MULTIPLE PREGNANCY

MULTIPLE PREGNANCY - development in the uterus simultaneously two or (more rarely) more fetuses. Its frequency is 0.4-1.6% of the number of all pregnancies. In recent years, it has become more common in connection with the widespread use of drugs that stimulate ovulation - clomiphene, pergonal, etc., as well as methods of in vitro fertilization, in which the uterus is introduced Not less than 2 - 3 embryos. In the emergence of multiple pregnancies, hereditary predisposition is important. The frequency of it increases in women over 30 years.

Multiple pregnancy occurs as a result of fertilization of two or more simultaneously maturing eggs, as well as the development of two or more embryos from a single fertilized egg. In the first case, bipedal or multi-egg twins are born, in the second - odnoyaytsovye. The appearance of identical twins (twins, thrones, etc.) is associated with the fertilization of an ovum having two or more nuclei or with the division in the stage of fragmentation of a single embryonic rudiment into parts, from which individual embryos subsequently develop. With the development of an identical placenta twins, the chorion and the capsular decidual membrane are common for both fetuses; The amnion can be common (monoamnotic twins) or separate for each fetus - biamnotic twins. Inspection of the membranes after their separation makes it possible to establish the same or different origin of the twins: in the case of a single-egg double, the septate separates the septum from two leaves, with the bipartite from four. With binary double, each fertilized egg after implantation forms its shells: amnion and chorion, in the future, for each fetus, its placenta is formed. With a significant removal of the sites of implantation of a fertilized egg cell, the capsular decidual membrane is formed separately for each fetus. If the implantation occurred at a close distance, then the edges of both placentas are so closely adjacent to each other that the placentas seem to merge into one, but the chorion and amnion of each fetus remain separate, and the capsular decidual envelope is common.

Pregnancy in multiple pregnancies is characterized by a number of features. Pregnant women often complain of fatigue, dyspnea, frequent urination, constipation. Often there are anemia, toxicosis of pregnant women , there is an expansion of the veins of the lower extremities. There may be observed polyhydramnios in one of the fetuses, which leads to a sharp increase and overgrowth of the uterus, the appearance of dyspnea, tachycardia and other disorders. Sometimes, in many fetuses, water may be accompanied by waterlessness in another. Due to the large area of ​​the placenta, its presentation may occur. In the case of uneven supply of nutrients from the common placenta, it is possible that the development of one of the fetuses is up to its pre-natal death. Sometimes there are malformations of the fruit (for example, fused twins). Often observed incorrect presentation of the fruit, in about 1/3 of cases - breech presentation (see Pelvic presentation of the fetus). Often a multiple pregnancy ends with premature birth.

Diagnosis of multiple pregnancies in early pregnancy is difficult, but there is an unusually rapid increase in the size of the uterus. The diagnosis is made by ultrasound examination when two or more fetuses are detected; The detection of one placenta indicates an odnoyaytsovoy double. Before the introduction of ultrasound used such signs of multiple fertility as a rapid increase in the height of the standing of the uterine fundus and abdominal circumference at the level of the navel more than 100 cm, the feeling of fetal movements simultaneously and different places and palpation of small parts of the fetus in different parts of the abdomen, saddle shape of the uterus, the appearance of furrows between fruits ; The definition of three (or more) large parts of the fruit, the presence of two points of distinctly heard heart tones in different places of the uterus with a difference in frequency of 10 beats per minute and more, as well as a "silence zone" between them.

Pregnant women with multiple births should be under close supervision of a woman's consultation doctor (in rural areas - midwives of a feldsher-midwife station). The frequency of visits to a doctor (midwife) in the second trimester of pregnancy should be at least 2 times a month, in the third trimester - at least 1 time per week. A diet containing a large amount of protein and iron is recommended. It is necessary to monitor the dynamics of body weight - its increase should not exceed the weight gain in usual pregnancy by more than 50%. To prevent the delay of fruit development, it is recommended to take folic acid. For the same purpose, as well as to prevent premature termination of pregnancy, antispasmodics (no-shpu, etc.) are prescribed, and from the 24th week of pregnancy, tocolytic drugs (partushen, ritodrin) are prescribed. At the end of II - the beginning of the third trimester of pregnancy (especially at the time from 29 to 32 weeks) a sparing regimen is necessary (during this period the pregnant woman can be hospitalized). Hospitalization is also suitable for 4 weeks before the expected term of labor, even in the normal course of pregnancy. In the case of the appearance of the first signs of complications a woman is hospitalized regardless of the period of pregnancy. When the threat of premature birth is appropriate to prescribe tocolytic drugs in combination with drugs that improve the metabolism of the placenta.

Childbirth in multiple pregnancies should be taken by a doctor. Often they are complicated by the weakness of labor due to overstretch of the uterus. In connection with the possibility of improper position and presentation of fruits, a high location of the presenting part may be untimely rupture of the bladder. With the rapid discharge of amniotic fluid, there is a danger of prolapse of the umbilical cord and small parts of the fetus, the formation of the transverse fetal position, premature detachment of the placenta. In the III period of labor and the early postpartum period, hypotonic uterine bleeding is not uncommon.

Keeping childbirth requires a lot of attention. It is necessary to carefully monitor the status of the parturient woman and the fetus, the dynamics of childbirth, monitor the function of the bladder and intestine, and systematically produce the toilet of the external genitalia. In the first stage of labor to prevent the weakness of labor activity, the woman in labor should enter estrogens, vitamins, glucose, calcium preparations, ATP and cocarboxylase. In the case of a weakness of labor, funds are prescribed that enhance the contractile activity of the uterus. In case of a polyhydramnios or a stressed fetal bladder (in case of a head presentation of the first fetus) and incomplete opening of the uterine throat (by 3-4 cm), it is recommended to open the fetal bladder. To avoid a rapid outflow of amniotic fluid, it is best to open it from the side, above the inner uterine throat. Amblerous water should be released slowly, without removing the hand from the vagina, to prevent the prolapse of the cord or the handle of the fetus. II period of labor is waitive. To active actions resorted only to the occurrence of complications that threaten the condition of the mother and the fetus. Prevent hypoxia of the fruits. After the birth of the first fetus, not only the fruit, but also the mother's end of the cord is carefully bandaged, since in the case of an identical double, the second fetus may die from hemorrhage.

After the birth of the first fetus, an external obstetric examination is performed and the position of the second fetus, the nature of its heartbeat, is determined. Contractions often begin right after the birth of the first fetus. In this case, as well as in the absence of fights in 10-15 minutes, it is recommended to open the fetal bladder of the second fetus and to wait expectantly in the longitudinal position of the fetus. In the transverse position of the second fetus, an external turn or a combined external internal rotation of the fetus is performed. In case of complications (bleeding from the birth canal, hypoxia of the fetus), depending on the obstetric situation, the fetus is extracted with the help of obstetric forceps, the fetus rotates onto the stem with subsequent extraction, etc. The born after (afterwards) is examined in order to establish their integrity and determine one- Or the heterogeneous origin of the twins. In the first hours after childbirth, it is necessary to closely monitor the condition of the newborn and the puerpera (contraction of the uterus, the amount of blood released from the genital ways, etc.). Involution of the uterus in the postpartum period is slower than usual, and in this connection, funds are prescribed that cut the uterus.

The prognosis for the mother and the fetuses in multiple pregnancies is largely determined by the course of pregnancy and childbirth. It worsens with severe toxicosis of pregnant women, premature birth, prolonged delivery. For a woman's life and health, hypotonic bleeding is a risk in the third stage of labor and the early postpartum period. Twins born premature often die. In newborns, the effects of intrauterine hypoxia are more often noted.

Prevention of complications consists of careful monitoring of pregnant women in the antenatal clinic (in the rural area - at the feldsher-midwife point), early detection of pathological changes in the body of the pregnant woman and the fetus, timely hospitalization and the necessary medical measures.