Despite the fairly high modern level of development of obstetrics and obstetric care, women with multiple births are still at high risk. Management of multiple pregnancies and childbirth itself differ significantly from normal pregnancy one fruit. They demand from medical personnel experience and deep knowledge of this condition.

Relevance of the topic

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

Perinatal mortality in multiple pregnancies, compared with singleton pregnancies, is about 10% and in to a large extent associated with 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 incidence of cerebral palsy in a child of twins is 3-7 times more common, of triplets is 10 times more common, and the number of complications in the mother throughout the entire pregnancy period is 2 or more times (up to 10).

Causes of multiple pregnancy

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 births among all pregnant women amounted to 0.7-1.5%, the birth of twins in relation to the number of all births - 1: 87, triplets - 1: 6,400, quadruplets - 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 multiple pregnancies or in their families, especially female line, there were similar cases.
2. An increased level of follicle-stimulating hormone in a woman’s blood, which promotes the development and maturation of two or more eggs at the same time. This may be due to heredity, taking drugs that stimulate ovulation during the treatment of infertility, pregnancy immediately after discontinuation of ok (), especially against the background of the use of ovulatory stimulation agents.
3. Carrying out 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.
4. Number of births: with repeated pregnancy and childbirth, the likelihood of multiple births increases.
5. A woman over 35 years of age. It is believed that this is due to decreased 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.
6. Anomalies in the development of internal genital organs.

The many reasons for multiple pregnancies, the main ones listed above, indicate that this issue is still insufficiently studied.

Classification of multiple births

In deciding on the tactics of managing such a 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 containing a double complete set of chromosomes. The 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

According to the number of fetuses, pregnancies are differentiated into 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 opportunity to develop independently, individually. This type of twins is called monozygotic, or identical, and the children are called twins. They have the same gender, eye and hair color, skin pattern of fingers, blood type, location and shape of teeth.

Bizygotic

The simultaneous maturation and release of two or more eggs can occur either in one ovary or in both during one menstrual cycle. Bizygotic or dizygotic embryos develop from two fertilized eggs and account for an average of 70%. The children are called "twins". They can be both same-sex and different-sex, 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 dizygosity in various combinations are possible.

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 membranes and two amniotic membranes. Therefore, such embryos in the classification are called di- (or bi-)-chorionic, diamniotic dizygotic twins.

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

1. 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, dichorionic, diamniotic monozygotic twins are formed, in which one placenta is possible, formed from the fusion of two placentas, or two separate placentas.
2. If the division of the egg occurs in the interval of 4-8 days after its fertilization, when the formation of the inner cell layer has already completed, and the chorion has formed 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 occurred by the time the fertilized egg separates, 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 the 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 conjoined.

The easiest way to determine if you are monozygotic or dizygotic is to be examined by an obstetrician after the children are born. The septum between twins consists of two water (amniotic) membranes, and between “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 when different groups blood, compared to a singleton, places 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 a pregnant woman’s body, the volume of circulating blood increases (by 50-60%), which creates an additional load on cardiac function, while with one fetus this figure does not exceed 40-50%. Due to hemodilution (blood dilution), anemia and an increased need for vitamins, macro- and microelements, especially folic acid and iron, are often observed.

Women are much more likely to report shortness of breath, fatigue, painful heartburn, urinary problems and constipation. These phenomena especially worry them latest dates. In addition, toxicoses are more common among them, develop earlier, and their course is more severe. Large sizes the uterus reaches not only due to multiple pregnancy, but also as a result of cases frequent development polyhydramnios, which can cause renal dysfunction. 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) during 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 twins surgical treatment is effective in strengthening the cervix, then as the triplets grow, etc., the sutures applied often cannot withstand the load and are cut through. Therefore, in some cases, the additional use of a special pessary helps.

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

• disorders placental circulation due to disruption of the uterine vasculature after surgery, which leads to intrauterine growth retardation and/or intrauterine asphyxia;
• placenta previa;
• threat of miscarriage;
• incorrect position of the fruits;
• failure of the scar on the uterus and its rupture, which is the most dangerous.

In some cases, with multiple pregnancy, as with singleton pregnancy, on the 8th day it is possible spotting from the vagina, lasting about 4 days - this is, as a rule, minor implantation bleeding that accompanies the introduction (implantation) of a fertilized egg into the uterine mucosa. However, when two or more such eggs are implanted, it can be longer, more repeated and more 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, prescription of antispasmodics, etc.

Risks to the fetus(es)

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

Of fundamental importance when detecting congenital malformations in one of the fetuses is the determination during the prenatal period of zygosity, since in the case of dizygotic twins, the second fetus may be without pathology, and in the case of monozygotic twins, the probability 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 monozygotic twins it is 2-3 times higher.

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

In a monochorionic placenta, and much less frequently in a bichorionic 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 in the placental vascular system is symmetrical, the development of the fetus occurs under equal conditions. But with monozygotic twins, these conditions can be disrupted due to asymmetric blood circulation in the placenta, as a result of which the supply of arterial blood to one of the fetuses is reduced, 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 goes to one of the twins - the development of feto-fetal transfusion syndrome (FFTS) is possible, which is noted especially in cases of monochorionic multiple pregnancies (from 5 to 25%), hypertension , enlargement of the heart, etc. in one of the fetuses. The second may develop deformity, cessation of heart function, or he gradually dies and undergoes mummification (spontaneous reduction of the fetus). This process can be complicated by the development of DIC syndrome (disseminated intravascular coagulation) in a woman, which threatens her life.

Fetal reduction during multiple pregnancy

In some cases, fetal reduction is carried out artificially. The need for this often occurs after IVF. Artificial reduction is associated with certain risks and complications, and therefore is performed only 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. The presence of contraindications for a woman to carry a multiple pregnancy.

The artificial reduction procedure is usually carried out no earlier than 7 and no later than 13 weeks. It involves stopping the heart of an unpromising fetus (or fetuses) by injecting a special drug or air into his/their heart. To do this, a puncture of the uterine cavity is performed transvaginally (at 7-8 weeks) or transabdominally (at 8-13 weeks) after local anesthesia with a needle under the control of an ultrasound device. Subsequently, fetal tissue is reabsorbed.

How to sleep during multiple pregnancy?

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

All venous blood from the lower half of the torso and abdominal cavity collects in the vein, then it enters the right atrium, etc. The cause of this syndrome is high blood pressure in the abdominal cavity due to an enlarged uterus. When a woman lies horizontally on her back or on her right side, compression of the inferior vena cava occurs 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 most, this goes unnoticed, but in about 10%, symptoms such as a sharp decrease in blood pressure, dizziness, pallor, nausea, vomiting, and in severe cases loss of consciousness and collapse, the appearance of convulsions are possible.

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

Signs of multiple pregnancy and its management

Early multiple pregnancy

Diagnostics

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

At what stage is a multiple pregnancy determined?

In the early stages, an assumption about the presence of two or more fetuses can be made based on a set of signs:

• anamnesis that the couple or their immediate family is one of 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 with the duration of pregnancy, which also occurs with hydatidiform mole.

At later stages, in making a presumptive diagnosis, importance is attached to such data as:

• early movement during a multiple pregnancy, which can be felt by a woman from the 15th week, while in the first singleton - from the 20th, and in subsequent ones - from the 18th week;
• the size of the abdominal circumference and the height of the uterine fundus, which exceed the expected duration of a singleton pregnancy;
• palpation through the anterior abdominal wall in the second half of gestation of floating 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 fundus of the uterus of a depression formed by the protrusion of its corners by large fetal parts (in case of twins);
• auscultatory determination of two points of the heartbeat, especially if there is a zone of absence of tones between them (the “silence” zone);
• different (10 beats difference) heart rate in different points, which can also be determined using 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 of hCG (human chorionic gonadotropin) and placental lactogen in the blood. This laboratory biochemical testing is not completely reliable, but is relatively informative. Thus, the level of hCG during a multiple pregnancy at each stage of the gestational period exceeds the norm for a single pregnancy.

Determining the content of progesterone in the blood is of similar importance. Increased progesterone during multiple pregnancy , compared to the norms determined for a singleton, will be in each corresponding trimester.

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

In addition, echography allows in the second and third trimesters to determine the nature of fetal development and the contours of the fetuses, which helps to identify conjoined twins, FFTS, the location and number of placentas and amniotic (water) cavities, identify congenital malformations, antenatal death, etc. According to echometric biometry, the following five types of twin development are distinguished:

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

Options for fetal presentation

Ultrasound also allows you to determine the presentation of the fetuses 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.), it provides for the prevention of gestosis, their early detection and treatment in a hospital setting, control of the blood coagulation system, function of the cardiovascular system and kidney function.

Recommendations are also given on a woman’s proper balanced and sufficiently high-calorie diet, 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- staying in bed during the day 3 times for 1-2 hours, taking tocolytics and bed rest in case of 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 should be done every week after 30 weeks. If possible, a blood flow study is also carried out on each fetus separately.

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

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

Childbirth and its management

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

Due to the overstretched uterus, weakness of labor forces develops, and the dilation 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 simultaneously with the first, and this takes long time. The muscles of the anterior abdominal wall are weakened and overstretched, causing the period of pushing to lengthen or become 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 dissection of the perineum.

A serious complication during the expulsion period - premature detachment 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 heavy bleeding and the development of hypoxia in the second child. To prevent it, the obstetrician performs an emergency opening of the second amniotic sac.

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

Management of childbirth during multiple pregnancy

It consists of careful monitoring of the cardiac activity of the fetuses using cardiac monitors and the condition of the woman in labor. It is advisable to conduct them in the first period on the left side to prevent inferior vena cava syndrome. With the development of weakness of labor forces, stimulation of the latter is carried out through intravenous drip administration of a solution of glucose with oxytocin, anesthesia using the method of epidural analgesia.

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

Umbilical cord ligation is carried out not only at the fetal end, but also at the maternal end, since after its dissection in 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 will open amniotic sac, A amniotic fluid are slowly released, after which labor is carried out naturally(in longitudinal position).

In case transverse position or incorrect insertion of the head of the second fetus into the small pelvis under general anesthesia The child is turned onto the leg and removed. If it is impossible to give birth naturally (impossibility of turning, large baby, cervical spasms, signs acute hypoxia one of the fetuses, loss 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 fusion of twins, is a cesarean 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 an 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 injected intravenously for 2 hours. If there is no effect, manual separation of the placenta and subsequent massage of the uterus on the fist are performed.

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

Thus, although a multiple pregnancy is not 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 observations and care of newborn babies are required.

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A multiple pregnancy is a pregnancy in which a woman carries more than one fetus. During natural conception, it occurs in the proportion of 1 case per 80 births. When using reproductive technologies, whether it is stimulation of superovulation or the IVF method, the chances that the expectant mother will carry twins, triplets or quadruplets increase sharply.

The recorded record for multiple pregnancies is the birth of ten twins. However, not all of them survived. The largest number of twins that have been born and survived are octuplets. However, carrying multiple fetuses at the same time increases the risks of premature birth, early pregnancy loss, and neurological problems in children after birth.

How does a multiple pregnancy happen?

Multiple pregnancy photo (twins)

Several babies can appear for two reasons: either the mother had several mature eggs fertilized at the same time, or the zygote of one egg separated several hours after fertilization.

In the first case, the twins will be called fraternal; the embryos are implanted in different segments of the uterine body. Normal in everyone menstrual cycle One egg must mature. But hormonal imbalance or stimulation of superovulation can lead to the formation of several dominant follicles at once, which enlarge and produce several eggs ready for fertilization.

By the way, within 1 - 2 months after stopping a course of oral contraceptives, a rebound effect may occur, when the woman’s body also produces several eggs in one cycle.

In the second case, when a division of one female cell has occurred, the twins will be called identical. The division of a zygote can be either spontaneous (which happens very rarely) or hereditary (which happens much more often). It is typical for identical twins that an ultrasound scan in such a multiple pregnancy in the early stages may not show that there are several embryos.

Having twins or triplets is a challenge not only for morale future parents, but also for them family budget. Therefore, the sooner the number of embryos is established, the more opportunities the couple will have to prepare for further waste. In addition, it is important to monitor signs of multiple pregnancy in the early stages after stimulation of superovulation, so that at 10–12 weeks it is possible to carry out selective reduction if there are too many embryos in the uterus.

Among the first symptoms of the presence of several embryos are the following:

1. The level of hCG in a blood test does not correspond to the parameters observed in the presence of one child - the levels of this hormone are much higher.
2. Toxicosis begins earlier than pregnancy is detected by ultrasound, that is, before 21 days from conception.
3. During a bimanual examination, the gynecologist states that the enlargement of the uterus occurs more intensely, and the size reproductive organ more than during pregnancy with one fetus at one time or another.

As the period increases, ultrasound can determine the amount fertilized eggs, and then, in the second trimester, the number of embryos in one fetal egg (if the twins are identical).

Methods for accurately diagnosing multiple pregnancies

In addition to symptoms, there are ways to accurately diagnose multiple pregnancies - this is assessing the dynamics of hCG and evaluating the results ultrasound examination. Moreover, the doctor must take both results into account, especially if the woman only passed a test to determine the level of the pregnancy hormone.

HCG during multiple pregnancy reaches 31,500 mU/ml at 4 weeks, 82,300 mU/ml at 6 weeks and 291,000 mU/ml at 11 weeks. This is several times more than the hormone level during pregnancy of one fetus. If a woman is carrying more than two embryos, the rates may be even higher.

But a high level of hCG is not always the first accurate sign of multiple pregnancy. Sometimes it may indicate chromosomal abnormalities that the fetus has. For this reason, the woman is prescribed an examination by an uzist.

Ultrasound, especially performed after 10 weeks, it will be able to tell with high accuracy whether the expectant mother is carrying several embryos or one. If the twins are fraternal, then this may become obvious already at 5–6 weeks, when two or more fertilized eggs can be distinguished in the uterine cavity.

If the twins are identical, then the diagnosis can be more accurate in the second and even third trimester. The doctor will have to determine whether each baby has its own placenta or whether they are shared, as well as the level of development of the children, because there are often cases when one of the twins receives little nutrition and lags behind his brother or sister.

If the doctor suspects twins, then ultrasound remains the only accurate and in a safe way how to determine multiple pregnancy.

Babies develop in exactly the same way as if they were alone in the mother's womb. The only peculiarity in this regard may be that they may not gain weight as steadily and intensively as in the case of a singleton pregnancy. But some differences can be observed in the mother’s well-being and in the doctor’s attitude:

• Increased tiredness and fatigue. In this regard, the gynecologist will give a recommendation to observe semi-bed rest more often, especially if diagnosed increased tone uterus.
• During a multiple pregnancy, the abdomen can have much larger volumes - this is associated with the risk of severe stretch marks, which will then be difficult to remove.
• The doctor's attention will be more careful, since when carrying twins and triplets, the risk of developing eclampsia and pre-eclampsia is much higher than when carrying one child.

Features of childbirth during multiple pregnancy

The main task of the gynecologist is to prolong the pregnancy until such time that the children are viable and the likelihood of brain hemorrhage at birth is minimal. Births during multiple pregnancies often become premature, especially for triplets and quadruplets.

If doctors have even minimal doubts that natural childbirth may be complicated, the woman is usually sent for a caesarean section to minimize risks.

Babies are born with a short interval of a few minutes. There are cases when a second child was born a few days after the first, but such situations are rare, and they are possible only with fraternal twins.

The main reason for such a large interval is considered to be a weekly delay in the development of one of the children in a multiple pregnancy.

Multiple pregnancies are much less common than regular pregnancies, when a woman carries only one baby. But if you have had similar cases in your family or for some other reason there is a suspicion that the addition to the family will be larger than expected, you should definitely figure out whether this is so. After all, women with multiple pregnancies need to be even more attentive to their well-being and the health of their babies, and visit the doctor more often.

But how to determine whether one fetus or twins is developing? What are the early signs of multiple pregnancy? When can twins be seen on an ultrasound?

Woman's well-being

Pregnancy is a period when female body it is necessary to ensure the life support of one’s own body and the fetus. When a woman is pregnant with twins, the load increases even more. This has a noticeable effect on the condition expectant mother.

If a woman is pregnant for the second time, she will most likely be able to easily identify a multiple pregnancy even before an ultrasound. But it is more difficult for first-time mothers to do this, since they have nothing to compare their well-being with.

Still, there are some signs of twin pregnancy that can be noticed in the early stages:

• Constantly makes you sleepy.
• Severe early toxicosis.
• Fetal movements are felt early.
• Often women intuitively realize that they are carrying more than one child.

Let's take a closer look at how the signs of twins appear in the early stages and why it happens this way.

Constant sleepiness

Most women note that one of the first changes that they notice even after a few weeks is the desire to sleep when relatively little time has passed from waking up. During multiple pregnancy, drowsiness is constant.

From the very early stages you want to sleep in the morning; work that requires a high concentration of attention and reaction speed is difficult.

But it is worth considering that this does not happen to everyone. In addition, drowsiness may be a sign of lack of energy associated with completely different reasons, for example, malnutrition, excessive physical activity or stress that a pregnant woman endures more severely than other people.

Nausea in the morning

Signs of a multiple pregnancy almost always include early start toxicosis. In addition, in women who are carrying twins, it occurs more often and manifests itself more intensely. This is due to the fact that with this type of pregnancy changes hormonal levels and others physiological processes, which occur in the body during the period of bearing a child, are more pronounced.

First manifestations early toxicosis manifest themselves in poor health in the first half of the day. This may include nausea, dizziness, or severe loss of strength. In case of multiple pregnancy, such symptoms appear in very early stages, when the woman may not yet be aware of her situation. Therefore, if there is a possibility that a girl has become pregnant and she does not feel well in the morning, it is better to immediately check her condition, for example, do a test, even if the time frame is too short.

Of course, not everyone who had a multiple pregnancy had toxicosis at all. In addition, sometimes there is a very difficult pregnancy even when carrying one fetus. Therefore, you should not focus only on your well-being when trying to determine how many babies you should expect.

Premonition

Often, when a doctor tells an expectant mother during an ultrasound that she is expecting several children, this does not cause much surprise. Somehow, sometimes women figure this out on their own.

This fact may seem strange, but there are several points that can explain it:

• Often, a woman who is about to have twins already has such cases in her family. It is passed on genetically and usually appears within one generation.
• Often multiple pregnancies occur during in vitro fertilization or when conceiving after prolonged use hormonal contraceptives. Typically, such women know that in their case the probability of multiple pregnancy is very high.
• Women have very good intuition and strong emotional connection with an unborn child. This is especially pronounced among those who already have children and, accordingly, they can compare real pregnancy from the previous one.

If for some reason such a premonition arises, it is better to go to the doctor and get checked, because if it is confirmed, you will need to register earlier.

Early movements

Normally, the expectant mother begins to feel fetal movements from 18 weeks during the first pregnancy or after 16 weeks during subsequent ones. If there are two or more children, kicking and pushing may be felt a couple of weeks earlier. When there are several babies, they take up more space and it is more difficult for them to move without touching each other and the walls of the uterus.

In addition to the fact that movements begin to be felt very early, there are noticeably more of them. It happens that the periods of fruit activity do not coincide, then movements are felt almost constantly. In the later stages, you may even feel some pain.

Doctor's examination

If the pregnancy is multiple, an experienced doctor will guess this at the very first examination. They usually come in at 8-12 weeks. If, upon examination, the doctor gets the impression that a woman has twins or triplets, he may refer her for an ultrasound to determine whether this is actually the case.

Of course, the longer the period, the more signs can be noticed without additional examination. But below are the very first signals that may indicate the need to conduct a pregnancy as multiple.

Visual inspection

The first thing a woman who realizes that she is pregnant begins with a gynecologist is a visual examination. The doctor assesses the condition, shape and size of the uterus.

Multiple pregnancy, the signs of which are noticeable to the doctor upon examination:

• Gestational age is greater than the actual gestational age. This indicator is obtained by measuring the distance between the top of the pubis and the top of the uterus. Naturally, when the child is not alone, the belly will grow much faster. In the early stages this is visually imperceptible, but it will definitely be reflected in the doctor’s measurements.
• There is a longitudinal or transverse depression on the surface of the uterus. This is the place where one fruit touches another.
• A deepening of the uterine fundus is observed. When the baby is alone, it is located approximately in the middle, but if there are twins in the stomach, they are closer to the corners of the uterus, which leads to their protrusion.

Each of these signs may be due to other reasons. But if everyone is present, we can conclude that the probability of having several children is quite high.

Palpation

Palpation does not always help to determine how many babies are being formed in the uterus if it is carried out at very early stages. But towards the end of the first trimester, this method of obstetric examination already helps to obtain a lot of information.

What is revealed during palpation during multiple pregnancy:

• More than two large parts are felt. You can usually feel the head and pelvic end. In a normal pregnancy, both parts are found. When there are several children in the uterus, they can be located in such a way that it is difficult to feel all parts at the same time, so it is difficult to determine the exact number of twins using this method.
• Large parts can be felt in different parts uteruses that are too distant from each other compared to the normal size of the fetus at the expected period.
• Movements are felt simultaneously in several areas that are located relatively far from each other.

Palpation helps to establish the fact of multiple pregnancy, but in order to find out how many children there will be, you need to do an ultrasound.

Analysis indicators

The hormonal levels of a woman pregnant with twins or triplets are very different from normal levels. This can be seen from the very first weeks.

Test results that indicate multiple pregnancy:

• Fat lines on a pregnancy test. This is the most common and accessible method for determining hCG levels ( human chorionic gonadotropin human) is a hormone that increases sharply during pregnancy. In case of twins, the line will be very clear already at 10 days.
• The level of hCG in blood tests is too high, even for indicators in pregnant women.
• Increased AFP analysis result. The level of alpha-fetoprotein increases in the presence of developmental pathologies in the fetus. But if there are several fruits, the indicators will be very high even with the normal development of each of them. In the early stages, this analysis is prescribed very rarely.

The test results need to be assessed only as a whole. This is the only way to determine what exactly they are talking about: about disturbances in the development of the baby, about problems during pregnancy, or about such an unusual phenomenon as carrying twins.

Survey results

During pregnancy, every woman needs to undergo a number of mandatory instrumental examinations. The main purpose of this procedure is to detect and eliminate any violations that could jeopardize the birth healthy child. But these same methods can accurately determine how many babies are developing in the stomach.

If basic examinations confirm the fact of multiple pregnancy, additional tests are usually prescribed. In addition, they will need to be done a little more often than other women.

Ultrasound

Ultrasound is the most common basic examination, which is prescribed to absolutely all pregnant women. It is repeated at least three times. This helps to obtain the most accurate information about the condition of the fetus at various stages of its development.

It is possible to determine the number of fetuses using ultrasound even in the early stages.

Of course, at 4 or 5 weeks it will hardly be possible to say anything for sure. But at a period of 8–12 weeks during pregnancy with twins, two small living lumps will already be clearly visible on an ultrasound.

There are often cases when very early ultrasound, for example, at 5 weeks, two fetuses were noticeable, but a month later only one child was seen. This is because even when several eggs are fertilized, it is not uncommon for only one embryo to survive.

Listening to the heartbeat

In addition to ultrasound, there are many mandatory examinations and those appointed to special cases. Based on the results of many of them, one can judge how many children there will be.

For example, listening to the heartbeat is often used. Using a stethoscope, this can only be done towards the end of pregnancy. But modern equipment allows you to count the pulse from a period of 4 weeks, as soon as the fetal heart begins to beat on its own. If the child is not alone, several heartbeats will be heard in different places.

Every woman who finds out about her pregnancy wants to be aware of who and when she will give birth. And if there are usually no special problems, then the gender can only be determined by ultrasound, and even then it is not always correct. But what to do in the case when a woman is expecting not one, but several children. How can you suspect that you have a multiple pregnancy? The signs exist, but they differ from girl to girl and are not always reliable, but we will still try to describe them.

Multiple pregnancy: signs

Most often, women carrying two or more children note very rapid fatigue. This is understandable, because the body experiences heavy loads, and therefore fatigue occurs much faster. At the same time, it happens that a woman does not pay attention to this, because she believes that she has become older and has more responsibilities than during her first pregnancy. Some people don't notice this sign at all.

What else could indicate a multiple pregnancy? Toxicosis manifests itself much earlier and more severely: more nausea, more ailments, and vomiting may occur more often. If you are very concerned about toxicosis, you should complain to your doctor.

Rapid weight gain, especially in the first trimester, may indicate that a woman is expecting more than one child. This happens due to fast increase uterus and blood volume. True, sometimes even when carrying a singleton pregnancy, women quickly gain weight, especially when taking hormonal drugs.

Another difference that can tell a pregnant woman that she will have not one baby, but two or three - large size belly. At the same time, you need to know that during pregnancy the belly grows faster compared to the first pregnancy and may not always indicate multiple births.

It should also be said that women begin to feel the movement of fetuses in the stomach earlier if they are carrying twins. Although this is very individual.

How to determine multiple pregnancy

During an examination by a gynecologist, he can determine a multiple pregnancy due to the discrepancy between the size of the uterus and the expected period - it will be larger. But the doctor will not be able to say for sure, since the same picture is observed with uterine fibroids, or polyhydramnios.

A survey of the expectant mother is required antenatal clinic, and if she or her husband have twins in their family, then this may indicate the development of a multiple pregnancy. Information about or stimulation of ovulation may also be a clue.

Elevated levels of hormones also indicate multiple pregnancy: ά-fetoprotein and human chorionic gonadotropin.

Most exact way Confirm that you have a multiple pregnancy - ultrasound diagnostics. This method allows you to determine the number of embryos in the early stages with an accuracy of 99.3%.

In the second half of a multiple pregnancy, the signs are clearer and it is easier to determine its presence. significantly exceed the prescribed period, the abdominal circumference can be more than 110 cm.

The uterus may have a specific shape - saddle-shaped, since its corners protrude due to the position of the fetuses. On the front wall there is a horizontal or longitudinal groove, depending on the transverse or longitudinal one, respectively.

Clear identification of three parts of the fetus upon palpation: two heads and a pelvis, or two pelvises and a head.

When listening, the presence of two heartbeat points is revealed; there should be a difference of 10 beats/minute.

It turns out that a multiple pregnancy has signs and can be determined by different dates with varying degrees of reliability.