When to call a health care professional during weeks 13 to

You're probably finding your fourth month of pregnancy to be easier than your first three. Even so, knowing about potential problems and when to contact your health care provider are just as important now as they were during the first trimester.

This month, you may be interested in:

• "Decision Guide: Understanding prenatal testing," page 289

• "Complications: Preterm labor," page 533

• "Complications: Depression during pregnancy," page 545

When to call

I Here's a guide to possibly troublesome signs and symptoms and when you I I should notify your health care provider in the fourth month.

Signs or symptoms

When to tell your health care provider

Vaginal bleeding, spotting or discharge

Slight spotting

Same day

Any spotting or bleeding lasting longer than a day

Immediately

Moderate to heavy bleeding

Immediately

Any amount of bleeding accompanied by pain, cramping, fever or chills

Immediately

Passing of tissue

Immediately

Persistent vaginal discharge that's greenish or yellowish, strong-smelling or accompanied by redness, itching and irritation around the vulva throughout the day

Within 24 hours

Pain

Occasional pulling, twinging or pinching sensation on one or both sides of your abdomen

Next visit

Occasional mild headaches

Next visit

A moderate, bothersome headache that doesn't go away after treatment with acetaminophen (Tylenol, others)

Within 24 hours

A severe or persistent headache, especially with dizziness, faintness, nausea or vomiting, or visual disturbances

Immediately

Moderate or severe pelvic pain

Immediately

Any degree of pelvic pain that doesn't subside within four hours

Within 24 hours

Leg cramp that awakens you from sleep

Next visit

Leg pain with redness and swelling

Immediately

Pain with fever or bleeding

Immediately

Vomiting

Occasional

Next visit

Once every day

Next visit

More than three times a day or with inability to eat or drink between vomiting episodes

Within 24 hours

With pain or fever

Immediately

Signs or symptoms

When to tell your health care provider

Other

Chills or fever (102 F or higher)

Immediately

Painful urination

Same day

Cravings for nonfood substances, such as clay, dirt and laundry starch

Next visit

Consistently low mood, loss of pleasure in things you normally enjoy

Next visit

Above signs and symptoms along with thoughts of harming yourself or others

Immediately

For about three in every 100 pregnant women, this month's visit to their health care provider will bring the surprising news that they're expecting twins, triplets or more, called multiple gestations.

The number of women having multiples is on the rise. Two factors help explain the increase. First, more women over 30 are having babies, and multiple gestations occur more frequently in women over 30. Second, the use of fertility drugs and assisted reproductive technologies results in more multiples. Physical signs of a multiple pregnancy, such as a uterus that's larger than normal or more than one fetal heartbeat, are easily detected during a routine physical exam. The results of a "triple screen" test also can suggest twins or other multiples.

If your health care provider suspects that you're carrying multiple babies, he or she will probably perform an ultrasound exam to confirm these suspicions. During an ultrasound exam, sound waves are used to create a television-like picture of your uterus and your baby — or babies. Because of today's widespread use of ultrasound, more than 90 percent of twin pregnancies are diagnosed before delivery.

How multiples are made

How multiples are made

Identical twins occur when a single fertilized egg splits and develops into two fetuses that have identical genetic makeups.

Fraternal twins, the most common kind, occur when two different eggs are fertilized by two different sperm.

Twins come in two types: identical and fraternal. Identical twins occur when a single fertilized egg splits and develops into two fetuses. Genetically, the two babies are identical. They will be the same sex and look exactly alike.

Fraternal twins occur when two separate eggs are fertilized by two different sperm. In this case, the twins can be two girls, two boys or a boy and a girl. Genetically, the twins are no more alike than are any other siblings.

It may be possible to determine whether twins are identical or fraternal with an ultrasound. For instance, if one is a boy and one is a girl, they're fraternal. In addition, the membranes around the fetuses may or may not suggest identical twins. Additional testing may be needed after the babies are born to determine if they're identical.

Triplets can occur in several ways. In most cases, three separate eggs produced by the mother are fertilized by three separate sperm. Another possibility is for a single fertilized egg to divide two ways, creating identical twins, with a second egg fertilized by a second sperm resulting in a fraternal third baby. It's also possible for a single fertilized egg to divide three ways, resulting in three identical babies, although this is very rare.

What multiples mean for mom

If you're carrying twins, triplets or other multiples, some of the side effects of pregnancy may be particularly unpleasant. Nausea and vomiting, heartburn, insomnia and fatigue may be especially troublesome. Because of the increased space required by your growing babies, you may also have abdominal pain and shortness of breath. Later in your pregnancy, you may feel pressure on your pubic bone, the structure located over the lowest part of the front of your pelvis.

Carrying multiple babies means you'll probably be seeing your health care provider more often. Special care is essential in multiple pregnancies. It allows your health care provider to track the growth of your babies and closely monitor your health, anticipating potential problems before they occur.

With more than one baby to nourish, your nutrition and weight gain become even more important. You'll likely have to eat more, gain more weight and get more iron. If you're carrying twins, your health care provider may recommend that you take in about 300 more calories a day, for a total of 2,700 to 2,800 calories. With twins, the American Dietetic Association recommends a weight gain of 34 to 45 pounds. With triplets, it recommends a weight gain of 50 pounds.

A lowered blood cell count (anemia) is more likely with multiples. Thus, your health care provider may recommend that you take a supplement with 60 to 100 milligrams of elemental iron. You may also be asked to limit some of your activities, such as work, travel and exercise. Work with your health care provider to develop a list of recommendations.

Possible complications of multiples

Carrying more than one baby increases your chances of some pregnancy complications. The more babies you're carrying, the greater your chances of having problems. These can include:

• Preterm labor. Preterm labor occurs when contractions begin to open the cervix before the 37th week of pregnancy. It happens more often in multiple pregnancies than in pregnancies involving just one baby.

Preterm labor can result in the early birth of one or more of the babies. Nearly 60 percent of twins and more than 90 percent of triplets are born before 37 weeks' gestation. The average gestational age of twins is 37 weeks. Triplets frequently arrive by 35 weeks, sometimes earlier. Almost all quadruplets and higher-order multiples come early.

Babies that arrive early have a greater chance of being low birth weight

(under 51/2 pounds) and having other health complications. For that reason, your health care provider will likely monitor you closely for signs of preterm labor. You'll want to do the same. If you start having contractions that are more frequent or are becoming stronger, contact your health care provider immediately.

Depending on the age of your babies, preterm labor can sometimes be managed with careful observation and bed rest. For more on preterm labor, see page 533.

• Preeclampsia. High blood pressure caused by pregnancy (preeclampsia) also is more common in mothers of multiples. It tends to occur earlier in those carrying more than one child. Signs and symptoms of preeclampsia include rapid weight gain, headaches, abdominal pain, vision problems, and swelling of your hands and feet. Contact your health care provider if you experience these problems.

• Higher risk of Caesarean birth. The chance of having a Caesarean birth is higher with twins and other multiples. However, about half of women carrying twins can expect to have a vaginal birth. If you're carrying more than two babies, your health care provider may recommend a Caesarean birth as the safest delivery method for the babies.

• Twin-twin transfusion. Twin-twin transfusion occurs only in identical twins. It can happen when a blood vessel in the placenta connects the circulatory systems of the two babies. It's possible that one twin may receive too much blood flow and the other too little. A baby receiving too much may grow larger and develop an overload of blood in its circulatory system. The other twin may be smaller, grow more slowly and become anemic. The situation can put one or both babies in jeopardy. At times, early delivery of the twins may be necessary.

Some new treatments may help. Studies suggest that use of amniocentesis to drain off excess fluid can help. At some specialized hospitals, laser surgery is used to seal off the connection between the blood vessels. Generally, a team of high-risk-care obstetricians and neonatologists care for these babies. The babies are usually delivered as soon as the benefits of early birth outweigh the potential problems of prematurity.

• Vanishing twin syndrome. At times, an early ultrasound may show twins. But later ultrasounds may show little or no evidence of one of the twins. This is called the vanishing twin syndrome. Experts aren't sure why it happens. It may be frustrating or confusing, but don't blame yourself for it. Moms-to-be don't have any control over this outcome.

• Conjoined twins. Conjoined twins can result from an incomplete division of identical twins. In the past, babies with this condition were commonly referred to as Siamese twins. This occurs very rarely, only in one in 100,000 births. Conjoined twins may be joined at the chest, head or pelvis. In some cases, the twins may share one or more internal organs. At times, surgery is used to separate conjoined twins. The success of the operation depends in part on where the twins are joined and how many organs are shared.

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