Download Information for Women

Information for Women
Bogulkunta, Hyderabad - 500 001
Ph : 040 - 40222300 Fax : 040 - 24753482
Email : [email protected]
Web : www.fernandezhospital.com
What is a Multiple Pregnancy?
A multiple pregnancy is a pregnancy with two or more babies.
The different terms used depend on the number of babies:
Two : Twin Four : Quadruplets Six : Sextuplets Three : Triplets
Five : Quintuplets
Seven : Septuplets
Multiples account for only a small percentage (3%) of all births,
but the multiple pregnancy rate is rising.
Why are Multiple Pregnancies Increasing?
The reason why a woman has a multiple pregnancy may be due to
many factors. A few important ones are :

Hereditary :
A family history increases the chance of having a multiple
pregnancy.

Maternal Age :
About one-third of the increase in multiple pregnancies is due to
the fact that more women over age 30 are having babies. Women
in this age group are more likely than younger women to conceive
multiples.

Assisted Reproduction :
Medicines that stimulate ovulation help produce many eggs,
which if fertilized can result in a multiple pregnancy. In-vitro
fertilization, during which eggs are removed from the mother,
fertilized in the lab and then transferred to the uterus, result in
the transfer of many fertilized eggs into the uterus, thus resulting
in a multiple pregnancy.
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Types of Twin Pregnancy
There are two kinds of twins.

Non-identical (dizygotic) :
Eighty percent of all twins are non-identical. That means they
come from two eggs with two sperms fertilizing them. These
twins are as similar as siblings can be, of the same or different
sex. They have their own placenta (dichorionic) and pregnancy
sacs (diamniotic) and are called Dichorionic Diamniotic (DCDA )
twins. The majority of twins from IVF are from two embryos and
are non-identical.

Identical (Monozygotic) :
Twenty percent of twins are identical where one egg is fertilized
and then divides into two embryos. These twins are of the same
sex, are genetically identical and look alike, but most importantly
they share the same placenta (monochorinoic), have separate
sacs (diamniotic) and are called Monochorionic Diamniotic
(MCDA) twins. Very rarely about 1% of twins may be in the same
sac. This is referred to as a Monochorionic Monoamniotic (MoMo)
twin pregnancy and carries the highest risk of pregnancy loss.
Dichorionic
Diamniotic
Monochorionic
Diamniotic
Monochorionic
Monoamniotic
Why is Multiple Pregnancy a Concern?
Most people think of a pregnancy as a happy occasion and consider
it a miracle of life. But if one is expecting twins or triplets, one’s joy is
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often accompanied by a certain amount of anxiety. Mothers carrying
multiple pregnancy have a higher chance of developing complications
when compared with those mothers with a single baby.

Nausea and Vomiting :
This can be excessive due to higher levels of pregnancy hormones
(Hcg). Other complications include higher chances of miscarriage,
which can happen in the first 12 weeks.

Vanishing Twin :
Sometimes only one baby is lost during the first trimester of
pregnancy, but this does not affect the development of the
remaining baby. The twin gets completely reabsorbed by the
mother (vanishing twin) with no symptoms, and the pregnancy
continues.

Anemia :
This is twice as common in twins than in singletons.
 Preeclampsia :
Preeclampsia, Pregnancy Induced Hypertension (PIH) 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.

Intrauterine Growth Restriction (IUGR) :
About half of twins and almost all higher order multiples are
born with low birthweights, less than 2,500 gms. This could be
due to pre-term birth or poor fetal growth. 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
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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 any
more growth and because the babies are competing for nutrients.
The growth of the babies will be monitored with serial growth
scans.

Gestational Diabetes:
This is more common in these women since most of them are in
the older age group. The increased risk for gestational diabetes
in a multiple pregnany appears to be a result of the two placentas
increasing the resistance to insulin, increased placental size, and
an elevation in placental hormones.
 Pre-term Labour :
Labour before 37 weeks of pregnancy is called pre-term. More
than 50% of twins, 90% of triplets and all quadruplets are born
pre-term. The length of pregnancy decreases with each additional
baby. On an average, the mean age for delivery is 35 weeks for
twins; 32 weeks for triplets; and 29 weeks for quadruplets.

Post-Partum Haemorrhage :
This could occur because of an overdistended uterus and a large
placenta.
Management of Multiple Pregnancy
We recommend the following :

More Frequent Antenatal Visits should be made to check for
complications and for monitoring.

Nutritional Needs have to be addressed, since more calories
are needed to nourish the growing babies and to also meet the
mother’s energy needs.
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
More Frequent Fetal Assessment by ultrasound as well as
electronic fetal heart monitoring, especially if the twins are
monochorionic, small or discordant in growth.

Frequent Assessment of Cervix : Ultrasound / clinical
assessments of the cervix may be done at regular intervals for
measuring the length, since a short cervical length is found to
be associated with a higher chance of premature delivery.

Cervical Cerclage : A procedure used to suture the cervical
opening is done only if the cervix is very short or open, but it is
not routinely done in all patients with multiple pregnancy.

Restricted Physical Activity : Depending upon complications,
one may be advised rest, but staying in bed is not advisable. If
a patient goes into pre-term labour, drugs used to stop uterine
contractions (Tocolytics) may be advised very judiciously so that
delivery can be postponed for a few days at least.

Need for Neonatal Care : Since a majority of these babies are
either low-birth weight or premature, they need the highest level
of neonatal care.
How are Multiple Babies Delivered ?
Delivery depends on many factors including fetal positions,
gestational age and health of the mother and babies. If both the babies
are in head down positions and there are no other complications, a
vaginal delivery is possible.
Caesarean delivery is for babies who are in abnormal positions, or
who are discordant in growth, in higher order multiples like triplets
and more.
Vaginal delivery may take place in the operating room because of
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a greater risk of complications, which may require a Caesarean
Section.
What is Multi-Fetal Pregnancy Reduction ?
In recent years, a procedure called multi-fetal pregnancy reduction
has been used for very high numbers of fetuses, especially four
or more. This procedure involves injecting one or more fetuses
with medications, causing fetal death. The objective of multi-fetal
reduction is to give the remaining fetuses a better chance for survival
and health.
A Multifetal Pregnancy Reduction (MFPR) :
• decreases miscarriage
• helps carrying your pregnancy longer
• decreases neonatal deaths
• improves chances of delivering one or more healthy babies
Risks
The risks of multifetal pregnancy reduction include miscarriage and
premature birth of pregnancies with four or five fetuses. About 5%
miscarry after being reduced to twins. The risk of a premature birth
is lower in the case of a multifetal reduction than it is for a triplet or
more pregnancy.
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Monochorionic Diamniotic Twins
What are Monochorionic Twins?
These are twins who come from the same egg, which splits into two
and develop into two babies. They share the same placenta are
identical and are of the same sex.
Why are We Worried?
In the majority of women, these pregnancies progress normally, but
there is a higher risk of problems than with a single pregnancy or with
a twin pregnancy where each baby has its own placenta.
The complications which can occur are :

Fetal Growth Restriction
Because the babies share the same placenta, there are connections
between the babies’ blood circulation systems. The blood vessels
run backwards and forwards between the two halves of the
twins’ shared placenta and each baby receives the same amount
of blood from the mother.
However, while in some Monochoronic pregnancies the placenta
is divided equally between the twins, in approximately 40% of
cases one baby has a disproportionately smaller share of placenta.
This may result in that baby not growing as well. This is known
as fetal growth restriction. In most pregnancies complicated in
this way, one twin is small and the other grows normally. This
is known as discordant growth. However, in some pregnancies
both twins can be small.
 Twin-to-Twin Transfusion Syndrome (TTTS)
What is Twin-to-Twin Transfusion Syndrome (TTTS) ?
About 20 percent of identical twins who share a single placenta,
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develop a complication which is called Twin-to-Twin Transfusion
Syndrome.
In TTTS, there are abnormal connecting vessels in the placenta that
shunt the blood from one twin (the donor) to the other twin (the
recipient). As a result, the donor twin receives very little blood from
the shared placenta and the recipient twin may have more blood flow,
causing it to grow bigger at the expense of the smaller twin. This also
causes the larger twin to produce more urine, which is responsible
for an increased amount of fluid around the baby (polyhydramnios).
The smaller twin is the compromised one and shows a decreased
amount of amniotic fluid (oligohydramnios). Conversely, the recipient
twin receives too much blood from the shared placenta, which is
responsible for cardiac overload and failure. TTTS can arise at anytime
in pregnancy but most commonly before 22 weeks.
How is TTTS Diagnosed?
TTTS is detected by ultrasonography. Difference in the weights, or
their bladder size, or the volume of fluid around each twin, is the
basis for diagnosis of TTTS. Monochorionic twins are screened for
evidence of TTTS at 16, 19 and 22 weeks. The severity of TTTS ranges
from mild to severe.
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Mild TTTS does not require treatment and can be monitored by
frequent ultrasound as it may resolve spontaneously. Severe TTTS
requires intervention.
How will Your Babies be Monitored?
The detection of TTTS calls for intensive surveillance of both the babies - the recipient for evidence of cardiac failure and the donor for
evidence of growth failure. This is done by regular ultrasounds starting at 16 weeks and then repeated every 2 – 3 weeks.
Is TTTS Preventable?
Blood vessel connections are formed during the formation of the
placenta in early pregnancy and hence TTTS is not preventable.
Is there any Treatment for TTTS?
Severity of TTTS and the duration of pregnancy determine the need
for treatment. The aim of management is to prolong pregnancy till
the baby is mature enough to survive outside the womb. The large
baby is affected by the overload of excess blood and the smaller twin
suffers from under-supply of blood. The aim of treatment is to stop
the abnormal connection in the placenta between the two babies.
With recent advances, survival rates for severe TTTS have improved.
The treatment for TTTS is laser surgery for sealing off the connections
in the placenta.
In the absence of laser, amnioreduction is used as a complementary
therapy to drain off excess fluid from the recipient twin to improve
survival chances. Amnioreduction alone can save up to 64% of
affected babies. Removing the excess fluid appears to improve blood
flow in the placenta and also reduce the risk of pre-term labor. Laser
surgery is a one-step treatment. Amnioreduction may need to be
repeated.
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Do All TTTS Twins Need Laser Surgery?
Although laser surgery is a remarkable tool, it is best reserved for
severe TTTS or when twin-size difference (discordance) is more than
40%. Laser surgery is an invasive procedure, with its procedurerelated risks. Hence these mothers are offered comprehensive
therapy for TTTS, which may include amnioreductions, restricted
activity, nutrition supplements, a cervical encerclage (stitch) and the
option of laser therapy.
What are the potential complications of Twin to Twin
Transfusion Syndrome ?
 Premature labour 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
Management of Monochorionic Diamniotic Pregnancy
1. The mother will be having a Nuchal scan, between 11 and 13
weeks + 6 days of pregnancy, which is a screening test for Down’s
Syndrome.
2. The mother will be monitored closely with regular ultrasound
scans every 2–3 weeks from 16 to 24 weeks’ gestation, to check
the growth of the babies and for signs of TTTS. This is done by
looking at amniotic fluid volumes and blood-flow between
the twins. A detailed scan looking at the development of the
babies (Anomaly Scan) is performed between 18–22 weeks. This
includes a scan that looks at the structure of the babies’ hearts,
(Fetal Echo) as Monochorionic twins are at greater risk for heart
abnormalities.
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3. After 24 weeks of gestation, ultrasound scans will be performed
to monitor fetal growth. These will be at intervals of 2–4 weeks.
4. If there is any discordance in the growth of the babies the
mother will require frequent fetal surveillance with weekly visits
and measurement of amniotic fluid volumes.
5. Between 32 and 34 weeks there will be a discussion with the
Consultant’s Team regarding how the babies will be delivered.
The decision is based on the individual circumstances. If the
pregnancy has been uncomplicated and both babies are
presenting head first, a vaginal delivery may be an option. If there
have been problems of any kind or the babies are presenting
by the bottom (breech), then a Caesarean Section is the usual
choice of delivery.
6. If all is well, the delivery should be prior to 37 weeks gestation.
7. If it looks as though the babies are going to be born prematurely,
it is advisable to visit the Neonatal Unit and be seen by the
Neonatologist.
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Monoamniotic Twins
Monoamniotic twins are rare, occurring in approximately 1 in 35,000
to 1 in 60,000 pregnancies. The survival rate for Monoamniotic twins
is approximately 50%.
Complications Associated with Monoamniotic Twins
Cord Entanglement : Cord entanglement is one of the main
complications associated with monoamniotic twins. Because the
twins have no amniotic membrane separating them, their umbilical
cords can easily become entangled. This can hinder fetal movement
and development. Additionally, if the twins become tied together
in the uterus, one twin may become stuck in the birth canal during
labor and delivery, which can be life threatening. Cord entanglement
happens, to some degree, in almost all monoamniotic twins.
Cord Compression : Cord compression is another life threatening
condition common in monoamniotic twins. As the twins move
around in the amniotic sac, it is possible that one will compress the
other’s umbilical cord. This can prevent vital food supply, oxygen and
blood from travelling to the other baby, resulting in fetal death.
Twin-to-Twin Transfusion Syndrome (TTTS):
Pre-term Birth: All monoamniotic twins are born prematurely. The
risk for cord entanglement and compression increases greatly after
34 weeks.
For this reason, all Monoamniotic twins are delivered by caesarean
section between 32–34 weeks. However, many Monoamniotic twins
experience life-threatening complications as early as 26 weeks,
and need to be delivered immediately. Pre-term delivery is often
associated with a number of life-threatening conditions.
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The patient should have twice-weekly monitoring of fetal heart
rate and movement, particularly after the 26th week. After the 28th
week, many women enter the hospital so that they can be constantly
monitored. Aggressive monitoring can help to lower the risk of fetal
death considerably.
The best treatment for Monoamniotic twins is to have regular and
aggressive fetal monitoring. The mother should be sure to see a
Perinatologist (also called a maternal-fetal medicine specialist)
regularly, throughout her pregnancy.
Importance of Wholesome Nourishment for
Twin, Triplet Pregnancies
If you are expecting twins or multiples, get ready for some exciting
times ahead! Not only can a multiple pregnancy be a very enjoyable
and uplifting experience, but you also get to welcome multiple
bundles of joy into your family! Of course, being pregnant with twins
or multiples can also be very challenging. In particular, you will need
to pay close attention to your pregnancy nutrition to be sure that you
and your babies are getting all the vitamins, minerals, and energy
that you need to stay healthy.
Most importantly weight gain is positively related to birth weight of
twin babies. Weight gain is to be consistent through pregnancy with
an early weight gain (2 – 4 kgs.) in first trimester and a weekly gain of
0.75 kgs during 2nd and 3rd trimester : The nutritionist will help plan
the calorie requirement specific to each patient based on the prepregnancy weight and expected weight gain.
A diet rich in good quality protein, iron, folic acid, calcium with
optimum calories is recommended for better pregnancy outcomes.
The quantity of each meal has to be customized as per calories
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required based on BMI. If the patient is diabetic, hypertensive or
suffering with any other medical ailment, diet has to be altered
accordingly.
Optimal amount of protein is required to ensure proper growth of the
babies and to support changes in the mother. Egg, chicken, fish, soya
nuggets, cottage cheese, tofu and nuts need to be taken regularly to
meet the increased protein requirement.
Iron deficiency during pregnancy increases maternal anemia and
low birth weight in infants. Legumes, dried fruits and green leafy
vegetables, fish, chicken, egg contain iron. Fruits rich in Vitamin ‘C’
like amla, guava and citrus fruits improve iron absorption from plant
foods.
Optimal Folic acid intake increases birth weight and reduces
congenital abnormalities. Green leafy vegetables, legumes, nuts and
liver are good sources of folic acid.
In twin pregnancies calcium requirements are very high. Ensure
intake of milk, yogurt, tofu, cheese, butter, fish, green leafy vegetables
daily.
Choose wholesome nutritious foods like whole grains, fruits, milk,
sprouts, rather than processed foods like chocolates, soft drinks,
and pastries.
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Why Do You Need A Special Clinic?
The earlier one knows that one is carrying more than one baby, the
better it is for mother and babies to visit a Special Clinic. There is
enough evidence to support the need for special outpatient clinics
devoted to these mothers.
The outcome is much better, with these dedicated clinics offering
close monitoring and counseling. This approach leads to many
benefits for the parents and the babies. The babies of mothers who
have been followed by a specialized clinic / team tend to be born
closer to term and are larger at birth.
There is a decrease in premature deliveries, and most importantly
the Clinic allows parents to meet other such parents, giving them
the opportunity to talk and to be more at ease while discussing their
experiences. Keeping in mind the rising number of mothers with
multiple pregnancy, their special needs and the need for a dedicated
clinic, the Twins, Triplets and More Clinic was started at Fernandez
Hospital in 2006.
This clinic is a multi-disciplinary clinic with a dedicated Obstetrician,
Fetal Medicine Specialist, Nutritionist, Lactation Consultant and an
excellent Neonatal Team that provides round-the-clock service and
deals with about 120 twin and 10 triplet pregnancies per year. This
clinic is the only one of its kind in Andhra Pradesh.
For Queries please email :
[email protected]
Cell : 8008304318
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Name : _________________________________________________
M. R. No. : _____________________ Age : ____________________
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Contact Details
UNIT 1 – BOGULKUNTA
4-1-1230, Bogulkunta
Hyderabad – 500001
UNIT 2 – HYDERGUDA
3-6-282, Opp. Old MLA Qrtrs.,
Hyderguda, Hyderabad – 500029
UNIT 3 – JUBILEE HILLS
D. No. 8-2-293/82/A/769/1
Plot No. 769, Road No. 44
Jubilee Hills, Hyderabad – 500033
Centralized Tel. No. : Ph : +91 40 40222300
Email : [email protected]
Website : www.fernandezhospital.com