Your 40-week Journey - Twins and Multiple Births We are having more than one (part 1)

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Q: We are expecting twins following IVF treatment. How will we manage?
A: Although finding out that you will be the parent of two babies rather than one can be a shock, the initial surprise will settle down and you will soon start to get used to the idea. There are many organizations that offer information and support to parents of twins, as well as companies that make products for parents of two or more children. Your midwife and obstetrician will offer information and support and may put you in touch with local multiple birth support groups. You will also be going to more regular prenatal appointments and scans than if you were having just one baby to keep an eye on the growth of your babies.

As with all multiple births there is increased risk of complications such as preterm labor, and high blood pressure but with support and care you can have a normal pregnancy and healthy babies

Q: We're having triplets. Help! My wife is over the moon, but I feel numb. Where can we get advice?
A: As having triplets is relatively rare—approximately 160 per 100,000 births—the majority of information and support for couples does relate to having twins. However, more and more research is being done to find out how to help and support parents having more than two children.

Your midwife and obstetrician will be great sources of information and will be able to put you in touch with other parents of multiple-birth children. There are also several organizations that offer support and information for parents having a multiple birth. As you and your wife learn more about having triplets, your anxiety will hopefully start to ease.

Q: How will I know if I'm carrying twins?
A: It used to be that when a slightly smaller than expected baby made her entrance into the world, a wise doctor or midwife would reach for another baby coming close behind. Today, though, a multiple pregnancy is suspected when parents have had fertility treatment or if the uterus is larger than expected for the gestational age at the initial visit. An ultrasound is requested and in short order the results are known. Confirmation of the diagnosis of twins or a multiple pregnancy can typically be done by 12–16 weeks but is often made as early as 5–6 weeks by ultrasound when two embryos or two gestational sacs are seen.

Midwives and doctors are educated to be alert for signs and symptoms of twin gestation. These include a uterine size that is larger than dates would indicate; quad screen (4-marker screen) results that are higher than usual or abnormal; two heart beats are being are heard with the doppler; maternal weight gain is larger than expected; severe pregnancy-related nausea and vomiting (morning sickness) is experienced; anemia (low iron) is confirmed; or an exceptional amount of fetal movement (after 18 weeks or so) is detected.

Q: Does taking folic acid increase the incidence of twins?
A: There has been some debate and conflicting studies about whether taking folic acid pre-conceptually could increase the chance of having twins. A study in Sweden found a higher incidence of multiple births among women taking folic acid. However, this could be attributed to factors such as a greater number of women undergoing fertility treatment, which carries an increased probability of twins. Also, subsequent studies have refuted these findings; in 2003, a large-scale study in China found no significant difference in the number of women carrying twins who had taken folic acid. Women undergoing assisted reproduction should not exceed recommended doses of folic acid.
Q: Are all same-sex twins identical?
A: No. Whether or not twins are identical depends on how they were conceived, not what sex they are (see How are twins conceived). While identical twins are obviously the same sex, nonidentical same-sex twins are as similar or different as any other nontwin siblings.
Q: How likely is it that our twins will be identical?
A: One in 80 pregnant women carries twins and one-third of twins are identical. Although there are factors that make you more likely to have nonidentical twins, such as a family history of twins or being over 35, having identical twins is not an inherited trait and there are no other factors that make this more likely.
Q: Will I know after the birth if they are identical?
A: The term “zygosity determination” means finding out whether twins, triplets, or more are identical (monozygotic) or nonidentical (dizygotic or fraternal). It is natural for parents to want to learn all about their babies, and with twins this includes their zygosity. As well as for reasons of natural curiosity, knowing whether twins are identical can help parents determine the chance of having a multiple pregnancy again, and also has implications on care during pregnancy, since identical twins, especially if they share a placenta, are higher risk, and so the pregnancy may be more closely monitored.

In two-thirds of cases, the placenta provides the answer as to whether twins are identical. If the babies have a single amniotic sac surrounded by one outer protective membrane, known as the chorion, they are monozygotic. However, one-third of identical twins whose egg split early, before the placenta started to form, have two chorions with either a fused placenta, where two placentas grow together, or two separate placentas. These placentas are hard to distinguish from those of dizygotic twins.

Q: We don't know if our twins are identical. Will it be obvious after the birth?
A: In a third of cases, twins are different sexes and therefore obviously nonidentical. In same-sex twins, by the time the children are around two years old, their “zygosity” is usually quite clear from their physical features. Before this, there are many indications as to whether twins are identical, such as the color of their hair and eyes, the shape of their ears, the eruption and formation of teeth, the shape of the hands and feet, and the pattern of growth. If there is doubt as to whether twins are identical, the most accurate way to determine zygosity is by the DNA probe method, when tiny amounts of DNA are collected with a swab from inside each twin's mouth. A laboratory examines specific markers present in the DNA and diagnostic targets are compared. Although nonidentical twins may share some marker patterns by chance, monozygotic, or identical, twins will have the same pattern for all markers.
Q: Will I love one twin more than the other?
A: Although this can be a concern, it is more likely to be the case that rather than favor one child over the other, a parent gives more love and attention to the baby who needs it most at that particular time.

It is also possible that the strain of having two new babies in the house may increase the likelihood of delayed bonding, although this can also happen if the birth has been traumatic; if the mother or indeed the father is exhausted; or if one baby has taken time to establish feeding, or is more fussy than the other. This does not mean that bonding will not take place over time, but if this is worrying you, you should mention it to your midwife or doctor, since they may well be able to offer some helpful advice.

In every family, there are bound to be ebbs and flows of love between parents and children, which is normal and not a cause for concern. When a parent has two children born at different times, that parent may love one child differently than the other, but this does not mean that the love a parent has for one child is to the detriment of the other.

Q: Will the side effects of pregnancy be much worse with a multiple pregnancy?
A: Although in some cases the side effects of pregnancy may be the same when you are expecting two or more babies, the likelihood is that many pregnancy symptoms will be exaggerated. Symptoms such as morning sickness, fatigue or exhaustion, disturbed sleep, and swollen hands and feet are often worse with a multiple pregnancy. Unfortunately, women with multiple pregnancies also tend to suffer more from varicose veins. In addition to these increased side effects, weight gain is greater and more rapid for mothers carrying more than one baby and the uterine measurement is often increased for the gestational age. This extra weight and size caused by carrying two or more babies may also cause more constipation, hemorrhoids, urinary tract infections, and vaginal yeast infections.

Although there may be more exaggerated symptoms with a multiple pregnancy, the majority of these problems can be monitored by your midwife or doctor, and they may be able to offer advice and treatment to ease these symptoms.

Q: Will my weight gain be much greater than for someone who is having just one baby?
A: Mothers of twins or triplet pregnancies are likely to gain more weight than women having one baby. Indeed, in the first trimester, rapid weight gain may be an indicator of a multiple pregnancy. The increased blood volume and size of the uterus, as well as each baby's weight, possibly two placentas, and the amniotic fluid for each baby, will continue this pattern of greater weight gain during pregnancy.

Although on average a woman having a multiple pregnancy is likely to put on around 10 lb (4.5 kg) or more than a woman having one baby, this is not double the weight gain. If you are having twins, you should raise your calorie intake by only 500 calories per day, compared to 200 calories more for a single pregnancy.

Q: I'm only 24 weeks, expecting twins, and already I've got high blood pressure. What can I do?
A: Unfortunately high blood pressure is more likely to start, or worsen if you already have the condition, in a twin pregnancy since the rates of pregnancy induced hypertension (PIH) and preeclampsia are increased in multiple pregnancies. There is little that can be done to prevent PIH. General lifestyle changes, such as reducing your salt intake, avoiding alcohol and tobacco, getting gentle, regular exercise, and getting enough rest, are thought to help. You should also ensure that you get to all your prenatal appointments and contact your midwife or doctor if you experience headaches or visual disturbances such as flashing lights or there is reduced movement from your baby.
Q: What can go wrong if I have a vaginal delivery?
A: If both twins are head down, a vaginal birth is usually possible. Sometimes, the first twin may be head down and born vaginally, but the second twin may be breech. Sometimes, the second twin will turn and be head down after the birth of the first twin, and you are then more likely to deliver both twins vaginally. Studies suggest that there has been a significant increase in combined vaginal-cesarean births of twins and a decrease in vaginal only births, which may be due to the fact that there is a greater willingness nowadays to allow women carrying twins to try for a vaginal delivery, which also increases the likelihood of this scenario. If you have a vaginal delivery, there is a greater chance of one or both twins having an assisted delivery by vacuum extraction or forceps , either because one or both twins is positioned in a tricky way, for example facing the mother's back, or because the labor may be longer and weaker because of the amount of work involved in pushing two babies out. Fetal distress can also occur more commonly in a multiple birth.
Q: Why might the doctors decide to deliver my twins by cesarean?
A: An elective cesarean might be recommended for a twin delivery for several reasons, but ultimately it is your decision. The optimum time for delivering any baby is at term (37–40 weeks' gestation) and this remains the case for delivering twins since they may well be smaller than a singleton baby, having had to share your supply of nutrients. However, if one or both of the babies are compromised, possibly due to twin-to-twin transfusion syndrome or raised blood pressure in pregnancy, there may be a need to deliver the babies preterm.

Many doctors recommend a cesarean for a breech baby, where the baby is bottom down inside the womb, because there are more risks associated with a breech vaginal delivery. In a twin pregnancy, if the first baby is breech, this puts the second twin at risk too. Also, if the first twin is breech and the second is head first (cephalic), a cesarean is recommended due to the rare complication of “locked” twins, when the babies' chins get locked together.

If both babies are head down and appear to be thriving, many midwives and doctors will encourage a vaginal delivery. Your doctor and midwife will discuss the risks and benefits of both as you get closer to delivery time.

Q: Will my triplets need to be delivered before 40 weeks?
A: Yes, it is very likely that your triplets will be delivered before 40 weeks. Although most twins are born at around 37 weeks, which is considered to be a term pregnancy, it is rare for triplets to reach term, and most are delivered at around 32–36 weeks' gestation.

As a woman's body is designed to carry one infant at a time, carrying more than one increases the risks for both mother and babies, and the decision to deliver your triplets will be made when one or more of the babies is not coping well. To improve the chances of a good outcome, get plenty of rest and eat a healthy diet . Although premature deliveries do carry a risk to the infant, if the baby's well-being is compromised an early delivery is necessary. If you go into premature labor, you may be given medication to try to stop labor long enough to administer steroids, which will help to mature the babies' lungs before delivery—as long as this does not put the babies at risk.

Q: How likely is it that my twins will have a lower than average birth weight?
A: Almost half of all twins are born weighing fewer than 51/2 lbs (2500 gms) and are therefore considered “low birthweight.” this may be the result of preterm delivery or insufficient fetal growth. These babies are at increased risk for complications during birth and for life-long disabilities such as cerebral palsy as well as neurological and sensory impairment.
Q: Do twins run out of room to turn in the womb?
A: It does tend to be the case that, in the third trimester, twins find a position and settle there at an earlier stage of pregnancy than if there was just one baby. Generally, with twin pregnancies there seems to be a lot less change in presentation from about 32–34 weeks. However, how your twins are likely to be delivered depends largely on the direction that the twin who is lowest in the pelvis is facing. If twin a is head down, then a vaginal delivery could be possible and the second twin may be able to be gently coaxed into a favorable position, or may need to have an assisted delivery.
Q: I've been told that one baby isn't developing as well as the other. What will the doctors do?
A: Although it is common for twins to grow at a different rate in the womb, if there is a significant difference in size, it may be that one baby is getting a greater proportion of the nutrients than the other. It is important to check that your babies are developing in line with their gestational age. However, if your doctor is concerned about the development of one baby, they will probably refer you to a fetal medicine specialist: an obstetrician with additional training in caring for the unborn baby. He or she may do blood tests and perform an ultrasound to assess the growth of each baby and investigate why there is a difference.

You may continue to have additional scans, known as growth scans, which will help the doctor assess if one baby is small or growing slowly. These usually start around 24 weeks and continue every 2–4 weeks until your babies are due. They look at a number of areas including the head, abdomen, and thigh bone measurements; the amount of amniotic fluid around the babies; the babies' levels of activity; the blood flow in the umbilical cord and the position of the placentas. Your doctor should explain the findings of the scans and if there is a concern you will be closely monitored. An early delivery may be planned if one of the babies is compromised.

Q: What is twin-to-twin transfusion syndrome?
A: This is a rare but serious condition that occurs only in identical twins who share a placenta. It is caused when there is an abnormal blood supply and a blood vessel directly connects the twins. One twin pumps blood around his own body and that of his twin and, as a result, he does not grow properly. An early delivery is usually needed to save the smaller twin.
Q: Am I likely to lose one or more of my babies?
A: There are increased risks for both mother and babies associated with multiple pregnancies and sadly there are occasions when one or more of the babies dies in the uterus. This occurs in around 2.5–5 percent of twin pregnancies most commonly after in vitro fertilization and transplant of several embryos. In some circumstances if there is a fetal abnormality in one twin the doctor may suggest that one or more of the babies is terminated in the very early weeks to allow the normal healthy development of the other baby or babies. However, many doctors believe that this is unnecessary since the procedure itself carries the risk of losing all the babies. Although incredibly hard, this is ultimately your decision, so you should spend time discussing the options with your doctor.

Unfortunately, the death of a baby in a twin pregnancy can sometimes cause problems for the surviving twin, although the degree and type of problem depends on whether the twins were identical or nonidentical. If identical, the doctors will assess whether it was a monochorionic pregnancy (in which the twins share the same placenta) or a dichorionic pregnancy (in which they have a different placenta). When the placenta is shared, there is a 30 percent risk of death or a neurological problem to the surviving twin if the other dies; if there are two placentas, there is a lower risk, of 5–10 percent, of death or disability occurring in the surviving twin.

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