A multiple pregnancy comes with additional risks for both the mother and her babies

They are called multiple births – twins, triplets, quadruplets and so on – and they are on the rise in a medically advanced, prosperous country like Singapore.

Couples who enjoy the active lifestyle the Lion City offers are planning for kids later in life. But starting a family later means the woman is likely to be older, and conception, probably harder. Often, many turn to fertility drugs or assisted reproductive technology, such as in vitro fertilisation (IVF), which can lead to multiple-birth pregnancies.

But a multiple-birth pregnancy – as opposed to a single-birth one – carries serious risks.

Be aware of the risks and prepared for the worst

“Chances are the mother would have a successful pregnancy and go home with healthy babies,” said Dr Tan Wei Ching​, Senior Con​​sultant at th​e Department of Obstetrics and Gynaecology, Singapo​re General Hospital (SGH), a member of the SingHealth​ group.

“But she must also be aware of the risks and be prepared for the worst – the worst being premature, sick babies who require prolonged hospital stays.”

Dr Tan, who has practised in Singapore for nearly 15 years, estimated that 80 per cent of the multiple-birth pregnancies she sees end up with no problems for the mother or her newborns.

Risk rises with number of foetuses in pregnancy

But the risk of complications goes up dramatically with the number of foetuses in one pregnancy. The risk of cerebral palsy, for example, is three times higher for triplets, and rises to 10 times for quadruplets, Dr Tan said. Older mothers are also at risk of having babies with Down's syndrome. In Singapore, women older than 35 years of age are considered to be at higher risk of having a baby with Down’s Syndrome.

Other risks in a multiple birth pregnancy include miscarriage; foetal growth restriction as foetuses fight for food and room in the womb; pre-term labour; and prematurity of the newborn.

The woman pregnant with multiple foetuses will also be more prone to hypertension, or pre-eclampsia, due to the larger placenta needed to support more than one foetus, as well as gestational diabetes.

Identical twins usually share one placenta, the flat organ attached to the inside of the uterus and connected to the foetus by the umbilical cord. Non-identical foetuses often have their own placenta. The placenta links the blood supply of the embryo to the blood supply of the mother, allowing the exchange of oxygen, nutrients, and waste products. The larger placenta and higher hormone levels can cause severe morning sickness, which can lead to the mother and her foetuses becoming malnourished.

Multifoetal pregnancy reduction: a possible option

Potential parents must be aware of their options when risks arise. Having bed rest or taking vitamins or hormones can help reduce the risk of pre-eclampsia or pre-term labour. When a multiple foetal pregnancy starts to become too much of a health risk for the mother and/or the foetuses, the family may be offered the option of reducing the number of foetuses in the womb. Known as multifoetal pregnancy reduction, the ultrasound-guided procedure can reduce the number of foetuses to lower the risks that a larger number of foetuses present to the mother and the pregnancy.

“It doesn’t eliminate the risk of your pregnancy as compared to any other single (foetal) pregnancy, but you no longer have the risks associated with a multiple (foetal) pregnancy,” said Dr Tan. But the procedure is not a “surefire method” either, she added. It must be done before the 11th to 13th week of gestation, and mothers face the risks of bleeding, infection or losing some, or all of the remaining foetuses.

Before the procedure is allowed, the case has to be put forward to the hospital’s Bioethics Committee for consideration and approval. The family will also be counselled by a psychologist.

Once the mother and babies go home, she faces the prospect of considerable physical fatigue, especially if she’s breastfeeding more than one newborn, which is a round-the-clock affair and can be difficult. If the new mother has the support and encouragement she needs from her partner and other family members, it will help her on the road to recovery.

Facts and figures on multiple pregnancies and childbirth

  1. 1988 was the year the first IVF triplets were born in Singapore.
  2. 1989 was the year the first surviving IVF quadruplets were born in Singapore.
  3. 1997 was the year the first IVF quintuplets were born in Singapore.
  4. 1998 was the year the first IVF sextuplets were born in Singapore.
  5. 1.16 is Singapore’s total fertility rate, the average number of children a woman would bear in her lifetime.
  6. 2.1 is the replacement rate of a developed country like Singapore.
  7. 24 weeks is the earliest a foetus can attempt to survive outside the womb.
  8. 35 years of age is the threshold for a woman to have her first child before she is considered of advanced maternal age.
  9. 37-40 weeks is when a foetus reaches full term, ready to be delivered.
  10. 500 grams is the minimum weight for any newborn to survive.
  11. $3,000 is the maximum the government will co-fund an assisted reproductive technology cycle. The grants are based on certain criteria, including a maximum of three cycles per patient.

Ref: U11