Multiple pregnancy is always a high-risk pregnancy, because nature has provided for the birth of one child in a person, and in the process of gestation, everything in a woman's body is rebuilt to meet the needs of one fetus.
Pregnancy with twins or triplets is a double or triple load, and therefore its management and childbirth have a number of significant differences.
How to conceive twins or triplets?
Many would like to know if it is possible to conceive twins or even triplets of their own free will? It is possible, but only in the IVF protocol. During in vitro fertilization, a woman's egg cells are found with a man's sperm in a laboratory test tube, or rather, in a Petri dish, and only the woman herself and the fertility doctor decide how many embryos to plant in the uterine cavity... And again, there are no guarantees that they will all take root.
In all other cases, proliferation is the providence of higher powers. Science knows exactly how twins or triplets are formed, but it has found an answer to the question of why this happens.
Any woman of reproductive age ovulates once a month. Usually, this significant event occurs exactly in the middle of the menstrual cycle. After the next menstruation, several follicles begin to ripen in the ovaries, but only one becomes dominant, the growth of the rest will be slowed down by follicle-containing hormones. One mature egg comes out of one follicle in the middle of the cycle into the fallopian tube. When fertilized, a zygote is formed - a single-celled organism containing a set of DNA from a new person. Next, implantation occurs and the bearing of one fetus begins.
Sometimes, for some unknown reason, this well-oiled mechanism gives a certain malfunction, and on the day of ovulation, two eggs are released into the fallopian tube at once. If each is fertilized, twins will be born... They will be different from each other, each will have a different genome, they may have a different gender, different characters and talents. Each child in the womb will have its own placenta, which will nourish and supply him with oxygen, each will have his own "house" - a fetal bladder with amniotic fluid. Such twins are called dizygotic or fraternal, but simply twins.
On the day of ovulation, a woman may leave one egg from the follicle, which will be successfully fertilized, but for some unknown reason, the zygote will begin to divide into two after a few days. This is how monozygous or identical twins are formed. They will have an identical set of DNA, which will provide them with external similarity, the same gender.
If the zygote divides into two in the first or third days after fertilization, then each of the babies will have its own placenta and its own fetal bladder. If the separation happens after three days, the babies will huddle in one fetal bladder-house and feed from one placenta through two umbilical cords. When the zygote is divided too late - 10 days after fertilization, accrete or Siamese twins are formed.
If on the day of ovulation two eggs came out, and both turned out to be fertilized, and one then divided into two zygotes, triplets are formed, two children in it will be identical twins and will have the same sex, and the third child will differ from them and the set of DNA, and, possibly gender.
More favorable prognosis for carrying multiple pregnancies is the presence of dichorionic diamniotic twins, when each child has its own placenta and its own membranes... The most alarming situation is the situation of conceiving identical twins, who are located in the same fetal bladder and are fed from a single placenta. In this case, with a high degree of probability, the stronger will “rob” the weaker.
Causes
The exact reasons why a woman suddenly becomes a mother of two, three, or even four babies at once, medicine does not know. But there are known predisposing factors for multiple pregnancy.
It is believed that the probability of conceiving more than one child is higher in the following situations.
- There is a genetic predisposition... In the family of a man or woman, there have been cases of the birth of twins or twins. Especially you should pay attention to such cases in the ascending female line - the chances of giving birth to twins or triplets are higher in women whose ladies in the family (especially, great-grandmother, grandmother, mother) gave birth to twins.
- Hormonal background... If the concentration of FSH (follicle-stimulating hormone) in a woman's blood is exceeded, the likelihood that not one, but two or even three eggs will mature, increases by about 30%. An increase in the level of this hormone can be hereditary, or it can be caused by hormonal drugs, which are sometimes prescribed to stimulate ovulation in infertile women. It is noteworthy that the level of FSH is almost always increased in women who have canceled the use of oral hormonal contraceptives the whole cycle ago. If, at the same time, a woman has managed to take means to stimulate ovulation, then the probability of multiple pregnancy will be very high for her.
- With IVF... To increase the chances of pregnancy in the treatment cycle of in vitro fertilization, several eggs are fertilized, and to increase the likelihood of implantation of at least one, 2-3 zygotes are planted. If everyone is implanted, a multiple pregnancy occurs.
- With repeated pregnancy... In primiparas, multiple pregnancies are rather rare, most often two or three babies "make happy" parents who already have children of their own. Repeated births increase the chance of conceiving multiple fetuses, but only slightly.
- Age of the future mother... Usually, the likelihood of multiple pregnancies increases with the age of the woman. In women over 35, the probability of conceiving two or three children is estimated at 25%.
Statistics
The number of multiple pregnancies is increasing worldwide. Over the past two decades, the number of such cases has doubled. In the total number of pregnant women carrying twins or triplets, they account for about 1-1.5%. For every 87 births there are one twins, for every 6.5 thousand births - triplets... The quadruple is born in one case per 51 thousand births.
In women carrying multiple fetuses, the risk of miscarriage and premature birth is 5 times higher than in singleton pregnancies. The birth of children with extremely low body weight with multiple pregnancies occurs 10 times more often than with a singleton pregnancy. 54% of multiple pregnancies end in premature birth. All this explains why doctors are so sensitive to pregnant women with twins or triplets, why there is a special plan for the management of such expectant mothers.
Signs at the initial stages
In the earliest stages before the delay, a multiple pregnancy is not much different from a singleton. No special sensations will appear either a week after sex, which led to conception, or two weeks later. The biggest thing that a woman can feel before the delay and in the first week after it is the effect of progesterone. But it is equally felt by future mothers of twins and future mothers of one baby.
How is the effect of this hormone manifested, which ensures the safety of pregnancy:
- fatigue increases, drowsiness appears;
- headaches may become more frequent;
- body temperature may rise slightly, there is a feeling of chills or heat;
- urination becomes more frequent;
- there may be a feeling of nasal congestion due to swelling of the mucous membranes under the influence of progesterone;
- appetite increases or disappears.
All the same signs may (or may not) be present in singleton pregnancies.
Even after the fact of pregnancy ceases to be a secret for a woman, she may not even guess for a long time that more than one baby is developing inside her.
The statements that toxicosis is stronger with twins do not correspond to reality. There are many women who did not suffer from toxicosis at all, carrying twins, and there are those who suffered with one baby.
It is thus impossible to recognize the symptoms of multiple pregnancy before the delay in menstruation and for some time after it.... Some women, according to reviews, claimed that they felt twins intuitively, but this question has nothing to do with medicine, there is no way to find an explanation for it.
Diagnostics
Some people start looking for diagnostic signs of multiple pregnancies almost with a test that is carried out at home. Women claim that with a double or triplet, the stripes on the test are brighter than with a singleton pregnancy... This can be partially explained - if the fetuses form two different placentas, the level of chorionic gonadotropin (the hCG hormone) will be twice as high, namely, it stains the test strips.
A blood test for hCG also shows doubled with twins or tripled with triplets, but only if the fetuses have different placentas. If monochorionic twins develop, then the hCG level will be standard.
A more informative method for determining multiple pregnancies is ultrasound. Already at the 7th week of pregnancy, it is possible to determine the presence of identical twins, and twins are visible even earlier - at 6 weeks in the uterus, two fetal eggs are clearly visualized.
After 5 weeks of pregnancy, the heart begins to beat in the fetus. With a transvaginal probe, when undergoing an ultrasound scan from 6 weeks of gestation, you can hear the fetal heartbeat. Multiple heartbeats can make the doctor think of multiple pregnancy. But at this time, the heart of even one fetus beats inconsistently, and therefore registration of fetal heartbeats after 10 weeks of pregnancy is considered more reliable.
At a later date, signs indicating multiple pregnancies begin to move earlier - from about 15-16 weeks, while a woman begins to feel one baby from about 19-20 weeks. The size of the uterus and the height of its fundus will exceed the gestational norm. From the middle of pregnancy, the doctor, by auscultation, listens through the anterior abdominal wall not one, but two or three points of the heartbeat at once.
Blood tests of a pregnant woman will also be not one hundred percent, but quite informative for the doctor: in the blood of a future mother expecting twins or triplets, not only the hCG content, but also the concentration of placental lactogen, progesterone, is increased from the first trimester.
Thus, a woman can get data that the current pregnancy is multiple fetuses as early as 6-7 weeks of pregnancy.
How does the fruit develop?
Early period - the period of embryogenesis in all embryos, regardless of their number in the uterus, proceeds the same... Bodies and systems are formed at the same time.
The differences between children in multiple pregnancies and singleton pregnancies begin after the end of the first trimester, when a period of active growth and weight gain begins. Babies, of which there are several, usually weigh lessthan their peers, who live in the uterus alone, there is a difference in growth rates.
Here are the main stages in the development of twins or triplets in the womb.
- Week 5 (just a week after the start of the delay) in children, hearts are formed, the heartbeat starts, the kidneys and liver are laid.
- At week 6 hands, initial facial structures are formed. The organs of the immune system are laid.
- At week 7 the first nerve fibers are formed, which will become the basis of the nervous system. The only intestine in each fetus is divided into sections of the gastrointestinal tract.
- At 8 weeks babies start to move. The young placenta begins to work. The brain is separated from the spinal cord, the legs grow.
- At week 9 the embryonic tail decreases, the rudiments of teeth are formed.
- At week 10 the embryonic period ends. Children are called fruits. All internal organs are formed. Babies move, swallow, clench their hands into fists. The bones of the skeleton begin to harden.
- At 11 weeks grasping and sucking reflexes are formed.
- At 12 weeks babies acquire taste buds and begin to distinguish the taste of waters, the formation of genitals is completed.
- At 13 weeks active growth of the brain substance begins.
- At week 14 each of the twins gets their own fingerprints, and even identical ones with identical DNA have different fingerprints.
- At 15-17 weeks muscle formation is completed. The process of accumulation of subcutaneous fat begins. Women feel movements, babies have mastered a large number of facial expressions.
- At 18-20 weeks the mineralization of the bones of the skeleton is completed. Hearing is formed at 20 weeks.
- From week 22 lanugo begins to fall out - thin hairs on the skin that hold a protective layer of cheese-like lubricant. From this time on, childbirth is not considered a miscarriage. They are classified as premature birth.
- At 23 weeks the formation of the spine is completed.
- From 24 weeks the maturation of lung tissue begins, a special substance is produced in the tiny alveolar vesicles - a surfactant, which, when accumulated in the right amount, will allow children to breathe after childbirth on their own.
- At week 26 During pregnancy, growth hormones begin to be produced, in boys, the testicles begin to descend into the scrotum. Eyesight improves.
- At week 28 women go on prenatal leave. With a singleton pregnancy, maternity leave occurs only at 30 weeks.
- At week 30 babies bend to fit in the uterus and significantly reduce physical activity.
- From 34 weeks the placenta (or placenta) begins to age.
- From 35 weeks children activate the adaptive mechanisms of the central nervous system. This will help them adapt to their new environment after birth.
- From week 37 babies are considered fully term.
Mom's well-being
The course of multiple pregnancies differs markedly from the course of the usual one, therefore, most of the clinical recommendations that exist for pregnant women are not very relevant for twice or three times expectant mothers. The main difference between pregnancy with twins or triplets is the increased risk of complications.... Unfortunately, medical statistics are disappointing - up to 85% of multiple pregnancies occur with various complications.
In pregnant women, the belly begins to grow with more than one baby, the state of health and condition worsens earlier, it is just 2-3 times harder for them to carry their children. After the news that a woman is expecting twins, she should prepare in advance for the fact that it will be very difficult. Very often, such pregnant women develop iron deficiency anemia. Double doses of iron preparations will help to avoid the unpleasant consequences of this condition., which will be prescribed by the doctor from the very first trimester of pregnancy.
With multiple pregnancies, severe toxicosis often develops in the early stages, which may require hospitalization and treatment in a hospital setting. The risk of severe gestosis in the second or third trimester of pregnancy is 5 times increased. The risk of the formation of abnormalities of the placenta is 4 times increased - its presentation or partial presentation, which will make natural childbirth impossible, children will be born by cesarean section.
If babies feed from the same placenta (monochorionic twins), then there is a high risk of premature aging of the placenta."Children's place" develops its resource faster. Such a complication threatens the state of intrauterine hypoxia for children, developmental delay and even intrauterine death. There is a risk of fetal misrepresentation. Particularly dangerous is the pelvic or transverse presentation of the child that is closer to the exit from the uterus. In this case, you will also have to give birth by caesarean section on the operating table.
The risk of premature birth is very high, with almost half of multiple pregnancies ending well ahead of schedule.
The uterus grows twice as fast, the first movements are felt earlier, but already at the end of the second trimester, the uterus is excessively stretched, which leads to a variety of pain sensations.
The load on all systems of the female body during multiple pregnancies is high. Therefore, at any moment, old, chronic diseases, the existence of which, perhaps, the woman has long forgotten, can aggravate. Diseases of the heart and blood vessels, kidneys and liver are most often exacerbated. The risks of hemorrhoids, varicose veins, and hypertension increase several times.
The nature of the discharge during a multiple pregnancy is not much different from the discharge during a singleton pregnancy; at this point, you should not look for significant differences.
Pregnancy management
Obstetricians and gynecologists have special instructions for managing multiple pregnancies, because the risks are really high and the danger is not exaggerated at all.
A woman who is carrying several fetuses will have to visit her doctor more often.... The condition of such a pregnant woman needs more frequent monitoring. Everything is important - weight gain, and the appearance of edema, and urine tests. Particular attention will be paid to the prevention of gestosis. A woman several times during the gestation period will have to do a coagulogram - a special blood test that shows the factors of its coagulability, often take a general blood test for early detection of changes in hemoglobin concentration.
From the very first trimester, the expectant mother of two or three children will receive all recommendations on proper nutrition, in terms of the level of physical activity. Multiple pregnancies are considered a good reason for limiting physical activity from the second trimester to reduce the risk of preterm birth.
At 20 weeks, the state of the cervix will be examined in order to exclude its premature shortening, isthmic-cervical insufficiency, because the pressure of the fetus on the internal os of the cervix is twice as high.
From 29-30 weeks, pregnant women with several fetuses are assigned a weekly CTG. A cardiographic study (non-stress test) will provide a rich food for thought to the doctor - how babies feel, are there signs of hypoxia, whether their autonomic nervous system is well developed. In case of any doubts, an ultrasound scan with Doppler (Doppler) will be performed to assess the nature and speed of blood flow in the umbilical cords of each fetus, the state of the placenta (or placenta, if it is one for two).
A woman should prepare herself mentally in advance for the fact that in any incomprehensible situation, if the test indicators deteriorate, she will be hospitalized in a hospital. Under medical supervision, the chances that everything will be in order with the children and their mother are always much higher.
Childbirth
Clinical recommendations of the Russian Ministry of Health indicate that in case of multiple pregnancies, carrying up to 40 weeks is undesirable... Therefore, if labor itself does not begin before 37 full weeks, when the babies are considered fully term, it is recommended to hospitalize the pregnant woman and stimulate labor.
If there is an indication for a caesarean section, it is recommended to perform it at 37-38 weeks of pregnancy, whereas with a singleton pregnancy - at 39 full weeks. With identical twins in one fetal bladder, the operation time is 33-34 weeks, since there are high risks of twisting of the umbilical cord, and with triplets, it is recommended to perform a caesarean section at 34 full weeks.
A decision in favor of a caesarean section is usually made if:
- during pregnancy there were complications, there is gestosis, pathological weight gain, edema;
- presentation of the first fetus is not head, but any other;
- twins are not just monochorionic (having one placenta for two), but also monoamniotic (one fetal bladder for two);
- placenta previa;
- the presence of chronic diseases in the mother, in which natural childbirth may have poor prognosis;
- pregnancy resulting from the IVF cycle.
Many are interested in whether natural childbirth is possible with multiple pregnancy. Yes, they are quite possible, and many mothers successfully give birth to their babies through the physiological birth canal. But for those who are about to give birth naturally, you should know that every third woman in labor has amniotic fluid poured out prematurely, while quite often the umbilical cord loops, the limbs of babies fall out into the genital tract. Other possible complications of childbirth include the risk of weakness of labor forces, which occurs due to the fact that the walls of the uterus are critically overstretched.
The period of expulsion of the first of the children usually slows down until prolonged childbirth, which is dangerous with acute fetal hypoxia, death of babies or their disability.
If childbirth is premature, then they often proceed rapidly, which is fraught with birth trauma and rupture of the perineum, cervix.
The most dangerous complication is considered to be premature discharge of the placenta after the birth of the first child. If this happens, the second baby may experience acute hypoxia, which can kill him or cause irreparable damage to the state of his brain.
Throughout the entire birth process, doctors closely monitor the state of the fetal heartbeat using CTG. At any time, an epidural anesthesia will be ready, drugs that stimulate contractions, if the labor forces weaken. Modern obstetricians are always reinsured, and while the woman in labor is in the stage of labor, they prepare the operating and surgical team in case complications arise and an emergency caesarean section has to be performed - with multiple births, such a need really arises quite often.
