Multi Pregnant

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Multiple pregnancies carry their own particular problems, mainly as a result of chorionicity and the presence of other risk factors, such as the chance of chromosome anomaly and potential interventions, such as selective reduction.
For reasons of risk stratification in multiple pregnancies, one of the most important goals of early ultrasound in this population is the determination of chorionicity and amnionicity.35–37 Early in gestation (6–9 weeks), the presence of two separate gestational sacs indicates dichorionicity. From 10–14 weeks onwards, a thick septum and a triangular tissue projection at the placental base of the separating membrane (lambda sign) predict dichorionicity27 (see Fig. 13.1; Fig. 13.2). This is due to four layers of the intertwin membrane: amniotic and chorionic layers of fetus 1 and chorionic and amniotic layers of fetus 2. Monochorionic twins show a very thin intertwin membrane (only two amniotic layers) and no lambda sign, since there are no chorionic layers between the two amniotic layers of the membrane (see Fig. 13.2). Misdiagnosis of monoamniotic twins due to visualization of a single gestational sac may occur, if identification of the thin separating membrane is difficult. Later during pregnancy, identification of fetal gender may also be helpful in the assessment of chorionicity, although overall two-thirds of twins are of the same sex: one-third consists of all monochorionic twins and the other one of 50% of all dichorionic twins. Discordant sex indicates dichorionicity.
Regarding amnionicity, the lack of an intertwin membrane, despite careful scanning of the whole amniotic cavity, leads to the diagnosis of monoamniotic twinning.25 The presence of a unique yolk sac also indicates monoamnionicity.7
URL: https://www.sciencedirect.com/science/article/pii/B9780444518293000131
Sieglinde M. Müllers, ... Fergal D. Malone, in Fetal Medicine (Third Edition), 2020
The incidence of multifetal gestations has risen dramatically over the past number of decades. Assisted reproductive techniques (ARTs) and the rising trend in advanced maternal age at first birth are the principal factors involved.1,2 Despite restrictions in numbers of embryo transfers, the twin birth rate began to rise again from 33.7 to 33.9 per 1000 between the years 2013 and 2014.3 The incidence of higher order multifetal gestations has decreased steadily since the peak of 193.4 per 100,000 in 1998 to 113 per 100,000 in 2014.4
These trends implicate an increasing need for specialised tertiary referral fetal medicine units to address the increasing workload generated with twins and multifetal pregnancies. This includes the accurate assignment of chorionicity, prenatal screening and optimal antenatal surveillance aimed at reducing the associated perinatal disease burden, which extends to include the availability of experts in fetal intervention techniques.
The risks for stillbirth and perinatal mortality in twins and perinatal death in triplets are approximately five, seven and nine times those of singleton pregnancies, respectively.5,6 This is largely attributable to the increased rate of spontaneous and iatrogenic preterm delivery, in which multifetal gestations are 13 times more likely to deliver less than 32 weeks’ gestation compared with singleton pregnancies.4 The increased rate of preterm delivery confers a risk for developing cerebral palsy to be four times that of singletons.5,6 Withstanding the short and long-term complications of prematurity, multiple pregnancy is associated with increased risk for congenital anomalies, disorders of fetal growth and twin–twin transfusion syndrome (TTTS), in addition to the increased maternal complications of preeclampsia, gestational diabetes, antepartum haemorrhage and the requirement for caesarean delivery.7
By applying a strategy of close antenatal surveillance and delivery at 36 to 37 weeks’ gestation for uncomplicated monochorionic (MC) twins, extending this to 38 weeks’ gestation for dichorionic (DC) twins, it has been suggested that perinatal morbidity can be minimised significantly, albeit with a residual risk for 1.5% of late IUFD in MC twins.8 The goal of antenatal surveillance and optimum timing of delivery in multiple pregnancies is thus aimed at reducing the risk for in utero demise, balanced against minimising perinatal morbidity from prematurity.
Given that outcome in twins in largely driven by chorionicity, early determination of chorionicity, with emphasis on identifying the less common MC pairs, is critically important in minimising the perinatal disease burden. Assignment of chorionicity in the first trimester and before 14 weeks’ gestation approaches a sensitivity and specificity of 100% and 99%, respectively.9 A DC twin pregnancy is determined by the presence of two placental masses and the characteristic ‘lambda’ sign, in which the two thick chorionic plates join. An MC twin pregnancy is determined by the presence of a single placental mass and a thin wispy membrane, with the ‘T’ sign, which is created by a lack of intervening chorion.
After the second trimester, the lambda sign can disappear in up to 7% of DC pregnancies because of regression of the chorion frondosum10; hence, determination of chorionicity is more challenging with advancing gestation. Discordant fetal gender or a thick intertwin membrane may assist in the late identification of DC pregnancies. In cases of concordant fetal gender and delayed assignment of chorionicity, pregnancies should be described as ‘undetermined chorionicity’, and monochorionicity should be assumed unless proven otherwise.11 Ultimately, definitive examination of the placenta after delivery should be undertaken.
URL: https://www.sciencedirect.com/science/article/pii/B9780702069567000440
Multiple pregnancy leads to a strong increase in obstetric complications, perinatal morbidity, maternal and child mortality rate, congenital malformations, pre-term birth, and long-term social, psychological and financial difficulties. The occurrence of this side effect of ART is a test case for the moral quality of the field. The most recent report of pregnancy rates in Europe after medically assisted reproduction indicates that there are still huge differences: in 2011, twin pregnancies after IVF or ICSI occurred in 4.9% of cases in Sweden, 22.1% of cases in Spain, and 41.5% of cases in Greece (Kupka et al., 2016). Whereas CBRC is often cited as leading to more multiple pregnancies, one might also argue that patients from countries with a high multiple pregnancy rate should, for their own and their child’s safety, seek treatment in countries with a low multiple pregnancy rate. The conclusion is that whether or not CBRC jeopardizes patients’ health depends on the starting conditions at home and on the general conditions in the destination country.
It seems that generally speaking most clinics in member states of the European Union follow good practice guidelines, partially imposed by the European Tissues and Cells Directive, and that risks for the patients are not significantly higher when they seek treatment elsewhere. For countries outside the European Union, things are less clear but still there are no studies showing that there are major reasons for concern as far as safety is concerned.
URL: https://www.sciencedirect.com/science/article/pii/B9780128012383649085
Multiple pregnancies have a recognised baseline increase in adverse perinatal outcomes compared with singletons. The presence of a twin gestation adds another layer of complexity to AF volume assessment in terms of techniques of assessment, cause of AF variance and management. The dividing membrane in diamniotic multiple pregnancies complicates the conduct and reproducibility of ultrasound-based AF assessments. A recent systematic review on the assessment of AF volume in twin pregnancies demonstrated that AFI and/or MVP was typically used for ultrasound volume studies.22 The AFI and MVP performed equivalently when compared with dye-dilution techniques, but concerns have been raised about the reliability of AFI in twin pregnancies.23 It has been reported that there is no significant relationship between gestation and MVP in diamniotic twins,24 although a recent study of uncomplicated monochorionic diamniotic twins has demonstrated this does not hold true in this subset.25 This may well be secondary to the predominance of dichorionic pregnancies in the initial paper24 and the focus solely on monochorionic pregnancies in the second.25 Most centres have moved to using MVP for multiple pregnancies because of its ease of use, reliability and more robust performance characteristics for oligohydramnios24 (Fig. 43.4). In general, an MVP less than 2 cm is used to define oligohydramnios, and an MVP greater than 8 cm to define polyhydramnios.24 For monochorionic twins, an MVP greater than 10 cm is used to define polyhydramnios after 20 weeks’ gestation.25
URL: https://www.sciencedirect.com/science/article/pii/B9780702069567000439
Zeynep Alpay Savasan, ... Stewart F. Graham, in Advances in Clinical Chemistry, 2021
Multiple pregnancy is another risk factor for CP, presenting a fourfold increased risk compared to a singleton pregnancy [67]. This is mostly due to the increased risk of preterm birth and lower birthweight. Monochorionic placentation is also a risk factor for CP, which results from the complications associated with the monochorionic placenta, such as twin to twin transfusion, unequal placental sharing, congenital birth defects, and prematurity [67]. Many other factors, such as perinatal stroke [68], tight nuchal cord at delivery [57], and male gender [69] are also linked to increased risk of CP.
URL: https://www.sciencedirect.com/science/article/pii/S006524232030041X
Randall S. Hines MD, Bryan D. Cowan MD, in Clinical Gynecology, 2006
Multiple pregnancies are also associated with infant and childhood morbidity such as cerebral palsy and mental retardation.41 Two recent studies of the incidence of cerebral palsy reported dramatically increased risks in multiple births: twins had risks approximately 5 times higher and triplets 17 times higher than singletons, and the risk of producing at least one child with cerebral palsy was estimated to 1% to 5% for twin, 8% for triplet, and almost 50% for quadruplet pregnancies.42,43
Most studies of child development after IVF carried out to date include relatively small numbers of children and have a limited period of follow-up, and consequently the risks for long-term handicap are not well established.
Which methods are available today to reduce the number of multiple births after ART? An overall change in transfer policy to transfer only one embryo at a time would certainly result in mainly singletons.44,45 This might be unacceptable to both patients and practitioners, who aim at the best possible rates of success. An alternative to an overall one-embryo transfer would be an individualized embryo transfer policy. It seems possible to identify a subgroup of patients having an increased risk of multiple birth and offer them one-embryo transfers. In a recent publication, elective one-embryo transfer showed a satisfactory pregnancy rate (29.7% per transfer) in a selected group of patients, the pregnancy rate being similar to that of the routine two-embryo transfer program.
Embryo/fetal reduction, as a third strategy to reduce the number of multiple births, has been used worldwide.46 Despite the fact that collaborative data have reported satisfactory outcome for the children and limited risks for the mother, this kind of intervention raises serious ethical and psychological problems. It may be indicated in cases of particularly high-order multiple pregnancies but can never be justified for reduction of twins.
URL: https://www.sciencedirect.com/science/article/pii/B9780443066917500583
Jennifer M.H. Amorosa, ... Mary E. D'Alton, in Fetal and Neonatal Physiology (Fifth Edition), 2017
Multiple pregnancy has a physiologic impact on both the mother and the fetus. The mother is at increased risk for adverse outcomes such as iron deficiency anemia, gestational diabetes, gestational hypertension, placental abnormalities, preterm delivery, cesarean delivery, and postpartum hemorrhage. The fetus is at increased risk for anatomic and genetic anomalies, growth abnormalities, prematurity, and several problems related to monochoronicity.
Fetal outcomes are dependent on gestational age at delivery and on chorionicity. Adverse outcomes are more commonly associated with monochorionicity. Ultrasound imaging is the cornerstone of management in these patients. It is critical for diagnosis of chorionicity and structural abnormalities, as well as for surveillance of fetal growth and well-being. To date, no strategies have proved useful to prevent adverse outcomes in these pregnancies. However, antenatal corticosteroids should be administered if preterm delivery is anticipated. Furthermore, patients with complex issues unique to multiple gestations should be referred to a tertiary care center with maternal fetal medicine, neonatology, and pediatric specialists proficient at caring for such patients.
URL: https://www.sciencedirect.com/science/article/pii/B9780323352147000160
Multiple pregnancy and miscarriage rates following endometrial scratching are very poorly documented and no conclusion can therefore be drawn from current literature.
Pain and bleeding are underreported and have only been assessed systematically in one study (Nastri et al., 2013), whereas elsewhere, only spontaneous pain complaint was reported. It is presumed that endometrial scratching is associated with a subjective increase in pain and a risk of bleeding. Theoretically, endometrial scratching in the luteal phase could be harmful to a spontaneous pregnancy, ocurring at that moment. Therefore, couples are asked to refrain from intercourse in the cycle where scratching is performed. There is no documentation on the potential risk of Asherman syndrome. More systematic studies are warranted from a standardized ‘scratching’ procedure to address these adverse events.
Post-injury infection has not been reported. There is insufficient evidence to recommend the use of prophylactic antibiotics.
Overall, the procedure seems to be quite easy to perform in an out patient setting, to carry little risk and to be fairly well tolerated. Nevertheless it must be kept in mind not to propose a painful intervention at a supplementary cost to women without established added benefit.
URL: https://www.sciencedirect.com/science/article/pii/B9780128012383648778
Darcy E. Broughton, Emily S. Jungheim, in Avery's Diseases of the Newborn (Tenth Edition), 2018
Multiple pregnancies account for a small percentage of overall live births but are responsible for a disproportionate amount of morbidity and mortality. This is largely attributable to complications of prematurity, as women with multiple pregnancies are six times more likely to deliver preterm and 13 times more likely to deliver before 32 weeks than those with a singleton. Of multiple pregnancies, 11% are delivered before 32 weeks and 59% before 37 weeks, compared with 9.6% of singletons delivered preterm (Hamilton et al., 2015). As a consequence, multiples have a fivefold increased risk of stillbirth and a sevenfold increased risk of neonatal death (Scher et al., 2002). The risk of prematurity increases with fetal number, with 9 out of every 10 triplets being born preterm or low birthweight (Hamilton et al., 2015). The average gestational ages at delivery for twins, triplets, and quadruplets are 35.3, 31.9, and 29.5 weeks, respectively (American College of Obstetricians and Gynecologists; Society for Maternal-Fetal Medicine, 2014), corresponding to neonatal intensive care unit (NICU) admission rates fivefold higher in twins and 17-fold higher in triplets and HOMs (Ross et al., 1999).
Fetal and maternal complications are more common in twin pregnancies, and this risk increases with triplets and HOMs (Table 7.2). Multiples have increased risks of intraventricular hemorrhage, periventricular leukomalacia, cerebral palsy, sepsis, necrotizing enterocolitis, and respiratory distress syndrome (Blondel and Kaminski, 2002; Rettwitz-Volk et al., 2003; Salihu et al., 2003; Luke and Brown, 2008). Surviving infants of preterm multifetal pregnancies have higher rates of developmental handicap (Yokoyama, et al., 1995; Rettwitz-Volk et al., 2003; Luke et al., 2006). Higher fetal number correlates with increased risk of growth restriction, earlier delivery, low birth weight (LBW), NICU admission, length of stay, risk of major handicap and cerebral palsy, and death in first year of life (Garite et al., 2004; Luke and Brown, 2008). A review of 100 triplet gestations (88 with assisted conception) revealed that 78% experienced preterm labor (PTL), 14% delivered before 28 weeks, 5% had congenital anomalies, and 9.7% died in the perinatal period (Devine et al., 2001).
It is important to note that singleton pregnancies after assisted conception have increased complications, including preterm delivery, LBW, prolonged hospital stay, cesarean deliveries, blood transfusion, NICU admission, and mortality compared with spontaneous singletons (Helmerhorst et al., 2004; Jackson et al., 2004; Van Voorhis, 2006; Schieve et al., 2007; Martin et al., 2016). A common phenomenon in ART is the “vanishing twin,” an arrest of development and subsequent absorption of one or more fetuses of a multiple gestation in the first trimester (Practice Committee of the American Society for Reproductive Medicine, 2012). Estimates of the incidence of a vanishing twin after ART range from 10%–30% and are increased in HOMs (Landy and Keith 1998; Tummers et al., 2003; McNamara et al., 2016). Recent evidence suggests that the surviving twin(s) is at increased risk for LBW, preterm birth, and possibly cerebral impairment (Pinborg et al., 2005, 2007; Anand et al., 2007a, 2007b; Luke et al., 2009). The risk of LBW is related to the gestational age at the time of a twin demise, with later gestations conferring more risk (Pinborg et al., 2007). The majority of vanishing twins (80%) occur prior to 9 weeks (McNamara et al., 2016). Demise of a twin after the first trimester is more common in monozygotic gestations (Burke, 1990).
Similar to ART singleton versus spontaneous singleton outcomes, ART multiples may have higher morbidity compared with spontaneous multiples. Assisted-conception twins are at increased risk for LBW, preterm delivery, ces
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