Twin Pregnancy Care in Ahmedabad: How I Monitor Twins and Triplets

Twins who share a placenta (monochorionic twins) have blood vessels that connect their circulations, and the flow between them can become unbalanced. I therefore scan them every two weeks from 16 weeks. Twins with separate placentas are scanned about every four weeks.

Twin pregnancies are more common than they used to be, mainly because of IVF and because more women conceive at an older age. Compared with a single baby, twins bring a higher chance of preterm birth, anaemia, gestational diabetes, pre-eclampsia and growth problems. Most of these can be foreseen, screened for and managed when the scan schedule is set correctly from the start.

My care includes regular checks for TTTS (an imbalance of blood flow between twins) and selective growth restriction. My maternal-fetal medicine training was done at Fernandez Hospital, Hyderabad, and the Fetal Medicine Foundation (UK) has accredited me for the NT scan. Twins and triplets under my care are born at Divine Women's Hospital, Gota, where neonatal staff are available 24×7.

Twin Pregnancy Types: Placentas, Sacs and What Each Means

Twins are classified by how many placentas and how many sacs they have. It is this - not whether the twins are identical - that decides how closely the pregnancy is watched. Non-identical twins always have two separate placentas, whereas about two-thirds of identical twins share one.

Chorionicity is most reliably seen at 11–14 weeks, from the shape of the dividing membrane where it joins the placenta (the lambda sign or the T sign). If it cannot be worked out, I manage the pregnancy as monochorionic until it is proven otherwise.

What Makes Twins More Likely

Non-identical twins come from two eggs released in the same cycle, so anything that makes double ovulation more likely raises the chance of having them. Identical twins come from a single embryo that splits; this is largely chance, although it happens a little more often after IVF.

Factors that raise the chance of twins:

• IVF, especially when more than one embryo is transferred.
• Ovulation induction with tablets or injections.
• A mother aged 35 or more.
• Non-identical twins on the mother's side of the family.
• An earlier twin pregnancy
• A larger number of previous births.

Twin Pregnancy Symptoms: Why Carrying Two Can Feel Harder

Early twin pregnancy symptoms are the usual ones, only stronger. None of them can confirm twins; only a scan (sonography) can do that.

• Morning sickness is often stronger and lasts longer, because hormone levels are higher.
• The bump grows faster, so backache, breathlessness, heartburn and swollen feet tend to start earlier.
• Tiredness is common, partly because anaemia is frequent in twin pregnancies in India. I usually start iron and folic acid early and check haemoglobin more often.
• Work and home: many women find it helps to cut down on work earlier, often from around 28–32 weeks. Arranging help at home for the first months after birth also helps. I suggest this because of the extra physical load, not because rest prevents complications.

Twin Pregnancy Complications With a Shared Placenta: TTTS, sGR and TAPS

Twin-to-twin transfusion syndrome (TTTS) affects about 10–15% of monochorionic twins. Blood passes from one twin (the donor) to the other (the recipient) through connections in the placenta. The donor passes little urine and has little fluid around it; the recipient has too much. TTTS usually shows itself between 16 and 26 weeks and can worsen quickly - this is the reason for the two-weekly scans.

Selective growth restriction (sGR) affects a similar proportion, because the placenta is shared unequally.

Twin anaemia-polycythaemia sequence (TAPS) is rarer and develops more slowly. I detect it with MCA Doppler - measuring the blood flow in the brain artery of each baby.

• Treatment for TTTS: when TTTS reaches a stage where treatment is needed, the connecting vessels are sealed with laser at a specialised fetal therapy centre. I arrange the referral promptly, and your care continues with me afterwards.
• Milder stages are often watched with more frequent scans, because a proportion stay stable.
• If one twin dies in a monochorionic pregnancy, the surviving twin can suffer a sudden drop in blood pressure through the shared circulation. Care then includes counselling, a brain scan of the surviving baby a few weeks later, and a delivery plan.

Do your twins share a placenta? Then between 16 and 26 weeks, watch for sudden tightness of the abdomen or a bump that grows quickly. If you notice either, you need a scan within 24 hours.

Twin Pregnancy Scan: What I Check Each Time

At every visit I measure the same things in both babies and compare them with the previous scan. A change between scans matters more than a single reading.

• The deepest pool of fluid around each baby, and whether each baby's bladder can be seen.
• The estimated weight of each baby and the percentage difference; a difference over 20–25% is significant.
• Umbilical artery Doppler, and MCA Doppler in monochorionic twins to look for TAPS.
• Cervical length at the time of the anomaly scan, because a short cervix predicts early birth.
• A detailed anomaly scan at 18–22 weeks, which takes longer than for a single baby.
• The position of the placenta and where each cord is inserted.

Twin Pregnancy Care Tips for Your Own Health

• Pre-eclampsia is two to three times as likely as in a single pregnancy. I often advise low-dose aspirin from 12 weeks if you have one more risk factor, and I check your blood pressure and urine at every visit.
• Gestational diabetes testing follows the usual 24–28 week window.
• Nutrition: you need more calcium, iron, folic acid and protein. Calorie needs go up by roughly 300 kcal a day in the second half of pregnancy - not double.

Early Arrival of Twins and How I Manage It

About half of all twins are born before 37 weeks, and about one in ten before 32 weeks. Routine bed rest, routine progesterone and a routine cervical stitch have not been shown to help twin pregnancies as a whole. So I use them selectively: progesterone or a stitch may be considered if the cervix is short.

If labour starts early, or looks likely to:

• Steroid injections are given to mature the babies' lungs.
• Magnesium sulphate is given before 32 weeks to protect the babies' brains.
• The neonatal (newborn) team is involved early.

Twin Pregnancy Delivery Week and the Mode of Birth

The usual twin pregnancy delivery week depends on the placentas. Planning the birth reduces the risk of a late stillbirth, which rises in twin pregnancies beyond a certain week. As a guide:

• Uncomplicated DCDA twins are delivered at 37 weeks.
• Uncomplicated MCDA twins are delivered at 36 weeks.
• Delivery is earlier if complications develop.

A vaginal birth (normal delivery) is a reasonable choice when the first twin is head-down and there is no other reason for a caesarean. The team is ready to help the second baby. A caesarean is usually advised when the first twin is not head-down, for monoamniotic twins, and for most triplets.

During a twin labour both babies are monitored continuously, each with a separate heart trace. I often recommend an epidural, so that the team can help the second baby quickly - by turning it or with an assisted delivery - if needed. The gap between the two births is usually less than 30 minutes.

Recovery and Feeding After a Twin Birth

• Bleeding after birth (PPH) is more likely because the uterus has been more stretched. Medicines that help the uterus contract are given routinely, and blood is kept available.
• Breastfeeding twins is possible. Help is available from the very first feed, including tandem feeding positions.
• The six-week check covers haemoglobin, blood pressure, contraception and mood.
• Future pregnancies: having had twins does not by itself make the next pregnancy high-risk. If you conceived through IVF, it is worth discussing single embryo transfer next time.

Twin Pregnancy Care Week by Week

Here is how a typical twin pregnancy runs under my care. Your own calendar is adjusted to your twins' type and to anything that turns up along the way.

Twin Pregnancy Delivery Charges: What They Depend On

I cannot give one fixed figure for twin delivery charges, because two twin pregnancies rarely follow the same path. The total is shaped mainly by:

• The type of twins. Shared-placenta twins need a scan every two weeks from 16 weeks. Separate-placenta twins need one about every four weeks from 20 weeks.
• The mode of birth. This means a vaginal birth or a caesarean, and whether an epidural is used.
• How many days you stay after the birth.
• The babies' needs. Twins born early may need care in the neonatal unit, for a few days or several weeks.
• Extra tests or treatment, such as steroid injections, magnesium sulphate or a referral for laser treatment elsewhere.

The current charges for scans, delivery and the hospital stay are given by Divine Women's Hospital on request. I am happy to explain at a visit which of these items are likely to apply to your pregnancy.

Your Twin Pregnancy Plan in Five Steps

1. Chorionicity scanin the first trimester, which sets the whole schedule.
2. A personal scan calendar, booked in advance.
3. Screening at the right weeksfor blood pressure, haemoglobin, blood sugar and cervical length; aspirin and iron started where needed.
4. A delivery plantiming, mode and neonatal support - agreed from about 32 weeks.
5. After the birthactive management of bleeding risk and feeding help from the first day.

When to See a Twin Pregnancy Doctor

• An early scan has shown two or more babies.
• You are expecting twins after IVF or ovulation induction.
• You have been told the twins share a placenta.
• A scan has shown a difference in weight or in fluid between the twins.
• You are carrying twins and have a short cervix, high blood pressure or diabetes.

Twin Pregnancy Myths I Often Hear

Questions Patients Ask Me About Twin Pregnancy