From the Guidelines
The best next step in management for this 27-year-old woman with a twin pregnancy at 14 weeks gestation is to refer her to a maternal-fetal medicine specialist for high-risk pregnancy care. Twin pregnancies carry increased risks including preterm birth, preeclampsia, gestational diabetes, and fetal growth restriction, as highlighted in the 2024 update of the ACR Appropriateness Criteria for multiple gestations 1. The patient should be scheduled for more frequent prenatal visits than a singleton pregnancy, typically every 2-4 weeks initially, and more frequently as the pregnancy progresses. She should receive additional ultrasounds to monitor fetal growth, with serial growth scans starting at around 16 weeks and continuing every 3-4 weeks thereafter, as recommended for multiple gestations 1.
Some key points to consider in the management of this patient include:
- The importance of determining chorionicity, as monochorionic (MC) pregnancies are at higher risk for complications such as twin-twin transfusion syndrome (TTTS) and twin anemia-polycythemia syndrome (TAPS) 1
- The need for careful monitoring of fetal growth and development, as twin pregnancies are at higher risk for growth restriction and other complications 1
- The importance of counseling the patient on the signs and symptoms of preterm labor, as twins have a significantly higher risk of delivering before 37 weeks
- The need for nutritional counseling, as twin pregnancies require additional caloric intake (approximately 600 extra calories daily) and higher supplementation of certain nutrients like iron and folic acid
- The importance of addressing the patient's current nausea and vomiting symptoms, potentially with antiemetics if severe.
Given the higher risk of complications in twin pregnancies, it is essential to prioritize close monitoring and management to minimize risks and optimize outcomes for both the mother and the fetuses 1.
From the Research
Patient Management
The patient is a 27-year-old woman, gravida 1 para 0, presenting with daily nausea and vomiting for the last 2 months, and an ultrasound showing 2 intrauterine fetal poles measuring 14 weeks gestation. The best next step in management of this patient would be to:
- Confirm the gestational age and fetal growth through ultrasound, as described in the study by 2
- Assess the patient's symptoms and medical history to determine the best course of treatment for nausea and vomiting, considering the use of antiemetics such as ondansetron, as discussed in studies by 3, 4, 5, and 6
- Monitor the patient's condition and adjust treatment as necessary to ensure the best possible outcome for both the mother and the fetus
Treatment Options
The patient's symptoms of nausea and vomiting can be treated with antiemetics, such as:
- Ondansetron, which has been shown to be effective in treating nausea and vomiting during pregnancy, as discussed in studies by 3, 4, 5, and 6
- Other antiemetics, such as metoclopramide, promethazine, or prochlorperazine, which may also be effective in treating nausea and vomiting, as discussed in studies by 5 and 6
Fetal Growth and Development
The patient's ultrasound shows 2 intrauterine fetal poles measuring 14 weeks gestation, which is consistent with a normal pregnancy. The study by 2 discusses the importance of fetal biometry and growth assessment in pregnancy, and the use of ultrasound to estimate fetal weight and gestational age. Regular ultrasound scans can help monitor fetal growth and development, and identify any potential issues early on.