4. Conclusions

Multiple Pregnancy - New Challenges was observed that the presence of medical risk may impair the process of the building of representation of the child-to-be as well as the of themselves as mothers [79]. In twin pregnancies, antenatal care involves more intensive monitoring and protocols that are usually different to those for a singleton pregnancy. Ultrasound assessment of fetal biometry, anatomy and Doppler velocimetry is used to monthly monitor dichorionic twin pregnancies [7], while, since risks are significantly higher in monochorionic compared with dichorionic pregnancy [8], antenatal assessment should be scheduled more often in order to prevent adverse perinatal outcomes associated to this type of twin pregnancy. This frequent and intensive monitoring constantly remind to the mother that twin pregnancies could be associated with serious risks for the babies and the mothers [4], such as preterm delivery, low birth weight, IUGR, presence of discordant anomalies, increased risk of mortality and morbidity, preeclampsia, gestational diabetes and placental abruption [80]. When pregnancy is diagnosed as MC twin pregnancy, these could be even amplified for parents. The announcement of monochorionicity and its specific risks influences how parents deal with pregnancy [13]. Morbidity and mortality rates are higher than in DC pregnancies, and parents have to face concepts related to different complications associated with this kind of pregnancies as twin-to-twin

As the presence of medical complication during pregnancy, also the loss of a baby in a previous pregnancy may have an impact on maternal well-being as well as on prenatal attachment in the subsequent pregnancy. Fetal loss may represent the breaking of a preexisting attachment bond [61] to someone who would eventually have contributed to the bereaved individual's life [70]. For mothers who experience fetal loss, the sufferance could be linked to their experience of being pregnant and this may worry them in a subsequent pregnancy [81]. As seen before, a concerning factor for fetal risk in twin pregnancy is the phenomenon of the "vanishing twin." This event is not only a potential risk factor for the development of complications in the surviving fetus [31]. In fact, the possible loss of a fetus during pregnancy usually triggers considerable negative feelings and thoughts in mothers, and this may be an obstacle

Moreover, it was also observed that higher level of negative mood states during pregnancy may be an obstacle for prenatal attachment. The risks usually associated to twin pregnancy could lead to higher level of negative mood states in mothers of twins [9–11, 16, 18]. The risks usually associated to twin pregnancy lead to higher level of stress [17] and increased the incidence of depression and anxiety in mothers of twins during pregnancy [6, 9–11, 16, 18]. It was observed that during twin pregnancy 33.3% of mothers-to-be suffer from major depression and experience higher level of stress and greater emotional and social fragilities. Moreover, the presence of medical risk as well as psychological suffering in mothers during twin pregnancy is generally associated to higher level of fatigue, loss of energy and feelings of worthlessness and guilt [14]. Worried, depressed and stressed mothers may not be able to start to create a mental space for the representation of the child-to-be, and this could be a disadvan-

Despite most of the studies focused on risks factors for prenatal attachment, previous works observed that higher level of perceived social support as well as a positive relationship with

transfusion syndrome (TTTS) or severe sIUGR.

90 Multiple Pregnancy - New Challenges

for the building process of the babies' representations.

tage for the construction of mother-fetus relationship.

Given the current "epidemic of multiple pregnancies" in much of the Western countries, it is surprising that still few studies examined the psychological impact of twin pregnancy and twin birth on parents' experience.

This chapter underlined that twin babies are generally more fragile and more at risks of born preterm and with lower birth than singleton babies. The medical risks associated to twin pregnancies may influence both twins' developmental outcomes [84] and the building of a close and positive mother-child relationship [85]. It was also pointed out that medical risks, usually associated to twin pregnancy, may be linked to negative effects on parents' and especially mothers' experiences.

In particular, it was observed that despite it is possible to identify some similarities to singleton pregnancy, the experience of expecting twins may be very different. Parents and in particular mothers of twins have unique needs and have to face unique challenges. Risks usually associated to twin pregnancy may lead to higher level of stress and negative mood states in parents. In fact, mothers of twins seem to be less psychological adjusted to their pregnancy in terms of lower level of prenatal attachment.

In reviewing the research that investigated prenatal attachment, it was observed that the quality of the relationship established by the mother-to-be with their fetus could be an important diagnostic information to identify as soon as possible women who may have difficulties during the interaction with their babies mostly because prenatal attachment is usually associated to the quality of mother-infant interaction in the postpartum period [68, 76].

Healthcare practitioners should be aware of the unique experience and challenges associated to expecting and parenting twins, which are often underestimated by society and even by other new mothers. In addition, it is known that perinatal period until the first 3 months postpartum has been demonstrated to be the most vulnerable period for mothers of twin [86]. Paying attention to the issues involved in expecting and parenting twins, starting from pregnancy, may support mothers in their transition to motherhood. This may be accomplished by the implementation of target peer support group prenatally and/or postnatally (both during hospitalization and then after discharge at home), so that women can gain from the experience of others with a similar life event.

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