Crossword puzzle on the topic of multiple pregnancy. Multiple pregnancy, ultrasound during multiple pregnancy. Main stages of human embryogenesis

Multiple pregnancy is considered to be a pregnancy with two or more fetuses at the same time.

What is the birth rate of twins?

The rate of identical twins remains relatively stable at approximately 1 in 225 births, regardless of race or the number of previous births a woman has had.

The ability to have fraternal twins in women is hereditary. In 1895, the French biologist D. Hellin formulated the law on the birth of twins, according to which in the population one birth of twins occurs in 85 single births, births of triplets - in 85 twins, quadruplets - in 85 triplets, etc.

Consequently, before the widespread introduction of new infertility treatments, there was one triplet per 7,000 births, one quadruplet per 680,000, and one quadruplet per 4,712,000,000 births. The likelihood of having fraternal twins increases with the number of births (after the second birth - two times, after the fifth - five times) and the age of the woman (over 30-35 years), their high growth and excess weight. In addition, the mothers of such twins most often have AB (IV) blood type. The likelihood of repeating a multiple pregnancy increases over a generation: if a grandmother once had twins, then her granddaughter also has a high risk of having a multiple pregnancy.

It is impossible to exclude the fact that there are men who cause multiple births in their wives. At least two similar cases are known in Russia. In 1755, sixty-year-old Yakov Kirillov, a peasant from the village of Vvedensky, married twice, was introduced to Empress Elizaveta Alekseevna. During 21 pregnancies, his first wife gave birth to 57 living children, 4 times four, 7 times three and 10 times two. The second one gave birth to 15 children in 7 pregnancies, 1 time three and 6 times two. In total, Kirillov had 72 children from two wives.

In February 1782, an accounting record was delivered to Moscow from the Nikolsky Monastery, located in Shuisky district. It said that the peasant Fyodor Vasilyev, married twice, had 87 children from both marriages. During 27 births, the first wife gave birth to four children 4 times, three times 7 times, and two times 16 times. The second wife gave birth 2 times to three and 6 times to two children. Vasiliev was then 75 years old, and of the children there were 82 living.

The number of twins varies significantly across races, from less than 1 in 100 births in Japan to 1 in 30 births in Nigeria.

Since the development of modern infertility treatment methods, the number of fraternal twins has doubled, and the number of triplets or more multiple pregnancies has increased by 500%. Today, more than 1% of all pregnancies are multiple.

Twins or twins

There are two types of twins: fraternal (heterozygous, “false”) and identical (monozygous, “true”). Children born from fraternal twins are called “twins,” and children born from identical twins are called “twins.” “Twins” can be either the same sex or different sexes, while “twins” can only be of the same sex. Twins can also be mirrored (one twin is left-handed, the other is right-handed, the hair on the tops of their heads is curled in different directions).

Heterozygous twins (70% of twins) develop from two eggs when they are fertilized during one menstrual cycle by two different sperm. In this case, two different fertilized eggs are formed, which are implanted in the uterus nearby and subsequently develop autonomously. Each embryo/fetus develops its own placenta, and each is surrounded by its own amniotic and chorionic membranes, creating an interfetal septum of four layers.

Such twins are called bichorionic biamniotic. There is no functional connection between the two embryos/fetuses. Genetically, they are related in the same way as any children of the same parents; they may have different fathers and be conceived more than a week apart. There is a classic case when a white woman, with an interval of 1 hour, gave birth to a white child, the son of a white father, and a mulatto, the son of a black man (the so-called “superfertilization”).

Identical or monozygotic twins (30%) appear when one fertilized egg, under the influence of factors still unknown to us, is divided into two eggs, each of which will further develop independently. Both fetuses, formed from one fertilized egg, divided into two equal parts, receive a completely identical set of chromosomes and genes.

After birth, these true twins will become doubles, an exact copy of each other with the same blood type, eye color, hair color, location and shape of teeth, identical fingerprints in 95% of cases, or in accordance with the now classic formulation of “one person in two copies.” This striking similarity is not limited only to external data, it also applies to intelligence, psyche, and predisposition to a number of diseases.

The number of placentas formed in this case will depend on the stage of development of the fertilized egg at which its division occurred.

Twins with separate amnions and chorions/placentas are born when separation occurs within 3 days after fertilization. The partition between them consists of four leaves, as in fraternal twins. Such twins are called bichorionic biamniotic.

If the division of the egg occurs between 3 and 8 days after fertilization, then two embryos, two amnions and only one chorion/placenta are formed. The septum between the fetuses is formed from two layers of amnion. This type of identical twins is called monochorionic biamniotic.

When the egg divides in the interval 8-13 days after fertilization, two embryos and one chorion are formed, surrounded by a single amniotic membrane. There is no interfertal septum. Such identical twins are called monochorionic monoamniotic.

If separation occurs after the 13th day, conjoined twins (Siamese twins) are formed.

The best option is to have two placentas and two amniotic sacs, since in this case the twins are independent of each other. If there is one placenta for two, there is blood exchange between children, that is, sometimes one can receive more blood than the other (feto-fetal transfusion syndrome (FFTS) or donor-recipient syndrome), the first fetus suffers from excess blood, and the second - from its deficiency (discordant fruit growth). Due to excess blood in the first case, congestive heart failure is possible (the heart needs to perform backbreaking work, leading to an increase in its size).

In the second case, anemia or growth retardation (hypotrophy) caused by insufficient blood flow is possible. As a result, the woman should be under constant medical supervision. To identify early signs of FFH, pregnant women with twins need to undergo examinations, including ultrasound, more often than with a singleton: examinations after 20 weeks - once every two weeks and after 30 weeks - weekly.

Complications of multiple pregnancy

Multiple pregnancies carry risks for both mother and children, and such pregnancies are more likely to have complications. 54% of twins and 93% of all triplets or more multiple pregnancies are born prematurely. In multiple pregnancies, late toxicosis (preeclampsia), maternal anemia, and miscarriage (including premature birth) are more common and more severe.

The course of a multiple pregnancy, as already mentioned, is often complicated by delayed development of one of the fetuses, the level of which is 10 times higher than in a singleton pregnancy.

One of the most common complications of multiple pregnancies is premature birth, caused by overdistension of the uterus due to the large number of fetuses and due to frequent polyhydramnios in these pregnancies. The duration of pregnancy directly depends on the number of fetuses. The duration of singleton, twin and triplet pregnancies averages 39, 36-37 and 34 weeks, respectively. However, nature protects twin newborns: their ability to adapt after childbirth at the specified time is much higher than that of a child born during a singleton pregnancy.

In order to prevent premature birth, pregnant women with multiple pregnancies are recommended to limit physical activity and increase the duration of daily rest up to three times for 1-2 hours). You need to lie more on your side so that the heavy uterus does not compress the inferior vena cava. And after the 20th week of pregnancy, a woman is recommended to stop engaging in active sports (except, perhaps, swimming), intensive work, and sex life. In our country, a woman expecting several children at once is entitled to longer maternity leave: 84 days before (from 28 weeks of pregnancy) and 110 days after childbirth.

To identify the threat of premature birth, an obstetrician-gynecologist evaluates the condition of the cervix (including its length) using ultrasound every two to three weeks. If it shortens before 23 weeks, sutures are placed on the neck (cerclage). The insertion of an obstetric support pessary into the vagina also has a good effect. It is important not to miss the time for these procedures. After 23 weeks, in order to eliminate the threat of premature birth, it is possible to prescribe drugs that reduce the tone of the uterus. If there is a threat of premature birth, all pregnant women are given medication to prevent respiratory disorders in newborns born prematurely.

Pregnant women with multiple pregnancies should receive up to 60 mg of iron and 1 mg of folic acid per day as a preventive measure from the second trimester. In addition, the diet must include foods rich in iron: liver and other offal, beef, cereals, sardines, artichoke, melon, turnips, jacket potatoes, spinach, soy beans.

The average weight of a newborn baby during a singleton pregnancy is 3360 grams, for twins - 2400, and for triplets - a little more than 1700 grams. As a rule, the difference in body weight between newborn twins is small, amounting to about 200-300 g. Less often, a significant difference in their body weight is detected (dissociated development in FFTS) - up to 1 kg or more.

To minimize the possibility of having low birth weight babies, a pregnant woman should pay significant attention to her nutrition, especially in the first trimester. Each child needs up to 400 calories per day.

Women with multiple births need to know that if in the case of a singleton pregnancy the optimal weight gain is up to 12-13 kg, then in a twin pregnancy the total weight gain during pregnancy should be at least 18-20 kg, which is important for guaranteed physiological growth of the fetus has a weight gain of at least 10 kg in the first half of pregnancy.

Childbirth with multiple births

In the case of multiple pregnancies, childbirth is a more complex process, especially for the second twin; sometimes a caesarean section is the best choice, or the doctor pre-programs the operation.

Indications for surgical delivery in multiple pregnancies are: excessive uterine distension and large fetuses (total weight more than 6 kg); severe late toxicosis (preeclampsia), which is a contraindication to vaginal delivery; breech presentation of the first fetus (in first-time mothers), entailing all the problems associated with childbirth in the breech position.

The question of a cesarean section during childbirth during a multiple pregnancy may arise for other reasons: persistent weakness of labor, placental abruption, loss of small parts of the fetus, umbilical cord loops in cephalic presentation, signs of acute oxygen starvation of one of the fetuses, and others.

If there are no absolute indications, then vaginal delivery is preferable. If there are three or more fetuses, regardless of the woman’s condition, it is recommended to perform surgical delivery at 34-35 weeks of pregnancy.

How much does pregnancy cost?

What called multiple pregnancy? Multiple pregnancy is a pregnancy with two or more fetuses. If there is a pregnancy with two fetuses, they speak of twins, with three - of triplets, etc. Each of the fetuses in a multiple pregnancy is called a twin.

How often meets multiple pregnancy? Multiple pregnancies account for 0.5 to 2.0% of all births and usually end with the birth of twins, less often triplets. Triplets make up about 1% of all multiple births.

To calculate the frequency of multiple pregnancies in a population, Hellin's rule can be used. The frequency of births of twins is 1:80, triplets - 1:80 2, quadruplets - 1:80 3, quintuplets - 1:80 4. However, it is necessary It should be noted that half of the fetal eggs undergo resorption in the early stages of pregnancy. Resorption of the embryo is observed mostly during the first 7 weeks of gestation and does not occur after 14 weeks (vanishing twin syndrome).

Currently, there is an increase in the number of women with multiple pregnancies.

Which causes influence on frequency multiple pregnancy?

The incidence of multiple pregnancies is influenced by the age of the mother, number of births, time of conception after stopping oral contraceptives, stimulation of ovulation, multiple pregnancies in the spouses' pedigree and history, as well as the spouses' belonging to a particular ethnic group. Thus, in China, the birth rate of twins is

is 3:1000 live births, and in Nigeria - 57.2:1000. The increase in the number of multiple pregnancies coincides with an increase in maternal age (from 35 to 39 years) and an increase in the number of births. The likelihood of pregnancy with two fetuses increases when taking oral contraceptives for six months and within one month after their discontinuation, as well as when using medications that stimulate ovulation, IVF (in vitro fertilization).

Which kinds twins exist?

There are two types of twins:

2) dizygotic (fraternal, dizygotic, heterologous, fraternal).

Monozygotic twins have the same genotype (always the same sex, look alike, have the same blood type), which is associated with their origin - early atypical division of an egg fertilized by one sperm (polyembryony), or fertilization of an egg with more than one nucleus .

Dizygotic twins are formed when two eggs are fertilized by two sperm (in one or two ovaries or two eggs in one follicle), so their genotype is not identical.

Identical twins are much less common than fraternal twins (1:10).

Which kinds multiple pregnancy allocate V dependencies from placental-membranous relationships? Multiple pregnancy is divided into:

- bichorionic biamniotic twins, which is typical only for fraternal twins (each twin has its own chorion and amnion, so the septum consists of four leaves - two amnions and two smooth chorions lying between them), while the placenta can be separate or fused;

With identical twins, the following options are possible: monochorionic biamniotic twins(both amnions are enclosed in one common chorion - a septum between the

dami consists of two layers of amnion); monochorionic mo-noamniotic twins(the amniotic cavity is common for two twins - there is no septum) (Fig. 14.1, 14.2, 1 4.3).

Rice. 14.1. Schematic representation of the membranes and placenta in twins:

a - two placentas, two amnions, two chorions; b - one placenta, two amnions,

two chorions; V - one placenta, two amnions, one chorion

What way type formed placental complex influences on flow And Exodus pregnancy? The types of formed placental complex directly affect the course and outcome of pregnancy: perina-

Fig 14.2. Afterbirth for fraternal twins.

The partition consists

of four shells: two

amnions ( 1 ) and two chorions (2)

Rice. 14.3. Afterbirth with monooval

twins The partition consists of two

amnion layers

The total mortality rate in monochorionic pregnancy is higher than in bichorionic pregnancy. The reasons are as follows: for example, with monoamniotic twins, the umbilical cords of both fetuses are attached to the placenta very close to each other, as a result of which they may become twisted and the death of both fetuses; in addition, it is with monoamniotic twins that a type of fetal development anomaly is formed, such as conjoined, or Siamese, twins. In 75% of cases these are girls. The name of conjoined twins is given depending on the place of their fusion: craniopagus (head), thoracopagus (thoracic region), ompha-lopagus (abdominal region), pygopagus (buttocks and lower spine), and their combinations are also possible (thoracoompha-lopagus).

However, the most common cause of perinatal mortality in monochorionic pregnancy is the formation of anastomoses between the vessels of the circulatory systems of twins in the common placenta. Depending on the type of anastomoses (and they can be arterio-arterial, arterio-venous or venous-venous) and the diameter of the vessels that form them, the following pregnancy outcomes are possible:

Development of two normal fetuses;

Feto-fetal transfusion;

Normal development of one fetus and severe pathology in the other.

What such feto-fetal transfusion syndrome?

Twin transfusion syndrome is observed only in the monochorionic type. This syndrome is caused by the presence of vascular anastomoses between twins, which leads to impaired blood circulation.

When feto-fetal transfusion syndrome develops, one fetus becomes donor another - recipient. Vascular anastomoses are found in 50-100% of cases of monochorionic pregnancy.

As a result of the discharge of blood from one system to another, one fetus (donor) develops anemia, hypoxia, developmental delay, and oligohydramnios. Often the donor dies in utero.

The other fetus (recipient) develops polycythemia, cardiomegaly, congestive heart failure, nonimmune hydrops, and polyhydramnios.

With transfusion syndrome, the size of one fetus is significantly larger than the size of the other (the difference in weight can reach 20% or more). These twins are called

discordant.

Which clinical signs multiple pregnancy exist?

Clinical signs of multiple pregnancy include:

An increase in the size of the uterus compared to the expected gestational age;

Detection of three or more large parts of the fetus during external obstetric examination;

Listening to two or more points for determining the fetal heartbeat and the “silent” zone between them (Fig. 14.4).

Which additional methods research use For

diagnostics multiple pregnancy?

The most reliable method for diagnosing multiple pregnancy in the first half of pregnancy is ultrasound (from 4.5 weeks of gestation). Ultrasound allows you to differentiate a multiple pregnancy from polyhydramnios, hydatidiform mole, uterine tumor (fibroids), or a large fetus. In addition, the role of ultrasound is increasing due to the increasing incidence of fetal malformations in multiple pregnancies.

To diagnose multiple pregnancy in the early stages, you can use the determination of the level of human chorionic gonadotropin (HCG) in the urine or blood of the pregnant woman. If there are two or more embryos, the hCG level will be higher than with one embryo at the same stage of pregnancy.

What are peculiarities currents pregnancy at multiple births?

The course of pregnancy, childbirth and the postpartum period during multiple pregnancy has its own characteristics. In terms of the number of complications for the mother, fetus and newborns, it is classified as pathological obstetrics. With multiple pregnancy, pregnancy occurs with complications in 70-85 % women.

Perinatal mortality in multiple births is 3-4 times higher than in singleton births. The unfavorable outcome of childbirth for the mother and fetus is mainly due to miscarriage, its complicated course, and an insufficiently differentiated approach to childbirth.

With multiple pregnancy in the first trimester of pregnancy, the most common complications are the threat of miscarriage and vomiting of pregnancy. In 15-20% of cases during multiple pregnancies, one of the fertilized eggs dies, which may be due to anembryony (absence of an embryo) or the death of one of the embryos.

The most common complications of the second and third trimesters with multiple pregnancy are the threat of miscarriage and premature birth, anemia of pregnant women, preeclampsia, polyhydramnios, and premature rupture of water. In addition, if there are two or more fetuses in the uterus, delayed development of the fetus or fetuses, congenital anomalies, in particular the union of twins (conjoined, or Siamese, twins), premature abruption of a normally located placenta, abnormal position of the fetus, and transfusion syndrome of twins often occur.

What are peculiarities conducting pregnancy at multiple births?

The prognosis of pregnancy and childbirth with multiple pregnancies is less favorable than with a single fetus. Therefore, medical supervision of pregnant women with multiple pregnancy is carried out taking into account possible complications, identifying them at risk for the development of perinatal pathology. If there is the slightest deviation from the normal course of pregnancy, mandatory hospitalization is indicated. To prevent possible complications, especially premature birth, planned hospitalization is recommended at 28 weeks (bed rest in a hospital setting), from 32 to 34 weeks - bed rest at home, from 34 to 36 weeks - restriction physical activity. Repeated hospitalization in the antenatal department is carried out 2 weeks before the due date, the purpose of which is to examine the pregnant woman and determine the date and method of delivery. For three or more fetuses, inpatient monitoring is recommended from 26 weeks until delivery.

What are peculiarities currents childbirth at multiple births?

With multiple births, childbirth has the following features: untimely discharge (early or premature) of amniotic fluid is often observed, weakness of labor (weakness of contractions and pushing), premature detachment of a normally located placenta after the birth of the first fetus, fetal hypoxia, prolapse of small parts of the fetus and umbilical cord, which Irregular positions and small size of fruits contribute to this.

A rare complication of twin births is the confluence of twins.

What such collision twins?

Twin collision is more common with breech presentation of the first fetus and cephalic presentation of the second fetus. Childbirth can proceed without complications until the birth of the body of the first fetus, then the head of the first fetus is not born, since the head of the second fetus is wedged between its body and the head. In most cases, childbirth ends with the death of the first fetus. If a twin collision is detected, an immediate cesarean section is required.

What are principles choice way delivery at pregnant women twins?

When managing childbirth in pregnant women with twins, the most important thing is the choice of method of delivery - through the vaginal birth canal or by cesarean section. Ideally, the decision should be made before labor begins.

The most important factors on the basis of which the decision on delivery tactics is made are: presentation, position and weight of the fetus.

What are readings For operational delivery at

multiple pregnancy?

Given the high level of perinatal mortality in multiple pregnancies, in modern obstetrics there is a tendency to expand the indications for abdominal delivery in the interests of the fetus.

Indications for delivery by cesarean section for twins are:

Monoamniotic twins;

Premature fetuses (up to 34 weeks of pregnancy);

Breech presentation or transverse position of the first fetus;

Combination of multiple pregnancy with obstetric or extragenital pathology.

What are peculiarities conducting I period childbirth at multiple pregnancy?

Managing childbirth during multiple pregnancy requires a lot of attention, clear orientation in the obstetric situation and highly qualified doctor, allowing him to perform any operation.

Multiple pregnancy

During vaginal delivery, it is necessary to carry out cardiac monitoring of the condition of both fetuses. After the birth of the first fetus, monitoring of the condition of the second fetus continues. Due to the high frequency of labor anomalies, it is necessary to register the contractile activity of the uterus using a monitor and a graphical representation (partogram) of the dynamics of the opening of the uterine pharynx in the first stage of labor. Pain relief during labor should be kept to a minimum level. If labor is weak, careful administration of oxytocin is used (slow rate of administration with assessment of the condition of the fetus and labor).

What are peculiarities conducting II period childbirth at multiple pregnancy?

In the second stage of labor, weakness in pushing often occurs, therefore, to prevent weakness of labor during the expulsion period, oxytocin is administered intravenously at a rate of 5-8 drops per minute. Immediately after the birth of the first fetus, the umbilical cord is clamped and a vaginal examination is performed. If the fetus is in a longitudinal position, the amniotic sac should be opened, which promotes contraction of the overstretched uterus and is an effective means of preventing placental abruption.

If the fetus is in a transverse position, labor may end with rotation of the fetus by the leg, followed by extraction by the pelvic end or a cesarean section.

For multiple births, the presence of two midwives and two neonatologists is required.

What are peculiarities conducting trailing And early postpartum periods at multiple pregnancy? The third stage of labor and the early postpartum period are especially dangerous due to the development of bleeding. For this purpose, the administration of uterotonic drugs is continued for 2 hours after birth.

After the birth of the placenta, it is thoroughly examined to determine the integrity of the lobules and membranes and to preliminarily determine the type of twins (one- or two-egg). In the postpartum period, careful monitoring of the postpartum woman is necessary.

What are peculiarities conducting early neonatal period?

Management of the early neonatal period in newborns from multiple pregnancies requires special attention to a certain extent, but should not differ from the management of children from singleton pregnancies, excluding, of course, cases of premature birth and the birth of children with severe developmental delay.

Multiple pregnancy The likelihood of twins increases: History of twins (being a twin) Mother's age from 35 to 39 years Number of births Belonging to the black race Use of assisted reproductive technologies Conception after taking COCs High level of secretion of pituitary gonadotropins

Multiple pregnancy Classification By zygosity: Dizygotic (dizygotic, non-identical) Monozygotic (monozygotic, identical) By chorionicity (placentation): Bichorionic - biamniotic Monochorionic - biamniotic Monochorionic - monoamniotic

Multiple pregnancy Multiple pregnancy Fertilization of two or more oocytes Simultaneous ovulation followed by fertilization of two or more eggs matured in different follicles of one ovary Simultaneous ovulation followed by fertilization of two or more eggs matured in different follicles in both ovaries Ovulation and fertilization of two or more eggs, matured in one follicle Superfertilization - fertilization of two or more simultaneously ovulated eggs by sperm from different men Fertilization of an egg ovulated against the background of an existing pregnancy

Multiple pregnancy Early division of a fertilized egg (depending on the time from fertilization to bifurcation of the zygote, one of 4 options for twins): 0-72 hours - bichorionic - biamniotic monozygotic twins 25% 4-8 days - monochorionic - biamniotic monozygotic twins 70% 9-13 day - monochorionic - monoamniotic monozygotic twins 5% After 13 days - conjoined (Siamese) twins

Multiple pregnancy Diagnosis Clinical and anamnestic signs: Excessive weight gain The height of the uterine fundus is 4 cm or more more than is typical for this period, an increase in abdominal circumference. Palpation of parts of the fetus, the size of the fetal head does not correspond to the size of the uterus. Auscultation at two or more fetal heartbeat sites

Multiple pregnancy Ultrasound is the gold standard in the diagnosis of multiple pregnancy Accuracy - 99.3% Possible from 6 - 7 weeks of gestation When using a vaginal sensor from 4-5 weeks of gestation Allows you to determine the number of fetuses, amnions, but reality (especially in the first 14 weeks) Differential diagnosis of bichorionic from monochorionic twins is easier in the first trimester and can be performed with transvaginal ultrasound at 5 weeks

Multiple pregnancy Complications in the mother: Anemia (2 times more often than in a singleton pregnancy) Spontaneous abortions (2 times more often than in a singleton pregnancy) in 50% - fetuses were subjected to resorption - anembryony - death of the “vanishing twin” embryo - “disappeared” phenomenon twin” no later than 14 weeks

Multiple pregnancy Complications for the mother during pregnancy: Early toxicosis (nausea and vomiting are more severe) Pregnancy-induced hypertension (3 times more often than with a singleton) Preeclampsia (in 20-40% of pregnant women with multiple pregnancy) Threat of premature birth, premature birth (36 .6%-50%)

Multiple pregnancy Complications for the mother during pregnancy: Premature rupture of amniotic fluid (25% of cases), which is twice the frequency of singleton pregnancies. Polyhydramnios is observed in 5-8% of twin pregnancies, especially with monochorionic twins. Acute polyhydramnios before 28 weeks of pregnancy occurs in 1.7% of twins. Impaired glucose tolerance Cholestasis of pregnancy

Multiple pregnancy Complications in the fetus: High perinatal mortality is 15% increases in direct proportion to the number of fetuses - increases in direct proportion to the number of fetuses - per 1000 births in twins per 1000 births in triplets per 1000 births in triplets

Multiple pregnancy Complications in the fetus: Prematurity - low birth weight (55% weight less than 2500) - respiratory distress syndrome - intracranial hemorrhage - sepsis - necrotizing enterocolitis Average duration of pregnancy: Twins - 35 weeks Triplets - 33 weeks Quadruples - 29 weeks

Multiple pregnancy Complications in the fetus: Congenital malformations Observed 2-3 times more often than during pregnancy with one fetus Observed 2-3 times more often than during pregnancy with one fetus Monochorionic anomalies are twice as likely as bichorionic ones Frequency ranges from 2 to 10 % Frequency ranges from 2 to 10% The most common are: cleft lip cleft palate cleft palate defects of the central nervous system defects of the central nervous system heart defects

Multiple pregnancy Complications in the fetus: Conjoined twins Frequency - 1: 900 twin pregnancies Classification is based on the part of the body by which they are connected to each other: thoracopagus - conjoined in the chest area (40%) omphalopagus - conjoined in the anterior abdominal wall (35%) pygopagus - fused in the sacral area (18%) ischiopagus - fused in the perineal area (6%) craniopagus - fused in the head area (2%)

Multiple pregnancy Complications in the fetus: Pathology of the umbilical cord and placenta: - placenta previa - placental abruption (usually in the second stage of labor) - velamentous attachment of the umbilical cord (7% in twins) - umbilical cord previa (8.7% in twins), - umbilical cord prolapse in childbirth

Multiple pregnancy Complications in the fetus: Feto-fetal transfusion syndrome (twin transfusion syndrome) a complication of monochorionic multiple pregnancy with a frequency of up to 15% frequency of up to 15% The development of FFTS is due to the presence of vascular anastomoses, leading to pathological shunting of blood from one fetus to another The development of FFTS is due to the presence of vascular anastomoses leading to pathological shunting of blood from one fetus to another. One fetus becomes a donor and the other a recipient

Feto-fetal transfusion syndrome Donor Chronic blood loss Anemia HypovolemiaHypoxia Restricted growth Reduced renal blood flow Oligohydramnios Oliguria Amnion compression Recipient Chronic increase in blood volume Hypervolemia PolycythemiaHypertension Non-immune hydrops Cardiomegaly PolyuriaPolyhydramnios

Multiple pregnancy Complications in the fetus: Incorrect presentation of the fetus during childbirth (50% - 10 times more often than in singleton pregnancy): -Cecephalic-cephalic 50% -Cecephalic-pelvic 30% -Pelvic-cephalic 10% -Transverse for one or two fruits 10%

Multiple pregnancy Complications in the fetus: Collision - Coupling of twins during childbirth Frequency 1: 1000 twins and 1: births Perinatal mortality with this complication reaches 62-84% Diagnosis is made during the period of expulsion of fetuses Diagnosis is made during the period of expulsion of fetuses Observed in breech-cephalic presentation

Multiple pregnancy Complications in the fetus: Various options for impaired development of one or both twin fetuses - a consequence of placental insufficiency 5 types of prenatal development of fetuses from twins (M.A. Fuchs): 5 types of prenatal development of fetuses from twins (M.A. Fuchs): physiological development of both fetuses - 17.4% uniform malnutrition of both fetuses - 30.9% uniform malnutrition of both fetuses - 30.9% uneven development of twins - 35.3% congenital pathology of fetal development - 11.5% antenatal death of one fetus - 4 ,1%

Multiple pregnancy Complications in the fetus: Intrauterine growth restriction of the fetus frequency is 70% compared to 5-10% in singleton pregnancy. Delay in the development of one of the fruits (differences in size and weight of more than 15-25%) with a frequency of 4-23%. Neurological disorders: infantile paralysis microcephaly microcephaly encephalomalacia encephalomalacia In twins born prematurely, the incidence of brain tissue necrosis reaches 14%. In twins born prematurely, the incidence of brain tissue necrosis reaches 14%.

Multiple pregnancy Management of pregnancy: Early diagnosis of multiple pregnancy Dynamic observation once every two weeks in the first half of pregnancy, once a week in the second half of pregnancy Good nutrition “Bed rest” position Prevention of iron deficiency anemia

Multiple pregnancy Management of pregnancy: Ultrasound monitoring of fetal development - Screening (standard) ultrasound per week. to exclude developmental anomalies (taking into account the increased background risk of congenital anomalies) - Dynamic ultrasound starting from 24 weeks. every 3-4 weeks. before delivery (to assess fetal growth and timely diagnosis of FFTS)

Pregnancy management: assessment of the condition of the fetus according to CTG (non-stress test) should begin within a week. and continue weekly until delivery If there is evidence of deterioration in fetal growth, weekly assessment of the biophysical profile, amniotic fluid index, weekly CTG and Doppler blood flow in the umbilical cord is necessary from the moment of diagnosis of this pregnancy complication Multiple pregnancy

Management of pregnancy: For diagnosed FFTS syndrome: - Conservative treatment (observation, early delivery if necessary) - Amnioreduction (a series of therapeutic amniocentesis 1-12, removal of 1-7 liters) - Fetoscopic laser coagulation of vascular anastomoses - Septostomy (puncture of the amniotic septum) - Septostomy (puncture of the amniotic septum) - Selective euthanasia of the fetus (donor) embolization, coagulation, ligation

Multiple pregnancy Management of labor: At the beginning of the first period, an ultrasound is necessary to clarify the position and presentation of the fetuses (the position may change compared to what it was a few days before the onset of labor) Monitoring of both fetuses by recording CTG is necessary during the first stage of labor

Multiple pregnancy Indications for cesarean section: Monoamnial fetuses, regardless of the position of the fetuses Conjoined twins Transverse position of the first fetus Breech presentation of the first fetus with excessive tilting of the head Transverse position of the second fetus, which remains unchanged after the birth of the first fetus and an attempt at external rotation of the second More than two fetuses

Multiple pregnancy Management of vaginal birth: If the second fetus is transversely positioned, an ultrasound scan should be performed to monitor possible changes in its position. External-internal rotation followed by extraction of the fetus by the pelvic end is undesirable due to severe traumatic complications for the fetus. After the birth of the second fetus and placenta, it is necessary to prevent bleeding

State budgetary educational institution

secondary vocational education

"Medical School No. 4

Department of Health of the City of Moscow"

by PM. 02 Participation in diagnostic, treatment and rehabilitation processes

topic “Nursing care

in obstetrics and pathology of the reproductive system in men and women"

Prepared by:

teacher PM.02

E. A. Vinokurova

Crossword 1

The science of physiological and pathological processes associated with pregnancy and childbirth

Of great importance is ………… Michaelisa

Internal reproductive organ that performs reproductive function

One of the levels of regulation of the menstrual cycle

Muscular layer of the uterus

The superior thickened edge of the ilium wing

Uterine mucosa

Paired endocrine gland

Ripenes in the ovary………..

First phase of the uterine cycle

Release of a mature egg

Corpus luteum hormone

symphysis pubis

There are big and small……….

Crossword 2

Vertically:

2. Fuzzy shell

9. Inspection of the amniotic sac

12. Water shell

Horizontally:

1. Fusion of sperm and egg

3. Children's place

11. The relationship of the fetal back to the left or right side of the uterus

13. Umbilical cord

Crossword 3

1. Fusion of sperm and egg

2. Fuzzy shell

3. Children's place

4. Relationship between the fetal axis and the uterine axis

5. The relationship of the large part of the fetus to the entrance to the pelvis

6. Pelvis measuring tool

7. Used to listen to the fetal heartbeat

8. Puncture of the amniotic cavity

9. Inspection of the amniotic sac

10. Attachment of the fertilized egg to the wall of the uterus

11. Relationship between the back of the fetus and the walls of the uterus

12. Water shell

13. Umbilical cord

14. Presumable sign of pregnancy

15. Blueness of the vaginal mucosa

Crossword 4

Vertically:

1. The relationship of the longitudinal axis of the fetus to the longitudinal axis of the uterus

2. Water shell

4. Used to listen to the fetal heartbeat

5. The process of implantation of the fertilized egg into the uterus

7. Relationship between the back of the fetus and the walls of the uterus

Horizontally:

3. Presumable sign of pregnancy

4. Umbilical cord

5. Fuzzy shell

6. The placenta, umbilical cord, membranes make up……..

7. The physiological process of expulsion of the fetus and placenta from the uterus

8. Inspection of amniotic fluid

9. Blueness of the vaginal mucosa

Crossword 5

1. Ancestral expelling forces

2. Contraction of muscle fibers

3. Change in the shape of the head as it passes through the birth canal

mothers

4. One of the signs of placenta separation

5. The set of movements performed by the fetus during passage

through the birth canal

6. The physiological process of expulsion of the fetus and placenta from the uterus

7. First stage of labor

8. Children's place

9. Reverse development of the uterus

10. Postpartum discharge

Vertically:

The area of ​​clinical medicine that studies the processes associated with conception, pregnancy, childbirth and the postpartum period

Crossword 6

Vertically:

1. Clinical sign of eclampsia

2. One of the symptoms of nephropathy

3. Presence of protein in urine

4. Premature……..normally located placenta

5. General swelling

6. Edema of pregnant women

7. The main symptom of placental abruption

Horizontally:

2. Presence of red blood cells in urine

3. The condition of the newborn is determined according to the scale……..

4. Spontaneous miscarriage

5. With premature detachment, the uterus is formed……….

6. Nephropathy is characterized by ………….. symptoms

7. Clinical sign of placenta previa

8. Severe form of toxicosis

Crossword 7

Vertically:

1. The relationship of the large part of the fetus to the entrance to the pelvis

2. Instrument for listening to the fetal heartbeat

3. The process of fusion of male and female reproductive cells

4. Water shell

5. Cord-like formation between mother and fetus

Horizontally:

1. Baby in the womb

2. Organ that bears the fetus

3. Pelvis measuring tool

4. ……..Michaelis is of great importance

5. The relationship of the longitudinal axis of the fetus to the longitudinal axis of the uterus

6. Inspection of amniotic fluid

7. Taking amniotic fluid for research

8. Relationship between the back of the fetus and the walls of the uterus

Crossword 8

1. External genitalia

2. Female reproductive gland

3. Corpus luteum hormone

4. The fourth phase of the uterine cycle

5. Organ that bears the fetus

6. Collection of data on previous diseases

7. Uterine mucosa

8. Fuzzy shell

9. Release of a mature egg

10. Desquamation is actually ………………

11. Founder of psychoprophylactic training

Horizontally:

Physiological process in a woman’s body from the moment of conception to childbirth

Crossword 9

Horizontally :

1. First stage of labor

2. Generic expellers………..

3. Rhythmic contractions of the uterine muscles

4. This drug is used to prevent gonoblenorrhea

5. The set of movements that the fetus makes when

passing through the mother's birth canal

6. Woman after childbirth

7. The first moment of the biomechanism of childbirth

8. Ancestral expelling forces

Vertically:

1. The physiological process of expulsion of the placenta from the uterus

2. Contraction of muscle fibers

3. Postpartum discharge

4. The umbilical cord, placenta and membranes make up ………….

5. Hemorrhage under the periosteum

6. Second stage of labor

7. Reverse development of the uterus

Crossword 10

1. Presence of red blood cells in urine

2. This toxicosis is characterized by a triad of symptoms

3. Presence of protein in urine

4. Increased blood pressure

5. Form of early toxicosis

6. General swelling

7. Bubble………….

8. Main symptom of eclampsia

9. Spontaneous………..

10. Edema or………..

Standard answers

for crossword 1

1. Obstetrics

2. Diamond

3. Uterus

4. Hypothalamus

5. Myometrium

6. Comb

7. Endometrium

8. Ovary

9. Follicle

10. Desquamation

11. Ovulation

12.Progesterone

13. Symphysis

14. Pelvis

Standard answers

for crossword 2

Vertically:

2. Chorion

4. Position

5. Presentation

7. Stethoscope

9. Amnioscopy

10. Implantation

12. Amnion

15. Cyanosis

Horizontally:

1. Fertilization

3. Placenta

6. Tazomer

8. Amniocentesis

11. Position

13. Umbilical cord

14. Nausea

Standard answers

for crossword 3

1. Fertilization

2. Chorion

3. Placenta

4. Position

5. Presentation

6. Tazomer

7. Stethoscope

8. Amniocentesis

9. Amnioscopy

19. Implantation

11. Position

12. Amnion

13. Umbilical cord

14. Nausea

15. Cyanosis

Standard answers

for crossword 4

Vertically:

1. Position

2. Amnion

3. Tazomer

4. Stethoscope

5. Implantation

6. History

7. Position

Horizontally:

1. Presentation

3. Nausea

4. Umbilical cord

5. Chorion

6. Afterbirth

7. Childbirth

8. Amnioscopy

9. Cyanosis

Standard answers

for crossword 5

1. Contractions

2. Contraction

3. Configuration

4. Shredder

5. Biomechanism

6. Childbirth

7. Disclosures

8. Placenta

9. Involution

10. Lochia

Vertically: Obstetrics

Standard answers

for crossword 6

Vertically:

1. Cramps

2. Hypertension

3. Proteinuria

4. Detachment

5. Anasarka

6. Dropsy

7. Pain

Horizontally:

2. Hematuria

3. Apgar

4. Abortion

5. Kuvelera

6.Triad

7. Bleeding

8. Eclampsia

Standard answers

for crossword 7

Vertically:

1. Presentation

2. Stethoscope

3. Fertilization

4. Amnion

5. Umbilical cord

Horizontally:

1. Fruit

2. Uterus

3. Tazomer

4. Diamond

5. Position

6. Amnioscopy

7. Amniocentesis

8. Position

Standard answers

for crossword 8

1. Pubis

2. Ovum

3. Progesterone

4. Secretion

5. Uterus

6. History

7. Endometrium

8. Chorion

9. Ovulation

10. Menstruation

11. Platonov

Horizontally: Pregnancy

Standard answers

for crossword 9

Horizontally:

1. Disclosures

2. Powers

3. Contractions

4. Albucid

5. Biomechanism

6. Postpartum woman

7. Flexion

8. Pushing

Vertically:

1. Childbirth

2. Contraction

3. Lochia

4. Afterbirth

5. Cephalohematoma

6. Expulsions

7. Involution

Standard answers

for crossword 10

1. Hematuria

2. Nephropathy

3. Proteinuria

4. Hypertension

5. Vomiting

6. Anasarka

7. Skid

8. Cramps

9. Abortion

10. Dropsy

Multiple pregnancy is a pregnancy with two or more fetuses. If there is a pregnancy with two fetuses, they speak of twins, three - of triplets, etc. Each fetus in a multiple pregnancy is called a twin. Births of twins occur once in 87 births, triplets - once in 872 (6400) twins, quadruplets - once in 873 (51200) triplets, etc. (according to Gallin's formula).

Causes of multiple pregnancy.

It has been proven that two or more follicles can mature in one ovary. In addition, ovulation can occur simultaneously in both ovaries. The above possibilities are supported by the facts of detection during surgery for tubal pregnancy in the same ovary of two blooming corpora lutea or in each of the ovaries one blooming corpus luteum. In addition, one follicle can contain two or more eggs. The cause of multiple pregnancy can be fertilization with the sperm of different partners, fertilization against the background of an existing pregnancy, or induced pregnancy. Twins formed from the fertilization of two eggs are called dizygotic; identical twins result from atypical fragmentation of the egg. Where the separation of the egg occurs completely, two completely identical twins are formed. Such twins are called identical. Identical twins are much less common than fraternal twins (1:10). If, with complete separation of the egg, both embryos are located in the uterus at a sufficient distance from each other, then the embryos developing from them form each a separate amnion and remain separate - biamniotic twins. If both amnion sacs are enclosed in one chorion common to both twins, and the septum between them consists of two membranes (two amnions), then such twins are called monochorionic. They share a placenta. If both embryos lie side by side, this leads to the formation of one amniotic cavity common to both (monoamniotic twins). Identical twins are always the same sex - either both boys or both girls, they look alike, their blood type is always the same.

COURSE AND MANAGEMENT OF MULTIPLE PREGNANCY

During multiple pregnancy, due to the heavy load on the body, women report early fatigue, shortness of breath, difficulty urinating, and constipation. Frequent and early complications of pregnancy are premature birth (50% of cases), toxicosis and gestosis, varicose veins, polyhydramnios, low weight and immaturity of the fetus, and the death of one of the fetuses. In some cases, polyhydramnios in one cavity may be accompanied by oligohydramnios in the other.

Recognizing multiple pregnancies in the first months is quite difficult and becomes easier in the second half of pregnancy. Pay attention to the discrepancy between the size of the uterus and the gestational age. Upon palpation, many small parts are identified, two heads, two backs. During auscultation - two or more points for determining the fetal heartbeat and a zone of silence between them. The height of the uterine fundus is greater than during a singleton pregnancy at the same time. When measuring the length of the fetus with a pelvis, the fetus is long with a small head. The most reliable diagnostic method is ultrasound.

In the vast majority of twins (88.0%), both fetuses are in a longitudinal position and occupy one the right and the other the left half of the uterus. Most often, both fetuses are presented head-on (45.0%). Other options for the location of the fetus in the uterus are possible. One fetus may be in a cephalic presentation, the second in a pelvic presentation (43.0%). Both fetuses are in breech presentation (6.0%). One fruit is in a longitudinal position, the other is in a transverse position (5.5%), or both fruits are in a transverse position (0.5%). Medical supervision of pregnant women with multiple pregnancies is carried out taking into account possible complications, identifying them at risk for the development of perinatal pathology.

COURSE AND MANAGEMENT OF LABOR

The prognosis of pregnancy and childbirth with multiple pregnancies is less favorable than with a single fetus. At the slightest deviation from the normal course of pregnancy, mandatory hospitalization is indicated. Repeated hospitalization in the antenatal department is carried out 2-3 weeks before the due date, the purpose of which is to examine the pregnant woman and determine the date and method of delivery.

Multiple births are accompanied by frequent complications of childbirth. Most births occur prematurely, the weight of newborns is less than 2500 g, pelvic and transverse positions of the second fetus are possible. Frequent untimely rupture of amniotic fluid may be accompanied by prolapse of small parts of the fetus and the umbilical cord, which is facilitated by the pelvic and transverse positions and the small size of the fetus.

During the period of dilation, functional insufficiency of the overstretched, thinned muscles of the uterus appears, weakness of labor forces develops, premature rupture of amniotic fluid occurs, so the period of dilation is prolonged.

The period of expulsion may also be delayed due to the development of labor anomalies. Prolonged labor poses a danger to the mother (bleeding, infection) and fetus (hypoxia).

Placental abruption before the birth of the second fetus leads to its intrauterine death. There may be a transverse position of the second fetus, twin collision (adhesion of two large parts of the body), bleeding in the third stage of labor, in the early postpartum period, delayed uterine involution and infectious diseases.

Managing childbirth during multiple births requires a lot of attention, clear orientation in the obstetric situation and high qualifications to perform any operation. During the period of dilatation, it is necessary to carefully monitor the condition of the woman in labor and the fetus. If there is polyhydramnios, opening of the amniotic sac is indicated when the cervix is ​​opened by 4 cm and slow removal of water (within 1-2 hours).

In order to reduce complications of childbirth in case of multiple pregnancy and perinatal mortality of the second fetus, it is currently recommended to open the amniotic sac of the second fetus immediately after the birth of the first fetus, and immediately begin intravenous drip administration of 5 units. oxytocin in a 5% glucose solution in order to accelerate the second stage of labor until the placenta is separated. In case of bleeding, development of hypoxia of the second fetus or its transverse position, for the purpose of rapid delivery, a classic external-internal obstetric rotation of the fetus onto a leg is indicated, followed by its extraction by the pelvic end

The third stage of labor and the early postpartum period are especially dangerous due to the development of bleeding. After the birth of the placenta, a thorough examination is carried out to determine the integrity of the lobules and membranes and the type of twins (one- or two-egg).

In the postpartum period, careful monitoring of the postpartum woman and prevention of uterine subinvolution is necessary.

Perinatal mortality in multiple births is 2 times more likely than in single births. Therefore, in modern obstetrics there is a tendency to expand the indications for abdominal delivery in the interests of the fetus. Indications for cesarean section associated with polyhydramnios include triplets, transverse position of both or one of the fetuses, breech presentation of both fetuses or the first of them, and not associated with multiple pregnancy - fetal hypoxia, labor anomalies, umbilical cord prolapse, extragenital pathology of the mother, severe gestosis, previa and placental abruption.

Prevention of complications during multiple pregnancy is the prevention of complications during pregnancy.