Multiple pregnancy: what changes and what care is needed

It’s hard to find anyone who isn’t delighted to find twins, triplets or even more babies. Many parents even dress them in identical clothes. However, a multiple pregnancy, or a twin, needs a lot of care and close clinical monitoring to prevent and treat possible serious outcomes for the mother or babies.

A pregnancy with more than one baby is technically called a multiple pregnancy. “It occurs when the formed embryo divides, generating identical twins (univitelinos), or when the woman ovulates more than one egg and they are fertilized by different sperm, generating more than one baby, in this case, different babies (invitelinos)”, describes Patrícia Fonseca, obstetrician at MEJC (Januário Cicco School ternity) at UFRN (Federal University of Rio Grande do Norte)), linked to the Ebserh Network.

In Brazil, a survey carried out by the Department of Informatics of the Unified Health System (Datasus), in 2020, showed that single pregnancies correspond to 97.7% of cases, double pregnancies to 2.1% and triple pregnancies or more to 0. .05%.

After the initial “scare”, a multiple pregnancy usually brings a lot of joy to future mothers, after all, not all of them live this experience. However, she needs much more attention than a single pregnancy.

Conrado Milani Coutinho, an obstetrician specializing in maternal-fetal medicine and assistant physician at the HCFMRP (Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto) at USP (University of São Paulo), explains that this type of pregnancy increases the risk of several conditions both for both the fetus and the mother.

Among the most common risks for babies is prematurity, and all the complications that this can entail. In about 60% of these pregnancies, babies are born prematurely.

“In the gestation of two, the average age of birth is around 36 weeks, triplets drops to 32 weeks, and quadruplets drops to 28 or 26 weeks, making it difficult for these babies to survive”, emphasizes Herlânio Costa, obstetrician, head of the Service of Fetal Medicine at the Assis Chateaubriand Maternity School, at UFC Federal University of Ceará), linked to the Ebserh Network.

There is also the risk of fetal growth restriction, in addition to possible malformations. In more developed countries, the number of deaths is lower than in developing countries, such as Brazil.

“It is estimated that the risk of intrauterine death is four times greater, if compared to a single pregnancy”, says Coutinho, an obstetrician specializing in maternal-fetal medicine.

Pregnant women are at greater risk of developing preeclampsia, gestational diabetes, preterm labor, anemia and placental abruption. Predisposition to thrombosis, dermatological problems and other pathologies can also influence the outcome of pregnancy.

The mortality rate of women varies according to their own health, prenatal care and childbirth. But it is worth noting that if the woman already has hypertension, diabetes or suffers from a heart problem, the risks increase.

“It is a condition that we call high-risk pregnancy, so it needs to be monitored by a professional specialized in these cases”, says Coutinho. The doctor says that any complication that can occur in a single pregnancy has increased risks in cases of multiple.

The number of placentas greatly influences pregnancy.

In a multiple pregnancy, both babies may share the same placenta – this is called a monochorionic pregnancy – or, each have their separate placenta and amniotic sac, this is called a dichorionic.

A large British study by researchers at the Harris Birthright Research Center for Fetal Medicine and King’s College Hospital, published in 2020, evaluated more than 6,000 multiple pregnancies between 11 and 13 weeks.

Considered by experts the most robust work in fetal medicine to date, the study confirmed that the risk of a multiple pregnancy increases depending on factors such as gestational age, the number of placentas and pouches.

According to Costa, the risk of a multiple pregnancy baby not evolving can reach 8% in the first trimester of pregnancy, but when this happens up to twelve weeks, the risk of life for the other baby is practically nil, and the pregnancy continues as a single pregnancy.

On the other hand, when one of the babies dies after the first trimester, there is a risk of complications for the other due to the vascular communication that they had, in addition to the possibility of having sequelae. But that’s only in the case of a monochorionic pregnancy.

Cesarean section is not mandatory in multiple pregnancies

Unlike single pregnancy, where the baby can be born as early as 41 weeks, in multiple this does not happen – experts do not allow it to go beyond 38 weeks, in order to reduce possible complications during delivery.

According to Costa, head of the Fetal Medicine Service at the Assis Chateaubriand Maternity School, it is possible to continue with the multiple pregnancy for nine months, as long as it is dichorionic (two separate placentas), the babies are well and the mother does not present any complications.

“Interruption of a twin pregnancy should be indicated prematurely between 32 and 34 weeks, in the case of a twin pregnancy with a single placenta and a single water bag or when there are more than two fetuses – triplet, quadruplet…”, highlights Patrícia Fonseca, obstetrician at the Maternity Hospital of the Federal University of Rio Grande do Norte.

Regarding the type of delivery, experts point out some situations in which a cesarean section will be necessary. Are they:

• First twin in non-cephalic presentation (baby sitting or cross);
• Twins with a single placenta and a single water pouch;
• Multiple pregnancies with more than 2 fetuses;
• Maternal, fetal or placental pathology;
• Impairment of the vitality of one or both fetuses;
• And how the pregnancy flowed until the moment of delivery.

But take a good look: when there are no risks for vaginal delivery, it is not contraindicated, as some studies have already shown.

“Multiple pregnancy is not a prerequisite for having a cesarean section, but, due to all the risk factors involved in this delivery, we do have an increased rate of cesarean sections”, comments Coutinho, the obstetrician at the Hospital das Clínicas da Faculdade de Medicine of Ribeirão Preto.

Despite the risks, the number of multiple pregnancies continues to increase significantly, for two main reasons, as explained by Coutinho.

“First, because women these days are choosing to get pregnant later, and the later she gets pregnant, the more likely she is to have a double or triple ovulation. through assisted reproduction techniques (artificial insemination or the “test tube baby”) and, in these cases, it is much more common to have multiple pregnancies”, he says.

Multiple pregnancy requires more care

Surely you’ve heard the saying that pregnancy is not a disease. In fact, it is not. But, as mentioned earlier, cases of multiple pregnancies do need more care.

For starters, prenatal care needs to be accompanied by an obstetrician who specializes in high-risk pregnancies. “This prenatal care cannot be done, for example, in a health center without additional resources. And when I say that I am referring mainly to ultrasound exams”, says Coutinho, an obstetrician specializing in maternal-fetal medicine.

He explains that the pregnant woman will need to undergo a battery of ultrasound examinations to identify a series of conditions, including the number of placentas and the number of pouches.

“Depending on the case, we have to do ultrasounds every two or four weeks. So it’s a much more rigorous follow-up that we must have preventively to avoid the loss of one or both babies”, emphasizes Coutinho.

Vitamins and medications are individualized, but day-to-day care is no different from a single pregnancy. In this sense, eating for two, three or four is a myth.

The ideal, therefore, is that the expectant mother follows the nutritional guidelines – do not feel like it, but manage to maintain a balance. In general, the recommendation is that pregnant women consume 20% protein, 40% carbohydrates and 40% lipids (fats) daily, in addition to drinking plenty of water.

“Performing physical activity throughout pregnancy is important and provides great benefits for pregnant women with twins, as long as there is no contraindication. Among the activities we should encourage yoga, walking, pilates, swimming and water aerobics”, suggests Fonseca, obstetrician at the Januário Cicco Maternity School.

The recommendation is that the woman is aware of some symptoms – which can arise in any type of pregnancy – such as uterine cramps similar to contractions, pain, bleeding, loss of fluid, not noticing the movement of babies, fever that does not stop. In any of these cases, do not hesitate, she goes immediately to the hospital.

Mental health matters too!

Although the arrival of a child brings a lot of joy to the family, the feeling of worry, fear and insecurity also permeate the women. Now imagine who is pregnant with twins or more children.

When the family doubles in members in a short period, all the yearnings for a single pregnancy increase. That is why it is important that this woman has a good psychological follow-up, so that she can assimilate the change that is taking place in her body and that will occur later in her life. (and what a change!)

A study published in the American Academy of Pediatrics included a total of 8,069 women and showed that mothers of multiple births were 43% more likely to have moderate to severe depressive symptoms nine months after delivery, compared to mothers of only children.

Joel Rennó Júnior, director of ProMulher (Mental Health Program for Women) at IPq-HCFMUSP (Institute of Psychiatry, Hospital das Clínicas, Faculty of Medicine, University of São Paulo) and professor of psychiatry at USP, says that the idea of ​​having a childbirth premature birth already makes women more anxious and stressed.

For the specialist, who is also coordinator of the Women’s Mental Health Commission of the ABP (Brazilian Association of Psychiatry), today, it should be mandatory for any pregnant woman to have a good psychological evaluation at the beginning of prenatal care in order to track health problems. mental health or work so that they do not develop.

The specialist also cites the importance of demystifying pejorative concepts related to the mental health of the future mother. “She is still treated as a background and when we do not take care of mental health properly, the woman can have losses, including negative obstetric and neonatal outcomes. So it is important to ensure that this pregnant woman has comprehensive care”, ends.