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Received: 26 February 2020    Accepted: 9 April 2020

DOI: 10.1002/ijgo.13168

REVIEW ARTICLE
Obstetrics

Management of multiple gestations

Mary E. D'Alton | Noelle Breslin*

Department of Maternal and Fetal

Medicine, Columbia University Irving
Medical Center, NY, USA
*Correspondence
Noelle Breslin, Columbia University Irving
Medical Center, New York, NY, USA.
Email: Nb2565@cumc.columbia.edu
Abstract
Multiple gestations are commonly encountered in both high-­risk and low-­risk obstet-
ric practices and, since the advent of assisted reproductive technologies in the 1980s,
the numbers of multiple gestations have grown rapidly. Thus, an understanding of
both the maternal and fetal risks associated with multiple gestations should be central
to all obstetric care. The ability to foresee issues and the know how to respond to
the complications that develop are central to the correct management of these preg-
nant women. For some, appropriate management may include referral to a specialist
maternal and fetal medicine physician or, in some cases, to a specialist fetal center.
The present review provides a comprehensive and simplified overview of multiple
gestations, including incidence, diagnosis, genetic considerations, complications (both
general and specific to multiple gestation subtypes), and delivery management. It is
essential that providers recognize the high-­risk and specific complications that may
affect a multiple gestation in order to provide the highest possible level of care for
these pregnant women.

KEYWORDS
Chorionicity; Multiple gestation; Preterm delivery; Twins

1 |  INTRODUCTION
The incidence of multiple gestations has risen rapidly over the past
several decades due to the widespread use of assisted reproductive
technologies (ART), as well as increasing maternal age. In 2016, the
twin birth rate in the United States was 33.4 per 1000 births, a slight
decrease from the highest-­ever reported rate of 33.9 twins per 1000
births in 2014.1
Twins gestations can differ in zygosity and chorionicity. Zygosity
reflects the genetic makeup of the pregnancy and, as such, determines
whether the fetuses share the same risk for genetic abnormalities.
Monozygotic twins occur in 4 of every 1000 deliveries and are the
result of one ovum and one sperm creating one zygote, which then
splits into two genetically identical twins. The stage of development
at which splitting occurs determines the chorionicity (Table  1), and
indeed the complexity of the pregnancy.
Dizygotic twins result from the fertilization of two separate ova by
sperm, creating two zygotes. They are also known as fraternal twins
and may be of the same or different sex. The incidence of dizygotic
twins is influenced by many factors including maternal age, the use of
fertility drugs, and family history. Each fetus has an independent risk
of aneuploidy.
Chorionicity refers to the placentation of the pregnancy; in other
words, do the twins share a placenta? Dizygotic twins will develop as
dichorionic–diamniotic (DCDA) pregnancies as a result of the fertiliza-
tion of two ova, which creates two separate placentas. Monozygotic
twins may be monochorionic (MC) or dichorionic (DC), depending on
the stage at which the single zygote splits. Overall, 80% of monozy-
gotic twins are DC and 20% are MC (Table 1).
It is essential to diagnose chorionicity because MC twins may
develop unique and potentially fatal complications because of the
shared placenta; in other words, what happens to one fetus, directly
affects the other (see the section on “Monochorionic pregnancies”).
Multiple gestations are associated with an increased risk of both
fetal and maternal complications. The risk of prematurity, both sponta-
neous and iatrogenic, as well as congenital anomalies, monochorionicity,
and growth restriction all contribute to the increased incidence of peri-
natal morbidity and mortality. Rates of maternal complications such as
hyperemesis gravidarum, hypertensive disorders of pregnancy, anemia,
and gestational diabetes are also increased. As such, twin pregnancies

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4       D'Alton and Breslin
require diligent surveillance throughout the antepartum period to diag-
nose and manage both the increased risk of common obstetrics compli-
cations and those rare or unique complications of twins. The aim of the
present review is to provide a simplified overview of the management
of multiple gestations from early gestation to delivery.
2 |  DIAGNOSING MULTIPLE
GESTATIONS AND CHORIONICITY
Early diagnosis of multiple gestations is essential in optimizing prena-
tal care and perinatal outcomes. Ultrasound is the definitive diagnostic
tool to confirm the presence of multiple gestations. A twin pregnancy
may be diagnosed as early as five gestational weeks through the obser-
vation of one gestational sac containing multiple yolk sacs or two ges-
tational sacs each containing a yolk sac. At six gestational weeks, a twin
pregnancy may be diagnosed due to the finding of one gestational sac
containing multiple fetal poles with cardiac activity, or multiple gesta-
tional sacs each containing a fetal pole with cardiac activity.2
Ultrasound performed in the first trimester can determine chorio-
nicity. Two separate gestational sacs containing one yolk sac and fetal
pole within each sac indicates a DCDA pregnancy. The presence of
one gestational sac containing two yolk sacs and two fetal poles indi-
cates a MCDA pregnancy, whereas the presence of one yolk sac and
two fetal poles indicate an MCMA pregnancy (Table 2).
The following ultrasound observations can also be used to
determine chorionicity.
• Fetal sex—if the twins are of opposite sex, the pregnancy is DC
because MC twins have the same sex.
• Placental mass—the presence of two placental masses indicates a
DCDA pregnancy. Occasionally, DCDA twins can be difficult to ascer-
tain based on placental number due to fusion of the placental masses.
• Dividing membrane—if the dividing membrane is more than 2 mm
or composed of 3–4 layers, this suggests a DCDA pregnancy.
Furthermore, visualization of a triangular projection known as the
“twin peak” or “lambda sign” seen between the layers of the mem-
brane also indicates a DCDA pregnancy. Overall, if a thin membrane
is seen, an MCDA pregnancy should be considered; if no membrane
is seen, an MCMA pregnancy is likely.
T A B L E   1   Effect of day of zygote cleavage on chorionicity.
Percentage of
Day of cleavage Chorionicity–amnionicity monozygotic twins
1–3 DCDA 25–30
4–8 MCDA 75
8–13 MCMA 2
13–15 Conjoined twinsa
Abbreviations: DCDA, dichorionic–diamnionitic (two placentas, two amni-
otic sacs); MCDA, monochorionic–diamniotic (one placenta, two amniotic
sacs); MCMA, monochorionic–monoamniotic (one placenta, one sac).
a
One placenta, one sac, twins joined.
T A B L E   2   Determining chorionicity in the first trimester.
Fetal pole
Gestational Yolk sac per per gesta-
Chorionicity sacs gestational sac tional sac
Dichorionic– 2 1 1
diamniotic
Monochorionic– 1 2 2
diamniotic
Monochorionic– 1 1 2
monoamniotic
Using all of the above factors together rather than independently
greatly increases the positive predictive value of diagnosing monocho-
rionicity to 92%.3
3 | PRENATAL
SCREENING AND DIAGNOSES
The risk of aneuploidy is increased in multiple pregnancies due to
the presence of more than one fetus and the positive association
between maternal age and twin gestation. The American College of
Obstetricians and Gynecologists (ACOG) has stated that “all women
with multifetal gestations, regardless of age, are candidates for rou-
tine aneuploidy screening”.4
Because monozygotic twins share the same genetic information,
their risk of chromosomal abnormalities may be considered the same
as that of a singleton pregnancy except in the rare case of postzygotic
nondisjunction. By contrast, dizygotic twins are genetically different,
so each fetus has an independent risk of aneuploidy.
3.1 | First-­trimester screening
First-­trimester screening combined with nuchal translucency mea-
surement and serum pregnancy-­associated plasma protein A and
human chorionic gonadotrophin (HCG) is recommended for all women
in the first trimester. However, the levels of these serum analytes are
higher in twin gestations and are also influenced by ART, making their
reliability and interpretation more complex for twin gestations.5 Serum
analytes detected in maternal blood represent an average from both
fetuses, so there is a possibility that an affected twin may be masked
by an unaffected twin if the calculated average remains within nor-
mal limits. The use of nuchal translucency allows the calculation of
fetus-­specific risk, which is especially useful in dizygotic pregnancies.6
Increased nuchal translucency among monozygotic twins may indicate
the development of twin-­to-­twin transfusion syndrome (TTTS) in a
MCDA gestation.
3.2 | Second-­trimester screening
The presence of a twin gestation also affects the analytes measured
in routine second-­trimester screening (α-­fetoprotein, β-­HCG, uncon-
jugated estriol, and inhibin-­A). First-­trimester biochemical and nuchal
D'Alton and Breslin
translucency is the preferred method for aneuploidy screening in twin
gestations due to its sensitivity of 86%–87% at a 5% false positive
rate as compared with 50%–60% sensitivity with a 10% false positive
rate for second-­trimester screening.6
3.3 | Cell-­free fetal DNA screening
Studies evaluating the use of cell-­free fetal DNA screening (cffDNA)
to detect aneuploidy in twin gestations are limited. Due to the excess
placental tissue, the fetal fraction of DNA detected in maternal
serum is higher than that of singletons. A higher fetal fraction may
be required to differentiate between euploid and aneuploid pregnan-
cies, and zygosity can affect the fraction obtained. Monozygotic twins
contribute equally to the fetal fraction because they have identical
DNA, whereas dizygotic twins do not and a euploid twin may mask
6 twins and 18 weeks for DC twins to detect growth disturbance, amni-
the excess genetic maternal of an aneuploid twin. If an abnormality
is detected, cffDNA alone cannot predict which twin is affected. Due
to a lack of evidence demonstrating the reliability of cffDNA use in
multiple gestations, ACOG does not currently recommend referring
women with multiple gestations for cffDNA testing.7
3.4 | Invasive prenatal diagnosis
3.4.1 | Amniocentesis
Amniocentesis for genetic analysis is performed in the mid-­second tri-
mester. The risk of procedure-­related loss in twin gestations is difficult
to estimate owing to heterogeneity in the definition of loss among
8 nios or maternal indications.
studies. It is advisable to inform women that the risk of procedure-­
related loss associated with amniocentesis in singleton pregnancies is
1 in 300–500, but that the risk in twin gestations remains unclear.
3.4.2 | Chorionic villus sampling
Chorionic villus sampling is performed between 10 and 14 gestational
weeks. It should not be performed before 10 weeks owing to the risk
of limb-­reduction defects and oromandibular hypogenesis. In MC 8
pregnancies, a single sampling site can be used. In DC pregnancies,
each placenta should be sampled.
3.5 | Ultrasound
Ultrasound is integral in the diagnosis of multiple gestations, the deter-
mination of chorionicity, and the diagnosis of structural abnormalities.
There is a 6% incidence of congenital abnormalities in twin gestations,
and the incidence of structural anomalies is 2.5-­fold higher among
9
monozygotic twins than among dizygotic twins. Placental location
and cord insertion must also be determined owing to the increased
risk of velamentous cord insertion and vasa previa in multiple gesta-
tions. Cardiac anomalies are increased in both monozygotic pregnan-
cies and pregnancies conceived by assisted reproductive techniques.
Fetal echocardiography is recommended for these pregnancies and
will detect the majority of major cardiac anomalies. 8,10
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4 | PRENATAL CARE
Due to the increased maternal and fetal risks associated with multiple
gestations, twin pregnancies should be cared for by specialist physi-
cians. Women should be advised regarding folic acid supplementation
(1 mg daily), iron supplementation (60–120 mg daily), and daily pre-
natal multivitamins. The recommended range of total weight gain for
normal weight women, overweight women, and obese women with
a twin gestation is 16.9–24.5 kg (37–54 lb), 14.1–22.7 kg (31–50 lb),
and 11.3–19.1 kg (25–42 lb), respectively.11
4.1 | Fetal surveillance
Serial ultrasound surveillance is warranted from 16  weeks for MC
otic fluid abnormalities, cervical shortening, and other complications
specific to multiple gestations. Serial ultrasound examinations to
evaluate fetal growth should be performed every 3–4 weeks in twin
gestations. Singleton growth charts may be used. Growth discordance
is expressed as a percentage; most ultrasound reports will automati-
cally generate the percentage discordance. Twin growth discordance
is associated with a higher likelihood of fetal and perinatal death as
compared with concordantly grown twins.12
A 20% discordance or intrauterine growth restriction warrants
twice weekly fetal surveillance with a nonstress test, biophysical pro-
file, and Doppler velocimetry of the umbilical artery. Weekly testing
may also be instigated due to other indications such as oligohydram-
4.2 | Preterm labor and preterm birth
Preterm birth (PTB) occurs in more than 50% of twin gestations, and
twin PTB accounts for a significant proportion of all early and late pre-
term deliveries.13 A routine measurement of cervical length at 16–24
gestational weeks can help to identify those women at risk of PTB. A
cervical length shorter than 2.0–2.5  cm is found in 5%–10% of twin
pregnancies and is associated with a 3–5-­fold higher likelihood of PTB.14
Despite the ability to predict those at greatest risk of PTB, inter-
ventions shown to decrease the risks in singleton gestations do not
result in the same decreased risks in twin gestations. Cervical cerclage
placement has not been shown to prolong gestation for women with
a twin gestation and a short cervix; thus, ACOG does not recommend
the use of cerclage for these women.4 Similarly, the use of progester-
one supplementation has not been clearly shown to benefit those with
either a short cervix or a history of PTB and a twin gestation. Bed rest
and use of tocolytic drugs for women without symptomatic preterm
labor should be avoided.
Women should be educated regarding the symptoms and signs
of preterm labor. Prenatal corticosteroids should be administered to
women at 24–34 gestational weeks if delivery is anticipated within
the next 7 days. The decision to administer steroids in the periviable
period should be made in consultation with the patient and pediatric
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6       D'Alton and Breslin

team. A repeat dose of steroids may be considered for women who are T A B L E   3   Delivery time for multiple gestations.
expected to deliver in the next 7 days and who remain at less than 34
Delivery tim-
gestational weeks if at least 7–14 days have passed from administra- Chorionicity Complications ing, wk
tion of the first course of steroids.
DCDA Uncomplicated 38+0–38+6
The benefit of steroids for twin gestations in the late preterm
Isolated growth 36+0–37+6
period has not be demonstrated because multiple gestations were not
restriction
included in the study population in the antenatal late preterm steroid
Concurrent condition 32+0–34+6
trial.15 Tocolytics should be reserved for those in documented preterm (abnormal Doppler
labor in order to allow for the administration of prenatal steroids and findings, maternal
transfer to a tertiary medical center with appropriate neonatal care comorbidity)
facilities. Prolonged use of tocolytics is not recommended. Magnesium MCDA Uncomplicated 34+0–37+6
sulfate for fetal neuroprotection should be administered to women at Isolated fetal growth 32+0–34+6
less than 32 gestational weeks who have documented evidence of restriction
preterm labor and to women for whom prenatal fetal testing predicts Concurrent condition 32+0–34+6
that iatrogenic delivery is imminent. 4 (abnormal Doppler
findings, maternal
comorbidity)
MCMA Uncomplicated/IUGR/ 32–34
5 |  MATERNAL COMPLICATIONS concurrent condition
Triplet/higher order Individualized
Multiple pregnancies are at increased risk of pregnancy complications
Abbreviations: DCDA, dichorionic–diamniotic; IUGR, intrauter-
including hyperemesis gravidarum, anemia, urinary tract infection,
ine growth restriction; MCDA, monochorionic–diamniotic; MCMA,
gestational diabetes, and hypertensive diseases. monochorionic–monoamniotic.

5.1 | Gestational hypertension and pre-­eclampsia 6.2 | Mode of delivery

The incidence of gestational hypertension and pre-­eclampsia is
increased in multiple gestations because of the presence of a larger pla-
cental mass. Pre-­eclampsia is more likely to occur earlier in pregnancy
and maybe severe or atypical. ACOG recommends the use of low-­dose
16
aspirin in all multiple gestations to reduce the risk of pre-­eclampsia.
5.2 | Gestational diabetes
A 50-­g glucose challenge test should be performed between 24 and
28 gestational weeks. Earlier screening should be performed in the
first or second trimester if the woman has other risk factors for diabe-
tes. If the test is positive, a 3-­hour 100-­g oral glucose tolerance test
should be performed.
6 |  INTRAPARTUM MANAGEMENT
6.1 | Timing of delivery
Delivery timing is often dictated by the development of maternal or
fetal indications for delivery or the occurrence of spontaneous PTB. For
complicated twin pregnancies, the goal is to optimize fetal outcomes
for both fetuses without leading to significant compromise of either
maternal health or the healthy twin in the case of fetal complications.
For uncomplicated DCDA pregnancies, delivery should occur
between 38 and 39  weeks because perinatal morbidity and mor-
tality rise after 39  weeks.17 Delivery should occur between 34 and
37+6 weeks for uncomplicated MCDA twins, and between 32 and 34
gestation for uncomplicated MCMA twins18 (Table 3).
A bedside ultrasound examination should be performed to confirm
presentation and to plan for delivery. Approximately 40%–45% of
twin pregnancies will be in the vertex–vertex position and, as such,
vaginal delivery should be attainable, notwithstanding maternal or
fetal indications for cesarean delivery. Women should be encour-
aged to have continuous epidural anesthesia owing to the possibil-
ity of emergent obstetric interventions. Continuous fetal monitoring
throughout labor is required: a fetal scalp electrode on the presenting
twin is invaluable in helping to differentiate the two fetal heart rates.
The maternal heart rate should be also continuously monitored.
Prostaglandins, intracervical Foley balloon, and oxytocin can be
used for labor induction. A twin gestation is not a contraindication for
a trial of labor after one previous low-­transverse cesarean delivery.19
Once the woman is fully dilated, delivery should take place in an oper-
ating room prepared for both a vaginal and operative delivery with
anesthesia, and with obstetric nursing and pediatric colleagues pres-
ent. Ultrasound examination should be used to confirm the presen-
tation of the second twin after delivery of the first twin. Amniotomy
and oxytocin are safe to use to expedite delivery of the second twin,
because a longer duration to delivery of the second twin is associated
with increased rates of cesarean delivery and worsening cord pH.20
At the time of admission for delivery, 35%–40% of cases will be
vertex–breech or vertex–transverse. A vaginal delivery can still be
achieved if there are no contraindications to breech extraction and
there is a skilled healthcare provider available.19 If the second twin is
transverse or footling breech, membranes should remain intact until
both feet can be secured in the pelvis; amniotomy can then be per-
formed, followed by a complete breech extraction.
D'Alton and Breslin
There are some contraindications for breech extraction of a
second twin:
• Estimated fetal weight less than 1500 g or more than 3500 g
• Hyperextended neck
• Second twin significantly larger than first twin (>20% discordance)
• Provider not skilled/comfortable with breech extraction
In addition, external cephalic version should be avoided owing to the
risks of cord prolapse and placental abruption.
Cesarean delivery is recommended if both twins are in
non-­vertex presentation.19
6.3 | Delayed interval delivery
This is a rare situation more commonly seen in extreme prematurity
with higher-­order multiple gestations where delivery of one fetus occurs
spontaneously and is not followed soon after by delivery of the second
fetus. Delayed interval delivery is only permissible in cases of extreme
prematurity and is contraindicated in the presence of placental abrup-
tion, chorioamnionitis, MC gestation, or maternal indications for delivery.
There is insufficient data on the best management of these pregnancies,
but it may include broad-­spectrum antibiotics, cerclage, and tocolytics.19
7 | SPECIAL CONSIDERATIONS
7.1 | Monochorionic pregnancies
Monochorionic pregnancies are associated with unique complications
because of the communicating fetal blood vessels; in other words,
what happens to one twin directly affects the other. Unequal placental
sharing (UPS), TTTS, and twin anemia–polycythemia sequence (TAPS)
may occur. Thus, serial ultrasound surveillance is recommended every
2 weeks beginning at 16 gestational weeks for MC pregnancies.
7.1.1 | Unequal placental sharing
UPS results when one twin receives a greater share of the placenta rel-
ative to the other, resulting in selective growth restriction or growth
discordance. Evaluation of placental cord insertion during an anatomic
survey can help to identify those pregnancies at increased risk of growth
abnormalities because velamentous cord insertion is often seen in those
with UPS. Amniotic fluid levels may remain normal or slightly abnormal.
There is no available treatment for UPS; however, regular twice
weekly surveillance based on biophysical profile, Doppler evaluation of
the umbilical artery, and nonstress tests is recommended to assess the
health of the fetuses and to time interventions such as admission, steroid
administration, and delivery. UPS may exist in conjunction with TTTS.
7.1.2 | Twin-­to-­twin transfusion syndrome
The pathophysiology of TTTS, which occurs in approximately
8%–10% of MC pregnancies, is due to the presence of arterio-­venous
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      7
anastomoses on the placental surface, allowing transfusion of blood
from one fetus (the donor) to the other fetus (the recipient).21
Diagnosis is made when the recipient is found to have polyhydram-
nios with a maximal vertical pocket of fluid (MVP) of more than 8 cm,
and the donor is found to have oligohydramnios with an MVP of
less than 2  cm. The donor twin may show signs of growth restric-
tion, oligohydramnios, or anhydramnios, which may give a “stuck
twin” appearance on ultrasound. The recipient twin will demonstrate
polyhydramnios, and echocardiography may indicate biventricular
hypertrophy due to fluid overload and progressive cardiac failure.20
Because of polyhydramnios, the pregnancy is at risk of preterm pre-
mature rupture of the membranes, preterm labor, and cord prolapse.
The Quintero system is used to stage TTTS22 (Table 4).
Mortality for both twins approaches 80%–100% if TTTS remains
untreated. Management depends on gestational age at diagnosis,
prognosis, and staging, but it includes pregnancy termination, selec-
tive fetal reduction, amnioreduction, fetoscopic laser (FLS) surgery,
expectant management, and delivery. In cases of stage III–IV TTTS
diagnosed before 24–26 gestational weeks, selective FLS coagula-
tion with or without amnioreduction offers the best outcomes. FLS is
offered at specialist fetal intervention centers, and it is imperative that
women with suspected TTTS of any stage are referred expeditiously
for consultation and management. The utility of FLS for stage-­I TTTS
is currently under investigation.
7.1.3 | Twin anemia–polycythemia sequence
TAPS is characterized as a discordance in hemoglobin between MC
twins occurring in the absence of amniotic fluid abnormality. TAPS
occurs in 10%–13% of cases after laser ablation for TTTS, but may
occur spontaneously in 3%–5% of MC twins. Small (<1 mm) arterio-­
venous anastomoses allows a chronic, slow transfer of blood from
the donor to the recipient; thus, most cases do not present until after
26 gestational weeks or 1–5  weeks after laser therapy for TTTS.
Diagnosis can be made either prenatally based on middle cerebral
artery peak systolic velocity (MCA-­PSV) Doppler discordance or post-
natally based on hemoglobin and reticulocyte count discordance. The
optimal management strategy and delivery timing for TAPS has yet to
be established.
T A B L E   4   Quintero staging system for TTTS.
Stage Clinical features
1 MCDA pregnancy with oligohydramnios (MVP <2 cm) and
polyhydramnios (MVP >8 cm)
2 Absent bladder in donor
3 Abnormal Doppler velocimetry findings (including absent/
reversed end diastolic flow; absent/reversed flow in
ductus venosus; pulsatile flow in the umbilical vein)
4 Fetal hydrops
5 Death or one or both fetuses
Abbreviations: MCDA, monochorionic–diamniotic; MVP, maximal vertical
pocket of fluid; TTTS, twin-­to-­twin transfusion syndrome.
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8       D'Alton and Breslin

risk of hypertensive disease of pregnancy,25 gestational diabetes,26

7.2 | Demise of one twin
Owing to the shared placenta in an MC gestation, at the time of death
of one fetus, significant hypotension occurs in the other fetus, which
may lead to cotwin death or severe neurologic morbidity in the surviv-
ing twin in 26% of cases.23 This effect can be seen as early as the first
trimester in the setting of a “vanishing twin,” but is most significant
when death occurs in the second or third trimester. Because neuro-
logic injury seems to occur at the time of death, it may not be prevent-
able by immediate delivery of the surviving fetus. However, owing to
the ongoing risk of stillbirth for the surviving twin, delivery at 34–36
24
gestational weeks is reasonable.
antepartum hemorrhage, premature rupture of membranes, postpar-
tum hemorrhage,27 and both spontaneous and iatrogenic PTB.28
In terms of delivery mode, robust data to support vaginal
delivery are lacking; thus, these pregnancies are best delivered by
cesarean, not only due to the difficulties in accurately monitoring
all fetuses in labor but also due to the increased risk of neonatal
morbidity and mortality.29,30 Owing to the increased risks associated
with higher-­order gestations, women may be counseled regarding
multifetal pregnancy reduction, which has been shown to improve
perinatal outcomes.31

7.3 | Monoamniotic twin
Monoamniotic twins occur in approximately 1% of monozygotic ges-
tations. These gestations have an increased risk of perinatal morbidity
and mortality secondary to the above-­mentioned complications, as
well as a unique complication of cord accidents including cord com-
pression and prolapse.19 Women should be counselled regarding the
difficulty in achieving continuous monitoring, the risk of missing a ter-
minal event in the case of non-­continuous monitoring, and the risk
of iatrogenic prematurity. These women are offered hospital admis-
sion for either frequent nonstress tests or continuous fetal monitor-
ing to evaluate the presence and frequency of variable decelerations,
which may be a sign of impending terminal cord compression (Fig. 1).
Delivery by cesarean should be planned for 32–34 gestational weeks.
7.4 | Higher-­order multiple gestations
Similar to twinning, the incidence of triplet or higher-­order multiple
gestations rose by over 400% from 1980 to 1998. Since then, the
incidence has fallen by 48% to the current rate of 101.4 per 100 000
births in 2016.1 Higher-­order multiple gestations carry an increased
8 | CONCLUSION
Twin gestations are a common occurrence in clinical practice. An
understanding of the nuances and complexities of these pregnancies
is essential in order to achieve optimal maternal and fetal outcomes. It
is important that providers are able to recognize cases of twin gesta-
tion that require subspecialty care from a maternal and fetal medicine
physician. Monochorionic multiple gestations represent a particular
challenge in clinical practice and research is ongoing as to the optimal
timing or indeed, the optimal form of intervention for complex prob-
lems such as early stage TTTS or TAPS.
AU T HO R CO NT R I B U T I O NS
MD and NB both contributed to content creation, research, writing
and editing. Both authors approved the final version of the manuscript
for publication.
CO NFL I C TS O F I NT ER ES T
The authors have no conflicts of interest.

F I G U R E   1   Continuous electronic fetal monitoring of monochorionic–monoamniotic twins at 31 gestational weeks. The chart shows
increased frequency of variable decelerations and fetal tachycardia of twin B before a prolonged deceleration. The red line corresponds to twin
A's fetal heart tracing while the blue line indicates Twin B's fetal heart tracing. The black line indicates uterine activity detected via an abdominal
tocometer. The woman underwent an emergency cesarean delivery with tightly wound umbilical cords noted at delivery.
D'Alton and Breslin
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