Multiple Pregnancy - Specialists and Information on Complications and Prenatal Care

When a woman is pregnant with more than one embryo in her uterus, it is called a multiple pregnancy. Depending on the number of embryos, it is referred to as a twin, triplet, quadruplet, or sextuplet pregnancy.

This can result in identical or fraternal twins:

Identical twins develop from a single fertilized egg (zygote). Both embryos are genetically identical. They are of the same sex. An identical twin pregnancy is also called a monozygotic pregnancy (mono = single).

Fraternal twins develop from two fertilized (different) eggs. Experts refer to this type as a dizygotic pregnancy (di = two). Although both eggs mature in the ovaries at the same time, they originate from two different sperm cells. The twins are genetically different.

One-third of multiple pregnancies are identical (monozygotic) twins. The remaining two-thirds are fraternal (dizygotic) twin pregnancies.

Newborn twin boys @ Vad-Len / AdobeStock

• Dichorionic-diamniotic: Each embryo is in its own amniotic sac (amniotic cavity) with its own amniotic cavity (chorionic cavity). Each twin has its own placenta.
• Monochorionic-diamniotic: The identical twins each have their own amniotic sac (amniotic cavity). They share a common chorionic cavity and a single placenta.
• Monochorionic-monoamniotic: The multiples are located in a shared amniotic sac (amniotic cavity) and a shared chorionic cavity. In this case, the twins may be conjoined (Siamese twins) if the division process does not proceed correctly. This occurs in less than 0.5% of cases of identical twin pregnancies.

Siamese twins @ lunamarina /AdobeStock

 

Each type provides the unborn children with different developmental conditions. Therefore, doctors must closely monitor the pregnancy so they can carefully observe the development of the unborn children.

Multiple pregnancies involving two or more embryos usually result from hormone treatment. The hormones administered as part of fertility treatment stimulate the ovaries more intensely, allowing multiple eggs to mature.

Multiple pregnancies often result from assisted reproductive technologies (in vitro fertilization, IVF, ICSI). Doctors transfer one, two, or a maximum of three fertilized eggs into the expectant mother’s uterus.

The primary goal of fertility treatment is to increase the likelihood of pregnancy. For this reason, doctors and expectant mothers accept the risk of a multiple pregnancy.

Multiple pregnancies are very rare without hormonal support. Natural factors include the mother’s advancing age or a genetic predisposition, such as when the mother herself is a multiple.

• Elevated levels of the pregnancy hormone HCG (human chorionic gonadotropin)
• Morning sickness with vomiting in the first weeks of pregnancy
• Significant weight gain in the first trimester (weeks 1 through 12 of pregnancy),
• A significantly enlarged abdominal circumference, and
• A significantly enlarged uterus. A gynecologist can feel this during a physical exam or detect it via ultrasound.

General prenatal checkups during pregnancy include:

• Checking blood type, hemoglobin levels, and urine
• Regular measurement of body weight, abdominal circumference, and blood pressure (BP)
• Checking the size of the uterus
• Examination of the pelvis and cervix

In multiple pregnancies, the usual pregnancy symptoms occur more intensely:

• Severe nausea with frequent vomiting 
• Fluid retention (congestive edema) and tingling in the legs starting in the 14th week of pregnancy
• Back pain due to weight gain
• Shortness of breath (due to pressure from the multiples on the lungs)
• Strong kicks and jabs against the abdominal wall
• General restlessness and inability to sit still

• Hyperemesis gravidarum: Frequent vomiting
• Preeclampsia: High blood pressure with protein in the urine
• Increased Risk of Preterm Birth: Doctors define a birth that occurs before the 37th week of pregnancy as a preterm birth. Signs of preterm birth include, for example, premature contractions, premature rupture of membranes, or a significantly shortened cervix (cervix uteri) measuring less than 3 centimeters
• Acute or chronic placental insufficiency: Gas exchange and blood flow are inadequate. This can lead to damage to the fetus or fetuses.
• Reduced fetal growth or fetal shrinkage (hypotrophy)
• Neurological damage to the fetus or fetuses: In the event of a reduced supply of oxygen or nutrients
• Miscarriage: When the pregnancy ends before the 23rd or 24th week of gestation. At this stage, the babies are not yet viable. To determine the developmental status of the fetuses following a multiple pregnancy, the initial examinations by a pediatrician are important.
• Feto-fetal transfusion syndrome: Occurs in twin pregnancies when the two fetuses share a single placenta in the womb. The problem with this condition is that blood flow is unevenly distributed between the two fetuses. While one receives too much blood, the other receives too little. Both are harmed. Laser ablation can help in this case. During laser ablation, the blood vessel connections within the placenta are cauterized using a laser. This procedure is risky. Therefore, laser ablation should only be performed at specialized centers.

If the following symptoms occur during a multiple pregnancy, please take them seriously and contact a doctor immediately:

• Contractions: These indicate that labor is about to begin.
• Bleeding: If you experience bleeding, please call emergency services immediately.
• Abdominal pain: You should have this checked by a doctor as soon as possible.
• Fever: Indicates an infection or another complication.
• Severe pain in one or both legs: This may indicate a deep vein thrombosis.
• A decrease in fetal movements: This requires urgent medical evaluation.
• Leakage of amniotic fluid
• Burning pain when urinating: Indicates a urinary tract infection that requires treatment.
• Deterioration in general health due to preeclampsia (high blood pressure and abnormal protein in the urine).
• Signs of eclampsia (seizure)

There is also an increased risk for multiple pregnancies during childbirth.

The following complications may occur:

• A prolonged first stage of labor lasting more than twelve hours.
• Premature placental abruption after the birth of the first twin.
• Umbilical cord prolapse: In which vital blood vessels in the umbilical cord are compressed. This results in oxygen deprivation (hypoxia) in the baby.
• Severe postpartum hemorrhage: caused by reduced contractions of the uterine muscles (uterine atony).

If you are pregnant with multiples, avoid stress and physical exertion. The primary goal of a multiple pregnancy is to maintain the pregnancy for as long as possible. 

Women who go into labor before the 34th week of pregnancy or who suffer from cervical insufficiency (opening of the cervix) are given medications such as tocolytics or corticosteroids. Corticosteroids are medications that accelerate lung maturation in the unborn babies. They are most commonly used in cases of preterm birth.

The birth plan includes all important information about pregnancy and childbirth. It also documents the health status of the unborn babies and that of the mother.

For example:

• Is a natural vaginal birth possible?
• Was pain management administered?
• Is a cesarean section planned?

Since a natural birth is complicated and risky in multiple pregnancies, doctors usually perform a cesarean section (sectio caesarea).