effective. Rectal cytotex can be used after vegetable flow to prevent uterine sputum.

If the vegetables are bleeding, remove the artificial vegetables and check the uterus. Check the vegetable cake for vegetables, missing membranes, and determine if there are twins with one ovule or two ovules

Checking vegetable cakes: after the vegetable book, it is necessary to systematically check the vegetable cake and the vegetable membrane to identify single-oocyte or multiple placentae. For convenience for checking as well as for fetal safety in case of multiple pregnancies, after the first pregnancy registration, the umbilical cord toward the veggie sandwich is a clamp; next to second miscarriage, clamp 2 clamp; third pregnancy clamp 3 clamp.  .. Consider the relationship of the vegetable membranes, amniotic fluid. If a single amniotic sac, or with separate amniotic sacs but the membranes are not separated, the babies are of monolithic origin. If the adjacent amniotic chambers are separated by separate membranes, it is also possible to have a monocort, but more often than not, multiple placentae.

If the babies were born of the same sex, the umbilical blood type test could be done to determine if the babies had multiple ovules. If the umbilical blood samples are all of the same blood type, it is necessary to use a more complicated technique, which is chromatography, DNA, to confirm the presence of multiple oocytes.

Caesarean section

Caesarean section indicated in multiple pregnancies is limited because the fetus is usually small and has the ability to deliver lower sugar. In some cases, a cesarean section is required:

The first poles of the two crowns tip down at the same time, inserting each other, causing labor to stop and the attempt to push the second reincarnation up fails.

The first pregnancy is inverted, with the chin attached to the second reincarnation without pushing the second reincarnation upwards.

The first pregnancy was impaired, and the vegetable cord was not pushed up.

The two pregnancies stick together. In some cases, the fetus sticking together can give birth to the lower line. Caesarean section should be done if it is possible that the ability to deliver lower sugar can cause serious trauma to the mother.

Postpartum period

For pregnant women: need to be closely monitored in the first hours after giving birth because the bleeding occurs due to sputum of the uterus.

Ensure good nutrition and rest so that pregnant women have enough milk to feed their babies and recover quickly.

Close monitoring of pulse, temperature, epidemic ... for early detection of postpartum infection.

New-borns need special care against respiratory failure due to endothelial disease, hypothermia because they often have multiple pregnancies or premature birth, so the lungs are immature, and the thermostat centre is incomplete. Make sure the temperature is warm enough, best nurture breast milk, and prevent infection so that the baby can soon adapt to the outside environment.