Multiple pregnancy: how to endure it? Multiple pregnancy

02.08.2019

Children are a real miracle! How touching to look at someone's rounded tummy and imagine that real life is developing there. And how amazing it is when two, three, or even four such lives grow there at the same time!

Statistics say that today about 1.5% of newborns are twins. And their number has been constantly increasing in recent years. There are already about 100 million of them on the entire planet. The most "prolific" nation is Africa. But the least lucky with the twins of the Mongoloid race.

Causes of multiple pregnancies

Multiple pregnancy is the simultaneous development of two or more fetuses. Why does one woman become the future mother of only one baby, and the other - four sons and a little daughter at once?

Doctors have not yet given an unambiguous answer. In their opinion, many factors can influence this at once. Of course, women who have already had such cases in their family are more likely to have twins. Accordingly, one of the reasons is heredity. Moreover, equally - as a future father with many children, and a future mother.

Another factor is age. According to statistics, older women develop multiple pregnancies much more often than younger women. It's just that the former greatly increase the level of gonadotropin, a hormone that stimulates the development of the egg and its release from the ovary.

Another factor, according to doctors, is the intake of hormonal drugs, both for the treatment of infertility and as a method of preventing unwanted pregnancy. And, of course, twins and twins appear much more often with an egg: firstly, a woman takes special drugs against infertility, and secondly, she is injected with several fertilized eggs at once.

Features of multiple pregnancy

In natural multiple fertilization, immediately after the fusion of the female and male germ cells, one egg divides, or two (or even more) eggs are fertilized at the same time. In the first case, monozygotic - that is, identical - twins appear, in the second - dizygotic, or fraternal.

Monozymes - babies who are born with one fertilized egg. In this case, the twins are always of the same sex and the same blood group. They have the same set of genes. Siamese twins are identical - their egg divides into two at the wrong time.

Two eggs are babies born during the fertilization of two eggs. They can be of the same sex, or both boys and girls can be born at the same time. The same applies to the blood group - one can take mom's, the other - dad, or all the kids will have the same group. They have from 40 to 60% genes in common.

Women with multiple pregnancies are at risk, because nature is designed so that the body should bear and feed only one child. In the womb, babies do not have enough oxygen, space, nutrients, and therefore, in case of multiple fetuses, various complications such as miscarriage, malformations and fetal death, intrauterine growth retardation, premature birth, and low birth weight are not excluded.

The main problem of multiple mothers is very large tummies. In addition, after the 20th week of pregnancy, they are advised to stop practicing active sports, to give up, from sexual activity. A mom, in whose belly several babies are growing at once, must observe strict bed rest - for example, she must rest at least 8 hours in the afternoon. It is also good to be under the supervision of your doctor.

Such a mom should pay special attention to her nutrition, because if a woman with a singleton pregnancy should gain 12-13 kg, then for a multiple pregnancy this increase should be at least 18-20 kg.

Early signs of multiple pregnancy

Multiple pregnancies can be determined by. True, in the early stages it is not always "discovered", since the probability of an error is high. More precisely, a woman is diagnosed towards the end of pregnancy. The conclusion about multiple pregnancy is also based on the large and increased size of the uterus for a given period, palpation of the three largest parts of the fetus, listening to several heart rhythms, and in different places. All these signs are determined by the gynecologist during an in-person examination of his patient from the second trimester of pregnancy.

But can a woman on her own even in the early stages of pregnancy, if not determine, then at least suspect that she is carrying more than one life inside herself?

Obstetricians say that there are no specific symptoms that would indicate the development of multiple pregnancies. As always, a woman can feel any sign indicating conception has taken place: nausea, vomiting, fatigue, impotence, an increase in the size and sensitivity of the mammary glands, a slight increase in body temperature and / or an increase in basal temperature, etc., etc.

Nevertheless, some features of the course of pregnancy may still be a hint of multiple pregnancy. Among them, in particular, the following can be distinguished:

The pregnancy test reacts with a second strip even before the delay, which is due to an increased (compared to a normal pregnancy) level of the hCG hormone in a woman's body, which is produced by two (or more) embryos at once.
Nausea and vomit more and more often, that is, a pronounced early toxicosis in severe form is more likely to develop.
The woman feels very tired and wants to sleep almost all the time, because the body is forced to work several times harder.
The tummy looks larger than it actually is, since the uterus grows faster than in a singleton pregnancy.
The weight gain is in excess of the allowable limits, and this is not related to nutrition or other visible reasons.

Once again, we draw your attention to the fact that these signs can only indicate the likelihood of multiple pregnancy, but in no case are it confirmation.

Childbirth with multiple pregnancies

As a rule, women with multiple pregnancies have childbirth: babies are usually born with a small percentage of prematurity. What will be the delivery depends, first of all, on the babies. If both have a cephalic presentation, then natural childbirth is quite acceptable. In other cases, everything is decided by the doctor who observes the woman.

Such a mother usually has a poorly manifested labor activity or she is very weakened, and therefore often labor has to be stimulated. The amniotic fluid leaves ahead of time, and the placenta of the second fetus also exfoliates in advance. The fetus often has abnormal presentation and hypotonic bleeding. Here a great responsibility lies with obstetricians and gynecologists.

However, there is absolutely no need to be afraid and worried if you are carrying several children at once: more than 90% of multiple pregnancies proceed practically without any complications and are resolved safely and happily. Complications and difficulties may be, but will not necessarily be, and not a single pregnant woman is insured against this, no matter how many babies she carries.

Specially for- Maria Dulina

Today the number has increased significantly compared to the last century. This is due to the fact that the number of induced conceptions and the age of parturient women have increased. But in parallel with the number of such pregnancies, the risks associated with bearing two, or even three babies at once, and their birth are also increasing. Such a pregnancy is initially considered as difficult, with a high risk of various complications and health problems, therefore it is carried out according to special rules and with more targeted observation. Let's dwell on all its nuances in more detail.

Features of multiple pregnancy

Multiple pregnancy, or otherwise - bearing two or three, and sometimes more, fetuses at once, refers to a serious problem of modern obstetrics. The periods after the 22nd week of pregnancy up to delivery and the first 6-8 weeks of the postpartum period, when the woman's body becomes pre-pregnant, are especially difficult in terms of management and prognosis, complications and their elimination. It is at this time that the likelihood of complications is high, babies with malnutrition and the development of chronic are much more often born. In addition, with multiple pregnancies, the likelihood of developing intrauterine fetal malformations, both one and all at once, is higher.

Attention!Such a pregnancy is always treated as initially complicated, when compared with normal gestation. Therefore, it is necessary to register and be monitored by the mother of twins or triplets as early as possible, and strictly monitor the state of their health.

The mortality rate of children and women in labor is close to 8-10%, which is associated with a high risk of complications and a lower weight of children in comparison with the birth of one fetus. The risk of intrauterine malformations is increased by 2-3 times, the risk of intrauterine fetal death is sharply increased if they are not properly monitored, and such indicators, despite all the efforts of doctors, do not decrease for a long time.

Causes of multiple pregnancies

Multiple pregnancy is a collective term that includes the bearing of more than one fetus in the uterus. These can be twins, triplets and more children. Over the past quarter of a century, the number of such pregnancies has increased in different regions and countries by 2-3 times, making today up to 1.5-2% of all pregnancies. In this case, twins are most often born, according to data - 1:90 of all genera. The birth of triplets is 1: 6500 births, and the greater number of fetuses is 1: 55000 and above.

The exact reasons for the birth of several children at once have not been sufficiently studied, but due to progress in reproductive medicine and inducing pregnancy (artificial insemination, ICSI and other methods), the number of such pregnancies has become higher. If we talk about the appearance of twins and triplets in a natural way, then the main factors are:

Heredity if twins or twins were born in the family of one of the parents. The connection along the female line is especially clearly traced, moreover, this phenomenon usually manifests itself through a generation.
Increase in the blood plasma of the expectant mother of the FSH level(follicle-stimulating hormone) that helps in the growth and maturation of the egg. Exceeding its physiological level leads to the simultaneous maturation of two or more follicles. A similar fact can be both hereditary and acquired in nature - the FSH level is stimulated by taking drugs for, taking and then abruptly canceling them, using various stimulation techniques.
Repeated pregnancies usually they are more often multiple due to the fact that the body has already "rolled" the mechanisms of follicle maturation and fertilization, gestation and childbirth.
Significantly affects and a woman's age, usually exceeding 30-35 years... According to scientists, this is due to a decrease in fertility as a result of the gradual extinction of ovarian functions and the monthly maturation of eggs. This leads to the accumulation of the level of stimulating hormones and their effect on the ovaries with the maturation of two or three follicles at once.
May also be the reason anomalies in the structure of the genitals that affect the cleavage of the zygote during the implantation period.

But most of the causes of multiple pregnancy have not yet been identified, there are families where twins are born from generation to generation, but there are also those in which they appear for the first time in genealogical history.

Pregnancy with IVF

A special option for the development of multiple pregnancies is application (in vitro fertilization, outside the body, the conception and development of embryos occurs with their further implantation into the mother's uterus). With it, active stimulation of the ovaries takes place with the receipt of several mature eggs at once, which, after fertilization with the spouse's sperm and successful development, are implanted into the uterine cavity. Usually, two or more fertilized embryos are transplanted at once due to the fact that not all of them take root. But it is also possible to develop two or even three babies at once.

Types of multiple pregnancy: classification

According to the peculiarities of fetal development, based on whether they are monozygous or dizygotic, and also based on what chorions they have (outer membranes of the fetus), the number of amniotic cavities is used to monitor the pregnant woman and the tactics of its management. Therefore, the classification of multiple pregnancies has its own characteristics.

By zygosity, that is, according to the cell from which children develop, they distinguish:

monozygous twins, which are formed from initially one cell, which, for various reasons, gave birth to two embryos at once.
dizygotic twins, these are, in fact, ordinary brothers and sisters, born on the same day, they turned out from two different eggs, simultaneously matured and fertilized.

Dizygotic twins

If there is a simultaneous release of two eggs from the ovary at once in one menstrual cycle, and both of them are fertilized, then pregnancy with dizygotic twins can develop. The percentage of such gestations reaches 70%, and at the same time children are similar to each other like ordinary siblings... They can be of different sexes, have different hair and eye colors, different chromosomes and individual characteristics. They can have different blood types and Rh factors, and these babies are called twins or fraternal twins.

During pregnancy with triplets and a large number of fetuses, variants of both monozygous and dizygotic pregnancies are possible in various combinations.

Fraternal twins always have their own placenta and their own set of membranes. Each of them has its own fetal bladder and amniotic fluid. In fact, in the mother's belly, they live like neighbors, in different “apartments”.

Monozygous twins

According to the number of fetuses, monozygous twins and triplets can be distinguished. They account for about 30% of all multiple pregnancies. Children in a similar situation are formed from one common cell, which at the early stages of development was divided into two or more embryos. In the future, babies will develop completely identical, but according to an individual program, like two separate organisms.

These are the so-called identical or monozygotic twins or twins. They are always of the same sex, have an identical set of chromosomes, look like two drops of water - with the same eye and hair color, blood group, finger skin patterns, tooth shape and other features.

Features of the development of monozygotic twins, depending on the period

Identical twins form in the early stages of the division of a fertilized egg (zygote). Depending on how early it was divided into two independent organisms, there will be features in the development of such babies. So if:

If the zygote is divided between the 9th and 13th days from conception, a common placenta and fetal membranes are formed, and children with such a division can be partially fused - Siamese twins ... Fusion can be of varying degrees - common pelvis and lower limbs with separate chest and upper body parts, fusion in the back, head, etc.

Difference between types of twins: how to identify?

You can find out the exact belonging of twins to one type or another after birth. If there are partitions between twins of only two membranes, these are identical twins, if there are four partitions and the placentas are different, these are identical babies. In addition, today this can be found out according to data starting from the second trimester of pregnancy, and this is important in order to build a plan for the management of pregnancy and predict its possible complications and tactics in childbirth. It is important to closely monitor the development of fetuses in any type of multiple pregnancy, since various pathologies in the development of fetuses and special phenomena (for example, a syndrome or the phenomenon of stealing one fetus by another) are possible.

The course of multiple pregnancies

Initially, such a pregnancy is difficult for the expectant mother, and it is classified as pathological, requiring detailed, active and dynamic observation. From the very first trimester, various complications and health problems are possible, about which a woman should be warned so that she does not worry and see a doctor on time.

note

According to doctors, carrying twins, and especially triplets, is a difficult process. The situation is especially serious with those twins who have different blood types and Rh factors. Twins are more difficult to bear than twins, due to the fact that the latter have one chromosome set, they are perceived by the mother's body as a single whole. And twins have two different chromosome sets, and the mother's immunity perceives them as two half-alien subjects.

On average, a pregnancy with two fetuses reaches a maximum of 37 weeks, and with three - up to 35 weeks and earlier.

Features of the course and possible complications in the early stages of pregnancy

In the early stages of multiple pregnancies, there are no special differences, but by the eighth day, implantation bleeding is possible, which on average can last up to 4 days, and which is formed during embryo implantation. During pregnancy with twins, it can be more noticeable and pronounced, repeated and sometimes turns into and. In addition, after implantation, all signs of pregnancy and, which happens in almost all women, and with, and severe malaise, are more pronounced.

Multiple pregnancy problems in the middle of term

One of the serious and common problems in the second trimester with multiple pregnancies can be ICI (isthmic-cervical insufficiency when the cervix is too weak for increased stress and cannot bear the weight of the fetus). This complication occurs much more often than during normal gestation, and occurs due to a more active and pronounced stretching of the walls of the uterus, an increased amount of amniotic fluid and the mass of children.

Usually it can be expected after 22 weeks of pregnancy, it develops quickly and without treatment is prone to progression. If sutures on the neck can still help with twins, then when carrying three or more children this does not help, the seams can be cut due to heavy loads. Therefore, the wearing of an additional unloading pessary is often also used.

Possible problems late in pregnancy

As babies grow and body weight gains, the volume of blood circulating in the vessels increases by at least half, which leads to increased stress on the myocardium, while when carrying one baby, the load usually does not exceed 30% or a little more. There is also a dilution of blood, which threatens polyhydramnios, and this, in turn, threatens problems in the functioning of the kidneys. Frequent, and the more fetuses in the uterus, the more likely they are.

Multiple pregnancies can be a background for the development of diabetes in pregnant women, and also refers to background conditions for exacerbation of chronic pathologies, in connection with which it is important to constant dynamic observation by a doctor with regular passing of all tests.

Multiple pregnancy after cesarean section

The problem can become especially serious if the multiple pregnancy is not the first and it occurs after the previous one. It is associated with an even greater risk, both for the expectant mother herself and for the babies developing in the uterus. If we talk about the complications that are possible with such a gestation, these include:

Circulatory problems in the wall of the uterus where there is a scar after surgery, especially if the placenta of one or both fetuses is attached in this area. This can threaten nutrient and oxygen deficiencies, which can lead to developmental delays.
Due to the scar, placenta previa or its low location can form, there is a risk of its premature detachment with bleeding.
Threats of termination of pregnancy may form.
The position of the fruit may be incorrect (oblique, transverse,).

The most dangerous will be the complication that is formed as a result of the failure of the suture, then it runs the risk of rupture, which is life-threatening.

Alena Paretskaya, pediatrician, medical columnist

Under the concept of multiple pregnancy, modern medicine implies a situation when several future babies (from two or more) develop in the womb instead of one fetus. The name of such a pregnancy is different, and depends on how many fetuses the expectant mother develops. If a woman bears twins, then such a development of pregnancy is called twins, if more, then, respectively, triplets and ascending.

Multiple pregnancies are considered to be quite rare phenomena, which in percentage terms is expressed in terms of 0.7 to 1.5% in European countries and the American continent. This number is gradually starting to rise with the advent of new reproductive opportunities that increase the likelihood of developing multiple pregnancies. Two healthy babies can arise from two types of pregnancy, differing from each other in the mechanism of conception.

Pregnancy can be:

Dvuyatsova (dizygotic);
Monozygotic (monozygous).

In the first case, children are considered twins, and in the second method, twins. In 70% of cases, such a pregnancy takes place in a bilingual form. In the case of a monozygous course of pregnancy, babies will be completely identical in appearance, since they develop from a single egg and, accordingly, have the same genes. At the same time, twins differ both in gender and in many external features, since a dizygotic pregnancy endows babies with a different composition of chromosomes. The development of a double pregnancy is facilitated by the simultaneous fertilization of two eggs, which are attached in different parts of the uterus.

Very often, such conception occurs during several sexual intercourses during one period of ovulation. Although there are times when two eggs are fertilized during one sexual intercourse. The condition for such fertilization is the presence of eggs from both ovaries.

Twin pregnancy - twins

A fraternal pregnancy involves the presence of its own placental membrane and a separate fetal bladder for each fetus. From a medical point of view, the situation where each fetus has its own bladder and an individual placenta is referred to as bichorionic biamniotic twins.

Twins

In other words, in the uterus there are simultaneously 2 placentas (biharial) together with two fetal bladders (biamic) and each child grows each in its own placenta. During an identical pregnancy, both embryos begin to develop from one egg, which at a certain moment divides into two independent cells and a new life of the unborn child develops in each of them.

It is impossible to name the exact number of placentas and fetal bladders during such a pregnancy: this individual factor depends on the time when the fertilized egg was divided. If such a separation occurs within 72 hours after conception, during which the fertilized egg does not yet have time to attach to the uterine wall, then two fetal bladders with two placentas are formed.

From a medical point of view, such a pregnancy is also called bichorial biamniotic (two placentas and two fetal bladders). In the case when the separation of the oocyte occurred at a later period, but no longer than 8 days (at the stage when the egg has already attached to the uterus), then in this case, the formation of two embryos with two fetal bladders, however, is the same for two surrounding placenta. there are future twins separated from each other by the fetal bladders, but they receive food from the common placenta. In accordance with the facts, such a development of pregnancy is called monochorionic (one-placental) biamniotic (with two bubbles).

The latter situation is associated with the division of the egg in the period from 8 to 13 days - the female body will be able to form two fetuses, but with a common placenta and with a single fetal bladder. Nutrition will come from one placenta - for each baby it will be fed through a separate umbilical cord for each embryo.

Such a pregnancy is called monochorionic (single placenta) monoamniotic (single fetal bladder). The separation of the ovum, which occurs after 2 weeks from the moment of fertilization, leads to the development of Siamese twins - that is, babies with fused body parts.

For the body of a future mother, the safest types of double pregnancy are two-egg and identical bichorionic biamniotic twins. During the development of monochorionic biamniotic pregnancy, there is a possibility of complications of pregnancy and delayed development of embryos. Potential mothers with a monochorionic monoamniotic course of fetal development are at greatest risk.

During natural fertilization, the possibility of developing multiple pregnancies is equal to a maximum of 2%. Among these two percent, the majority of pregnant women (99%) have twins, and only one percent of conception is due to pregnancies with triplets and a large number of children. The development of fetal pregnancy is accompanied by several factors:

The woman is over 35 years old;
Conception during the period of lengthening daylight hours (in spring);
Mothers who have had a similar pregnancy before;
Conception with the help of additional reproductive technology solutions.

The use of such modern medicines as "Clostilbegit" or "Clomiphene", increase the likelihood of developing multiple pregnancies up to 8%.

At the same time, we note that in the case when agents containing gonadotropin were used to improve the reproductive form, the chance of conceiving twins increases by 25-35%. The maximum likelihood of multiple pregnancies is provided by the use of reproductive technologies (IVF). In patients using this system, the likelihood of multiple conception increases to 40%.

The use of in vitro fertilization from various sources increases the likelihood of multiple conception from 35% to 55%. The number of developing embryos in this case can be from two to four. IVF technology operates on the following principle: four embryos are placed in the uterus and how many of them eventually take root, the woman will give birth to as many children later.

As practice shows, any number of attached embryos can take root at the same time: that is, it can be one child, or maybe all four attached fetuses. Accordingly, a woman, in this case, is faced with a multiple pregnancy.

Subsequent ultrasound will show the number of surviving embryos, and after that the expectant mother will be asked to make a choice to preserve all the embryos that have taken root, or to go for an operation to remove excess embryos. If only half of the embryos have taken root, it is recommended to leave both. But, of course, the mother-to-be has the last word. A pregnant woman can also leave three or all four embryos that have taken root, if she so wishes, and as a result, she will become a mother for three or four babies.

The next stages of fetal development in women using the IVF system for conception is no different from conceptions that occurred naturally. The operation, during which an extra embryo is removed from the uterus, is called "Reduction".

Nowadays, the reduction is offered not only to mothers who artificially conceived three or more embryos, but also to persons who have three or more fetuses after natural conception. This is done to reduce the likelihood of complications during pregnancy, childbirth and postpartum development that can develop under the influence of multiple pregnancies.

During the operation, doctors always leave two fetuses in case one of the embryos dies or a miscarriage occurs. In any case, the reduction procedure is carried out entirely at the request of the pregnant woman. It is up to her to decide how many embryos to leave for further development, and how many to remove. In what cases the reduction is contraindicated:

If the pregnancy is more than 10 weeks;
The presence of acute infections and inflammatory diseases;
With the threat of miscarriage.

At a later date, it is unacceptable to carry out a reduction, since the remnants of fetal tissues, which cannot always be completely removed, can provoke irritation of the walls of the uterus and cause a miscarriage. Modern medicine offers several types of reduction.

Transcervical method

Performed under ultrasound control. For him, a soft and flexible enough catheter is used, which is inserted into the uterus (having previously connected an aspirator to a vacuum). The catheter is slowly advanced towards the embryo to be removed. When the tube touches the fetal bladder, a vacuum aspirator is launched, sucking the embryo along with the surrounding fetal bladder into a special container.

We can say that this type of reduction is similar to the method of incomplete vacuum abortion. However, this method is not the safest for the uterus and, therefore, its use is rare.

Transvaginal method

During the operation, anesthesia is used. The procedure is also performed using an ultrasound scan. With the help of a biopsy adapter, the embryo is pierced with a puncture needle, which is immediately removed after the procedure. This method is common in many clinics.

Transabdominal method

During the operation, general anesthesia and ultrasound control are used. The technique is similar to the amniocentesis procedure. With the help of a puncture made on the abdominal wall, a needle is inserted, which subsequently pierces the embryo, and the needle is removed.

No matter how modern the reduction methods used are, any of them carries a potential danger. Up to 35% of pregnant women who used the reduction surgery had complications or experienced miscarriage as a result. That is why most expectant mothers prefer the difficulties of carrying multiple pregnancies than the likelihood of losing their unborn child after surgery.

Note that obstetrics has stepped forward and today it is much easier and safer to carry two or more babies than, say, 15 years ago.

The currently known multiple pregnancy record was recorded in 1946 - a resident of Brazil carried 8 girls and 2 boys. But the joy of motherhood did not last long. All the children died within six months. In addition to her, a Spanish woman in 1924 and a Chinese woman in 1936 became the owners of bearing 10 children.

Today, the maximum number of babies that can be safely carried is six fetuses. With a larger quantity, there is a delay in growth and development, which does not disappear over time.

As the practice of recent years shows, multiple pregnancies, regardless of the method of conception (natural or artificial), occurs much earlier than usual and ends at 40 weeks of pregnancy. Already during this period, women begin childbirth due to too much stretching of the uterus.

Naturally, such babies are born prematurely. The onset of premature birth directly depends on the number of children being born: the more babies are expected, the earlier the birth will begin.

The average time to the end of pregnancy for multiple pregnancies is as follows:

Twins are born at 36-37 weeks;
The triplet is born at 33-34 weeks;
Four babies are usually born at 31 weeks.

Age

One of the possible causes of multiple pregnancies is the age of the expectant mother. After 35 years, the female body begins hormonal changes and gradually prepares for pre-climatic changes. As a result, the number of simultaneously ripening eggs from one can change by several pieces. And this can happen in every cycle. The likelihood of multiple pregnancies also increases in those who have given birth before.

Ginetics

The next reason: genetic predisposition. According to statistics, the ability to have multiple pregnancies is expressed in one generation. With a genetic tendency, the likelihood of multiple pregnancy increases up to 8 times.

Hormonal

Use of reproductive drugs. All hormonal drugs aimed at increasing the likelihood of getting pregnant or curing infertility, as well as drugs used to restore the menstrual cycle, increase the likelihood of maturation of several eggs ready for fertilization at once.

Frequent labor

Frequent childbirth. Frequent childbirth can be one of the reasons for the development of several embryos at the same time.

Artificial insemination

In vitro fertilization. Borrowed mature eggs are artificially fertilized using male sperm in a pre-treated test tube. The fertilized cells are attached to the uterus. This method involves attaching 4 embryos at once, as a result of which multiple pregnancies are very often obtained.

Such a large number of embryos are planted for the reason that any or a few of them may not take root and die. It also happens that all attached embryos begin normal development. But this is more of a rare occurrence than commonplace. Most often, one, two or three fertilized eggs take root.

The best modern method for determining multiple pregnancies is ultrasound diagnostics. But besides her, there are a number of signs by which doctors monitored pregnancy in the old days. These signs are still relevant today. It is they who will help the expectant mother and the doctor in time to determine the likelihood of carrying a multiple pregnancy and then make the most accurate ultrasound, showing or refuting the theory in detail.

The size of the uterus does not correspond to the duration of pregnancy (the size is increased);
Inconsistency of the location of the pelvis or the head of the unborn child at the entrance to the pelvic region. In this case, the high standing of the day of the uterus is also taken into account;
The volume of the abdomen does not match the size of the fetus;
Too large belly at an early stage;
Fast weight gain;
The equipment listens for 2 heartbeats;
The level of hCG and lactogen exceeds the standard values several times;
Increased toxicosis already in the early stages;
High physical fatigue;
Frequent constipation
Swelling of the legs;
High blood pressure.

If a pregnant woman has several of the listed signs at once, then the likelihood of developing multiple pregnancies is high. But to confirm the diagnosis, it is imperative to undergo an ultrasound scan - only it can accurately diagnose the type of pregnancy.

Another way to confirm such a pregnancy is to take a blood test for hCG - but if you have a choice, it is better to use the ultrasound diagnostic method, as it is more accurate.

Ultrasound - diagnosis of multiple pregnancies

Ultrasound can be performed within a month after conception. On the monitor, the doctor can see, if any, several developing embryos. The method of managing multiple pregnancies depends, first of all, on the number of placentas and fetal blisters formed. Monozygotic or bilingual pregnancy does not affect the choice of pregnancy monitoring tactics.

The best is the development of bichorionic biamniotic twins, in which each fetus has its own placenta and fetal bladder. Monochorionic monoamniotic variation of pregnancy, in which several embryos are connected by one common placenta and a common fetal bladder (nutrition in this case comes from one source and is delimited by separate umbilical cords) is considered the most difficult in terms of maintaining the bearing and the prosperous development of the unborn child.

During the ultrasound diagnostics, the specialist will immediately see all the necessary points in the development of embryos, as well as the total number of placentas and fetal bladders. Ultrasound diagnostics is extremely important for multiple pregnancies. It is it that will show the violation of the development of the fetus and possible congenital defects. Biochemical blood tests cannot detect such abnormalities. In this regard, ultrasound examination must be carried out already in the early stages of 10-12 weeks of pregnancy - during this period, the quality of development of each fetus is already visible.

HCG tests are rather an additional way to confirm the course of pregnancy than the main source of information. HCG rises several times higher than the normal pregnancy rate if several fetuses develop in the uterus at once.

The development of multiple pregnancies

Any pregnancy is a test for the female body. Multiple pregnancies increase the already difficult workload by several times. Practically all organs and life support systems are tested.

The greatest load falls on:

Cardiovascular system;
Urinary system;
Respiratory system.

The bone marrow, spleen and liver begin to work in an enhanced mode, without giving any rest and fasting days. And all this happens for 40 weeks. After all, the body supports not one life, but two or more growing organisms in the womb. With each new day, embryos require more space and nutrition. Therefore, it is not surprising that expectant mothers who are faced with multiple pregnancies are more likely to suffer from various infections and diseases.

The likelihood of catching the same flu or cold increases 3-7 times in comparison with pregnant women who carry one child under their heart. The more embryos the expectant mother carries, the higher the likelihood of catching any infection or catching a cold out of the blue.

If, before the onset of pregnancy, a woman had problems with any chronic disease, then its consequences will definitely return to her, but in an even more severe form. The same goes for infectious diseases. All this is due to too much stress that the female body faces throughout pregnancy.

Gestosis

Almost half of pregnant women face such a problem as preeclampsia. Not a single pregnant woman with multiple fetuses has escaped leg edema and high blood pressure in the second and third trimesters for a long time. And this is considered absolutely normal, since developing fruits require more and more nutrition and special conditions.

Anemia

A disease such as anemia is also widespread among expectant mothers with multiple pregnancies. Therefore, it is imperative to carry out prophylaxis through fortified food and the intake of special dietary supplements containing iron. For the full development of future babies, their mother must eat intensively and fully.

Weight gain during multiple pregnancies

After all, her need for daily calorie intake is several times higher and reaches 4500 kilocalories per day. At the same time, it is not recommended to use chocolate and a large amount of flour products to replenish nutrients. It should be healthy food with a wide range of nutrients. Poor nutrition leads to depletion of the body, which in turn increases the likelihood of developing severe pathologies in a chronic form, and also creates the likelihood of complications during gestation.

With multiple pregnancies, a woman on average gains about 22 kilograms, while half of this weight is added at the very beginning of pregnancy. Statistics show that with the development of multiple pregnancies, one fetus is always larger than the second.

The ratio in the difference in weight and height can reach 20%. If this is shown more, then there is a possibility of a delay in the development of the second fetus. This phenomenon also occurs in singleton pregnancies, but with multiple pregnancies, the likelihood of developmental delay is 10 times higher. The greatest risk is observed in women with a monochorionic course of pregnancy, while those with a bichorionic biamniotic course are less likely to encounter this problem.

Multiple pregnancies, due to the high stress on the uterus, usually ends earlier than a normal pregnancy. Those who carry twins usually give birth at 36-37 weeks, mothers of three babies at 33-34 weeks. If 4 babies are born at the same time, then the timing of childbirth is shifted to 31 weeks. Multiple pregnancies prevent babies from gaining the necessary body weight. Therefore, children are born with less weight and relatively short stature. Otherwise, multiple pregnancies are no different from single-child pregnancies.

Multiple pregnancies can be accompanied by the following complications:

Miscarriage in the first trimester of pregnancy;
Premature birth;
Death of one or more embryos during development;
Gestosis;
Prolonged bleeding after childbirth;
Hypoxia;
Fetal collision due to which both children are ready to leave at the same time;
Fetofetal blood transfusion;
Congenital malformations of one or more fetuses;
Birth of Siamese twins.

Other complications are the same as in a singleton pregnancy. If the fetuses are arranged vertically, as expected, then during childbirth there are no problems with leaving the uterus. But often doctors have to do a caesarean section. due to complications that occurred during gestation.

For those who are faced with multiple pregnancies, it is important to be hospitalized in the maternity ward about a month before the expected date of birth of children. Being under the supervision of specialists and having passed all the necessary examinations, the doctor leading you will decide on the method of giving birth to babies: whether it will be a natural birth or a cesarean section.

Typically, the decision tree looks like this:

a caesarean section occurs if there is a complication during pregnancy, or one of the babies is incorrectly positioned. Caesarean is also used in a situation where both fetuses are simultaneously in the pelvic region and in the presence of scars on the uterus.

If the fetus is in the correct position and the woman feels well, then natural childbirth is recommended. If they have problems, the doctor may perform an unplanned caesarean section.

Nowadays, doctors are increasingly using a planned cesarean section.

When they give sick leave

In case of multiple pregnancy, the expectant mother can go to hospital as early as 28 weeks, in contrast to the 30 week period of a singleton pregnancy. In all other respects, the period of validity of the sick leave does not differ.

Most often, women experience multiple pregnancies vividly and, as a result, speak positively about it, despite all the difficulties they face in the process of gestation. Speaking of difficulties, I mainly recall fatigue, a large belly and swelling. According to those who have already given birth to several babies, the greatest difficulties begin from the fifth month of pregnancy. They associate this with a large weight gain and, as a result, an increased load on the musculoskeletal system.

In addition, most new mothers talk about the importance of moral preparation for the dire physical consequences of gestation. Many were constantly tormented by the feeling of hunger, despite the abundant and nutritious food. Most women gave birth at 36-38 weeks, and mainly by caesarean section. Those few mothers who gave birth naturally agree that there is nothing particularly difficult in such births and positively perceive their experience.

Remember, being a mother is not only a great happiness for any woman, but also a great responsibility. If you are facing multiple pregnancies, don't panic. Talk to your doctor, discuss the current situation with loved ones. It is up to you to decide whether to maintain a multiple pregnancy. If you are not ready for this, doctors will come to your aid. But if you want to take a chance and give birth to two, or even more babies at a time, then you should know that you will succeed.

Despite the fairly high modern level of development of obstetrics and obstetrics, women with multiple pregnancies are still at high risk. The management of multiple pregnancies and childbirth itself are significantly different from the usual pregnancy with one fetus. They require experience and in-depth knowledge of this condition from medical personnel.

Relevance of the topic

Features of multiple pregnancies determine the relevance of the problem for obstetrics in general and, in particular, for obstetrics of the perinatal period (from 22 weeks of intrauterine development to 28 weeks of the postpartum period). These features are a high percentage of complications, prematurity and the risk of premature birth, severe placental insufficiency, fetal malnutrition and intrauterine hypoxia, the possibility of severe malformations, etc.

Perinatal mortality in multiple pregnancies, compared to singleton pregnancies, is about 10% and is largely associated with fetal body weight. Malformations are recorded 2 times more often, intrauterine mortality is 3-4 times higher, and over the past 30 years it has practically not decreased. The incidence of cerebral palsy in a child of twins is 3-7 times more often, triplets - 10 times, and the number of complications in the mother throughout the entire period of pregnancy - 2 or more times (up to 10).

Causes of multiple pregnancies

The development of two or more fetuses in a woman's body is called multiple pregnancy. Over the past 20 years, it has doubled, and women with multiple pregnancies accounted for 0.7-1.5% of all pregnant women, the birth of twins in relation to the number of all births - 1: 87, triplets - 1: 6 400, quadruples - 1: 51,000.

Many reasons for multiple pregnancy have been noted, which indicates that this issue is still insufficiently studied. The likelihood of multiple pregnancies is largely determined by the following factors:

Heredity, that is, if the spouses or one of them come from multiple pregnancies or in their families, especially in the female line, there have been similar cases.
An increased content of follicle-stimulating hormone in the woman's blood, which promotes the development and maturation of two or more eggs at the same time. This may be due to heredity, the use of drugs that stimulate ovulation in the treatment of infertility, pregnancy immediately after the abolition of ok (), especially against the background of the use of ovulatory stimulation agents.
In vitro fertilization (), the program of which includes drug hyperstimulation of the ovaries to obtain a large number of mature eggs. Multiple pregnancy with IVF is also due to the implantation of several fertilized eggs into the uterine cavity, the possibility of implantation and development of more than one.
The number of births: with repeated pregnancies and childbirth, the likelihood of multiple births increases.
The woman is over 35 years old. This is thought to be due to a decrease in fertility at this age due to the lack of monthly ovulation. As a result, there is an accumulation of hormones and their effect in the form of ovulation of two or more eggs.
Anomalies in the development of internal genital organs.

The many causes of multiple pregnancies, the main ones of which are listed above, indicate that this issue is still insufficiently understood.

Classification of multiple pregnancies

In deciding the tactics of such pregnancy and childbirth, zygosity, chorionicity and the number of amniotic cavities are of considerable importance. A zygote is a cell formed from the fusion of an egg with a sperm and contains a double complete set of chromosomes. Chorion is one of the three (outer) membranes of the fetus. The amniotic cavity is a cavity bounded by an aqueous membrane (amnion) and filled with amniotic fluid.

Monozygous

In accordance with the number of fetuses, pregnancy is distinguished by twins, triplets, etc. About 30% of twins are formed from one fertilized egg. Subsequently, as a result of its division, two similar structures develop, which have the ability to develop independently, individually. This type of twins is called monozygous, or identical, and children are called twins. They have the same sex, eye and hair color, skin pattern of fingers, blood type, position and shape of teeth.

Bizygotic

Simultaneous maturation and release of two or more eggs can occur both in one ovary and in both during one menstrual cycle. Bizygotic, or bivalent embryos develop from two fertilized eggs and account for an average of 70%. Children are called "twins." They can be either same-sex or heterosexual, with the same or different blood groups and be in the same genetic relationship. In cases of a larger number (triplets, quadruplets, etc.), both monozygosity and dysygosity in various combinations are possible.

Each of the double embryos has its own chorial / placental and amniotic membranes. Each embryo has its own placenta. Thus, a four-layer septum is formed between the two embryos, consisting of sections of two chorionic / placental and two amniotic membranes. Therefore, such embryos in the classification are called di- (or bi-) - chorial, diamniotic dizygotic twins.

The formation of identical twins occurs at the early stages of development, division and transformation of a fertilized egg and depends on the time of these processes:

If the division of the egg occurs during the first 72 hours, counting from the moment of fertilization, that is, before the formation of the inner cell layer and the change in the cells of the outer layer of the egg, then two chorions and two amniotic cavities develop. As a result, dichorial, diamniotic monozygous twins are formed, in which one placenta is possible, formed from the fusion of two placentas, or two separate placentas.
If the division of the oocyte occurs within 4-8 days after fertilization, when the formation of the inner cell layer has already ended, and the chorion has begun to form from the outer layer, but the amniotic membranes are not yet laid, then each embryo will develop in a separate amniotic cavity. Thus, embryos with individual water sacs will be surrounded by one common chorion, as a result of which diamniotic, monochorionic monozygous twins develop.
If the laying of the amniotic membrane has already taken place at the time of separation of the ovum, which usually occurs by the 8th day after the fusion of the egg with the sperm, this will lead to the development of embryos with a common water sac and one chorion - monoamniotic, monochorionic monozygous twins.
The division of a fertilized egg at a later date (after 13 days), when the embryonic disc has already formed, will be only partial. This will lead to the development of twins who have grown together.

The easiest way to determine whether you are identical or fraudulent is to be examined by an obstetrician after the birth of children. The partition between twins consists of two water (amniotic) membranes, and between the "twins" - of four: two amniotic and two chorionic.

Features of the course of multiple pregnancy

Possible complications for the mother

Pregnancy with two or more fetuses, especially with their different blood groups, in comparison with singleton, makes higher demands on the woman's body. In addition, the flow in the dichorionic type is more severe than in the monochorionic type. The average gestation period for twins is about 37 weeks, for triplets - 35 weeks.

In the body of a pregnant woman, the volume of circulating blood increases (by 50-60%), which creates an additional load for the cardiac function, while with one fetus this figure does not exceed 40-50%. Due to hemodilution (blood dilution), anemia, an increased need for vitamins, macro- and microelements, especially folic acid and iron, are often noted.

Women are much more likely to notice shortness of breath, rapid fatigability, excruciating heartburn, urinary disorders and constipation. They are especially worried about these phenomena in the last stages. In addition, toxicosis and among them are more common, develop earlier, and their course is more severe. The uterus reaches a large size not only because of multiple pregnancies, but also as a result of cases of frequent development of polyhydramnios, which can cause renal dysfunction. The number of premature births is in direct proportion to the number of fetuses and ranges from 25 to 50%.

A very common problem is cervical insufficiency (ICI) in multiple pregnancies. It develops much more often than with singleton, especially in the presence of triplets or more, which is associated with the influence of a mechanical factor (increased pressure in the uterine cavity and its stretching). ICI usually begins to develop after 22 weeks and is characterized by rapid progression. If, with twins, surgical treatment to strengthen the neck is effective, then as the triplets grow, etc., the superimposed sutures often do not withstand the load and are cut through. Therefore, in some cases, the additional use of a special pessary helps.

With multiple births, chronic somatic diseases also develop more often, exacerbate and become more severe. Multiple pregnancies after cesarean section require special attention and strict constant follow-up, due to the large number of risks for both the fetus and the woman. The main risks with a high frequency include:

disorders of the placental circulation due to a violation of the vasculature of the uterus after surgery, which leads to intrauterine growth retardation and / or intrauterine asphyxia;
placenta previa;
the threat of termination of pregnancy;
wrong position of the fruit;
failure of the scar on the uterus and its rupture, which is the most dangerous.

In some cases, with multiple pregnancies, as well as with singleton, on the 8th day, bloody discharge from the vagina is possible, lasting about 4 days - this is, as a rule, minor implantation bleeding, which accompanies the introduction (implantation) of a fertilized egg into the mucous membrane uterus. However, when two or more of these eggs are implanted, it can be longer, repeated and abundant and lead to spontaneous miscarriage. In these cases, it is necessary to carry out differential diagnosis and treatment in a hospital setting, where assistance is provided in the form of hemostatic therapy, rest, the appointment of antispasmodics, etc.

Risks to the fetus (s)

Compared with singleton pregnancies, the delay in the development of one fetus in multiple pregnancies occurs 10 times more often and is 20% for dichorionic twins, 30% for monochorionic twins, and the delay in the development of twins as a whole is 1.7% and 7.5%, respectively.

Of fundamental importance in detecting congenital malformations in one of the fetuses is the determination of zygosity during the prenatal period, since in the case of dizygotic twins, the second fetus may be without pathology, and with monozygous twins, the likelihood of defects in one of them is quite high. The likelihood of developing fetal structural abnormalities in singleton pregnancies and dizygotic twins is the same, and in the case of monozygous twins, it is 2-3 times higher.

In order to detect trisomy of fetuses, which include Down's disease, Edwards and Patau syndromes, a non-invasive prenatal test is performed with significant reliability. Its essence lies in the genetic study of fetal DNA particles in the venous blood of a woman in the 9th - 24th weeks. In case of a positive result, additional, but already invasive, genetic studies are carried out. When confirming the results, the tactics of further management of pregnancy is to artificially terminate it.

In the monochorionic, much less often in the bichorial placenta, there are frequent cases of the formation of an arterio-arterial or arterio-venous anastomosis (a connection between two arteries or between an artery and a vein). The second type is the most unfavorable, since in this case there is an outflow of blood from the artery of one fetus into the vein of another. In these cases, if the pressure is symmetric in the placental vascular system, the development of the fetus occurs under equal conditions. But with monozygous twins, these conditions can be violated with asymmetric blood circulation in the placenta, as a result of which the supply of arterial blood to one of the fetuses decreases, it does not receive sufficient nutrition and its development is delayed.

A significant imbalance in the placental vascular system is the reason that almost all blood circulation passes to one of the twins - the development of fetal-fetal transfusion syndrome (FFTS) is possible, which is noted especially in cases of monochorial multiple pregnancy (from 5 to 25%), hypertension , heart enlargement, etc. in one of the fruits. The second may develop deformity, cessation of heart function, or he gradually dies and undergoes mummification (spontaneous fetal reduction). This process can be complicated by the development of a woman's DIC syndrome (disseminated intravascular coagulation), which threatens her life.

Fetal reduction in multiple pregnancies

In some cases, the reduction of the fetus is carried out artificially. The need for this is more common after IVF. Artificial reduction is associated with certain risks and complications, and therefore is performed if there are strict indications:

The need to reduce the number of fetuses implanted after IVF.
Pathological changes in them.
The risk of miscarriage.
A woman has contraindications for carrying multiple pregnancies.

The artificial reduction procedure is usually carried out no earlier than 7 and no later than 13 weeks. It consists in stopping the heart of a hopeless fetus (or fetuses) by puncture injection of a special drug or air into his / their heart. To do this, transvaginally (at 7-8 weeks) or transabdominal (at 8-13 weeks) after local anesthesia with a needle under the control of an ultrasound device, a puncture of the uterine cavity is performed. In the future, resorption of fetal tissues occurs.

How to sleep with multiple pregnancies?

Arising in the third trimester in almost half of women with one fetus, the so-called inferior vena cava syndrome, can complicate the course of pregnancy. With multiple pregnancies, it occurs earlier and can be much more severe.

All venous blood is collected in the vein from the lower half of the body and abdominal cavity, then it enters the right atrium, etc. The cause of this syndrome is increased pressure in the abdominal cavity due to the enlargement of the uterus. With a horizontal position of a woman on her back or on her right side, the inferior vena cava is compressed between the uterus and the spine.

Against the background of an increased volume of circulating blood and a woman's increased need for blood supply to the brain and heart, the supply of the required volume of blood to them when the inferior vena cava is compressed is sharply reduced due to a decrease in the return of arterial blood, and the blood supply to the fetus also suffers. For the majority, this proceeds imperceptibly, but approximately 10% may experience symptoms such as a sharp drop in blood pressure, dizziness, pallor, nausea, vomiting, and in severe cases, loss of consciousness and collapse, and the appearance of seizures are possible.

Blood circulation is quickly restored when the uterus is displaced by the hand to the left or as a result of the woman turning to the left side, which helps to release the inferior vena cava from compression. Therefore, being in a horizontal position, you must lie on your left side.

Signs of multiple pregnancy and its management

Multiple early pregnancy

Diagnostics

Widespread use in clinical practice of obstetrics and gynecology has made it possible to diagnose multiple pregnancies in the early stages. Before ultrasound, this diagnosis was often difficult. Basically, it was more or less reliable in the later stages, and sometimes only during childbirth.

How long is multiple pregnancy determined?

Early assumptions about the presence of two or more fruits can be made on the basis of a set of signs:

anamnesis that the married couple or their immediate family members are one of the twins or "twins";
availability of data on the performed ovulation hyperstimulation and IVF;
early development and more severe course of induced hypertension, symptoms of toxicosis (vomiting, nausea), swelling of the mammary glands;
inconsistency in the first trimester of the size of the uterus with the duration of pregnancy, which also occurs with or gallbladder drift.

At a later date, in the formulation of a presumptive diagnosis, importance is attached to such data as:

early movement during multiple pregnancy, which can be felt by a woman from the 15th week, while with the first singleton - from the 20th, and with subsequent ones - from the 18th week;
the size of the abdominal circumference and the height of the fundus of the uterus, which exceed the expected timing of a singleton pregnancy;
palpation through the anterior abdominal wall in the second half of gestation of large ballot pieces of fetuses (heads and pelvis) in different parts of the abdomen;
palpation of a large number of small parts;
the presence in the middle sections of the bottom of the uterus of a depression formed by the protrusion of its corners by large fetal parts (with twins);
auscultatory determination of two points of the heartbeat, especially if there is a zone of absence of tones between them (zone of "silence");
different (difference in 10 beats) heart rate at different points, which can be determined by means of cardiac monitors.

How to identify multiple pregnancies in the early stages more reliably?

In making such a diagnosis, to a certain extent, one can focus on the concentration of hCG (human chorionic gonadotropin) and placental lactogen in the blood. This laboratory biochemical testing is not entirely reliable, but relatively informative. So, the level of hCG in multiple pregnancies at each stage of the gestational period exceeds the norm for a singleton pregnancy.

Determination of the content of progesterone in the blood is of similar importance. Increased progesterone in multiple pregnancies , in comparison with the norms determined for a singleton, will be in each respective trimester.

The main method of early diagnosis and a means of helping to prevent many complications of multiple pregnancies is ultrasound. The accuracy of this diagnostic method, including the earliest dates, is more than 99%. It is based on the visual identification of several fertilized eggs or embryos from the 5th to the 6th week.

In addition, echography allows in the second and third trimesters to determine the nature of fetal development and the contours of the fetus, which helps to identify fused twins, FFTS, localization and number of placentas and amniotic (water) cavities, to identify congenital malformations, antenatal death, etc. In accordance with echometric biometrics, the following five types of development of twins are distinguished:

Physiological - both fruits.
Signs of hypotrophy with uneven (dissociated) development.
Uneven development of both fetuses with a difference of 10% from the body weight of the largest of them.
The presence of congenital developmental pathology.
Intrauterine death of one fetus.

Fetal presentation options

Ultrasound also allows you to establish the presentation of the fetus and their position, which is especially important before the onset of labor.

In addition to some of the above points (reduction, prevention of compression syndrome of the inferior vena cava, etc.) provides for the prevention of gestosis, their early detection and treatment in a hospital setting, control of the blood coagulation system, the function of the cardiovascular system and kidney function.

Recommendations are also given on the correct balanced and sufficiently high-calorie diet of a woman, folic acid intake of 0, 001 grams per day and iron supplements (up to 100 mg) are prescribed. In addition, in order to prevent premature birth, it is recommended to limit physical activity - being in bed 3 times for 1-2 hours during the day, taking tocolytics and bed rest in case of a threat of premature birth.

One of the ways to predict the resolution of pregnancy is the use of non-stress testing of the state of fetal heart function in response to their movement. The test must be performed every week after the 30-week period. If possible, a blood flow study is also carried out in each of the fetuses.

In case of uncomplicated pregnancy, hospitalization in the maternity ward is necessary before the expected due date for 2-3 weeks in the presence of twins and for a month - triplets. In the absence of the onset of labor at a period of 37 weeks, it is advisable to stimulate it, and in some cases - a planned caesarean section at a period of 37-38 weeks. The presence of a scar on the uterus with multiple pregnancies is a direct indication for a cesarean section.

The optimal method of delivery in the case of monochorionic and monoamniotic twins is a cesarean section at 33-34 weeks (due to the high risk of cord torsion), and for pregnancy with 3 or more fetuses - at 34 weeks.

Childbirth and their management

A normal birth course is often accompanied by complications. In the first stage of labor, on average, 30% of women in labor have premature or earlier rupture of amniotic fluid. Moreover, it is often accompanied by the loss of small parts - umbilical cord loops, legs or handles.

Due to the overstretched uterus, weakness of labor forces develops, and the opening of the cervix is significantly delayed. The duration of the period of expulsion of the first fetus often increases. The presenting part of the second tends to be inserted into the pelvis at the same time as the first, and this takes a long time. The muscles of the anterior abdominal wall are weakened and overstretched, due to which the stretching period is lengthened or impossible. All this leads to prolonged labor, which threatens infection of the uterine cavity and the development of hypoxia (oxygen starvation) of the fetus.

During the period of expulsion of premature fetuses, there is a risk of rapid labor and rupture of the perineum. Prevention of this complication requires timely pudendal (perineal) anesthesia and perineal dissection.

A serious complication during the expulsion period is premature placental abruption, especially after the birth of the first child, which is associated with a sharp decrease in pressure inside the uterus and a decrease in its volume. This complication threatens with profuse bleeding and the development of hypoxia in the second child. To prevent it, the obstetrician performs an emergency opening of the second fetal bladder.

A very rare but difficult complication is the adhesion of the heads to each other, as a result of which they tend to enter the pelvis at the same time.

Labor management in multiple pregnancies

It consists in careful monitoring of the cardiac activity of the fetus with the help of cardiac monitors and the condition of the woman in labor. Their maintenance in the first period is desirable on the left side to prevent inferior vena cava syndrome. With the development of weakness of the labor forces, the latter are stimulated by intravenous drip of a glucose solution with oxytocin, anesthesia by the method of epidural analgesia.

In the case of the development of weakness of labor and fetal hypoxia during the period of expulsion, obstetric surgical aids are carried out in the form of the imposition of obstetric forceps on the head (with cephalic presentation) or extraction (with breech presentation) by the pelvic end.

Ligation of the umbilical cord is carried out not only at the fetal end, but also at the maternal end, since after its dissection with monochorionic twins, the death of the second fetus as a result of bleeding from the umbilical cord is possible.

The birth of the second child should occur no later than 10-15 minutes after the first. Otherwise, the obstetrician opens the fetal bladder, and the amniotic fluid is slowly released, after which childbirth is carried out naturally (with a longitudinal position).

In the case of a transverse position or incorrect insertion of the head of the second fetus into the small pelvis under general anesthesia, the child is turned on the pedicle and the child is removed. If it is impossible to give birth in a natural way (impossibility of turning, a large child, spasm of the neck, signs of acute hypoxia of one of the fetuses, prolapse of the umbilical cord and small parts, persistent secondary birth weakness), delivery is carried out by cesarean section. The optimal delivery option for triplets or more, as well as in the case of twins fusion, is a cesarean section.

The successive period (before the separation of the placenta - the placenta with membranes) proceeds in the same way as in a singleton pregnancy. However, due to the overstretched uterus and a decrease in its tone, the frequency of delayed separation of the placenta and the associated profuse bleeding is much higher and more dangerous. Therefore, at the end of the second period, methylergometrine is administered intravenously, and after the birth of children, oxytocin is injected drip within 2 hours. If there is no effect, manual removal of the placenta and subsequent massage of the uterus on the fist are performed.

The incidence of complications in the postpartum period is also significantly higher. They are manifested by late postpartum bleeding, delayed reverse development of the uterus to the previous state (subinvolution), postpartum. Therefore, after childbirth, anti-inflammatory drugs and uterine-reducing drugs are prescribed.

Thus, despite the fact that multiple pregnancy is not a pathological condition, it requires increased attention and a specific approach to each woman at every stage from conception to the postpartum period. In addition, special supervision and care of the born babies is necessary.