Twins & Multiple Pregnancy

“CONGRATULATIONS!! you are having twins”

It’s very exciting to hear the news of twins or multiple pregnancy, but do you know, it can become worrisome if you and your family is not prepared for the changes during twin pregnancy, proper care and associated problems for you and babies.

This blog will give you some guidance for any pregnancy where more than one baby is expected.  You will get information about care during pregnancy, options about mode and time of delivery to make an informed choice and avoiding problems.

What is twin pregnancy?
If you are expecting two babies at one time, they are called twins.

What is multiple pregnancy?
More than two babies expected at one time is called multiple pregnancy.

What are the chances of multiple pregnancy?
1 in 80 women have multiple pregnancy, now a days chances are increasing due to use of fertility treatment medicines and procedures.

What causes multiple pregnancy?
Following factors can be vital:

• Ovulation induction drugs
• Assisted reproductive techniques (IVF, ICSI)
• Family history of twins
• Previous history of twins

What are types of twins ?
These are of two types:

• Dichorionic (separate placenta), or
• Monochronic (same placenta)

What are Dichorionic Twins?
These are formed from two eggs and two sperms, having separate placenta. They have separate fluid sacs (amniotic sac); di chorionic di amniotic (DCDA). The gender of babies could be same or different.

What are Monochorionic Twins?
They are formed from a single fertilized egg, having same placenta. Their fluid sac can be different; monochorionic di amniotic (MCDA). Their fluid sac can also be same; monochorionic monoamniotic (MCMA).

Why it’s important to know about type of twins?
If the babies are sharing placenta monochorionic then risk of complications are more as compared to a singleton pregnancy or a twin pregnancy with separate placenta.

What are problems of multiple pregnancy for mother?
All the common problems of pregnancy worsen with multiple pregnancy like vomiting, morning sickness, weakness, tiredness, backache, swollen(varicose) veins, swelling feet. Nearly all of them settle after delivery.

But there are certain medical conditions which need to be addressed in timely fashion:

• Anemia (low hemoglobin)
• Gestational diabetes (high blood sugars during pregnancy)
• Pre-eclampsia (high blood pressure during pregnancy + proteins in urine)
• Antepartum hemorrhage (bleeding during pregnancy)
• post-partum hemorrhage (bleeding after delivery)
• Preterm labor (before 37 weeks)

What are problems for babies?
Some of the common problems are:

• Intrauterine growth restriction(small babies)
• Problems of pre-maturity
• Breathing difficulty
• Jaundice
• Infections
• Feeding problems

What are problems of babies with common placenta (monochorionic)?
The problem is due to shared blood circulation system. In 20% of cases; blood flows from one to second twin causing  recipient twin to grow big with more fluid around it, whereas donor twin becomes small with less surrounding water. This is called twin to twin transfusion syndrome (TTS). It is very serious condition as it can take lives of both twins.

What is the treatment of twin transfusion?
The main treatment is cessation of blood flow from donor to recipient twin. Fetal medicine consultant lead team performs various treatments and conducts follow-ups.

The latest treatments are:

• Serial amniotic fluid reduction
• Umbilical cord ligation
• Coagulation of placental vessels by laser
• Pregnancy termination in selected cases

What is the role of ultrasound in management of multiple pregnancy?
In cases where there is Single Placenta (Mono-chorionic) 16 week onwards, ultrasound is done after every 2 weeks whereas in cases of separate placenta (Di-chorionic) 18 week on wards, serial ultrasound are performed every month to check the size and growth of babies, amount of fluid (liquor), placental blood flow and any signs of twin to twin blood transfusion. In suspected cases of preterm labor cervical canal length measurement can help in diagnosing and treating such cases.

What special care is needed during pregnancy?
A twin pregnancy is a high risk pregnancy and should be managed in a tertiary care unit with consultant lead team experienced in care of such cases.

At each antenatal visit, routine checkup is done to determine mother and babies well-being, including blood pressure measurement, testing blood for hemoglobin and blood sugar levels, urine for glucose and proteins. Routine ultrasound is also done to check growth of babies. Iron, folate, multi-vitamins and calcium supplements are given throughout pregnancy.

What are chances of having premature delivery?
It is very common to deliver twins before 37 weeks of pregnancy, about 60 in 100 women with twins have a premature delivery whereas 10 in 100 women with a singleton pregnancy have this issue of premature delivery.

Remember, if you are going into premature labor or due to some problem there is a plan to deliver before 37 week, you will be given steroid injections for baby lung maturity to minimize the risk of breathing problems after delivery.

What is appropriate time of delivery?
Time and mode of delivery depends on type of multiple pregnancy and how it has been progressing. Elective birth is recommended according to type of twins :

• 37 week for dichorionic twins(separate placenta)
• 36 week for monochorionic twins( same placenta)
• 35 week for triplets

What is the appropriate hospital for twin delivery?
These babies need special nursery care, any tertiary care hospital with a consultant lead maternity unit would serve the purpose.

How the babies are delivered?
It depends on the growth of babies, placental position, history of previous Caesarean, maternal medical problems like high blood pressure, diabetes during pregnancy, malpresentations and malposition’s require a Caesarean delivery. If all risk factors are excluded then mode of delivery depends on position of first twin during labor, if its head then vaginal delivery is possible. There is also possibility of Caesarean delivery of second twin, in cases of mispositioning and malpresentation or abnormal heart tracing or fetal distress.

What is post-delivery care?
A strong support system is really helpful in coping with the problems of managing newborns. It is very common to feel depressed, sad or experience low mood after twin delivery, it needs to be informed to your medical adviser and treated accordingly.

Breast feeding should be encouraged.

REMEMBER! twin pregnancy has complications BUT with proper care and monitoring, most women with twins have a healthy pregnancy and healthy babies.

Dr. Ayesha Azam Khan