Incidents 

Is it possible to intentionally conceive twins naturally? Symptoms and signs of multiple pregnancy

Despite the rather 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 conventional pregnancy with one fetus. They require experience and in-depth knowledge of the condition from medical personnel.

Relevance of the topic

Features of multiple pregnancy 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 postpartum). These features are a high percentage of complications, prematurity and the risk of preterm birth, severe form of placental insufficiency, fetal malnutrition and intrauterine hypoxia, the possibility of severe malformations, etc.

Perinatal mortality in multiple pregnancies, compared with single pregnancies, is about 10% and is largely related to the body weight of the fetus. Malformations are registered 2 times more often, intrauterine mortality is 3-4 times higher, and over the past 30 years it has practically not decreased. The frequency of development 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 pregnancy

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

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

  1. Heredity, that is, if the spouses or one of them comes from a multiple pregnancy or in their families, especially in the female line, there were similar cases.
  2. An increased content of follicle-stimulating hormone in the blood of a woman, which contributes to the development and maturation of two or more eggs at the same time. This may be due to heredity, taking 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.
  3. Conducting in vitro fertilization (), the program of which includes drug-induced ovarian hyperstimulation to obtain a large number of mature eggs. Multiple pregnancy with IVF is also due to the planting of several fertilized eggs in the uterine cavity, the possibility of implantation and development of more than one.
  4. The number of births: with repeated pregnancy and childbirth, the likelihood of multiple pregnancies increases.
  5. Women over 35 years of age. This is thought to be due to reduced fertility at this age due to the lack of monthly ovulation. As a result of this, there is an accumulation of hormones and their effect in the form of ovulation of two or more eggs.
  6. Anomalies in the development of internal genital organs.

Many causes of multiple pregnancy, the main of which are listed above, indicate that this issue is still insufficiently studied.

Classification of multiple pregnancy

Zygosity, chorionicity, and the number of amniotic cavities are of considerable importance in resolving questions about the tactics of conducting such a pregnancy and childbirth. A zygote is a cell formed from the fusion of an egg with a sperm and containing a complete double 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.

monozygotic

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

Bizygous

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

Each of the dizygotic embryos has its own chorionic/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:

  1. If the division of the egg occurs within 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, a dichorionic, diamniotic monozygotic twin is formed, which may have one placenta formed from the fusion of two placentas, or two separate placentas.
  2. If the division of the egg occurs within 4-8 days after its fertilization, when the formation of the inner cell layer has already ended, and the laying of the chorion has occurred from the outer layer, but the amniotic membranes have not yet been laid, then each embryo will develop in a separate amniotic cavity. Thus, embryos with individual water sacs will be surrounded by one common chorion, resulting in the development of diamniotic, monochorionic monozygotic twins.
  3. If the laying of the amniotic membrane has already taken place by the time of separation of the fetal egg, which usually occurs by the 8th day after the fusion of the egg with the sperm, then this will lead to the development of embryos with a common water sac and one chorion - monoamniotic, monochorionic monozygotic twins.
  4. 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 fused together.

The easiest way to determine if you are monozygotic or dizygotic is to be examined by an obstetrician after the birth of children. The septum between the 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 types, in comparison with a singleton, makes higher demands on the woman's body. In addition, the course of the dichorionic type is more severe than that of 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 burden on 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, fatigue, painful heartburn, urination disorders and constipation. These phenomena are especially disturbing in the last stages. In addition, toxicosis among them are more common, develop earlier, and their course is more severe. The uterus reaches a large size not only because of multiple pregnancy, but also as a result of cases of frequent development of polyhydramnios, which can cause impaired renal function. The number of premature births is directly dependent on the number of fetuses and ranges from 25 to 50%.

A very common problem is isthmic-cervical insufficiency (ICI) in multiple pregnancies. It develops much more often than with a 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 the 22nd week and is characterized by rapid progression. If with twin surgical treatment to strengthen the cervix is ​​effective, then as the triplets grow, etc., the sutures often do not withstand the load and cut through. Therefore, in some cases, the additional use of a special pessary helps.

With multiple pregnancies, chronic somatic diseases also develop more often, become aggravated and more severe. Multiple pregnancies after caesarean section require special attention and strict ongoing dynamic monitoring due to the large number of risks for both the fetus and the woman. The main risks with high frequency include:

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

In some cases, with a multiple pregnancy, as with a singleton, on the 8th day, bleeding from the vagina is possible, lasting about 4 days - this is usually a slight implantation bleeding that 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, where assistance is provided in the form of hemostatic therapy, rest, prescription of antispasmodics, etc.

Risks to the fetus(es)

Compared with a singleton pregnancy, the developmental delay of one fetus in a multiple pregnancy is 10 times more common and amounts to 20% for dichorionic twins, 30% for monochorionic twins, and the developmental delay of twins as a whole is 1.7% and 7.5%, respectively.

Of fundamental importance in the detection of congenital malformations in one of the fetuses is the definition during the prenatal period of zygosity, since in the case of dizygotic twins, the second fetus may be without pathology, and in case of monozygotic twins, the probability of defects in one of them is quite high. The probability of developing fetal structural anomalies in singleton pregnancy and dizygotic twins is the same, and in the case of monozygotic twins it is 2-3 times higher.

In order to detect fetal trisomy, which includes Down's disease, Edwards syndrome and Patau syndrome, a non-invasive prenatal test is performed, which has significant reliability. Its essence lies in the genetic study of DNA particles of fetuses in the venous blood of a woman at the 9th - 24th weeks. In case of a positive result, additional, but already invasive, genetic studies are carried out. When the results are confirmed, the tactics of further management of pregnancy consists in its artificial termination.

In the monochorionic, much less frequently in the bichorial placenta, there are frequent cases of the formation of an arterio-arterial or arterio-venous anastomosis (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 in the system of placental vessels is symmetrical, the development of the fetus occurs under equal conditions. But with monozygotic twins, these conditions can be disturbed by asymmetric blood circulation in the placenta, as a result of which the flow 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 system of placental vessels is the reason that almost all blood circulation passes to one of the twins - it is possible to develop feto-fetal transfusion syndrome (FFTS), which is noted especially in cases of monochorionic multiple pregnancy (from 5 to 25%), hypertension , expansion of the heart, etc. in one of the fetuses. The second may develop deformity, cessation of heart function, or it gradually dies and undergoes mummification (spontaneous reduction of the fetus). 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 pregnancy

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

  1. The need to reduce the number of fetuses implanted after IVF.
  2. They have pathological changes.
  3. Risk of miscarriage.
  4. A woman has contraindications to carrying a multiple pregnancy.

The procedure for artificial reduction is usually carried out at a time not earlier than 7 and not later than 13 weeks. It consists in cardiac arrest of an unpromising 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 transabdominally (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 the tissues of the fetus occurs.

How to sleep during multiple pregnancy?

Occurring 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 pregnancy, it occurs earlier and can be much more difficult.

All venous blood from the lower half of the trunk and abdominal cavity is collected in a vein, then it enters the right atrium, etc. The cause of this syndrome is increased pressure in the abdominal cavity due to an increase in the uterus. When a woman is in a horizontal position 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 an increased need for a woman in the blood supply to the brain and heart, the flow of the required volume of blood to them during compression of the inferior vena cava is sharply reduced due to a decrease in the return of already arterial blood, and the blood supply to the fetus also suffers. For most, this goes unnoticed, but about 10% may experience symptoms such as a sharp decrease in blood pressure, dizziness, pallor, nausea, vomiting, and in severe cases, loss of consciousness and collapse, seizures may occur.

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

Signs of multiple pregnancy and its management

Multiple pregnancies in early pregnancy

Diagnostics

The widespread use in clinical practice of obstetrics and gynecology has made it possible to diagnose multiple pregnancies in the early stages. Prior to 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 a multiple pregnancy?

An early assumption about the presence of two or more fetuses can be made on the basis of a set of signs:

  • a history that the couple or their closest relatives are one of the twins or "twins";
  • availability of data on ovulation hyperstimulation and IVF;
  • early development and more severe course of induced hypertension, symptoms of toxicosis (vomiting, nausea), swelling of the mammary glands;
  • discrepancy in the first trimester of the size of the uterus to the duration of pregnancy, which also occurs with or cystic skidding.

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

  • early stirring during multiple pregnancy, which can be felt by a woman from the 15th week, while in the first single pregnancy - from the 20th, and in subsequent ones - from the 18th week;
  • the size of the circumference of the abdomen and the height of the fundus of the uterus, which exceed the expected duration of a singleton pregnancy;
  • palpation through the anterior abdominal wall in the second half of gestation of balloting large parts of the fetus (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 of 10 beats) heart rate at different points, which can also be determined by means of cardiac monitors.

How to determine multiple pregnancy in the early stages more reliably?

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

Of similar importance is the determination of the content of progesterone in the blood. Elevated progesterone in multiple pregnancies , compared with the norms defined for a singleton, will be in each respective trimester.

The main method of early diagnosis and a tool that helps prevent many complications of multiple pregnancy is ultrasound. The accuracy of this diagnostic method, including the earliest dates, is over 99%. It is based on the visual identification of several fertilized eggs or embryos from the 5th to 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 conjoined twins, FFTS, the location and number of placentas and amniotic (water) cavities, to identify congenital malformations, antenatal death, etc. according to echometric biometrics, the following five types of twin development are distinguished:

  1. Physiological - both fruits.
  2. Signs of malnutrition with uneven (dissociated) development.
  3. Uneven development of both fetuses with a 10% difference from the body weight of the larger one.
  4. The presence of congenital pathology of development.
  5. Intrauterine death of one fetus.

Fruit 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 the syndrome of compression of the inferior vena cava, etc.), it provides for the prevention of preeclampsia, their early detection and treatment in a hospital, control of the blood coagulation system, the function of the cardiovascular system and kidney function.

Recommendations are also given on the correct balanced and sufficient high-calorie nutrition of a woman, folic acid intake of 0.001 grams per day and iron preparations (up to 100 mg) are prescribed. In addition, in order to prevent preterm birth, it is recommended to limit physical activity - staying in bed 3 times for 1-2 hours during the day, taking tocolytics and bed rest in case of a threat of preterm 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 should be done every week after the 30-week period. If possible, a blood flow study is also performed in each of the fetuses individually.

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

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

Childbirth and their management

The 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 - loops of the umbilical cord, legs or handles.

Due to the overstretched uterus, the weakness of the generic forces develops, and the opening of the cervix is ​​significantly delayed. Often the duration of the period of expulsion of the first fetus also 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 straining period is lengthened or becomes impossible. All this leads to protracted 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 perineal rupture. Prevention of this complication requires timely pudendal (perineal) anesthesia and perineal dissection.

A serious complication in the period of exile is premature detachment of the placenta, 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 heavy bleeding and the development of hypoxia of the second child. To prevent it, the obstetrician performs an emergency opening of the second fetal bladder.

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

Birth management in multiple pregnancies

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

In case of development of weakness of labor activity and fetal hypoxia during the period of exile, obstetric operational aids are carried out in the form of obstetric forceps applied to the head (with cephalic presentation) or extraction (with breech presentation) by the pelvic end.

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

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 the birth is carried out naturally (in 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 leg and the child is removed. If it is impossible to give birth naturally (impossibility of turning, a large child, cervical spasm, 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 caesarean section. The optimal delivery option for triplets or more, as well as in the case of twin fusion, is a caesarean section.

The succession 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 heavy 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 dripped for 2 hours. If there is no effect, manual separation of the placenta and subsequent massage of the uterus on the fist are carried out.

The frequency of complications in the postpartum period is also significantly higher. They are manifested by late postpartum hemorrhage, delayed reverse development of the uterus to its previous state (subinvolution), postpartum. Therefore, after childbirth, anti-inflammatory drugs and uterine contractions 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. Besides, special supervision and care of the born babies are necessary.

Under the concept of multiple pregnancy, modern medicine assumes a situation where several future babies (from two or more) develop simultaneously in the womb of the mother 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 is carrying twins, then this development of pregnancy is called twins, if more, then, respectively, triplets and in ascending order.

Multiple pregnancies are considered quite rare phenomena, which as a percentage is expressed in terms of 0.7 to 1.5% in European countries and the Americas. This number gradually begins to grow with the emergence of new reproductive options that increase the likelihood of multiple pregnancies. Two healthy babies can appear from two types of pregnancy, which differ in the mechanism of conception.

Pregnancy may be:

  • Bizygotic (dizygotic);
  • Identical (monozygous).

In the first case, the children are considered twins, and in the second method, twins. In 70% of cases, such a pregnancy takes place in a twin form. In the case of a monozygotic pregnancy, the babies will be completely identical in appearance, as 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 gives babies a different composition of chromosomes. The development of a twin pregnancy is facilitated by the simultaneous fertilization of two eggs, which are attached in different parts of the uterus.

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

Twin pregnancy - twins


A twin pregnancy involves its own placental membrane and a separate amniotic sac for each fetus. From a medical point of view, the situation when each fetus has its own bladder and individual placenta is referred to as bichorionic biamniotic twins.

Twins

In other words, 2 placentas (biharial) are simultaneously located in the uterus, along with two fetal bladders (biamnic), 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 in each of them a new life of the unborn child develops.

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 separation of the fertilized egg occurred. If such a separation occurred within 72 hours after conception, during which the fertilized egg does not yet have time to attach to the wall of the uterus, then two fetal bladders with two placentas are formed.

From a medical point of view, such a pregnancy is also called bichorionic biamniotic (two placentas and two amniotic sacs). In the case when the separation of the egg occurred at a later period, but not longer than 8 days (at the stage when the egg has already attached to the uterus), then in this case two embryos are formed with two fetal bladders, but the surrounding placenta is the same for two. Then there are future twins separated from each other by fetal bladders, but they receive nutrition from a common placenta. In accordance with the facts, such a development of pregnancy is called monochorionic (single 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 come through a separate umbilical cord for each embryo.

Such a pregnancy is called monochorionic (single placenta) monoamniotic (single amniotic sac). The separation of the fetal egg, 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 the expectant mother, the safest types of double pregnancy are considered twins and identical bichorionic biamniotic twins. During the development of monochorionic biamniotic pregnancy, there is a possibility of pregnancy complications and delayed embryo development. Potential mothers with a monochorionic monoamniotic course of fetal development are most at risk.


During natural fertilization, the possibility of developing a multiple pregnancy equates to a maximum of 2%. Among these two percent, the majority of pregnant women (99%) have twins, and only one percent of conceptions occur 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 lengthening of daylight hours (spring);
  • Mothers who have previously had a similar pregnancy;
  • Conception with the help of additional reproductive technology solutions.

The use of such modern drugs as "Klostilbegit" or "Clomiphene", increase the likelihood of developing a multiple pregnancy course up to 8%.

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


The use of in vitro fertilization from different 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 according to the following principle: four embryos are placed in the uterus and how many of them will eventually take root, how many children the woman will subsequently give birth to.

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 ultrasounds will show the number of surviving embryos, and after that, the expectant mother will be asked to make a choice to preserve all the engrafted fetuses or go for an operation to remove excess embryos. In the event that only half of the embryos have taken root, it is recommended to leave both. But, of course, the last word remains with the future mother. A pregnant woman can also leave three or all four implanted embryos, if she so desires, and in the end she will become a mother for three or four babies.

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

Nowadays, reduction is proposed not only for mothers who have artificially conceived three or more embryos, but also for persons who have three or more fetuses after natural conception. This is carried out in order to reduce the likelihood of complications during pregnancy, childbirth and postpartum development, which may develop under the influence of multiple pregnancies.


During the operation, doctors always leave two fetuses, in case one of the embryos dies or miscarriages occur. In any case, the reduction procedure is carried out completely 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 is reduction contraindicated:

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

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

Transcervical method

Performed under ultrasound guidance. For it, a soft and fairly flexible catheter is used, which is inserted into the uterus (having previously connected to a vacuum aspirator). 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, together with the fetal bladder surrounding it, 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

Anesthesia is used during the operation. The procedure is also performed using ultrasound. Using 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 operation had complications or suffered a miscarriage later. That is why most expectant mothers prefer the difficulties of bearing multiple pregnancies than the likelihood of losing the unborn child after surgery.

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


The currently known record of multiple pregnancy 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 before they lived even six months. In addition to her, a Spaniard in 1924 and a Chinese woman in 1936 became the owners of bearing 10 children.

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


As the practice of recent years shows, multiple pregnancy, 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 give birth due to too much stretching of the uterus.

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

The average time to end a pregnancy with multiple pregnancy is as follows:

  • Twins are born at 36-37 weeks;
  • Triplets are born at 33-34 weeks;
  • Four babies are usually born at 31 weeks.


Age

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

gynetics

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

Hormonal

The use of reproductive drugs. All hormonal drugs aimed at increasing the likelihood of becoming 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 childbirth

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 with the help of male sperm in a pre-treated test tube. Fertilized cells attach to the uterus. This method involves the attachment of 4 embryos at once, as a result of which a multiple pregnancy is very often obtained.

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


Ultrasound diagnostics is considered the best modern method for determining multiple pregnancy. But besides it, 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 terms of pregnancy (increased size);
  • Inconsistency in the location of the pelvis or head of the unborn child at the entrance to the pelvic region. At the same time, the high standing of the day of the uterus is also taken into account;
  • The volume of the abdomen does not correspond to the size of the fetus;
  • Too big belly at an early stage;
  • Rapid weight gain;
  • The equipment listens to 2 heartbeats;
  • The level of hCG and lactogen exceeds the standard values ​​several times;
  • Enhanced 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 probability of developing a multiple pregnancy 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 pregnancy


Ultrasound can be performed as early as a month after conception. On the monitor, the doctor can see, if available, several developing embryos. The method of managing a multiple pregnancy depends, first of all, on the number of placentas and fetal bladders formed. Monozygotic or twin pregnancy does not affect the choice of tactics for monitoring pregnancy.

The best is the development of bichorionic twins, in which each fetus has its own placenta and fetal bladder. The most difficult in terms of maintaining gestation and the successful development of the unborn child is the 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 a single source and is delimited by separate umbilical cords).

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

HCG tests are more of 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.

Development of multiple pregnancy


Any pregnancy is a test for the female body. Multiple pregnancy several times increases the already difficult load. Almost all organs and life support systems are tested.

The greatest load falls on:
  • the 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 within 40 weeks. After all, the body no longer supports one life, but two or more growing organisms in the womb. With each new day, the embryos require more space and nutrition. Therefore, it is not surprising that expectant mothers who are faced with multiple pregnancies are more likely than others to suffer from various infections and diseases.

The probability of catching the same flu or cold increases by 3-7 times compared to pregnant women who carry one child under their hearts. The more embryos the expectant mother bears, 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 applies to infectious diseases. All this is due to too much stress that the female body faces throughout pregnancy.


Preeclampsia

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

Anemia

Such a disease as anemia is also widespread among expectant mothers with multiple pregnancies. Therefore, it is imperative to carry out prevention through fortified nutrition 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 pregnancy

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 large set 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 in the process of gestation.

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

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

Due to the large load on the uterus, multiple pregnancy 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 pregnancy does not allow babies to gain the necessary body weight. Therefore, children are born with less weight and relatively short stature. Otherwise, multiple pregnancy is no different from pregnancy with one child.


Multiple pregnancy may be accompanied by the following complications:

  • miscarriage in the first trimester of pregnancy;
  • premature birth;
  • Death of one or more embryos during development;
  • preeclampsia;
  • Prolonged bleeding after childbirth;
  • hypoxia;
  • A collision of fetuses due to which both children are simultaneously ready to leave;
  • Fetofetal blood transfusion;
  • Congenital malformations of one or more fetuses;
  • The birth of Siamese twins.

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

For those who are faced with a multiple pregnancy, it is important to be hospitalized in the maternity ward about a month before the expected date of birth of the 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: will it be a natural birth or a caesarean section.

A typical decision tree looks like this:

a caesarean section occurs if there is a complication during pregnancy, or one of the babies is incorrectly positioned. A cesarean section is also resorted to in situations where both fetuses are simultaneously in the pelvic area and in the presence of scars on the uterus.

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

Nowadays, doctors are increasingly using a planned caesarean section.

When sick leave

With a multiple pregnancy, the expectant mother can go to the hospital already at 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 vividly experience multiple pregnancy and, as a result, speak positively about it despite all the difficulties they face in the process of bearing. Speaking of difficulties, I mostly remember fatigue, a big 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 attribute this to a large weight gain and, as a result, an increased load on the musculoskeletal system.

In addition, most young mothers talk about the importance of moral preparation for the difficult physical consequences of bearing. Many were constantly tormented by the feeling of hunger, despite plentiful and nutritious food. Childbirth in most women occurred at 36-38 weeks and, mainly, by caesarean section. Those few mothers who have given birth naturally agree that there is nothing particularly difficult in such childbirth 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're having multiple pregnancies, don't panic. Talk to your doctor, discuss the situation with loved ones. It is up to you to decide whether to keep 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 know that you will succeed.

Cases when not one, but two or more babies settle in the mother's stomach are not so common - 1.5-2.5% of all pregnancies. How does it work? How is a multiple pregnancy different? Can twins be scheduled? Our expert - Anna Romanovna PASTUKHOVA, an obstetrician-gynecologist at the Toast of Family Medicine Centers, answers all questions.

What is the chance of getting pregnant with twins

First, some statistics. As we have already mentioned, this amazing phenomenon occurs in 1.5-2.5% of pregnancies in Europe. It is believed that the appearance of twins, triplets and twins is genetically determined - more often they are born in families where one or both parents were born as a result of multiple pregnancy. However, there are other reasons, including .

  • The birth of twins occurs with a frequency of geometric progression, obstetricians even have a special formula: for 87 births there is one twin, for 87 twins - one triplet, for 87 triplets - one quadruple, etc. True, today this formula needs to be corrected - multiple pregnancies have become more common.
  • Identical or identical twins are less common, with an average of 1 in 250 births.
  • Most often, multiple pregnancies are observed in Africa, least often in Asia.

Types of multiple pregnancy

Let's start with a well-known fact. There are two types of twins: identical or monozygotic and fraternal (they are also called dizygotic).

  • Monozygotic twins result from the division of one egg fertilized by one sperm. It is they who surprise everyone with their striking resemblance.
  • Fraternal twins result from the fertilization of several eggs by several sperm. They can be of the same or different sexes, often differ in character and are not always similar in appearance.

Expert comment

A multiple pregnancy is a pregnancy when more than one fetus develops in the mother's body, but several at once. In medicine, identical or fraternal twins (triplets and so on) are distinguished. Identical twins are always the same sex, have the same blood type, and are very similar in appearance. Fraternal twins have phenotypic differences (eye color, facial features), can be either the same or different blood type. Fraternal twins may be of different sexes.

How are identical twins made?

To be honest, we have no idea! The reasons why, instead of a single baby from one egg and one sperm, two (three, four) appear are not really known - a miracle, and nothing more. The mechanism of the appearance of monozygotic twins, however, is described in sufficient detail. Everything starts as if nothing had happened: one egg, one sperm, meeting, fertilization... Then the resulting zygote begins to divide, grow and, at some point, under the influence of factors that are not entirely clear, it suddenly splits into two or more parts, each of which takes on a life of its own.

Expert comment

The development of identical twins occurs when one egg is fertilized by one sperm cell, in the process of dividing the fetal egg into two, three or four parts at different stages of its development. In this case, each part develops as a separate organism. It is assumed that such separation can occur when the implantation (attachment) of the fetal egg is delayed due to oxygen deficiency. Also, the occurrence of identical twins is associated with the fertilization of an egg that had two or more nuclei.

Do the twins interfere with each other?

It is very important at what point the splitting of the egg occurs, since the further intrauterine development of the twins depends on this.

There are 3 options for the development of monozygotic twins

  • Separation of the fetal egg occurred in the first five days after fertilization. In this case, both future babies begin to develop completely independently, each "grows" its own placenta and . Until recently, it was believed that such a development was characteristic only of fraternal twins and identical twins in such cases were erroneously identified as dizygotic (maybe this happened to the Olsen sisters?)
  • The zygote split approximately 5-8 days after fertilization. By this time, the outer fetal membrane has already begun to form: remains common in babies, however, the inner fetal membrane (amnion) develops in each of them. If babies have a common placenta, then one child can suppress the other - their competition begins with conception.
  • Separation occurred on day 8 and later (1% of all monozygotic twins). At this time, the fetal bladder is already beginning to form, so the separated embryos will grow in the common amnion and common fetal waters. This situation is considered not the most favorable, there is a risk that the kids each other.

The life of fraternal twins in the womb is organized with great comfort: each of them develops their own personal placenta (sometimes they grow together with walls), which means that babies do not need to seriously compete for a place “under the sun”.

So, if the embryos have different placentas, then most likely they are fraternal, and if the babies “settled” with a common placenta, then these are identical twins who will be born similar as ... twins.

Expert comment

There are the following types of multiple pregnancy:

  • Monochorionic monoamniotic twins when there is a common placenta and there is no septum between the twins. It's always identical twins
  • Monochorionic diamniotic twins, when there is a common placenta and septum, i.e. each fetus has its own amniotic sac
  • Dichorionic diamniotic twins, when each fetus has its own placenta and its own amniotic bladder.

How are fraternal twins made?

Non-identical twins develop from two or more fertilized eggs. How does this happen? The most common reason for this is the so-called "multiple ovulations", when several mature eggs come out of one or both ovaries at once. The reasons for this phenomenon may be different: genetic predisposition, artificial ovarian stimulation, the first cycle after the abolition of hormonal contraceptives.

Do you know that....

  • The difference in the time of conception of fraternal twins can be from several hours to several days.
  • In very rare cases, a new pregnancy is added to an existing pregnancy. As a rule, after fertilization and implantation of the fetal egg, ovulation is immediately blocked. If, due to hormonal imbalance, this mechanism does not work immediately, a younger brother or sister is added to the older child in utero.
multiple pregnancy- this is such a pregnancy in which not one, but several (two, three or more) fetuses simultaneously develop in the woman's uterus. Usually, the name of a multiple pregnancy is given depending on the number of fetuses: for example, if there are two children, then they talk about pregnancy with twins, if three, then triplets, etc.

Currently, the frequency of multiple pregnancy is from 0.7 to 1.5% in various European countries and the USA. The widespread and relatively frequent use of assisted reproductive technologies (IVF) has led to an increase in the incidence of multiple pregnancies.

Depending on the mechanism of the appearance of twins, dizygotic (twin) and monozygotic (identical) multiple pregnancies are distinguished. The children of fraternal twins are called twins, and the children of identical twins are called twins or twins. Among all multiple pregnancies, the frequency of twins is about 70%. Twins are always of the same sex and are like two drops of water similar to each other, because they develop from the same fetal egg and have exactly the same set of genes. Twins can be of different sexes and are similar only as siblings, since they develop from different eggs, and, therefore, have a different set of genes.

A twin pregnancy develops as a result of the fertilization of two eggs at the same time, which are implanted in different parts of the uterus. Quite often, the formation of fraternal twins occurs as a result of two different sexual intercourses, carried out with a small interval between each other - no more than a week. However, fraternal twins can also be conceived during one sexual intercourse, but on condition that the maturation and release of two eggs from the same or different ovaries occurred simultaneously. With fraternal twins, each fetus necessarily has its own placenta and its own fetal bladder. The position of the fetuses, when each of them has its own placenta and fetal bladder, is called bichorionic biamniotic twins. That is, in the uterus there are simultaneously two placentas (bichorionic twins) and two fetal bladders (biamniotic twins), in each of which the child grows and develops.

Identical twins develop from one fetal egg, which after fertilization is divided into two cells, each of which gives rise to a separate organism. With identical twins, the number of placentas and fetal bladders depends on the period of separation of a single fertilized egg. If separation occurs during the first three days after fertilization, while the fetal egg is in the fallopian tube and has not attached to the wall of the uterus, then two placentas and two separate fetal sacs will form. In this case, there will be two fetuses in the uterus in two separate fetal bladders, each feeding on its own placenta. Such twins are called bichorionic (two placentas) biamniotic (two amniotic sacs).

If the ovum divides on days 3-8 after fertilization, that is, at the stage of attachment to the uterine wall, then two fetuses, two fetal bladders, but one placenta for two, are formed. In this case, each twin will be in its own sac, but they will eat from one placenta, from which two umbilical cords will depart. This variant of twins is called monochorionic (one placenta) biamniotic (two amniotic sacs).

If the fetal egg is divided on the 8th - 13th day after fertilization, then two fetuses will form, but one placenta and one fetal bladder. In this case, both fetuses will be in one for two fetal bladder, and eat from one placenta. Such twins are called monochorionic (one placenta) monoamniotic (one amniotic sac).

If the fetal egg divides later than 13 days after fertilization, then as a result of this, Siamese twins develop, which are fused with different parts of the body.

From the point of view of safety and normal development of the fetus, bichorionic biamniotic twins, both monozygotic and dizygotic, are the best option. Monochorionic biamniotic twins develop worse and the risk of pregnancy complications is higher. And the most unfavorable option for twins are monochorionic monoamniotic.

Probability of multiple pregnancy

The probability of multiple pregnancy with an absolutely natural conception is no more than 1.5 - 2%. Moreover, in 99% of multiple pregnancies are represented by twins, and triplets and a large number of fetuses only in 1% of cases. With natural conception, the likelihood of multiple pregnancy increases in women over 35 years old or at any age in the spring season against the background of a significant lengthening of daylight hours. In addition, in women in whose family twins or twins have already been born, the likelihood of multiple pregnancy is higher than in other representatives of the weaker sex.

However, if pregnancy occurs under the influence of drugs or assisted reproductive technologies, then the likelihood of twins or triplets is significantly higher than with natural conception. So, when using drugs to stimulate ovulation (for example, Clomiphene, Clostilbegit, etc.), the probability of multiple pregnancy increases to 6 - 8%. If drugs containing gonadotropin were used to improve the chances of conception, then the probability of twins is already 25 - 35%. If a woman becomes pregnant with the help of assisted reproductive technologies (IVF), then the probability of a multiple pregnancy in this situation is from 35 to 40%.

Multiple pregnancy with IVF

If a woman becomes pregnant with the help of IVF (in vitro fertilization), then the probability of multiple pregnancy is, according to various researchers, from 35% to 55%. In this case, a woman may have twins, triplets or quadruplets. The mechanism of multiple pregnancy during IVF is very simple - four embryos are placed in the uterus at the same time, hoping that at least one of them will take root. However, not one, but two, three or all four embryos can take root, that is, be implanted in the wall of the uterus, as a result of which a multiple pregnancy is formed in a woman.

If during the ultrasound after IVF a multiple pregnancy (triplets or quadruplets) was detected, then the woman is offered to “remove” the extra embryos, leaving only one or two. If twins are found, then the embryos are not offered to be removed. In this case, the decision is made by the woman herself. If she decides to keep all three or four embryos that have survived, then she will have quadruplets or triplets. The further development of a multiple pregnancy that has developed as a result of IVF is no different from the natural one.

Reduction in multiple pregnancy

The removal of an "extra" embryo in a multiple pregnancy is called reduction. This procedure is offered to women who have more than two fetuses in the uterus. Moreover, at present, reduction is offered not only to women who become pregnant with triplets or quadruples as a result of IVF, but also who conceived more than two fetuses at the same time in a natural way. The purpose of the reduction is to reduce the risk of obstetric and perinatal complications associated with multiple pregnancies. With reduction, two fetuses are usually left, since there is a risk of spontaneous death of one of them in the future.

The reduction procedure for multiple pregnancy is carried out only with the consent of the woman and on the recommendation of a gynecologist. At the same time, the woman herself decides how many fruits to reduce, and how much to leave. Reduction is not carried out against the background of the threat of abortion and in acute inflammatory diseases of any organs and systems, since against such an unfavorable background, the procedure can lead to the loss of all fetuses. Reduction can be carried out up to 10 weeks of pregnancy. If this is done at a later stage of pregnancy, then the remnants of the fetal tissues will irritate the uterus and provoke complications.

Currently, the reduction is carried out by the following methods:

  • Transcervical. A flexible and soft catheter connected to a vacuum aspirator is inserted into the cervical canal. Under ultrasound guidance, the catheter is advanced to the embryo to be reduced. After the tip of the catheter reaches the fetal membranes of the reduced embryo, a vacuum aspirator is turned on, which tears it off the uterine wall and sucks it into the container. In principle, transcervical reduction is inherently an incomplete vacuum abortion, during which not all fetuses are removed. The method is quite traumatic, so it is rarely used now;
  • Transvaginal. It is performed under anesthesia in the operating room, similar to the process of taking oocytes for IVF. The biopsy adapter is inserted into the vagina and, under ultrasound control, a puncture needle is used to pierce the embryo to be reduced. Then the needle is removed. This method is currently the most commonly used;
  • Transabdominal. It is performed in the operating room under anesthesia in a similar manner to the amniocentesis procedure. A puncture is made on the abdominal wall, through which a needle is inserted into the uterus under ultrasound control. The embryo to be reduced is pierced with this needle, after which the instrument is removed.
Any reduction method is technically difficult and dangerous, since in 23-35% of cases pregnancy loss occurs as a complication. Therefore, many women prefer to face the burden of bearing several fetuses than to lose the entire pregnancy. In principle, the current level of obstetric care makes it possible to create conditions for carrying multiple pregnancies, as a result of which quite healthy children are born.

The most multiple pregnancy

Currently, the most multiple pregnancy recorded and confirmed was a tenth, when ten fetuses appeared in the woman's uterus at the same time. As a result of this pregnancy, a resident of Brazil in 1946 gave birth to two boys and eight girls. But, unfortunately, all the children died before reaching six months of age. There are also references to the birth of the tenth in 1924 in Spain and in 1936 in China.

To date, the most multiple pregnancy that can successfully result in the birth of healthy children without deviations is the gear. If there are more than six fetuses, then some of them suffer from developmental delay, which persists throughout their lives.

Multiple pregnancy - due dates

As a rule, a multiple pregnancy, regardless of the method of its development (IVF or natural conception), ends before the 40-week period, as the woman begins preterm labor due to excessive stretching of the uterus. As a result, babies are born prematurely. Moreover, the greater the number of fetuses, the earlier and more often preterm birth develops. With twins, as a rule, childbirth begins at 36 - 37 weeks, with triplets - at 33 - 34 weeks, and with quadruple - at 31 weeks.

Multiple pregnancy - causes

Currently, the following possible causative factors that can lead to multiple pregnancy in a woman have been identified:
  • genetic predisposition. It has been proven that women whose grandmothers or mothers gave birth to twins or twins are 6 to 8 times more likely to have multiple pregnancies compared to other women. Moreover, most often multiple pregnancy is transmitted through the generation, that is, from grandmother to granddaughter;
  • The age of the woman. In women over 35, under the influence of hormonal premenopausal changes, in each menstrual cycle, not one, but several eggs can mature, so the likelihood of multiple pregnancy in adulthood is higher than in young or young. The probability of multiple pregnancy is especially high in women over 35 years of age who have previously given birth;
  • The effects of drugs. Any hormonal agents used to treat infertility, ovulation stimulation or menstrual disorders (for example, oral contraceptives, Clomiphene, etc.) can lead to the maturation of several eggs at the same time in one cycle, resulting in multiple pregnancy;
  • A large number of births in the past. It has been proven that multiple pregnancy mainly develops in re-pregnant women, and its probability is higher, the more births a woman had in the past;
  • In vitro fertilization. In this case, several eggs are taken from a woman, fertilized with male sperm in a test tube, and the resulting embryos are placed in the uterus. At the same time, four embryos are introduced into the uterus at once so that at least one can be implanted and begin to develop. However, two, three, and all four implanted embryos can take root in the uterus, as a result of which a multiple pregnancy develops. In practice, most often as a result of IVF, twins appear, and triplets or quadruplets are rare.

Signs of multiple pregnancy

Currently, the most informative method for diagnosing multiple pregnancies is ultrasound, but the clinical signs on which doctors of the past were based still play a role. These clinical signs of multiple pregnancy allow a doctor or woman to suspect the presence of several fetuses in the uterus and, on the basis of this, conduct a targeted ultrasound study that will confirm or refute the assumption with 100% accuracy.

So, the signs of multiple pregnancy are the following data:

  • Too large size of the uterus, not corresponding to the period;
  • The low location of the head or pelvis of the fetus above the entrance to the pelvis, in combination with the high standing of the uterine fundus, which does not correspond to the period;
  • Mismatch between the size of the fetal head and the volume of the abdomen;
  • Large volume of the abdomen;
  • Excessive weight gain;
  • Listening to two heartbeats;
  • The concentration of hCG and lactogen is two times higher than normal;
  • Rapid fatigue of a pregnant woman;
  • Early and severe toxicosis or preeclampsia;
  • Stubborn constipation;
  • Severe swelling of the legs;
  • Increased blood pressure.
If a combination of several of these signs is detected, the doctor may suspect a multiple pregnancy, however, to confirm this assumption, it is necessary to perform an ultrasound scan.

How to determine multiple pregnancy - effective diagnostic methods

Currently, multiple pregnancy is detected with 100% accuracy during conventional ultrasound. Also, the determination of the concentration of hCG in venous blood has a relatively high accuracy, but this laboratory method is inferior to ultrasound. That is why ultrasound is the method of choice for diagnosing multiple pregnancies.

Ultrasound diagnosis of multiple pregnancy

Ultrasound diagnostics of multiple pregnancy is possible in the early stages of gestation - from 4 to 5 weeks, that is, literally immediately after the delay of menstruation. During the ultrasound, the doctor sees several embryos in the uterine cavity, which is undeniable evidence of multiple pregnancy.

The number of placentas (chorionicity) and amniotic sacs (amniotic) is decisive for the choice of pregnancy management tactics and the calculation of the risk of complications, and not the number of fetal or monozygotic fetuses. Pregnancy proceeds most favorably with bichorionic biamniotic twins, when each fetus has its own placenta and fetal bladder. The least favorable and with the maximum possible number of complications is a monochorionic monoamniotic pregnancy, when two fetuses are in the same fetal bladder and feed on the same placenta. Therefore, during the ultrasound, the doctor counts not only the number of fetuses, but also determines how many placentas and fetal bladders they have.

In multiple pregnancy, ultrasound plays a huge role in detecting various malformations or fetal growth retardation, since biochemical screening tests (determining the concentration of hCG, AFP, etc.) are not informative. Therefore, the detection of malformations by ultrasound in multiple pregnancies must be carried out in the early stages of gestation (from 10 to 12 weeks), while assessing the condition of each fetus separately.

HCG in the diagnosis of multiple pregnancy

HCG in the diagnosis of multiple pregnancy is a relatively informative method, but inaccurate. Diagnosis of multiple pregnancy is based on the excess of hCG levels of normal concentrations for each specific gestational age. This means that if the concentration of hCG in a woman's blood is higher than normal for a given period of pregnancy, then she has not one, but several fetuses. That is, with the help of hCG, multiple pregnancy can be detected, but it is impossible to understand how many fetuses are in a woman’s uterus, whether they are in the same fetal bladder or in different ones, they have two placentas or one is impossible.

Development of multiple pregnancy

The process of developing a multiple pregnancy creates a very high load on the mother's body, since the cardiovascular, respiratory, urinary systems, as well as the liver, spleen, bone marrow and other organs continuously work in an enhanced mode for quite a long period of time (40 weeks) to provide one, but two or more growing organisms with everything you need. Therefore, the incidence in women carrying a multiple pregnancy increases by 3-7 times compared with a singleton. Moreover, the more fetuses in a woman's uterus, the higher the risk of complications from various organs and systems of the mother.

If a woman suffered from any chronic diseases before the onset of a multiple pregnancy, then they will definitely become aggravated, since the body experiences very strong stresses. In addition, with multiple pregnancies, half of the women develop preeclampsia. All pregnant women in the second and third trimesters develop edema and arterial hypertension, which are a normal reaction of the body to the needs of the fetus. A fairly standard complication of multiple pregnancy is anemia, which must be prevented by taking iron supplements throughout the entire period of childbearing.

For normal growth and development of several fetuses, a pregnant woman must eat fully and intensively, since her need for vitamins, trace elements, proteins, fats and carbohydrates is very high. The daily calorie intake of a woman carrying twins should be at least 4500 kcal. Moreover, these calories should be gained from nutrient-rich foods, and not from chocolate and flour products. If a woman during a multiple pregnancy eats poorly, this leads to the depletion of her body, the development of severe chronic pathologies and numerous complications. During a multiple pregnancy, a woman normally gains 20-22 kg in weight, with 10 kg in her first half.

In multiple pregnancies, one fetus is usually larger than the other. If the difference in body weight and height between the fetuses does not exceed 20%, then this is considered the norm. But if the weight and growth of one fetus exceeds the second by more than 20%, they speak of a delay in the development of the second, too small child. Delayed development of one of the fetuses in multiple pregnancies is observed 10 times more often than in singleton pregnancies. Moreover, the probability of developmental delay is highest in monochorionic pregnancy and minimal in bichorionic biamniotic.

Multiple pregnancies usually end in preterm delivery because the uterus is stretched too much. With twins, births usually occur at 36-37 weeks, with triplets - at 33-34 weeks, and with quadruples - at 31 weeks. Due to the development of several fetuses in the uterus, they are born with a smaller weight and body length compared to those born from a singleton pregnancy. In all other aspects, the development of a multiple pregnancy is exactly the same as that of a singleton.

Multiple pregnancy - complications

With multiple pregnancy, the following complications can develop:
  • miscarriage in early pregnancy;
  • premature birth;
  • Intrauterine death of one or both fetuses;
  • Severe preeclampsia;
  • Bleeding in the postpartum period;
  • Hypoxia of one or both fetuses;
  • Collision of fruits (clutch of two fruits with heads, as a result of which they simultaneously find themselves at the entrance to the small pelvis);
  • Syndrome of fetofetal blood transfusion (FFG);
  • Reverse arterial perfusion;
  • Congenital malformations of one of the fetuses;
  • Delayed development of one of the fetuses;
  • Fusion of fetuses with the formation of Siamese twins.
The most severe complication of multiple pregnancies is the fetofetal hemotransfusion syndrome (FFTS), which occurs with monochorionic twins (with one placenta for two). SFFH is a violation of blood flow in the placenta, as a result of which blood from one fetus is redistributed to another. That is, one fetus receives an insufficient amount of blood, and the other - an excess. In SFFG, both fetuses suffer from inadequate blood flow.

Another specific complication of multiple pregnancies is fetal fusion. Such fused children are called Siamese twins. The fusion is formed in those parts of the body with which the fruits are most tightly in contact. Most often, fusion occurs in the chest (thoracopagi), the abdomen at the navel (omphalopagus), the bones of the skull (craniopagi), the coccyx (pygopagi), or the sacrum (ischiopagi).

In addition to those listed, with multiple pregnancy, exactly the same complications can develop as with a singleton.

Childbirth with multiple pregnancy

If the multiple pregnancy proceeded normally, the fruits have a longitudinal arrangement, then natural delivery is possible. In multiple pregnancies, complications in childbirth develop more often than in singleton pregnancies, which leads to a higher frequency of emergency caesarean sections. A woman with a multiple pregnancy should be hospitalized in a maternity hospital 3-4 weeks before the expected date of birth, and not wait for the start of labor at home. A stay in the maternity hospital is necessary for examination and assessment of the obstetric situation, on the basis of which the doctor will decide on the possibility of natural childbirth or on the need for a planned caesarean section.

The generally accepted tactics of delivery in multiple pregnancy is the following:
1. If the pregnancy proceeded with complications, one of the fetuses is in a transverse position or both are in a breech presentation, the woman has a scar on the uterus, then a planned caesarean section is performed.
2. If a woman has approached childbirth in a satisfactory condition, the fetuses are in a longitudinal position, then it is recommended to give birth through natural routes. With the development of complications, an emergency caesarean section is performed.

Currently, with multiple pregnancies, as a rule, a planned caesarean section is performed.

Multiple pregnancy: causes, varieties, diagnosis, childbirth - video

When they give sick leave (maternity leave) with multiple pregnancy
pregnancy

With a multiple pregnancy, a woman will be able to receive a sick leave (maternity leave) two weeks earlier than with a single pregnancy, that is, within 28 weeks. All other rules for issuing sick leave and cash benefits are exactly the same as for a singleton pregnancy.