Multiple Births Carrying Multiples:-Triplets, Quadruplets, Quintuplets, Sextuplets Multiple pregnancies occur when the uterus nurtures more

than one fetus. Giving birth to twins is the most common form of multiple pregnancies. In human, multiple pregnancies are very rare. They are more common in the animal kingdom. One, out of 80 women, gives birth to twins. The other forms of multiple pregnancies are too rare, with only one in every 6,400 women giving birth to triplets. Higher order multiple births like quadruples and quintuplets are ever rarer. However, high order multiple pregnancies are not completely unknown. Many times, the babies are safely delivered and they have good chances of survival too. There have been a few cases of octuplets (eight offspring) too. Only one of them died at birth, while the rest are still leading a normal like. Frequencies of multiple pregnancies: Twins are born to one in 80 women. Triplets are born to one in every 6400 women, while the higher order pregnancies happen to one in every 700,000 women. However, in most cases of higher order multiple pregnancies, the babies fail to survive for too long There are three subtypes of multiple pregnancies:

Monozygotic: When one zygote (egg), splits into two or more embryos. Monozygotic pregnancy gives birth to identical twins, of the same sex, as all the embryos are carrying the same genetic material from one single zygote. These twins are maternal twins Dizygotic: When more than one ovum is released during the menstrual cycle, and each one of them are then fertilized by more than one sperm, it gives birth to dizygotic twines. These twins are genetically different from one another, and can also have different sex; they are also caller fraternal twins. Polyzygotic: This case is a combination of monozygotic and dizygotic twins. It is a very rare process. Most multiple pregnancies are a result of polyzygotic phenomenon.

Causes of Multiple pregnancies:

Naturally: Twins, triplets and quadruples may bear naturally, by fertilization of multiple eggs or splitting of the eggs. Fertility treatment: Fertility reproduction and Assisted Reproductive technology (ART) may result in the higher orders of multiple pregnancies. Fertility drugs enable the maturation of more than one egg in one menstrual cycle. As a result, each of these eggs gets fertilized to cause multiple pregnancies. Old age: As women grow old, their hormonal systems start altering. Follicle-stimulating hormones are secreted more in women who are above 35. This may result in multiple pregnancies. Genetic: Multiple pregnancies may be genetic in the womans side of the family. Race: Multiple pregnancies are more common amongst the black Africans.

Risks of multiple pregnancies: Incomplete separation: The twins may be physically joined, sharing the same amniotic sac, leading to entanglement and suppression of umbilical cord. Their internal body parts may not be properly functioning. They have low birth weight. The mortality rate of the children is generally very high. Many times it may also lead to prenatal deaths.

Most of the multiple pregnancies lead to preterm births. 50% of the twins 90% of the triplets are born preterm, with several physical and immunity problems. They may be born with several problems in their central nervous system. The most common one being cerebral palsy. Women cannot opt for normal delivery in case of multiple pregnancies. It is very painful and unbearable, involving a lot of life risks. If a caesarean operation in not done at the right time, it may lead to death of the mother too. How to prepare for multiple pregnancies: Take very hygienic and healthy pregnancy diet. Ask the doctor what food would suit you best. Take more calcium and folic acid. You need it more, if you are giving birth to more than one baby. Also increase your protein intake. Eat about 300 calories for each fetus in a day. Make regular visits to the doctor. In you are having multiple pregnancies, you might be asked to visit the doctor more often. Listen to all his instructions very carefully. If you are having multiple babies, then you are likely to gain more weight. Ask your doctor, whether you are having the right weight or not, considering the number of fetus you are carrying, and your pregnancy week. Multiple pregnancies can often lead to preterm labor. So be sure that by third trimester, you are surrounded with good available doctors, nurse, and some experienced female family members, who can deal with the occasional complications of pregnancy. If possible keep a good certified midwife. Taking care of multiple babies: It may be very difficult for you to take care of your kids all alone, especially when they are below one. This is because; each kid will have a different timings and different demands, which you may not be able to handle alone. So try to involve as many people as possible, including a governess, an old female family member, neighbors etc. Feed the babies one by one, or two at a time. Do breast feed them regularly. It would be the best source of nutrition for them especially if they are preemies or underweight. Clean your nipples with warm water before feeding your kids. Do not carry more than two babies with you. Multiple babies may be very weak, and vulnerable. So keep them very safe and secured, away from all infections. Do not touch them immediately after one comes home from outside. Make the person change the clothes, wash the hands properly with antiseptic, and then touch the babies. You too observe the same. Wash your babies and your clothes with a soft antiseptic soap. You can rather consider yourself different, if you have multiple pregnancies. However, it involves a lot of risk and so you would be luckier if your babies are bonny and healthy. So take every care and precautions to have an enjoyable motherhood with multiple kids. Pathophysiology The 2 types of twin pregnancies are dizygotic and monozygotic. Dizygotic twins develop when 2 ovum are fertilized. Dizygotic twins have separate amnions, chorions, and placentas (see the image below).

Diamniotic/dichorionic placentation.

The placentas in dizygotic twins may fuse if the implantation sites are proximate. The fused placentas can be easily separated after birth. Monozygotic twins develop when a single fertilized ovum splits after conception. An early splitting (ie, within 2 d after fertilization) of monozygotic twins produces separate chorions and amnions. These dichorionic twins have different placentas that can be separate or fused. Approximately 30% of monozygotic twins have dichorionic/diamniotic placentas. Later splitting (ie, 3-8 d after fertilization) results in monochorionic/diamniotic placentation (see the image below).

Diamniotic/monochorionic placentation. Approximately 70% of monozygotic twins are monochorionic/diamniotic. If splitting occurs later (ie, 912 d after fertilization), monochorionic/monoamniotic placentation occurs (see the image below).

Monoamniotic/monoamniotic placentation. Monochorionic/monoamniotic twins are rare; only 1% of monozygotic twins have this form of placentation. Monochorionic/monoamniotic twins have a common placenta, with vascular communications between the 2 circulations. These twins can develop twin-to-twin transfusion syndrome (TTTS). If twinning occurs more than 12 days after fertilization, then the monozygotic fertilized ovum only partially splits resulting in conjoined twins. Triplet pregnancies result from various fertilization, splitting, and development scenarios that involve ovum and sperm. For example, triplets can be monozygotic, dizygotic, or trizygotic. Trizygotic triplets occur when 3 sperm fertilize 3 ova. Dizygotic triplets develop from one set of monozygotic cotriplets and a third cotriplet derived from a different zygote. Finally, 2 consecutive zygotic splittings with a vanished fetus can also result in monozygotic triplets. Zygosity in quadruplets and higher order multiples also varies. Although the evaluation of the placenta or placentas after the birth is important in all multifetal pregnancies, the examination may not always help determine zygosity.[1] Epidemiology United States The incidence of monozygotic twins is constant worldwide (approximately 4 per 1000 births). Approximately two thirds of twins are dizygotic. Birth rates of dizygotic twins vary by race (10-40 per 1000 in blacks, 7-10 per 1000 births in whites, and approximately 3 per 1000 in Asians), maternal age (ie, increasing frequency with increasing maternal age 40 y), and other factors such as parity and mode of fertilization (ie, most artificially conceived twins are dizygotic; however, 6-10% are monozygotic).

Naturally occurring triplet births occur in approximately 1 per 7000-10,000 births; naturally occurring quadruplet births occur in approximately 1 per 600,000 births. Since 1970, the prevalence of multiple births has been increasing. A combination of factors including the widespread use of assisted reproductive techniques and advancing maternal age at conception are associated with this phenomenon. In the United States, a plateau in the prevalence of multiple births has been observed since 2004. From 20042006, the prevalence of twin deliveries in the United States has remained stable at approximately 32 per 1000 live births, compared with the decreasing prevalence of higher order multiple deliveries.[2] International The birthrate of monozygotic twins is constant world wide (approximately 4 per 1000 births). Birth rates of dizygotic twins vary by race. The highest birth rate of dizygotic twinning occurs in African nations, and the lowest birth rate of dizygotic twinning occurs in Asia. The Yorubas of western Nigeria have a birth rate of 45 twins per 1000 live births, and approximately 90% are dizygotic. Mortality/Morbidity Multifetal pregnancies are high-risk pregnancies. Multifetal pregnancies are complicated by a higher incidence of hypertensive diseases, anemia, preterm labor, premature rupture of membranes, hyperemesis gravidarum, placenta previa, polyhydramnios, and delivery complications (eg, Cesarean delivery, placental abruption, operative delivery, malpresentation, cord accidents, postpartum endometriosis). Because of advancements in perinatal and neonatal care, the major issues that affect neonatal outcome of multiple fetal pregnancies include preterm delivery, low birth weight, and intrauterine growth retardation. In 2006 in the United States, 11% of singletons were premature (< 37 weeks' gestation) and 61% of multiples were premature, combining for a total preterm delivery rate of 12%; 6% of singletons had low birth weight (birth weight < 2500 g) and 59% of multiples had low birth weight, combining for a total low birth rate percentage of 8%.[2] The percentage of very low birthweight neonates (birth weight < 1500 g) was 1% in singletons and 11% in multiples, combining for a frequency of 1%. The mean gestational age at delivery is approximately 37 weeks for twins, 33 weeks for triplets and 28 weeks for quadruplets. Divergence from singleton growth curves occurs at approximately 32 weeks' gestation in twins, 29-30 weeks' gestation in triplets, and 27 weeks' gestation in quadruplets. Specific morbidities in multiple fetal pregnancies are controversial. Neonatal outcomes at specific gestational ages and birth weights are similar to singleton pregnancies. Neonates born to multiple fetal pregnancies may have a higher risk of acute respiratory morbidities, such as respiratory distress syndrome[3] but do not have a higher incidence of chronic lung disease. Other major morbidities, including intraventricular hemorrhage, periventricular leukomalacia, retinopathy of prematurity, necrotizing enterocolitis, patent ductus arteriosus, nosocomial infection ,and length of hospital stay, demonstrate no statistical difference between singletons and multiples.[4, 5] The risk of cerebral palsy in multiple fetus pregnancies parallels decreasing gestational age. A second association during the late preterm period (34-37 weeks' gestation) may correlate with the increasing maternal morbidities of multiple fetal pregnancies during this time frame (ie, fetal growth restriction, hypertensive disorders, placental insufficiency).[6] The neonatal mortality rate in multiple fetal pregnancies is similar to singleton rates and parallels decreasing gestational age. In a prospective cohort study of monochorionic twins followed up from the first trimester until a mean age of 24 months, Ortibus et al found that twin-to-twin transfusion syndrome and assisted conception increased the risk of both death and neurodevelopmental impairment, whereas early onset discordant

growth increased only the risk of death. Of the 136 pregnancies studied, 90% resulted in both twins surviving, 4% resulted in 1 survivor, and 6% resulted in no survivor. Overall, mortality was 8% and neurodevelopmental impairment occurred in 10% of infants. History Most multifetal pregnancies are prenatally diagnosed. Maternal complaints of excessive weight gain, hyperemesis gravidarum, the sensation of more than one moving fetus, use of ovulation-inducing drugs, or family history of dizygotic twins should alert caregivers to the possibility of a multifetal pregnancy. Physical Women with multifetal pregnancies may have a uterine size that is inconsistently large for dates and may experience accelerated weight gain. Upon auscultation, more than one fetal heart rate may be heard. Causes

Risk factors for multifetal pregnancy can be divided into natural and induced. Risk factors for natural multifetal pregnancy include advanced maternal age, family history of dizygotic twins, and race. Induced multifetal pregnancies occur following infertility treatment via the use of ovulationinducing agents or gamete/zygote transfer.

Laboratory Studies The evaluation of a multifetal pregnancy involves routine prenatal and postnatal care, as well as specific evaluation directed by the type of multiple pregnancy and neonatal complications. Guidelines for complicated multifetus pregnancies have been established by American College of Obstetricians and Gynecologists.[7]

Obstetrical: Routine prenatal laboratory studies are indicated. Neonatal: A CBC count is obtained to evaluate for anemia and polycythemia. ABG and cord blood gas (CBG): These are measured to evaluate for respiratory distress, hypoxia, acidosis, and perinatal depression. Metabolic panel: Fluid and electrolyte levels should be obtained and metabolic status should be determined, including screening for hypoglycemia and hypocalcemia. Bilirubin level: This is obtained to screen for increased risk of hyperbilirubinemia associated with prematurity and polycythemia.

Imaging Studies

Obstetrical: Prenatal ultrasonography is used to confirm multifetal pregnancy and to monitor intrauterine fetal growth. Fetal echocardiography: This is used to screen for congenital heart disease in neonates. Fetal MRI: This is used to screen for fetal anomalies. Neonatal: Chest radiography is used to evaluate respiratory distress. Ultrasonography: This is used to screen for intraventricular hemorrhage, periventricular leukomalacia, and abdominal abnormalities. Echocardiography: This is used to screen for congenital heart disease.