Week 13 Assignment 1: Multiple Gestation Pregnancy Case Study Worksheet

Week 13 Assignment 1: Multiple Gestation Pregnancy Case Study Worksheet


Multiple Gestation Pregnancy Case Study Worksheet

The rates of multiple gestation pregnancy are higher in assisted reproductive treatment cycles due to the apparent need of stimulating excess follicles and transferring excess embryos to attain reasonable pregnancy rates (Suhag & Berghella, 2018). As compared to singletons, perinatal mortality rates are four times higher for twins and six times higher for triplets. Given that the main goal of infertility therapy is to promote the delivery of healthy babies, then multiple gestation pregnancy puts this goal at risk. As such, they must be considered a serious complication that requires appropriate prenatal care. The purpose of this paper is to develop a teaching plan for a primipara woman who presented to the clinic for her first prenatal visit at the 12th week of gestation with twins.

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Types of Twins

            Currently, more twins are being born than before. The CDC reported that 32.1 out of 1000 births in America in 2019 were twins (Mushtaq & Shastham Valappil, 2022). The two most common types of twins are identical and fraternal twins. Identical twins are conceived from a single fertilized egg, which separates into two embryos and develops into two completely identical babies assigned the same sex at birth. Fraternal twins on the other hand occur when the body of the birthing parent releases two eggs which are fertilized with different sperms. The two babies might not look alike as in identical twins, and can or cannot be of the same sex. The third type of twins is very rare known as half identical or polar body twins. Despite this type of twins has not yet being confirmed, studies claim that this might be the reason why some fraternal twins usually look so similar. The egg released from the ovaries can split into two halves, with the smaller one referred to as the polar body. The polar body has all the necessary chromosomes needed to be fertilized with sperm and create a baby. Nevertheless, the cytoplasm is usually limited hence minimizing the survival rate of the child.

Chronicity and Amnionicity

Early in multiple gestation pregnancy, an ultrasound is usually ordered to find out whether each fetus has its amniotic sac (amnionicity) and chorion (chronicity). Three types of twins normally exist in terms of chronicity and amnionicity (Suhag & Berghella, 2018). The first type is the dichorionic diamniotic twins who have their amniotic sac and chorion. The second type is monochorionic diamniotic twins who have separate amniotic sacs but share a chorion. The last type is the monochorionic monoamniotic twins who share one amniotic sac and one chorion. Chronicity and amnionicity are associated with several complications with increased incidences of preterm births, with prognosis worst for monochorionic monoamniotic twins with more than 50% perinatal mortality rates. For monochorionic diamniotic twins, the perinatal mortality is 20% whereas that of dichorionic diamniotic twins is 10%.

Risks of Multiple Gestation Pregnancy to the Mother

Having twins does not only put risks to the baby but also to the mother. For instance, the mother can go into preterm labor before the 37th week of pregnancy which increased the risk of premature birth (Laine et al., 2019). During the first trimester, the mother is usually at high risk of miscarriage which may lead to excessive bleeding causing anemia to the mother, and stillbirth before week 20 of gestation. The mother is also at risk of chronic hypertension and gestational diabetes before week 20 of gestation. The blood pressure can however increase even after 20 weeks of gestation leading to preeclampsia. Polyhydramnios is usually reported in the third trimester, with increased risks of postpartum hemorrhage and postpartum depression.


Risks of Multiple Gestation Pregnancy to the Baby

In multiple pregnancies, the baby usually develops health complications associated with increased risks of preterm births before the 37th week of gestation (Mushtaq & Shastham Valappil, 2022). The baby is usually at risk of birth defects like congenital heart defects, cerebral palsy, and neural tube defects like spina bifida, especially during the first 12 weeks of gestation given that this is the time when major organs and body systems are forming. Multiple pregnancies also put the baby at high risk of low birth weight and growth problems. Neonatal death can also occur within the first 28 days of life.

What to Expect when Delivering Twins

Giving birth to twins usually occur before 38 weeks of pregnancy hence the need for mothers to be aware of the birth option. Studies show that less than 50% of all twin pregnancies usually last beyond 37 weeks (Zafarmand et al., 2021). Positioning of the babies in the uterus normally plays a significant role in determining the process of delivery, either vaginally or by cesarean. More than 50% of twins are usually born vaginally, at intervals of approximately 17 minutes. Cesarean births usually account for less than half of the delivery of twins. Additional reasons for cesarean births other than positioning of the baby include active genital herpes, placenta previa, and labor complications such as fetal distress. In rare cases, both C-sections and vaginal birth can be done, normally in case, there is an emergency with the second baby. Such emergencies include severe malpresentation, placental abruption, and cord prolapse.

Breastfeeding of Twins

Most women are usually able to produce adequate breast milk for twins. However, breastfeeding twins is associated with multiple challenges like finding the best feeding pattern for each baby and sustaining the energy levels of the mothers (Russell & Russell, 2021). To avoid these challenges mothers are advised to seek antenatal classes and visit a breastfeeding specialist or lactation consultant when preparing to breastfeed. To get the breastfeeding of twins off to a good start, it is necessary to promote skin-to-skin contact with each child. Nursing both babies at the same time is usually recommended to promote an easy feeding routine.


The number of multiple gestational pregnancies has increased over the past decade. Having multiple pregnancies increases the risks of several health complications for both the mother and the baby as described above. As such, effective prenatal care with adequate patient education on the associated risks and measures that can help prevent such risks is crucial to promote the chances of survival of the baby.



Laine, K., Murzakanova, G., Sole, K. B., Pay, A. D., Heradstveit, S., & Räisänen, S. (2019). Prevalence and risk of pre-eclampsia and gestational hypertension in twin pregnancies: a population-based register study. BMJ Open9(7), e029908. http://dx.doi.org/10.1136/bmjopen-2019-029908

Mushtaq, U., & Shastham Valappil, S. (2022). Multiple Gestation. In Quick Hits in Obstetric Anesthesia (pp. 251-257). Springer, Cham. https://doi.org/10.1007/978-3-030-72487-0_38

Russell, S., & Russell, N. (2021). Breastfeeding Twins and Multiples. In Twin and Higher-order Pregnancies (pp. 355-362). Springer, Cham. https://doi.org/10.1007/978-3-030-47652-6_24

Suhag, A., & Berghella, V. (2018). What’s new in the multiple gestations literature?. Journal of Perinatal Medicine46(8), 823-824. https://doi.org/10.1515/jpm-2018-0304

Zafarmand, M. H., Goossens, S. M. T. A., Tajik, P., Bossuyt, P. M. M., Asztalos, E. V., Gardener, G. J., … & Hutchens, D. (2021). Planned Cesarean or planned vaginal delivery for twins: secondary analysis of the randomized controlled trial. Ultrasound in Obstetrics & Gynecology57(4), 582-591. https://doi.org/10.1002/uog.21907

Patient Introduction

Shannon is a 35-year-old African American married woman.

History of Present Illness: presents to the office with private insurance with a chief complaint of amenorrhea for 6 weeks. Denies headache, edema, vaginal bleeding or discharge. Patient does have nausea and vomiting for the last week that occurs three times a day. UCG done at home one week ago was positive. Negative urine protein, glucose and nitrates.

  • Allergies: She has no reported allergies.
  • Past Medical History: Past medical history is consistent for infertility; however this pregnancy was achieved spontaneously; HPV, obesity and hypothyroidism.
  • Medications: She takes Valtrex 1 g two tablets by mouth repeated every 12 hours for cold sores and levoxyl 0.125 mg qd.
  • Family Medical History: Family history is consistent for colon cancer – maternal grandfather; diabetes- maternal mother; and hypertension in both the patient’s parents
  • Surgical History: None
  • Gynecology History: Menstrual history: menarche at 12 occurring every 36 days lasting seven days. Menstrual history: menarche at 12 occurring every 36 days lasting seven days.
  • Obstetrics History: The patient did have one pregnancy two years ago that resulted in an early spontaneous miscarriage with no complications.
  • Social History: Patient has been married for seven years and works as a business manager full-time. Social history is negative for tobacco, alcohol, and drugs.

Initial Physical Exam

  • Weight: 258 lbs. Height 65 inches VS 98.4 -84-20-128/74
  • General appearance alert, no acute distress, well hydrated, well developed, obese appearing woman
  • Neuro: oriented to time and place and has appropriate affect and mood.
  • Head: normocephalic, atraumatic.
  • Ears: the Tympanic membranes are intact and clear with normal canals, hearing intact bilaterally.
  • Eyes: normal vision, no discharge, no double vision, blurry vision. Nose: no discharge, inflammation or lesions
  • Mouth: has no deformity or lesions, good dentition, uvula rise midline, tonsils 1+
  • Skin: normal Turgor and color, no rashes, no lesions, no bruising, no edema, normal nails and hair
  • Neck: supple no adenopathy, trachea is midline, no bruits, thyroid normal in size and symmetrical, no nodules palpated
  • Cardiac: 76, regular rhythm, no murmurs or gallops
  • Lungs: no respiratory distress, no use of accessory muscles, lungs are clear to auscultation; symmetrical lung expansion, percussion is resonant throughout
  • Breasts are large and pendulous, symmetrical, nipples are everted, no skin changes, nipple discharge, masses or tenderness; no lymphadenopathy
  • Abdomen: obese, non-distended, non-tender, positive bowel sounds, tympanic throughout, no hepatosplenomegaly noted.
  • External genitalia: normal appearance, normal hair distribution, no lesions or masses
  • Vagina: no lesions, no masses, has adequate pelvic support, the cervix is midline, nullip, with a bluish hue, and no lesions and no cervical motion tenderness
  • Uterus is 6 weeks in size, mobile, non-tender,
  • Adnexa: normal, no masses and non-tender.

Initial Laboratory

  • CBC: Hemoglobin of 13.1, hematocrit 37.6, white blood cell 9.7, red blood cell 4.32, platelets 190,000.
  • Blood type: O positive and negative antibody
  • TSH: 16.76
  • T4: .70
  • Random blood sugar: 102
  • Varicella: immune
  • Rubella: immune
  • RPR: non-reactive
  • Chlamydia: negative
  • Gonorrhea: negative
  • HIV: negative
  • Hepatitis B surface antigen negative; surface antibody positive; Hepatitis C negative
  • Cystic fibrosis: negative
  • Pap within normal limits- negative HPV
  • Urine culture: negative
  • Urinalysis: normal
  • Hemoglobin Electrophoresis: A1 96.3% A2 3.6% F 0.1%

7 week prenatal visit

Shannon returns to the office 1 week later, when she presents with vaginal bleeding x 3 hours, pt. states bleeding started this am, when she got up to go to the bathroom. She reports the bleeding as red, light to moderate in amount. No pain or cramping noted. Weight was 256 lbs. B/P 120/70, negative urine protein, glucose and nitrates; no headache, nausea, vomiting, no edema, vaginal discharge; patient is taking her vitamins.

29 week prenatal visit

Shannon returns for her routine prenatal visit at 29 weeks. Since treating her thyroid condition, she has no further bleeding and the pregnancy has been uneventful. Wgt 254, B/P 122/76, urine is 2+ glucose, trace protein, negative ketones. Shannon indicates that she feels the baby move every day, no leaking, bleeding or contractions. She is taking her PNV qd along with the levoxyl 0.25mg. Shannon indicates that she has some white clumpy vaginal discharge that is very itchy, for the past few days. No odor or burning. Fetal heart is 160, Fundal height is 31 cm

Laboratory: NIPT was normal, AFP 1.60 MoM, Her TSH last visit was 2.4, CBC at 16 weeks was normal, one hour gtt today was 167.

US: Her sequential screen from earlier in the pregnancy is normal.

Fetal Survey at 20 weeks was normal.

33 week prenatal visit

Shannon returns for a routine prenatal visit at 33 weeks. Wgt is 256, B/P 128/80, FHR is 164 and Fundal height is 36 cm. Shannon indicates she feels the baby move every day and performs her kick counts daily. She is taking her PNV and Levoxyl as ordered. She completed the monistat given a few weeks ago, and has no further symptoms. Shannon had an elevated 1 Hour at her 29 week visit and had a 3 hour gtt. Shannon met with the diabetic educator and endocrinologist and was started on NPH 5 units TID. She is doing home blood glucose sticks with a goal of FBS < 90 and 2 hour postprandial of < 120.

Laboratory: 3 hour gtt- FBS 98, 1 hour-164, 2 hour-160, 3 hour 135.

US: Cephalic position, EFW 2812 gr (90%), AFI 21 cm. Posterior fundal grade 2 placenta, 3 vessel cord.

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