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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 type.

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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Multiple pregnancy management | News and promotions of the European Medical Center "UMMC-Health"

Multiple pregnancy is a pregnancy with two or more fetuses. On the one hand, parents have more pleasant chores and happy smiles, but there are additional health risks. The world average is 10 twins per 1000 births. In Europe and the US, about 1 in 30 people has a twin brother or sister. Let's look at how auxiliary ones affect the likelihood of multiple pregnancy, and consider its features.

Who gives birth to twins and triplets

With natural conception, the probability of giving birth to several children at once is low - only 1.5-2%. If a man or woman themselves was born in such a family, and they have twins or twins, most likely they will become the parents of twins. There is also a high probability of multiple pregnancy in a woman with congenital structural features of the uterus.

In recent years, the use of modern reproductive techniques such as IVF has increased and the incidence of multiple pregnancies has increased. The probability of developing pregnancy with multiple fetuses during IVF is more than 50% of cases. The reason is that several embryos are placed in the uterus, and all of them can take root. The woman herself decides how many fruits she will keep.

ART has a significant impact on the twin birth rate and can change demographic policy. For example, in the UK since 2009, multiple pregnancy standards have been established for clinics practicing ART.

Will the children be similar?

Many are confused as to why children born at the same time can be like two peas in a pod and completely different. The answer lies in how exactly they developed in the mother's uterus. There are dizygotic and identical twins.

Two ova make twins, which may not look alike. Each fetus has its own set of chromosomes, doctors say that this is the easiest option for multiple pregnancy. Each embryo has its own placenta and fetal sac, and the fetuses develop independently, in other words, they do not share resources and territory among themselves. When carrying such twins, ultrasound is done more often than with a singleton pregnancy to monitor the condition and growth of the fetus. This reduces the incidence of obstetric complications.

If the twins are identical, the fetuses have an identical set of genes, so they are very similar to each other. Such children at birth are called twins, and often only relatives can distinguish them. But with such a pregnancy, you need to monitor the health of the mother and fetus more carefully. There are biamniotic and monoamniotic twins.

In the first case, the fetuses have a single placenta, but each has its own gestational sac, they are separated by a septum. Twins may have common vessels connecting their circulatory systems, which increases the risk of developing pathologies and complications. Be prepared for the fact that the obstetrician-gynecologist will prescribe additional studies from the first trimester.

Monoamniotic twins are the rarest and most difficult pregnancy case. The fetuses have one placenta and share one gestational sac. The risk of complications is high, so doctors advise keeping such a pregnancy under constant control. Ultrasound in this case should be done even more often.

How to Diagnose

It is important to diagnose multiple pregnancies as early as possible in order to monitor fetal health and minimize risks. The doctor can determine the presence of two or more fetuses before 5 weeks at the examination. A sign is a large volume of the uterus (compared to what it should be at your time). Also, as prescribed by a doctor, a woman donates blood to determine the hCG hormone in dynamics, if the level of chorionic gonadotropin rises quickly, this indicates to the doctor about multiple pregnancy.

Risks for mother and children

With multiple pregnancy, complications can occur in both mother and fetus, which is why a woman undergoes more examinations and is under the close attention of doctors over the course of nine months. Of course, this will not eliminate all risks, but it will greatly reduce the possibility of their development.

When carrying a multiple pregnancy, the load on the heart increases due to an increase in the volume of circulating blood, the load on the lower extremities also increases, which causes varicose veins of the lower extremities. Pregnancy is often accompanied by a decrease in hemoglobin levels (anemia). Women get tired faster, feel weak, heartburn, shortness of breath and constipation may appear.

Often there are complications associated with fetal growth (growth retardation syndrome), impaired blood flow in the umbilical cord. In case of circulatory disorders in monochryal twins (one placenta in both fetuses), one of the fetuses can receive a larger volume of circulating blood, as if “robbing” the other fetus. This threatens to stop growth for another fetus.

Features of pregnancy management

Multiple pregnancy refers the patient to a medium or high risk group for the formation of complications of its course and delivery. Therefore, an individual pregnancy management plan is drawn up in each trimester. Perhaps the patient will need to come to the antenatal clinic more often, do more ultrasound and additional studies.

A woman's need for vitamins, proteins and minerals is increasing, so it is important to make the right diet, as well as add moderate physical activity. In the early stages, doctors prescribe folic acid and iron to prevent anemia.

Based on the results of the research, the tactics of childbirth is determined. It depends on the condition of the mother and the fetus whether a caesarean section is required, or whether there will be a natural birth.

Caesarean or natural childbirth?

When pregnant with two fetuses, both delivery options are possible. First of all, doctors are guided by the desire of a woman to give birth through the birth canal, then the obstetric situation is determined: the correct position of one fetus (the baby should lie head down), the readiness of the birth canal, and the absence of other contraindications.

Indications for cesarean delivery:

• Presence of three or more fetuses
• Anatomical pelvic contraction
• Incorrect position of the first fetus
• Signs of intrauterine distress in one or both fetuses
• Complications of pregnancy requiring rapid delivery

The obstetrician-gynecologist makes a decision individually depending on the obstetric situation.

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