Antenatal Care – During Pregnancy
A good and regular (3-4weekly) follow is utmost important in women with twin pregnancy. This not only helps to monitor the growth of the babies, but also enables to pick up early complications and therefore helps in management.
Ultrasonography are done as in normal pregnancy i.e. at 11-12 weeks, at 20 weeks, at 32-34 weeks. Additional sonography may be advised if the obstetrician suspects some abnormalities. A Doppler sonography wherein the blood flow to the babies is evaluated may be done one or two times between 28-34 weeks or as suggested by the obstetrician.
Other than monitoring the growth of the babies some things which sonography may help in is the location of placenta (After births), position of babies (Head down or feet down), and cervical length( length of mouth of uterus)Blood tests may be done more frequently almost every 11/2 to 2 months for early detection of anemia, deranged blood sugar etc.
Prevention of complications
- Regular antenatal check ups, frequent Ultrasonography and blood tests.
- Oral supplements for iron, vitamins, calcium and proteins. Very rarely if the women does not respond to medical management, supplements may be given in intravenous form.
- Cervical os tightening (Stitch taken at the mouth of uterus) in certain selected cases where in there are high chances of mouth of uterus opening very early in pregnancy.
- Prophylactic betamethasone injections at 7-8 moths to facilitate fetal lung maturity in case of premature birth and thereby reduce fetal morbidity.
- Additional drugs like L-Argine or ecosprin low dose to prevent PIH.
If all goes well, delivery is usually planned around 36-37 weeks. If a cervical knot is taken, then the most suitable time to cut it is around 36 weeks. Mode of delivery whether normal or cesarean depends upon the gestation period, location of placenta, the weights and condition of babies and position of babies. Depending upon all these factors the obstetrician will sketch a plan after discussing with you and your partner. It is always better to deliver at a place where NICU facilities are available as one orbothe the babies may need some initial care.
Preterm labour and PROM
Pregnancies after Infertility treatment have higher risk of preterm labour and PROM (Premature rupture of membranes). 8% of women who have undergone IVF or ICSI have a risk of delivering prematurely as against 5%of women with natural conception. Part of this risk may be associates with more incidence of twin pregnancies in IVF treatment.
Causes of preterm labour and PROM:
- Infection in pregnancy is the most common cause. Infection may reach the uterus via the vagina or spread from other body parts like dental infection, urinary tract infection, bowel infection (Diarrhoea), respiratory tract infection or hepatitis.
- Higher order pregnancy for eg: twins or more may be an important cause.
- Weakness of the cervix or mouth of uterus is responsible for extreme prematurity. This may be inherent or induced by various surgeries on the uterus or cervix prior to conceiving.
- Gaining too much or too little weight during pregnancy. Optimal weight gain during pregnancy is between 12-16 kg. The amount of weight gain also depends on prenatal weight of the mother.
- Development of anemia (low hemoglobin levels), hypertension or diabetes in pregnancy may lead to induced preterm where there is no option but to deliver the baby prematurely to avoid serious complication.
Complication of preterm delivery:
Mainly preterm delivery may lead to increased morbidity and mortality in the new born babies.
There is an increased risk of NICU admission. The baby may have difficulty in breathing, develop infection and need IV drugs.
There is an increased risk of jaundice in such babies. The baby may also have difficulty in breast feeding. All this increases the parental stress in addition to financial burdun.
- Avoiding or early treatment of any infection with antibiotics. Use of prophylactic prebiotics and probiotics can significantly reduce the incidence of vaginal and bowel infections. A short course of vaginal antibiotics one or two times between 24-34 weeks may treat any bacterial vaginal infection and thereby preventing it to ascend up into the uterus.
- Try to reduce higher birth order pregnancy i.e. triplets and quadruplets to twins or singleton pregnancy.
- To take a prophylactic cervical stitch at 14-18 weeks in women with a history of operative procedure done on the uterus.
- To take regular nutritional supplements like iron, folic acid and calcium to avoid deficiencies and thereby preventing complications like anemia or hypertension.
- Regular monitoring of cervical length by trans vaginal scan so as to pick up early shortening of cervix and treating it with either vaginal progesterone or cervical stitch.
- Regular blood checks up to detect anemia or diabetes in pregnancy.
- Prophylactic doses of injection betamethasone at 28-32 weeks in certain high risk women to ensure fetal lung maturity and prevent neonatal morbidity and need of NICU.
As such pregnancies after treatment of infertility are not at a very high risk of developing IUGR as compared to normal pregnancies. IUGR stands for intrauterine growth restriction which means that the baby is slow in growth and therefore low birth weight. However there might be slight increase in growth restriction of the fetus in following situations:
- Twin pregnancy where in either one or both the twins may have growth restriction.
- Women with preexisting hypertension or who develop moderate to severe PIH during pregnancy.
- Women with preexisting diabetes mellitus or those who develop gestational diabetes in pregnancy. Incidence is particularly higher if the sugars are uncontrolled.
- Women with preexisting chronic liver, lung or kidney diseases as commonly found in women above 40 years of age. Mothers with thalassemia minor or sickle cell disease may also develop a growth restricted baby.
- Dietary deficiencies like anemia or protein inadequacy may lead to IUGR.
- Infections like malaria, hepatitis, multiple times Urinary tract infection may also lead to IUGR.
All the above situations mainly lead to IUGR because they affect the placenta i.e. the organ supplying blood to fetus from the mother. The mechanism may be different but the effect is same i.e. IUGR
Complication of IUGR:
IUGR mainly affects the fetus and may lead to increased morbidity and mortality in the newborn baby. Complications like preterm baby, difficulty in breathing, need for IV drugs and need for NICU care increase in such babies.
Also there is a high chance that the mother may need to undergo a cesarean section as these babies do not take the stress of labour very well.
- Regular monitoring of high risk pregnancy with USG and Doppler studies to pick up early IUGR, which can be treated with drugs or IV medicines.
- Prenatal control of blood pressure and diabetes to avoid them worsening during pregnancy.
- Adequate dietary supplementation with Iron, multivitamins, calcium and proteins to obatain adequate growth of the baby.
- Early diagnosis and treatment of infection.