Multiple Pregnancy: Types, Signs, Diagnosis & Complications

The signs of multiple pregnancies can significantly vary based on their type.

Written by Dr. Ritika Shah • 

Multiple pregnancy refers to a condition where a pregnant woman carries more than one baby (1). The US Department of Health and Human Services reports that the rate of twin birth has increased by more than 50% since the 1980s. Pregnancy with triplets, quadruplets, and other multiples has also grown over the years.

A reason for the increase in multiple births may be that women are utilizing artificial reproductive technologies to conceive.

Read this post for more information on the types, signs, and complications of multiple births.

What Are The Types Of Multiple Pregnancies?

The following are some names for multiple pregnancies depending on the number of fetuses (2).

  • Twins – Two fetuses
  • Triplets -Three fetuses
  • Quadruplets – Four fetuses
  • Quintuplets – Five fetuses

How Do Multiple Pregnancies Happen?

If the ovaries release more than one egg during ovulation and the sperm fertilizes more than one egg, then multiple embryos begin to grow in the mother’s womb. It leads to fraternal or non-identical babies, and it may produce girls or boys or both. Fraternal multiples have a separate amniotic sac and placenta each.

When a single fertilized egg splits into two, it results in multiple identical embryos. It may produce either all girls or all boys. They may have individual placentas and amniotic sacs, but most share the placenta and have separate sacs. Very rarely, identical twins may share one placenta and a single amniotic sac. However, fraternal babies are more common than identical babies (2)(3).

What Are The Signs Of A Multiple Pregnancy?

According to the American Pregnancy Association, women carrying multiples may experience one or more of the following symptoms. However, the only way to confirm a multiple pregnancy is an ultrasound (4).

1. Doppler heartbeat count

Late in the first trimester, fetal heartbeat can be heard using a Doppler ultrasound device. Experienced doctors or midwives may detect multiple heartbeats; however, it is not very accurate. As even with a single fetus, the heartbeat can be heard at multiple spots through the abdomen.

2. Elevated hCG levels

Women who are pregnant with twins may have elevated hCG levels. hCG is a hormone that is produced during pregnancy. However, increased hCG levels do not directly indicate a multiple pregnancy, and only further investigation can confirm it.

3. Pregnancies measuring larger for the gestational age

Doctors or midwives may measure the distance between the top of the pubic bone to the top of the uterus (the fundal height) during pregnancy. This measurement helps in indicating the gestational age of the baby.

Women with multiple babies may have increased uterine stretching, and the fundal height may be greater than the actual gestational age. Other factors may cause uterine stretching, apart from multiple pregnancies.

4. Weight gain

Women carrying multiples may gain some more weight than women with a single baby.

5. Early or frequent fetal movement

There is no medical evidence that supports the claim. Nevertheless, it is usually observed that some pregnant women with multiples report feeling fetal movement earlier than expected.

6. History of a multiple pregnancy

Multiple pregnancies may run in families. A woman with a previous history of multiple pregnancy may have an increased chance of having it again the second time.

What Factors May Lead To Multiple Pregnancy?

The following factors might increase the chances of a woman becoming pregnant with multiple fetuses (1)(2)(5)(6).

  • A woman in late 30s or in 40s might be at a higher risk of developing multiple pregnancy because the body begins to release multiple eggs at a time with increasing age.
  • If you are a twin yourself.
  • If you have twins from your previous pregnancy.
  • If you have twins in your family.
  • If you are using fertility drugs or undergo an ART-like IVF as it involves transferring multiple fertilized eggs in the mother’s womb.

How Is Multiple Pregnancy Diagnosed?

A multiple pregnancy can be diagnosed early in pregnancy, especially when artificial reproductive technologies help with the conception. Apart from a complete medical history and physical examination, the following may be used to aid in diagnosis (7).

  • Pregnancy blood testing: The blood levels of hCG may be quite high with multiple babies.
  • Ultrasound: Ultrasounds use high-frequency sound waves to view the blood vessels, tissues, and organs. Early in pregnancy, ultrasound may be performed vaginally, and later in pregnancy, it is done abdominally.

What Are The Complications Linked To Multiple Births?

While most women carrying multiple babies go on to have healthy pregnancies, it is important to keep in mind that you should take ample care and preferably have a good support system throughout your pregnancy.

Women with multiple pregnancies may have the following issues (6).

1. Increased pregnancy symptoms

  • Increased breast soreness
  • Persistent heartburn and indigestion, which may increase as the pregnancy progresses
  • Morning sickness lasting longer than usual
  • Varicose veins in the legs and vulva
  • Swollen ankles due to the increased pressure from the womb on the tummy
  • Pelvic pain
  • Increased exhaustion

2. Anemia

While anemia in pregnancy is common, you are at a higher risk of developing anemia when carrying multiples. Eating a balanced diet, taking all suggested prenatal vitamins, and concentrating on eating more iron-rich food can help prevent anemia.

3. Preeclampsia

Preeclampsia is a condition only pregnant women experience. It is characterized by a combination of high blood pressure and increased protein in the urine (proteinuria). Multiple babies can make you more susceptible to developing preeclampsia. Your health care provider might suggest you use low-dose aspirin from the 12th week onwards of your pregnancy to reduce the risk.

4. Gestational diabetes

Women with multiple fetuses are at a higher risk of developing gestational diabetes.

5. Antenatal depression

It is normal for women to be overwhelmed to find out that they are having twins or triplets. Having a baby is a life-changing event and can be exhausting and stressful. If you are having multiple babies, you may have to cope with a difficult pregnancy, labor, birth, and childcare.

Depression is common, real, and there is nothing to be ashamed of if you are experiencing antenatal or postnatal depression. The condition may be mild to severe and can affect each woman differently.  If you are feeling sad at all times for weeks or months now, or are clouded by negative thoughts, bring it to your doctor’s notice.

6. Intrahepatic cholestasis of pregnancy (ICP)

ICP can be more common in multiple pregnancies and is a potentially serious liver disorder that may develop in pregnancy. The main symptom is itching, and usually, there is no accompanying rash.

7. Blood clots

Deep vein thrombosis (DVT) is a serious condition characterized by the formation of a blood clot in the leg. It is not too common in pregnancy, but pregnant women may develop DVT at any point in time during pregnancy or up to six weeks after childbirth. A woman carrying multiple babies may be at a slightly higher risk of developing DVT than a woman with a single child.

Contact emergency services if you see any of these symptoms.

  • Throbbing or cramping in calf or thigh of one or both legs
  • Swelling in one or both legs
  • Warmness of skin around the painful area
  • Skin discoloration around the painful area
  • Swollen, hard, or sore veins

8. Complications in labor

Multiple pregnancy may increase the chances of you needing to have your labor induced, or have a cesarean section or assisted birth to deliver your babies. You may also bleed very heavily after birth.

The babies may have the following issues.

9. Problems with growth

There is a probability of having complications with the functions of placenta. It can affect the babies’ growth and development. At times, one of the babies might be significantly smaller than the others. This is called “selective” fetal growth restriction. It can occur in 10-20% of multiple pregnancies.

10. Premature birth

Most twins and triplets are born spontaneously. It can happen spontaneously in about 60% of all twin pregnancies and 75% of all triplet pregnancies. However, babies born prematurely may not be fully developed, have low birth weight, and may need special care.

11. Twin-to-twin transfusion syndrome (TTTS)

It is termed a monochorionicpregnancy. In TTTS, the twins sharing the same placenta may also share the same blood supply. In about 15 in 100 monochorionic twin pregnancies, the blood flow may be unbalanced. It is characterized by one fetus getting very little blood flow and having low blood pressure while the other gets a lot of blood and has high blood pressure. It is known as twin-to-twin transfusion syndrome.

12. Baby loss

Unfortunately, losing a baby is more common for women carrying multiples. It might occur due to the aforementioned complications or other issues associated with multiple pregnancies, such as chromosomal abnormalities. There could be situations where one of the various babies may survive.

Frequently Asked Questions

1. How much weight should I gain if I’m pregnant with multiples?

Weight gain depends on several factors such as body type, height, and pre-pregnancy weight. However, most women carrying twins are expected to gain about 35 to 45 pounds, and women with triplets are advised to gain 50 to 60 pounds. Currently, there isn’t enough information available on healthy weight gain for quadruplets and quintuplets (8).

2. Can I be active and exercise during multiple pregnancy?

According to the American College of Obstetricians and Gynecologists (ACOG), women carrying multiples should refrain from aerobic exercise as it may potentially cause problems with the pregnancy. However, each pregnancy is different, and you must discuss with your healthcare provider if you want to engage in any kind of physical activity when pregnant with multiples (9).

3. How should I prepare for delivery?

Women with multiples may be at a higher risk of going for a cesarean section. Even though you and your doctor are comfortable choosing a vaginal delivery, be prepared that you might need to go for a cesarean section. Discuss your birth plan with the midwife and doctor. You might need more care after delivery. It might seem scary, but your doctors and midwives are well equipped to handle multiple pregnancies (6).

If you are pregnant with multiples, you must be well informed and prepared about the potential red flags and management of complications that may arise in multiple pregnancies. Contact your healthcare provider if you have any unusual symptoms to avoid complications for yourself and your babies.

Key Pointers

  • Multiple pregnancies are referred to as twins, triplets, quadruplets, and so on, depending on the number of fetuses.
  • Identical infants are all girls or boys, but fraternal babies might be both girls and boys.
  • An ultrasonographic examination is the only method to confirm multiple pregnancies.
  • Women having multiple pregnancies are more prone to anemia, hypertension, intrahepatic cholestasis, labor problems, etc.


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