Multiple Pregnancy Health Article

Definition

Multiple pregnancy, usually referred to as multiple gestation, is one in which more than one fetus develops simultaneously in the mother's womb.

Description

The frequency of multiple births in the United States has been steadily increasing with advances in reproductive technologies. It is estimated that pregnancies resulting from assisted technologies have a 25–30 percent incidence of twins and a 5 percent incidence of triplets. The frequency of naturally occurring twins is approximately one in 80 births; however the frequency of multiple births in the United States for 2002 was as follows:

• twins, one in 32
• triplets, one in 583
• quadruplets, one in 9,267
• quintuplets and up, one in 58,286

Twin birth is by far the most common multiple birth. There are two types of twin pregnancy: fraternal and identical. Fraternal twins develop from two separate ova released at the same time and fertilized by two separate sperm. Fraternal twins are referred to as dizygotic twins, meaning that two unions of two gametes or male/female sex cells occurred to produce two separate embryos. Characteristically, with fraternal twins, each has its own placenta and amniotic sac. They may be the same or different sex, occur twice as frequently as identical twins, and have a mortality rate of 11.5 percent. Identical twins represent the splitting of a single fertilized zygote (union of two gametes or male/female sex cells to produce a developing embryo) into two separate individuals. Identical twins will have the same DNA, genetic material (genotype), but it may be expressed differently (phenotype). There are three ways identical twins can exist in the uterus: dichorionic-diamniotic twins; monochorionic-diamniotic twins; monochorionic-monoamniotic twins. In the instance of dichorionic-diamniotic twins, division of the fertilized egg occurs within 72 hours past fertilization, before the inner cell mass has developed. About 30 percent of identical twins have this classification, and each twin has its own chorion, amnion, and placenta. The mortality rate for this type of twinning is 9 percent. With monochorionic-diamniotic twins, division occurs in the range of four to eight days after fertilization, and the inner cell mass divides in two. The placenta has one chorion and two amnions, so each twin has its own amniotic sac. Approximately 68 percent of identical twins are in this classification, and they have a mortality rate of 25 percent. Thirdly, monochorionic-monoamniotic twins are contained in the same amniotic sac. The division of the fertilized egg in this case occurs nine to 13 days past fertilization or near the time of implantation in the uterus. Since they share an amniotic sac, they have an increased risk of their umbilical cords becoming entangled or knotted. Only 2 percent of identical twins are in this classification, and they have a mortality rate of greater than 50 percent. If a complete separation does not take place during the division process, the result is Siamese (or conjoined) twins.

The human female typically releases only one egg every menstrual cycle. A hormone called progesterone, released by the first egg to be produced, prevents any other egg from maturing during that cycle. When this control fails, fertilization of more than one egg is possible. Fertility drugs inhibit these controls, allowing multiple gestation to occur. It seems as if, however, that more pregnancies start out naturally with twins than was originally believed. The development of improved technology, such as ultrasound, has made it possible to determine more accurately the early pregnancy loss rate of twins to include both complete pregnancy loss and spontaneous resorption of one twin, frequently referred to as the vanishing twin phenomenon. Recent research suggests that 75 percent of twin pregnancies are lost before the end of the first trimester. Moreover, only about 50 percent of pregnancies diagnosed in the first trimester with twins result in the birth of two live infants.

An old adage related to multiple gestation is the human female was not meant to have more than twins because she only had two breasts for feeding. Of course, pregnancies with more than two babies have occurred throughout history. However, once the number of babies reaches three, overexpansion of a woman's uterus begins to cause difficulties. The implantation of several embryos and placentas in the endometrium of the uterus results in a competition for space and inevitably some implant in an area without good circulation. During a pregnancy, it is essential that the uterus be well perfused to sustain the fetus with nutrients and oxygen. A lack of oxygen can cause central nervous system damage in the fetuses that implanted in a less than desirable area. Since the human female was not made to carry an indefinite number of fetuses, multiple gestations can have many of the following complications:

• increased rate of spontaneous abortion
• two to three times greater risk of developing severe hypertension or preeclampsia (increased blood pressure)
• maternal anemia due to increased fetal demands
• premature rupture of membranes (bag of water)
• incompetent cervix (cervix opens due to pressure)
• intrauterine growth restriction of one or more fetuses
• preterm labor due to overstretched uterus
• abnormal fetal presentations
• need for cesarean section
• rare complications with twins, such as twin-to-twin-transfusion syndrome (one fetus receives more nutrients than the other due to more blood vessels perfusing one baby)
• conjoined twins
• postpartum hemorrhage