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articles from the specialists of the clinic "Mother and Child"

Arifullina Claudia Viktorovna

Gastroenterologist

Clinical Hospital "AVICENNA" GC "Mother and Child"

There is data on the frequency of twins in case of anomalies in the development of the uterus, characterized by its bifurcation (bicornuate uterus, having a septum in the cavity, etc. ). The cause of polyembryony may be the separation of blastomeres (in the early stages of crushing), resulting from hypoxia, cooling, acidity and ionic composition of the medium, exposure to toxic and other factors. Multiple pregnancy can occur: as a result of the fertilization of two or more simultaneously mature eggs, as well as the development of two or more embryos from one fertilized egg.

Twins formed from two (three, etc.) eggs are called dizygotic (polyzygotic), those arising from one are called identical. The origin of fraternal twins (polyzygotic twins): the simultaneous maturation (and ovulation) of two or more follicles in one ovary is possible. There may be maturation of two or more follicles and ovulation in both ovaries.

A third way of the origin of fraternal (multi-ovular) twins is possible - the fertilization of two or more eggs that have matured in one follicle. The origin of identical twins: most often, the occurrence of identical twins is associated with the fertilization of an egg that has two or more nuclei. a single embryonic germ in the stage of crushing is divided into two parts; from each part an embryo (fruit) is formed. Twin twin. Fertilized eggs develop on their own. After penetration into the mucous membrane, each embryo develops its own aqueous and fleecy membranes; in the future, each twin forms its own placenta with an independent network of vessels, each fetal egg, except for the chorion and amnion, has an independent capsular membrane (decidua capsularis). In some cases, anastomoses are formed between the vessels of independent placentas. Twins can be same-sex (both boys or both girls) or different-sex (boy and girl). Their blood type can be the same or different. Identical twin. Identical twins have a common capsular and fleecy membrane and a common placenta; the vessels (both arterial and venous) of both twins in the placenta communicate with the help of numerous anastomoses. The water membrane of each twin is separate, the septum between the fetal sacs consists of two water membranes (biamniotic twins).

Identical twins always belong to the same sex (both boys or both girls), look alike, have the same blood group.

In fraternal twins, the membranes in the septum are arranged as follows: amnion - chorion, chorion - amnion; with monozygotic amnion-amnion.
Important signs for the diagnosis are: blood type (and other blood factors), eye color, hair color, skin texture of the fingertips, shape and location of teeth. In identical twins, these signs are completely the same. Fraternal twins share the same similarities as normal siblings.

MULTIPLE PREGNANCY
With multiple pregnancy, increased demands are made on the woman's body: the cardiovascular system, lungs, liver, nights and other organs function with great stress. In this regard, multiple pregnancies are more difficult than single pregnancies.

• Pregnant women often complain of fatigue and shortness of breath, which increases towards the end of pregnancy. The cause of shortness of breath is a difficulty in the activity of the heart due to a significant displacement of the diaphragm by the bottom of the uterus, the size of which is larger in multiple pregnancy than in singleton.
• Often there is a dilation of the veins of the lower extremities. By the end of pregnancy, there is often an increase in the urge to urinate due to the pressure of a large fetus on the bladder.
• Pregnant women often complain of heartburn and constipation.
• In multiple pregnancies, toxicosis occurs more often than in singleton pregnancies: vomiting, salivation, edema, nephropathy, eclampsia.
• With twins, polyhydramnios of one of the fetuses is often found, which leads to a sharp increase and hyperextension of the uterus, shortness of breath, tachycardia and other disorders. Polyhydramnios is more common in one of the identical twins. In some cases, the polyhydramnios of one twin is accompanied by an oligohydramnios of the other fetus.
• Premature termination of multiple pregnancies often occurs.
• With twins, preterm birth occurs in at least 25% of women.
• Prematurity is more common in triplets than in twins. The greater the number of gestated fetuses, the more often preterm births are observed.
• Development of term twins is normal in most cases. However, their body weight is usually less than that of single fetuses. Often there is a difference in body weight of twins by 200-300 g, and sometimes more.
• Uneven development of twins is associated with unequal intake of nutrients from a single placental circulation.
• Often there is a difference not only in weight, but also in the length of the body of the twins. In connection with this, the theory of supergenesis (superfoetatio) was put forward. Proponents of this hypothesis believe that fertilization of eggs of different ovulation periods is possible, i.e., the onset of a new pregnancy in the presence of an already existing, previously occurring, pregnancy.
• Due to the uneven delivery of nutrients and oxygen, a significant developmental disorder and even death of one of the twins can occur. This is more commonly seen in identical twins. The dead fetus is squeezed by the second, well-growing fetus, the amniotic fluid is absorbed, the placenta undergoes regression. The compressed mummified fetus ("paper fetus") is released from the uterus along with the placenta after the birth of a live twin. Polyhydramnios of one fetus, which occurs during multiple pregnancies, often also prevents the other twin from developing correctly. With pronounced polyhydramnios, certain anomalies in the development of the fetus, which grows with an excess of amniotic fluid, are often observed. Rarely, fused twins are born (fusion can be in the head, chest, abdomen, pelvis) and twins with other malformations.
• The position of the fetus in the uterine cavity in most cases (about 90%) is normal. In the longitudinal position, different presentation options are observed: both fetuses are presented with the head, both with the pelvic end, one with the head, and the other with the pelvic end. With longitudinal presentation, one fetus may be behind the other, which makes diagnosis difficult. Less commonly observed is the longitudinal position of one fetus and the transverse position of the other. The most rare is the transverse position of both twins.
• Position of the twins in the uterus, both fetuses are presented with the head, one fetus is presented with the head, the second - with the pelvic end, both fetuses are in the transverse position
• In case of multiple pregnancies, women are taken to a special account and carefully monitored. When the earliest signs of complications appear, the pregnant woman is sent to the pregnancy pathology department of the maternity hospital. Given the frequent occurrence of preterm birth, it is recommended that a pregnant woman with twins be sent to the maternity hospital 2 to 3 weeks before delivery, even in the absence of complications.

RECOGNITION OF MULTIPLE PREGNANCY

Diagnosis of multiple pregnancy often presents significant difficulties, especially in its first half. In the second half, towards the end of pregnancy, the recognition of twins (triplets) is facilitated. However, diagnostic errors occur during the study at the end of pregnancy and even during childbirth.

When recognizing a multiple pregnancy, the following signs are taken into account:

• The enlargement of the uterus in multiple pregnancy occurs faster than in pregnancy with one fetus, so the size of the uterus does not correspond to the gestational age. The bottom of the uterus is usually high, especially at the end of pregnancy, the circumference of the abdomen during this period reaches 100-110 cm or more.
• The following signs are unstable and not sufficiently reliable: a) deepening of the uterine fundus (saddle uterus), the formation of which is associated with protrusion of the corners of the uterus with large parts of the fetus; b) the presence of a longitudinal depression on the anterior wall of the uterus, which is formed as a result of the fruits that are in a longitudinal position adjacent to each other; c) the presence of a horizontal groove on the anterior wall of the uterus with the transverse position of the fetus.
• The small size of the presenting head with a significant volume of the pregnant uterus and the high standing of its bottom also make it possible to suspect a multiple pregnancy. The presence of this sign is explained by the fact that the study determines the head of one and the pelvic end (in the bottom of the uterus) of another fetus, which lies slightly higher.
• Feeling the movement of the fetus in different places and probing parts of the fetus in different parts of the abdomen (both on the right and on the left) also indicate multiple pregnancies.

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OB/GYN

A pregnancy is called multiple when two or more babies are expected to be born. The children in this case will be twins. There are several reasons for the "double happiness". Most often, this can happen if one of the parents has twins or triplets in the family.

The woman's age also matters. After 35 years, the chances of becoming a mother of several crumbs at once increase slightly. With age, the physiological ability to conceive begins to decline, ovulation does not occur every month. In the body, the level of a hormone that stimulates the growth of follicles rises, and ovulation can occur with the release of several eggs at once. And finally Recently, twins have become more frequent due to the widespread use of modern assisted reproductive technologies such as ovulation stimulation and IVF.

In any case, such future mothers are always under closer supervision of doctors, they have to visit antenatal clinics more often and undergo examinations. But all the inconvenience pays off a hundredfold when healthy twins, or even triplets, are born.

In case of multiple pregnancy, the duration of maternity leave is increased. It is issued to the expectant mother of twins at 28 weeks (in a normal pregnancy, a disability certificate for pregnancy and childbirth is issued for a period of 30 weeks).

One, two, three, many

Twins can be fraternal (dizygotic) or identical (monozygotic). In the first case, pregnancy occurs as a result of the fertilization of two or more zygote eggs at once, which have matured in one or both ovaries. Children born from such a multiple pregnancy are called twins or triplets, they can be either the same or different sex and usually look alike, like ordinary brothers and sisters.

In the second case, the only fertilized zygote is divided into 2 or more parts. The earlier this happened, the more the twins are separated from each other, which means that the conditions for their development are more favorable. For example, if the separation occurred on the 1-3rd day of the existence of the zygote, each twin is surrounded by two fetal membranes, has either a separate placenta, or a common placenta, consisting of two merged together. Accordingly, their nutrition and blood circulation will be "separate" - therefore, the risk of complications is also reduced. If the egg starts dividing between days 4 and 8, the twins will have a common placenta, which means that the circulatory systems will communicate with each other to a greater or lesser extent.

Division on day 8 means that the embryos will share both the placenta and the amniotic sac. Since nothing separates the babies, they swim in the amniotic fluid together and, while moving through the birth canal, can “catch” on each other. In this case, doctors will offer the expectant mother to have a caesarean section before the onset of labor. The division that began on the 13th day will no longer be complete and will lead to the formation of the so-called Siamese (fused) twins. Identical twins are like two peas in a pod, they are always the same sex, they have the same eye color, hair, blood type, skin texture of the fingertips, shape and arrangement of teeth.

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Special features

Having multiple pregnancies is very difficult, because the female body is more inclined to bear one baby. For this reason, such expectant mothers have a higher risk of complications. With multizygous pregnancy in the first trimester, in 15–20% of cases, the phenomenon of death of one of the fetal eggs is noted. It stops developing, gradually resolves, but its remnants can remain in the uterine cavity until childbirth. This usually does not affect the development of the other twin. But in some cases, there may be a threat of spontaneous abortion. Under such circumstances, the expectant mother is hospitalized and prescribed drugs that help relax the uterus.

In the second trimester of pregnancy, women who are expecting the birth of any twins are diagnosed with physiological anemia. You should not worry: such a complication with multiple pregnancies is considered “usual”. After all, the volume of circulating blood increases by 50-60% (in normal pregnancy - by 40-50%), mainly due to the fact that there is more plasma. This leads to "dilution" of the blood and a decrease in hemoglobin levels. For the prevention of anemia, iron-containing drugs and folic acid are prescribed.

Due to the increased load on the body in the second half of pregnancy, the risk of developing gestosis (increased blood pressure, the appearance of edema and protein in the urine) is increased. Urinary tract infections are also more common. The reason is simple. The uterus "grows" faster than during a normal pregnancy, and more compresses the internal organs. This leads to a violation of the normal outflow of urine, which means that pathogens are more difficult to remove from the body.

In addition, the expectant mother of twins has a much higher risk of miscarriage at any stage and preterm birth. According to one theory, overstretching of the muscles of the uterus is to blame for such an unfavorable development of events. To cope with such a complication, taking medications that relax the uterus helps.

Rare case

During a multiple pregnancy, the risk of intrauterine developmental disorders in unborn children is doubled, and it is higher in monozygotic twins. The most serious complication of multiple monochorionic pregnancy, when the crumbs have a common placenta, is feto-fetal transfusion. In this case, the blood flows from one twin to another - from the "donor" to the "recipient". The "donor" has a decrease in total blood volume, which leads to anemia, intrauterine growth retardation, decreased urine production and oligohydramnios. The latter circumstance prevents the normal development of lung tissue. The "recipient" has the opposite effect. Due to the fact that his blood volume increases sharply, the load on the heart, lungs and kidneys increases, heart failure occurs. Its most frequent manifestations are polyhydramnios and accumulation of fluid in different parts of the body.

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In previous years, the forecast was the most unfavorable. But now doctors have learned to cope with such a complication. The expectant mother is given laser coagulation of the vessels of the placenta, that is, simply put, they share the blood flow of the twins. This endoscopic operation saves the lives of future crumbs. When the time comes, the woman gives birth to ordinary twins, who then develop normally.

Dynamic surveillance

Doctors treat expectant mothers who are expecting the birth of several babies with special attention. But a lot depends on the woman herself. In order for doctors to be able to notice the slightest problems in time and take appropriate measures, a pregnant woman should register at the antenatal clinic as soon as possible and strictly follow the recommendations and appointments of specialists.

The doctor may suspect a multiple pregnancy already at the first gynecological examination if the size of the uterus is larger than the corresponding period of gestation. With greater certainty, this can be judged by ultrasound at 5-6 weeks. In the uterine cavity, several fetal eggs or embryos are then visible. The study is carried out by transvaginal access, that is, using a sensor that is inserted into the vagina. At such an early stage, it is very important to determine whether the twins belong to identical or multi-twins. The peculiarity of pregnancy management and the prognosis of possible complications depend on this.

To avoid trouble, the expectant mother also needs to carefully control her weight. If during a singleton pregnancy the physiological weight gain is 10–12 kg, then with a multiple pregnancy it is about 15 kg.

The expectant mother of twins visits the antenatal clinic more often than with a singleton pregnancy. Up to 28 weeks - 2 times a month, at later dates - 1 time in 7-10 days. Examinations and analyzes will be the same as when carrying one baby, but the interval between them will be less. For example, if it is recommended to do ultrasound 3 times in a singleton pregnancy, then in a multiple pregnancy, depending on the circumstances, 5 or more times. In the later stages, the study allows you to track the physiological development of future babies, to establish their position and presentation, the structure and number of placentas, amniotic cavities and the volume of amniotic fluid. This allows timely detection of complications characteristic of monochorionic twins. Depending on the indications, the doctor also determines how the birth will take place - through natural routes or by caesarean section.

In multiple pregnancies, the results of double and triple tests, which are used to judge the presence of chromosomal diseases and malformations, are not indicative. In any case, the level of hormones will be increased, because a woman bears not one, but several babies. Doctors in this case are guided more by the data obtained during the ultrasound examination.

You will also have to take a blood test to detect iron deficiency anemia more often. Since women who have multiple children are more likely to develop gestational diabetes, if necessary, a glucose tolerance test (it is not included in the standard of examinations of the usual antenatal clinic and is carried out additionally) is prescribed earlier - usually at 22-24 weeks (with singleton pregnancy - on the 24-28th).

Non-stress test

Due to the increased risk of preterm birth, a woman after 22 weeks may have another test called fetal fibronectin. This substance is a protein that is present in vaginal secretions. Its detection may be a signal that the body is preparing for childbirth. If the result is negative, then the risk of preterm birth in the next 2 weeks is minimal. If possible, this test should be repeated up to the 34th week of pregnancy. True, it is not made in every laboratory. The technique is used mainly in perinatal centers and clinics that combine scientific and practical work.

After the 28th week, a so-called non-stress test, or cardiotocography, is often prescribed, a study that allows you to measure the heartbeat and motor activity of future twins. The woman lies calmly on her left side for 40-60 minutes, and the external ultrasonic sensor located on her stomach registers the cardiac activity of future babies. During the test, the reaction of the cardiovascular system of each crumb to its movements is studied. The data obtained helps to understand whether future babies have problems due to the fact that they develop in cramped conditions. With the help of an additional sensor, uterine contractions are also detected, which may be a sign of impending labor.

The doctor may also recommend a biophysical profile. In this case, a non-stress test is combined with a detailed ultrasound. In real time, the respiratory movements of future crumbs, their motor activity, tone, volume of amniotic fluid and the degree of maturity of the placenta are measured. The study is carried out in the III trimester, since it is impossible to obtain objective data at an earlier date.

After the 30th to 32nd week of pregnancy, your doctor may recommend that you have these tests once a week. With multiple pregnancies, delivery usually occurs earlier - at 36–38 weeks if twins are expected, and at 34–36 weeks if triplets are gestated.

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Early development

Multiple pregnancies usually give birth 2-3 weeks earlier than single pregnancies.

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