complications of pregnancy: multifetal gestation, fetal death, abnormal labor

assisted reproduction

-ovulation induction, IVF

biggest risk for multifetal gestation

clomiphene, letrozole, gondatropins

medications for ovulation induction

African ancestry

Tall stature

Higher BMI

demographics increasing risk for multifetal gestation

Two separate ova fertilized by two sperm

Always dichorionic-diamniotic (Di-Di)

define dizygotic twins

single fertilized ovum splits

-chorionicity depends on timing of division

what makes a monozygotic twin

day 1-3

timing of split to make dichorionic-diamniotic monozygotic twins

monochorionic-diamniotic

most common type of monozygotic twins

day 4-8

timing of split to make monochorionic-diamniotic twins

day 8-13

timing of split to make mono mono twins

>13 days

if ovum doesn't split by day _____ it makes conjoined twins

monochorionic monoamniotic

highest risk twin type

Number of fetuses

Chorionicity & amnionicity (MOST important)

what can you determine about a multifetal gestation from first trimester ultrasound

dichorionic pregnancy

lamda sign on US indicates

monochorionic pregnancy

T-sign on ultrasound indicates

lamda sign

dichorionic twins

T-sign

monochorionic diamniotic

growth US q4 weeks

monitoring requirement for di-di twins

Growth + TTTS screening q2 wks starting ~16 wks

monitoring requirement for mono-di twins

Inpatient monitoring late pregnancy

monitoring requirement for mono-mono twins

~38 weeks

typical delivery timing of di-di twins

~34-36 weeks

typical delivery timing of mono-di twins

~32-34 weeks (planned C-section)

typical delivery timing mono-mono twins

Hyperemesis gravidarum

Preeclampsia

Gestational diabetes

Anemia

maternal complications associated with multifetal gestation

Preterm birth (most common)

Low birth weight

Intrauterine growth restriction

fetal complications associated with multifetal gestation

twin-to-twin transfusion syndrome

shunting of venous or arterial blood from one twin to another through placental circulation

Twin-to-Twin Transfusion Syndrome (TTTS)

Twin anemia-polycythemia sequence (TAPS)

Selective IUGR

Cord entanglement (mono-mono twins)

Intrauterine fetal demise of co-twin

complications specific to monochorionic twins

chorion

Outermost layer of the two membranes surrounding the embryo; it forms the fetal part of the placenta.

amnion

Innermost membranous sac surrounding the developing fetus

mono-chorionic

shared placenta = vascular complications

chromosomal abnormalities

most common cause of first trimester fetal death

Cervical insufficiency

Placental abnormalities (abruption, previa)

Maternal infections (TORCH, syphilis)

most common causes of second trimester fetal demise

weeks 14-27

define the second trimester

Placental insufficiency

Hypertensive disorders (preeclampsia)

Placental abruption

most common causes of fetal demise in third trimester

decreased or absent fetal movement

most common presenting complaint of fetal demise

power, passenger, passage

3 causes of abnormal labor patterns (labor dystocia)

No cervical change ≥ 4 hrs with adequate contractions

OR ≥ 6 hrs with inadequate contractions

clinical definition of arrest of dilation

No descent after ≥2 hrs (multiparous) or ≥3 hrs (nulliparous)

Add +1 hr if epidural

clinical defintion of arrest of descent

protracted dilation (active labor)

in active labor

primigravida: <1 cm/hour

multigravida: <2cm/hr

augment labor

-may try position changes first

protracted descent

< 1cm/hr change in station in nulliparous; <2 cm in multiparous

Hypotonic uterine dysfunction (most common)

Hypertonic uterine dysfunction (ineffective, uncoordinated contractions)

disorders of power --> abnormal labor patterns

hypotonic uterine dysfunction

occurs during active labor (dilation more than 5 to 6 cm) when contractions become poor in quality and lack sufficient intensity to dilate and efface the cervix

hypertonic uterine dysfunction

uncoordinated uterine activity. Contractions are frequent and painful but ineffective in promoting dilation and effacement.

Inadequate contractions

Epidural effects

Uterine fatigue

Chorioamnionitis

causes of inadequate power in abnormal labor

Macrosomia

Malpresentation (breech, face, brow)

Malposition (occiput posterior)

Multifetal gestation

'passenger' causes of abnormal labor

Contracted pelvis

Pelvic deformities

Obstructing fibroids

'passage' causes of abnormal labor

chorioamnionitis

inflammation of the chorion and amnion

Chorioamnionitis

Postpartum hemorrhage (uterine atony)

Uterine rupture

Operative vaginal delivery

Cesarean delivery

maternal complications associated with prolonged labor

Fetal distress

Acidemia

Birth trauma

Shoulder dystocia

Hypoxic-ischemic encephalopathy

Neonatal sepsis

fetal complications associated with prolonged labor

Induction of labor

Augmentation of labor (hypotonic labor)

Prolonged labor

Prevention/treatment of postpartum hemorrhage

indications for oxytocin (pitocin)

Prior classical uterine incision

Uterine rupture

Placenta previa

Vasa previa

Transverse fetal lie

absolute contraindications to oxytocin

One prior low transverse C-section

No other uterine scars

Clinically adequate pelvis

indications for a trial of labor after cesarean

Uterine rupture (≈0.5–1%)

Emergency C-section

Fetal hypoxia/death (rare but catastrophic)

risks associated with trial of labor after cesarean

Prior classical or T-shaped incision

Prior uterine rupture

Inability to perform emergency C-section

contraindications to a trial of labor after cesarean

Mauriceau-Smellie-Veit maneuver

Piper forceps for after-coming head

delivery maneuvers for breech presentation (if C-section not available)

Mauriceau-Smellie-Veit maneuver

Used with breech delivery to maintain flexion of the head if needed

-W/ dominant hand palmar side up, place index and middle fingers on either side of the nose on the maxilla, with chest and body resting on palm and legs straddling forearm

-The other hand is placed on top of the baby with the index finger on one side and middle finger on the other side of the neck extending over the shoulder for traction

-again apply downward traction until the suboccipital region

-now apply upward traction while elevating body to deliver head through via the curve of Carus

Help

Episiotomy (for space, not cure)

Legs → McRoberts maneuver

Pressure → suprapubic

Enter maneuvers (Rubin, Woods corkscrew)

Remove posterior arm

Roll patient (Gaskin)

steps to manage shoulder dystocia labor (HELPERR)

McRoberts maneuver

sharp flexion of the maternal hips that decreases the inclination of the pelvis increasing the AP diameter of the free anterior shoulder

-helps in shoulder dystocia

Manual elevation of fetal head

Knee-chest or Trendelenburg

Avoid handling cord

Oxygen to mother

immediate management of uterine cord prolapse

uterine cord prolapse

Protrusion of the umbilical cord alongside or ahead of the presenting part of the fetus.

Prompt recognition is key.

Sterile gloved hand in vagina and holds the presenting part off the umbilical cord until delivery.

If mothers cervix is not fully dilated, prepare for an emergency c-section.

McRoberts maneuver

first line maneuver for shoulder dystocia