Rajiv Gandhi University of Health Sciencies Bangalore, Karnataka

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCIES BANGALORE, KARNATAKA.

MASTER OF SURGERY

IN

OBSTETRICS AND GYNECOLOGY

SRI DEVRAJ URS MEDICAL COLLEGE TAMAKA, KOLAR - 563101.

" A PROSPECTIVE STUDY OF MATERNAL AND FETAL OUTCOME IN MULTIFETAL GESTATION "

BY

DR. SHIVALEELA ANGADI SRI DEVRAJ URS MEDICAL COLLEGE TAMAKA, KOLAR - 563101.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE , KARNATAKA - 563101

PROFORMA FOR REGISTRATION OF SUBJECT OF DISSERTATION

1) Name of the candidate

: DR. SHIVALEELA ANGADI

Address in block letters

P.G LADIES HOSTEL

SRI DEVRAJ URS MEDICAL COLLEGE

TAMAKA , KOLAR - 563101 .

2) Name of the institution

: SRI DEVRAJ URS MEDICAL COLLEGE Tamaka, Kolar-563101.

3) Course of the study and subject

: M.S (O.B.G)

4) Date of admission to course

5) Title of the topic
31-5-2007

A PROSPECTIVE STUDY OF MATERNAL AND FETAL OUTCOME IN MULTIFETAL GESTATION

6) Brief resume of intended work: 6.1)Need for the study:

The incidence of twins and higher order multiple pregnancy has increased dramatically over the last two decades . The greatest contributor to this explosion in multiple gestation has been delayed fertility and the use of assisted reproductive technology .

Multiple gestation having increased placental and fetal mass is likely to have increased physiologic responses compared with singleton pregnancies . These exaggerated physiologic changes and mechanical stress in multiple pregnancies could be associated with an increase in adverse maternal outcomes such as pulmonary oedema due to decreased cardiac reserve , venous thromboembolic disease and even death . Complications of pregnancy like pregnancy induced hypertension , gestational diabetes , anaemia , antepartum haemorrhage , malpresentation , placenta previa etc could be more

2 3

frequent and severe in multifetal gestation compared to singleton pregnancy Multiple pregnancy due to overdistension of the uterus could have a higher rate of preterm delivery than singleton pregnancies and a substantially higher perinatal morbidity

4

and mortality .

Moreover, the potential for fetal growth restriction is increased in multifetal gestation due to an increase in fetal metabolic demands , placental and cord anomalies , increased incidence of maternal complications .

So multiple pregnancy is a high risk pregnancy which could adversly affect both mother and fetus . Moreover, delivery of multiple fetuses may present psychological, social and

i i6

economic problems .

In view of this , it was decided to collect the data about the pregnant women with multifetal gestation attending R.L.Jalappa Hospital and Reaserch Centre , Tamaka , Kolar to study the maternal and fetal outcome in multifetal gestation .

6.2) Review of literature :

The incidence of multifetal gestation has increased significantly with the introduction of ovulation inducing agents . Multiple pregnancy presents serious obstetric problems because of difficulties connected with early diagnosis , increased incidence of delivery complications and a five fold increase in neonatal mortality among the newborn . The

pregnancy outcome especially preterm labour and pre-eclampsia occurred with greater

frequency in triplet gestation . Neonatal outcome was better after abdominal delivery as

7 compared to vaginal delivery .

In twin pregnancy , perinatal mortality was significantly higher in second of the twins

o

than first of the twins .

Pregnancy induced hypertension , anaemia , diabetes mellitus , abruptio placenta , premature rupture of membranes , caesarean delivery , cardiac morbidity , haematologic morbidity , postpartum haemorrhage , prolonged hospital stay , need for obstetric

intervention , hysterectomy were increased in women with triplets , quadruplets and

1 9 higher order multifetal gestation . '

Perinatal outcomes were improved by various antenatal interventions like routine

hospitalization , prophylactic oral or intravenous tocolysis , cervical cerclage and home

. . 10 uterine contraction monitoring.

6.3)Objective of the study :

To study the maternal and fetal outcome in multifetal gestation in rural area Kolar . 7) MATERIALS AND METHODS :

7.1) Source of data :

Study will be carried out on pregnant women with multifetal gestation attending R.L.Jalappa Hospital and Research Centre , attatched to Sri Devraj Urs Medical College , Tamaka, K

7.2)Method of collection of data :
Design of the study :

A prospective study of 50 cases of multifetal gestation will be carried out from 1st October 2007 by detailed history taking followed by a complete general physical examination , systemic examination and a complete obstetrical examination . Routin relevant investigations will be carried out. Pregnancy outcome will be recorded in te of type of delivery , duration of labour , complications noted at the time of delivery a fetal outcome will be recorded and data will be analysed by using descriptive analysi like proportions .

Incusion criteria :

Pregnant women with multifetal gestation attending R.L.Jalappa Hospital and ReseE Centre.

Exclusion criteria :

Pregnant women with multifetal gestation with pre-existing medical disorder that wo likely increase their risk of pregnancy complications (i.e ., pre-exesting hypertension pregestational diabetes , cardiac disorder, renal disease or collagen vascular disease

7.3)Does the study require any investigations or interventions t<
conducted on patients ? If so please describe briefly .

Routine and relevant investigations such as Hb %, blood grouping and typing , urine albumin , sugar , microscopy , random blood sugar with Ultrasonography for fetal maturity and well being and cardiotocographic fetal monitoring will be required .

7.4)Has ethical clearance been obtained from your institution in c
of 7.3.

The study has been discussed and obtained clearance from the ethical clearance committee of Sri Devraj Medical College , Tamaka , Kolar .

8) List of references :

1) Mark C , Walker, Kellie E, Murphy , Saiyi pan , Qiuying Yang,Shiwuwen ." Advance maternal outcome in multifetal pregnancies "Br J obstet Gynaecol 2004 ;111:1294-1296 .

2)Cynthia Gyamfi , Joanne Stone , Keith A . Eddleman . "Maternal complications of multifetal pregnancy "Clin Perinatal 2005;32:431-442 .

3)Misty C . Day , John R. Barton , John M . O'Brien ,Niki B.Istwan, RN and Baha M .Sibai. "The effect of fetal number on the development of hypertensive conditions of pregnancy ."Obstet Gynaecol 2005 ;106 -.927-931.

4)Micheal O. Gardener , Robert L . Goldenberg , Suzanne Cliver ."The origin and outcome of preterm twin pregnancies "Obstet Gynaecol 1995 ; 85 (4):553-557.

5)Emily F . Hamilton , Robert W . Platt, Luccie Morin Robert Usher and Michael Kramer . "how small is too small in a twin pregnancy T'Am J Obstet Gynaecol 1996 ; 179:682-685.

6)Holcberg G,Bide Y, J_£wenthal H ,Insler .V. " Outcome of pregnancy in 31 triplet
gestations ." Obstet Gynaecol 1982 ;59 (4):472-476 .

7)Kushla Pathania , Advitendra Singh , Gupta K.B . "Outcome of Triplet Gestation in an
Apex Institution ." J Obstet Gynecol Ind 2001; 51: 108-110.

8)Anahita Pandole , Swamy M.S.C, Nagendra Sardeshpande . " Perinatal Mortality in
Twin Pregnancy - A Retrospective Analysis "J Obstet Gynecol Ind . 2003 ; 53 :
138-139.

9)Shi Wu Wen , Kitaw Dimissie , Qiuying Yang , Marc C . Walker. . "Maternal
morbidity and obstetric complications in triplet pregnancies and quadruplets and higher
order multiple pregnancies .Am J Obstet Gynecol 2004;191:254-258.

10)Alan M. Peaceman,Sharon L. Dooley, Ralph K. Tamura and Michael L . Socol.
"Antepartum Management of triplet gestations "Am J Obstet Gynecol 1992 : 167;

1117-20.

9) Signature of the candidate :

10)Remarks of the guide : With this study , we hope we can decrease the maternal and fetal morbidity and mortality associated with multifetal gestation by understanding associated risk factors and adopting better preventive and management measures .

11)Name and designation of

11.1)Guide: DR. SHEELA .S.R M.D

PROFFESOR OF OBSTETRICS AND GYNAECOLOGY

SRI DEVRAJ URS MEDICAL COLLEGE TAMAKA, KOLAR - 563101 .

11.2)SIGNATURE :

11.3)HEAD OF THE DEPARTMENT :

DR. HEMALATHA MAHANTH SHETTI M.D PROFFESOR AND HEAD OF THE DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY

SRI DEVRAJ URS MEDICAL COLLEGE TAMAKA , KOLAR-563101

11.4)Signature:

12)Remarks of the Chairman / Principal : Signature :

PROFORMA

NAME:AGE:IP NO:DOA: DOD:

OCCUPATION:ADDRESS :

SOCIOECONOMIC STATUS :EDUCATION:

H/O Amonorrhoea : Presenting complaints : History of presenting complaints : Obstetric history :

Gravida : Para : Abortions : Living / dead :

Marital status : Consanguinous / Non-consanguionous marriage : Married life: Previous pregnancy details : Present pregnancy details :

Time of diagnosis :Infertility treatment :

Use of tocolytics :Mode of conception :

Use of steropids :Timing and length of bed rest :

Number and length of hospitalization :

Prenatal care utilization : 1) Adequate

2) Inadequate Menstrual history :

A.O.M -PMC-LMP -EDD-

Past history :

Family history :

Personal history : Sleep - Diet - Appetite -Bladder / Bowel babbits :

General physical examination :

Built - General condition : Hieght- Weight - BMI Nourishment - Temparature - Pulse - Blood pressure -Respiratory rate - Pallor - Icterus - Clubbing - Cyanosis -

Lymphadenopathy - Oedema of feet -
Breast -Thyroid -Spine -

Systemic examination : Cardiac examination : Respiratory system : Per abdomen : Per speculum : Per vagina :

Details of delivery : Timing and mode of delivery :

Fetal presentation :

Chorionicity : Post-partum complications :

Details of neonate :

Sex :Birth weight: Birth order : Gestational age :

APGAR Scores : 1) 1' 2)5'

General physical examination :

Anthropometry :

Discordancy : 1)2)3)

Systemic examination -

CVS-RS-P/A-CNS-

INVESTIGATIONS -

Hb%- PCV - Blood groping - Urine analysis - Random blood sugar

HBsAg- HIV- VDRL-Bleeding time - Clotting time -

Obstetric ultrasound -

Any investigation then specify –

Condition at the time of discharge –

Follow up -