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Multiple Pregnancy: What You Need to Know

In August of 2012, Lisa Pizzi was pregnant with twins. She and her husband Eric knew a twin pregnancy came with extra risks, but Lisa’s pregnancy had been wonderful. 

“We visited the hospital at 9 a.m. for what I thought would be a 10-minute appointment for high blood pressure. The maternal and fetal medicine doctors rushed me upstairs to labor and delivery. I didn’t leave the hospital for 12 days,” says Lisa.  

Lisa had developed HELLP Syndrome, a rare but life-threating liver disorder. The syndrome is a variant of preeclampsia, and occurs in 0.1 percent of all pregnancies. The doctors gave Lisa steroid injections to help develop her twins’ premature lungs.

“Scarlett and Grayson were delivered in an emergency cesarean section. I spent the next 24 hours in an ice bath with a magnesium drip, worried I might not survive the night,” says Lisa.

While Lisa was being treated, Scarlett and Grayson were immediately transferred to the Brigham and Women’s Hospital (BWH) Neonatal Intensive Care Unit (NICU), which provides Level III care for premature and seriously ill babies.

Mothers Carrying Multiple Babies Require Extra Care

While multiple babies account for only three percent of all births, the multiple birth rate is rising. According to the National Center for Health Statistics, the twin birth rate has risen 70 percent since 1980 (about 33 per 1,000 live births). The birth rate for triplets and other higher-order multiples rose dramatically, but has slowed since 1998. 

A multiple pregnancy can increase the risk for complications to both the baby and mother. To find complications early enough for management or treatment, mothers carrying more than one child typically require more frequent visits with their doctors.  

“Visits every two-to-four weeks allows for more ultrasounds, lab work and special testing to monitor the health of the babies. We will also conduct genetic screenings to evaluate the risk of genetic conditions,” says Carolina Bibbo, MD, a maternal-fetal medicine specialist in the Division of Maternal-Fetal Medicine within the Department of Obstetrics and Gynecology at BWH.

Maternal-fetal medicine specialists work with high-risk patients to help mothers achieve the healthiest pregnancy and delivery possible. They also collaborate with specialists within the Department of Pediatric Newborn Medicine.   

Scarlett and Grayson Pizzi

Challenges that May Affect the Mother 

While mothers carrying multiple babies face more challenges than a single pregnancy, these risks can be managed with the guidance of a maternal fetal medicine specialist who can offer specialized high-risk pregnancy care for women who may develop a medical condition while pregnant.

Premature birth

The more babies a mother carries, the greater the chance there is for an early birth. More than 60 percent of twins and nearly all higher-order multiples are born premature (before 37 weeks).

“Premature babies are born before their bodies and organ systems have fully matured. These babies often have very low birthweights (less than 5.5 pounds), and they may require help breathing, eating, fighting infections, and staying warm,” says Dr. Bibbo. 

Premature babies born even earlier, before 28 weeks, are particularly vulnerable. Many of their organs may not be ready for life outside the mother's uterus and may be too immature to function properly. Many multiple birth babies will need care in a Neonatal Intensive Care Unit.


Due to the increased risk for complications, and the potential need for cesarean birth, delivery of multiple babies may occur in an operating room. Cesarean delivery is usually needed for babies that are in challenging positions, for certain medical conditions of the mother, or if the baby is in distress. 

The mother’s nutrition

Mothers carrying two or more babies require more calories, protein, and other nutrients. It’s common for a mother who is carrying more than one child to feel full more often. As such, it can be harder to consume the necessary calories, and it’s important for a mother to closely monitor her nutritional status and weight.

“I recommend healthy dietary changes that may include eating small, frequent snacks, and extra protein through shakes. Also, mothers should supplement with 30 milligrams of iron in the first trimester, and 60 milligrams until delivery. I usually refer mothers to a nutritionist, who can help them better understand their daily calorie requirements, and learn more about the nutritious foods they should be eating to maintain a healthy pregnancy,” says Dr. Bibbo. 

Weight gain

For multiple pregnancies, above average weight gain is recommended. The Institute of Medicine recommends that a woman carrying twins who has a normal body mass index should gain between 37 and 54 pounds. Those who are overweight should gain 31 to 50 pounds, and obese women should gain 25 to 42 pounds.

Low-back pain  

The extra weight to the front of a mother’s body can strain muscles in the lower back, buttock, thigh, and abdomen. This can lead to low-back pain and sciatica (pain that travels down to the legs). Back pain during pregnancy is common and typically resolves after delivery. 

Acid reflux

It’s also common for a pregnant mother to experience heartburn, or acid reflux. If this causes too much discomfort, your doctor may prescribe a safe medication to resolve heartburn.

Gestational hypertension 

Women with multiple babies are more than twice as likely to develop high blood pressure during pregnancy, a condition known as gestational hypertension. This form of high blood pressure often develops early in a pregnancy (~20 weeks), and is more severe than a pregnancy with one baby. A mother’s blood pressure will be closely followed if it’s higher than 140 over 90. 

Gestational diabetes 

Gestational diabetes is a form of diabetes that develops during pregnancy. Unlike Type 1 diabetes, gestational diabetes is not caused by having too little insulin. Instead a hormone made by the placenta keeps the body from properly using the insulin (called insulin resistance). Blood sugar then accumulates in the blood instead of being absorbed by the cells. 

“A mother with gestational diabetes will have their blood sugar closely monitored. The condition can usually be controlled with diet, exercise, or a safe medication. The symptoms of gestational diabetes usually disappear after delivery, but sometimes they do not, and a mother may be at a greater risk of developing Type 2 diabetes,” says Dr. Bibbo.   

Lisa and Eric Pizzi with their children Grayson and Scarlett.

Challenges that May Affect the Baby

Multiple pregnancy increases the risk for complications to the baby. However, more frequent visits with an obstetrician or maternal-fetal medicine specialist can help find complications early and manage or treat any potential problems.


A phenomenon called “vanishing twin syndrome,” in which a baby vanishes (or is miscarried), can occur in the first trimester, and is more likely in multiple pregnancies. The risk of pregnancy loss is increased in later trimesters as well.

Birth defects

Multiple birth babies have about twice the risk of congenital (present at birth) abnormalities, including neural tube defects (e.g., spina bifida), gastrointestinal, and heart abnormalities. 

Growth restriction  

The growth of a baby can be restricted if they are not receiving the nutrition they need. A “growth restriction” diagnosis is made if a baby is less than 10 percent of the growth curve. Depending on the size of the baby, there may be a need for an earlier delivery.

Twin-to-twin transfusion syndrome

Twin-to-twin transfusion syndrome (TTTS) is a rare condition of the placenta that develops only with identical twins. It happens in about 15 percent of twins with a shared placenta.

“It’s important to know that TTTS is extremely rare. In most cases, this syndrome is diagnosed in an early, mild stage. A diagnosis of TTTS requires frequent ultrasounds,” says Dr. Bibbo.

The Pizzis Start their Lives   

After the birth of their two children, Lisa and Eric returned to the NICU every day for several months. Scarlett stayed in the NICU for 54 days, Grayson stayed for 103 days. Since they couldn’t bring their babies home, they brought their home to their babies by decorating the hospital rooms with family pictures. 

“It wasn’t how we had planned to have our kids, but we connected with so many wonderful people in the NICU, and came out of the experience with life-long friends. The NICU staff truly became part of our family,” says Lisa, who now serves as the Chair of the NICU Parent Advisory Board. 

One cherished member of their family is Michael Prendergast, MD, their neonatologist, and the medical co-director of the NICU. The night Dr. Prendergast helped deliver Lisa’s children, it was his first night on call. He was steady, calm and skillful.

Several months after the delivery, the Pizzis brought Scarlett and Grayson home and started their life together. They are now healthy five-and-a-half-year-olds. They perform occupational therapy and physical therapy twice a week, but aren’t limited in any kindergarten activities, including rolling around in the April mud at their farm school in Brookline.   

- Dustin G. 

In this video, Lisa and Eric Pizzi share helpful advice for working with the NICU care team.