Possible Risks for Mom of a Multiple Birth Pregnancy

Question: I am pregnant with multiples. What are the possible risks to me carrying multiple babies?

A usual part of every young person’s fantasy is envisioning their future, future job, car, house, partner and possibly children. While the majority don’t necessarily envision having twins, triplets or more, multiple births are a definite possibility. Several factors weigh in when considering whom will have multiples: the age of the mother when she conceives (women over 35 years old are more like to spontaneously conceive multiples); if Mom already has had several children; if multiples run in your family; or if fertility assistance was used to help you get pregnant. If none of these situations describe you, consider the fact that multiples start with someone, so why not you?

A multiple birth pregnancy is automatically called “high risk”. While this term generally has a negative connotation, it is also a security blanket, so to speak, for parents expecting multiples. Mom is followed more closely, can expect more ultrasounds, blood tests, fetal monitoring, has different nutritional needs than if she was carrying one baby, can expect a greater number of visits with her doctor and may be referred to obstetrician to deliver the babies, all in the wish to ensure a happy, healthy outcome to this multiple birth pregnancy.

While any pregnant woman might experience some concerns during her pregnancy such as gestational pregnancy diabetes, anemia (water retention and subsequent swelling), vaginal bleeding, preeclampsia (rise in blood pressure, sudden weight gain, water retention) and kidney infection, there remain other possible concerns in a multiple pregnancy and the following looks at some of these possibilities. The goal is to look at each topic and to familiarize yourself with some of the warning signs. An immediate call to your doctor enables early detection of any concerns and ensures timely and appropriate treatment. They are not listed in any particular order.

NOTE: This information is not intended to replace expert medical advice. If you have any concerns about any aspect of your pregnancy, PLEASE CONSULT YOUR DOCTOR IMMEDIATELY.

While some women may experience slight bleeding within the first few days after the fertilized eggs have implanted, it can be heavier with multiples. This bleeding is completely normal and is often mistaken for a light period before the pregnancy is confirmed. More serious bleeding later in the pregnancy may signal a miscarriage. With multiples, the risk of miscarriage before the 20th week of pregnancy is slightly higher than with a singleton. There is also a slight chance that one or more of the fetuses could miscarry (see Vanishing Twin) and the pregnancy continue with the healthy delivery of the remaining baby or babies.

As compared to a singleton pregnancy, many women report increased nausea and vomiting in the initial stages of the pregnancy, as well as feeling extreme fatigue. Much of this is due to the vast amount of hormones that are raging through Mom’s body as the babies are establishing themselves. Many women state that they generally begin feeling better after the fourth month. As in a singleton pregnancy, for some women nausea can last for the duration of the pregnancy. In the third trimester, fatigue is a common complaint as is the inability “to get comfortable” and “to get a good night’s sleep”. The increased baby load and the awkwardness of the size and shape of Mom’s abdomen, makes it a fatiguing load to carry.

Incompetent Cervix

A possible reason for bleeding early in the pregnancy is a condition in which the cervix spontaneously and painlessly opens early in the pregnancy. This is believed to be the cause of many second-trimester miscarriages. When detected early enough, an incompetent cervix can be sutured closed. For a mother pregnant with multiples, early detection is essential due to the increased pressure on the pelvic floor as her babies grow. Of course the higher the number of babies she is carrying, the earlier and greater the pressure on her cervix. It is not unusual for Mom to be put on bed rest and/or be required to spend some time in a tilted bed (tredelenburg position), with the lower body elevated above the head, relieving pressure on the pelvic floor.

Placental Problems

This is the most common reason for complications and bleeding after the 20th week of pregnancy. A condition called abruptio placenta occurs when the placenta partially detaches from the uterus before delivery. This may result in some bleeding and some abdominal pain.

With placenta previa, the placenta can implant low in the uterus, partially or completely covering the cervix. Placenta previa presents as painless bleeding and because the placenta is covering the cervix, a c-section may be necessary. This situation is more common in multiple pregnancies owing to the increased number and/or size of placentas present.

Iron-deficiency Anemia

The majority of women pregnant with multiples eventually develop iron-deficiency anemia, a condition characterized by low levels or iron in the red blood cells which carry oxygen to the tissues. The risk increases with each additional baby that is carried, particularly if you had low or borderline iron reserves before becoming pregnant. Symptoms include fatigue, light-headedness, pallor and shortness of breath. If untreated, anemia can adversely affect the babies’ growth, as well as increase your own risk for complications both during the pregnancy and after the birth. Because of the risk of iron and/or folic acid deficiency, the doctor may prescribe supplements in order to ensure that deficiency will not be a problem for Mom and her babies.

Gestational Diabetes

Common in women who are over the age of 30 years, overweight or have a family history of diabetes. Expectant mothers of multiples develop this kind of gestational diabetes two or three times more often than Moms carrying singletons. Gestational diabetes will clear up after birth.

Intrauterine Growth Restriction

Multiples usually grow slower than single babies while in utero and, additionally, do not always grow at the same rate as each other. This can be a result of unequal sharing of the available maternal nutrition. Depending upon nature’s distribution of the maternal nutrition available, the babies may therefore grow at different rates. Such a discrepancy can be revealed through ultrasound and may be evident quite early in the pregnancy.

Preeclampsia

Characterized by a rapid rise in blood pressure, the presence of protein in the urine, sudden and extreme weight gain and swelling of the hands and face from fluid retention. While this condition occurs in about one out of ten singleton pregnancies, it occurs in nearly one in three multiple gestations. It typically occurs in the second half of pregnancy. Bed rest is usually the recommended treatment. Severe cases may require hospitalization and medication will be given to lower your blood pressure.

Preterm Labour

A major concern in a multiple pregnancy. This is probably the most common concern that anyone pregnant with multiples might face. Approximately 50% of twins, 90% of triplets and virtually all quadruplets are either preterm or of a low birth weight. Among infants born prematurely, nearly one in ten do not survive. Although the majority of premature babies do very well, they are at a somewhat higher risk of a variety of medical problems, some of which are lifelong. These can include hearing loss, vision problems, developmental disabilities and delays. The more premature the babies are, the more severe the complication could be: e.g. cerebral palsy. Discuss with your doctor the signs and symptoms of premature labour. Both you and your partner need to be fully aware of the signs and symptoms of premature labour as well as the appropriate course of action to take should you feel that you are experiencing preterm labour.

Extended Bed Rest

It is common, but is not always the case, for Moms expecting multiples to have to spend some time on bed rest. This can be at home, with bathroom privileges and maybe going to the table for meals, or it can be on hospital bed rest with no privileges but to stay in bed. Bed rest at home may be helpful for those families with other young children at home, but those with young children, the doctor may insist on hospital bed rest so that Mom will actually rest. Bed rest can be prescribed when there is a danger that she may go into preterm labour or if she is showing some signs of physical stress. Bed rest and subsequent monitoring of Mom and the babies, may allow the situation to calm down and when (if) things are settled after a week or so, Mom may be permitted more activity.

For Moms expecting triplets, quadruplets or quintuplets there is an increased chance that some of the time will be spent on bed rest. When bed rest is prescribed, this takes pressure off of the cervix, helps to reduce strain on your heart, improves blood flow to the kidneys, which helps to eliminate excess fluids, increases circulation to the uterus thus providing additional oxygen and nutrients to your unborn babies. Further, it minimizes blood levels of catecholamines, the stress hormones that can trigger contractions and conserves your energy so that more of what you eat goes directly to promoting the babies’ growth.

The Disadvantages of Bed Rest

Bed rest may present an increased risk of blood clots. In some cases of extended bed rest, doctors may prescribe injections of heparin, a blood thinner, to lower the risk of blood clots. Prolonged inactivity may highlight or exacerbate heartburn, constipation, leg swelling or backache. Your doctor can provide some suggestions to alleviate some of your concerns. Inactivity may decrease your appetite and as you can appreciate, this will impact on your babies’ development. An extended period of bed rest could pose some financial difficulties with the loss of an income which you can ill afford. Bed rest can be boring and even very difficult for women who are used to being active and on the go.

An extended period of bed rest may affect your muscles. One mother had a massage therapist come to the hospital a couple of times in order to help keep her muscles in shape. It can be difficult to move about properly after the babies’ birth if your muscles are even somewhat atrophied.

It is important to keep in mind why bed rest has been recommended and that the longer your babies stay in utero, the healthier they will be at delivery and the sooner they can go home with you. Bed rest is a time to read, keep a journal, speak on the phone with family and friends, knit or crochet. See the time on bed rest as a “Count Up” to a healthy birth and healthy babies. Some parents may view bed rest as a time to worry, but keep in mind that the babies are growing and this time on bed rest is important to assist them in getting the best possible start to life. Bed rest requires giving up control and allowing others to do for you. Some women have difficulty with being dependent upon others. (See Web Site Page on Bedrest for more ideas.)

Depending upon how long the pregnancy continues and the number of babies Mom is carrying, there is a spectrum of outcomes that she might, to some degree, experience:

• Foot size may change after the pregnancy. As the babies grow, the continued pressure on Mom’s feet may cause a change in foot size as the foot settles to accommodate the additional weight size. A foot size change will not reverse itself after the birth.
• Change in body shape. Mom’s body will probably change, i.e. thighs and upper legs will thicken to better support her expanding abdomen. This may or may not right itself with exercise after pregnancy. There will be an expansion of the rib cage. As the babies slowly develop under the rib cage, it expands and after birth, does not always return to its original shape.
• Due to increased hormone changes, it is not unusual for moles that were normally flush with the skin to appear to “grow” during the pregnancy. This apparent “growth” will disappear after the pregnancy.
• Hair may be luxurious and healthy during the pregnancy and then, for sometime after the birth, fall out in handfuls and/or become limp and not hold any curl. This will rectify itself over time (3-4 months) after birth. This potential hair loss is attributed to hormonal changes and can occur with any pregnancy, not just with multiples.

As the pregnancy progresses and the babies grow, keeping your balance can be a cause for concern. Mom’s enlarged and extended abdomen changes her centre of gravity and it is important to be very careful about maintaining your balance, especially when going down the stairs or when it is slippery outside. Late in my own pregnancy, on a wonderful Summer day, I turned quickly and my tummy kept going, while I did not. I landed flat on my face but did manage to get my arms around by stomach before I fell. The fact that I was laying on my arms didn’t permit me to push myself upright. Luckily it was the weekend and my husband was home. He heard my yell as I went over and rushed to help. Another Mom reported falling down the stairs at 16 weeks pregnancy as her twins were both lying to one side of her abdomen and therefore her balance centre was off. Always hold the railing when descending the stairs.

Some Moms have reported that due to positioning within the womb, a baby may lie on arteries or nerves to her lower extremities. This can be quite uncomfortable and limit Mom’s mobility until the baby moves and then the discomfort usually corrects itself.

Knowing ahead of time what might occur permits us to take quick, timely appropriate action in order to rectify the situation. While many of the above possibilities may not happen to you, it is wise to be informed and able to make the best possible decision based on your individual situation. Knowledge is power.

Bibliography

• Twins, Triplets and More: Their Nature, Development and Care, by Elizabeth Bryan, London, Multiple Birth Foundation, 1995
• When You’re Expecting Twins, Triplets or Quads by Dr. Barbara Luke and Tamara Eberlein, Harper Perennial, 1999
• Double Duty, by Christina Baglivi Tinglof, Contemporary Books, 1998
• The Art of Parenting Twins by Patricia Maxwell Malmstrom and Janet Poland, Ballantyne Books, 1999
• Multiple Blessings, by Betty Rothbart, Hearst Books, 1994

Additional Resources

If you have further questions about risks during pregnancy, please visit askanob.com.

• Expectant Mom Tips, Multiple Births Canada Fact Sheet
• You’re Having Multiples, Multiple Births Canada Fact Sheet
• Twin Care: Prenatal to Six Months, Multiple Births Canada
• Finding our Way, by Triplets, Quads, Quints Association, 2001
• This article was written with grateful input and assistance from:
  – Dr. Elizabeth Bryan, Multiple Births Foundation, London, England
  – Dr. Karen Fung Kee Fung, Ottawa, Ontario, Canada