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Multiple Pregnancies: Twins, Triplets and More

Having a pregnancy with one baby causes enough changes in your life 〞 not to mention your body. It's hard to imagine adding one, or two, or even more to the mix. However, many more women and families in America are managing more multiple pregnancies than ever before. According to the National Center for Health Statistics, the number of twin births increased 74%, and the number of higher order multiples (twins, triplets, quadruplets, etc.) increased 5 fold from 1980 to 2000. Most of this increase is due to women delaying their child bearing years into their 30's, and the rise in fertility treatments. So if you've found us because you feel like you may be giving birth to a small litter, you are not alone. We hope this will begin a safe, enjoyable journey to multiples.

Signs that I might be carrying more than one
♂Rapid weight gain in the first trimester
♂Uterus is larger than expected
♂More severe or intense nausea, vomiting, breast tenderness or other pregnancy symptoms.
♂Higher hCG levels

Complications I may be at risk for
♂Preterm delivery
♂Low birth weight
♂Preeclampsia (high blood pressure)

Special considerations I should be aware of:
♂Early prenatal care is imperative
♂Early increased nutritional intake
♂More frequent trips to your health care provider
♂More ultrasounds may be needed
♂Increased potential for bed rest

Please check back frequently for more detailed information on Multiples in the weeks to come as we add more tips, tools and tricks of the trade. We believe you will find the following links helpful as you begin this amazing journey to multiples.
♂www.twinsmagazine.com
♂www.multiplebirthsfamilies.com
♂www.womenshealthchannel.com/multiplepregnancies/index.shtml
♂www.asrm.org/Patients/FactSheets/complications-multi.pdf
♂www.nomotc.org

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How a multiples pregnancy occurs

How a multiples pregnancy occurs is based on cell division at conception. The numbers of pregnancies that are multiples have increased over the last twenty years. This increase is primarily due to the fact that one third of women who are having babies are over the age of thirty, and these women are more likely to conceive multiples. Another reason for the increase in multiples is due to fertility drugs and fertility procedures. Even with this, there are still two basic types of multiples: identical/monozygotic and fraternal/dizygotic.

What are identical/monozygotic multiples?

Identical/Monozygotic multiples come from a single fertilized egg and are genetically identical. Monozygotic multiples are often referred to as identical twins/multiples. These multiples would all be the same gender and look alike.

How do identical/monozygotic multiples occur?

The occurrence of identical multiples is considered a random event and is not influenced by age, race, or heredity. Identical multiples occur in 3 to 4 of every 1,000 live births.
What are fraternal/dizygotic multiples?

Dizygotic multiples or fraternal multiples, result from multiple eggs that are fertilized by different sperm. These multiples may be the same gender or different genders. This form of multiples would be no more genetically identical than normal siblings.

How do fraternal/dizygotic multiples occur?

The most common type of multiples is fraternal/dizygotic multiples. Dizygotic multiples occur commonly with infertility treatments. The increase of fraternal multiples is also due to the fact that older women are more likely to have multiples, and many women today are conceiving at a later age. Other women who have an increased chance of fraternal multiples include those who have a higher body mass index (BMI), have recently discontinued hormonal birth control, and those who have had more babies.

Which category does higher order multiples (triplets, quadruplets, etc.) fall into?

Higher order multiples (triplets, quadruplets, etc.) are all a variation of identical or fraternal multiples. For example, triplets can be result from one zygote (an egg fertilized by one sperm) dividing into three. This means that the triplets would be genetically identical. Triplets could also occur if one of two zygotes divide in half. This would mean that two of the triplets would be genetically identical while the third child is considered a fraternal multiple. Similar scenarios occur in quadruplets and other forms of multiples.

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Signs & Symptoms of Multiples

Many women suspect that they might be carrying more than one baby, but how can you know for sure. The following indicators may point towards a multiples pregnancy.

Ultrasound Confirmation

This is the only way to know for sure if you are carrying more than one baby. Multiples can be identified in an ultrasound.

∴Doppler Heartbeat Count

Fetal heart sounds may be detected by a Doppler system late in the first trimester. Experienced doctors and midwives may be able to detect multiple heart beats; however, this can be inaccurate since a single pregnancy heartbeat can be detected in several areas of the mother*s abdomen.

∴Elevated hCG Levels

hCG is the hormone that is produced during pregnancy. Women who are carrying multiples may have increased levels of hCG; however, increased levels of hCG does not automatically indicate multiples. Further investigation would need to be done to verify the cause of a high hCG level.

∴Abnormal AFP Test Results

Alphafetoprotein (AFP) Screenings are performed during the second trimester. It is also called the maternal serum screening or the triple marker test and is used to detect certain birth defects. This test measures the amount of a certain protein that is secreted by the fetal liver. Therefore, a multiples pregnancy may give off a positive or high test reading.

∴Measuring Large for Gestational Age

Most doctors and midwives monitor a women*s fundal height (the distance between the top of the pubic bone to the top of the uterus) during pregnancy. This measurement can help indicate the gestational age. Women who are carrying multiples often experience more uterine stretching, and the fundal height may be greater than the actual gestational age. However, there may be other factors that cause this to occur.

∴Weight Gain

There are numerous factors that can cause excessive weight gain, and most are attributed to poor eating habits. The amount of weight a woman should gain depends on her height, body type, and pre-pregnancy weight. On an average, women who are carrying multiples only gain about 10 more pounds than those carrying a single pregnancy.

∴Excessive Morning Sickness

About half of all pregnant women experience some form of morning sickness during their pregnancies. While some mothers of multiples report an increase in the severity of morning sickness, many do not. Just because a woman is pregnant with multiples does not mean that she will experience a double or triple dose of morning sickness.

∴Early or Frequent Fetal Movement

Although controversial within the medical community, some moms of multiples do report that they felt the baby move earlier than expected. It is also important to know that most women do experience earlier movement in subsequent pregnancies than in their first pregnancy.

∴Extreme Fatigue

While this can also be caused by stress, work, and responsibilities, it is also commonly reported by women who are pregnant with multiples. This may be associated with the mother*s body attempting to provide nutrients to more than one baby.
History or Intuition

A multiples pregnancy can run in certain families while some mother*s may have an uncanny intuition that they are pregnant with multiples.

Remember that many of these signs can indicate that something else is going on, and the only way to be 100% positive that you are carrying multiples is through ultrasound confirmation.

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Complications in a Multiples Pregnancy

Of all multiples, twins normally face the fewest medical problems and complications. Each additional baby a woman carries at one time increases the possibility of developing complications.

∴What are the most common complications associated with multiples?
♂Preterm Labor/Delivery
♂Low Birthweight
♂Intrauterine Growth Restriction (IUGR)
♂Preeclampsia
♂Gestational Diabetes
♂Placental Abruption
♂Fetal Demise/Loss
♂Cesarean

∴Preterm Labor/Delivery:

Preterm labor/delivery is defined as delivery before 37 completed weeks of pregnancy. The length of gestation decreases with each additional baby. On average most single pregnancies last 39 weeks, twin pregnancies 36 weeks, triplets 32 weeks, quadruplets 30 weeks, and quintuplets 29 weeks. Almost 60% of twins are delivered preterm, while 90% of triplets are preterm. Higher order pregnancies are almost always preterm. Many times premature labor is a result of preterm premature rupture of the membranes (PPROM). PPROM is rupture of membranes prior to the onset of labor in a patient who is at less than 37 weeks of gestation.

∴Low Birth Weight:

Low birth weight is almost always related to preterm delivery. Low birth weight is less than 5.5 pounds (2,500 grams). Babies born before 32 weeks and weighing less than 3.3 pounds (1,500 grams) have an increased risk of developing complications as newborns. They are at increased risk for having long-term problems such as mental retardation, cerebral palsy, vision loss, and hearing loss.

∴Intrauterine Growth Restriction (IUGR):

Multiple gestations grow at approximately the same rate as a single pregnancy up to a certain point. The growth rate of twin pregnancies begins to slow at 30 to 32 weeks. Triplet pregnancies begin slowing at 27 to 28 weeks, while quadruplet pregnancies begin slowing at 25 to 26 weeks. IUGR seems to occur because the placenta cannot handle any more growth and because the babies are competing for nutrients. Your doctor will monitor the growth of your babies by ultrasound and by measuring your abdomen.

∴Preeclampsia:

Preeclampsia, Pregnancy Induced Hypertension (PIH), Toxemia, and high blood pressure are all synonymous terms. Twin pregnancies are twice as likely to be complicated by preeclampsia as single pregnancies. Half of triplet pregnancies develop preeclampsia. Frequent prenatal care increases the chance of detecting and treating preeclampsia. Adequate prenatal care also decreases the chance of a serious problem resulting from preeclampsia for both the babies and mother.

∴Gestational Diabetes:

The increased risk for gestational diabetes in a multiple pregnancy appears to be a result of the two placentas increasing the resistance to insulin, increased placental size, and an elevation in placental hormones. The occurrence of gestational diabetes in a multiple pregnancy is still being tested at this time. In one study, an increased risk of gestational diabetes did seem to be apparent, but the doctors involved recommended that further testing be conducted.

∴Placental Abruption:

Placental abruption is three times more likely to occur in a multiple pregnancy. This may be linked to the fact that there is an increased risk of developing preeclampsia. It most often occurs in the third trimester, but the risk significantly increases once the first baby has been delivered vaginally.

∴Fetal Demise or Loss:

Intrauterine fetal demise is extremely uncommon. Your healthcare provider will determine whether it is best to expose the other baby(ies) to the fetus that has died or to proceed with delivery. If the pregnancy is dichorionic (two chorions present), then intervention may not be necessary. (The chorion is a membrane that forms the fetal portion of the placenta. Fraternal twins always have two chorions while identical twins can have one or two chorions.) If the pregnancy has a single chorion then fetal maturity will be assessed to see if immediate delivery is achievable. In this situation it would be necessary to evaluate the risks between having a premature baby to the risks of remaining in utero.

∴Cesarean:

If you are pregnant with multiples it does not necessarily mean that you will have a cesarean birth. The common recommendation for the delivery of triplets and higher order multiples is a cesarean, but twins are commonly delivered vaginally. The vaginal delivery of twins depends on the presentation of the babies. Twins can be delivered vaginally when:
♂The gestation is greater than 32 weeks
♂Twin A (the baby closest to the cervix) is the largest
♂Twin A is head down
♂Twin B is head down, Breech, or sideways
♂Twin B is smaller than twin A
♂There is no evidence of fetal distress
♂There is no cephalopelvic disproportion (CPD)

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Twin to Twin Transfusion Syndrome (TTTS)

Twin to twin transfusion syndrome (TTTS) is a serious disorder that occurs in identical twins and higher order multiples who share a placenta. This occurs when there is a connection in the two babies* blood vessels of their shared placenta. This results in one baby (this twin is referred to as the recipient) receiving more blood flow, while the other baby (this twin is referred to as the donor) receives too little. Twin to twin transfusion syndrome is also referred to as chronic intertwin transfusion syndrome.

∴How often does Twin to Twin Transfusion Syndrome occur?

TTTS occurs about 15 percent of the time among identical twins. Fraternal twins are not at risk for this syndrome because they do not share a placenta.
What can I do to make sure my twins do not develop Twin to Twin Transfusion Syndrome?

TTTS is a random event that cannot be prevented by doing or not doing any specific thing. It is not a genetic disorder nor is it a hereditary condition.

∴How is Twin to Twin Transfusion Syndrome diagnosed?

Your healthcare provider may suspect this disorder if any of the following is seen during an ultrasound:
♂Marked difference in the size of fetuses of the same gender
♂Difference in size between the two amniotic sacs
♂Difference in size of the umbilical cords
♂A single placenta
♂Evidence of fluid build up in the skin of either fetus
♂Findings of congestive heart failure in the recipient twin
♂Polyhydraminos (excess amniotic fluid) in the recipient twin
♂Oligohydraminos (decreased or too little amniotic fluid) in the donor twin

∴Does the mother have any signs of Twin to Twin Transfusion Syndrome?

A mother whose twins have TTTS may experience:
♂Sensation of rapid growth of the womb
♂A uterus that measures large for dates
♂Abdominal pain, tightness, or contractions
♂Sudden increase in body weight
♂Swelling in the hands and legs in early pregnancy

∴What treatment options are available for Twin to Twin Transfusion Syndrome?

Up until recently twin to twin transfusion syndrome has claimed the life of both babies, but technology has brought about two new treatment options for this condition. The use of amniocentesis to drain off excess fluid appears to improve the blood flow in the placenta and reduce the risk of preterm labor. Amniocentesis can save approximately 60% of affected babies. Laser surgery can also be used to seal off the connection between the blood vessels and appears to save 60% of affected babies. Delivery is also an option if your healthcare provider determines the twins* lungs have reached maturity.

∴What are the advantages of having laser surgery instead of an amniocentesis?

Amniocentesis may need to be done repeatedly throughout the pregnancy to maintain proper blood flow in the placenta, while laser surgery usually only requires one treatment.

∴What are the potential complications of Twin to Twin Transfusion Syndrome?
♂Premature labor either due to ruptured membranes or induction
♂Respiratory, digestive, heart, or brain defects in the recipient
♂twin because of excess fluids Donor twin developing anemia
♂Fetal demise/death

∴Is there anything else that I need to be aware of if I have been diagnosed with Twin to Twin Transfusion Syndrome?

The Twin to Twin Transfusion Syndrome Foundation recommends that weekly ultrasounds be performed after 16 weeks through the end of the pregnancy to monitor TTTS. They recommend that this be done even if the warning signs of TTTS have decreased.

The TTTS Foundation can be contacted at http://www.tttsfoundation.org/ or at 1-800-815-9211.

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Vanishing Twin Syndrome

Vanishing twin syndrome was first recognized in 1945. Vanishing twin syndrome is when one of a set of twin/multiple fetuses disappears in the uterus during pregnancy. This is the result of a miscarriage of one twin/multiple. The fetal tissue is absorbed by the other twin/multiple, placenta or the mother. This gives the appearance of a ※vanishing twin§.

∴How is Vanishing Twin Syndrome identified?

Before the use of ultrasound, the diagnosis of the death of a member of a multiple pregnancy was made through an examination of the placenta after delivery. Today, with the availability of early ultrasounds, the presence of twins or multiple fetuses can be detected during the first trimester. A follow-up ultrasound may reveal the ※disappearance§ of a twin.

For example, a woman may have an ultrasound at 6 or 7 weeks gestation. The doctor identifies two fetuses and the woman is told she is having twins. When the woman returns for her next visit, only one heartbeat can be heard with Doppler. A second ultrasound is conducted and only one fetus is observed.

Sometimes a woman may have symptoms that would indicate a miscarriage, yet, with an ultrasound, a single baby is found in her uterus.

Vanishing twin syndrome has been diagnosed more frequently since the use of ultrasonography in early pregnancy. A conservative estimate of frequency is that vanishing twin syndrome occurs in 21-30% of multifetal pregnancies.

∴What is the cause of Vanishing Twin Syndrome?

The cause of vanishing twin syndrome is frequently unknown. Abnormalities that result in the vanishing twin appear to be present from early in development rather than from a sudden occurrence. Analysis of the placenta and/or fetal tissue frequently reveals chromosomal abnormalities, while the surviving twin is usually normal. Improper cord implantation may also be a cause.

∴What are the effects of Vanishing Twin Syndrome on the mother and surviving twin?

If the loss occurs within the first trimester, neither the remaining fetus nor the mother has clinical signs or symptoms. The prognosis of the surviving twin is usually excellent, but it depends on the factors that contributed to the death of the other twin. If the twin dies in the second or third trimester, there are increased risks to the surviving fetus. This could include a higher rate of cerebral palsy and a threat to the continuation of the pregnancy.

When a twin dies after the embryonic period of gestation (eight weeks), the water within the twin*s tissues, the amniotic fluid, and the placental tissue may be reabsorbed. This results in the flattening of the deceased twin from the pressure of the surviving twin. At delivery, the deceased fetus may be identified as fetus compressus (compressed enough to be noticed) or as fetus papyraceous (flattened remarkably through loss of fluid and most of the soft tissue).

∴What are the signs of a possible Vanishing Twin Syndrome?

Research indicates more cases in women over the age of 30 years.

Problems will usually begin early in the first trimester. The most common symptoms include bleeding, uterine cramps and pelvic pain.

∴What medical care is recommended for Vanishing Twin Syndrome?

No special medical care is necessary with an uncomplicated vanishing twin in the first trimester. Neither the surviving twin nor the mother would require medical treatment. If the fetal death is in the second or third trimester, the pregnancy may be treated as high-risk. Cerebral palsy may result in the surviving twin.

Pregnant women should seek medical care if they are experiencing bleeding, cramping and pelvic pain. They should be evaluated at a place with ultrasound capabilities. The use of an ultrasound is important to determine that no viable fetus remains before deciding if a D&C might be indicated. The woman can choose to wait for a natural miscarriage in many cases.

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Prenatal Care in a Multiples Pregnancy

Women expecting multiples have many different and unique experiences than those women who are carrying a single pregnancy. Since multiples are at a greater risk of developing complications, your healthcare provider will want to see you more frequently.

∴How often should I expect to visit my healthcare provider?

Your first trimester prenatal schedule may not differ from that of a single pregnancy, however you may discover that your healthcare provider wants to see you every two to three weeks. Once you enter into your second trimester you should expect to have two prenatal visits per month. During the third trimester you should anticipate weekly prenatal appointments. Your healthcare provider may change the amount of appointments based on the health of you and your babies.

∴Why do I need to make more frequent visits?

Women who are having multiples are at a greater risk of experiencing complications during their pregnancy. Frequent prenatal visits allow your healthcare provider to monitor both your health and the health of the babies. This allows for proper prevention, detection, and treatment of any complications that could occur. If complications were to occur then your visits would become even more frequent. Your healthcare provider will determine the exact prenatal schedule that will benefit both you and your babies.

∴What kind of complications will I be monitored for?
The most common complications include:
♂Preterm labor
♂Preeclampsia or pregnancy induced hypertension (PIH)
♂Intrauterine Growth Restriction (IUGR)
♂Fetal well-being
♂Gestational diabetes
♂Fetal demise or loss

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Weight gain with Multiples

You have just discovered that you are carrying a multiple pregnancy. Whether you are ecstatic or shocked and overwhelmed, your head is probably spinning with a million questions at this point. One that may be particularly important at this time is how much weight should you expect to gain during the next several months.

∴Why is weight gain with multiples important?

Eating right and gaining the recommended amount of weight is important in any pregnancy, but this is especially important when carrying more than one baby. This is important because there is a higher risk of preterm labor and low birth weight in a multiples pregnancy. Weight gain is especially important between weeks 20 to 24 of pregnancy. If a mother of twins gains 24 pounds by the 24th week of pregnancy she reduces her chance of preterm labor. Early weight gain is also vital for the development of the placenta which aids in the passing of nutrients to the babies.

∴How much weight should I gain?

Weight gain depends on a number of factors including height, body type, and pre-pregnancy weight. However, most women who are carrying twins are encouraged to gain 35 to 45 pounds. Women carrying triplets are advised to gain 50 to 60 pounds. At this time there is not enough information on quadruplets and quintuplets to suggest any guidelines. Because opinions vary, it is important to discuss your specific weight gain with your healthcare provider who will be most familiar with you specific healthcare needs.

∴How fast should the weight gain occur?

Women carrying twins will only gain 4 to 6 pounds during the first trimester. During the second and third trimester they should expect to gain 1 ½ pounds per week. If you are carrying triplets you should expect to gain 1 ½ pounds per week throughout the entire pregnancy. Once again, because opinions vary, you need to consult with your healthcare provider and keep them informed on your weight gain.

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Safe Exercise during a Multiples Pregnancy

You have been told that you are expecting multiples and that you will need to gain more weight, eat more calories, and possibly expect greater pregnancy symptoms. So, how does this affect your exercise routine? It means that you need to be educated on what is best for both you and your babies.

∴Is exercise safe?

The answer to this question can be extremely confusing. The recommendation for a single pregnancy is 30 minutes or more of moderate exercise a day. However, the American College of Obstetricians and Gynecologists (ACOG) suggest that women carrying multiples refrain from aerobic exercise because of high risks for potential problems. It is best to discuss your desire to stay physically active with your health care provider. If you were physically active before you were pregnant, you will most likely be encouraged to remain active for as long as your health care provider feels it is safe.

∴What exercises can I do?

Once you have received permission from your health care provider you may begin an exercise routine. If you walked daily before your pregnancy there is a good chance that you will be able to continue this for the first half of your pregnancy. Non-weight bearing exercises are often encouraged because they are tolerated better. Other exercises that are considered safe include the stationary bike, arm exercises, and swimming. Many women find the buoyancy of the swimming pool comforting and enjoyable. Pregnancy yoga and Kegel exercises are also recommended.

∴What exercises should I avoid?

You should refrain from doing any exercises that require you to lie flat on your back. Weight training and resistance exercises should also be avoided. You should also refrain from doing any type of exercise if you are running a fever or if it is hot and humid outside. Hot tubs and saunas should be avoided as well.

∴What are the warning signs that I need to stop exercising?
♂Feel like you are having contractions
♂Feel pelvic pressure
♂Experience vaginal bleeding or discharge
♂Feel lightheaded
♂Swelling, especially in your feet

Make sure that you are communicating with your health care provider about your exercise routine throughout your pregnancy.

∴When should I cut back on exercise?

As long as you are feeling healthy and not experiencing any complications, most women who have exercised regularly throughout pregnancy can continue to as long as they feel comfortable. Some healthcare providers encourage women to cut back on exercise at 20 weeks (singleton pregnancies cut back at 28 weeks). Obviously if you are experiencing complications that require partial or total bed rest, this would occur even sooner. The best thing to do is to discuss your exercise options and desires with your prenatal care provider.

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Multiple Pregnancy: Twins or More - Topic Overview

∴What is a multiple pregnancy?

A multiple pregnancy means that a woman has two or more babies in her uterus. These babies can come from the same egg or from different eggs.

Babies that come from the same egg are called identical. This happens when one egg is fertilized by one sperm. The fertilized egg then splits into two or more embryos. Experts think that this happens by chance. It isn't related to your age, race, or family history.

If the babies you're carrying are identical, they:
♂Are either all boys or all girls.
♂All have the same blood type.
♂Probably will have the same body type and the same color skin, hair, and eyes. But they won't always look exactly the same. They also won't have the same fingerprints.

Babies that come from different eggs are called fraternal. This happens when two or more eggs are fertilized by different sperm. Fraternal babies tend to run in families. This means that if anyone in your family has had fraternal babies, you're more likely to have them too.

If the babies you're carrying are fraternal, they:
♂Can be both boys and girls.
♂Can have different blood types.
♂May look different from each other or may look the same, as some brothers and sisters do.

∴What causes a multiple pregnancy?

If you take fertility drugs or have in vitro fertilization to help you get pregnant, you're more likely to have a multiple pregnancy.

Fertility drugs help your body make several eggs at a time. This increases the chance that more than one of your eggs will be fertilized.

In vitro fertilization is the most common kind of assisted reproductive technology used to help women get pregnant. Several of your eggs are mixed with sperm in a lab. When the eggs are fertilized, they're put back inside your uterus. The doctor puts in several fertilized eggs to increase your chances of having a baby. But this also makes a multiple pregnancy more likely.

You're also more likely to have more than one baby at a time if:
♂You're age 35 or older.
♂You're of African descent.
♂You've had fraternal babies before.
♂Anyone on your mom*s side of the family has had fraternal babies.
♂You've just stopped using birth control pills.

∴What are the risks of a multiple pregnancy?

Any pregnancy has risks. But the chance of having serious problems increases with each baby you carry at the same time.

If you're pregnant with more than one baby, you're more likely to:
♂Develop a problem that causes your blood pressure to get too high (preeclampsia).
♂Develop a type of diabetes that can occur while you're pregnant (gestational diabetes).
♂Deliver your babies too early. When babies are born too early, their organs haven't had a chance to fully form. This can cause serious lung, brain, heart, and eye problems.
♂Have a miscarriage. This means that you may lose one or more of your babies.

There is also a greater chance that one or more of your babies may be born with a disease that is caused by a bad gene or group of genes. If you or anyone in your family has had a child with a disease that is linked to a gene change, let your doctor know. There are tests that you can have between 10 and 20 weeks of your pregnancy that can tell if your babies are at risk for certain genetic disorders or birth defects.

Keep in mind that these problems may or may not happen to you. Every day, women who are pregnant with more than one baby have healthy pregnancies and have healthy babies.

∴How can you tell if you're carrying more than one baby?

While you may feel like you're carrying more than one baby, only your doctor can say for sure. He or she will do a fetal ultrasound to find out. This test can give your doctor a clear picture of how many babies are in your uterus and how well they're doing.

If the test shows that you're carrying more than one baby, you'll need to have more ultrasounds during your pregnancy. Your doctor will use these tests to check for any signs of problems that your babies may have as they grow.

∴What type of treatment will you need?

If you're pregnant with more than one baby, you'll need to see your doctor more often than you would if you were having just one baby. This is because you and your babies have a greater chance of developing serious health problems.

Your doctor will do a physical exam at each visit. It*s important that you go to every appointment. Your doctor may also do a fetal ultrasound, check your blood pressure, and test your blood and urine for any signs of problems. Early treatment can help you and your babies stay healthy.

∴You're having multiples. Now what?

The thought of having more than one baby may be scary, but it doesn't have to be. There are some simple things you can do to keep you and your babies healthy.

The best thing you can do is take care of yourself. The healthier you are, the healthier your babies will be.

While you're pregnant, be sure to:
♂Go to every doctor*s appointment.
♂Eat a healthy diet. Take in plenty of calories from foods rich in folic acid, iron, and calcium. These nutrients are essential for the healthy growth of your babies. Breads, cereals, meats, milk, cheeses, fruits, and vegetables are all good choices. If you're not able to eat enough because of severe morning sickness, call your doctor.
♂Don't smoke, drink alcohol, or use illegal drugs.
♂Avoid caffeine.
♂Avoid using any medicines, vitamins, or herbs unless your doctor says it*s okay.
♂Talk to your doctor about what activities are okay for you to do while you're pregnant.
♂Get a lot of rest.

After your babies are born, you may feel overwhelmed and tired. You may wonder how you're going to do it all. This is normal. Most new moms feel this way at one time or another.

Here are some things you can do to ease the stress:
♂Ask your family and friends for help.
♂Rest as often as you can.
♂Join a support group for moms with multiples. This is a great place to share your concerns and hear how other moms cope with the demands of raising multiples.
♂If you feel sad or depressed for more than 2 weeks, call your doctor.

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Multiple Pregnancy: Twins or More - Symptoms

If you are pregnant with more than one fetus, you can expect to have the same symptoms as those of a pregnancy with one fetus (called a singleton pregnancy). But the symptoms may happen earlier and may be worse. A multiple pregnancy is likely to cause:
♂Early and excessive nausea and vomiting in the first trimester.
♂Extra weight gain.
♂Backache.
♂A uterus that is larger than expected for your due date.
♂More fetal movement than expected during the second trimester and later.

Later in the pregnancy, you are more likely to have:
♂Varicose veins.
♂Constipation.
♂Hemorrhoids.
♂Increasing backache.
♂Difficulty breathing (caused by pressure on the lungs from the uterus pushing up on the diaphragm).
♂Indigestion (caused by pressure on the stomach from the large uterus).
♂A very large abdomen.
♂Gestational diabetes.
♂Preeclampsia, a serious disorder of circulation and blood pressure that affects both mother and fetuses.
♂Preterm labor.

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Multiple Pregnancy: Twins or More - Exams and Tests

In years past, women often had no idea that they were carrying twins until the end of pregnancy or the actual childbirth. Since the development of better tests, most multiple pregnancies are now identified during the first or second trimester.

A fetal ultrasound can show whether there is more than one fetus in the uterus. If you have more than one fetus, you will have an ultrasound several times during the pregnancy to monitor fetal growth and amniotic fluid.

Sometimes, the first sign of a multiple pregnancy is from a test that was done for another reason. For example, a very high level of human chorionic gonadotropin (hCG), the "pregnancy test" hormone, can be a sign of multiple pregnancy.
Tests used to check for genetic disorders and birth defects

Fetuses in multiple pregnancies have an increased risk of genetic disorders and birth defects.

Test options include:
♂Chorionic villus sampling (CVS). It uses a tiny piece of the placenta, taken by passing a thin tube through your vagina and cervix and into the uterus. The sampling and genetic testing are done between 10 and 12 weeks of pregnancy.
♂Amniocentesis, which uses a small amount of amniotic fluid, taken by inserting a needle into your abdomen and uterus. The sampling and genetic testing are usually done between 15 and 20 weeks of pregnancy. (Amniocentesis is also sometimes used in the last trimester to see whether the fetuses' lungs are mature enough to breathe well after delivery.)

CVS and amniocentesis have the same slight miscarriage risk when used to test a multiple pregnancy. You may want earlier CVS results if you have to make decisions about treating or continuing a pregnancy.

Tests used to monitor the fetuses and mother during a multiple pregnancy:
♂Blood pressure checks at every prenatal appointment are used to monitor you for high blood pressure or preeclampsia.
♂Blood testing is used to check you for low iron (anemia). Anemia is a common problem for women with multiple pregnancy, because the fetuses use a great amount of the mother's iron stores.
♂A urine test and urine culture can be used to screen you for a urinary tract infection (UTI).
♂Transvaginal ultrasound may be used to check the length of your cervix. A short cervix is a sign of an increased risk of preterm labor.
♂In the second trimester, you may have an oral glucose screen to check for gestational diabetes.
♂Electronic fetal heart monitoring may be used before or during delivery, to make sure the fetuses are doing well.

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Multiple Pregnancy: Twins or More - Treatment Overview

Always be sure to take extra good care of yourself when you are pregnant. When carrying twins or more (multiple pregnancy), be sure to eat a balanced and nutritious diet of quality calories. And make sure that you get enough calcium, iron, and folic acid.
You can expect to gain weight more quickly than you would with one fetus. With each additional fetus a woman carries, her range of weight gain will increase.

Your range of healthy weight gain will be different if you started your pregnancy underweight or overweight.
High-risk pregnancy care

If you are pregnant with twins or more, good prenatal care will help you and your health professional prevent and watch for problems. You will have more frequent checkups than you would for a pregnancy with one fetus.

Complications can occur at any time during and after a multiple pregnancy. These include medical complications that:
♂Affect the mother and fetuses, such as miscarriage, preterm labor and/or preterm birth, preeclampsia, gestational diabetes, and serious placenta problems.
♂Affect the fetuses before birth, such as vanishing twin syndrome, twin-to-twin transfusion, and a higher risk of disability and genetic disorders.
♂Affect the newborns because of premature birth, such as lung, brain, heart, and eye problems.
♂Result in long-term disability for the babies. These can include mental retardation, cerebral palsy, learning disabilities, blindness, or deafness. These are most likely among babies born before 28 weeks.

Because you are more likely to deliver early, be sure to plan ahead. Ask your health professional about making arrangements to deliver at a specially equipped hospital. Such a hospital has facilities for emergency cesarean delivery and a neonatal intensive care unit (NICU).

Early pregnancy decisions about triplets or more

When there are three or more fetuses in the uterus, their risks of disability or death are higher with each additional fetus. If you are carrying triplets or more after infertility treatment, your doctor may offer the option of multifetal pregnancy reduction (MFPR) near the end of your first trimester. A successful MFPR increases the chances of healthy survival for the remaining fetuses and reduces risks to you. But MFPR sometimes leads to miscarriage.

The decision to have a multifetal pregnancy reduction is difficult and traumatic. If you are faced with this decision, talk to your doctor about your personal risks from trying to carry multiple fetuses to term compared to the risks of choosing MFPR. Also consider discussing your decision with a counselor or spiritual advisor.

Multiple pregnancy: Should I have a multifetal pregnancy reduction?

Preterm labor is more common in a multiple pregnancy than in a pregnancy with one fetus. If you go into preterm labor and premature delivery is likely, your health professional may recommend taking one or more precautions, such as:
♂Limiting your activity level.
♂Staying in the hospital. This is often so that you can receive steroid medicine to help your babies' lungs develop faster. In some cases, tocolytic medicine is used in an attempt to delay preterm birth. You are closely watched if you are treated with a tocolytic medicine. Complications of some tocolytics, such as pulmonary edema, are more common when you are carrying twins or more.

There is no evidence that bed rest and home labor monitoring can prevent premature labor.1 But they still are sometimes done. Talk to your doctor about whether partial bed rest and reduced activity might work well for you. See the topic Preterm Labor for more information.

Possible pregnancy problems that can be more likely when you are carrying twins or more include:
♂Preeclampsia and high blood pressure. Treatment depends on how severe your condition becomes. It may include medicine, bed rest, fetal monitoring, and early delivery. For more information, see the topic Preeclampsia and High Blood Pressure During Pregnancy.
♂Problems with the placenta, such as placenta abruptio or placenta previa. For more information, see the topics Placenta Abruptio and Placenta Previa.
♂Anemia, which is treated with iron-rich foods and iron supplements. If this doesn't help, you can be tested for other problems that can cause anemia.
♂Too much amniotic fluid in the uterus (polyhydramnios). Treatment can include medicine and removal of amniotic fluid.
♂Urinary tract infection (UTI), which is treated with antibiotics.
♂Heavy blood loss after delivery (postpartum hemorrhage), which can require a blood transfusion.
♂The need to deliver by cesarean section (C-section). This is usually the case when fetuses are not turned head-down in time for birth (breech or transverse fetus ).

Any pregnancy can have these complications, but there is more concern about them happening during a multiple pregnancy.

Fetal complications

Possible complications that can affect multiple fetuses during pregnancy include labor complications, the healthy growth of one twin and poor growth of the other twin, and birth defects.

Infant complications

Giving birth early, called premature birth, is common in multiple pregnancies. Premature newborns usually need care in a neonatal intensive care unit (NICU) until they are mature and well enough to go home.

When born too early, a premature infant's major organs are not fully developed. This can cause health problems. Although any premature infant has some increased risk of medical complications, those who are born before 32 weeks of pregnancy have a higher risk. This risk increases with each additional week of prematurity.

Long-term disability resulting from premature birth requires specialized care over time. For more information, see the topic Premature Infant.

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Multiple Pregnancy: Twins or More - Home Treatment

A multiple pregnancy can make morning sickness worse during the first months of pregnancy. You can treat your symptoms at home, unless you have become dehydrated or are not getting enough to eat because of vomiting.

∴Pregnancy: Dealing with morning sickness

Learn the signs of early labor. They include:
♂Cramping similar to menstrual cramps.
♂Abdominal cramps, possibly with diarrhea.
♂Contractions of your uterus that don't go away, about 4 or more in 20 minutes or about 8 or more within 1 hour.
♂Pressure in your lower back, especially if it comes and goes.
♂An increase in your usual amount of vaginal discharge.

Call your health professional immediately if you have symptoms of early labor.

Call your health professional or go to the hospital if you begin bleeding from the vagina or if your water breaks.

∴Self-care for multiple pregnancy

If you are pregnant with twins or more, you will be advised to:
♂Make sure that you are taking in enough nutritious calories, folic acid, iron, and calcium to nourish you and your fetuses.
♂Avoid alcohol, smoking, caffeine, most medicines, chemicals, X-rays, some cosmetic products, getting too hot, and eating contaminated food. All of these precautions are advised for any pregnancy. For more information, see the topic Pregnancy.
♂Reduce your physical activity. Most doctors will recommend that you stop physically demanding exercise after 24 weeks of a multiple pregnancy. Talk to your doctor about walking or swimming.
♂Get plenty of rest, especially after the 24th week of pregnancy. Studies show that strict bed rest does not prevent early (premature) delivery in multiple pregnancies.1
♂Consider whether you need to change your daily work activities, based on how well your pregnancy is going. Be sure to follow any advice to reduce your activity level.
♂See your health professional often. Beginning in the 20th week of pregnancy, you may be checked every other week. Beginning at the 30th week, you may be checked more often.

For more information on what to expect during pregnancy, labor, and childbirth, see the topic Pregnancy.

∴After the babies are born

Coping. Having a multiple pregnancy and caring for two or more infants at the same time can be overwhelming and exhausting. Lack of sleep, the increased amount of work, less personal time, and difficulty maintaining the home are common sources of frustration for parents of multiple infants.

With multiple newborns to care for, it is common to feel frustrated or guilty about not managing your life as easily as before. This is normal. Get extra help for as long as possible after your babies are born. Rest as often as you can during the day. Accept help from friends and family. They can bring meals, go grocery shopping, do household chores, or care for your children while you take some time for yourself.

Feeling sad or depressed (postpartum blues or postpartum depression) is more common after delivering twins or more.3 If you feel depressed for longer than 2 weeks or if you have troubling or dangerous thoughts, see your health professional. It is important that you get treatment. For more information, see the topic Postpartum Depression.

∴Depression: Managing postpartum depression

Consider joining a support group for parents of twins or more. Sharing your experience with other people who are in a similar situation may help you with the demands of caring for your babies. For more information, see the Other Places to Get Help section of this topic.

Breast-feeding? Breast-feeding more than one baby can be challenging, but it helps to build the bond between you and each baby. It gives your babies excellent health benefits. If you plan to breast-feed your babies, seek out support and information from your health professional, the hospital, or a lactation consultant before and after the birth. For more information, see the Other Places to Get Help section of this topic and the topics Breast-Feeding and Bottle-Feeding.

Parenting. Look for your new babies' personality differences and help them build their own identities over time. Give each of your children time alone with you. If you have an older child or children, schedule individual time with them too.
Loss and grieving

Multiple pregnancy increases the risk of fetal death. Whether early in pregnancy or after birth, if one or more of your infants die, you and your family will need time to grieve.

Your hospital can help you contact support groups for grieving parents. Talking about your loss with friends, a spiritual advisor, or a counselor may also help. For more information on grief support, see the Other Places to Get Help section of this topic and the topic Grief and Grieving.

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Multiple Pregnancy: Twins or More - Other Places To Get Help
Organizations

∴American College of Obstetricians and Gynecologists (ACOG)
409 12th Street SW
P.O. Box 96920
Washington, DC20090-6920
Phone: (202) 638-5577
E-mail: [email protected]
Web Address: www.acog.org

American College of Obstetricians and Gynecologists (ACOG) is a nonprofit organization of professionals who provide health care for women, including teens. The ACOG Resource Center publishes manuals and patient education materials. The Web publications section of the site has patient education pamphlets on many women's health topics, including reproductive health, breast-feeding, violence, and quitting smoking.

∴American Pregnancy Association
1425 Greenway Drive
Suite 440
Irving, TX75038
Phone: 1-800-672-2296
Fax: (972) 550-0800
E-mail: [email protected]
Web Address: www.americanpregnancy.org

The American Pregnancy Association is a national health organization committed to promoting reproductive and pregnancy wellness through education, research, advocacy, and community awareness. You can call a toll-free helpline or use the Web site to request patient education materials.

∴American Society for Reproductive Medicine
1209 Montgomery Highway
Birmingham, AL35216-2809
Phone: (205) 978-5000
Fax: (205) 978-5005
E-mail: [email protected]
Web Address: www.asrm.org

This organization provides literature and information on infertility.

∴La Leche League International (LLLI)
P.O. Box 4079
Schaumburg, IL60168-4079
Phone: 1-800-LA-LECHE (1-800-525-3243)
(847) 519-7730
Fax: (847) 969-0460
TDD: (847) 592-7570
Web Address: www.llli.org

La Leche League International (LLLI) offers information and encouragement-mainly through personal help-to all mothers who want to breast-feed their babies. It also offers support and information about breast-feeding babies with various disabilities, such as cleft lip or cleft palate. Call for information about a chapter in your area.

∴National Organization of Mothers of Twins Clubs, Incorporated
P.O. Box 700860
Plymouth, MI48170-0955
Phone: 1-877-540-2200 (referral line)
(248) 231-4480
E-mail: [email protected]
Web Address: www.nomotc.org

The National Organization of Mothers of Twins Clubs (NOMOTC) was founded in 1960 to promote the special aspects of child development that relate to multiple-birth children. NOMOTC has more than 400 support groups with over 25,000 members.

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Twin Pregnancy Week by Week

∴Week 6: By the sixth week, twin embryos are visible on an ultrasound. Their major organs, such as brains, kidneys, livers, and reproductive organs are developing. In addition, their arms and legs are growing.

∴Weeks 8 through 12: These weeks represent the last month of the embryonic phase. You may be fighting fatigue and nausea. Your breasts may be tender as well. However, your twins are likely thriving, their weight and length has quadrupled since gestation. Nail beds and tiny teeth buds are forming as well as fingers, toes, eyelids, and genitals.

∴Weeks 12 to 16: Your twins have earned a new name this month〞-fetus. Their kidneys are functioning and fluids are flowing through their body and organs. They can swallow and release amniotic fluid (by urination) and measure approximately 6 inches by week 16.

∴Weeks 16 to 20: Your twins are now fully formed, measuring approximately 8 inches each. You may be elated to feel their energy and movements inside you. The rest of their time in the womb will allow them to plump and swell, until they reach their full birth weight.

∴Weeks 20 to 24: Your twins are now coated with downy hair and vernix, a protective layer thought to preserve baby's delicate skin. Though their skin is relatively wrinkled, they are slowly filling out as fat forms, weighing in at approximately a pound and a half a piece. They have also developed footprints and fingerprints.

∴Weeks 24 to 28: Your twin's weight climbs in these weeks, doubling by week 28. They measure approximately 15 inches and have distinct features. Due to increased pressure on your bladder, you may once again encounter frequent urination. It may also be increasingly difficult to move as your belly is cumbersome and your back aches.

∴Weeks 28 to 32: Your twins weigh in at approximately 4 pounds each and measure 16 inches. Their bones are soft and pliable, but will strengthen in the last weeks, as calcium and iron are stored.

∴Weeks 32 to 36: At nearly 5 pounds each, your twins are outgrowing their home in your womb. You may be contending with contractions (Braxton Hicks) and a plethora of aches and pains, such as heartburn and insomnia. Your twin's lungs are developing rapidly, preparing for their first breaths and wails in the world. Finger and toenails are fully grown. Your twins are fattening adequately.

∴Weeks 36 to 40: If you have managed to keep your twins contained, they will be extremely cramped in their quarters. Many women give birth by week 37, though full term twin pregnancy is generally counted at week 38. These weeks will be bursting with busyness, including frequent doctor visits and exams.

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∴Twin Pregnancy FAQ
Frequently Asked Questions About Pregnancy with Twins
http://multiples.about.com/od/twinpregnancyfaq/a/twinpregnancy.htm

∴Identical Twins
Facts and FAQs About Identical Twins
http://multiples.about.com/od/funfacts/a/identicaltwins.htm

∴Breastfeeding Twins: Frequently Asked Questions About Breastfeeding Multiples
http://multiples.about.com/od/breastfeeding/a/twinbreastfeed.htm

∴Top 10 Stupid Questions People Ask About Twins/Multiples
http://multiples.about.com/od/familyissues/tp/aatpquestions.htm

∴Ultrasound: Week by week Twins calendar
http://www.i-am-pregnant.com/Pregnancy/calendar/twins/4-8

∴Twin Pregnancy Week By Week Guide
http://www.twin-pregnancy-and-beyond.com/twin-pregnancy-week-by-week.html

∴Twin Pregnancy Week by Week
http://www.motheroftwins.com/pregnancyweek2.html

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