Health Surprises to Expect When You're Pregnant With Multiples

Like most new moms-to-be, I was ecstatic to see two lines on my home pregnancy test stick—an event dwarfed only by the subsequent news that I was carrying twins. Shortly after, the parenting advice started to stream in, the most memorable of which came from my ob-gyn. "Women who carry twins can have health surprises," he said. "So if something seems off, let us know."

Nothing did, until the end of my second trimester, when my palms started to itch—a stinging that couldn't be eased by even the strongest lotion. A week later, the soles of my feet began to tickle, too, followed by my earlobes and knees. I called my ob-gyn.

One ultrasound and several blood tests later, I received my diagnosis: cholestasis of pregnancy, a condition that impairs the flow of bile from the liver, resulting in extreme itchiness, usually on the hands and feet but often on many other parts of the body. Left unmonitored, cholestasis can increase the risk of preterm birth and cause severe complications for the baby, so I was put on medication and slated for weekly ultrasounds until I delivered.

As I learned firsthand, twin pregnancies are associated with higher hormone levels that can cause a number of health twists, including cholestasis. "Twin pregnancies often play out differently from single births, since carrying two babies at once stresses the body a lot more," says Jeffrey Ecker, M.D., associate director, Maternal Fetal Medicine Fellowship at Massachusetts General Hospital in Boston. Here, a little health know-how and some potential surprises you might expect if you're expecting multiples.

You'll need more nutrients

As a twin-mom-to-be, you'll need higher levels of certain baby-building vitamins and minerals. "Twin moms require a higher amount of folic acid to help prevent birth defects like spina bifida, so I recommend 1,000 micrograms a day, as opposed to the 400 micrograms women take when carrying a single baby," says Dr. Ecker. And while it's normal to be tired (hello, you're growing two human beings), you should clock your couch potato time, as extreme fatigue can also be a sign of anemia. "This condition is common in twin pregnancies, because the two babies require iron for development and they automatically suck that from mom," Dr. Ecker says. So look for a prenatal vitamin that contains 30 mg of anemia-preventing iron. (Many pills contain these nutrient levels, but always check the label!) You'll spend more time at your doctor's office

Twice the babies can mean twice the risks, and that means "more ultrasound monitoring is needed," says Margaret Dow, M.D., obstetrician and laborist at Mayo Clinic. "The uterus can get cramped for space, particularly in the second and third trimester, so we like to administer more scans to check for growth or signs of fetal distress."

Carrying identical twins that share a placenta? Twin-to-Twin Transfusion Syndrome (TTTS), a rare condition that appears in 10 percent of pregnancies, is one reason you may be monitored more. This occurs when the blood supply of one twin moves to the other via the shared placenta. The twin that loses the blood is called the donor twin; the twin that receives the blood is called the recipient twin. Both infants may have problems, depending on how much blood is passed from one to the other. Treatment may include repeated amniocentesis to remove excess amniotic fluid from the sac of the recipient twin, and fetal laser surgery may be done to stop the flow of blood from one twin to the other. According to Dr. Dow, even without TTTS, twins that share a placenta have a higher risk of fetal anomalies (malformations), growth problems, and preterm birth.

Your shape may change—a lot

"Twin moms need more calories than a woman carrying one baby, so their targeted weight gain during pregnancy is higher," says Dr. Ecker. Twins moms are advised to gain between 35 and 50 pounds. But that's not a license to start shoveling in sweets. Instead, aim for a well-rounded diet and ask your doctor about an appropriate eating plan, since proper nutrition is important for your babies' development.

Another body change to expect? "Twin moms tend to retain more water and experience more swelling," says Dr. Dow. Why? "Women naturally retain more water when pregnant, and two babies always make for more." That said, extreme swelling, called edema, in the hands, face, and feet can be a sign of a more serious condition (like preeclampsia), says Dr. Dow, so call your provider if you're concerned.

Your nose and gums may bleed

Surprise: Your gums and nose may go a little nuts during pregnancy—especially if you're carrying multiples. All of that extra blood volume, plus surging hormones, can cause the delicate network of blood vessels in your nose and mouth to dilate, Dr. Dow says, and that can cause nosebleeds, nasal congestion, and bleeding gums after brushing. It can be disconcerting, she says, but it's completely benign. Just don't stop brushing and flossing, as poor dental hygiene during pregnancy is associated with preterm birth and possibly even preeclampsia.

Your wrists might hurt

Carpal tunnel syndrome is another common twin pregnancy complaint—thanks to, once again, that extra blood volume. "All of this extra blood can cause the median nerve in the wrist—a naturally narrow, cramped area—to become compressed, causing pain, numbness or tingling in the hands and wrists," Dr. Dow says. The good news: Carpal tunnel is usually temporary, and typically dissipates within 6 to 12 weeks after delivery, according to Dr. Dow.

You won't automatically need a C-section

While the chances of having a C-section are higher in twin pregnancies, due to the higher potential of health complications of having two babies in utero, "it's not something we now push as providers," says Dr. Ecker, "unless other risk factors like maternal health, fetal heart rate, or positioning interfere. Many women with twins should, in fact, expect and have vaginal deliveries."

You're at increased risk for the three Ps: preeclampsia, preterm labor and PUPPP

These pregnancy complications are all more common during twin pregnancies, particularly in the last two trimesters, says Dr. Dow. Preeclampsia, which is classified as high blood pressure, protein in the urine, and dysfunction of some of the mother's organs, is more than twice as common in twin pregnancies. The exact cause isn't known, but experts believe it begins in the placenta. Early in pregnancy, Dr. Dow explains, new blood vessels develop to efficiently send blood to the placenta. In women with preeclampsia, these blood vessels don't seem to develop properly, sparking the symptoms mentioned above.

Preterm labor is a common condition in twin moms, but doctors still don't know what spurs early labor. One theory? "The uterine muscle is only designed to be distended only so far before it wants to start contracting to get back to its normal size," explains Dr. Dow. "And with twins, this distention starts earlier and can be more extreme." In fact, according to the March of Dimes, close to 60 percent of all twins are born prematurely (before 37 weeks), with the average twin pregnancy lasting 35 weeks.

PUPPP, which stands for pruritic urticarial papules and plaques of pregnancy, is a red, relentlessly itchy rash that can occur in your third trimester—first as hive-like patches on the belly, then moving to the thighs, buttocks, and back.

"The itchiness was unbearable," recalls Malia Vanaman, a mom of twins from Indianapolis. Vanaman, who developed the condition at 32 weeks with her twins, tried remedies like lukewarm oatmeal baths and lotion to soothe her stinging skin. Finally, she consulted her ob-gyn. "The topical cream she prescribed worked wonders—and once my babies were born at 37 weeks, my rash disappeared," she says.

No one knows what causes PUPPP, but it's more common in twin moms, possibly due to the extra amount of hormones, says Dr. Dow. Luckily, the condition won't trigger other health complications, and although it's uncomfortable, the symptoms can generally be managed with prescription antihistamines, oral steroids, or topical ointments.

Your gallbladder could go haywire

Your gallbladder stores bile, which helps your body break down and digest the fats you eat. The problem? "During pregnancy, the gallbladder empties poorly, due to the higher amounts of hormones in the body like progesterone, which naturally relaxes and slows the function of smooth muscle organs," Dr. Dow says. "And increased estrogen, which naturally occurs during pregnancy, and is even higher in twin pregnancies, also prompts more secretions, so everything bogs down, setting the stage for the formation of painful gallstones." The result? Severe nausea after eating, as well as a nagging pain beneath your ribs. "Sometimes we can manage problems with diet changes and medication during pregnancy," says Dr. Dow, "but in severe cases, surgery may be needed."

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