Risks for multiple pregnancy. Features of multiple pregnancy: probability, causes, types

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Multiple pregnancy - definition and varieties (twins and twins)

Multiple pregnancy - This is such a pregnancy at which in the wizard's uterus simultaneously develops not one, but several (two, three or more) fruits. Usually the name of multiple pregnancy is given depending on the amount of fruits: for example, if a child is two, then they talk about pregnancy twins, if three, then triple, etc.

Currently, the frequency of multiple pregnancy ranges from 0.7 to 1.5% in various countries in Europe and the United States. The widespread and relatively frequent use of auxiliary reproductive technologies (ECO) led to an increase in the frequency of occurrence of multiple pregnancy.

Depending on the mechanism of the appearance of twins, the dialing (bilayer) and monosigital (single-way) multiple pregnancy are distinguished. Children of bilayer twins are called twins, and single-horse - twins or twins. Among all multiple pregnancies, the frequency of the bilayer twins is about 70%. Gemini always come alone and as two drops of water are similar to each other, as they develop from one fruit egg and have a completely identical set of genes. Twins can be of different sexes and are similar only as native brother and sister, because they develop from different eggs, and, therefore, have a different set of genes.

Double pregnancy develops due to the fertilization of both two eggs, which are implanted in different parts of the uterus. Quite often, the formation of bilayer twins occurs as a result of two different sexual intercourse, conducted with a small interval between each other - no more than a week. However, binary twins can be conceived during one sexual intercourse, but provided that there have been simultaneous maturation and the yield of two eggs from one or different ovaries. With a bike double, each fruit necessarily has its own placenta and its own fret bubble. The position of the fruit, when each of them has its own placenta and a fetal bubble, is called a bichorial biamniotic double. That is, in the uterus there are both two placenta (Bichorial twins), and two fruit bubbles (biamniotic twins), in each of which the child grows and develops.

Single twin develops from one fruit egg, which, after fertilization, is divided into two cells, each of which gives the beginning of a separate organism. With a single-engine double, the number of placenta and the fruit bubbles depends on the term of separation of the only fertilized egg. If the separation occurs during the first three days after fertilization, while the fruit egg is in the uterine tube and did not attach it to the wall of the uterus, then two placenta and two separate fetal bag are formed. In this case, two fetus will be in the uterus in two separate fruit bubbles that eat each of their placenta. Such twin twins is called bichorial (two placenta) biymniotic (two fruit bubbles).

If the fetal egg is divided into 3 - 8 days after fertilization, that is, at the stage of attachment to the wall of the uterus, two fetus are formed, two fruit bubble, but one for two placenta. In this case, each twin will be in its fruit bubble, but they will be eaten from one placenta, from which two umbilies will be left. This option is twins called a monochorial (one placenta) biymniotic (two fruit bubble).

If a fetal egg is divided into 8 - 13 day after fertilization, then two fetus are formed, but one placenta and one fruit bubble. In this case, both fruits will be in one for two fruit bubble, and eat from one placenta. Such twin is called monochorial (one placenta) monoamniotic (one fruit bubble).

If a fetal egg is divided later than 13 days after fertilization, then as a result of this, Siamese twins are developing, which are sprung by various parts of the body.

From the point of view of safety and normal development of the fetus, the best option is biocheorial biamniotic twins, both single-engine and bilayer. Monochorial biamniotic twins develop worse and risk of pregnancy complications above. And the most unfavorable option twins are monochorial monoamniotic.

Probability of multiple pregnancy

The probability of multiple pregnancy at an absolutely natural conception is no more than 1.5 - 2%. Moreover, in 99%, multiple pregnancy are represented by twins, and triples and a large number of fruits only in 1% of cases. With natural conception, the likelihood of multiple pregnancy increases in women over 35 years old or at any age in the spring time of the year amid a significant lengthening of the daylight day. In addition, women, in the nature of which twins or twins have already been born, the likelihood of multiple pregnancy is higher than other representatives of weak gender.

However, if pregnancy occurs under the influence of drugs or auxiliary reproductive technologies, the probability of twins or triple is significantly higher than with natural conception. Thus, when using drugs to stimulate ovulation (for example, clomiphene, clostilby, etc.), the probability of multiple pregnancy increases to 6 - 8%. If, to improve the chances of conception, preparations containing gonadotropin were used, the probability of twins is already 25 - 35%. If a woman pregnant with auxiliary reproductive technologies (ECO), the probability of multiple pregnancy in such a situation ranges from 35 to 40%.

Multiple pregnancy at eco

If a woman is pregnant with ECO (extracorporeal fertilization), the probability of multiple pregnancy is, according to various researchers, from 35% to 55%. At the same time, a woman can be twins, triple or a quarters. The mechanism of multiple pregnancy at ECO is very simple - four embryos are simultaneously sitting in the uterus, hoping that at least one of them takes. However, it is necessary, that is, implanted into the wall of the uterus, maybe not one, and two, three or all four embryos, as a result of which a woman is formed a multiple pregnancy.

If during the ultrasound after ECO, multiple pregnancy (triple or quadruple) was revealed, then a woman is offered to "remove" extra embryos, leaving only one or two. If a twin is detected, then the embryos are not proposed. In this case, the decision is taken by the woman itself. If she decides to leave all three or four arrogant embryos, then she will have a quirger or triple. Further development of multiple pregnancies, developed as a result of Eco, is no different from the occurring natural way.

Reduction with multiple pregnancy

Removal of the "excess" embryo in multiple pregnancy is called reduction. This procedure is offered to women who have more than two fruits in the uterus. Moreover, currently reduction is offered not only to women, pregnant in a triple or quadruple as a result of Eco, but also in a natural way at the same time more than two fruits. The purpose of the reduction is to reduce the risk of obstetric and perinatal complications associated with multiple pregnancy. During reduction, two fetus usually leave, since there is a risk of spontaneous death of one of them in the future.

The reduction procedure for multiple pregnancy is carried out only with the consent of the woman and on the recommendation of the gynecologist. At the same time, the woman itself decides how many fruits to subjected reduction, and how much to leave. The reduction is not conducted against the background of the threat of abortion and during acute inflammatory diseases of any organs and systems, since on such an unfavorable background, the procedure may lead to the loss of all fruits. Reduction can be held up to 10 weeks of pregnancy. If you do it at later pregnancy, then the remains of the fetal tissues will have an annoying effect on the uterus and provoke complications.

Currently, reduction is made by the following methods:

• Transcervical. A flexible and soft catheter connected to a vacuum aspirator is introduced into the cervical cervical channel. Under the control of ultrasound, the catheter is promoted to the embryo to be reduced. After reaching the tip of the catheter of the fruit shells of the reduced embryo, the vacuum aspirator includes a vacuum aspirator, which takes it off from the wall of the uterus and sucks into the container. In principle, transcerexcal reduction in its essence is an incomplete vacuum abortion, during which not all the fruits are removed. The method is quite traumatic, so it is currently used rarely;
• Transvaginal. It is produced under anesthesia in the operating room similar to the process of fence of oocytes for ECO. The biopsy adapter is introduced into the vagina and under the control of the ultrasound puncture needle pierce the embryo to be reduced. After that, the needle is extracted. This method is currently used most often;
• Transabdominal. It is carried out in an operating room under anesthesia. Similar to the amniocentes procedure. On the abdominal wall they make a puncture through which the needle is administered to the ultrasound under control. This needle is pierced the embryo to be reduced, after which the tool takes out.

Any reduction method is technically complex and dangerous, since at 23 - 35% of cases, pregnancy loss occurs as a complication. Therefore, many women prefer to face the severity of tooling several fruits than losing the whole pregnancy. In principle, the current level of obstetric care makes it possible to create conditions for nullifying multiple pregnancy, as a result of which completely healthy children are born.

Most multiple pregnancy

Currently, the most multiple fixed and confirmed pregnancy was a decade, when there were ten fruits in the woman's uterus. As a result of this pregnancy, a resident of Brazil in 1946 gave birth to two boys and eight girls. But, unfortunately, all the children died without reaching the semi-annual age. There are also mentions of the birth of a decade in 1924 in Spain and in 1936 in China.

To date, the most multiple pregnancy, which can successfully end the birth of healthy children without deviations, is the gear. If the fruits are more than six, then some of them suffer from a developmental delay, which persists throughout their lives.

Multiple pregnancy - delivery times

As a rule, multiple pregnancy, regardless of the method of its development (ECO or natural conception), ends earlier than the term of 40 weeks, since women begin premature births caused by an overly strong stretch of the uterus. As a result, children are born premature. Moreover, the greater the number of fruits, the earlier and more often the premature labor is developing. Due to double, as a rule, the birth begin in the period of 36 - 37 weeks, with a triple - at 33 - 34 weeks, and at the fourtrity - at 31 weeks.

Multiple pregnancy - reasons

Currently, the following possible causal factors have been identified that can lead to multiple pregnancy in a woman:

• Genetic predisposition. It is proved that women, grandmothers or mother whose twins or twins gave birth, the likelihood of multiple pregnancy at 6 - 8 times higher compared to other representatives of the beautiful sex. Moreover, the most often multiple pregnancy is transmitted through the generation, that is, from grandmother to granddaughter;
• Age of a woman. In women older than 35 years, under the influence of hormonal preclusion perestroika in each menstrual cycle, it can be matured not one, but a few egg cells, therefore the probability of the occurrence of multiple pregnancy in adulthood is higher than in young or young. Especially high, the likelihood of multiple pregnancy in women older than 35 years, who have previously been giving birth;
• Effects of drugs. Any hormonal agents used to treat infertility, stimulation of ovulation or disorders of the menstrual cycle (for example, oral contraceptives, clomiphene, etc.), can lead to ripening of several eggs in one cycle at the same time, as a result of which multiple pregnancy occurs;
• A large number of birth in the past. It is proved that multiple pregnancy is mainly developing in reusing pregnant women, and its probability is the higher, the more childbirth was in the past;
• Extracorporeal fertilization. In this case, a woman takes a few egg cells, fertilize their male sperm in the test tube, and the resulting embryos are attached to the uterus. At the same time, four embryo is introduced into the uterus, so that I can be implanted and start developing at least one. However, two, and three, and all four embellished embryos can be taken in the uterus, as a result of which multiple pregnancy develops. In practice, twins appear as a result of Eco, and triple or quarters are rare.

Signs of multiple pregnancy

Currently, the most informative method for the diagnosis of multiple pregnancy is ultrasound, but the clinical signs on which the doctors of the past are still based on a role played. These clinical signs of multiple pregnancy allow a doctor or a woman to suspect the presence of several fruits in the uterus and, on the basis of this, make a sighting ultrasound study, which with 100% accuracy confirms or refute the assumption.

So, the following data are signs of multiple pregnancy:

• Too large uterus size, not appropriate;
• Low location of the head or fetal pelvis above the entrance to the pelvis in combination with a high standing bottom of the uterus, not appropriate;
• Non-compliance of the size of the fetus head and abdominal volume;
• Large abdomen;
• Excessive weight gain;
• Listening to two heartbeats;
• The concentration of hCG and lactogen is two times higher than the norm;
• Fast fatigue pregnant woman;
• Early and strong toxicosis or gestosis;
• Stubborn constipation;
• Pronounced swelling of the legs;
• Elevated blood pressure.

When identifying a combination of several specified signs, the doctor may suspect multiple pregnancy, however, to confirm this assumption, it is necessary to produce ultrasound.

How to determine multiple pregnancy - effective diagnostic methods

Currently, multiple pregnancy with 100% accuracy is detected during the usual ultrasound. Also relatively high accuracy is determined by the determination of the concentration of hCG in venous blood, however, this laboratory method is inferior to ultrasound. That is why ultrasound is a method of choice for the diagnosis of multiple pregnancy.

Ultrasound diagnosis of multiple pregnancy

Ultrasound-Diagnostics of multiple pregnancy is possible in the early period of gestation - from 4 to 5 weeks, that is, literally immediately after the menstruation delay. During the ultrasound, the doctor sees several embryos in the uterus cavity, which is undoubted proof of multiple pregnancy.

The number of complications (sorcerence) and fruit bubbles (amniotic), and non-bubbling or monoyard fruits, is crucial for the choice of pregnancy and the calculation of the risk of complications. The most favorable pregnancy occurs with a bichorial biamniotic double, when each fruit has its own placenta and a fetal bubble. A monochorial monoamniotic pregnancy occurs the least favorable and with the highest possible amount of complications, when two fetus are in one fruit bubble and feed on one placenta. Therefore, during the ultrasound, the doctor considers not only the number of fruits, but also determines how much the placento and fruit bubbles have.

With multiple pregnancy, ultrasound plays a huge role to identify various defects or delays in the development of the fetus, since biochemical screening tests (determination of the concentration of HCG, AFP, etc.) are not informative. Therefore, the identification of malfunctional defects on ultrasound during multiple pregnancy should be carried out in early terms of gestation (from 10 to 12 weeks), while evaluating the condition of each fetus separately.

Hgch in the diagnosis of multiple pregnancy

HCG in the diagnosis of multiple pregnancy is a relatively informative method, but inaccurate. The diagnosis of multiple pregnancy is based on exceeding the level of hCG of normal concentrations for each specific period of gestation. This means that if the concentration of hCG in the blood of a woman is higher than normal for a given period of pregnancy, then it does not have one, but several fruits. That is, with the help of hCG, you can identify multiple pregnancy, but to understand how much fruit is in the woman's uterus, in one fruit bubble or in different, two placenta or one - it is impossible.

Development of multiple pregnancy

The process of the development of multiple pregnancy creates a very high load on the mother's body, since cardiovascular, respiratory, urinary system, as well as liver, spleen, bone marrow and other organs continuously work in reinforced mode for quite a long time interval (40 weeks) to ensure not One, and two or more growing organisms with everything necessary. Therefore, the incidence of women who carry multiple pregnancy increases at 3 - 7 times compared with one-lodge. And the more fruits in the woman's uterus, the higher the risk of developing complications by various organs and mother systems.

If a woman, before the onset of multiple pregnancy, suffered from any chronic diseases, then they necessarily exacerbate, since the body is experiencing very strong loads. In addition, with multiple pregnancies, half of women develops gestosis. All pregnant women in the second and third trimesters appear swelling and arterial hypertension, which are a normal response of the body on the needs of the fruit. A pretty standard complication of multiple pregnancy is anemia that must be predicted by the reception of iron preparations throughout the entire period of nursing children.

For normal growth and development of multiple fruits, a pregnant woman should be fully and hardening, because its need for vitamins, trace elements, proteins, fats and carbohydrates is very high. The daily caloric content of a woman who is driving a twin must be at least 4500 kcal. Moreover, calorie data must be gained by rich food nutrients, not chocolate and flour products. If a woman with multiple pregnancies feeds poorly, this leads to the depletion of its body, the development of severe chronic pathologies and numerous complications. During multiple pregnancy, the woman adds in weight 20 - 22 kg, and 10 kg in her first half.

With multiple pregnancy, one fruit is usually larger than the second. If the difference in body weight and growth between fruits does not exceed 20%, then this is considered the norm. But when the mass and growth of one fetus is exceeded compared with the second, more than 20% talk about the delay in the development of the second, too small child. The delay in the development of one of the fruits in multiple pregnancy is noted 10 times more often than with one-lodge. Moreover, the probability of delay of development is highest with monochorial pregnancy and minimal - with a Bichorial Biamniotic.

Multiple pregnancy is usually completed by childbirth ahead of time, since the uterus is too stretched. With double, childbirth usually occur for 36 - 37 weeks, with a triple - for 33 - 34 weeks, and at the fourtrier - by 31 weeks. Due to the development of several fruits in the uterus, they appear on light with a smaller mass and body length compared to those born from unionless pregnancy. In all other aspects, the development of multiple pregnancy is exactly the same as one-lodge.

Multiple pregnancy - complications

With multiple pregnancy, the following complications may develop:

• Miscarriage on early pregnancy;
• Premature childbirth;
• Intrauterine death of one or both fruits;
• Heavy gestosis;
• Bleeding in the postpartum period;
• Hypoxia one or both fruits;
• Fruit collision (the grip of two fruits heads, as a result of which they are at the same time turn out to be in the entrance to a small pelvis);
• Fetopetal hemotransfusion syndrome (IPF);
• Inverse arterial perfusion;
• Congenital malformations of one of the fruits;
• Delay in the development of one of the fruits;
• The fighting of fruits with the formation of Siamese twins.

The most severe complication of multiple pregnancy is fetopteral hemotransfusion syndrome (ICD) arising from monochorial double (with one compound for two). SFFG is a violation of blood flow in a placenta, as a result of which blood from one fetus is redistributed to another. That is, there is an insufficient amount of blood to one fruit, and to the other - excessive. With enterprise, both fetus suffer from inadequate blood flow.

Another specific complication of multiple pregnancy is the fighting of fruits. Such collaborations are called Siamese twins. The battle is formed in those parts of the body, which the fruits are most tightly in contact. Most often, the battle occurs in breasts (Torakopagi), abdomen in the nesting area (omfalopaga), bones of the skull (craniophages), cocks (pig and pens) or sacrons (Ishiopags).

In addition to those listed, with multiple pregnancy, exactly the same complications may develop, as in one-bedroom.

Birth with multiple pregnancy

If multiple pregnancy proceeds normally, the fruits have a longitudinal location, then it is possible to root a natural way. With multiple pregnancy, complications in childbirth are developing more often than with one-bedless, which causes a higher frequency of emergency cesarean sections. A woman with multiple pregnancy should be for 3 - 4 weeks before the intended date of childbirth is hospitalized into the maternity hospital, and not wait for the beginning of the generic activity of the house. The stay in the maternity hospital needs to examine and evaluate the obstetric situation, on the basis of which the doctor will decide on the possibility of natural genera or the need for a planned cesarean section.

The generally accepted tactic of the delivery in multiple pregnancy is as follows:
1. If pregnancy proceeded with complications, one of the fruits is in cross position or both in a pelvic preview, a woman has a scar on the uterus, then a planned caesarean section is produced.
2. If a woman approached childbirth in a satisfactory condition, the fruits are in the longitudinal position, it is recommended to behave in the natural ways. When developing complications, an emergency caesarean section is performed.

Currently, with multiple pregnancy, as a rule, a planned caesarean section is produced.

Multiple pregnancy: causes, varieties, diagnostics, childbirth - video

When they give hospital (maternity leave) with multiple
Pregnancy

With multiple pregnancy, a woman can get a sick leave (maternity leave) for two weeks earlier than with one-bedless, that is, on the period of 28 weeks. All other rules for issuing a sick leave and monetary benefits are exactly the same as with one-bed pregnancy.

To date, the number of multiplication relatively with the past century has increased significantly. This is explained by the fact that the number of inducing increased, and the age of women who give birth to children rose. However, along with this, with a percentage of pregnancies, risks that are associated with the development of 2 or 3 and more kids are simultaneously, and their appearance.

Multipleness is a pregnancy with an increased risk of different complications, so observation of such women is kept more carefully than those who drive under the heart of one child. Let us look more detailed with all the nuances.

Features

The number of such pregnancies is about 60-70%, and the kids have the external similarity with each other as ordinary native sisters or take. It may be a boy and a girl, with different hair color, with a cut and eye color, with different characters. Such children are called diversity twins.

In this case, each fetal has its own placenta. Each child has a fetal bubble. They develop separately.

If a woman is tooling 3 and more children can be present dialing and monogo pregnancy at the same time.

Monosic twins

Depending on the number of kids, monosigital twins and triple are distinguished. In this case, the kids develop from one cell. At a certain time, she is to share for 2 and more embryo. Children all the subsequent time will develop the same, but in different programs.

In this case, we are talking about twins or monosigital twins. The external similarities of such children are 100%, they are equally all - the shape of the teeth, the hair blows and so on.

Features of the development of multium boulders

Single twins develops in the early stages of zygota fission. This is exactly the determining factor in the development of such children. So, if:

• The zygota shared during the first 2-3 days after fertilization, then children are formed 2 independent chorion and 2 amnions. Simply put - every child has a fetal bubble, a placenta. In some cases, the placenta of two kids can grow together.
• If the division occurred in a period of 4 to 8 days after fertilization, the children will develop in one placenta, combined with one shell. However, every child has a personal fuze bubble.

If division happens on 9 to 13 days, one placenta and shell is formed, most often Siamese twins are born.

Determine the accessory of twins to a specific type possible after delivery. If between the kids there are partitions from 2 shells, then these children are single-way, if the placenta is different and there are 4 partitions, then these are a variety chad.

To date, this can also be installed using ultrasound diagnostics, starting from the 4th month of to wear. This is necessary in order to find a pregnancy plan. If a woman is pregnant with two (or more) kids at the same time, then you need to carefully monitor how children develop, because there may be various violations in their development.

Flow

Initially, such pregnancy is quite problematic for a woman, it is classified as a deviation from the norm. This state must be regularly and carefully observed.

From the first 3 months of tooling, a variety of disorders may occur, deterioration of well-being. The task of the attending doctor who is pregnant, familiarize the future mother with potential abnormalities and violations so that it be aware of how to behave and when to contact the hospital.

Doctors suggest that multiplodes are a complex process. Maximum complications are possible in the case when a woman is pregnant with twins, which are distinguished by Rh factors and blood groups.

Problems in the early launches

At the initial stages of the nose, the condition does not have any particular differences, but for 7-8 days the bleeding can develop.

It can last about 3-4 days. In some cases, such bleeding is very much and spontaneous abortion begins - miscarriage. It should also be noted that with such pregnancy, symptoms of pregnancy and toxicosis are stronger.

Problems in the middle of the term

With multipleness, ICN develops very often in the middle of the term. With this state, the uterine neck becomes very weak, it becomes problematic to withstand the weight of kids. This state is developing due to the fact that the uterine walls are actively stretched, an increased amount of accumulating waters is observed, the fruits weigh more.

Such pathology usually occurs after 21-22 weeks of tooling, it occurs quite quickly, and it also quickly progresses. If, with multipleness, when it comes to two children, you can still put the seams on the neck, then during pregnancy triples and more, this will not help, since the load is very large.

Problems in late steps

As children develop and increase their weight increases the volume of circulating blood. This causes high loads on the heart muscle. Blood "divorce", which causes the development of anemia and an increased need of vitamin mineral components.

Often a woman is experiencing a strong heartburn, it is very quickly tired, it has disorders with a chair, in addition, urination is disturbed. This is explained by the fact that the uterus begins to actively increase in size, and presses the intestines, ureters and other organs.

In the last months of the baby tool, often in women with multipleness develops gestosis - late toxicosis, and they proceed very hard. In addition, in the uterus develops more than one fetus, it becomes very large due to the development of a multi-way basis, often accompanying multiple pregnancy. It provokes a disorder of the kidneys.

Often, childbirth is premature, and the more children get into the woman, the earlier childbirth may come.

After cesarean section

A particular danger may be a situation if the multiplot is not first and develops immediately after the birth of the children with the help of the cesarean section. The risk in this case is presented for both women and for children who develop in her stomach. So, we list the basic possible complications:

• Threats of premature birth may occur;
• The fruit in the uterus can take the wrong position;
• The scar can obey the fact that the placental sentence will be formed, or the placenta will be folded quite low. It threatens the premature placental detachment with bleeding.
• Blood impairment in the uterine wall, where there is a scar after cesarean section, especially if the placenta is attached to this area. This may cause a lack of oxygen and nutritional components, which can cause the development of intrauterine hypoxia.

Signs

The diagnosis of multipleness in the early stages (up to 28 weeks) is necessary in order to safely lead pregnancy, and to minimize the potential risk during childbirth. Diagnostics makes it possible to warn various complications, as well as the maximum to plan the childbirth.

Inspection of a woman with multipleness to be carried out every 10 days, and in the last stages of the tool - every 5-7 days.

With multiple pregnancy, the symptoms can be identified at the first reception of the doctor. A specialist looks at the size of the uterus that does not correspond to the term. At the same time, with the next visit, the uterus is very rapidly increasing in size.

In order to determine multiplodes or multi-way, additional research is appointed. With the help of electrocardiography, you can reveal a heart of several fruits. This can be done, starting from the 10th week of tolerance.

The ultrasound makes it possible to see a multiple pregnancy for a period of 9-11 weeks, but it is quite likely to mistakes. At a later stage, on time, the ultrasound can be revealed to the fact that one of the fruits stopped, or, on the contrary, it will be possible to see another child, which was not visible before the ultrasound.

Pregnancy, in which non-one develops in the female organism, and two or even more fruit - multiple pregnancy. Recently, the number of such pregnancies increased and amounts to about 2% of all cases, which is associated with the widespread use of reproductive methods.

But, in whatever high level, the sphere of gynecology and obstetrics, women with multiple pregnancy are still part of a group of increased risk. That is why the maintenance of multiple pregnancy occupies a special place in medical practice and requires deep knowledge.

Development of multiple pregnancy

There are different classifications of multiple pregnancy. It is subdivided:

• By the number of fruits - we are talking about whether twins are launched, triple.
• In terms of the number of eggs that were fertilized - for example, a twin is like a two-tailed, at which two eggs and one-way, at the same time, at which one egg cell is fertilized; two spermatozoa;
• According to the number of formed amniotic shells and chorions.

Chorion is an external dense envelope. It borders on the outer shell of the uterus, it is in this place and a placenta is formed.

With an increase in the amount of fruits, the duration of pregnancy decreases. With a bobby pregnancy, childbirth occur on average at 37 weeks, three-bedding - at 33 week, four-billion - by 29 week. With each additional fruit, the course of pregnancy is reduced by about 4 weeks.

The intrauterine development of any twins is associated with an increased risk.

Monosigital (single twins) twins are subjected to additional risk, the degree of which depends on the moment of its formation.

If the separation of the egg takes place in the first three days after fertilization, each fruit will be surrounded by its amniotiest bubble (amnion) and chorion.

When dividing a fertilized egg between 4 and 8 days, Chorion is already developing and amnion is not yet. Therefore, each fruit will be surrounded by a separate amnion, but one chorion.

If the division occurs from 9 to 12 days, after the development of amnion and chorion, both the fetus will be surrounded by one common shell.

If division occurs in a later date, it is incomplete. As a result, the fighting of twins occurs, which can be located between any parts of their torso. This rare pathology is found in the 1st case of their 70 thousand genera.

Multiple pregnancy: diagnostics

If earlier the diagnosis of multiple pregnancy was difficult, and often it could be determined already in late terms, then the modern clinical practice of obstetrics and gynecology allows this in the early stages. First of all, it is worth saying signs that give reason to assume that there is a multipleness:

• Data on the earlier procedure ECO and / or hyperstimulation of ovulation;
• Genetic predisposition to the birth of twins (already in the family);
• Stronger and early flow of symptoms of toxicosis, breast swelling, etc.;
• The inconsistency of the size of the uterus its intended size in the first trimester.

In addition, when diagnosing a multiple pregnancy, focus on the blood concentration of the HGG (human chorionic gonadotropin), as well as placental lactogen.

Naturally, they exceed the indicators for one-bed pregnancy. The same also applies to the content of a woman of the hormone of progesterone.

But the main and most reliable way of early diagnosis, allowing also to prevent many complications of multiple pregnancy, is ultrasound. This method has an accuracy of more than 99%, and allows you to visually identify all the eggs that were fertilized and are in the uterus cavity with the fifth-sixth week.

In the second-third trimester of pregnancy with the help of ultrasound, it is possible to determine the nature of the development of fruits, their contours, the number and location of the compound, congenital vices. Considerable importance is the opportunity to recognize the prelationship of fruits in advance.

Features of conducting multiple pregnancy

Considering all the nuances when entering more than one child, it is worth trusting the best specialists of their case that will be tracking, as a multiple pregnancy proceeds for weeks, and will be removed from the future mother the main part of the excitement and alarms.

After all, the maintenance of this pregnancy has its own characteristics that are concluded in:

• More frequent campaigns to the akuster-gynecologist - twice a month before the occurrence of 30 weeks and once a week after 30 weeks.
• Support control in weight - with multi-flowing need the need for vitamins, minerals and the number of calories consumed with food. Weight gain should be approximately 20-22 kg;
• Compliance with the recommendations on the regime of the day - a decrease in physical exertion, a full dream at night and day rest for another couple of hours;
• Binding, starting from 16-20 weeks of pregnancy reception of iron preparations for the prevention of anemia, and polyvitamins throughout the term;
• Control over the state of fruits to detect their pathologies (ultrasound);
• Control over the state of the cervix, placenta and groundwater waters;
• Control over the cardiovascular system and kidneys, glucose content and other blood indicators;
• Conducting dopplerography for each of the fruits separately;
• Additional surveys for genetic malformations of development, etc.;
• Departation on the hospital already on the period of 28 weeks.

Paid maintenance of multiple pregnancy implies the following services:

• Unlimited number of visits to a personal doctor, as well as the possibility of round-the-clock contact with it (by phone);
• Registration of all medical documents required during pregnancy;
• Consultations of narrow specialists and conducting the entire spectrum of laboratory and instrumental research - ultrasound, ECG, KTG, Doppler;
• Hold all the surveys necessary on testimony.

In addition, the maintenance of pregnancy in a specialized clinic implies also the control of the manager to make the client to come to his doctor in time and did not forget the appointed surveys in a timely manner. Therefore, the cost of conducting multiple pregnancy ultimately turns out to be absolutely justified.

Possible complications

Entering more than one fetus is always a risk for health and future mom and fruit themselves. Even if pregnant is completely healthy, it does not exclude the possibility of congenital malformations in fruit and their improper development.

Multiple pregnancy is associated with increased perinatal morbidity. The most significant cause of the incidence is premature birth, followed by the development delay.

During the entire period, such complications of multiple pregnancy may appear:

• Late beds - about half of all such pregnancies;
• Rapid exacerbation of a woman of its chronic diseases;
• A sharp drop in the level of hemoglobin in the blood, leading to anemia;
• Spontaneous interruption of pregnancy, i.e. miscarriage;
• The risk that childbirth will begin prematurely;
• Intrauterine delay in the development of both or only one fetus;
• Chromosomal anomalies or malformations in fruits;

But if the listed complications are possible in one-bedless pregnancy, that is, a number of situations that may occur only at multi-flow. This, first of all, the fertile hemotransfusion syndrome, the result of which the defective blood distribution between the fruits becomes.

Birth with multiple pregnancy

Birth in a multiple pregnancy situation is also fraught with a high risk of complications, including premature disintegration of ammunition and / or pairing placenta. In addition, there is a risk that the fruit heads "fit" and will begin to flow into the pelvis cavity at the same time.

We also have a weakened generic activity and strong postpartum bleeding, because in most cases the delivery in multiple pregnancy is recommended to be carried out by cesarean section. It is especially important to do this in cases of acute hypoxia (lack of air) of one of the fruits and when the cord loops is losing.

But if childbirth is behaved naturally, then, with multiplodes, doctors can apply the overlaying of obstetric forceps on the fetus head or remove it for the pelvic end. At the same time, after the birth of the first of the children, the UPPOVIN is tied up not only on it, but also on the maternal end, otherwise the risk of death of the second child due to bleeding.

And the next child should be born no later than 15 minutes after the first, otherwise the obstetra will independently open the fetal bubble and stimulates natural childbirth.

The postpartum period with multiple pregnancy is in general, as well as in the case of usual, except for the delay in the segment of the penis and the risk of bleeding increases.

And in order to avoid complications, women prescribe anti-inflammatory and reducing money uterus. From all this it follows that multiple pregnancy is not pathology, it is happiness that requires special attention and individual approach to each of the women.

This is the case when parents consider children with nothing understanding fools. You, "protecting the psyche of a child," forced the elder child to suffer, look for a beloved cat, knowing that she died. Most likely, he was not so stupid, he understood that "she became easier for her, but she ran away from the clinic," most likely, it means that Mom is just lying, but the logic entered into a conflict with a confidence in the mother when you think What if Mom says, then she is right - and he understood what happened, but still continued to wait and hope: "What if it really is alive, because mom can't lie?" And then, when even the younger told you that he still understands everything (and they certainly discussed the case with each other, and more and more came to disappointing conclusions that Mom was lying), you also convinced him that he was supposedly " Not to blame. " In my opinion, this is a direct way to raise children who are not able to bear responsibility for their actions. I think here it would be much more useful to say that yes, kusy died, because you came up, but nothing can be done, and now you know that your damp and experiments can lead to severe consequences, and, of course, you are so You will never do anymore. The child would blow and forever remembered what he did. And the personality of man develops precisely from memories. And please do not promote mosquito nets as protection against cat dropping. They are intended to protect your home from insects, and no more. Maximum, can protect your parrot from departure from the window. Here I recently glorified in the news that a one-year-old child fell out with such a net from the 10th, or the floor ... died, of course. These grids will not protect either a cat or a child. They are made of plastic, and glued with double-sided scotch, or they jumped with buttons. The slightest load is and the grid crashes. The cat can jump onto the grid behind the bird or butterfly, and fly down. Or it may simply begin to tear it, the exact claws, and break. If you start a cat, then buy and install the "Antikot" grid, this is a metal grid, which is firmly attached to the frame on self-drawing or bolts, and can even withstand an adult.

Despite the fairly high modern level of development of obstetrics and objects, women with multipleness are still included in the high risk group. Multiple pregnancy and directly childbirth differ significantly from the usual pregnancy with one fruit. They require the medical personnel experience and deep knowledge of this state.

Relevance of the topic

Features of multiple pregnancy is the relevance of the problem for obstetrics in general and, in particular, for the obstetrics of the perinatal period (from 22 weeks of intrauterine development up to 28 weeks of the postpartum period). These features are a high percentage of complications, presence and risk of premature births, a severe form of fetoplacentage insufficiency, fruit hypotrophy and intrauterine hypoxia, the possibility of severe developmental defects, etc.

Perinatal mortality in multiple pregnancy, compared with one-lodge, is about 10% and largely related to the mass of the body of fruits. Development defirms are registered 2 times more often, intrauterine mortality is 3-4 times and over the past 30s, it is practically not reduced. The frequency of development of the cerebral paralysis in the child twins is 3-7 times, triples - 10 times, and the number of complications of the mother throughout the entire period of pregnancy - at 2 or more times (up to 10).

Causes of multiple pregnancy

The development of two and more fruits in the female organism is called multiple pregnancy. Over the past 20 years, it has doubled, and women with multiple slope among all pregnant women accounted for 0.7-1.5%, the birth of twins in relation to all clans - 1: 87, Trina - 1: 6 400, quarters - 1: 51 000.

Many reasons for multipleness are noted, which indicates another insufficient study of this issue. The probability of multiple pregnancy is largely determined by the following factors:

1. Inheritance, that is, if spouses or one of them come from multiple pregnancy or in their families, especially on the female line, there were similar cases.
2. In the increased blood content of a follicular hormone woman, promoting development and ripening at the same time two or more eggs. This may be due to heredity, reception of drugs that stimulate ovulation in the treatment of infertility, pregnancy immediately after canceling OK (), especially against the background of the use of means of ovulatory stimulation.
3. Conducting in extracorporeal fertilization (), the program of which includes drug-based ovaries to obtain a large number of mature eggs. Multiple pregnancy at ECO is also due to the uterus of several fertilized eggs, the possibility of implantation and development more than one.
4. The number of childbirth: during re-pregnancy and childbirth, the probability of multipleness increases.
5. Aged women exceeding 35 years. It is assumed that this is due to a decrease in the ability to conceive at this age due to the lack of a monthly ovulation. As a result, hormones accumulate and their effect in the form of ovulation of two or more eggs.
6. Anomalies for the development of internal genital organs.

Many reasons for multiple pregnancy, the main of which are listed above, indicates an insufficient study of this issue.

Classification of multiple

In solving questions about the tactics of such pregnancy and labor, consistency, chorilation and the number of amniotic cavities are considerably. The zygote is a cell resulting from the fusion of an egg cell with a sperm and a double full set of chromosomes. Chorion is one of the three (outer) fetal shells. The amniotic cavity is a cavity bounded by aquatic shell (amnion) and filled with an oily-free liquid.

Monosigito

In accordance with the number of fruits, the pregnancy is distinguished by a double, triple, etc., about 30% of the two is formed from one fertilized egg. In the future, as a result of its division, two similar structures are developing, which have the opportunity to develop independently, individually. Such a type of twins is called monosigital, or single-horse, and children are twins. They have the same gender, eye color and hair, skin pattern, blood group, location and shape of teeth.

Double

Simultaneous maturation and yield of two and more eggs can occur both in one ovary and in both for one menstrual cycle. Twisted, or bike embryos develop from two fertilized eggs and averaged 70%. Children are called "twins". They can be both same-sex and in general, with the same or different groups of blood and are in the same genetic connection. In cases of larger number (triple, quarters, etc.) are possible both monosicity and diality in various combinations.

Each of the bike germ has its own chorial / placental and amniotic shells. Each embryo corresponds to its placenta. Thus, a four-layer partition is formed between two embryos, consisting of sections of two chorial / placental and two amniotic shells. Therefore, such embryos in the classification are referred to as di- (or bi -) - chorial, diaminiotic dialing double.

The formation of one-way twins occurs at the early stages of development, division and conversion of the fertilized egg and depends on the time of these processes:

1. If the division of the egg takes place within the first 72 hours, counting from the moment of fertilization, that is, before the formation of the inner cell layer and the change in the cells of the outer layer of an egg, two chorion and two amniotic cavities are developing. As a result, a dichorial, diaminiotic monosigital twin is formed, in which one placenta is possible, formed from the confluence of two compounds, or two separate placenta.
2. If the division of the egg takes place in the range of 4-8 days after its fertilization, when the formation of the internal cell layer has already been over, and the chorion laying has occurred from the outer layer, but the amniotic shells are not laid, then each embryo will develop in a separate amniotic cavity. Thus, embryos with individual aquatic bags will be surrounded by one common chorion, resulting in a diaminiotic, monochorial monosigital twin.
3. If the laying of the amniotic shell has already accomplished by the time of the separation of the fetal egg, which usually occurs to the 8th day after the fusion of the egg cell with a sperm, it will lead to the development of embryos with a common aqueous bag and one chorion - monoamniotic, monochorial monosigital twin.
4. The separation of the fertilized egg at the later deadlines (after 13 days), when the embryonic disk has already been formed, it will be only partial. This will lead to the development of twins that have grown among themselves.

The easiest way to determine belongings to one-way or bilayades is an inspection of an obstetrician after the birth of children. The partition between the twins consists of two aquatic (amniotic) shells, and between "twins" - of four: two amniotic and two chorionic.

Features of the flow of multiple pregnancy

Possible complications for mother

Pregnancy is two and more fruits, especially with their different blood groups, compared with one-lodge, presents the body of a woman higher demands. In addition, the flow during the dichorial type is heavier than in monochorial. The average disintegration time with twins constitutes about 37 weeks, with triples - 35 weeks.

In the body of a pregnant woman increasing the volume of circulating blood (by 50-60%), which creates an additional load for the heart function, while at one fruit this indicator does not exceed 40-50%. Because of hemodilution (blood breeding), anemia is often noted, an increased need for vitamins, macro- and microelements, especially in folic acid and iron.

Women significantly marked shortness of breath, quick fatigue, painful heartburn, urination disorders and constipation. Especially these phenomena are concerned about the last time. In addition, toxicosis and among them are more common, develop earlier, and their heavier. The majority of the uterus reaches not only due to the multipleness, but also as a result of the cases of frequent development of the multi-way, which may cause the renal function. The number of premature births is directly dependent on the number of fruits and ranges from 25 to 50%.

Very common problem is the Eastic-cervical insufficiency (ICH) with multiple pregnancy. It develops significantly more often than with one-bedless, especially in the presence of triple and more, which is associated with the influence of the mechanical factor (increased pressure in the uterine cavity and its stretching). ICN usually begins to develop after the 22nd week and is characterized by rapid progression. If, with twins, the operational treatment to strengthen the neck is effective, then as triplery increases, etc. The superimposed seams often do not withstand the load and cut through. Therefore, in some cases, additional use of special pessary helps.

With multipleness, it also develops more often, chronic somatic diseases occur harder. Special attention and strict constant dynamic observation requires multiple pregnancy after cesarean section, due to the large number of risks, both for fruits and women. The main risks with high frequency include:

• disorders of placental blood circulation due to violation of the vascular network of the uterus after surgery, which leads to a delay in intrauterine development and / or intrauterine asphyxia;
• prelation of the placenta;
• threat of abortion;
• improper position of fruits;
• the failure of the scar on the uterus and its gap, which is the most dangerous.

In some cases, with multiple pregnancy, as in one-bedroom, on the 8th day, bloody discharge from the vagina, ongoing about 4 days, is, as a rule, a minor implantation bleeding, which accompanies the introduction (implantation) of the fertilized egg to the mucous membrane uterus. However, with implantation of two or more such eggs, it can be longer, repeated and abundant and lead to spontaneous miscarriage. In these cases, it is necessary to conduct differential diagnosis and treatment under hospital conditions, where assistance is carried out in the form of hemostatic therapy, peace, the appointment of antispasmodic agents, etc.

Risks for the fetus (s)

Compared to one-fledged pregnancy, the delay in the development of one fetus in multiply occurs more often 10 times and constitutes with a dichorial double 20%, during monochorial - 30%, and the delay in the development of twins in general is 1.7% and 7.5%, respectively.

Of principled significance, when detecting congenital malformations, one of the fruits is detected during a prenatal period of zeality, since in the case of a dialicotal twin, the second fetus can be without pathology, and with monosigitally, the probability of vices has enough of one of them. The likelihood of the development of the fruit structural anomalies in one-fledged pregnancy and the dialing double is the same, and in the case of monosigital twins - above 2-3 times.

In order to identify the trisomy of fruits to which Down disease, Edwards and Patau syndromes include a non-invasive prenatal test, which has significant accuracy. Its essence lies in a genetic study of particles of DNA fruits in the venous blood of a woman in the 9th - 24th week. In the case of a positive result, additional, but already invasive, genetic studies are carried out. In confirming the results of the tactics of further pregnancy, it is artificially interrupted.

In monochorial, significantly less frequently in the Bichorial placenta, cases of formation of arterio-arterial or arterio-venous anastomosis (compound between two arteries or between the arteries and veins). The second type is the most unfavorable, since in this case there is an outflow of blood from the artery of one fetus to the vein of the other. In these cases, if the pressure of the placental vessels is symmetric, the development of fruits occurs in equal conditions. But with monosigitious twins, these conditions may be disturbed in an asymmetric blood circulation in the placenta, as a result of which the flow of arterial blood to one of the fruits is reduced, it does not receive sufficient food and its development is delayed.

A significant violation of equilibrium in the system of placental vessels is the reason that almost all blood circulation proceeds to one of the twins - the development of feto-fetal transfusion syndrome (FTTS), which is noted especially in cases of monochorial multiple pregnancy (from 5 to 25%), hypertension , the expansion of the heart, etc., in one of the fruits. The second can develop ugliness, stopping the heart function, or it gradually dies and exposed to mummification (spontaneous reduction of the fetus). This process may be complicated by the development of a WHS-syndrome woman (disseminated intravascular coagulation), threatening her life.

Reducing of the fetus with multiple pregnancy

In some cases, the reduction of the fetus is carried out artificially. The need for this is more often after ECO. Artificial reduction is associated with certain risks and complications, and therefore it is performed in the presence of strict readings:

1. The need to reduce the number of implanted after eco fruits.
2. Pathological changes in them.
3. The risk of unbearable.
4. The presence of a woman's contraindications to tooling multiple pregnancy.

The procedure of artificial reduction is usually carried out in terms of not earlier than 7 and no later than 13 weeks. It consists in stopping the heart of an unpromising fetus (or fruit) by punking a special preparation or air into his / their heart. For this, transvaginally (in 7-8 weeks) or transabdomomotional (in 8-13 weeks) after local anesthesia needle under the control of the device for ultrasound research is carried out puncture of the uterus. In the future, the fruit tissue is dissolved.

How to sleep with multiple pregnancy?

Arising in the third trimester in almost half of women with one fruit, the so-called lower hollow syndrome is capable of complicating the course of pregnancy. With multi-flow, it occurs earlier and can proceed much harder.

All venous blood from the lower half of the body and the abdominal cavity is assembled in Vienna, then it enters the right atrium, etc. The reason for this syndrome is increased pressure in the abdominal cavity due to increasing the uterus. With a horizontal position of a woman on the back or on the right side, there is a compression of the lower hollow vein between the uterus and the spine.

Against the background of the increased volume of circulating blood and the increased need of a woman in the blood supply to the brain and heart, the receipt of the required volume of blood to them during the squeezing of the lower vein is sharply reduced by reducing the return of the fruit already, and the blood supply to the fetus suffers. Most of this flows imperceptibly, but about 10% such symptoms may arise as a sharp decrease in blood pressure, dizziness, pallor, nausea, vomiting, and in difficult cases there are loss of consciousness and collapse, the appearance of convulsion.

The blood circulation is rapidly restored when the uterus shifts with a hand to the left or as a result of the turn of the woman on the left side, which contributes to the release of the lower hollow vein from the compression. Therefore, being in a horizontal position, you must lie on the left side.

Signs of multiple pregnancy and its maintenance

Multiple pregnancy early

Diagnostics

Widespread use in the clinical practice of obstetrics and gynecology made it possible to diagnose multiplotion in the early stages. Until ultrasound, this diagnosis was often difficult. Basically, more or less reliable it was in the later dates, and sometimes only during childbirth.

What time determines multiple pregnancy?

The assumption in the early terms about the presence of two or more fruits can be made on the basis of a set of features:

• anamnesis that a married couple or her closest relatives are one of the twins or "twins";
• the presence of data on the hyperstimulation of ovulation and ECO;
• early development and more severe course of induced hypertension, symptoms of toxicosis (vomiting, nausea), milk gland swelling;
• the inconsistency in the first trimester of the magnitude of the uterus time of pregnancy, which is also found with or bubble drift.

At later deadlines in the formulation of the presumptive diagnosis, it is given to this data as:

• early movement in multiple pregnancy, which can be felt by a woman from the 15th week, while at the first one-lodge - from the 20th, and upon the next - from the 18th week;
• the dimensions of the abdomen circle and the standing height of the bottom of the uterus, which exceed the estimated deadlines for one-bed pregnancy;
• palpation through the front abdominal wall in the second half of the gestation of running large parts of fruits (heads and pelvis) in different parts of the abdomen;
• palpation of a large number of small pieces;
• the presence in the middle sectors of the bottom of the uterine of the deepening, formed by the protrusion of its corners with large frenses (at double);
• auscultative definition of two heart patent points, especially if there is a zone between the tones (silence zone ");
• various (difference in 10 strikes) The frequency of heart abbreviations at different points, which can be determined by and through cardiological monitors.

How to identify multiple pregnancy in the early time more reliably?

In the formulation of such a diagnosis to a certain extent, it is possible to focus on the concentration in the blood of the HCG (human chorionic gonadotropin) and placental lactogen. This laboratory biochemical testing is not fully reliable, but relatively informative. Thus, the level of hCG in multiple pregnancy at each stage of the gestational period exceeds the rate of such for one-bed pregnancy.

The definition of progesterone in the blood also has a similar meaning. Increased progesterone with multiple pregnancy , compared to the norms defined for one-lodge, will be in each relevant trimester.

The main method of early diagnosis and means to help prevent many complications of multipleness is an ultrasound study. The accuracy of this diagnostic method, including the earliest time, is more than 99%. It is based on the visual definition of several fertilized eggs or embryos from the 5th - 6th week.

In addition, the echography allows in the second and third trimesters to determine the nature of the fruit development and the contours of the fruit, which helps to identify the surfacing twins, FFTS, localization and the number of compound and amniotic (aqueous) cavities, identify congenital defects, antenatal death, etc. Compliance with echometric biometry distinguishes the following five types of twin development:

1. Physiological - both fruits.
2. Signs of hypotrophy with uneven (dissociated) of their development.
3. The uneven development of both fruits with distinction from the body's mass of greater of them is 10%.
4. The presence of congenital development pathology.
5. Interene death of one fetus.

Preparation options for fruits

Ultrasound also allows you to establish the prelationship of fruits and their position, which is especially important before the start of childbirth.

In addition to some of the above mentioned moments (reduction, prevention of the squeezing syndrome of the lower hollow vein, etc.) provides for preventing gestosis, the early detection and treatment and treatment in hospital conditions, control of the coagulation system, the functions of the cardiovascular system and the kidney function.

Recommendations on the correct balanced and sufficiently caloric nutrition of women are also given, a folic acid is prescribed 0, 001 grams per day and iron preparations (up to 100 mg). In addition, in order to prevent premature births, restriction of physical activity is recommended - finding the day in bed 3 times to 1-2 hours, the reception of the tocologists and bed regime in the event of a threat of premature births.

One of the ways to predict pregnancy pregnancy is to use non-stroke testing of the heart function of fruits in response to their movement. The test must be held every week after a 30-week period. If possible, each of the fruits is separately conducted by the blood flow.

With the uncomplicated course of pregnancy, hospitalization is necessary in the maternity branch to the intended term of birth in 2-3 weeks in the presence of twins and for the month - triple. In the absence of the beginning of the generic activity on a period of 37 weeks, it is advisable to conduct its stimulation, and in some cases the planned cesarean section for a period of 37-38 weeks. The presence of a scar in the uterus in a multi-flow is a direct indication for the cesarean section.

The optimal method of roostening in the case of monochorial and monoamniotic twins - caesarean section in terms of 33-34 weeks (due to the high risk of cord), and during pregnancy 3 fruits and more - at 34 weeks.

Childbirth and their maintenance

Normal labor flow is often accompanied by complications. In the first period of genera, on average, 30% of the feminine is noted premature or previously influence of the ammunition. At the same time, it is often accompanied by the loss of small parts - the loops of the umbilical, legs or pens.

Because of the original uterus, the weakness of the generic forces is developing, and the cervical disclosure is significantly tightened. It often increases the duration of the expulsion of the first fetus. The presets part of the second tends to insert into the pelvis simultaneously with the first, and it takes a long time. The muscles of the anterior abdominal wall weakened and overwhelmed, because of which it is lengthened or becomes impossible. All this leads to a protracted childbirth, which threatens the infection of the uterus and the development of hypoxia (oxygen starvation) of fruits.

During the expulsion of premature fruits, there is a risk of rapid genera and crotch break. The prevention of this complication requires timely carrying porendal (perineal) anesthesia and crotch dissection.

A serious complication in the period of expulsion is a premature detachment of the placenta, especially after the birth of the first child, which is associated with a sharp decrease in pressure inside the uterus and a decrease in its volume. This complication threatens with rich bleeding and the development of the second child's hypoxia. To prevent an obstetrician, an emergency autopsy of the second fruit bubble is carried out.

Very rare, but seriously occurring complication is the clutch of the heads among themselves, as a result of which they strive for the entrance to a small pelvis at the same time.

Maintaining labor with multiple pregnancy

It is a thorough observation of the heart activity of fruits with the help of cardiomonitors and the condition of the fever. The maintenance of them in the first period is desirable on the left side for the prevention of the bean's lower hollow syndrome. When developing the weakness of the generic force, stimulation of the latter by intravenous drip administration of glucose solution with oxytocin, carrying out an anesthesia by epidural analgesia method.

In the case of the development of weakness of generic activity and fruit hypoxia during the period of expulsion, obstetric operational benefits are carried out in the form of imposing obstetric forceps to the head (with a head preview) or extraction (with a pelvic preview) for a pelvic end.

Pupil's interference is carried out not only on the fetal end, but also on maternal, since after its dissection, the monochorial double is possible the death of the second fetus as a result of bleeding from the umbilical cord.

The birth of the second child should occur no later than 10-15 minutes after the first. Otherwise, the obsucher is revealed by a fruit bubble, and the oily water of the water is slowly produced, after which the childbirth is carried out naturally (with a longitudinal position).

In the case of the transverse position or improper insertion of the head of the second fetus in a small pelvis under general anesthesia, a turn on the leg and removal of a child is carried out. If it is impossible for its birth naturally (the impossibility of turning, a large child, spasmodization of the neck, signs of acute hypoxia of one of the fruits, the falling out of the umbilical cord and small parts, a persistent secondary generic weakness) is carried out by cesarean sections. The optimal option of the delivery of the triple and more, as well as in the case of the twins, the cesarean section.

Last period (before the sections of the post - placenta with shells) flows the same way as with one-bed pregnancy. However, due to an empty uterine and reduce its tone, the frequency of the delay of the segment of the penis and the associated abundant bleeding is much higher and more dangerous. Therefore, at the end of the second period, intravenously methyl ergometrine is administered, and after the birth of children for 2 hours, oxytocin is injected droplet. In the absence of effect, a manual separation of the placenta is carried out and the subsequent massage of the fist.

Also significantly above the frequency of complications and in the postpartum period. They are manifested by late postpartum bleeding, slowed down the reverse development of the uterus to the previous condition (subbavor), postpartum. Therefore, after delivery, anti-inflammatory drugs are prescribed and reducing the uterus.

Thus, despite the fact that multiple pregnancy is not a pathological condition, it requires increased attention and a specific approach to each woman at each stage from conception to the postpartum period. In addition, special observations are needed and care for born babies.