No doubting it, the news of welcoming twins is one of the most exciting news for any mother-to-be. However, twin pregnancy poses a significantly higher risk than a single pregnancy. 

That said, expecting mothers should be well-schooled on the nitty-gritty of bearing twins, they should be closely monitored, and evaluated from time to time by the health care professionals to ensure the babies and mother are safe at the end of the road. This guide will help you understand everything you need to know on twin pregnancy.

What is a twin pregnancy?

A twin pregnancy is a pregnancy that results in two babies–twins. It is by far the commonest type of multiple pregnancies. In recent times, there has been an uptick in the incidence of twinning the world over, thanks to assisted reproduction techniques and other artificial fertility products.

Based on appearance, twins can be classified into identical (monozygotic) and fraternal (dizygotic twins). Identical twins like the name imply, have the same sex, face, and genetic makeup. On the other hand, dizygotic twins are not facially alike, they have different genetic makeup, and sometimes even different sexes.

Generally speaking, twinning is more common in African-Americans than in Caucasians (where it is about 1:80).

How does a twin pregnancy happen?

Broadly speaking, twins can be divided into fraternal (dizygotic) and identical (monozygotic). Essentially, the two types of twins develop differently.

Identical or monozygotic twins develop from one zygote which is one egg fertilized by a spermatozoon. The zygote divides quite early in development. As such, the duo has the same genetic makeup hence the same sex, face, and like. It is quite rare.

Note: Siamese twins (conjoined twins) develop when something goes wrong and the splitting of the zygote is incomplete hence they can share organs like the brain, heart, etc.

Contrastly, fraternal twins develop from two separate ova that were developed from two different ova fertilized by two separate spermatozoa. As such the twins could be of two different sex, appearance and the like. It is more common than identical twins.

Though twinning is firstly genetically enabled, there are extrinsic factors that can trigger it. They include: 

• Maternal Age: The higher the mother's age the higher the possibility of twinning. However, this possibility drops after 35 years.
• The Parity: Giving birth to more babies increases the possibility of having a twin down the road.
• The Race: Studies have shown that the incidences of twinning vary from race to race, being least in the far east climes like Japan and highest in Sub Saharan African
• The body build: There is a trend that women who bear twins are most taller and heavier than singletons' mothers
• The Food: A chemical substance that resembles clomiphene found in some staple food has been found to increase the rate of twinning.

Twin Pregnancy Symptoms

• As expected, the symptoms of pregnancy like headaches, morning sickness, increased smell sensation,  and fatigue is exaggerated in twin pregnancy.
• The baby bump is larger than the baby bump of a singleton's pregnancy at the same age of gestation. 
• The pedal edema (foot swelling) in this case is severe.
• More fetal movements 
• The risk of pregnancy-induced hypertension and anemia is increased
• On examination, the doctor may discover two baby heads and multiple fetal parts.

The gold standard in diagnosing twinning is an Ultrasound scan. The instrument sends sound waves to the abdomen and shoots images, videos that the doctor interprets. It can diagnose twin pregnancy quite early.

Twin Pregnancy Medical Care

Because of the significantly higher risk of giving birth to twins, the mother-to-be should be given adequate attention to make sure she and her little duo are fine at the end of the pregnancy. The medical care is tailor-made to suit her demands and the peculiarities of her babies.

The first step of meaningfully managing twin gestation is by making a diagnosis of twin gestation:

Diagnosis

The mother should know early enough that she is pregnant with twins, she also needs to be well informed on what to expect, possible complications, and warning signs of the complications from the pregnancy and the dos and don'ts in twin pregnancy. Complaints such as fever, vaginal discharge, abdominal tightness should be properly investigated and treated.

Nutrition

There are increased demands of calories, carbohydrates, iron, and folates for the mothers to keep up. This is not only important for the mother to keep the babies and herself nourished but also to maintain the adequate weight gain that will support the babies.  The Institute of Medicine (2009) recommends that gaining weight of 16.8–24.5 kg (37–54lb), 14.1–22.7  kg(31–50lb), 11.3–19.1 kg (25–42 lb) for normal weight, overweight and obese mothers respectively. 

Regular Antenatal visits

The twin pregnancy is a high-risk pregnancy and should be treated as such. The twin-baby mothers should engage in more frequent antenatal visits (usually every two to four weekly visits are highly recommended) than their singleton mother counterparts. The main aim of frequent antenatal visits helps medical personnel to pick up complications very early which can go a long way in helping the health care professionals prevent and manage the complications effectively.

Bedrest

The importance of bed rest in twin-baby mothers cannot be overemphasized. The mothers should be well-schooled on ways to have refreshing bed rest. She should also learn to restrict her activities for the good of herself and the babies. It could prove to be very important in carrying her duo to term.

Expert Management

The medical team consisting of the nutritionist, the perinatologist, the obstetrician, the midwives/nurses, the pediatrician, etc should be fully involved from the get-go. The perinatologist carries out ultrasound investigations to ascertain the health wellbeing of the baby. 

Monitoring

the babies and mothers should be closely monitored by the medical team for complications. As such, they need to carry out several tests, especially ultrasound scans to monitor the baby's growth regularly.

In some, the doctor may request both blood work and genetic profiling to rule out congenital abnormalities. 

By the second trimester, the ultrasound scan is repeated to demonstrate all the structures of the baby and make sure there is no problem.

Tocolytic Medication

Keeping in mind that premature contraction of the uterus is a possible complication, tocolytics are employed to abort or to slow down the contractions if it occurs. Tocolytics can be administered orally, intravenously. Common tocolytics include magnesium sulfate, indomethacin, and nifedipine.

Prophylaxis

there should be a steady intake of supplemental folate, iron, and drugs to treat diseases endemic in that area like malaria.

Corticosteroid Medication

One of the unique challenges of twin pregnancy is lung immaturity. Corticosteroid is given to help the lungs of the babies mature.

Cervical Cerclage

Because there is a good possibility of the mother developing an incompetent weak down the road most mothers may need cerclage (shutting the cervix with suture) to keep the pregnancy in. 

Admission

You must report the mother develops complications like preterm labor, pre-eclampsia, and slow baby growth, she should be admitted for bed rest and direct observation.

Before the doctors determine which medical course to  start for the pregnancy, they would take some particular things into considerations including:

• Birth history: It encompasses the history of births, the ages they were delivered, complications during or after birth, history of miscarriages
• Medical history
• Comorbidities like sickle cell disease, diabetes mellitus, hypertension
• Allergies to specific medications
• The mother's choice

Twin pregnancy birth options

There are two birth options–vaginal delivery and cesarean section. The mode of delivery would depend on a lot of factors like maternal health, type of twins, fetal lie, complications during the gestation period, gestational age, etc.

Vaginal delivery

For a mother to deliver a set of twins vaginally they have to be in the cephalic presentation (I.e the vertices of their heads pointing down). But in the case that the first fetus is presenting cephalic and the other is not, the doctor can first deliver the cephalic presenting baby and then maneuver the other baby to position him cephalic and then deliver him/her via the vagina.

But these maneuvers pose a lot of risks for both the mothers and babies, hence most doctors would want to play the 'safe card' and deliver the duo via cesarean section.

Cesarean Section (C-Section)

The fact that you have a twin, does not necessarily mean that you need a c-section to deliver them. But there are peculiar settings where the doctors and midwives usually opt for cesarean section, such as:

• If the babies are in distress
• If the first baby is presenting with the back (Breech Presentation)
• If the babies share the same placentas
• If there are certain medical conditions in the mother that can threaten the mother's and/or the babies life
• If there is intrauterine growth restriction (poor growth of the baby)

Nutrition during a twin pregnancy

Eating a well-balanced meal is very important in twin pregnancy, your body has extra nutritional needs. More so, your body has needs for some specific nutrients like folic acid and iron to shore up the increased demands.

You need calories, carbohydrates, protein, vitamins, minerals, etc. Try sticking to fresh sources and avoid processed and chemically preserved food. You can have small frequent snacks that are protein-rich.

You must maintain a balanced diet, here is a list you can pick up from since it contains food from the 4 main food groups:

• Starchy food like rice, wholegrain, potatoes, pasta, and bread
• Proteinous foods meat, fish, eggs, and dairy products such as cheese, milk, and yogurt
• Fresh fruits and vegetables
• Folic: Take 30mg of supplemental Iron during the first trimester and 60mg till birth
• Iodine, mainly seafood, vitamins like Vit D, etc

You can also seek the doctor's advice on the exact proportion of nutrients and calories to support your twin pregnancy.

Risks During A Twin Pregnancy

Needless to say that twin pregnancy comes with a lot of risks. Mothers must be made to understand these risks or complications and know when to raise the red flag. They include: 

Complications in the mother

• Exaggeration of Symptoms: It is commonplace for the symptoms of pregnancy to be exaggerated. Nothing to be worried about!
• Anemia: There is a distinct yet possible risk of anemia hence the place of nutritional iron and folic acid can not be overemphasized.
• Pregnancy-induced hypertension: The twin pregnancy can offset hypertension in the mother. This condition coupled with protein in urine is called pre-eclampsia which can also graduate to another severe form called preeclampsia where the mother can have convulsive fits.
• Gestational Diabetes: Gestational Diabetes that is noticed for the first time during pregnancy. The substances secreted by the placenta of the babies predispose the mother to get gestational diabetes. This type of diabetes is also likely to stop once the pregnancy has ended. But while it lasts, you should control the blood sugar essentially by dietary modifications and recommended drugs that are safe in pregnancy. 
• Pressure Effects: Because of the double pressure, you can expect to have more low backaches, heartburn, varicose, prominent veins. These are purely common challenges and are nothing to worry about. 
• Vaginal bleeding: this could be a harbinger of possible miscarriage. It is very important that you report any bleeding at all–either spotting or heavy bleeding. 

Complications in the babies

• Miscarriage: The risk for miscarrying twins is significantly higher than in singletons.
• Prematurity: If you are pregnant with twins, they will likely be born premature before the 38-weeks mark for normal pregnancy. But not to worry, the medical team can take good care of the baby and make sure they develop optimally.
• Intrauterine Growth Restriction: it means poor growth of one or two of the babies. the growth could be retarded for a host of reasons, this reinforces the need for constant monitoring. Medically speaking, intrauterine growth restriction occurs when the baby is only having less than ten percentile of the growth curve of that particular gestational age when measured with ultrasound. 

The baby or babies that have restricted growth are not getting adequate nutrients. This, therefore, puts a cap on the growth of fetuses prematurely.

• Congenital Malformations: fetal abnormality is a distinct possibility.
• Twin-to-twin transfusion syndrome: it is a very rare complication of twin pregnancy that occurs in babies that share the same placenta. Normally, babies with the same placenta share a blood supply, but one baby can donate more blood–and by extension more nutrients, more oxygen, etc to the other. As such, one of the babies (the recipient) gets bigger, thanks to the extra blood in his system at the expense of the other–who gets smaller.
• Umbilical Cord Entanglement: This is common in fetuses that share the same placenta, since the two separate cords are wobbling in the same space there is always the risk of entanglement that can cause traction of some sort and is a slippery slope to more complication if not managed appropriately.

Conclusion

The prospect of receiving a set of twins is indeed a cheery one, but it has its risks. The high risk of complication is perhaps the nerviest element of the story, but most twins pull through without any issues.

There is a multi-faceted approach to this condition and includes a wide range of medical professionals.  It entails having frequent monitoring, checkups, and feeding adequately to forestall the adverse effects of nutritional deficiencies. These can pave the way for safely delivering your healthy little duo while avoiding issues in the mother–a win-win.