Obstetrics and Gynecology - A. M. Gromova 2000

Multiple Pregnancy
Course and Management of Multiple Pregnancy

In multiple pregnancies, all forms of gestosis develop significantly more often than in singleton pregnancies, and their clinical course is notably more severe. The incidence of Late gestosis can exceed 40%. Multiple pregnancies are also more frequently complicated by the threat of Miscarriage, anemia, lower extremity varicose Veins, polyhydramnios, and fetal malformations. The mother's Cardiovascular system, Liver, and Kidneys operate under increased strain, leading to Complaints of fatigue, shortness of breath, frequent urination, and constipation.

Between 50% and 70% of twin pregnancies do not reach the 10th obstetric month. As the number of fetuses in the uterine cavity increases, the duration of gestation decreases, averaging 37 weeks in multiple pregnancies.

In cases of monochorionic Multiple Pregnancy, an uneven supply of nutrients and oxygen to one of the twins—caused by Specific features of Fetal Circulation—becomes a critical factor. As a result, one fetus may develop intrauterine growth restriction or even demise. The deceased fetus is compressed by the co-twin, the Amniotic Fluid is reabsorbed, and the Placenta undergoes degenerative changes. Such a mummified fetus (referred to as a "paper doll fetus" or fetus papyraceus) is delivered alongside the placenta of the surviving infant.

The course of pregnancy in women with multiple gestations is accompanied by a wide range of complications, which often present more severely than in singleton pregnancies.

The pathological course of pregnancy is driven by the high physiological demands placed on the maternal Organism by multiple fetuses.

A woman carrying a multiple pregnancy is classified as high-risk for both pregnancy and delivery. Careful monitoring of her overall condition, as well as the function of her cardiovascular system, liver, kidneys, and Blood system, is essential. If any deviations from a normal physiological course arise, the patient is hospitalized in an obstetric department.

Women with multiple pregnancies are subject to planned hospitalizations for prophylactic purposes at 18–22 weeks and 31–34 weeks—which are considered "critical periods"—as well as for antenatal preparation at 36–37 weeks of gestation.

The critical periods in a multiple pregnancy include 18–22 weeks and 31–34 weeks (regarding the risk of miscarriage); 18–32 weeks (regarding anemia); 26–36 weeks (regarding The Development of late gestosis); and 11–22 weeks (regarding polyhydramnios).

Multiple pregnancies frequently involve the development of Fetoplacental insufficiency, leading to fetal hypotrophy and intrauterine growth restriction (IUGR) syndrome.

To prevent these complications, the following measures are implemented:

1. Dynamic ultrasound examinations are performed every 4 weeks to monitor fetal development, determine the type of placentation, and screen for polyhydramnios, Congenital Malformations, intrauterine fetal death, and other abnormalities.

2. Establishment of a protective regimen and hospitalization at 18–22 and 30–34 weeks of gestation, taking into account the critical periods for pregnancy loss.

3. A balanced diet emphasizing Vitamins and high-biological-value animal Proteins (such as lean meat and cottage cheese).

4. In the event of increased uterine tone or periodic crampy lower abdominal pain during critical periods for miscarriage, oral tocolysis with β-adrenergic agonists is indicated: starting from 20 weeks of gestation in courses of 2–4 weeks with 1–2 week intervals. Recommended medications include brinalix 25 mg (1/2 tablet 1–2 times daily) and partusisten 5 mg (1/4 tablet 1–2 times daily). Sedatives are also used to support tocolysis (valerian extract 2 mg tablets, 1 tablet 3 times daily; liquid motherwort extract 15.0:2000 mL, 1 tablespoon 3 times daily). In some cases, acupuncture or cervical cerclage for early signs of isthmic-cervical incompetence (functional or organic forms) may be utilized up to 20 weeks of gestation.

5. Prolonged oral administration of iron-containing preparations (starting from 16–20 weeks of gestation for up to 3 months): ferroplex 2 dragees 3 times daily, or ferro-folic 500, 1 tablet in the morning.

6. Improvement of uteroplacental circulation upon detecting signs of intrauterine growth restriction and fetal hypotrophy (prescribing sigetin tablets 0.1 g once daily; complamin dragees 0.15 g 3 times daily; trental tablets 0.1 g 3 times daily; cocarboxylase ampoules 0.05 g intramuscularly once daily; curantil tablets 0.025 g 3 times daily; rheopolyglucukin solution with glucose — 400 mL intravenous drip twice a week; Oxygen therapy; abdominal decompression).

7. Prevention of Respiratory distress syndrome (RDS) in fetuses starting from 28 weeks of gestation:

a) dexamethasone 2–4 mg intramuscularly twice daily for 2–3 days, or in tablets: 2 mg 4 times daily on the first day, 2 mg 3 times daily on the second day, and 2 mg twice daily on the third day (total course dose of 16–24 mg);

b) prednisolone 60 mg per day for 2 days; dexazone 4 mg intramuscularly twice daily for 2 days;

c) in the presence of hypertensive syndrome: euphylline 2.4% 10 mL and glucose solution 20% 10 mL administered intravenously once daily for 3 days;

d) ambroxol (lasolvan) 800–1000 mg per day as an intravenous drip for 5 days;

e) lactin intramuscularly twice a day for 3 days;

f) nicotinic acid 0.1 mg once daily per os;

g) microdoses of folliculin at 2500 IU intramuscularly twice a day.

8. Hospitalization of patients upon the detection of early signs of multiple pregnancy complications, regardless of gestational age, alongside planned antenatal hospitalization at 36 weeks to assess fetal condition and determine the optimal route and method of delivery.