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

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 prenatal development up to 28 weeks postpartum). These features are a high complication rate, prematurity, and the risk of premature birth, severe form of fetoplacental 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 in to a large extent associated with fetal body weight. 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 female line there have been 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 when early stages 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 when they different groups blood, 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 of particular concern for last dates. In addition, toxicosis among them are more common, develop earlier, and their course is more severe. Large sizes the uterus reaches not only because of multiple pregnancy, but also as a result of cases frequent development polyhydramnios, which can lead to 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 effective in strengthening the cervix, 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. Special attention and strict constant dynamic monitoring requires multiple pregnancy after caesarean section, due to the large number of risks, both for the fetus and for the woman. The main risks with high frequency include:

• disorders 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 multiple pregnancy, as with a singleton, on the 8th day, bloody issues from the vagina, lasting about 4 days - this is usually a slight 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, repeated and abundant and lead to spontaneous miscarriage. In these cases, it is necessary to 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, 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 include Down's disease, Edwards and Patau syndromes, a non-invasive prenatal test with 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 reason for this syndrome is high blood pressure in the abdominal cavity due to an enlarged 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 possible loss of consciousness and collapse, the appearance of convulsions.

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

Widespread use in clinical practice of obstetrics and gynecology has made it possible to diagnose multiple pregnancies on early dates. 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 in 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 with multiple pregnancy , 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 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 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. Availability congenital pathology 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- being in bed during the day 3 times for 1-2 hours, taking tocolytics and bed rest in case of threatened 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 - C-section at 33-34 weeks (due to high risk torsion of the umbilical cord), and during pregnancy with 3 fetuses or more - at 34 weeks.

Childbirth and their management

Normal generic course 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 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 - 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 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 applying obstetric forceps to the head (with cephalic presentation) or extraction (with breech presentation) for 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 amniotic sac, A amniotic fluid are slowly released, after which childbirth is carried out naturally(in the longitudinal position).

In the case transverse position or incorrect insertion of the head of the second fetus into the small pelvis under general anesthesia turn on the leg and remove the child. If it is impossible to give birth naturally (impossibility of turning, large child, cervical spasm, signs acute hypoxia one of the fetuses, prolapse of the umbilical cord and small parts, persistent secondary generic 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 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.

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

The recorded record for multiple pregnancy is the birth of ten twins. However, not all of them survived. The largest number of twins who were born and were able to survive - octuplets. However, carrying multiple fetuses at the same time increases the risk of preterm birth, early termination of pregnancy, and neurological problems in children after birth.

How is a multiple pregnancy?

Multiple pregnancy photo (twins)

Several babies can appear for two reasons: either several mature eggs were fertilized in the mother 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 every menstrual cycle one egg must mature. But hormonal disbalance 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 the abolition of the 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 there was a division of one female cell, the twins will be called identical. Separation of the zygote can be either spontaneous (which happens very rarely) or hereditary (which happens much more often). For identical twins, it is characteristic that ultrasound with such a multiple pregnancy in the early stages may not see that there are several embryos.

Having twins or triplets is a test not only for morale future parents, but also for their 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 the signs of multiple pregnancy in the early stages after stimulation of superovulation, so that at 10-12 weeks there is the possibility of selective reduction if there are too many embryos in the uterus.

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

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

With an increase in the period on ultrasound, it is possible to determine the amount fertilized eggs, and then, in the second trimester, the number of embryos in one fetus egg (in case the twins are identical).

Methods for accurate diagnosis of multiple pregnancy

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

HCG in 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 level of the hormone during the bearing of one fetus. If a woman is carrying more than two fetuses, then the rates may be even higher.

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

Ultrasound, especially produced after 10 weeks, 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 apparent as early as 5 to 6 weeks, when two or more fetal eggs are visible in the uterine cavity.

If the twins are identical, then the diagnosis may be more accurate in the second and even in the third trimester. The doctor will have to determine whether each baby has its own placenta or they are in common, as well as the level of development of the children, because it is not uncommon for one of the twins to receive little nutrition and lag behind a brother or sister.

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

The development of babies occurs in the same way as if they were alone in the mother's womb. The only feature in this regard may be that they may not gain weight as steadily and intensively as in the case of a singleton pregnancy. But in the well-being of the mother and in relation to the doctor, some differences can be observed:

• Increased tiredness and fatigue. In this regard, the gynecologist will give a recommendation to observe half-bed rest more often, especially if diagnosed increased tone uterus.
• With multiple pregnancies, the abdomen can have much larger volumes - this is associated with the risk of strong stretch marks, which then will be difficult to eliminate.
• The attention of the doctor will be closer, since when carrying twins and triplets, the risk of developing eclampsia and preeclampsia is much higher than when carrying one child.

Features of childbirth in multiple pregnancy

The main task of the gynecologist is to prolong the pregnancy until such a period at which the children will be viable, and the likelihood of cerebral hemorrhage at birth is minimal. Childbirth with multiple pregnancies often becomes premature, especially for triplets and quadruplets.

If doctors have even the slightest doubt that natural childbirth can be complicated, then usually the woman is sent for a caesarean section to minimize the risks.

Babies are born with a small interval of a few minutes. There are cases when the 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 lag in the development of one of the children in a multiple pregnancy.

Multiple pregnancy is much less common than normal, when a woman bears 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 more than expected, you should definitely find out if this is so. After all, women with multiple pregnancies need to be even more attentive to their well-being and the health of babies, to visit a doctor more often.

But how to determine whether one fetus or twins develops? 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 organism and the fetus. When a woman is pregnant with twins, the workload increases even more. This has a significant effect on the future mother.

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

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

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

Let us consider in more detail how the signs of twins appear in the early stages and why this happens this way.

Constant sleepiness

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

From the earliest dates, you want to sleep in the morning, it is difficult to work where you need a high concentration of attention and speed of reaction.

But keep in mind that this is not the case for everyone. In addition, drowsiness can be a sign of a breakdown associated with completely different causes, such as malnutrition, excessive physical activity or stresses that a pregnant woman endures harder than other people.

Nausea in the morning

Signs of multiple pregnancy almost always include early start toxicosis. In addition, in women who carry twins, it happens more often and is more intense. This is due to the fact that with this variant of pregnancy, changes hormonal background and others physiological processes that occur in the body during the period of bearing a child are more pronounced.

First manifestations early toxicosis manifest in poor health in the morning. It can be nausea, dizziness, a strong breakdown. With multiple pregnancies, such symptoms appear at a very early stage, when a woman may still not 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, take a test, even if the time is too short.

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

Premonition

Often, when an ultrasound doctor tells a future mother that she is expecting several children, this is not very surprising. Somehow, sometimes women figure it out on their own.

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

• Often in the family of a woman who is about to have twins, there are already such cases. It is passed down genetically and usually shows up after one generation.
• Often multiple pregnancy occurs during in vitro fertilization or conception after prolonged use hormonal contraceptives. Usually 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 has arisen, 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 at a period of 18 weeks during the first pregnancy or after 16 weeks with subsequent ones. If there are two or more children, pushing and kicking may be felt a couple of weeks earlier. When there are several babies, they take up more space, it is more difficult for them to move without touching each other and the walls of the uterus.

In addition to the fact that the 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, some soreness may even be felt.

Medical examination

If the pregnancy is multiple, an experienced doctor will guess this at the very first examination. It usually arrives at 8-12 weeks. If, upon examination, the doctor gets the impression that the woman has twins or triplets, he can send her for an ultrasound to determine if this is really 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 suspects that she is pregnant starts seeing a gynecologist with is a visual examination. The doctor evaluates the condition, shape and size of the uterus.

Multiple pregnancy, the signs of which are visible to the doctor during the examination:

• Gestational age is greater than actual gestational age. This indicator is obtained by measuring the distance between the upper part of the pubis and the upper part 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 certainly be reflected in the doctor's measurements.
• On the surface of the uterus there is a longitudinal or transverse depression. This is the place where one fruit comes into contact with another.
• There is a deepening of the uterine fundus. When the child is alone, it is located approximately in the middle, but if there are twins in the abdomen, 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 determine how many babies are being formed in the uterus if it is performed very early. But towards the end of the first trimester, this method of obstetric examination already helps to get a lot of information.

What is found during palpation in multiple pregnancy:

• More than two large parts are groped. You can usually feel the head and pelvic end. In 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 are palpable in different parts uterus, too distant from each other compared to the usual size of the fetus at the expected date.
• 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 background of a woman pregnant with twins or triplets is very different from normal levels. This can be seen from the very first weeks.

Test results that indicate a multiple pregnancy:

• Fat lines on a pregnancy test. This is the most common and affordable method for determining the level of hCG ( chorionic gonadotropin human) - a hormone that rises sharply during pregnancy. With twins, the strip will be very clear already for a period of 10 days.
• Too high, even as for indicators in pregnant women, the level of hCG in blood tests.
• 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 results of the analyzes should be evaluated only in the complex. This is the only way to determine what exactly they are talking about: about violations 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 must undergo a series of mandatory instrumental examinations. The main purpose of this order is to detect and eliminate any violations that could jeopardize the birth healthy child. But these same methods can accurately determine how many babies develop in the stomach.

If the fact of multiple pregnancy was confirmed during the main examinations, additional checks 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 state 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 something for sure. But for a period of 8–12 weeks during pregnancy with twins, two small living lumps will already be clearly visible on ultrasound.

There are frequent cases when early ultrasound, for example, at 5 weeks, two fetuses were visible, but after a month only one child was seen. This is because even when multiple eggs are fertilized, it is not uncommon for only one embryo to survive in the end.

Listening to the heartbeat

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

For example, listening to the heartbeat is often used. With 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 independently. 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 be born. And if there are usually no special problems with, then the sex can only be determined by ultrasound, and even then it is not always correct. And what to do in the case when a woman expects not one, but several children. How can you suspect that you have a multiple pregnancy? Signs exist, but they differ in different girls and are not always reliable, but still we will try to describe them.

Multiple pregnancy: signs

Most often, women bearing two children or more note very rapid fatigue. This is quite 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 do not notice this sign at all.

What else can indicate a multiple pregnancy? Toxicosis, which manifests itself much earlier and is stronger: more sick, more ailments, and more often there may be vomiting. If you are very worried about toxicosis, you should complain to the doctor.

Rapid weight gain, especially in the first trimester, may indicate that a woman is expecting more than one child. This happens due to rapid increase uterus and amount of blood. 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 - big size belly. At the same time, you need to know that during the time the stomach grows faster compared to the first and may not always indicate multiple pregnancy.

It should also be said that the movement of the fetus in the stomach of a woman begins to feel earlier if they are carrying twins. Although this is very individual.

How to identify multiple pregnancy

During an examination by a gynecologist, he can determine a multiple pregnancy due to a 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 myoma, or polyhydramnios.

Be sure to conduct a survey of the expectant mother in antenatal clinic, and if she or her husband has twins in the family, then this may indicate the development of a multiple pregnancy. Also, a hint may be information about or stimulation of ovulation.

An elevated level of hormones also indicates a 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 at an early stage 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 from them. significantly exceed the prescribed time, the abdominal circumference can be more than 110 cm.

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

A distinct definition of three parts of the fetus on palpation: two heads and a pelvis, or two basins 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 multiple pregnancy has signs, and can be determined on different terms with varying degrees of certainty.