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Multiple Pregnancy

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What is multiple pregnancy?

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Multiple pregnancy is a pregnancy with two or more fetuses. Names forthese 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 3percent), the multiple birth rate is rising. According to the National Centerfor Health Statistics, the twin birth rate has risen 59 percent since 1980,and is currently 30.1 per 1,000 live births. The birth rate for triplets andother higher order multiples has also risen a staggering 423 percent.However, since 1998, the birth rate for triplets and higher has slowed.

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What causes multiple

pregnancy?

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There 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 conception.

Many women today are delaying childbearing until later in life, andmay have twins as a result.

high parityHaving one or more previous pregnancies, especially a multiplepregnancy, increases the chances of having multiples.

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race

African-American women are more likely to have twins than any otherrace. 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 rate in recentyears 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) andother techniques help couples conceive. These technologies often useovulation-stimulating medications to produce multiple eggs which arethen fertilized and returned to the uterus to develop.

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How does multiple pregnancy

occur?

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Multiple pregnancy usually occurs when more than one egg isfertilized and implants in the uterus. This is called fraternal twinning

and 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 more

embryos. This is called identical twinning and produces all boys, orall girls. Identical multiples are genetically identical, and usually lookso much alike that even parents have a hard time telling themapart. However, these children have different personalities and aredistinct individuals. Identical multiples may have individualplacentas and amniotic sacs, but most share a placenta with

separate sacs. Rarely, identical twins share one placenta and asingle amniotic sac.

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Being pregnant with more than one baby is exciting and is often a happyevent for many couples. However, multiple pregnancy has increased risksfor 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 thepregnancy, the greater the risk for early birth. Premature babies are bornbefore their bodies and organ systems have completely matured. Thesebabies are often small, with low birthweights (less than 2,500 grams or 5.5

pounds), and they may need help breathing, eating, fighting infection, andstaying warm. Very premature babies, those born before 28 weeks, areespecially vulnerable. Many of their organs may not be ready for lifeoutside 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).

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pregnancy-induced hypertension

Women 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 chance of placental abruption (early detachment of the placenta).

anemiaAnemia 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 neuraltube defects (such as spina bifida), gastrointestinal, andheart abnormalities.

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miscarriageA phenomenon called the vanishing twin syndrome inwhich more than one fetus is diagnosed, but vanishes(or is miscarried), usually in the first trimester, is morelikely in multiple 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 placentathat develops only with identical twins that share aplacenta. Blood vessels connect within the placentaand divert blood from one fetus to the other. It occursin about 15 percent of twins with a shared placenta.

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abnormal amounts of amniotic fluid

Amniotic fluid abnormalities are more commonin multiple pregnancies, especially for twins thatshare a placenta.

cesarean deliveryAbnormal fetal positions increase the chances of

cesarean birth.postpartum hemorrhage

The large placental area and over-distendeduterus place a mother at risk for bleeding after

delivery in many multiple pregnancies

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What are the symptoms of multiple

pregnancy?

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The following are the most common symptoms of

multiple pregnancy. However, each woman mayexperience symptoms differently. Symptoms of multiple pregnancy may include:

uterus is larger than expected for the dates inpregnancy

increased morning sickness increased appetite

excessive weight gain, especially in early pregnancy

fetal movements felt in different parts of abdomen at

same time

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How is multiple pregnancy

diagnosed?

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Many women suspect they are pregnant with

more than one baby, especially if they have beenpregnant before. Diagnosis of multiple fetusesmay be made early in pregnancy, especially if reproductive technologies have been used. In

addition to a complete medical history andphysical examination, diagnosis may be made by:

pregnancy blood testingLevels of human chorionic gonadotrophin (hCG)

may be quite high with multiple pregnancy.

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alpha-fetoproteinLevels of a protein released by the fetal liver and foundin the mother's blood may be high when more thanone fetus is making the protein.

ultrasound - a diagnostic imaging technique whichuses high-frequency sound waves and a computer tocreate images of blood vessels, tissues, and organs.Ultrasounds are used to view internal organs as theyfunction, and to assess blood flow through variousvessels - with a vaginal transducer, especially in earlypregnancy, or with an abdominal transducer in laterpregnancy.

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Management of multiple

pregnancy:

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

your pregnancy, overall health, and medicalhistory

the number of fetuses

your tolerance for specific medications,procedures, or therapies

expectations for the course of the pregnancy

your opinion or preference

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Management of multiple pregnancy may include thefollowing:

increased nutritionMothers carrying two or more fetuses need morecalories, protein, and other nutrients, including iron.Higher weight gain is also recommended for multiple

pregnancy. The American College of Obstetricians andGynecologists recommends women carrying twins gainat least 35 to 45 pounds.

more frequent prenatal visits (to check forcomplications and to monitor nutrition and weight

gain)

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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 inthe hospital depending on pregnancy complications or thenumber of fetuses. Higher-order multiple pregnancies oftenrequire bedrest beginning in the middle of the secondtrimester.

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

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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 includeterbutaline and magnesium sulfate.

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

babies. cervical cerclage

Cerclage (a procedure used to suture the cervical opening) is usedfor women with an incompetent cervix. This is a condition in whichthe cervix is physically weak and unable to stay closed duringpregnancy. Some women with higher-order multiples may require

cerclage in early pregnancy.

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How are multiple pregnancies

delivered?

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Delivery of multiples depends on many factors includingthe fetal positions, gestational age, and health of motherand fetuses. Generally, in twins, if both fetuses are in thevertex (head-down) position and there are no othercomplications, a vaginal delivery is possible. If the first fetusis vertex, but the second is not, the first fetus may bedelivered vaginally, then the second is either turned to thevertex position or delivered breech (buttocks are presented

first). These procedures can increase the risk for problemssuch as prolapsed cord (when the cord slips down throughthe cervical opening). Emergency cesarean birth of thesecond fetus may be needed. Usually, if the first fetus is notvertex, both babies are delivered by cesarean. Most tripletsand other higher-order multiples are born by cesarean.

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Vaginal delivery may take place in an operating roombecause 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.

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C

areo

f multiple birth

babies:

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Because many multiples are small and born

early, they may be initially cared for in aspecial 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.

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Breastfeeding multiples is certainly possible andmany 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 theirbabies separately and together, and to increase

their milk supply. Mothers whose babies areunable to breastfeed because they are sick orpremature can pump their breast milk and storethe milk for later feedings.

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8/8/2019 dr repport


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