Multiple Births Follow-up

  • Author: Garth E Fletcher, MD; Chief Editor: Ted Rosenkrantz, MD   more...
 
Updated: Jul 8, 2009
 

Complications

Specific complications of multiple fetal pregnancies parallel increased risk of prematurity, low birth weight, and intrauterine growth retardation (IUGR).

  • Neonatal issues inherent to multifetal pregnancies: Neonates born to multiple fetal pregnancies may present unique personnel requirements at delivery and during hospitalization. Delivery room management requires adequate personnel skilled in neonatal resuscitation. Multifetal pregnancies have a significantly higher rate of cesarean delivery.
  • Cesarian delivery
    • Cesarean delivery is the usual method of delivery for twins in the following situations:
      • Breech/vertex presentation with the possibility of interlocking twins
      • Monoamniotic twins
      • Conjoined twins
      • Congenital anomalies that threaten increased neonatal morbidity in a twin
    • The usual method of delivery for higher-order multiple births (eg, triplets, quadruplets) is cesarean delivery.
  • Twin-to-twin transfusion syndrome (TTTS) syndrome: This syndrome occurs in monochorionic/monoamniotic or monochorionic/diamniotic twins. Vascular anastomoses in the monochorionic placenta may result in net transfusion of blood from one twin (ie, the donor) to the other twin (ie, the recipient). Polyhydramnios develops in the sac of the recipient twin because of the volume overload and increased fetal urine output. Oligohydramnios develops in the sac of the donor twin because of the hypovolemia and decreased urine output. Severe oligohydramnios can result in the stuck twin phenomena, in which the twin appears in a fixed position against the uterine wall.
  • Congenital anomalies, including acardia and twin-reversed arterial perfusion (TRAP) sequence: Congenital anomalies are more common in twins than a single fetus. CNS, cardiovascular, and GI defects occur with increased frequency. Monozygotic twins have increased prevalence of deformation secondary to intrauterine space constraints. Common deformation in twins include limb defects, plagiocephaly, facial asymmetry, and torticollis. Acardia is a rare anomaly unique to multifetal pregnancy. In this condition, one twin has an absent or rudimentary heart. TRAP sequence occurs when an acardiac twin receives all of the blood supply from the normal “pump” twin. This only occurs in monochorionic twins. Blood enters the acardiac twin in a reversed perfusion manner. Blood enters the fetus via an umbilical artery and exits via the umbilical vein. The excessive demands on the normal “pump” twin can cause cardiac failure in that twin.
  • Conjoined twins
    • Incomplete late division of monozygotic twins produces conjoined twins.
    • Conjoined twins are connected at identical points and are classified according to site of union; as follows:
    • Thoracopagus – Joined at chest (40%)
    • Xiphopagus/omphalopagus – Joined at abdomen (34%)
    • Pygopagus – Joined at buttocks (18%)
    • Ischiopagus – Joined at ischium (6%)
    • Craniopagus – Joined at head (2%)
  • Vanishing twin syndrome: Early ultrasonography diagnosis has revealed that as many as one half of all twin pregnancies result in the delivery of only a single fetus; the second twin vanishes. Intrauterine demise of one twin can result in neurologic sequelae in the surviving twin. Acute exsanguination of the surviving twin into the relaxed circulation of the deceased twin can result in intrauterine CNS ischemia.
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Prognosis

  • Improving the outcome of multifetal pregnancies involves decreasing the rate of preterm births, providing an optimal intrauterine environment for fetal growth, optimizing neonatal care in the delivery room, and neonatal ICU (NICU) if required.[8]
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Patient Education

  • When multifetal pregnancy is diagnosed, parental education on specific issues of a multifetal pregnancy should take place.
  • Most outcomes from multifetal pregnancies require only routine pediatric care; however, some patients may require specialized follow-up coordinated through a neonatal ICU (NICU) follow-up clinic.
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Contributor Information and Disclosures
Author

Garth E Fletcher, MD  Assistant Professor of Pediatrics and Staff Neonatologist, Joint Division of Newborn Medicine, University of Nebraska Medical Center and Creighton University

Garth E Fletcher, MD is a member of the following medical societies: American Academy of Pediatrics and National Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Terence Zach, MD  Department Vice-Chair, Professor, Department of Pediatrics, Section of Newborn Medicine, Creighton University

Terence Zach, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, and Nebraska Medical Association

Disclosure: Nothing to disclose.

Arun K Pramanik, MD, MBBS  Professor of Pediatrics, Director of Neonatal Fellowship, Louisiana State University Health Sciences Center

Arun K Pramanik, MD, MBBS is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, National Perinatal Association, and Southern Society for Pediatric Research

Disclosure: Nothing to disclose.

Susannah P Ford, MD  Fellow, Department of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

David N Sheftel  MD, Assistant Professor of Pediatrics, Chicago Medical School at Rosalind Franklin University of Medicine and Science

David N Sheftel is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine and American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

David A Clark, MD  Chairman, Professor, Department of Pediatrics, Albany Medical College

David A Clark, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Pediatric Society, Christian Medical & Dental Society, Medical Society of the State of New York, New York Academy of Sciences, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Carol L Wagner, MD  Professor of Pediatrics, Medical University of South Carolina

Carol L Wagner, MD is a member of the following medical societies: American Academy of Pediatrics, American Chemical Society, American Medical Women's Association, American Public Health Association, American Society for Bone and Mineral Research, American Society for Clinical Nutrition, Massachusetts Medical Society, National Perinatal Association, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Chief Editor

Ted Rosenkrantz, MD  Professor, Departments of Pediatrics and Obstetrics/Gynecology, Division of Neonatal-Perinatal Medicine, University of Connecticut School of Medicine

Ted Rosenkrantz, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Pediatric Society, Connecticut State Medical Society, Eastern Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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Diamniotic/dichorionic placentation.
Diamniotic/monochorionic placentation.
Monoamniotic/monoamniotic placentation.
 
 
 
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