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
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:
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.
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:
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.
Monitoring an pregnancy after treatment of infertility
Whenever a couple after few months or years of treatment for infertility becomes pregnant, it is a moment of great joy. But with that happiness there is apprehension too. Many questions pop up in their minds. The only treatment for this is proper and systematic monitoring with periodic counseling and assurance.
Monitoring includes blood tests and sonography,regular examinations and some alterations in medications. Here is a brief account of how we monitor our pregnancies. For simplicity purpose lets divide the pregnancy into three parts- first trimester (first three months), Second trimester (middle three months) and third or last trimester (last three months).
As soon as the lady skips her periods we do a blood test which measures the level of B-HcG (hormone secreted only in pregnancy). Rather than a single value of B-HcG, serial tests give us more information about progress of pregnancy. Simultaneously there will be few changes in medications for example some hormonal tablets are started for supporting the pregnancy. Also an injection which supplies B-HcG hormone is also given every 5 days, as this hormone is important for continuation of pregnancy,
If the B-HcG values increase progressively (usually three values are needed to conclude), that means the progress is good. However, if there is a decrease in value or if the values remain near same then it may either be a missed abortion or an ectopic pregnancy.
It has been widely reported that the incidence of miscarriage in pregnancies resulting from ART is higher than in spontaneous pregnancies. If the values increase is more than double of previous value, there are chances of multiple pregnancies. In natural conceptions, one in 80 pregnancies results in twins. However in ART, rate of multiple pregnancies is more than one in five. Apart from the increased rate of twins, triplets and quadruplets which are extremely rare in natural conceptions occur commonly in women undergoing ART.
As soon as the B-HcG levels shoot above 15000IU or at 5-6 weeks of gestation a transvaginal sonography is done to confirm the pregnancy. At this stage usually a fetal pole (baby) and cardiac activity (baby heart beat) can be seen on sonography.
This is the stage when all symptoms of pregnancy may be evident, like nausea, vomiting, mild on and off pelvic pain, breast tenderness, urinary frequency,gaseous distention and constipation. Some medications may be required to tackle with these symptoms. There is nothing to worry even if the dietary intake does not increase as during the first three months the requirement is less. The expected weight gain during first three months is 0-2 kg.
All medications and injections are continued in the same format as before and a dating sonography (sonography which will give an accurate delivery date) is done around 7-8 weeks.
There is slight more incidence of bleeding in first trimester in IVF pregnancies compared to natural conception. There is nothing to be worried about if such a thing happens as most of the times bleeding is controlled with medicines. Sometimes unfortunately it may end in abortion.
The same format of treatment continues till 11-13 weeks of gestation. During this time the first abnormality scan (including nuchal translucency) is done. Also blood tests like CBC, urine routine, TSH,Vit D, blood group and double marker test to judge the risk of abnormality in baby are done.
After going through the reports the injections and hormonal medications are stopped. Calcium and iron tablets are added at this point. After 13 weeks we enter the second trimester.
The middle three months (12-24 weeks) are called the second trimester. This is the best period of pregnancy as all the uncomfortable symptoms occurring before slowly disappear. One starts feeling hungry and eating more. This is the best time to travel or take a holiday. Also fight travel is safest during this period.
The women starts gaining weight and looking pregnant by the end of four months. She may be able to feel slight fetal movements by end of 5th month.
Two songraphies are done during this Period. One is around 18-20 weeks (Four and half months) and the second around 24- 25 weeks (End of 6th months). These are both abnormality scans done to pick up any structural abnormality In the baby.
Around 18 weeks we may do blood sugar and serum proteins tests. This is to detect pregnancy induced diabetes (Gestational diabetes) or hypoproteinemia. Both these disorders if detected early can be corrected with timely intervention, thus avoiding complications to occur.
In addition to folic acid, vitamin E, iron and calcium tablets, a protein powder may be added. A short course of antibiotics and probiotics are give as these have shown to decrease incidence of preterm labour and PROM.
Particular attention has to be given to the cervical length (The length of the mouth of the uterus) by doing 2-3 weekly transvaginal scan during this period. If the cervical length is short or the mouth of uterus opens up a suture may be needed to close it. This is called os tightening.
Our experience at Ankoor fertility clinic has shown that by regular monitoring of cervical length and giving short courses of prebiotics, the incidence of preterm delivery and consequently neonatal morbidity and mortality becomes negligible. This is because by this protocol we avoid occurrence of infection (which is a major cause of preterm delivery) and pick up early cervical shortening which can be treated with os tightening.
In the last few months the countdown begins. The baby gains maximum weight during this period. Third trimester starts from 24 weeks till 40 weeks. Most of the times delivery occurs before 38 weeks. In the last few weeks there may be symptoms like backache, lower abdominal pain, constipation and urinary frequency. There may be difficulty in sleeping.
A sonography with Doppler (to assess blood flow to the baby) between 32-34 weeks (8 months) is usually done. More sonography may be done if necessary.
Last few blood tests like CBC, urine and HIV, HbsAg, HCV are done as the delivery date approaches. If needed blood sugars and serum proteins may be repeated.
All medicines are continued as same. If Ecosprin is started previously, this may be stopped at 32 weeks.
Mode of delivery
Mode of delivery is usually discussed out with the patient at 36 weeks. Rate of cesarean section is usually greater in ART pregnancies compared to natural conception. This is not purely because the pregnancy after treatment is a precious pregnancy. It is so as ART pregnancies have higher rate of complications like Multiple pregnancies, Placenta previa, Pregnancy induced hypertension and Intrauterine growth retardation.
However normal vaginal delivery should be offered to all women who have uneventful antenatal course with no indication for cesarean section.