Bogulkunta, Hyderabad - 500 001 Ph : 040 - 40222300 Fax : 040 - 24753482

Email : info@fernandezhospital.com Web : www.fernandezhospital.com

Information for Women

What is a Multiple Pregnancy?

A multiple pregnancy is a pregnancy with two or more babies. The different terms used depend on the number of babies:

Two : Twin Three : Triplets Four : Quadruplets Five : Quintuplets Six : Sextuplets Seven : Septuplets

Multiples account for only a small percentage (3%) of all births, but the multiple pregnancy rate is rising.

Why are Multiple Pregnancies Increasing?

The reason why a woman has a multiple pregnancy may be due to many factors. A few important ones are :

Hereditary : A family history increases the chance of having a multiple

pregnancy.

Maternal Age : About one-third of the increase in multiple pregnancies is due to

the fact that more women over age 30 are having babies. Women in this age group are more likely than younger women to conceive multiples.

Assisted Reproduction : Medicines that stimulate ovulation help produce many eggs,

which if fertilized can result in a multiple pregnancy. In-vitro fertilization, during which eggs are removed from the mother, fertilized in the lab and then transferred to the uterus, result in the transfer of many fertilized eggs into the uterus, thus resulting in a multiple pregnancy.

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Types of Twin Pregnancy

There are two kinds of twins.

Non-identical (dizygotic) : Eighty percent of all twins are non-identical. That means they

come from two eggs with two sperms fertilizing them. These twins are as similar as siblings can be, of the same or different sex. They have their own placenta (dichorionic) and pregnancy sacs (diamniotic) and are called Dichorionic Diamniotic (DCDA )twins. The majority of twins from IVF are from two embryos and are non-identical.

Identical (Monozygotic) : Twenty percent of twins are identical where one egg is fertilized

and then divides into two embryos. These twins are of the same sex, are genetically identical and look alike, but most importantly they share the same placenta (monochorinoic), have separate sacs (diamniotic) and are called Monochorionic Diamniotic (MCDA) twins. Very rarely about 1% of twins may be in the same sac. This is referred to as a Monochorionic Monoamniotic (MoMo) twin pregnancy and carries the highest risk of pregnancy loss.

Why is Multiple Pregnancy a Concern?

Most people think of a pregnancy as a happy occasion and consider it a miracle of life. But if one is expecting twins or triplets, one’s joy is

Dichorionic Diamniotic

Monochorionic Diamniotic

Monochorionic Monoamniotic

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often accompanied by a certain amount of anxiety. Mothers carrying multiple pregnancy have a higher chance of developing complications when compared with those mothers with a single baby.

Nausea and Vomiting : This can be excessive due to higher levels of pregnancy hormones

(Hcg). Other complications include higher chances of miscarriage, which can happen in the first 12 weeks.

Vanishing Twin : Sometimes only one baby is lost during the first trimester of

pregnancy, but this does not affect the development of the remaining baby. The twin gets completely reabsorbed by the mother (vanishing twin) with no symptoms, and the pregnancy continues.

Anemia : This is twice as common in twins than in singletons.

Preeclampsia : Preeclampsia, Pregnancy Induced Hypertension (PIH) and high

blood pressure are all synonymous terms. Twin pregnancies are twice as likely to be complicated by preeclampsia as single pregnancies. Half of triplet pregnancies develop preeclampsia. Frequent prenatal care increases the chance of detecting and treating preeclampsia. Adequate prenatal care also decreases the chance of a serious problem resulting from preeclampsia for both the babies and mother.

Intrauterine Growth Restriction (IUGR) : About half of twins and almost all higher order multiples are

born with low birthweights, less than 2,500 gms. This could be due to pre-term birth or poor fetal growth. Multiple gestations grow at approximately the same rate as a single pregnancy up to a certain point. The growth rate of twin pregnancies begins to

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slow at 30 to 32 weeks. Triplet pregnancies begin slowing at 27 to 28 weeks, while quadruplet pregnancies begin slowing at 25 to 26 weeks. IUGR seems to occur because the placenta cannot any more growth and because the babies are competing for nutrients. The growth of the babies will be monitored with serial growth scans.

Gestational Diabetes: This is more common in these women since most of them are in

the older age group. The increased risk for gestational diabetes in a multiple pregnany appears to be a result of the two placentas increasing the resistance to insulin, increased placental size, and an elevation in placental hormones.

Pre-term Labour : Labour before 37 weeks of pregnancy is called pre-term. More

than 50% of twins, 90% of triplets and all quadruplets are born pre-term. The length of pregnancy decreases with each additional baby. On an average, the mean age for delivery is 35 weeks for twins; 32 weeks for triplets; and 29 weeks for quadruplets.

Post-Partum Haemorrhage : This could occur because of an overdistended uterus and a large

placenta.

Management of Multiple Pregnancy

We recommend the following :

More Frequent Antenatal Visits should be made to check for complications and for monitoring.

Nutritional Needs have to be addressed, since more calories are needed to nourish the growing babies and to also meet the mother’s energy needs.

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More Frequent Fetal Assessment by ultrasound as well as electronic fetal heart monitoring, especially if the twins are monochorionic, small or discordant in growth.

Frequent Assessment of Cervix : Ultrasound / clinical assessments of the cervix may be done at regular intervals for measuring the length, since a short cervical length is found to be associated with a higher chance of premature delivery.

Cervical Cerclage : A procedure used to suture the cervical opening is done only if the cervix is very short or open, but it is not routinely done in all patients with multiple pregnancy.

Restricted Physical Activity : Depending upon complications, one may be advised rest, but staying in bed is not advisable. If a patient goes into pre-term labour, drugs used to stop uterine contractions (Tocolytics) may be advised very judiciously so that delivery can be postponed for a few days at least.

Need for Neonatal Care : Since a majority of these babies are either low-birth weight or premature, they need the highest level of neonatal care.

How are Multiple Babies Delivered ?

Delivery depends on many factors including fetal positions, gestational age and health of the mother and babies. If both the babies are in head down positions and there are no other complications, a vaginal delivery is possible.

Caesarean delivery is for babies who are in abnormal positions, or who are discordant in growth, in higher order multiples like triplets and more.

Vaginal delivery may take place in the operating room because of

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a greater risk of complications, which may require a Caesarean Section.

What is Multi-Fetal Pregnancy Reduction ?

In recent years, a procedure called multi-fetal pregnancy reduction has been used for very high numbers of fetuses, especially four or more. This procedure involves injecting one or more fetuses with medications, causing fetal death. The objective of multi-fetal reduction is to give the remaining fetuses a better chance for survival and health.

A Multifetal Pregnancy Reduction (MFPR) :decreases miscarriage•helps carrying your pregnancy longer•decreases neonatal deaths•improves chances of delivering one or more healthy babies•

RisksThe risks of multifetal pregnancy reduction include miscarriage and premature birth of pregnancies with four or five fetuses. About 5% miscarry after being reduced to twins. The risk of a premature birth is lower in the case of a multifetal reduction than it is for a triplet or more pregnancy.

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Monochorionic Diamniotic TwinsWhat are Monochorionic Twins?

These are twins who come from the same egg, which splits into two and develop into two babies. They share the same placenta are identical and are of the same sex.

Why are We Worried?

In the majority of women, these pregnancies progress normally, but there is a higher risk of problems than with a single pregnancy or with a twin pregnancy where each baby has its own placenta.

The complications which can occur are :

Fetal Growth Restriction Because the babies share the same placenta, there are connections

between the babies’ blood circulation systems. The blood vessels run backwards and forwards between the two halves of the twins’ shared placenta and each baby receives the same amount of blood from the mother.

However, while in some Monochoronic pregnancies the placenta is divided equally between the twins, in approximately 40% of cases one baby has a disproportionately smaller share of placenta. This may result in that baby not growing as well. This is known as fetal growth restriction. In most pregnancies complicated in this way, one twin is small and the other grows normally. This is known as discordant growth. However, in some pregnancies both twins can be small.

Twin-to-Twin Transfusion Syndrome (TTTS)

What is Twin-to-Twin Transfusion Syndrome (TTTS) ?

About 20 percent of identical twins who share a single placenta, 8

develop a complication which is called Twin-to-Twin Transfusion Syndrome.

In TTTS, there are abnormal connecting vessels in the placenta that shunt the blood from one twin (the donor) to the other twin (the recipient). As a result, the donor twin receives very little blood from the shared placenta and the recipient twin may have more blood flow, causing it to grow bigger at the expense of the smaller twin. This also causes the larger twin to produce more urine, which is responsible for an increased amount of fluid around the baby (polyhydramnios).

The smaller twin is the compromised one and shows a decreased amount of amniotic fluid (oligohydramnios). Conversely, the recipient twin receives too much blood from the shared placenta, which is responsible for cardiac overload and failure. TTTS can arise at anytime in pregnancy but most commonly before 22 weeks.

How is TTTS Diagnosed?

TTTS is detected by ultrasonography. Difference in the weights, or their bladder size, or the volume of fluid around each twin, is the basis for diagnosis of TTTS. Monochorionic twins are screened for evidence of TTTS at 16, 19 and 22 weeks. The severity of TTTS ranges from mild to severe.

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Mild TTTS does not require treatment and can be monitored by frequent ultrasound as it may resolve spontaneously. Severe TTTS requires intervention.

How will Your Babies be Monitored?

The detection of TTTS calls for intensive surveillance of both the ba-bies - the recipient for evidence of cardiac failure and the donor for evidence of growth failure. This is done by regular ultrasounds start-ing at 16 weeks and then repeated every 2 – 3 weeks.

Is TTTS Preventable?

Blood vessel connections are formed during the formation of the placenta in early pregnancy and hence TTTS is not preventable.

Is there any Treatment for TTTS?

Severity of TTTS and the duration of pregnancy determine the need for treatment. The aim of management is to prolong pregnancy till the baby is mature enough to survive outside the womb. The large baby is affected by the overload of excess blood and the smaller twin suffers from under-supply of blood. The aim of treatment is to stop the abnormal connection in the placenta between the two babies.

With recent advances, survival rates for severe TTTS have improved. The treatment for TTTS is laser surgery for sealing off the connections in the placenta.

In the absence of laser, amnioreduction is used as a complementary therapy to drain off excess fluid from the recipient twin to improve survival chances. Amnioreduction alone can save up to 64% of affected babies. Removing the excess fluid appears to improve blood flow in the placenta and also reduce the risk of pre-term labor. Laser surgery is a one-step treatment. Amnioreduction may need to be repeated.

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Do All TTTS Twins Need Laser Surgery?

Although laser surgery is a remarkable tool, it is best reserved for severe TTTS or when twin-size difference (discordance) is more than 40%. Laser surgery is an invasive procedure, with its procedure-related risks. Hence these mothers are offered comprehensive therapy for TTTS, which may include amnioreductions, restricted activity, nutrition supplements, a cervical encerclage (stitch) and the option of laser therapy.

What are the potential complications of Twin to Twin Transfusion Syndrome ?

Premature labour either due to ruptured membranes or induction

Respiratory, digestive, heart, or brain defects in the recipient twin because of excess fluids

Donor twin developing anemia Fetal demise / death

Management of Monochorionic Diamniotic Pregnancy

1. The mother will be having a Nuchal scan, between 11 and 13 weeks + 6 days of pregnancy, which is a screening test for Down’s Syndrome.

2. The mother will be monitored closely with regular ultrasound scans every 2–3 weeks from 16 to 24 weeks’ gestation, to check the growth of the babies and for signs of TTTS. This is done by looking at amniotic fluid volumes and blood-flow between the twins. A detailed scan looking at the development of the babies (Anomaly Scan) is performed between 18–22 weeks. This includes a scan that looks at the structure of the babies’ hearts, (Fetal Echo) as Monochorionic twins are at greater risk for heart abnormalities.

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3. After 24 weeks of gestation, ultrasound scans will be performed to monitor fetal growth. These will be at intervals of 2–4 weeks.

4. If there is any discordance in the growth of the babies the mother will require frequent fetal surveillance with weekly visits and measurement of amniotic fluid volumes.

5. Between 32 and 34 weeks there will be a discussion with the Consultant’s Team regarding how the babies will be delivered. The decision is based on the individual circumstances. If the pregnancy has been uncomplicated and both babies are presenting head first, a vaginal delivery may be an option. If there have been problems of any kind or the babies are presenting by the bottom (breech), then a Caesarean Section is the usual choice of delivery.

6. If all is well, the delivery should be prior to 37 weeks gestation.

7. If it looks as though the babies are going to be born prematurely, it is advisable to visit the Neonatal Unit and be seen by the Neonatologist.

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Monoamniotic Twins

Monoamniotic twins are rare, occurring in approximately 1 in 35,000 to 1 in 60,000 pregnancies. The survival rate for Monoamniotic twins is approximately 50%. Complications Associated with Monoamniotic Twins

Cord Entanglement : Cord entanglement is one of the main complications associated with monoamniotic twins. Because the twins have no amniotic membrane separating them, their umbilical cords can easily become entangled. This can hinder fetal movement and development. Additionally, if the twins become tied together in the uterus, one twin may become stuck in the birth canal during labor and delivery, which can be life threatening. Cord entanglement happens, to some degree, in almost all monoamniotic twins. Cord Compression : Cord compression is another life threatening condition common in monoamniotic twins. As the twins move around in the amniotic sac, it is possible that one will compress the other’s umbilical cord. This can prevent vital food supply, oxygen and blood from travelling to the other baby, resulting in fetal death. Twin-to-Twin Transfusion Syndrome (TTTS):Pre-term Birth: All monoamniotic twins are born prematurely. The risk for cord entanglement and compression increases greatly after 34 weeks. For this reason, all Monoamniotic twins are delivered by caesarean section between 32–34 weeks. However, many Monoamniotic twins experience life-threatening complications as early as 26 weeks, and need to be delivered immediately. Pre-term delivery is often associated with a number of life-threatening conditions.

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The patient should have twice-weekly monitoring of fetal heart rate and movement, particularly after the 26th week. After the 28th week, many women enter the hospital so that they can be constantly monitored. Aggressive monitoring can help to lower the risk of fetal death considerably.

The best treatment for Monoamniotic twins is to have regular and aggressive fetal monitoring. The mother should be sure to see a Perinatologist (also called a maternal-fetal medicine specialist) regularly, throughout her pregnancy.

Importance of Wholesome Nourishment for Twin, Triplet Pregnancies

If you are expecting twins or multiples, get ready for some exciting times ahead! Not only can a multiple pregnancy be a very enjoyable and uplifting experience, but you also get to welcome multiple bundles of joy into your family! Of course, being pregnant with twins or multiples can also be very challenging. In particular, you will need to pay close attention to your pregnancy nutrition to be sure that you and your babies are getting all the vitamins, minerals, and energy that you need to stay healthy.

Most importantly weight gain is positively related to birth weight of twin babies. Weight gain is to be consistent through pregnancy with an early weight gain (2 – 4 kgs.) in first trimester and a weekly gain of 0.75 kgs during 2nd and 3rd trimester : The nutritionist will help plan the calorie requirement specific to each patient based on the pre-pregnancy weight and expected weight gain.

A diet rich in good quality protein, iron, folic acid, calcium with optimum calories is recommended for better pregnancy outcomes. The quantity of each meal has to be customized as per calories

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required based on BMI. If the patient is diabetic, hypertensive or suffering with any other medical ailment, diet has to be altered accordingly.

Optimal amount of protein is required to ensure proper growth of the babies and to support changes in the mother. Egg, chicken, fish, soya nuggets, cottage cheese, tofu and nuts need to be taken regularly to meet the increased protein requirement.

Iron deficiency during pregnancy increases maternal anemia and low birth weight in infants. Legumes, dried fruits and green leafy vegetables, fish, chicken, egg contain iron. Fruits rich in Vitamin ‘C’ like amla, guava and citrus fruits improve iron absorption from plant foods.

Optimal Folic acid intake increases birth weight and reduces congenital abnormalities. Green leafy vegetables, legumes, nuts and liver are good sources of folic acid.

In twin pregnancies calcium requirements are very high. Ensure intake of milk, yogurt, tofu, cheese, butter, fish, green leafy vegetables daily.

Choose wholesome nutritious foods like whole grains, fruits, milk, sprouts, rather than processed foods like chocolates, soft drinks, and pastries.

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Why Do You Need A Special Clinic? The earlier one knows that one is carrying more than one baby, the better it is for mother and babies to visit a Special Clinic. There is enough evidence to support the need for special outpatient clinics devoted to these mothers.

The outcome is much better, with these dedicated clinics offering close monitoring and counseling. This approach leads to many benefits for the parents and the babies. The babies of mothers who have been followed by a specialized clinic / team tend to be born closer to term and are larger at birth.

There is a decrease in premature deliveries, and most importantly the Clinic allows parents to meet other such parents, giving them the opportunity to talk and to be more at ease while discussing their experiences. Keeping in mind the rising number of mothers with multiple pregnancy, their special needs and the need for a dedicated clinic, the Twins, Triplets and More Clinic was started at Fernandez Hospital in 2006.

This clinic is a multi-disciplinary clinic with a dedicated Obstetrician, Fetal Medicine Specialist, Nutritionist, Lactation Consultant and an excellent Neonatal Team that provides round-the-clock service and deals with about 120 twin and 10 triplet pregnancies per year. This clinic is the only one of its kind in Andhra Pradesh.

For Queries please email : multiplepregnancy@fernandezhospital.comCell : 8008304318

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Name : _________________________________________________

M. R. No. : _____________________ Age : ____________________

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CoNTACT DETAILS

UNIT 1 – BoGULKUNTA4-1-1230, Bogulkunta Hyderabad – 500001

UNIT 2 – HYDERGUDA 3-6-282, Opp. Old MLA Qrtrs.,

Hyderguda, Hyderabad – 500029

UNIT 3 – JUBILEE HILLS D. No. 8-2-293/82/A/769/1 Plot No. 769, Road No. 44

Jubilee Hills, Hyderabad – 500033

Centralized Tel. No. : Ph : +91 40 40222300Email : info@fernandezhospital.com

Website : www.fernandezhospital.com