Multi‐fetal gestations are associated with low birth weight, fetal growth restriction, placental and cord abnormalities, preeclampsia, anemia, shorter gestation and an increased risk of infant mortality. Twin births account for 16% of all low birth weight infants. The risk of pregnancy complications is greater in women carrying twins and increases markedly as the number of fetuses increases (1, 2).

For twin gestations, the 2009 IOM recommendations provide provisional guidelines: normal weight women should gain 37‐54 pounds; overweight women, 31‐50 pounds; and obese women, 25‐42 pounds (3). There was insufficient information for the IOM committee to develop even provisional guidelines for underweight women with multiple fetuses. A consistent rate of weight gain is advisable. A gain of 1.5 pounds per week during the second and third trimesters has been associated with a reduced risk of preterm and low‐birth weight delivery in twin pregnancy (2). In triplet pregnancies the overall gain should be around 50 pounds with a steady rate of gain of approximately 1.5 pounds per week throughout the pregnancy (2). Education by the WIC nutritionist should address a steady rate of weight gain that is higher than for singleton pregnancies.

Pregnant or breastfeeding women with twins have greater requirements for all nutrients than women with only one infant. Postpartum, non‐breastfeeding women delivering twins are at greater nutritional risk than similar women delivering only one infant. All three groups of women would benefit greatly from the nutritional supplementation provided by the WIC Program.

References

1. Brown JE and Carlson M. Nutrition and multifetal pregnancy. J Am Diet Assoc. 2000; 100:343‐348.

2. Institute of Medicine. WIC nutrition risk criteria: a scientific assessment. National Academy Press, Washington, D.C.; 1996.

3. Institute of Medicine. Weight gain during pregnancy: reexamining the guidelines (Prepublication Copy). National Academy Press, Washington, D.C.; 2009. www.nap.edu. Accessed June2009.

Additional References

Brown JE, Schloesser PT. Pregnancy weight status, prenatal weight gain, and the outcome of term twin gestation. Am. J. Obstet. Gynecol. 1990; 162:182‐6.

2. Suitor CW, editor. Maternal weight gain: a report of an expert work group. Arlington, Virginia: National Center for Education in Maternal and Child Health; 1997. Sponsored by Maternal and Child Health Bureau, Health Resources and Services Administration, Public Health Service, U.S. Department of Health and Human Services.

3. Williams RL, Creasy RK, Cunningham GC, Hawes WE, Norris FD, Tashiro M. Fetal growth and perinatal viability in California. Obstet. Gynecol. 1982; 59:624‐32.

4. Worthington‐Roberts, BS. Weight gain patterns in twin pregnancies with desirable outcomes. Clin.Nutr. 1988; 7:191‐6

Implications for Minnesota WIC Services

Clarification:

Pregnant women with risk code 335 are considered high-risk. Women who are pregnant with multiples have greater nutrient requirements than women with singleton pregnancies.

The objectives and intervention strategies are:

Assist participant to achieve and maintain a steady rate of weight gain that is higher than for singleton pregnancies.

Assure adequate diet since a woman pregnant with multiples has greater requirements for all nutrients than a woman pregnant with one infant.

Assure that she is able to purchase a prenatal vitamin and she takes it as recommended.

Assessment Specific to Risk Code 335

The assessment should identify dietary patterns where nutrient inadequacies may occur for each individual woman who is pregnant with multiples. A diet rich in nutrients is very important for women who are pregnant with multiples. A thorough diet assessment requires asking a few additional questions along with the questions shown here: Pregnant Nutrition Assessment. Use open-ended questions and tailor the questions to the individual participant. Factors to consider for this risk code:

Assessment about diet:

What is her level of knowledge about healthy eating during pregnancy?

Is she taking a prenatal vitamin daily that is adequate in iron, folic acid, iodine?

Appetite? Any nausea and vomiting?

Does she consume regular meals and snacks?
Does her daily schedule interfere with eating regularly?

Ask about her typical intake from each food group. “Tell me about what foods you eat on most days.” It may be helpful to ask about:
Typical beverage intake each day.
Portion sizes.
Intake of iron-rich foods: meat and WIC cereals.
Protein foods: how much and how often does she eat protein? Is she getting 5-6 ounces per day?
Intake of low fat dairy foods or appropriate alternatives for adequate calcium and vitamin D? Three cups per day of dairy foods is recommended.
Vegetable and fruit intake: how often and how much?
Fiber intake and whole grains.

Any concerns about having adequate finances and transportation to obtain healthy foods?
Ask her what she does if she runs out of money for food.

Any medical or dental problems that affect appetite or eating ability?

Any gastrointestinal symptoms: constipation, heartburn, diarrhea?

Is stress or depression interfering with her appetite?

Nutrition Counseling for Risk Code 335

The nutrition counseling should focus on encouraging a variety of healthy foods including adequate protein (5-6 ounces/day), adequate calcium (3 cups dairy/day) and at least 5 cups fruits and vegetables per day. Taking a daily vitamin supplement with iron is important.

Explain that a consistent rate of weight gain is desirable and is higher than for a singleton pregnancy.
Provisional weight gain guidelines are discussed in the ‘Justification’ section of the WIC Nutrition Risk document.
A gain of 1.5 pounds per week during the second and third trimesters is typical for twin pregnancies.
A gain of 1.5 pound per week throughout the pregnancy is typical for triplet pregnancies.

Commend her for positive changes she has already made.

Help her identify foods to eat to improve the quality of her diet.

Suggest smaller, more frequent meals and snacks if she feels she cannot eat much at one time.

Encourage adequate fluid intake throughout the day, emphasizing water between meals.

Drink approximately 12 (8-fluid ounces) cups of water or other healthy beverages (caffeine-free) throughout the day.

Use the ‘Explore-Offer-Explore’ method to assess if ready to make a dietary change.

With her permission, help her prioritize nutrition concerns and help her identify 1 to 2 specific nutrition behaviors to work on. Examples of documentation for action steps in the high-risk care plan:
1. Eat at least 2 more servings of fruits/vegetables per day. She will bring fruit to work to eat for a mid-morning snack and will eat vegetables at dinner daily.
2. Avoid drinking tea with meals as tea can inhibit iron absorption. She will drink milk or water with meals.

If not taking prenatal vitamin supplement daily, help her to identify ways to remedy this.

Explain plans for future weight checks.

Provide referrals as needed:
Offer referral to Public Health Nursing Service.
Offer other referrals as needed such as a Mothers of Multiples group.

Guidance about Follow-up for Risk Code 335

Assure appropriate medical care.

Weigh participant at follow-up visit if applicable.
Document your assessment of her weight gain.

Follow-up on all action steps identified at previous visit.
Document progress on specific goals/action steps.

Follow-up on use of food benefits.

Educate about breastfeeding and Baby Behaviors.

Reference: Nutrition Care Manual; Academy of Nutrition and Dietetics. Multiple Gestation