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Multiple PregnancyWhat is multiple pregnancy?

Multiple pregnancy is a pregnancy with two or more fetuses.Names for these include the following:

Twins - 2 fetuses Triplets - 3 fetuses Quadruplets - 4 fetuses

Quintuplets - 5 fetuses Sextuplets - 6 fetuses Septuplets - 7 fetuses

While multiples account for only a small percentage of all births(about 3 percent), the multiple birth rate is rising. According to theNational Center for Health Statistics, the twin birth rate has risen59 percent since 1980, and is currently 30.1 per 1,000 live births.The birth rate for triplets and other higher order multiples has alsorisen a staggering 423 percent. However, since 1998, the birth ratefor triplets and higher has slowed.

What causes multiple pregnancy?

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

heredity A family history of multiple pregnancy increases thechances of having twins.

older ageWomen over 30 have a greater chance of multipleconception. Many women today are delaying childbearinguntil later in life, and may have twins as a result.

high parity

Having one or more previous pregnancies, especially amultiple pregnancy, increases the chances of havingmultiples.

race African-American women are more likely to have twinsthan any other race. Asian and Native Americans have thelowest twinning rates. Caucasian women, especially thoseover age 35, have the highest rate of higher-order multiple

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births (triplets or more).

Other factors that have greatly increased the multiple birth rate inrecent years include reproductive technologies, including thefollowing:

Ovulation stimulating medications such as clomiphenecitrate and follicle stimulating hormone (FSH) help producemany eggs, which, if fertilized, can result in multiplebabies.

Assisted reproductive technologies such as in vitrofertilization (IVF) and other techniques help couplesconceive. These technologies often use ovulationstimulating medications to produce multiple eggs which arethen fertilized and returned to the uterus to develop.

How does multiple pregnancy occur?

Multiple pregnancy usually occurs when more than one egg isfertilized and implants in the uterus. This is called fraternal twinningand can produce boys, girls, or a combination of both. Fraternalmultiples are simply siblings conceived at the same time. However,

just as siblings often look alike, fraternal multiples may look verysimilar. Fraternal multiples each have a separate placenta andamniotic sac.

Sometimes, one egg is fertilized and then divides into two or moreembryos. This is called identical twinning and produces all boys, or all girls. Identical multiples are genetically identical, and usuallylook so much alike that even parents have a hard time telling themapart. However, these children have different personalities and are

distinct individuals. Identical multiples may have individualplacentas and amniotic sacs, but most share a placenta withseparate sacs. Rarely, identical twins share one placenta and asingle amniotic sac.

Why is multiple pregnancy a concern?

Being pregnant with more than one baby is exciting and is often ahappy event for many couples. However, multiple pregnancy hasincreased risks for complications. The most common complicationsinclude the following:

preterm labor and birth About half of twins and nearly all higher-order multiples arepremature (born before 37 weeks). The higher the number of fetuses in the pregnancy, the greater the risk for earlybirth. Premature babies are born before their bodies andorgan systems have completely matured. These babiesare often small, with low birthweights (less than 2,500grams or 5.5 pounds), and they may need help breathing,eating, fighting infection, and staying warm. Very

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premature babies, those born before 28 weeks, areespecially vulnerable. Many of their organs may not beready for life outside the mothers uterus and may be tooimmature to function well. Many multiple birth babies willneed care in a neonatal intensive care unit (NICU).

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

anemia Anemia is more than twice as common in multiplepregnancies as in a single birth.

birth defectsMultiple birth babies have about twice the risk of congenital(present at birth) abnormalities including neural tubedefects (such as spina bifida), gastrointestinal, and heartabnormalities. This increased risk is limited to identicaltwins.

miscarriage A phenomenon called the vanishing twin syndrome inwhich more than one fetus is diagnosed, but vanishes (or is miscarried), usually in the first trimester, is more likely inmultiple pregnancies. This may or may not beaccompanied by bleeding. The risk of pregnancy loss isincreased in later trimesters as well.

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

abnormal amounts of amniotic fluid Amniotic fluid abnormalities are more common in multiplepregnancies, especially for twins that share a placenta.

cesarean delivery Abnormal fetal positions increase the chances of cesareanbirth.

postpartum hemorrhageThe large placental area and over-distended uterus placea mother at risk for bleeding after delivery in many multiplepregnancies.

What is multifetal pregnancy reduction?

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

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information.

What are the symptoms of multiple pregnancy?

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

uterus is larger than expected for the dates in pregnancy increased morning sickness increased appetite excessive weight gain, especially in early pregnancy fetal movements felt in different parts of abdomen at same

time

How is multiple pregnancy diagnosed?

Many women suspect they are pregnant with more than one baby,especially if they have been pregnant before. Diagnosis of multiplefetuses may be made early in pregnancy, especially if reproductivetechnologies have been used. In addition to reviewing your medicalhistory and a physical examination, diagnosis may be made by:

ultrasound - a diagnostic imaging technique which useshigh-frequency sound waves and a computer to createimages of blood vessels, tissues, and organs. Ultrasoundsare used to view internal organs as they function, and toassess blood flow through various vessels - with a vaginaltransducer, especially in early pregnancy, or with an

abdominal transducer in later pregnancy. pregnancy blood testing

Levels of human chorionic gonadotrophin (hCG) may bequite high with multiple pregnancy.

alpha-fetoproteinLevels of a protein released by the fetal liver and found inthe mothers blood may be high when more than one fetusis making the protein.

Management of multiple pregnancy:

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

your 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

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your opinion or preference

Management of multiple pregnancy may include thefollowing:

increased nutritionMothers carrying two or more fetuses need more calories,protein, and other nutrients, including iron. Higher weightgain is also recommended for multiple pregnancy. The

American College of Obstetricians and Gynecologistsrecommends women carrying twins gain at least 35 to 45pounds.

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

increased restSome women may also need bed rest - either at home or in the hospital depending on pregnancy complications or the number of fetuses. Higher-order multiple pregnancies

often require bed rest beginning in the middle of thesecond trimester.

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

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

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

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

How are multiple pregnancies delivered?

Delivery of multiples depends on many factors including the fetalpositions, 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 ispossible. If the first fetus is vertex, but the second is not, the firstfetus may be delivered vaginally, then the second is either turnedto the vertex position or delivered breech (buttocks are presentedfirst). Emergency cesarean birth of the second fetus may beneeded. Usually, if the first fetus is not vertex, both babies are

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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 fetusesthat are in abnormal positions, for certain medical conditions of themother, and for fetal distress.

Care of multiple birth babies:

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

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 learntechniques for breastfeeding their babies separately and together,and to increase their milk supply. Mothers whose babies areunable to breastfeed because they are sick or premature can pumptheir breast milk and store the milk for later feedings.

Families with more than one baby need help from family andfriends. The first two months are usually the most difficult aseveryone learns to cope with frequent feedings, lack of sleep, andlittle 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.

Content for the high-risk pregnancy module was reviewed by theEVMS Division of Maternal-Fetal Medicine .

Find an EVMS Division of Maternal-Fetal Medicine physician byclicking here .

Find a Children's Hospital of The King's Daughters physician byclicking here , or call (757) 668-7500 or (800) 395-2453, 8 a.m. to 5p.m., Monday through Friday. You may also e-mail us athealthline@chkd.org .

Important: This information is not intended to substitute or replace the professional medical advice you receive from your child's physician. The content provided on this

page is for informational purposes only, and was not designed to diagnose or treat ahealth problem or disease. Please consult your child's physician with any questions or concerns you may have regarding a medical condition.

Last updated March 2005.

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