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the reproductive years

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Multiple Pregnancy
Gestational Diabetes
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Eating Disorders
Preterm Labor

After Delivery
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Multiple Pregnancy

If you are pregnant with twins, triplets or more, you have a multiple pregnancy. Multiple pregnancies are considered "high risk". This means the odds that either you or one of your babies might have pregnancy related problems is increased compared to a woman carrying only one fetus. This doesn't mean you will have problems. Many women have successful, uncomplicated twin pregnancies. But, pregnancy involves some risk for every woman, and with each additional fetus the risks increase.

About Multiple Births
The chance of having a multiple birth depends on many factors. Multiple pregnancy can occur when one egg (ovum) splits before implanting. Identical twins or triplets occur with the fertilization of a single egg that later divides into two or three identical embryos. Identical twins or triplets have the same genetic identity, are always the same sex, and look almost exactly the same.

Fraternal multiples develop from separate eggs which are fertilized by different sperm. This can occur when the mother produces more than one ovum during ovulation. You have a higher chance of this happening if you are older, taller and heavier, if you are a twin yourself, or if having twins runs in the maternal side of your family. The use of drugs that increase fertility, such as Clomid and Pergonal, increases your chance of multiple birth.

Infertility procedures like in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT), increase the chance of a multiple gestation. These procedures often involve the transfer of more than one fertilized eggs into the mother's womb to increase the odds of pregnancy occurring.

In a pregnancy with triplets or more, the babies can be all identical, all fraternal, or a mixture of both. This can happen when multiple eggs are released by the mother and fertilized. If one or more of these fertilized eggs divides into two or more embryos, a mixture of identical and fraternal multiples will occur.

What are the Risks?
As a rule and when available, women having multiple pregnancies are often referred to a Perinatologist, or Maternal-Fetal Medicine (MFM) Specialist. This type of physician is an obstetrician with advanced training in high risk pregnancy care. MFM Specialists complement the care of general obstetricians by providing prenatal care for high-risk women. They are experienced at caring for the special needs of women having a multiple birth.

Increased Risks Of Multiple Pregnancy
Severe Nausea and Vomiting

Early in your multiple pregnancy you may experience all the discomforts a woman with a singleton pregnancy feels. Nausea, vomiting, fatigue and breast tenderness are more likely to be severe in multiple pregnancy. Sometimes a condition called "hyperemesis gravidarum" can occur. This is a condition where nausea and vomiting become so severe that dehydration can occur.

If you are experiencing a lot of vomiting or are unable consume liquids, you should call your provider. You may need intravenous fluid replacement and medication to reduce the vomiting. If you notice a decrease in the frequency of when you urinate, or if you notice that your urine is dark in color, you should call your provider. These can be signs of dehydration.

Preterm Delivery

One of the biggest risks of carrying twins or more is that you will deliver your babies early. Premature delivery occurs when you deliver your babies before the thirty-seventh week of gestation. Twin pregnancies have about a 30 percent chance of a premature delivery. The risk increases for triplets and if you are expecting quadruplets or more you can be fairly certain you will deliver early.

Early delivery can occur for a number of different reasons. Preterm labor is common in multiple pregnancy and is a leading cause of preterm delivery. Preterm labor occurs when uterine contractions become too frequent or intense enough to cause cervical shortening (effacement ) or opening (dilation) prior to week thirty - seven of your pregnancy.

If one or more of your babies appears to be small or have a growth rate that is declining, (intrauterine growth retardation or IUGR), early delivery could be indicated. Multiple pregnancies carry a higher risk of IUGR than singleton pregnancies.

Twin-to-Twin Transfusion

Twin to twin transfusion syndrome is a disease of the placenta. There are connections between the blood vessels of the babies. This can cause an overload of blood in one baby, the recipient, while the donor baby does not get a sufficient blood supply. When the condition is severe, it can result in one large baby with excess amniotic fluid (polyhydramnios) and one small baby with too little amniotic fluid (oligohydramnios). The smaller baby is referred to as a "stuck" twin.

Twins that develop from one egg (identical) can share some blood vessels. This can lead to a pregnancy complication called twin-to-twin transfusion syndrome(TTTS). Your babies' risk of developing this syndrome is determined in part by when the egg divides.

Eggs that divide within a few days of ovulation are known as diamniotic-dichorionic (Di-Di). The amnion and chorion are the two layers of the sac of fluid that surrounds and protects babies in your uterus. DI-DI means that each baby has its own amnion and its own chorion.. These twins do not develop twin-to-twin transfusion.

Eggs that split at about three to eight days after ovulation create twins that are diamnionic (each has it's own amnion) and monochorionic ( they share a single chorion). These identical twins share some placental vessels and have the highest risk of TTTS.

Discordant Growth If one of your babies isn't growing as fast as the other(s), your doctor may become concerned about the smaller baby's health. This discordant growth can occur for several reasons. One baby may have a placenta that implants in an area with a less abundant blood supply.
Pregnancy Induced Hypertension PIH is the same as preeclampsia-eclampsia. PIH usually occurs in the second half of pregnancy. It is characterized by increased blood pressure and protein in the urine. Hands and feet may become swollen. Women expecting twins or more develop pregnancy induced hypertension (PIH) more frequently. The risk increases with the more babies you are carrying.

Nutrition Tips for Twins and More

Weight Gain
Women expecting two or more babies should have a higher weight gain. If you are expecting twins, a net weight gain at term of about 35 - 45 pounds (16 to 20.5 kilograms) is recommended. If you started your pregnancy underweight, a little more weight gain is desirable. Women starting pregnancy at a heavier weight should gain a little less. Studies have shown that adequate second and third trimester weight gain is very important with twin pregnancies. Weekly weight increases of about 1.5 pounds per week (0.6 kilograms) are desirable at this time and weight loss should be avoided.

If you are expecting triplets or more, your weight gain should be even higher. There isn't enough information about these higher multiple pregnancies to give specific weight targets. Most weight gain goals for pregnant women are calculated based on a full term pregnancy (37 weeks gestation or more) and you are likely to deliver your babies before this if you are expecting three or more. Aim for a weight gain of 1.75 - 2.0 pounds (0.8 kilograms) or more per week in your second and third trimester. Discuss your weight gain with your provider at each prenatal visit.

Tips To Improve Weight Gain
  • Eat often
    Growing babies mean less room for your stomach to expand. Eating more often can compensate for smaller meals.
  • Drink in some calories
    Water takes up the same amount of room in your stomach as fruit juice or milk. Fruit smoothies and milkshakes are great sources of calories.
  • Choose high fiber foods
    Preventing constipation can help your appetite. Fruits, vegetables, whole grains, beans and bran cereals are good high fiber choices.
  • Choose nutrient dense snacks
    Peanut butter, nuts, cheese, dried fruit, granola and yogurt are a few.

Supplements
A prenatal vitamin is usually recommended with the increased nutrient needs of a multiple pregnancy. Be sure and take only one prenatal pill as multiple pregnancy does not double the need for supplementation and some vitamins or minerals can be harmful if taken in excessive amounts.

Vitamin and mineral supplements cannot replace a healthy diet. Protein, fluid, carbohydrate, fat and fiber are found in the foods and beverages you consume. Take only the supplements you have been prescribed, and rely on a healthy diet to meet most of your nutrition needs.

Your provider may prescribe additional iron or folate supplements if your lab results indicate you are anemic. Iron and folate are nutrients that support the expanding blood volume that occurs in all pregnancies.

Calcium rich foods and calcium supplements decrease iron absorption. Take your prenatal vitamin and iron with juice or water. Take any calcium supplements at another time of the day.

Choosing Healthy Foods
The food guide below can help you select the minimum number of servings from important food groups to ensure a healthy diet. Because calories are not addressed in this guide, you will need to consume extra foods from each category daily. Women expecting triplets will require even more. All pregnant women should keep themselves well hydrated. Consume 8-10 cups or more of liquids every day. You should be urinating regularly and your urine should be pale in color when your fluid intake is sufficient.

Daily Food Guide for Twin Pregnancy

Food Group

Serving Size Suggested Servings Each Day
Protein 2 eggs,cooked
3 oz cooked portion meat, fish or chicken
1 cup cooked beans
6 oz tofu
4 tbsp. Peanut butter
3 - 4
Milk and Calcium-Rich Foods 1 cup milk or yogurt
1 cup pudding or custard
11/2 oz hard cheese
1 cup fortified soy beverage
4 tbsp. Parmesan cheese
11/2 cup ice cream
8 oz calcium fortified orange juice
4
Vitamin C Rich Fruits and Vegetables 6 oz orange or grapefruit juices
1 orange, kiwi or mango
1/2 grapefruit or cantaloupe
1/2 bell pepper
1-2 or more
Beta Carotene Rich Fruits and Vegetables 6 oz apricot nectar
3 raw or 1/4 cup dried apricots
1 carrot
1/2 cup yams
1/2 cup winter squash (butternut,hubbard, acorn)
1 or more
Additional Fruits and Vegetables 6 oz fruit or vegetable juice
1 small piece fresh fruit
1 cup raw vegetables
1/2 cup cooked vegetable
1/2 cup canned fruit
3 or more
Unsaturated Fats 1/8 avocado
1 tsp. vegetable oil (canola & olive are good choices)
1 tsp. mayonnaise
1 tbs. sunflower seeds
2 tbs. nuts
1 tsp. margarine
2-4

Staying Healthy
Enrolling in prenatal care early and keeping all your appointments is of paramount importance. With a multiple pregnancy you will see your health care provider more frequently. You may also have additional appointments for tests such as ultrasounds, additional lab work, and specialist doctors. You may need to be evaluated by a registered dietitian to ensure your weight gain and nutrient intake is adequate.

All the precautions for a singleton pregnancy are even more important when your pregnancy is high risk. Avoid exposure to cigarettes and don't use alcohol or illegal substances. Check with your care provider before using any prescription drugs or over-the-counter medications. Ask about any restrictions on your physical activity. Avoid heavy lifting and discuss any concerns about your work or home environment with your provider.

Bedrest
Your provider may prescribe some bedrest or limited activity at some point in your pregnancy. Bedrest is a strategy employed to try and prevent preterm delivery. Medications to stop preterm labor may be used in conjunction with bedrest. It is important that you follow your provider's recommendations for bedrest and take any medication prescribed on schedule.

Avoid laying on your back while resting. The weight of your pregnant abdomen can compress the blood vessels supplying your babies. Laying on your left side increases the blood flow to your heart, uterus and babies.

Put an egg-crate type foam pad on your bed to help with the discomfort of laying down for long periods. Keep reading materials, snacks and water near you. This is a good time to start a pregnancy journal.

Getting Help
Caring for more than one newborn is daunting to say the least! Start lining up help as soon as you know you have a multiple pregnancy. If you end up on bedrest you will need help even before you deliver. Friends and family can help with baby care, housecleaning, food preparation and shopping. If you already have children, you may need some extra baby-sitting.

Most communities have local "Mother's of Twins" organizations. Hooking up with these groups early in your pregnancy is a great way to establish some contacts with experienced moms of multiples who can be a valuable source of practical information.

Not all exercises or diets are suitable for everyone. Before you begin this program, you should have permission from your doctor to participate in vigorous exercise and change of diet. If you feel discomfort or pain when you exercise, do not continue. The instructions and advice presented are in no way intended as a substitute for medical counseling. The creators, producers, participants and distributors of this site disclaim any liability or loss in connection with the exercise and advice provided here.

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