multiple pregnancy

Multiple pregnancy

Multiple pregnancyMultiple pregnanciy is a pregnancy with two or more fetuses. Or the term multiple pregnancy is used to describe the development of more than one fetus in utero at the same time. Names for these include the following: Twins - 2 fetuses

Triplets - 3 fetuses

Quadruplets - 4 fetuses

Quintuplets - 5 fetuses

Sextuplets - 6 fetuses

Septuplets - 7 fetuses

Multiple births occur when multiple fetuses are carried during one pregnancy. Twins are the most common type of multiple pregnancies. But worldwide,( Since 1970 ), the incidence of multiple pregnancies of all types - twins, triplets, quadruplets, quinteplets, sextets, and more - is increasing because of more widespread use of assisted reproductive technologies to treat infertility.

Multifetal pregnancies are high-risk pregnancies with numerous associated fetal and neonatal complications. The largest multiple pregnancies on record led to the birth of nine offspring.The clafication of multiple pregnancy is based on:

Number of fetuss twins, triplets, quadruplets etc

Number of placenta - chorionicity

Number of fertilized ova - zygosity

Number of amniotic cavities - amnionicity

Incidence: While multiples account for only a small percentage of all births (about 3 %), the multiple birth rates are rising.

Sign and symptoms of multiple pregnancy

The following are the most common symptoms of multiple pregnancy. However, each woman may experience symptoms differently. Symptoms of multiple pregnancy may include:

uterus is larger than expected (> 4 cm) for the dates in pregnancy

increased morning sickness

increased appetite

excessive maternal weight gain, especially in early pregnancy

fetal movements felt in different parts of abdomen at same time Polyhydramnios, manifested by uterine size out of proportion to the calculated duration of gestation, is almost 10 times more common in multiple pregnancy.

History of assisted reproduction.

Outline or ballottement of uterus more than one fetus.

Simultaneous recording of different fetal heart rates, each asynchronous with the mothers pulse and with each other and varying by at least 8 beats per minute. (The fetal heart rate may be accelerated by pressure or displacement.)

Palpation of one or more fetuses in the fundus after delivery of one infant.

DiagnosisLaboratory Findings Alpha-fetoproteinLevels of a protein released by the fetal liver and found in the mother's blood may be high when more than one fetus is making the protein. The majority of multiple pregnancies are currently identified by using maternal serum alpha-fetoprotein (MSAFP) screening. The hematocrit and hemoglobin values and the red cell count usually are considerably reduced, in direct relationship to the increased blood volume

Glucose tolerance tests demonstrate that both gestational diabetes mellitus and gestational hypoglycemia are much higher in multiple gestations compared with findings in singleton pregnancy. Glucose screening is the standard of care in multiple pregnancy. Pregnancy blood testing: Levels of human chorionic gonadotrophin (hCG) may be quite high with multiple pregnancy. Ultrasound Findings: Ultrasonography is the preferred imaging modality for diagnosis of multiple gestations, and is potentially able to differentiate multiple gestations as early as 4 weeks (by intravaginal probe).

Causes multiple pregnancyThere are many factors related to having a multiple pregnancy. Naturally occurring factors include the following:

HeredityA family history of multiple pregnancy increases the chances of having twins.

Older ageWomen over 30 have a greater chance of multiple conceptions. Many women today are delaying childbearing until later in life, and may have twins as a result.

High parityHaving one or more previous pregnancies, especially a multiple pregnancy, increases the chances of having multiples.

RaceAfrican-American women are more likely to have twins than any other race. Asian and Native Americans have the lowest twinning rates. Caucasian women, especially those over age 35, have the highest rate of higher-order multiple births (triplets or more).

Other factors that have greatly increased the multiple birth rates in recent years include reproductive technologies, including the following:

Ovulation-stimulating medications such as clomiphene citrate and follicle stimulating hormone (FSH) help produce many eggs, which, if fertilized, can result in multiple babies.

Assisted reproductive technologies such as in vitro fertilization (IVF) and other techniques help couples conceive. These technologies often use ovulation-stimulating medications to produce multiple eggs which are then fertilized and returned to the uterus to develop.

How does multiple pregnancy occur?

Multiple pregnancy usually occurs when more than one egg is fertilized and implants in the uterus. This is called fraternal twinning and can produce boys, girls, or a combination of both. Fraternal multiples are simply siblings conceived at the same time. However, just as siblings often look alike, fraternal multiples may look very similar. Fraternal multiples each have a separate placenta and amniotic sac.

Sometimes, one egg is fertilized and then divides into two or more embryos. This is called identical twinning and produces all boys, or all girls. Identical multiples are genetically identical, and usually look so much alike that even parents have a hard time telling them apart. However, these children have different personalities and are distinct individuals. Identical multiples may have individual placentas and amniotic sacs, but most share a placenta with separate sacs. Rarely, identical twins share one placenta and a single amniotic sac.

Complication

Being pregnant with more than one baby is exciting and is often a happy event for many couples. However, multiple pregnancy has increased risks for complications. The effects of multiple pregnancy on the patient include earlier and more severe pressure in the pelvis, nausea, backache, varicosities, constipation, hemorrhoids, abdominal distention, and difficulty in breathing. A large pregnancy may be indicative of twinning (distended uterus).

The most common complications include the following:

Preterm labor and birthAbout half of twins and nearly all higher-order multiples are premature (born before 37 weeks). The higher the number of fetuses in the pregnancy, the greater the risk for early birth. Premature babies are born before their bodies and organ systems have completely matured. These babies are often small, with low birthweights (less than 2,500 grams or 5.5 pounds), and they may need help breathing, eating, fighting infection, and staying warm. Very premature babies, those born before 28 weeks, are especially vulnerable. Many of their organs may not be ready for life outside the mother's uterus and may be too immature to function well. Many multiple birth babies will need care in a neonatal intensive care unit (NICU).

Pregnancy-induced hypertensionWomen with multiple fetuses are more than three times as likely to develop high blood pressure of pregnancy. This condition often develops earlier and is more severe than pregnancy with one baby. It can also increase the chance of placental abruption (early detachment of the placenta).

AnemiaAnemia is more than twice as common in multiple pregnancies as in a single birth.

Birth defectsMultiple birth babies have about twice the risk of congenital (present at birth) abnormalities including neural tube defects (such as spina bifida), gastrointestinal, and heart abnormalities.

MiscarriageA phenomenon called the vanishing twin syndrome in which more than one fetus is diagnosed, but vanishes (or is miscarried), usually in the first trimester, is more likely in multiple pregnancies. This may or may not be accompanied by bleeding. The risk of pregnancy loss is increased in later trimesters as well.

Twin-to-twin transfusion syndromeTwin-to-twin syndrome is a condition of the placenta that develops only with identical twins that share a placenta. Blood vessels connect within the placenta and divert blood from one fetus to the other. It occurs in about 15 percent of twins with a shared placenta. In TTTS, blood is shunted from one fetus to the other through blood vessel connections in a shared placenta. Over time, the recipient fetus receives too much blood, which can overload the cardiovascular system and cause too much amniotic fluid to develop. The smaller donor fetus does not get enough blood and has low amounts of amniotic fluid.

Abnormal amounts of amniotic fluidAmniotic fluid abnormalities are more common in multiple pregnancies, especially for twins that share a placenta.

Cesarean deliveryabnormal fetal positions increase the chances of cesarean birth.

Postpartum hemorrhageThe large placental area and over-distended uterus place a mother at risk for bleeding after delivery in many multiple pregnancies. Management of multiple pregnancy:

Specific management for multiple pregnancy will be determined by your physician based on:

pregnancy, overall health, and medical history

the number of fetuses

your tolerance for specific medications, procedures, or therapies

expectations for the course of the pregnancy

your opinion or preference

Management of multiple pregnancy may include the following:

Increased nutritionMothers carrying two or more fetuses need more calories, protein, and other nutrients, including iron. Higher weight gain is also recommended for multiple pregnancy. The American College of Obstetricians and Gynecologists recommends women carrying twins gain at least 35 to 45 pounds.

more frequent prenatal visits (to check for complications and to monitor nutrition and weight gain)

ReferralsReferral to a maternal-fetal medicine specialist, called a perinatologist, for special testing or ultrasound evaluations, and to coordinate care of complications, may be necessary.

Increased restSome women may also need bedrest - either at home or in the hospital depending on pregnancy complications or the number of fetuses. Higher-order multiple pregnancies often require bedrest beginning in the middle of the second trimester.

Maternal and fetal testingTesting may be needed to monitor the health of the fetuses, especially if there are pregnancy complications.

tocolytic medicationsTocolytic medications may be given, if preterm labor occurs, to help slow or stop contractions. These may be given orally, in an injection, or intravenously. Tocolytic medications often used include terbutaline and magnesium sulfate.

Corticosteroid medicationsCorticosteroid medications may be given to help mature the lungs of the fetus. Lung immaturity is a major problem of premature babies.

cervical cerclageCerclage (a procedure used to suture the cervical opening) is used for women with an incompetent cervix. This is a condition in which the cervix is physically weak and unable to stay closed during pregnancy. Some women with higher-order multiples may require cerclage in early pregnancy.

Twins pregnancyWhen two fetuses simultaneously develop in the uterus, it is called twins pregnancy. It is commonest variety of multiple pregnancy.Types of twins

1. Dizygotic twins: Dizygotic or binovular twins develop from two separate ova that are fertilized by two different spermatozoa, and are often referred to as non identical twins.2. Monozygotic or uniovulartwinsare also referred to as identical twins. They develop from the fusion of one ovum and one spermatozoa , which after fertilization splits in to two identical structures. Determination of zogocity

S.NFeatureUniovularBinovular

1.PlacentaOneTwo

2.

Membrane2amnion, one chorion2 amnion, two chorion

3.SexAlways sameMay differ(either same or different sex)

4Genetic featureSameDiffer

5Follow upUsually identicalNot identical

Causes Idopathic

Heridity

Multiparity

Advancing age of the mother (Above 30)

Assisted reproductive technologies

Iatrogenic (drug used for inductionof ovulation)Sign and symptoms (Same as multiple pregnancy)

Diagnosis

Abdominal examination

Inspection: abdomen is unduly enlarged

Palpation: The height of the uterus is more than the period of amenorrhoea, Palpation of too many fetal parts, Fetal bulkseems disproportionately larger in relation to the size of the fetal head,

The girth of the abdomen at the level of umbilicus is more than the normal average at term.Auscultation: FHS wil be heard in two different areas and difference of heart rate is at least 10 beats/m.General examination:

Prevalance of anaemia is more

Unusual weight gain

Evidence of preeclampsia (25%) is common association.

Internal examination

In some cases, one head is felt deep in the pelvis, while the other one is located by abdominal examination.

Ultrasound or X-rayManagementAntenatal management

Diet: Increased diatery supplement is needed for increased energy supply to the extent of 300kcal/day Increased rest

Supplement therapy eg iron therapy additional vitamins, calcium etc

ANC visit: More frequent

Management during labourFirst stage

Skilled obstetrician should be present

Use of analgesic drugs

Careful fetal monitoring

An intravenous line with RL solution should be set up for any urgent therapy, if required. Obstetrician an pediatrician should be informed.

Avoid early rupture of membrane.Second stageDelivery of first baby

The delivery should be conducted in the same guideline as normal delivery and give episiotomy if necessary

Check presentation

If a vertex presentation, allow labour to progress as for a single vertex presentation.

If breech presentation, apply the same guidelines as for a single breech presentation. If transverse lie, deliver by CS.

Delivery of second baby

Following the birth of the first baby, the lie ,presentation, size and FHS of second baby should be ascertained by examination.

Correct the longitudinal lie by external version Check FHS

Perform vaginal examination to determine if: The cord has prolapsed

The membranes are intact or ruptured

Presentation of other baby

From impact

3rd stage

To minimizethe risk of PPH, follow active management of third stage of labour

Continue the oxytocin drip for at least one hour, following delivery of the second baby

The mother is to be care fully watch for about 2 hours after delivery MECHANISM OF LABORThe ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of all pregnancies.

Definition- The series of movements that occur on the head in the process of adaptation during its journey through narrow and long twisted birth canal and the pelvis is called mechanism of labour.

The ability of the fetus to successfully negotiate the pelvis during labor involves changes in position of its head during its passage in labor. The mechanisms of labor, also known as the cardinal movements, are described in relation to a vertex presentation, as is the case in 95% of all pregnancies. There is mechanism for every presentation and position which can be delivered vaginally. During vaginal delivery the fetal presentation and position will govern the exact mechanism as the fetus responds to external pressures.

There is overlap of these mechanisms. The fetal head, for example, may continue to flex or increase its flexion while it is also internally rotating and descending.

Principles common to all mechanisms are:

Descent takes place throughout.

Whichever part leads and first meets the resistance of the pelvic floor will rotate forwards until it comes under the symphysis pubis

Whatever emerges from the pelvis will pivot around the pubic bone.

At the onset of labour, the commonest presentation is the vertex and the most common position either left or right occipitoanterior; therefore it is this mechanism, which will be described. When these conditions are met, the way that the fetus is normally situated can be described as follows:

The lie is longitudinal.

The presentation is cephalic.

The position is right or left occipitoanterior.

The attitude is one of good flexion.

The denominator is the occiput.

The presenting part is posterior area of the parietal bone.

Although labor and delivery occurs in a continuous fashion, the cardinal movements are described as 9 (different) discrete sequences, as discussed below.2

Engagement

The widest diameter of the presenting part (with a well-flexed head, where the largest transverse diameter of the fetal occiput is the biparietal diameter) enters the maternal pelvis to a level below the plane of the pelvic inlet.Or the fetal head is said to have engaged when the greatest transverse diameter, biparital diameter that is 9.5cm and anterioposterior diameter which varies with the degree of flexion or extension of the head, have crossed the plane of pelvic brim. On the pelvic examination, the presenting part is at 0 station, or at the level of the maternal ischial spines.In primigravida, engagement occurs in a signiment number of cases before the onset of labour while in multiparae, the same may occur in late first with rupture of the membranes.

Descent

It is the downward passage of the presenting part through the pelvis. Descent of the fetal head in to the pelvis often begins before the onset of labour. In primigravida it usually occurs during the latter weeks of pregnancy when engagement of the head provides confirmation that vaginal delivery is probable. Through out labour this occurs intermittently with contractions and retraction. The rate is greatest during the second stage of labor. The head generally enters the pelvis in the transverse and oblique position. The degree of descent is measured by stations.

Factors facilitating descent are uterine contraction and retraction, bearing down efforts and the pressure of amniotic fluid.

HYPERLINK "http://www.brooksidepress.org/Products/Military_OBGYN/Textbook/LaborandDelivery/Labor/Descent.jpg"

Flexion

It is bending movement of fetal head which is normal attitude of the fetus in utero. As the fetal vertex descents, it encounters resistance from the bony pelvis or the soft tissues of the pelvic floor, resulting in passive flexion of the fetal occiput. The chin is brought into contact with the fetal thorax, and the presenting diameter changes from occipitofrontal (11.0 cm) to suboccipitobregmatic (9.5 cm) for optimal passage through the pelvis. This functionally creates a smaller structure to pass through the maternal pelvis. When flexion occurs, the occipital (posterior) fontanel slides into the center of the birth canal and the anterior fontanel becomes more remote and difficult to feel. The fetal position remains occiput transverse.

Internal rotation

During a contraction the leading part is driven downwards onto the pelvic floor.The resistance of this muscular diaphrgm brings about rotation. As the contraction fedes the pelvic floor rebounds, causing the occiput to glide forwards. Resistance is therefore an important diterminant of rotation.The slope of the pelvic floor determines the direction of rotation.In a well flexed vertex presentation the occiput leads and meets the pelvic floor first and rotates anteriourly through one eight of a circle. This causes a slight tuist in the neck of the fetus as the head is no longer in direct alignment with the shoulders. The anterioposterior diameter of the head now lies in the widest (anterioposterior) diameter of the pelvic outlet, facilitating an easy escape. The occiput slips beneath the sub-pubic arch and crowning occurs when the head no longer recedes between contractions and the widest transverse diameter (Biparital ) is born.

Crowning

After internal rotation of the head , further descent occers until the subocciput lies underneath the pubic areh.At this stage, the maximum diameter of the head (biparital diameter) stretches the vulval outlet without any recessionof the head even after the contraction is over, called crowning of the head.

Extension of head

Once crowning has occurred the fetal head can extend, pivoting on the suboccipital region around the pubic bone.Or With further descent and full flexion of the head, the base of the occiput comes in contact with the inferior margin of the pubic symphysis. Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. This release the sinciput, face and chin which sweep the perineum and are born by a movement of extension.The curve of the hollow of the sacrum favors extension of the fetal head as further descent occurs. This is the means that the fetal chin is no longer touching the fetal chest.)

Restitution

It is visible passive movement of the head due to untuisting of the neck sustained during internal rotation. Movement of restitution occurs rotating the head through 1/8 of circle in the direction opposite to that of internal rotation. (When the fetus' head is free of resistance, it untwists about 45 left or right, returning to its original anatomic position in relation to the body.)

External Rotation: It is themovement of rotationof head visible externally due to internal rotation of shoulders. As the anterior shoulder rotate towards the symphysis pubis from the oblique diameter, it carries the head in a movement of external rotation through 1/8th circle in the same direction as restitution. The shoulders now lie in the anterior-posterior diameter.

Expulsion

After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic symphysis. The anterior shoulder is then rotated under the symphysis, followed by the posterior shoulder and the rest of the fetus.

Usually, labor progresses in this fashion, if the fetus is of average size, with a normally positioned head, in a normal labor pattern in a woman whose pelvis is of average size and gynecoid in shape

Internal rotationAs the head descends, the presenting part, usually in the transverse position, is rotated about 45 to anteroposterior (AP) position under the symphysis. Internal rotation brings the AP diameter of the head in line with the AP diameter of the pelvic outlet.

ExtensionWith further descent and full flexion of the head, the base of the occiput comes in contact with the inferior margin of the pubic symphysis. Upward resistance from the pelvic floor and the downward forces from the uterine contractions cause the occiput to extend and rotate around the symphysis. This is followed by the delivery of the fetus' head.

Restitution and external rotationWhen the fetus' head is free of resistance, it untwists about 45 left or right, returning to its original anatomic position in relation to the body.

Expulsion (Birth of shoulders and trunk)After the fetus' head is delivered, further descent brings the anterior shoulder to the level of the pubic symphysis. The anterior shoulder is then rotated under the symphysis, followed by the posterior shoulder and the rest of the fetus. After the shoulder are potioned in anterioposterior diameter of the outlet, further descent takes place until the anterior shoulder escapes below the symphysis pubis first. by a movement of lateral flexion of the spine, the posterior shoulder sweeps over the perineum. Rest of the trunk is then expelled out by lateral flexion.

Pathophysiology

Multiple births include twins and higher-order multiples (eg, triplets, quadruplets). The 2 types of twins are monozygotic and dizygotic.

Dizygotic twins, which sometimes are called fraternal twins, are produced when 2 sperm fertilize 2 ova. Separate amnions, chorions, and placentas are formed in dizygotic twins (see Media file 1). The placentas in dizygotic twins may fuse if the implantation sites are proximate. The fused placentas can be easily separated after birth.

Monozygotic twins develop when a single fertilized ovum splits during the first 2 weeks after conception. Monozygotic twins are also called identical twins. An early splitting (ie, within the first 2 d after fertilization) of monozygotic twins produces separate chorions and amnions (see Media file 1). These dichorionic twins have different placentas that can be separate or fused. Approximately 30% of monozygotic twins have dichorionic/diamniotic placentas.

Later splitting (ie,3-8 d after fertilization) results in monochorionic/diamniotic placentation (see Media file 2). Approximately 70% of monozygotic twins are monochorionic/diamniotic. If splitting occurs even later (ie, during 9-12 d after fertilization), monochorionic/monoamniotic placentation occurs (see Media file 3). Monochorionic/monoamniotic twins are rare; only 1% of monozygotic twins have this form of placentation. Monochorionic/monoamniotic twins have a common placenta with vascular communications between the 2 circulations. These twins can develop twin-to-twin transfusion syndrome (TTTS). If twinning occurs more than 12 days after fertilization, then the monozygotic pair only partially split, resulting in conjoined twins.

Triplets can be monozygotic, dizygotic, or trizygotic. Trizygotic triplets occur when 3 sperm fertilize 3 ova. Dizygotic triplets develop from one set of monozygotic cotriplets and a third cotriplet derived from a different zygote. Finally, 2 consecutive zygotic splittings with one split results in a vanished fetus and monozygotic triplets.

Although the evaluation of the placenta or placentas after the birth is important in all multifetal pregnancies, the examination may not always help determine zygosity, as in the case of monozygotic twins, in which 30% have a dichorionic/diamniotic placentation.

Mortality/Morbidity

Multifetal pregnancies are high-risk pregnancies. The fetal mortality rate for twins is 4 times the fetal mortality rate for single births. The neonatal mortality rate for twins ismore than 5timesgreater than the neonatal mortality rate for single births. Higher-order multiple births have even greater mortality rates than twin and single births.

A high prevalence of low birth weight infants, due to prematurity and intrauterine growth retardation (IUGR) and their associated complications, contribute to this problem. Twins have increased frequency of congenital anomalies, placenta previa, abruptio placenta, preeclampsia, cord accidents, and malpresentations, as well as asphyxia/perinatal depression, group B streptococcal (GBS) infections, hyaline membrane disease (HMD), and TTTS.

Management of multiple pregnancy:


your pregnancy, overall health, and medical history






increased nutritionMothers carrying two or more fetuses need more calories, protein, and other nutrients, including iron. Higher weight gain is also recommended for multiple pregnancy. The American College of Obstetricians and Gynecologists recommends women carrying twins gain at least 35 to 45 pounds.

more frequent prenatal visits (to check for complications and to monitor nutrition and weight gain) Multiple pregnancy increases the risk for complications. More frequent visits may help detect complications early enough for effective treatment or management. The mother's nutritional status and weight should also be monitored more closely. referralsReferral to a maternal-fetal medicine specialist, called a perinatologist, for special testing or ultrasound evaluations, and to coordinate care of complications, may be necessary.

increased restSome women may also need bedrest - either at home or in the hospital depending on pregnancy complications or the number of fetuses. Higher-order multiple pregnancies often require bedrest beginning in the middle of the second trimester.

maternal and fetal testingTesting may be needed to monitor the health of the fetuses, especially if there are pregnancy complications.


corticosteroid medicationsCorticosteroid medications may be given to help mature the lungs of the fetus. Lung immaturity is a major problem of premature babies.


How are multiple pregnancies delivered?

Delivery of multiples depends on many factors including the fetal positions, gestational age, and health of mother and fetuses. Generally, in twins, if both fetuses are in the vertex (head-down) position and there are no other complications, a vaginal delivery is possible. If the first fetus is vertex, but the second is not, the first fetus may be delivered vaginally, then the second is either turned to the vertex position or delivered breech (buttocks are presented first). These procedures can increase the risk for problems such as prolapsed cord (when the cord slips down through the cervical opening). Emergency cesarean birth of the second fetus may be needed. Usually, if the first fetus is not vertex, both babies are delivered by cesarean. Most triplets and other higher-order multiples are born by cesarean.

Vaginal delivery may take place in an operating room because of the greater risks for complications during birth and the need for cesarean delivery. Cesarean delivery is usually needed for fetuses that are in abnormal positions, for certain medical conditions of the mother, and for fetal distress.

Care of multiple birth babies:

Because many multiples are small and born early, they may be initially cared for in a special care nursery called the neonatal intensive care unit (NICU). Once babies are able to feed, grow, and stay warm, they can usually be discharged. Other babies, that are healthy at birth, may need only a brief check in a special care nursery.

Breastfeeding multiples is certainly possible and many mothers of twins and even triplets are successful in breastfeeding all of their babies. Lactation specialists can help mothers of multiples learn techniques for breastfeeding their babies separately and together, and to increase their milk supply. Mothers whose babies are unable to breastfeed because they are sick or premature can pump their breast milk and store the milk for later feedings.

Families with more than one baby need help from family and friends. The first two months are usually the most difficult as everyone learns to cope with frequent feedings, lack of sleep, and little personal time. Having help for household chores and daily tasks can allow the mother the time she needs to get to know her babies, for feedings, and for rest and recovery from delivery.

Care and Management of Multiple Pregnancy


Management of multiple pregnancy:


your pregnancy, overall health, and medical history






increased nutritionMothers carrying two or more fetuses need more calories, protein, and other nutrients, including iron. Higher weight gain is also recommended for multiple pregnancy. The American College of Obstetricians and Gynecologists recommends women carrying twins gain at least 35 to 45 pounds.

more frequent prenatal visitsMultiple pregnancy increases the risk for complications. More frequent visits may help detect complications early enough for effective treatment or management. The mother's nutritional status and weight should also be monitored more closely.

referralsReferral to a maternal-fetal medicine specialist, called a perinatologist, for special testing or ultrasound evaluations, and to coordinate care of complications, may be necessary.

increased restSome women may also need bedrest - either at home or in the hospital depending on pregnancy complications or the number of fetuses. Higher-order multiple pregnancies often require bedrest beginning in the middle of the second trimester.

maternal and fetal testingTesting may be needed to monitor the health of the fetuses, especially if there are pregnancy complications.


corticosteroid medicationsCorticosteroid medications may be given to help mature the lungs of the fetus. Lung immaturity is a major problem of premature babies.


How are multiple pregnancies delivered?

Delivery of multiples depends on many factors including the fetal positions, gestational age, and health of mother and fetuses. Generally, in twins, if both fetuses are in the vertex (head-down) position and there are no other complications, a vaginal delivery is possible. If the first fetus is vertex, but the second is not, the first fetus may be delivered vaginally, then the second is either turned to the vertex position or delivered breech (buttocks are presented first). These procedures can increase the risk for problems such as prolapsed cord (when the cord slips down through the cervical opening). Emergency cesarean birth of the second fetus may be needed. Usually, if the first fetus is not vertex, both babies are delivered by cesarean. Most triplets and other higher-order multiples are born by cesarean.

Click Image to Enlarge

Click Image to Enlarge

Click Image to EnlargeVaginal delivery may take place in an operating room because of the greater risks for complications during birth and the need for cesarean delivery. Cesarean delivery is usually needed for fetuses that are in abnormal positions, for certain medical conditions of the mother, and for fetal distress.

Click Image to EnlargeClick here to view theOnline Resources of Pregnancy & Childbirth

If the cervix is unripe, induction of labour can lead to complications. The Cochrane review in this section suggests that low-dose vaginal misoprostol may be effective for ripening the cervix, although the reviewed studies were not large enough to exclude the possibility of rare but serious adverse events. (For information on induction of labour for improving birth outcomes for women at or beyond term, see under "Prolonged pregnancy" under "Pregnancy complications".)

Induction of labour

- Misoprostol for cervical ripening and induction of labour

USEFUL LINKS

GFMERLink to obstetrics and gynaecology guidelines on the web

Women's Health Specialist LibraryUK NHS knowledge gateway to women's health

MedlinePlus - ChildbirthConsumer information by the National Library of Medicine in the U.S.A.

Corporate links

E-mail scams | RHL access | Acknowledgements | FAQs World Health Organization 2008. All rights reserved

Complications of Multiple Pregnancy


Why is multiple pregnancy a concern?

Being pregnant with more than one baby is exciting and is often a happy event for many couples. However, multiple pregnancy has increased risks for complications. The most common complications include the following:

preterm labor and birthAbout half of twins and nearly all higher-order multiples are premature (born before 37 weeks). The higher the number of fetuses in the pregnancy, the greater the risk for early birth. Premature babies are born before their bodies and organ systems have completely matured. These babies are often small, with low birthweights (less than 2,500 grams or 5.5 pounds), and they may need help breathing, eating, fighting infection, and staying warm. Very premature babies, those born before 28 weeks, are especially vulnerable. Many of their organs may not be ready for life outside the mother's uterus and may be too immature to function well. Many multiple birth babies will need care in a neonatal intensive care unit (NICU).

pregnancy-induced hypertensionWomen with multiple fetuses are more than three times as likely to develop high blood pressure of pregnancy. This condition often develops earlier and is more severe than pregnancy with one baby. It can also increase the chance of placental abruption (early detachment of the placenta).

anemiaAnemia is more than twice as common in multiple pregnancies as in a single birth.

birth defectsMultiple birth babies have about twice the risk of congenital (present at birth) abnormalities including neural tube defects (such as spina bifida), gastrointestinal, and heart abnormalities.

miscarriageA phenomenon called the vanishing twin syndrome in which more than one fetus is diagnosed, but vanishes (or is miscarried), usually in the first trimester, is more likely in multiple pregnancies. This may or may not be accompanied by bleeding. The risk of pregnancy loss is increased in later trimesters as well.

twin-to-twin transfusion syndromeTwin-to-twin syndrome is a condition of the placenta that develops only with identical twins that share a placenta. Blood vessels connect within the placenta and divert blood from one fetus to the other. It occurs in about 15 percent of twins with a shared placenta.

In TTTS, blood is shunted from one fetus to the other through blood vessel connections in a shared placenta. Over time, the recipient fetus receives too much blood, which can overload the cardiovascular system and cause too much amniotic fluid to develop. The smaller donor fetus does not get enough blood and has low amounts of amniotic fluid.

Click Image to Enlarge abnormal amounts of amniotic fluidAmniotic fluid abnormalities are more common in multiple pregnancies, especially for twins that share a placenta.

cesarean deliveryAbnormal fetal positions increase the chances of cesarean birth.

postpartum hemorrhageThe large placental area and over-distended uterus place a mother at risk for bleeding after delivery in many multiple pregnancies.

What is multifetal pregnancy reduction?

In recent years, a procedure called multifetal pregnancy reduction has been used for very high numbers of fetuses, especially four or more. This procedure involves injecting one or more fetuses with a lethal medication, causing fetal death. The objective of multifetal reduction is that by reducing the number of fetuses in the pregnancy, the remaining fetuses may have a better chance for health and survival. Consult your physician for additional information.

Last Update

February 3, 2008

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Amniotic Fluid Problems / Hydramnios /Oligohydramnios

Asthma

Antiphospholipid Syndrome (aPL)

Autoimmune Diseases

Myasthenia Gravis

Systemic Lupus Erythematosus (SLE, or Lupus)

Birth Defects

Bleeding in Pregnancy / Placenta Previa / Placental Abruption

Biophysical Profile (BPP)

Heart Disease

Cholestasis of Pregnancy

Chorioamnionitis

Chorionic Villus Sampling

Doppler Flow Studies

Diabetes

Digestive and Liver Disorders

Ectopic Pregnancy

Fetal Blood Sampling

Fetal Monitoring

Fetal Movement Counting

Genetics

Gestational Diabetes

Group B Streptococcus

HELLP Syndrome

Hepatitis B (HBV)

Herpes

Hyperemesis Gravidarum

Chronic Hypertension

Hypothyroidism

Hyperthyroidism

High-Risk Pregnancy

Intrauterine Growth Restriction (IUGR)

Urinary Tract and Kidney Infections

Listeriosis

Acute Fatty Liver of Pregnancy

Overview of Pregnancy Loss

Pregnancy Loss

The Lungs in Pregnancy

Maternal and Fetal Testing

Maternal and Fetal Infections

Miscarriage

About the Nervous System

Epilepsy

Neurological Conditions

Migraine Headache

Multiple Sclerosis

Nonstress Testing

Nutrition

Online Resources - High-Risk Pregnancy

Pregnancy Over Age 30

Pregnancy Complications

Pregnancy and Medical Conditions

Pregnancy-Induced Hypertension (PIH)

Planning a Pregnancy

Postpartum Hemorrhage

Post-Term Pregnancy

Alcohol and Pregnancy

Preconception Care

Medical Conditions and Pregnancy

Illegal Drug Use and Pregnancy

Medications and Pregnancy

Prenatal Counseling

Risk Factors

Smoking and Pregnancy

Premature Rupture of Membranes (PROM) / Preterm Premature Rupture of Membranes (PPROM)

Preterm Labor

Rh Disease

Sickle Cell Disease

Stillbirth

Thyroid Conditions

Postpartum Thyroiditis

Toxoplasmosis

Types of Genetic Diseases

Ultrasound

Complications of Pregnancy

First Trimester Screening

Second Trimester Prenatal Screening Tests

Glossary

More ... Multiple Pregnancy



Newborn Multiples

Overview of Multiple Pregnancy

Symptoms and Diagnosis of Multiple Pregnancy

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