Nutrition and Multiple Gestation

Barbara Luke, ScD, MPH, RD

Multiple pregnancy represents a state of magnified nutritional requirements, resulting in a

greater nutrient drain on maternal resources and an accelerated depletion of nutritional
reserves. The accelerated starvation which occurs in pregnancy is exaggerated with a
multiple gestation, particularly during the second half of pregnancy, with more rapid
depletion of glycogen stores and resultant metabolism of fat between meals and during an
overnight fast. A reduced glucose stream from mother to fetus results in slower fetal
growth, smaller birth size, as well as a higher risk of preterm labor and preterm birth. For
this reason, diet therapy with a diabetic regimen of 20% of calories from protein, 40% of
calories from carbohydrate, and 40% of calories from fat may be particularly useful.
Iron-deficiency anemia has also been linked to preterm delivery and other adverse preg-
nancy outcomes. Mobilization of maternal iron stores, in addition to an adequate amount
and pattern of gestational weight gain (including BMI-specific weight gain goals by 20 and
28 weeks gestation), has been associated with significantly better fetal growth and longer
gestations in twin pregnancies. Supplementation with calcium, magnesium, and zinc, as
well as multivitamins and essential fatty acids may also reduce pregnancy complications
and improve postnatal health for infants born from a multiple gestation. Diet therapy for
women pregnant with multiples is an important component of effective prenatal care.
Semin Perinatol 29:349-354 © 2005 Elsevier Inc. All rights reserved.

KEYWORDS multiple pregnancy, diabetic diets, targeted supplementation

M ultiple pregnancy represents a state of magnified nutri-

tional requirements, resulting in a greater nutrient
drain on maternal resources and an accelerated depletion of
nutritional reserves. The majority of studies to date have
evaluated the effects of nutritional factors on the course and
outcome of singleton pregnancies; the body of literature on
multiple gestations is growing, but there are still many gaps
in our knowledge of normal and abnormal physiologic
changes and effective interventions. The population of
women pregnant with multiple gestations is distinctly differ-
ent than the average pregnant woman in the United States
(Table 1). Over the past 20 years there has been a growing
trend in delaying pregnancy—this pattern is magnified
among women pregnant with multiples. Whereas the percent
of women ages 35 and older having a singleton baby has
increased threefold since 1980, the percent having twins has
increased nearly fourfold, and those having triplets or higher
order births nearly sixfold. Although older maternal age may
be associated with better financial and social resources, from
University of Miami, School of Nursing and Health Studies, Coral Gables,
FL.
Address reprint requests to Barbara Luke, ScD, MPH, RD, University of
Miami, School of Nursing and Health Studies, 5801 Red Road, Coral
Gables, FL 33143-3850. E-mail: BLuke@med.miami.edu
a physiologic perspective, the special nutritional demands of
a multiple pregnancy have important implications for the
mother’s future health. For example, when a woman has a
multiple pregnancy in her 40s or 50s, she may be within only
a few years of menopause, and the substantial calcium drain
may increase her risk for osteoporosis.1 The following chap-
ter summarizes current research on maternal pregravid
weight, gestational weight gain, carbohydrate metabolism,
iron status, and vitamin and mineral intake on fetal growth
and length of gestation in singletons, and when known, in
twin and triplet gestations.
Carbohydrate Metabolism
Pregnancy is a state of accelerated starvation, resulting in
lower fasting glucose levels and an exaggeration of the
insulin response to eating. In twin pregnancies, these
changes are magnified, particularly during the second half
of pregnancy, with significantly lower maternal serum glu-
cose and insulin concentrations, and higher plasma con-
centrations of ␤-hydroxybutyrate compared with maternal
concentrations in singleton pregnancies, indicating more
rapid depletion of glycogen stores and resultant metabo-
lism of fat between meals and during an overnight fast.2

0146-0005/05/$-see front matter © 2005 Elsevier Inc. All rights reserved. 349
doi:10.1053/j.semperi.2005.08.004
350 B. Luke

Table 1 Live Births by Maternal Age, Birth Order, and Plurality, United States, 1980, 1990, and 2002
Percent of Births
by Maternal Age
Birth Order Number of Births by Maternal Age (years) (year)
and Year All Ages <20 20-24 25-29 30-34 35-39 >40 >30 >35 >40
First births
1980 1,545,604 435,333 605,183 371,859 112,964 18,241 2,024 8.6 1.3 0.1
1990 1,689,118 401,900 515,455 465,458 230,612 66,541 9,152 18.1 4.5 0.5
2002 1,594,921 343,210 472,976 378,647 276,110 102,180 21,798 25.1 7.8 1.4
All births
1980 3,612,258 562,330 1,226,200 1,108,291 550,354 140,793 24,290 19.8 4.6 0.7
1990 4,158,212 533,483 1,093,730 1,277,108 886,063 317,583 50,245 30.2 8.8 1.2
2002 4,021,726 432,808 1,022,106 1,060,391 951,219 453,927 101,275 37.5 13.8 2.5
Plurality
and Year
Singletons
1980 3,478,715 545,958 1,184,408 1,064,764 526,049 134,294 23,242 19.7 4.5 0.7
1990 4,061,319 525,793 1,072,431 1,246,144 860,478 307,498 48,975 30.0 8.8 1.2
2002 3,889,191 425,880 998,739 1,028,038 911,431 430,447 94,656 36.9 13.5 2.4
Twins
1980 68,339 7,212 21,374 22,712 12,944 3,559 538 24.9 6.0 0.8
1990 93,865 7,605 20,945 30,020 24,466 9,587 1,242 37.6 11.5 1.3
2002 125,134 6,835 22,856 30,725 36,956 21,637 6,125 51.7 22.2 4.9
Triplets and more
1980 1,337 83 385 474 321 67 7 29.5 5.5 0.5
1990 3,028 85 354 944 1,119 498 28 54.3 17.4 0.9
2002 7,401 93 511 1,628 2,832 1,843 494 69.8 31.6 6.7
All multiples
1980 69,676 7,295 21,759 23,186 13,265 3,626 545 25.0 6.0 0.8
1990 96,893 7,690 21,299 30,964 25,585 10,085 1,270 38.1 11.7 1.3
2002 132,535 7,771 23,367 32,353 39,788 23,480 6,619 52.7 22.7 5.0

Both fasting and ketonuria have been linked to an increase
in preterm labor and preterm delivery, a phenomenon
termed the “Yom Kippur effect.”3 A reduced glucose
stream from mother to fetus results in slower fetal growth,
smaller birth size, and an increased risk of fetal growth
restriction.4 The diet therapy we have used successfully in
both twin and triplet pregnancies5,6 is based on the dia-
betic regimen of three meals and three snacks per day (see
Table 2). We have found in studies with both twins and
triplets5,6 that diet therapy with 20% of calories from pro-
tein, but a lower percentage of calories from carbohydrate
(40%) for better glycemic control, and a higher percentage
of calories from fat (40%), to provide additional calories
with less bulk, are most effective. The emphasis is also on
the use of low glycemic index carbohydrates to prevent
wide fluctuations in blood glucose concentrations.

Table 2 BMI-Specific Dietary Recommendations for Twin Gestations*

BMI Group Underweight Normal Weight Overweight Obese
BMI Range <19.8 19.8-26.0 26.1-29.0 >29.0
Calories 4,000 3,500 3,250 3,000
Protein (20% of calories) 200 g 175 g 163 g 150 g
Carbohydrate (40% of calories) 400 g 350 g 325 g 300 g
Fat (40% of calories) 178 g 156 g 144 g 133 g
Exchanges (Servings) per day
Dairy 10 8 8 8
Grains 12 10 8 8
Meat & meat equivalents 10 10 8 6
Eggs 2 2 2 2
Vegetables 5 4 4 4
Fruits 8 7 6 6
Fats & oils 7 6 5 5
*Adapted from Luke et al.5
Nutrition and multiple gestation
Iron Status
Iron-deficiency anemia is also significantly associated with
preterm delivery.7-9 Serum ferritin levels, which are lowered
with iron-deficiency and elevated in the presence of infec-
tion, have also been linked to prematurity. Extremes of ma-
ternal serum ferritin levels measured early in the second tri-
mester (15-17 weeks), as well as elevated levels at 24, 26, or
28 weeks, have been associated with preterm birth.10,11 It has
been shown that, when elevated third trimester serum ferritin
levels reflect a failure to decline from entry to care, they are
significantly associated with preterm and very preterm birth,
with iron-deficiency anemia and poor maternal nutritional
status underlying the relationship.11 Dietary sources of iron
are preferable, particularly heme-iron-rich sources such as
red meat, pork, poultry, fish, and eggs, because of better
absorption and utilization, their positive effect on nonheme
iron bioavailability, and their high quality and quantity of
protein and other nutrients. The inclusion of nonheme-iron
sources is encouraged as well, such as iron-fortified breads
and grains, vegetables, and nuts.
The few studies that have evaluated iron status in multiple
pregnancies have reported lower hemoglobin levels in the
first and second trimesters, higher rates of iron-deficiency
anemia, and even residual iron-deficiency anemia in the in-
fants, up to 6 months of age.12-14 Hediger and Luke15 evalu-
ated the hemodynamics during twin pregnancy and the as-
sociation of hemoglobin (Hgb) and hematocrit (Hct) levels
with maternal nutritional status and twin outcome. Serial
measures of iron status (Hgb, Hct) and measures of maternal
nutritional status, including weight gain, were collected for
293 twin pregnancies. As in singleton pregnancies, levels of
Hgb and Hct declined through the first trimester to a nadir at
20 to 24 weeks. Consistent with greater volume expansion in
twin pregnancies, the levels were even lower in the second
trimester than for singleton pregnancies. By the third trimes-
ter, lower levels of serum ferritin (indicating better volume
expansion) were associated with pregravid BMI (⫺0.50 ⫾
0.21 ␮g/L per kg gain, P ⫽ 0.02) and rate of weight gain to 20
weeks (⫺11.6 ⫾ 5.0 ␮g/L per kg weight gain, P ⫽ 0.02). As
shown in prior studies, both maternal pregravid BMI and rate
of weight gain before 20 weeks are consistently strong pre-
dictors of twin birth weight outcomes. Mean levels by trimes-
ter are shown in Table 3.
Iron status during pregnancy has also been linked to fetal
programming and the development of chronic disease. Low
maternal hemoglobin is strongly related to the development
of a large placenta and high placental/birth weight ratio,
which is seen as predictive of long-term programming of
hypertension and cardiovascular disease. Because the iron
Table 3 Changes in Maternal Iron Status in Twin Pregnancy
First Second Third
Trimester Trimester Trimester
Hemoglobin 12.8 g/dL 11.3 g/dL 11.0 g/dL
Hematocrit 37.3% 32.8% 32.0%
Ferritin 56.6 ␮g/L 34.3 ␮g/L 12.2 ␮g/L
351
demands of pregnancy may exceed one gram, with nearly
half this amount in the red cell mass increase in blood vol-
ume, the maternal preconceptional and early pregnancy iron
status are extremely important. Severe maternal iron-defi-
ciency anemia leads to placental adaptive hypertrophy, a fall
in the cortisol metabolizing system, and increased suscepti-
bility to hypertension in later life.
Calcium, Magnesium,
and Zinc Supplementation
Calcium, magnesium, and zinc have been identified by the
World Health Organization as having the most potential for
reducing pregnancy complications and improving out-
comes.16,17 Results of calcium supplementation trials among
high-risk women have been promising, with significant re-
ductions in preterm deliveries among teenagers and women
with low calcium diets.18,19 Other studies have shown incon-
sistent results in lowering the rates of pregnancy-induced
hypertension, and no effect on preterm delivery and small-
for-gestational age births.20,21 The ability of supplemental cal-
cium to decrease the risk of preterm delivery may be confined
to high-risk populations where there is either a severe dietary
restriction of calcium or, as in the case of adolescents and
multiple gestations, an increased physiologic demand for cal-
cium. Similar inconsistent results have also been reported in
studies of magnesium supplementation, which may have
been due to differences in study design, study populations,
and the concurrent use of other medications. Magnesium,
though, may have a neuroprotective role, particularly for the
premature infant, in addition to being an effective therapy for
preeclampsia. Although maternal zinc nutriture has been sig-
nificantly related to length of gestation, infection, and risk of
premature rupture of membranes,22,23 clinical trials of zinc
supplementation have yielded equivocal results.24 A trial that
randomly supplemented only women with plasma zinc levels
below the median reported an increase in length of gestation
of approximately 0.5 week and an increase in birth weight
(about half of which was explained by the longer duration of
gestation).25 To date, there have been no mineral supplemen-
tation trials with twin pregnancies. Scholl, Hediger, and co-
workers26 reported that a low dietary zinc intake during sin-
gleton pregnancy (ⱕ6 mg/d or ⬍40% of the RDA for
pregnancy) was associated with an increased incidence of
iron-deficiency anemia at entry to care, a lower use of prena-
tal supplements during pregnancy, and a higher incidence of
inadequate weight gain during pregnancy and an increased
risk of LBW, preterm delivery, and early preterm delivery.
The joint effect of iron-deficiency anemia at entry to care and
a low dietary zinc intake during pregnancy increased risk of
preterm delivery fivefold.
Multivitamin and
Multimineral Supplementation
Ideally, pregnant women should get the level and range of
required nutrients through a balanced diet. Recent national
352
dietary surveys indicate, though, that adult women fail to
meet the RDAs for five nutrients: calcium, magnesium, zinc,
and vitamins E and B6.27 In addition, prenatal use of vitamin-
mineral supplements among low-income women has been
shown to reduce the risks of preterm delivery and low birth
weight, particularly if initiated during the first trimester.28
Supplementation in excess of twice the recommended dietary
allowance (RDA) should be avoided, due to the potential for
birth defects. The fat-soluble vitamins, particularly vitamins
A and D, are the most potentially toxic during pregnancy.
The pediatric and obstetric literature includes case reports of
kidney malformations in children whose mothers took be-
tween 40,000 and 50,000 IU of vitamin A during pregnancy.
Even at lower doses, excessive amounts of vitamin A may
cause subtle damage to the developing nervous system, re-
sulting in serious behavioral and learning disabilities in later
life. The margin of safety for vitamin D is smaller for this
vitamin than for any other. Birth defects of the heart, partic-
ularly aortic stenosis, have been reported in both humans
and experimental animals with doses as low as 4000 IU,
which is 10 times the RDA (Recommended Dietary Allow-
ance) during pregnancy.
Essential Fatty
Acid Requirements
There is an established maternal drain of the essential fatty
acids during pregnancy, particularly during multiple gesta-
tion.29,30 Additional supplementation with omega-3 fatty ac-
ids, which are vital for neurological and retinal development,
may be particularly beneficial during pregnancy for both the
mother and her developing baby. Because many of the food
sources of omega-3 fatty acids may be contaminated with
environmental pollutants such as lead or mercury, supple-
ments may be a safer alternative. Populations with a higher
intake of omega-3 fatty acids have significantly lower rates of
preterm delivery and low birth weight.31 Infants whose
mothers had higher omega-3 fatty acid levels at birth dem-
onstrated better cognitive development.32 Many prenatal
supplements are now incorporating omega-3 fatty acids in
their formulation.
Table 4 Optimal Rates of Maternal Weight Gain and Cumulative Gain by Pregravid BMI Status*
Rates of Weight Gain (lbs/week)
0-20 20-28
Pregravid BMI weeks weeks
Underweight (BMI <19.8) 1.25-1.75 1.50-1.75
Normal Weight (BMI 19.8-26.0) 1.0-1.50 1.25-1.75
Overweight (BMI 26.1-29.0) 1.0-1.25 1.0-1.50
Obese (BMI >29.0) 0.75-1.0 0.75-1.25
*Adapted from Luke et al.43
BMI, body mass index.
Results are from models controlling for diabetes and gestational diabetes, preeclampsia, smoking during pregnancy, parity, placental
membranes, and fetal growth before 20 weeks.
B. Luke
Maternal Weight Gain
The pattern of maternal weight gain has been shown to be as
important as total weight gain in its effect on birth weight in
both singleton and twin pregnancies. Although the increase
in fetal weight is greatest during the third trimester (after 28
weeks), gains during mid-gestation (either second trimester
or 20-28 weeks) have the strongest association with birth
weight. In singletons, Abrams and Selvin33 demonstrated that
birth weight increased in each trimester by 18 g, 33 g, and
17 g, respectively, per kilogram per week of maternal weight
gain. Scholl, Hediger and coworkers34 reported that weight
gains to 20 weeks and to 28 weeks were most strongly related
to birth weight, contributing 22 to 24 g to birth weight per
kilogram per week of maternal weight gain. In addition, a low
rate of weight gain or a poor pattern of weight gain is associ-
ated with an increased risk of preterm birth. Studies in twins
by our research team have shown similar results, with low
weight gains consistently associated with reduced birth-
weights. Early- and mid-gestation weight gains seem to exert
an even greater effect on twin birthweights, with gains to 20
weeks, between 20 to 28 weeks, and from 28 weeks to birth
increasing birthweights by 65 g, 37 g, and 16 g, respectively,
per kilogram per week of maternal weight gain.35-37
BMI-specific weight gain guidelines are associated with the
best intrauterine growth and subsequent birthweights, and
longer length of gestation.38,39 Advice regarding weight gain
and target weight gain goals is important underlying factors
strongly associated with actual weight gain. But studies
among women pregnant with singletons40,41 and twins42 have
reported that more than one-fourth of women receive no
advice regarding weight gain. Among women who do receive
guidance, for more than one-third of women, the advice they
receive is inappropriate.40 In a study by our research team of
928 women who had been delivered of twins,42 those women
who received nutrition advice from a registered dietitian were
the most likely to have the highest weight gains (60% gained
ⱖ40 lbs, with an average gain of 46.3 lbs) and the lowest
proportion of very low birth weight infants (2% versus 12%
for women not receiving any advice). We have developed
BMI-specific guidelines for twins based on optimal rates of
fetal growth birthweights between the singleton 50th percen-
tile and twin 90th percentile at 36 to 38 weeks (2700-2800
g)43 (Table 4).
Cumulative Weight Gain (lbs)
28 weeks- to to to
delivery 20 weeks 28 weeks 36-38 weeks
1.25 25-35 37-49 50-62
1.0 20-30 30-44 40-54
1.0 20-25 28-37 38-47
0.75 15-20 21-30 29-38
Nutrition and multiple gestation
Weight Gain
in Triplet Pregnancies
In their analysis of 1138 triplet pregnancies, Elster and co-
workers44 reported several factors to be predictive of higher
average fetal weight for a given gestational age, including
male gender, older maternal age, maternal height, pregravid
weight and weight gain, and parity. These investigators also
reported that length of gestation correlated with maternal
age, parity, and weight gain. Maternal weight gain was even
more strongly associated with outcomes in triplets than in
twins, and gains in different periods of gestation affected
birth weight, birth weight-for-gestation (birth weight z
score), and length of gestation was demonstrated in a study of
144 triplets by Luke and coworkers.6 Regression analyses
indicated that the most significant periods of maternal weight
gain for average triplet birth weight were from conception to
20 weeks and between 20 to 28 weeks (158 g/lb/wk, P ⫽
0.001, and 111 g/lb/wk, P ⫽ 0.001, respectively); for average
triplet birth weight z score were between 20 to 28 weeks
(0.53 SD units/lb/wk, P ⬍ 0.0001); and for length of gesta-
tion from 28 weeks to delivery (4.6 days/lb/wk, P ⬍ 0.0001).
The effect of higher weight gain before 20 or 24 weeks on
twin and triplet birth weight is most pronounced among
infants of underweight gravidas.35,45 This early weight gain
may reflect the acquisition of maternal nutrient stores, par-
ticularly the deposition of body fat.46 In addition, levels of
fat-mobilizing hormones, such as follicle-stimulating hor-
mone (FSH) and human placental lactogen (hPL), may be
higher in normal weight and overweight women, as well as in
women with dizygotic twin pregnancies.47 Therefore, under-
weight women with low early weight gain may be lacking
appropriate nutrient reserves (including maternal stored fat)
as well as adequate levels of hormones to mobilize those
nutrient stores which are available, resulting in a high inci-
dence of birthweights ⱕ10th percentile in their infants.
Higher early gains may be particularly important in multiple
pregnancies for two distinct reasons. First, pregnancy is usu-
ally much shorter for multiple gestations, by as much as 4 to
12 weeks, thereby shortening the period for intrauterine
growth. As shown by Williams and coworkers,48 the peak
rate of growth in weight for multiples occurs at about 31
weeks compared with 33 weeks for singletons. Second,
higher gains during early gestation may influence the struc-
tural and functional development of the placenta.49 In mul-
tiple pregnancies, the placenta ages more quickly, shortening
the gestational period during which it can most effectively
transfer nutrients to the developing fetuses. Higher gains
during early gestation may therefore initially benefit placental
structure and function, and subsequently augment fetal
growth through more effective placental function as well as
the transfer of a higher level of nutrients.
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