If your doctor has just given you the happy news that you are pregnant with twins or triplets, you may have several questions about multiple pregnancies: How does a pregnancy like this occur? What is the best way to ensure your health and that of your babies? Are there any special steps you need to take to manage a twin pregnancy and carry it to term? What to expect in the delivery room? What to do once the babies are born? And will your babies be identical twins, or will you be able to tell them apart?

Knowing what to expect, including any risks or potential complications along the way, will help you make informed choices for you and your babies. Here is everything you need to know about multiple pregnancies.

  1. Signs you are carrying twins or multiples
  2. Types of multiple pregnancies
  3. What causes a twin pregnancy or a multiple pregnancy?
  4. Diagnosis of a multiple pregnancy
  5. Risks involved in a multiple pregnancy
  6. How to manage a multiple pregnancy: twin baby care during pregnancy
  7. Delivery of twins and higher-order multiple birth babies
  8. Twin care tips and care of multiple birth babies

Your doctor should be able to confirm a twin pregnancy or a multiple pregnancy by ultrasound between the 10th week of pregnancy and the 12th week of pregnancy. But you may start observing some of the signs and symptoms even before that. Here are some signs to look out for:

  • Your uterus is growing faster and bigger than it should in a normal pregnancy.
  • The morning sickness you are experiencing appears to be more severe in nature. (Note: if the nausea and vomiting seem quite excessive, visit a doctor as soon as possible to check for hyperemesis gravidarum during pregnancy - it is a serious condition that causes dehydration and weight loss, and may require hospitalisation.)
  • Your appetite is much bigger than it was before.
  • You have gained too much weight too early in the pregnancy, especially during the first trimester. By way of comparison, a woman pregnant with one baby and a pre-pregnancy body mass index (BMI) between 18.5 and 24.9 will probably gain less than two kilograms in the first trimester. If you have gained more than two kilograms, your doctor might do an ultrasound to check for a twin pregnancy.
  • You are experiencing foetal movements in different parts of your stomach at the same time.

A multiple pregnancy is a pregnancy with two or more foetuses. These multiple pregnancies happen only 3% of the time. In India, "twinning rate" is below nine per 1,000 live births, compared with over 18/1,000 births in several parts of Central Africa, according to one study. That said, Kodinhi, a village in Kerala, has one of the highest birth rates of twins in the world!

The following are the types of multiple pregnancies:

  • Two foetuses: Twins
  • Three foetuses: Triplets
  • Four foetuses: Quadruplets
  • Five foetuses: Quintuplets
  • Six foetuses: Sextuplets
  • Seven foetuses: Septuplets

As the number of foetuses rises, managing the pregnancy gets more difficult, the gestational period - the time the foetuses get inside the mother's womb - reduces, and the risks involved in the pregnancy increase.

A multiple pregnancy can occur in roughly three different ways, depending on how and when the egg or ovum was fertilised.

  • Identical twinning: When a single egg is fertilised and it then splits into two or more embryos, it leads to identical twinning. This mostly occurs with twins and triplets. In these cases, the babies usually share the same genetic identity, are almost always of the same gender (that is, all boys or all girls) and look identical or exactly like each other.
  • Fraternal twinning: If the mother releases multiple eggs at the same time and they are separately fertilised, then it leads to fraternal twinning. This also occurs mostly in the case of twins and triplets. In these cases, the babies do not share the same genetic identity, they can be of the same or different sexes, and they do not necessarily resemble each other.
  • Triplets or more: In the case of three or more foetuses, the babies can be all identical, all fraternal or a mix of both. This usually happens because these multiple pregnancies happened due to a mix of identical and fraternal twinning; multiple eggs are released by the mother and get separately fertilised (fraternal twinning) and then one or more of these eggs split to form more embryos (identical twinning).

Multiple pregnancies occur by a natural process. They just happen, and neither the father nor the mother is particularly or individually responsible for it. The following factors can cause multiple pregnancies:

  • Heredity: If there have been one or more cases of multiple pregnancies in your family, especially in your parents’ or grandparents’ generation, then the occurrence of a multiple pregnancy is likely in your case.
  • Mom-to-be is older than 30: The likelihood of multiple pregnancies increases in women who choose to become moms after 30 years of age.
  • High parity: If you have had one or more pregnancies, including a previous multiple pregnancy, then the chances of your next pregnancy resulting in twins or more babies are higher.
  • Race: While Asian and Native American women have the lowest rates of multiple pregnancies, African-American women have the highest rates. Caucasian women, especially ones above 35 years of age, have the highest rate of higher-order multiple births, that is, triplets or more.
  • Ovulation-stimulating medications: If you have infertility issues and are undergoing treatment for it, then the medications you are on can cause multiple pregnancies. Medicines like clomiphene citrate and follicle stimulating hormone can cause multiple eggs to be formed at the same time, which might get fertilised and result in fraternal twinning.
  • Assisted reproductive technology: Couples or women who are using assisted reproductive technologies to get pregnant, like in vitro fertilisation or IVF, are more likely to have multiple pregnancies. The technology used here involves the fertilisation of eggs in a lab, which are then transferred back into the woman’s body for the gestation period. These technologies also use ovulation-stimulating medications to increase fertility levels, and this could also cause a multiple pregnancy.

If you or your family already have a history of multiple pregnancies, or if you underwent fertility treatment to get pregnant, then your obstetrician may be able to diagnose your multiple pregnancy early on.

You might also suspect that you are carrying more than one baby, based on symptoms like faster and greater weight gain in the first trimester of pregnancy. If this is the case, please ask your doctor to confirm your multiple pregnancy. Your doctor may use one of these methods to make the diagnosis:

  • Beta hCG test: High levels of the human chorionic gonadotropin or hCG can be symptomatic of a multiple pregnancy. The beta hCG test is a type of blood test recommended in the first trimester itself, so you might be able to confirm how many foetuses you have growing inside your womb early on.
  • Alpha-fetoprotein test: The alpha-fetoprotein test is a blood test done to detect a specific type of protein (AFP) produced by the liver of the developing foetus. It usually leaks into the mother’s bloodstream via the placenta. So an AFP test on the mother’s blood can reveal if the AFP levels are too high to be maintaining a single pregnancy.
  • Ultrasound: An ultrasound is the best way to determine the number of foetuses. It is usually first done between the 7th week of pregnancy and the 9th week of the pregnancy, so you can get a confirmation early on and plan your pregnancy accordingly. Your doctor may also be able to hear two/multiple foetal heartbeats in a doppler ultrasound towards the end of your first trimester.

Once it’s confirmed that you are carrying more than one foetus, your first reaction might be happiness or excitement. While you should celebrate a multiple pregnancy, you should also be familiar with the risks involved and plan the rest of your pregnancy accordingly. The following risks are usually involved with multiple pregnancies:

  • Premature labour and birth: Most twins and higher-order multiples are unable to complete 37 weeks of pregnancy, and are born premature. Therefore, they may be smaller, underweight and might also need help breathing, eating, fighting infections and staying warm because their organs and immune systems aren’t fully developed. The higher the number of foetuses, the earlier the birth - so most higher-order multiples need special focus and care in neonatal intensive care units (NICU). 
  • Preeclampsia and pregnancy-induced hypertension: While experiencing nominally high blood pressure is normal in pregnancy, gestational hypertension can be more severe and start early on in the case of a multiple pregnancy. This type of hypertension can also lead to placental abruption and cause nutritional and existential difficulties for the foetuses. Preeclampsia may produce symptoms like headaches, swollen legs and abdominal pain during pregnancy in addition to a spike in blood pressure.
  • Birth defects: The chances of birth defects or abnormalities double in the case of multiple pregnancy babies. The children often have congenital abnormalities like neural tube defects, gastrointestinal defects and heart defects.
  • Anaemia: The chances that the mom-to-be will develop anaemia in pregnancy are doubled during a multiple pregnancy. Your doctor might give you more iron supplements and tailor your diet further to avoid the chances of this happening.
  • Vanishing twin syndrome: This syndrome usually occurs in the first trimester, but its chances are in no way reduced in the subsequent trimesters. Multiple foetuses can be diagnosed in the mother, but after a few days or weeks, one or more can be miscarried. This miscarriage may or may not cause bleeding during pregnancy, so it is more difficult to trace. Therefore, it might seem as if the foetus has simply vanished in the womb.
  • Twin to twin transfusion syndrome: This condition usually only develops in identical twins who share the same placenta. Their blood vessels connect within the placenta and divert blood from one twin to the other, leading to underdevelopment of one or both foetuses.
  • Abnormal amniotic fluid: The amniotic fluid, protected by the amniotic sac, is the environment in which the foetus usually thrives. In the case of a multiple pregnancy, amniotic fluid levels are prone to shooting up or dropping down. This disbalance can cause early labour and other complications.
  • Cesarean delivery: Foetuses in a multiple pregnancy can be positioned in the wrong way, and can require early intervention and a C-section (Caesarean delivery).
  • Postpartum haemorrhage: A larger than usual placenta and over-distended or overgrown uterus are common in a multiple pregnancy, and both of these can cause excessive post-delivery bleeding. If not stopped in time, it can be fatal, too.

Managing a multiple pregnancy needs even more care and precautions than a normal pregnancy. Consult your doctor about the specific precautions and supplements that you need to take. Here are a few things that all parents expecting twins or more babies must take care of:

  • More frequent prenatal visits: You will need to see your doctor more often to keep a track of foetal growth and any complications that might arise. Your doctor will suggest and organise this himself or herself, but you should also keep them informed in case of any uneasiness or new symptoms.
  • You will need to increase your nutritional intake and gain more weight to manage two or more fetuses. Your babies depend on you for nutrition and bodily support, so you need to increase everything from your calories to protein, fibre and vitamin intake. Your iron intake also needs to go up significantly to avoid the risk of anaemia.

Read more: Protein powder during pregnancy

  • You might also need a referral to a perinatologist or maternal-foetal medicine specialist for more frequent tests and ultrasounds. Both maternal and foetal tests need to be conducted more frequently and with better accuracy, so this is very important.
  • Many women carrying multiple foetuses are told to get more bedrest because exhaustion can be acute in this case. Usually, bed rest in the hospital or at home is recommended by the middle of the second trimester to avoid any complications.
  • Tocolytic medications or medicines that prevent premature labour and immature birth might be needed to manage the contractions or to stop them altogether. These are usually given orally, injected or administered intravenously.
  • Lung immaturity is a major problem with premature babies, especially in the case of multiple pregnancies. Corticosteroid medications may be administered to boost this development in your foetuses.
  • Cervical cerclage is a method used to reinforce weak cervixes using sutures or synthetic tape. This might be recommended early in your pregnancy if you are carrying multiple foetuses.

The delivery of multiple birth babies can be quite complicated.

In the case of twins, if both babies are positioned vertex or head first, then normal (vaginal) delivery is possible. If the first baby is positioned vertex, then he or she can be delivered vaginally. If the second baby is not vertex, then the doctor might change its position or deliver it breech (buttocks first) to facilitate vaginal delivery. If vaginal delivery for either or both babies is not possible, or if there are complications, then the doctor will perform a C-section to safely deliver the babies.

Most triplets and higher-order babies are delivered through a C-section.

Because multiple birth babies are mostly prematurely born, they need to be cared for in a neonatal intensive care unit or NICU for the remainder of their gestation. Once they are able to perform all the functions and acquire the immunity levels of a normal baby, they will be discharged and you can take your bundles of joy back home safely.

  • Ask your doctor about the possibility of skin-to-skin contact between the new mom and children in the first hour after birth.
  • Ask family members and hospital staff for help to start breastfeeding your twins and triplets - separately or together, depending on the number you have. Don't lose heart if this is not immediately possible, use a breast pump to store the milk for feedings. If you have triplets or more babies, then it might be best to use a breast pump and consult your doctor on how to manage it.
  • Having twins, triplets and more babies at one go might seem like a fun idea, but it can be an exhausting experience for most parents - especially for the first two months. Enlisting the help of family or friends is a good idea in case you cannot afford an extra pair of helping hands in the form of a full-time nanny or nurse.

References

  1. Stanford Children's Health: Lucile Packard Children's Hospital [Internet], Stanford. USA; Symptoms and Diagnosis of Multiple Pregnancy
  2. Children's Wisconsin [Internet]. Children's Hospital of Wisconsin: Children's Hospital and Health System, Inc. Milwaukee, Wisconsin, USA; Multiple pregnancy
  3. Cleveland Clinic. [Internet]. Cleveland. Ohio; Expecting Twins or Triplets
  4. American College of Obstetricians and Gynecologists. [internet], Bethesda (MD), USA; Multiple Pregnancy
  5. Stanford Children's Health: Lucile Packard Children's Hospital [Internet], Stanford. USA; Overview of Multiple Pregnancy
  6. National Collaborating Centre for Women's and Children's Health (UK). Multiple Pregnancy: The Management of Twin and Triplet Pregnancies in the Antenatal Period.. London: RCOG Press; 2011 Sep. (NICE Clinical Guidelines, No. 129.) 5, General care.
  7. Ri-Na Su, et al. Maternal and neonatal outcomes in multiple pregnancy: A multicentre study in the Beijing population. Chronic Dis Transl Med. 2015 Dec; 1(4): 197–202. PMID: 29063007
  8. Jun Wei, et al. Complications in multiple gestation pregnancy: A cross-sectional study of ten maternal-fetal medicine centers in China. Oncotarget. 2016 May 24; 7(21): 30797–30803. PMID: 27127170
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