What Kind of Care Is Needed in a Multiple Pregnancy? (podcast)

It’s an exciting time. Typically, when a perinatologist or a high-risk obstetrician sees these patients, the patients have already been seen by their OBs, and so they’ve been very excessively counseled.

For us as perinatologists or high-risk obstetricians, what’s important is the number of placentas these babies have. When we think about pregnancy, we think about mom, placenta and baby. The placenta is the intermediary between the two. It does all the functions as far as making sure the babies get oxygen through mom, gets rid of all the toxins. It’s important to know how many placentas babies have. If babies have a placenta of their own, and they’re in a separate sac than the other twin, then that has the least amount of morbidity or complications. But sometimes twins share one placenta and have two separate sacs, or sometimes they share the same sac, and those complications go up with those types of multiple gestations.

Multiple pregnancies have an increased risk for hypertension or high blood pressure in pregnancy. It increases your risk for developing diabetes in pregnancy. One of the biggest risk factors for babies is also preterm birth. These moms have a much higher risk of delivering prematurely. These moms also have a much higher risk of bleeding and requiring a cesarean section. Also remember, there are two babies, so there’s a high risk of chromosome abnormalities, and congenital abnormalities.

With preeclampsia, or elevation in the blood pressure, these symptoms are typically gaining a lot of weight all of a sudden. So in the last week, gaining about seven to 10 pounds, swelling of face or hands. Patients may have a really bad headache; they may have visual disturbance; they may have epigastric pain or pain in the middle of the chest or to the side of it on the right side.

With preterm labor, typically these patients are experiencing contractions. It’s a rhythmic contraction that patients experience. If they’re experiencing more than six to eight of these contractions in an hour, we ask them to be evaluated. They may go to the emergency room or go to the labor and delivery unit depending on the gestational age of the babies.

Since moms with multiple gestations are at an increased risk of developing preeclampsia, we advise taking low-dose aspirin or baby aspirin, typically anywhere between 12 to 28 weeks, the earlier, the better. This is to avoid the risk of elevated blood pressures in pregnancy.

We ask patients to focus on inflammation, which means making sure you get some sleep. Moms need to be selfish. They need to be taking care of themselves. They need to be in tune with their body.

We ask them to exercise, have a very well-balanced diet, make sure your mind is calm and cool. Avoid any exercises that put you at risk for a fall. Also make sure, you’re not smoking, not drinking and make sure you’re taking care of yourself.

We don’t know exactly what the deleterious effects are, but we know that stress is a silent killer of all of us. I tell patients, please make sure you engage in any type of activity you can to reduce your stress levels.

All of us respond differently to how do we cope with stress. Some like reading; some do meditation; breathing exercise is something I do. Some people go for walks. Do whatever it is that makes it better for you to manage stress and not react but respond. Whether it’s talking to your psychologist, talking to a psychiatrist, talking to friends, watching comedy, whatever it is, it’s important that you do that. Also find some silent moments for yourself. Be in a quiet place where you’re thinking, reflecting. It’s really important that mothers to-be think about themselves and take care of themselves.

Don’t eat sweets; put aside cakes, cookies, all that stuff. Eat as much as you can, as healthy and well-balanced as possible, no hormones or antibiotics in your food.

Think about types of foods that promote blood flow like pomegranate, beets, leafy green vegetables, berries. Obviously the common sense stuff. Don’t drink any alcohol, avoid any illicit drug use, smoking. Typically, that’s what I recommend to patients.

We also ask patients to increase their iron supplementation and also their folic supplementation. Moms who are carrying two babies or more, tend to be more anemic. So, it’s important to take your supplements.

If the baby delivers, for example, at 23 weeks or 24 weeks at gestation, these babies have significant complications. They could have blindness; they could have cerebral palsy; they could have respiratory issues. The lungs haven't fully developed. These babies can bleed inside their heads. They can have inflammation of the intestines. The complications could be very significant.

We have great neonatal intensive care units at all Scripps facilities. We have highly trained physicians and support staff that take care of these babies. We have very good outcomes. So, depending on the gestational age, there’s an inverse relationship with complications of prematurity.

On average twin babies are about five and a half pounds. If you have triplets, they’re usually about four pounds because of the gestational age. Typically, multiple gestations or twins that have two separate placentas, they can go all the way up to 38 weeks. These babies typically can be six pounds, five and a half, even seven pounds.

For us, the gestational age is very important. Remember, some of it is constitutional. A lot of it is genetics. So, if I have a small mom, I’m not expecting that mom at 37 weeks to have a seven-pound, eight-pound baby. It’s important to make sure that we get to a gestation age that’s safe for those babies and also that they have a healthy weight. But we also look at the parents because again, genetics matter.

A perinatologist is a consultant to obstetricians, to family practitioners, to midwives. We are fetal radiologists. We look at babies all the time when moms are pregnant. We’re also consultants to these other providers. We are part of the team. If our OBGYN wants to have a consultation with maternal fetal medicine regarding the complications associated with multiples, that’s what we do. We are working side by side with our patients' OBs and so it’s a team effort.

The perinatology program at Scripps Clinic started in August of 2018. We are a group of providers that are providing care to high-risk women across San Diego County. We have offices in Encinitas. We have offices in La Jolla, and Scripps Mercy, San Diego, and Chula Vista. We partner with other subspecialists, both in adult and pediatrics to make sure that we take the best care of our moms and babies.