Multiple Pregnancy
Discovering a multiple pregnancy is usually a surprise, even for couples who underwent in vitro fertilization. Joy and concern often coexist from the very first moment, along with many questions about how the pregnancy will develop and what this means in practice.
A multiple pregnancy is considered a high-risk pregnancy, not as a negative prediction, but as a clinical recognition that it requires specialized monitoring and an individualized care plan. With the right management, the vast majority of multiple pregnancies have an excellent outcome.
How common is a multiple pregnancy?
Naturally, a multiple pregnancy occurs in about 1 in 80 natural pregnancies. With the increase in assisted reproduction treatments (IVF, ovulation induction), this rate has risen in recent years.
The transfer of more than one embryo in IVF is the main reason for the worldwide increase in twin pregnancies.
Types of multiple pregnancy - Dizygotic and monozygotic twins
Not all twins are the same, and this distinction has important clinical implications.
Dizygotic (fraternal) twins
They result from the fertilization of two different eggs. They are genetically different, like two siblings who happen to be born together. They always have separate placentas and separate amniotic sacs. They are the most common type of twins.
Monozygotic (identical) twins
They result from the division of one fertilized egg. They are genetically identical. Depending on when the division occurs, they may have separate or a shared placenta, and this is crucial for monitoring.
What is chorionicity and why is it so important?
Chorionicity, meaning whether the twins share a placenta or have separate placentas, is the most critical piece of information in a twin pregnancy. It determines the level of risk and the monitoring schedule.
Dichorionic-diamniotic twins (DCDA)
Each fetus has its own placenta and its own amniotic sac. This is the most common and safest type.
Monochorionic-diamniotic twins (MCDA)
The two fetuses share one placenta but have separate amniotic sacs. They require closer monitoring because of the increased risk of twin-to-twin transfusion syndrome (TTTS).
Monochorionic-monoamniotic twins (MCMA)
The two fetuses share both the placenta and the amniotic sac. This is the rarest and most dangerous type and requires extremely close monitoring.
When is chorionicity diagnosed?
Ideally between weeks 6 and 10, and certainly before week 14. After that, determining it becomes significantly more difficult. Early diagnosis is essential for proper monitoring planning.
Risks and complications of multiple pregnancy
Prematurity
This is the most common risk. More than 50% of twins are born prematurely, before 37 weeks. The average duration of a twin pregnancy is about 35-36 weeks. Monitoring cervical length early on is critical for the timely detection of preterm birth risk.
TTTS
It occurs exclusively in monochorionic twins, in about 1 in 10 cases. It is caused by an imbalance in blood circulation between the two fetuses through vascular connections in the shared placenta: one fetus receives an excess of blood at the expense of the other. Early diagnosis through regular ultrasound scans and referral to a specialized center are vitally important.
Preeclampsia
The risk is about three times higher compared with singleton pregnancies. Regular monitoring of blood pressure and urine is an integral part of follow-up.
Gestational diabetes
This risk is also increased. Glucose tolerance testing is done earlier and monitored more frequently.
Fetal growth restriction
In some multiple pregnancies, one or both fetuses may show growth restriction, especially in the third trimester, when the demands for nutrients and oxygen increase.
How is daily life affected in a multiple pregnancy?
Beyond medical follow-up, a multiple pregnancy also affects daily life in ways that are worth knowing in advance.
Physical changes
Abdominal size increases more quickly, fatigue is often more intense, especially in the first and third trimesters, and nausea tends to be more pronounced due to higher hormone levels. Back pain, sleep difficulty, and a feeling of pressure in the pelvis appear earlier compared with a singleton pregnancy.
Work and activities
Reducing or stopping professional activities is usually considered necessary earlier, often by the end of the second trimester. If the nature of the job involves prolonged standing or physical strain, the assessment is individualized.
Nutritional needs
Requirements for calories, protein, iron, and folic acid are increased compared with a singleton pregnancy. Nutritional guidance is an integral part of overall follow-up.
Psychological aspect
Uncertainty about how the pregnancy will progress and concern for the health of both fetuses are feelings many women experience in a multiple pregnancy. Regular communication with the doctor and clear information at every stage are the best antidote to uncertainty.
How is a multiple pregnancy monitored?
Dichorionic twins:
- Growth ultrasounds every 4 weeks from week 20
- Regular blood pressure and urine checks
- Increased vigilance for signs of preterm labor
Monochorionic twins:
- Ultrasound scans every 2 weeks from week 16 for early detection of TTTS
- Doppler flow assessment at every visit
- Closer monitoring of growth and amniotic fluid
Triplets:
- Even more frequent monitoring from early in the second trimester
- Assessment of the possible need for hospitalization in the third trimester
Delivery in a multiple pregnancy
The mode of delivery depends on chorionicity, fetal position, and the course of the pregnancy. In dichorionic twins with the first fetus in cephalic presentation, vaginal delivery is often possible. In monochorionic twins, in triplets, or when the first fetus is not in cephalic presentation, cesarean section is usually the safest option.
The timing of delivery is planned carefully, usually earlier than in a singleton pregnancy, in order to avoid third-trimester complications. Delivery in a multiple pregnancy always takes place in a well-organized maternity unit with the appropriate facilities.
Frequently Asked Questions (FAQ)
With an ultrasound scan, ideally at 6-10 weeks. At this stage, determination is more reliable. Later on, it becomes significantly more difficult, which is why it is crucial not to delay it.
In some cases, yes, mainly when the first fetus is in cephalic presentation and the pregnancy has progressed without complications. The decision is always made on an individualized basis, with the safety of both fetuses and the mother as the priority.
Risk depends mainly on chorionicity, not on the method of conception. IVF twins are usually dichorionic, which is the most favorable form in terms of risk.
In some multiple pregnancies, one fetus stops developing early, usually in the first trimester, and is reabsorbed. The rest of the pregnancy usually continues normally. It is detected by ultrasound and requires information and follow-up.
Breastfeeding twins is possible, and many women do so successfully. It requires appropriate preparation and support. If you wish, we can direct you to a lactation consultant.
There is no single answer; it depends on the type of work, the course of the pregnancy, and the overall state of health. In general, many women with a twin pregnancy reduce or stop work around 28-30 weeks. The assessment is always individualized.
In multiple pregnancies that progress smoothly, hospitalization is not usually required. In monochorionic twins, or if complications arise, hospitalization may be considered necessary. The assessment is always individualized.
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