Carrying several babies in the womb at once has always been associated with numerous risks, both for the woman and for the health of future children, so for some indications it is sometimes necessary to resort to a procedure such as reduction.

What is fetal reduction?

Fetal reduction is a procedure during which, by surgical intervention under ultrasound control, one or more fetuses are removed from the uterus of a pregnant woman.

Indications for embryo reduction in multiple pregnancies

This procedure is associated with risks for the further course of pregnancy, so removal of “extra” fetuses from the uterus is carried out only according to indications:

  • weakened mother's body;
  • severe kidney or heart disease expectant mother;
  • tendency to miscarriages or;
  • detection of a fetus with a congenital anomaly;
  • implantation of more than 2 embryos into the uterine wall (for example, as a result of an IVF procedure), which can lead to miscarriage and many other complications.

Conditions for fetal reduction

When a woman is diagnosed with multiple births in the uterine cavity, as a rule, no more than 2 fetuses are left to develop, since carrying triplets or more embryos in most cases ends in failure and risks the life of the patient herself. The reduction is carried out over a period of 5-10 weeks, and before the procedure, the woman must obtain legally certified consent.

The procedure is carried out in an operating room with careful adherence to the rules of asepsis and antisepsis. When choosing which embryo to reduce, the doctor relies on the following criteria:

  • the presence of pathologies in the fetus;
  • embryo size (the smallest and least quality embryo can be reduced);
  • the location of the embryo relative to other fetuses in the uterine cavity (the most distant one is removed so as not to injure other fetuses and their membranes).

During the procedure, the doctor should touch the remaining embryos to a minimum so as not to disrupt their development and not provoke a miscarriage in the woman.

Methods of fetal reduction

Removal of “extra” fetuses from the uterine cavity is carried out using several methods:

  • Transcervical- is currently almost not used in obstetrics and reproductive medicine. The procedure is carried out at a period of 5-6 weeks using an elastic catheter, which is inserted through the cervical canal into the uterus and, under vacuum, “sucks out” the “extra” embryo;
  • Through the vagina (transvaginal)- carried out at 7-8 weeks of pregnancy. Under ultrasound control, a needle is inserted into the uterine cavity of the patient under general anesthesia, which destroys the membranes of the embryo and injects special medications into it to stop cardiac activity. Using this procedure, it is possible to reduce two fetuses at once, but no more, so as not to provoke uterine contractions and miscarriage. The tissues of the reduced embryo remain inside the uterus and dissolve on their own after a few days;
  • Transabdominal method- can be carried out at 9-11 weeks. A puncture is made through the anterior abdominal wall of the patient and a needle is inserted into the uterine cavity, the procedure is similar to the transvaginal method - the heartbeat of the reduced fetus is stopped by insertion into its body medicines. The operation is performed under general anesthesia, after which the patient must remain in bed for several hours.

Possible complications after embryo reduction

The procedure for artificial removal of one of the fetuses from the uterus is in any case dangerous and is fraught with the development of early or late complications.

Early complications:

  • bleeding during and after the procedure;
  • promotion ;
  • death of the remaining fetuses as a result of their accidental injury during the procedure;
  • infection in the uterus.

Late complications include:

  • intrauterine death of the remaining fetuses as a result of damage to their membranes;
  • constant threat of miscarriage;
  • miscarriage;
  • birth of fetuses ahead of schedule.

Features of fetal reduction during IVF

The IVF procedure is a process for the progress of which doctors cannot be held responsible in the future, that is, the task of the reproductive specialist is the successful fertilization of two cells in a test tube and the implantation of the embryo into the woman’s uterus. In order to increase the chances of pregnancy as a result of IVF, doctors transfer several embryos at once so that at least one of them attaches and begins to develop.

It happens that all 3 or even 4 embryos are attached, so doctors have to remove some of them artificially, which significantly increases the likelihood of further pregnancy. Any gynecologist will confirm that multiple pregnancies are always associated with an increased risk for the health and life of a woman; such expectant mothers more often than not experience gestosis, placental abruption and premature birth.

Irina Levchenko, obstetrician-gynecologist, especially for the site website

Modern medicine claims that multiple pregnancies are in most cases the result of artificial insemination. Parents, for whom such a long-awaited pregnancy was a real miracle, are happy to have two, three, or even four babies. But in this case, in order to avoid problems during the gestation period, doctors recommend carrying out a procedure such as embryo reduction with multiple pregnancy. This is a forced step in the name of the birth of a healthy baby.

Basic Concepts

The term “reduction” itself implies the removal of one or more fertilized eggs. This procedure is prescribed when the health of the expectant mother or babies is in danger. When fetal reduction in a multiple pregnancy is performed, the fetal tissue continues to be in the uterus and comes out on its own within several weeks.

Risks due to which this procedure is carried out:
· Premature birth
· Miscarriage
Death of all fruits
· Problem in fetal development
Death during childbirth of one of the children

Reduction in multiple pregnancies is carried out from 5 to 13 weeks after conception. The reason for this is the ability of some embryos to freeze or spontaneously disappear in the early stages. This procedure is also possible at a later date than indicated, but this is fraught with miscarriages.

The doctor who decides to carry out reduction must objectively assess the situation and remove only the weakest embryo, which is prone to pathologies and developmental problems.

Embryo reduction methods

Transcervical. It is carried out through the cervix at the beginning of pregnancy, at 5-6 weeks. To carry out this method, a vacuum aspirator is inserted into the uterine canal, which is brought as close as possible to the embryo, then it is removed. This operation does not require anesthesia. This method also has disadvantages. This is a possibility of damaging the fertilized egg adjacent to the one being removed, as well as the possibility of injuring the cervix, which can cause a miscarriage. You can only remove a certain embryo, which is closest to the exit from the cavity.

Transvaginal. It can be carried out at 7-8 weeks of pregnancy. The operation is performed using general anesthesia and with an ultrasound probe connected. Using a needle, a puncture is made in the wall of the uterus and a solution of potassium chloride is injected into the chest area of ​​the fetus, which stops its vital activity.

Transabdominal. The method is similar to the previous one, but differs in that it is performed under local anesthesia. The needle is inserted through the abdominal cavity. This procedure can be performed at 8-13 weeks of pregnancy.

Despite the widespread use of these methods, various complications may still arise. But we must remember that this is a necessary measure to bear strong and healthy babies.

After the artificial insemination procedure, there is a need to reduce the number of embryos. This measure of removing the fertilized egg through surgery is called embryo reduction. According to statistics, after IVF, half of women develop about four fetuses. Therefore, it is necessary to understand what embryo reduction is.

Indications

Embryo reduction is a rather difficult operation, with the help of which low-quality embryos that have taken root in the uterus are removed. It should be noted that this procedure is carried out not only as a result of artificial insemination.

When pathology was detected in twins, the following manipulation was performed. The other child remained alive. In modern times, if more than two embryos have implanted, then reduction is carried out in multiple pregnancies.

There are cases when one embryo divides and identical twins begin to develop. Here doctors recommend getting rid of them. If a married couple does not agree to perform the operation, then the doctors do not perform it. The agreement is drawn up in legal form.

  • if a woman cannot bear many fruits. These are mainly patients who are small in weight and height;
  • presence of disturbances in fetal development;
  • implantation of more than three embryos.

Thus, in order for a married couple to make a decision, conversations and consultations with specialists are initially held.

Dangerous moments of multiple pregnancy

Doctors make every effort to prevent multiple births by limiting the number of embryos that are transferred into the uterus. Basically, two embryos are implanted that have good vital signs. But this does not mean that multiple births are absent.

Hazardous factors:

  1. premature babies, as they almost always come premature birth;
  2. the possibility of death of all embryos that have attached;
  3. likelihood of miscarriage;
  4. developmental disorders;
  5. newborns often die;
  6. opening of bleeding, as a result of which the mother may die.

If you pay attention to the statistics, then in the presence of triplets the mortality rate is about 60%.

There are cases when the egg divides into two, so two implanted embryos turn into three. According to scientific data, artificial insemination does not become more successful when three or more embryos are transferred.

Some countries have documents that regulate the implantation of no more than one embryo. This is done to prevent multiple births.

Conditions and features of the event

If a multiple pregnancy is detected, then two embryos are preserved. Embryo reduction in multiple pregnancies is carried out between 5 and 11 weeks of pregnancy. The operation is performed by a qualified specialist.

The main condition is compliance with sanitary and hygienic standards. First, the patient undergoes all the necessary tests.

Fetal reduction for twins is carried out in rare cases. The embryo that will be removed is determined.

Criteria for selecting an embryo for removal:

  • fetal pathology;
  • small size;
  • so that access to other embryos is minimally traumatic;
  • small touch with other germs.

Reduction of one fetus in case of twins is carried out according to the written consent of the patient.

Artificial insemination is an unpredictable procedure and requires a supply of embryos. Doctors say that pregnancy occurs when several embryos are implanted in the uterus.

For example, previously about nine embryos were implanted, but only about three took root. Time passed, and the fertilization of eggs became better, so they began to implant about four embryos. Despite this, multiple pregnancies are still present.

Reduction methods

Currently, two embryos are implanted, since artificial insemination has become effective. If there is a multiple pregnancy, the woman and the fetus are at risk.

A woman experiences gestosis and a difficult birth with injuries. And children can be affected by cerebral palsy. Embryo reduction during IVF is used to reduce the possibility of an unpleasant scenario.

Techniques:

  • The transcervical method is performed at 5 weeks of pregnancy. In modern times, it is not used because serious complications are observed;
  • The transabdominal method is performed at 8–9 weeks. The procedure is done through the abdominal wall;
  • The transvaginal method is carried out at 7–8 weeks. The procedure is done through the vagina. Can only be used for two embryos. You can repeat it after certain days.

There are cases when self-reduction of the fetus occurs in twins. We are talking about the freezing of one of the fruits. If one fetus freezes, the second develops early stage pregnancy, then there is nothing wrong with it. It just dissolves over time. And on later this is fraught with consequences for the second fetus.

Thus, embryo reduction in twins is considered a complex process. Naturally, complications are possible after fetal reduction in the form of bleeding, death of other embryos, infection in the uterus, and premature termination of pregnancy.

Mothers who have undergone embryo reduction claim that this procedure is required. After all, a woman strives to bear and give birth to a normal and healthy baby.

Unlike natural conception, during the IVF procedure the probability of multiple pregnancy is 50%. But, as a rule, not all women are ready to give birth to several babies at once. Some people's health will not allow them to bear, for example, triplets, while others are not emotionally ready to become parents of several children at once. Everyone has their own reasons and possibilities. Therefore, the reduction procedure is relevant.

Fetal reduction is a procedure in which one or more fetuses are removed from a woman's uterus. As a rule, reduction is carried out in cases where, due to a multiple pregnancy, the life and health of the mother or the lives of all unborn children are at risk.

When carried into the uterus of a woman with high vital signs. The exact number depends both on the number of viable embryos and on the specific clinic where the IVF is performed. As mentioned earlier, the probability that if the procedure is successful, more than 1 embryo will implant in the uterus is about 50%. This is why twins and triplets are so often born after IVF. At the same time, for a woman with poor health or special indications in a multiple pregnancy, there are quite serious risks, which are the reasons for embryo reduction:

  • risk of premature birth;
  • risk and death of all embryos;
  • pathologies or disorders in the development of embryos;
  • complications that arose during pregnancy;
  • perinatal mortality – the second and subsequent fetuses are at high risk at birth.

Not only if available medical indications, but at the woman’s request, a smaller number of embryos can be transferred.

Embryo reduction is a serious procedure that is carried out only if there are special indications for it:

  1. During the development of pregnancy, serious pathologies were identified in one or more fetuses.
  2. After IVF, more than three embryos with good vital signs were implanted in the uterus.
  3. For some reason, a woman is not ready to bear and give birth to two or more children.

If circumstances have developed in such a way that reduction is still necessary, the following conditions must be met for it to occur:

  • pregnancy period from 5 to 11 weeks (dates may vary depending on the chosen reduction method);
  • an appropriate legal document must be drawn up, according to which the woman gives her consent to the embryo reduction;
  • the medical institution in which the procedure will be carried out must have the necessary equipment and sanitary conditions, the medical workers must have appropriate qualifications;
  • clinical tests of the woman’s urine and blood should be normal;
  • vaginal smear of II degree of purity;
  • The patient does not have HIV, hepatitis B or C, or syphilis.

If all these conditions are met, the reduction can be performed. The next step is to select one or more embryos to be removed. There are several criteria that a specialist uses when choosing the weakest embryo to be removed:

  • the fetus has been diagnosed with any developmental pathology;
  • the least developed embryo according to the coccygeal-parietal size indicator (the lower the CTE, the less developed the fetus);
  • the fetus with the smallest area of ​​contact with other embryos that should not be damaged;
  • a fetus that can be accessed without affecting embryos that are not subject to reduction.

Embryo reduction methods

Today there are three methods of embryo reduction. The choice of one of them depends on the individual indications of the patient, the duration of pregnancy, and the location of the fetuses. At the same time, each method has its own advantages and disadvantages.

  1. Transcervical method . As the name implies, reduction is carried out through the woman’s cervix. This method takes place between 5 and 6 weeks of pregnancy. During the procedure, under the control of ultrasound equipment, a special elastic catheter is inserted into the uterine cavity through the cervical canal. A catheter connected to a vacuum aspirator is brought to the desired embryo and its fertilized egg is removed. Using this method, it is not necessary to put the patient under anesthesia, since no punctures are made, however, the transcervical method still has more disadvantages than advantages.
    • You can only remove the fertilized egg closest to the internal os of the uterine cavity, so there will be no access to the remaining embryos;
    • is a very sensitive organ, especially during pregnancy, and reduction by this method can injure it, which will provoke miscarriage and death of all embryos;
    • since the reduction is carried out through the vagina, there is a high probability of infection of the uterine cavity with bacteria from the vaginal flora;
    • when one fetal egg is reduced, the membrane of another embryo may be damaged and cannot be removed.

    The risks associated with the use of the transcervical method are much greater than the benefits, so it is practically no longer used in modern clinics.

  2. Transvaginal method . Reduction by this method is carried out under general anesthesia with the help of ultrasound monitoring, provided that the gestational age is 7-8 weeks. To insert an ultrasound probe with a biopsy adapter, a puncture is made in the uterine wall through. The puncture site is selected as close as possible to the fetus that is to be removed. Observing the uterine cavity on the monitor, the specialist inserts a needle and mechanically destroys the embryo in the chest area. The cessation of cardiac activity can be accelerated by administering potassium chloride, glucose solution, or other drugs that have a similar effect.

    This method is only suitable for the reduction of one or two embryos, since removing more fetuses unnecessarily traumatizes the uterus, which can lead to a complete miscarriage after the procedure.

    The advantages of the transvaginal method are that, thanks to ultrasound, it can be used in the early stages, so the resorption of embryonic tissue occurs much faster. In addition, it is the least traumatic for the remaining embryos.

    The only danger in using this method is the possibility of incorrectly calculating the dose of a medicinal substance (for example, potassium chloride), the excess of which can harm other embryos.

  3. Transabdominal method Embryo reduction is used during pregnancy from 8 to 9 weeks. The exception is cases when sudden death of the embryo occurs at a period of more than 9 weeks. The procedure is performed under local anesthesia using ultrasound monitoring and a needle inserted through the abdominal wall. The advantages of this method are that the specialist gets access to almost any fetus, as well as the ability to reduce several embryos at once. The transabdominal method is similar to the transvaginal method.

    Other advantages of reduction using the transabdominal method include a low likelihood of infection of the uterine cavity. The fact that reduction by this method can be carried out at a later date can be considered both a minus and a plus, because the longer the period, the greater the opportunity to diagnose abnormalities in fetal development. But what larger size the embryo itself, the longer it takes for its tissues to be reabsorbed.

Possible complications after embryo reduction

Certain complications after the reduction of one or more embryos may arise regardless of the method of the procedure itself. There are two types of complications – early and late.

  1. Early complications
    • infection of the uterine cavity during reduction;
    • increased uterine tone after the procedure;
    • death of the remaining embryos;
    • appearance bloody discharge from the vagina;
    • unsuccessful reduction, as a result of which the embryo continues its development.
  2. Late complications
  • congenital pathologies of development of the remaining fetuses due to reduction;
  • complete miscarriage due to injury to the uterus or fertilized eggs of other embryos;
  • reduction can have an extremely negative impact on psychological state parents, since in fact it is the loss of one of the children.

Reduction of embryos during multiple pregnancy is advisable when there is a threat to the life and health of the mother or all embryos. Since the procedure itself is quite complex and dangerous, if there is insufficient need for it negative consequences may negate the benefits of its implementation.

Thank you

The site provides reference information for informational purposes only. Diagnosis and treatment of diseases must be carried out under the supervision of a specialist. All drugs have contraindications. Consultation with a specialist is required!

Multiple pregnancy - definition and types (twins and twins)

Multiple pregnancy- this is a pregnancy in which not one, but several (two, three or more) fetuses develop in a woman’s uterus at the same time. Typically, the name of a multiple pregnancy is given depending on the number of fetuses: for example, if there are two children, then they talk about the pregnancy with twins, if there are three, then with triplets, etc.

Currently, the incidence of multiple pregnancies ranges from 0.7 to 1.5% in various European countries and the USA. Widespread and relatively frequent use auxiliary reproductive technologies(IVF) has led to an increase in the incidence of multiple pregnancies.

Depending on the mechanism by which twins appear, dizygotic (fraternal) and monozygotic (identical) multiple pregnancies are distinguished. Children of fraternal twins are called fraternal twins, and children of identical twins are called twins or twins. Among all multiple pregnancies, the incidence of fraternal twins is about 70%. Twins are always of the same sex and are like two peas in a pod, since they develop from the same fertilized egg and have exactly the same set of genes. Twins can be of different sexes and are similar only as brother and sister, since they develop from different eggs and, therefore, have a different set of genes.

A twin pregnancy develops due to the simultaneous fertilization of two eggs, which are implanted in different parts of the uterus. Quite often, the formation of fraternal twins occurs as a result of two different sexual acts performed with a short interval between each other - no more than a week. However, fraternal twins can be conceived during the same sexual intercourse, but provided that the simultaneous maturation and release of two eggs from the same or different ovaries occurs. With fraternal twins, each fetus necessarily has its own placenta and its own amniotic sac. The position of the fetuses, when each of them has its own placenta and amniotic sac, is called bichorionic biamniotic twins. That is, in the uterus there are simultaneously two placentas (bichorionic twins) and two fetal bladders (biamniotic twins), in each of which the child grows and develops.

Identical twins develop from a single fertilized egg, which, after fertilization, divides into two cells, each of which gives rise to a separate organism. In identical twins, the number of placentas and membranes depends on the time of separation of the single fertilized egg. If separation occurs within the first three days after fertilization, while the fertilized egg is in the fallopian tube and is not attached to the wall of the uterus, then two placentas and two separate fetal sacs will form. In this case, there will be two fetuses in the uterus in two separate amniotic sacs, each fed by its own placenta. Such twins are called bichorionic (two placentas) biamniotic (two membranes).

If the fertilized egg divides 3–8 days after fertilization, that is, at the stage of attachment to the wall of the uterus, then two fetuses are formed, two amniotic sacs, but one placenta for both. In this case, each twin will be in its own amniotic sac, but they will be nourished by one placenta, from which two umbilical cords will depart. This variant of twins is called monochorionic (one placenta) biamniotic (two membranes).

If the fertilized egg divides on days 8 - 13 after fertilization, then two fetuses will be formed, but one placenta and one amniotic sac. In this case, both fetuses will be in the same amniotic sac, and will be fed from the same placenta. Such twins are called monochorionic (one placenta) or monoamniotic (one amniotic sac).

If the fertilized egg divides later than the 13th day after fertilization, the result is Siamese twins, which are fused with different parts of the body.

From the point of view of safety and normal development of the fetus the best option are bichorionic biamniotic twins, both identical and fraternal. Monochorionic biamniotic twins develop worse and the risk of pregnancy complications is higher. And the most unfavorable option for twins is monochorionic monoamniotic.

Probability of multiple pregnancy

The probability of multiple pregnancy with a completely natural conception is no more than 1.5 - 2%. Moreover, in 99% of multiple pregnancies there are twins, and triplets and a large number of fetuses in only 1% of cases. With natural conception, the likelihood of multiple pregnancy increases in women over 35 years of age or at any age in the spring season against the background of a significant lengthening of daylight hours. In addition, women who have already had twins in their family are more likely to have multiple pregnancies than other representatives of the fairer sex.

However, if pregnancy occurs under the influence of medications or assisted reproductive technologies, then the likelihood of twins or triplets is significantly higher than with natural conception. Thus, when using medications to stimulate ovulation (for example, Clomiphene, Clostilbegit, etc.), the probability of multiple pregnancy increases to 6 - 8%. If drugs containing gonadotropin were used to improve the chances of conception, then the probability of twins is already 25 - 35%. If a woman becomes pregnant with the help of assisted reproductive technologies (IVF), then the probability of multiple pregnancy in this situation is from 35 to 40%.

Multiple pregnancy with IVF

If a woman becomes pregnant using IVF (in vitro fertilization), then the probability of multiple pregnancy is, according to various researchers, from 35% to 55%. In this case, a woman may have twins, triplets or quadruplets. The mechanism of multiple pregnancy with IVF is very simple - four embryos are simultaneously implanted into the uterus, hoping that at least one of them will take root. However, not one, but two, three or all four embryos can take root, that is, be implanted into the wall of the uterus, resulting in a woman having a multiple pregnancy.

If an ultrasound after IVF revealed a multiple pregnancy (triplets or quadruplets), then the woman is offered to “remove” the extra embryos, leaving only one or two. If twins are detected, it is not recommended to remove the embryos. In this case, the decision is made by the woman herself. If she decides to keep all three or four implanted embryos, she will have quadruplets or triplets. The further development of a multiple pregnancy resulting from IVF is no different from that occurring naturally.

Reduction during multiple pregnancy

Removing the “extra” embryo during a multiple pregnancy is called reduction. This procedure offered to women who have more than two fetuses in the uterus. Moreover, reduction is currently offered not only to women who become pregnant with triplets or quadruples as a result of IVF, but also to those who naturally conceive more than two fetuses at the same time. The goal of reduction is to reduce the risk of obstetric and perinatal complications associated with multiple pregnancies. During reduction, two fetuses are usually left, since there is a risk of spontaneous death of one of them in the future.

The reduction procedure during multiple pregnancy is carried out only with the consent of the woman and on the recommendation of a gynecologist. In this case, the woman herself decides how many fruits to reduce and how many to leave. Reduction is not carried out against the background of a threat of miscarriage or in acute inflammatory diseases of any organs and systems, since against such an unfavorable background the procedure can lead to the loss of all fetuses. Reduction can be carried out up to 10 weeks of pregnancy. If you do this later in pregnancy, the remaining fetal tissue will irritate the uterus and cause complications.

Currently, reduction is carried out using the following methods:

  • Transcervical. A flexible and soft catheter connected to a vacuum aspirator is inserted into the cervical canal. Under ultrasound control, the catheter is advanced to the embryo to be reduced. After the tip of the catheter reaches the membranes of the reduced embryo, a vacuum aspirator is turned on, which tears it off from the uterine wall and sucks it into the container. In principle, transcervical reduction is essentially an incomplete vacuum abortion, during which not all fetuses are removed. The method is quite traumatic, so it is rarely used nowadays;
  • Transvaginal. It is performed under anesthesia in the operating room, similar to the process of oocyte collection for IVF. The biopsy adapter is inserted into the vagina and, under ultrasound control, the embryo to be reduced is pierced with a puncture needle. After which the needle is removed. This method currently used most frequently;
  • Transabdominal. It is performed in the operating room under general anesthesia, similar to the amniocentesis procedure. A puncture is made on the abdominal wall through which a needle is inserted into the uterus under ultrasound guidance. This needle is used to pierce the embryo to be reduced, after which the instrument is removed.
Any reduction method is technically complex and dangerous, since in 23–35% of cases pregnancy loss occurs as a complication. Therefore, many women prefer to face the burden of carrying several fetuses rather than lose the entire pregnancy. In principle, the modern level of obstetric care makes it possible to create conditions for carrying multiple pregnancies, as a result of which completely healthy children are born.

Most multiple pregnancy

Currently, the most multiple pregnancy recorded and confirmed was ten, when ten fetuses appeared in the woman’s uterus at the same time. As a result of this pregnancy, a resident of Brazil gave birth to two boys and eight girls in 1946. But, unfortunately, all the children died before reaching six months of age. There are also references to the birth of the tenth in 1924 in Spain and in 1936 in China.

Today, the most multiple pregnancy, which can successfully end in the birth of healthy children without abnormalities, is gear. If there are more than six fetuses, then some of them suffer from developmental delay, which persists throughout their life.

Multiple pregnancy - timing of delivery

As a rule, a multiple pregnancy, regardless of the method of its development (IVF or natural conception), ends before 40 weeks, since the woman begins premature labor due to excessive stretching of the uterus. As a result, children are born premature. Moreover, the greater the number of fetuses, the earlier and more often premature birth develops. With twins, as a rule, labor begins at 36–37 weeks, with triplets at 33–34 weeks, and with quadruples at 31 weeks.

Multiple pregnancy - reasons

Currently, the following possible causative factors that can lead to multiple pregnancy in a woman have been identified:
  • Genetic predisposition. It has been proven that women whose grandmothers or mothers gave birth to twins are 6 to 8 times more likely to have multiple pregnancies compared to other representatives of the fair sex. Moreover, most often multiple pregnancies are passed down through a generation, that is, from grandmother to granddaughter;
  • Woman's age. In women over 35 years of age, under the influence of hormonal premenopausal changes, not one, but several eggs may mature in each menstrual cycle, so the likelihood of a multiple pregnancy in mature age higher than in youth or young. The likelihood of multiple pregnancy is especially high in women over 35 years of age who have previously given birth;
  • Effects of drugs. Any hormonal drugs used to treat infertility, stimulate ovulation or menstrual irregularities (for example, oral contraceptives, Clomiphene, etc.) can lead to the maturation of several eggs at the same time in one cycle, resulting in multiple pregnancies;
  • A large number of births in the past. It has been proven that multiple pregnancies mainly develop in repeat pregnant women, and its likelihood is higher the more births a woman has had in the past;
  • In vitro fertilization. In this case, several eggs are taken from a woman, fertilized with male sperm in a test tube, and the resulting embryos are implanted into the uterus. In this case, four embryos are introduced into the uterus at once so that at least one can implant and begin to develop. However, two, three, or all four implanted embryos can take root in the uterus, resulting in a multiple pregnancy. In practice, twins are the most common result of IVF, but triplets or quadruplets are rare.

Signs of multiple pregnancy

Currently, the most informative method for diagnosing multiple pregnancies is ultrasound, but the clinical signs on which doctors of the past were based still play a role. These clinical signs of multiple pregnancy allow the doctor or woman to suspect the presence of several fetuses in the uterus and, based on this, perform a targeted ultrasound examination, which will confirm or refute the assumption with 100% accuracy.

So, the signs of multiple pregnancy are the following:

  • Too much large size uterus that does not correspond to the term;
  • Low position of the fetal head or pelvis above the entrance to the pelvis in combination with a high position of the uterine fundus, which does not correspond to the term;
  • Discrepancy between the size of the fetal head and the volume of the abdomen;
  • Large abdominal volume;
  • Excessive weight gain;
  • Listening to two heartbeats;
  • The concentration of hCG and lactogen is two times higher than normal;
  • Fatigue of a pregnant woman;
  • Early and severe toxicosis or gestosis;
  • Thrust locks;
  • Severe swelling of the legs;
  • High blood pressure.
If a combination of several of these signs is detected, the doctor may suspect a multiple pregnancy, but to confirm this assumption it is necessary to perform an ultrasound.

How to determine multiple pregnancy - effective diagnostic methods

Currently, multiple pregnancies are detected with 100% accuracy during a routine ultrasound. Also, determining the concentration of hCG in venous blood has relatively high accuracy, but this laboratory method is inferior to ultrasound. That is why ultrasound is the method of choice for diagnosing multiple pregnancies.

Ultrasound diagnosis of multiple pregnancy

Ultrasound diagnosis of multiple pregnancy is possible in the early stages of gestation - from 4 to 5 weeks, that is, literally immediately after a delay in menstruation. During an ultrasound, the doctor sees several embryos in the uterine cavity, which is undoubted evidence of a multiple pregnancy.

The number of placentas (chorionicity) and amniotic sacs (amnioticity) is of decisive importance for choosing pregnancy management tactics and calculating the risk of complications, and not the dizygoty or monozygocy of the fetus. Pregnancy proceeds most favorably with bichorionic biamniotic twins, when each fetus has its own placenta and amniotic sac. The least favorable outcome and with the greatest possible number of complications is a monochorionic monoamniotic pregnancy, when two fetuses are in the same amniotic sac and are fed from the same placenta. Therefore, during an ultrasound, the doctor counts not only the number of fetuses, but also determines how many placentas and amniotic sacs they have.

In multiple pregnancies, ultrasound plays a huge role in identifying various defects or delayed fetal development, since biochemical screening tests (determining the concentration of hCG, AFP, etc.) are not informative. Therefore, the identification of malformations by ultrasound in multiple pregnancies must be carried out in the early stages of gestation (from 10 to 12 weeks), while assessing the condition of each fetus individually.

HCG in the diagnosis of multiple pregnancy

HCG in the diagnosis of multiple pregnancies is a relatively informative method, but inaccurate. Diagnosis of multiple pregnancy is based on excess hCG level normal concentrations for each specific gestational age. This means that if the concentration of hCG in a woman’s blood is higher than normal for a given stage of pregnancy, then she has not one, but several fetuses. That is, with the help of hCG it is possible to detect a multiple pregnancy, but it is impossible to understand how many fetuses are in a woman’s uterus, whether they are in the same amniotic sac or in different ones, whether they have two placentas or one.

Development of multiple pregnancy

The process of developing a multiple pregnancy creates a very high load on the mother’s body, since the cardiovascular, respiratory, urinary systems, as well as the liver, spleen, bone marrow and other organs continuously work in an intensive mode for a fairly long period of time (40 weeks) in order to ensure one, but two or more growing organisms have everything they need. Therefore, the incidence in women carrying multiple pregnancies increases 3 to 7 times compared to singleton pregnancies. Moreover, the more fetuses in a woman’s uterus, the higher the risk of complications from various organs and systems of the mother.

If a woman suffered from any chronic diseases before the onset of a multiple pregnancy, then they will definitely become aggravated, since the body is under very strong stress. In addition, during multiple pregnancies, half of women develop gestosis. All pregnant women experience edema and hypertension in the second and third trimesters, which are a normal reaction of the body to the needs of the fetus. A fairly standard complication of multiple pregnancy is anemia, which must be prevented by taking iron supplements throughout the entire period of bearing children.

For normal growth and development of several fetuses, a pregnant woman must eat well and intensively, since her need for vitamins, microelements, proteins, fats and carbohydrates is very high. The daily calorie intake of a woman carrying twins should be at least 4500 kcal. Moreover, these calories should be gained from foods rich in nutrients, and not from chocolate and flour products. If a woman has poor nutrition during a multiple pregnancy, this leads to depletion of her body, the development of severe chronic pathologies and numerous complications. During a multiple pregnancy, a woman normally gains 20–22 kg in weight, with 10 kg in the first half.

In multiple pregnancies, one fetus is usually larger than the second. If the difference in body weight and height between fetuses does not exceed 20%, then this is considered normal. But if the weight and growth of one fetus exceeds the second by more than 20%, they speak of a delay in the development of the second, too small child. Delayed development of one of the fetuses in multiple pregnancies is observed 10 times more often than in singleton pregnancies. Moreover, the likelihood of developmental delay is highest in monochorionic pregnancy and minimal in bichorionic biamniotic pregnancy.

Multiple pregnancies usually end in premature birth because the uterus stretches too much. With twins, delivery usually occurs at 36–37 weeks, with triplets at 33–34 weeks, and with quadruples at 31 weeks. Due to the development of several fetuses in the uterus, they are born with less weight and body length compared to those born from a singleton pregnancy. In all other aspects, the development of a multiple pregnancy is exactly the same as a single pregnancy.

Multiple pregnancy - complications

During multiple pregnancy, the following complications may develop:
  • Miscarriage on early pregnancy;
  • Premature birth;
  • Intrauterine death of one or both fetuses;
  • Severe gestosis;
  • Bleeding in the postpartum period;
  • Hypoxia of one or both fetuses;
  • Fetal collision (the adhesion of two fetuses by their heads, as a result of which they simultaneously find themselves at the entrance to the pelvis);
  • Fetofetal blood transfusion syndrome (FTS);
  • Reverse arterial perfusion;
  • Congenital malformations of one of the fetuses;
  • Delayed development of one of the fetuses;
  • Fusion of fetuses to form Siamese twins.
The most severe complication of multiple pregnancy is fetofetal blood transfusion syndrome (FTS), which occurs in monochorionic twins (with one placenta for two). FFH is a disruption of blood flow in the placenta, as a result of which blood from one fetus is redistributed to another. That is, one fetus receives an insufficient amount of blood, and the other receives an excess amount. In FFH, both fetuses suffer from inadequate blood flow.

Another specific complication of multiple pregnancy is fetal fusion. Such conjoined children are called Siamese twins. The fusion is formed in those parts of the body with which the fruits are most closely in contact. Most often, fusion occurs with the rib cages (thoracopagus), bellies in the navel area (omphalopagus), skull bones (craniopagus), coccyx (pygopagus) or sacrum (ischiopagus).

In addition to those listed, with a multiple pregnancy, exactly the same complications can develop as with a single pregnancy.

Childbirth during multiple pregnancy

If a multiple pregnancy proceeded normally, the fetuses have a longitudinal arrangement, then natural delivery is possible. In multiple pregnancies, complications during childbirth develop more often than in singleton pregnancies, which leads to a higher frequency of emergency cesarean sections. A woman with a multiple pregnancy should be hospitalized in a maternity hospital 3 to 4 weeks before the expected date of birth, rather than wait for labor to begin at home. A stay in the maternity hospital is necessary for examination and assessment of the obstetric situation, on the basis of which the doctor will decide on the possibility natural birth or the need for a planned caesarean section.

The generally accepted delivery tactics for multiple pregnancies are as follows:
1. If the pregnancy proceeded with complications, one of the fetuses is in a transverse position or both are in a breech presentation, or the woman has a scar on the uterus, then a planned cesarean section is performed.
2. If a woman approaches childbirth in satisfactory condition, the fetuses are in a longitudinal position, then it is recommended to carry out childbirth through natural ways. If complications develop, an emergency caesarean section is performed.

Currently, in multiple pregnancies, as a rule, a planned caesarean section is performed.

Multiple pregnancy: causes, types, diagnosis, childbirth - video

When is sick leave (maternity leave) given for multiple births?
pregnancy

In case of multiple pregnancy, a woman will be able to receive sick leave ( maternity leave) two weeks earlier than with a singleton, that is, at 28 weeks. All other issuance rules sick leave and cash benefits are exactly the same as for a singleton pregnancy.