Multiple births: Twins and more

Multiple pregnancy means that there are two or more fetuses in the uterus. The babies may be identical or develop from different eggs. Babies that develop from one egg are called monozygotic. This happens when one egg is fertilized by one sperm and then divides into two or more embryos. Experts attribute the reason for the egg dividing into several parts to age, race, or family history.

Identical twins:

• Children of the same sex
• Have the same blood type
• They may have the same body type, skin color, hair color, and eye color, but that doesn't mean they will always look the same. And their fingerprints will also be different.

Children who develop from different eggs are called fraternal or non-identical. This happens when two eggs are fertilized by different sperm. Non-identical twins are born into families where this has happened before. Non-identical twins can:

• be of different sexes
• have different blood types
• be similar or different from each other

What causes multiple pregnancies?

Multiple pregnancy often occurs with artificial insemination or with fertility drugs. When taking fertility drugs, a woman's body can produce multiple eggs, so the chance of fertilizing multiple eggs increases.

In artificial insemination, several eggs are mixed with sperm in a laboratory. After fertilization, several eggs are placed back into the uterus to increase the woman's chances of having a baby.

The possibility of having several children at the same time increases:

• aged 35 or older
• if you have African roots
• if you have had twins before
• with a family predisposition
• when a woman has just stopped taking birth control pills

Multiple Pregnancy: Risk Factors

There is some degree of risk in any pregnancy, but it increases with multiple pregnancies. With multiple pregnancies, the risk increases:

• development of preeclampsia
• development of gestational diabetes
• premature birth (if the baby is premature, the organs may not yet be fully formed, which affects the condition of the lungs, brain, heart and vision);
• miscarriage (a woman may lose one or more children).

The genetic factor also plays an important role, since gene abnormalities provoke the development of birth defects. You should consult a doctor if someone in your family has had children with genetic diseases. There are certain tests that allow you to determine genetic disorders or defects as early as 10-20 weeks of pregnancy. Remember that this may not affect you. Healthy twins are born every day.

How to determine multiple pregnancy?

Only a doctor can say with certainty that you have multiple pregnancies using ultrasound. The monitor shows the number of fetuses and their condition. In case of multiple pregnancies, ultrasound diagnostics are performed more often in order to determine possible signs of fetal developmental disorders and how they grow.

Treatment for multiple births

In case of multiple pregnancy, you should visit the doctor a little more often than usual due to the risk of developing pathologies. During each visit, the doctor will conduct a physical examination, measure blood pressure, prescribe blood and urine tests, and also recommend an ultrasound. Try not to miss these scheduled visits, because in case of problems, you need to start treatment on time.

You have multiple pregnancies. What next?

The idea of having multiple children may seem daunting, but don't be afraid. Use these simple tips to keep yourself and your future children healthy.

Most importantly, take care of yourself. The better your health, the healthier your children will be. During pregnancy, you should:

• visit a doctor regularly
• stick to a healthy diet and eating regimen: eat high-calorie foods with a high content of folic acid, iron and calcium (they are necessary for the healthy development of the child); bread, cereals, meat, milk, cheeses, fruits and vegetables are the best; if you are constantly plagued by nausea and vomiting and you cannot eat normally, consult a doctor;
• don't smoke
• do not use alcohol or drugs
• don't drink coffee
• Do not take any medications, vitamins or herbs without first consulting your doctor.
• discuss with your doctor appropriate types of activity (exercise) that are suitable during pregnancy
• get plenty of rest

After giving birth, you will probably feel extremely tired and think that you will not be able to cope with all your responsibilities. Don’t worry, this is quite normal. Most new mothers feel the same way.

To relieve stress, use the following recommendations:

• ask family members or friends to help you
• rest as often as possible
• attend support groups for young mothers who have given birth to twins; there you will be able to get answers to all your questions
• If depression persists for more than 2 weeks, consult a doctor.

Reduction in the number of developing fetuses in multiple pregnancies

When using artificial insemination, you will need to discuss with your doctor how many embryos to transfer into the fallopian tube. The number of developing fetuses affects the course of the pregnancy and the condition of the babies at birth. If multiple pregnancies are diagnosed, you may be asked to consider reducing the number of developing fetuses to increase the chances of survival of one fetus.

Successful artificial insemination and the risk of multiple pregnancy

Women over 35 need to have more embryos transferred than younger women. The more embryos, the higher the chances of pregnancy and birth of a child. But at the same time, the risk of multiple pregnancy increases. Women over 40 are at risk of losing embryos when their own eggs are fertilized. In this case, donor eggs are used as an alternative. If you are considering artificial insemination and taking fertility drugs, you should definitely consult with your doctor about how to avoid multiple pregnancy, since the decision to reduce the developing fetuses is not easy and painful. Multiple pregnancy is considered a complication of artificial insemination, since the risks for both the mother and the fetuses increase (preeclampsia, miscarriage, premature birth and a number of health problems for children). The more fetuses develop in the uterus, the higher the risk of complications during childbirth.

Fetal reduction in multiple pregnancy is a procedure performed in the first trimester of pregnancy to reduce the number of fetuses when three, four or more fetuses are developing in the uterus. Usually, two are left. The goal of this procedure is to increase the chances of a healthy pregnancy and full-term births. If you are considering fetal reduction during pregnancy, consider the following:

• With each additional fetus in the womb, the risk of disease, death, or disability increases.
• Successful fetal reduction reduces the risk and is aimed at a healthy pregnancy and the birth of a full-term baby.
• The fetal reduction procedure can lead to miscarriage of other fetuses: more than 6 out of 100 cases of triplets end in miscarriage, while 19 out of 100 premature babies in such cases die in the first year of life.
• Early diagnostics (chorionic villus sampling and ultrasound) are aimed at identifying congenital defects of the fetus. This information will help make a decision on fetal reduction in multiple pregnancies.

Medical information

What is fetal reduction in multiple pregnancies?

This is a procedure that reduces the number of developing fetuses (three, four or more), leaving two and increasing their chances of survival.

This procedure is performed in the first trimester between 9-12 weeks of pregnancy, sometimes after genetic testing for signs of birth defects. The most common method of fetal reduction is transabdominal, during which the doctor uses ultrasound monitoring to select the fetus and stops its heartbeat. Vaginal bleeding is sometimes observed, which is considered normal. The dead embryo is absorbed by the mother's body. This process is similar to the spontaneous reduction of one or more fetuses in multiple pregnancies, known as "vanishing twin syndrome".

Benefits of fetal reduction in multiple pregnancies

Family life: Two years after birth, parents of twins reported that their lives were less stressful than parents of triplets.

Maternal health risks: Multiple pregnancies (three or more fetuses) increase the risk of complications such as gestational diabetes, preeclampsia, or anemia, and the risk increases with each additional fetus.

Risk to the health of the fetus. Multiple pregnancies increase the risk of miscarriage, stillbirth, premature birth, and disability. Only half of families who have triplets have healthy children. One third of parents who have quadruplets at the same time have healthy children. To reduce the risk, many doctors recommend fetal reduction in multiple pregnancies, as the procedure prevents miscarriage and increases the chances of having a full-term, healthy baby.

Multiple Pregnancy: Symptoms

With multiple pregnancy, a woman experiences the same symptoms as with a normal pregnancy, but they can appear much earlier and be complicated. With multiple pregnancy, the following is observed:

• early and severe toxicosis in the first trimester
• excessive weight gain
• lower back pain
• large uterus size for gestational age
• increased fetal activity in the second trimester and later

Later observed:

• Varicose veins
• Constipation
• Haemorrhoids
• Difficulty breathing (caused by excessive pressure on the lungs)
• Increased intensity of lower back pain
• Indigestion (due to pressure from the uterus on the stomach)
• Gestational diabetes
• Large belly size
• Preeclampsia (a disorder of blood circulation and pressure that affects the health of the mother and fetus)
• Premature birth

Multiple Pregnancies: Diagnosis and Testing

Previously, women did not even realize that they were carrying twins, triplets or more children until their birth. With the development of ultrasound diagnostics and modern testing, you can find out about multiple pregnancies already in the first or second trimester of pregnancy. Ultrasound can almost accurately show the presence of several fetuses in the uterus. Once multiple pregnancies are confirmed, you will need to undergo ultrasound diagnostics several times during pregnancy so that the doctor can monitor the growth of the fetuses and amniotic fluid. Sometimes, multiple pregnancies are found out after taking tests that were done for another purpose. For example, a high level of human chorionic gonadotropin indicates that a woman is carrying several fetuses.

Tests for Genetic Diseases and Birth Defects Fetuses in multiple pregnancies are at risk for genetic diseases and birth defects.

Testing:

• Chorionic villus sampling. A catheter is inserted through the vagina into the placenta and a small piece of the placenta is suctioned out. This procedure is usually performed between 10 and 12 weeks of pregnancy.
• Amniocentesis is the aspiration of the fluid (amniotic fluid) that the embryo is in while in the uterus by puncturing the amniotic sac through the abdominal wall. It is performed between 15 and 20 weeks of pregnancy, and in some cases at the end of the third trimester of pregnancy, to determine the condition of the baby's lungs just before birth.
• Chorionic villus sampling and amniocentesis have a small risk of miscarriage when testing for multiple pregnancies. Diagnosis of fetuses and mother in multiple pregnancies:
• Blood pressure is measured at each doctor visit for signs of preeclampsia.
• Blood test for signs of anemia (low iron levels in the blood). This problem is very common in multiple pregnancies, as the fetuses use a lot of iron from the mother's body.
• Urine test to detect urinary tract infection.
• Transvaginal ultrasound examination to determine the length of the cervix. A short cervix indicates an increased risk of premature birth.
• In the second trimester, an oral glucose tolerance test is performed for signs of gestational diabetes.
• Electronic fetal heart rate monitoring can be performed before and during labor to determine the health of the unborn baby.

Multiple Pregnancy: Treatment Overview

Always take care of your health during pregnancy. If you are carrying twins or more (multiples), try to eat a balanced, nutritious diet. Make sure you get enough calcium, iron, and folate.

You may gain more weight than you would with a normal single pregnancy. Each additional fetus adds extra pounds. The amount of weight you gain during pregnancy depends on whether you were underweight or overweight before conception.

Caring for a pregnant woman who is at risk

• In case of multiple pregnancy, the pregnant woman needs good care. This will help to avoid complications, but you will need to visit the doctor more often than usual.
• At any stage of pregnancy with multiple pregnancies, complications may develop. These include:
• Miscarriage, premature birth, preeclampsia, gestational diabetes and severe placental dysfunction.
• Spontaneous reduction of one or more fetuses in multiple pregnancies, known as "vanishing twin syndrome", the development of congenital defects and genetic disorders.
• Impaired vision, lung and heart function in a premature newborn.
• Mental retardation in a child, cerebral palsy, learning problems, blindness or deafness (most often develops in children born before 28 weeks).
• The risk of premature birth increases with multiple pregnancies, so plan ahead. Find a doctor and choose a maternity hospital that will perform a cesarean section if necessary and has intensive care.

Multiple Pregnancy: Complications

When three or more fetuses are developing in the uterus, the risk of birth defects or disorders increases with each additional fetus. If you are having triplets or more as a result of taking fertility drugs, your doctor may recommend fetal reduction surgery at the end of the first trimester. Successful fetal reduction increases the chances of having healthy babies, but very rarely causes miscarriage.

The decision to reduce the number of fetuses is not easy and is traumatic for parents. If you are faced with this problem, talk to your doctor about the risks of carrying all the fetuses versus reducing them. Be sure to consult with a psychologist or spiritual mentor. Preterm labor is more common with multiple pregnancies than with normal pregnancies. If labor has begun, your doctor may recommend the following:

• Limit physical activity.
• Go to hospital for observation, take steroids to speed up the maturation of the lungs. In some cases, tocolytic drugs are used (which reduce labor activity), but they have side effects, namely, pulmonary edema in multiple pregnancies.

There is no evidence that bed rest and home observation slow down labor. Talk to your doctor about partial bed rest and reduced activity at home.

Complications in multiple pregnancies:

• Preeclampsia and high blood pressure. Treatment depends on the severity of the condition and your overall health and may include medications, bed rest, fetal monitoring, and preterm delivery.
• Placental dysfunction: premature placental abruption, placenta previa.
• Anemia, for which iron-containing drugs are prescribed. If there is no positive result, additional testing is carried out to identify the causes.
• Large amounts of amniotic fluid in the fetal bladder (polyhydramnios). Treatment involves taking medications and pumping out excess fluid.
• An inflammatory process of the urinary tract, for which antibiotics are prescribed.
• Severe blood loss after childbirth requiring a blood transfusion.
• The need for a caesarean section in case of abnormal fetal positioning (breech presentation).
• Such complications can occur during any pregnancy, but multiple pregnancies significantly increase the risk of their development.

Newborn: Complications

Possible complications include difficult labor, healthy development of one twin and developmental delays in the other, and birth defects.

Complications that may arise in a baby with multiple pregnancies

• Premature births are common in multiple pregnancies. Premature babies usually require intensive care until their health condition stabilizes.
• If a child is born prematurely, its organs are not yet fully formed, which can lead to the development of various diseases, especially children born before 32 weeks are susceptible to this, and the risk increases with each week of prematurity.
• Premature birth can result in disability, which requires special care for children.

Multiple Pregnancy: Treatment at Home

In multiple pregnancies, severe morning sickness may occur in the first trimester of pregnancy, but the woman is hospitalized in case of dehydration and severe vomiting, when she cannot take food and liquids.

Signs of premature labor include:

• cramping pains similar to menstrual pain;
• abdominal pain, possibly accompanied by diarrhea;
• uterine contractions that do not subside for a long time (4 times in 20 minutes or 8 per hour);
• a feeling of pressure in the lower back, especially if it occurs from time to time.
• increased vaginal discharge.

Seek immediate medical attention if you experience symptoms of preterm labor.

Go to the maternity hospital immediately if you experience vaginal bleeding or rupture of the amniotic sac.

General recommendations for multiple pregnancies

• Eat a balanced diet: eat high-calorie foods, take folic acid and calcium for the full development of the fetus.
• Do not smoke, do not drink alcohol, do not drink caffeine, do not take medications without consulting a doctor, do not take chemicals, do not have x-rays, avoid using certain cosmetics, do not overheat (this is usually recommended for any pregnancy)
• Reduce your physical activity. Most doctors recommend stopping exercise after 24 weeks of multiple pregnancy. Talk to your doctor about taking walks in the fresh air and swimming.
• Get plenty of rest, especially after 24 weeks of pregnancy. Research shows that strict bed rest does not prevent premature birth.
• Consider changing your usual work schedule, especially if you are not feeling well. Sometimes your doctor may recommend reducing your activity to a minimum.
• Visit your doctor regularly. From week 20, you will need to see your doctor every two weeks, and after week 30, even more often.

When children are born

Carrying multiple babies and then caring for them at the same time is a very difficult task, which can leave mothers feeling overwhelmed and exhausted. Lack of sleep, increased workload, lack of personal time, and the difficulties of running a household are common among parents who have had multiples. When it comes to caring for newborns, most parents feel guilty because they cannot easily cope with their responsibilities as they used to. This is quite normal. Ask relatives or friends to help you. They can cook, go shopping, do housework, and watch the children when you need a rest. Rest whenever possible during the day.

Feelings of sadness and depression (postpartum depression) are common after the birth of twins. If this condition lasts for more than two weeks or if you experience anxious thoughts, consult a psychologist. It is important to start treatment in time.

Attend support groups for parents who have had twins. Sharing experiences with other parents can help you cope with temporary difficulties.

Breastfeeding. Breastfeeding multiple babies at once is challenging, but it helps you bond with each baby and helps them stay healthy. If you are planning to breastfeed twins, get all the information you need from a lactation specialist or your maternity hospital.

Parenting. Children will develop differently, so you need to help them form their own identity. Spend time with each child, spend time alone and talk about issues that concern you. If there are older children in the family, you should not forget about them, so think about when it is best to meet with them alone.

Loss and Grief

Multiple pregnancies increase the risk of intrauterine fetal death. Regardless of when it happens - early in pregnancy or after birth - give yourself time to grieve and understand the bitterness of loss.