Signs of Multiples in Early Pregnancy

The early days of pregnancy are often filled with feelings of excitement and nervousness — and likely a lot of questions. You may wonder what your pregnancy journey will involve, and what your baby will look like. You may even wonder if you’ll have more than one.

Multiple pregnancy is when you carry more than one baby — whether it’s twins, triplets, or more. “Every pregnancy is different, but there are some early signs that could suggest you’re carrying multiple babies,” says Carolina Bibbo, MD, a maternal and fetal medicine provider at Mass General Brigham.

Dr. Bibbo cares for patients at Brigham and Women’s Hospital and Newton-Wellesley Hospital, and is director of the Comprehensive Care Center for Multiples at the Brigham. Here, she describes some early signs and answers common questions related to multiple pregnancy.

Is there a difference between single and twin pregnancy symptoms?

Pregnancy symptoms are usually similar whether you have a single baby or twins. But people with twins and multiple pregnancy may experience certain symptoms more intensely than people with a single pregnancy.

Early signs and symptoms of multiple pregnancy

People who are pregnant with multiples may have:

• More severe morning sickness. Nausea and vomiting are common symptoms of pregnancy, especially in the first trimester, and can happen at any time of day. With single pregnancy, you usually feel sick for a short time and vomit once or twice a day. People who are pregnant with multiples may feel nauseous for several hours and vomit a few times each day (called hyperemesis gravidarum).
• More breast tenderness, where your breasts feel very sore.
• Faster weight gain in the first trimester. People who are pregnant with multiples need to gain more weight than people with a single baby, so they may also feel hungrier.
• More discomfort with back pain, difficulty sleeping, and acid reflux (where acid from your stomach comes back up and causes heartburn).

“Pregnancy symptoms are different for everyone — these signs don’t necessarily mean you have more than one baby,” Dr. Bibbo says. “Your provider usually discovers if you have a multiple pregnancy during an ultrasound exam.”

You’ll likely have your first ultrasound exam in the first trimester. This is called the dating ultrasound and happens around 8 weeks. This helps determine whether you’re having one baby or more and measures the size of the early growing embryo and the heartbeat.

Multiples hCG levels

When you’re pregnant, your body produces a hormone called human chorionic gonadotrophin (hCG). The baby also makes a protein called alpha-fetoprotein in your blood.

People with twin and multiple pregnancy have higher levels of hCG and alpha-fetoprotein than people with single pregnancy. Your provider checks these levels with a blood test. They may offer you a blood screening during your first trimester to check if your baby is at risk for Down syndrome or other genetic conditions.

If your blood test shows higher levels of hCG or alpha-fetoprotein, you may be more likely to have a multiple pregnancy. Your provider uses ultrasound to know for sure.

What causes multiple gestation pregnancy?

You get pregnant when an egg is released during your menstrual cycle and a sperm fertilizes it to create an embryo. Multiple pregnancy happens in one of two ways:

1. More than one egg is released and fertilized, leading to more than one embryo growing in your uterus, or womb. This creates fraternal twins, triplets, or more.
2. A single fertilized egg splits in two or more, creating multiple embryos in your womb. This leads to identical twins, triplets, or more.

Multiple pregnancy is more common in people who use fertility treatment like in medications to induce ovulation or in-vitro fertilization (IVF) to get pregnant. With IVF, a fertility specialist collects your eggs or uses donor eggs, fertilizes them with sperm in a lab, then places the embryo in your womb. They may place more than one embryo, or the embryo may split afterward, resulting in a multiple pregnancy.

Women or people assigned female at birth (AFAB) who are older than 35 years are also more likely to have a multiple pregnancy. They’re more likely to release more than one egg during their menstrual cycle or have their embryo split.

Is multiple pregnancy a risk?

Multiple pregnancy carries more risk than a pregnancy of a singleton baby — however, most twins do well without complications. Certain providers specialize in high-risk pregnancy and work closely with patients throughout their multiple pregnancy, delivery, and beyond. At Brigham and Women’s Hospital, Dr. Bibbo cares for patients as part of a unique center that meets the specific needs of families expecting multiples.

With multiple pregnancy, your care team works closely with you throughout your pregnancy to watch out for any problems and prepare you for a safe delivery. You’ll likely have more visits with your OB/GYN and more ultrasound exams. If your provider is concerned about anything, you might have more frequent check-ins or do special tests.

Common multiple pregnancy complications include:

• Premature birth, where you give birth early at less than 37 weeks of pregnancy. This increases your babies’ risk of short- and long-term health problems. It’s the most common complication of multiple pregnancy — more than half of all twins are born preterm, according to the American College of Obstetricians and Gynecologists (ACOG). Your babies may need special care in a neonatal intensive care unit (NICU) after birth.
• Abnormal growth. Twins tend to be smaller than singleton babies, mainly because the placenta has less room to grow. Sometimes twins are discordant in growth where one baby is smaller than the other. This is common with multiples and doesn’t always mean there’s a problem. However, the baby may not be growing because of a problem with the placenta, umbilical cord, or an infection.
• Preeclampsia, which causes high blood pressure (hypertension) and increases protein levels in your urine. It’s a condition that happens during or after pregnancy, and providers need to very closely monitor the pregnant person and the babies. Multiple pregnancy increases your risk of preeclampsia, and it may happen earlier and be more severe than in a singleton pregnancy. There are steps you can take to help prevent preeclampsia.
• Gestational diabetes, where you develop diabetes during pregnancy. This increases your risk of preeclampsia and having diabetes later on. Lifestyle changes like diet and exercise, and sometimes medication, can reduce your risk. If you develop gestational diabetes, a care team helps control your blood sugar to keep you and your babies healthy.
• Postpartum depression, where you have low mood and depressive symptoms in the weeks surrounding your birth. It may happen during pregnancy and up to a year after delivery. Talk to your provider if you experience intense feelings of sadness or anxiety that make it hard to do day-to-day tasks.
• Postpartum hemorrhage, where you have increased bleeding after birth. This is more common in a multiple gestation given the larger size of the uterus. Being pregnant with twins or more increases your risk of hemorrhage during delivery. Care teams experienced in high-risk pregnancy help reduce your risk during pregnancy and watch closely for any concerns during birth and postpartum.

Any of these complications can happen with a singleton pregnancy, too. Your risk increases with multiple pregnancy, but your care team monitors you more closely throughout your pregnancy journey.

Care and management of multiple pregnancy

If you’re pregnant with twins, triplets, or more, finding a care team experienced in multiple pregnancy is important.

The Brigham specializes in high-risk pregnancies and is home to one of the few comprehensive care centers for multiples in the U.S. and the only one in Massachusetts. Their providers know what to expect with multiple pregnancy, and they provide expert prenatal, delivery, and postnatal care for people with high-risk pregnancy. Since many multiple pregnancies lead to premature birth, the Brigham NICU is well-prepared for multiple newborns who need special care after birth. Rooms at the Brigham are ready for twins and triplets so parents can stay with their babies 24/7, and providers also offer breastfeeding and social work support for multiple newborns.

“Every pregnancy is special, but multiple pregnancy is an especially unique and exciting experience. It can also bring more challenges,” Dr. Bibbo emphasizes. “That’s why finding the right care team to help you navigate this journey is so important.”