Multiple Gestation: Clinical Characteristics and Management

Multiple gestations should be considered high-risk pregnancies because of the significant increase in perinatal morbidity and mortality, as well as significant potential for adverse maternal outcome. Such pregnancies should be managed under the supervision of obstetricians with experience in multiple gestations such as maternal-fetal medicine specialists and with immediate availability of advanced obstetric ultrasonography. Prenatal diagnosis of genetic conditions, together with ultrasound assessment of fetal anatomy, should be available for all patients with multiple gestations. Unique complications of monochorionic twin gestations, such as twin-to-twin transfusion syndrome, selective fetal growth restriction, discordant anomalies, and monoamniotic twins, require referral to a tertiary center with the availability of advanced neonatal facilities and with the potential to perform fetoscopic laser ablation of the placenta in select cases. Multifetal pregnancy reduction is important to consider in early pregnancy counseling to minimize the risks associated with higher order multiple gestations. Selective termination also plays a role in complicated monochorionic gestations, such that counseling and management in specialist fetal therapy centers should be considered for such pregnancies.