Pregnancy

Antenatal care

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.

Planning delivery

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.

Prevention:

• 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.

IUGR

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.

Prevention:

• 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.

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).

First trimester

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.

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.

Sonography

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.

Blood tests

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.

Medicines

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.

Third trimester

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.

Sonography

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.

Blood tests

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.

Medicines

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.