MULTIPLE BIRTHS MEDICAL CARE

Multiple Births Medical Care:
Medical care of the woman with multiple gestation pregnancy is beyond the scope of this chapter.
• Medical care of infants from multiple gestation births depends on complications.

• The usual method of delivery for higher order multiple births (eg, triplets, quadruplets) is cesarean delivery. Cesarean delivery is also the usual method of delivery for twins in the following situations:
o Breech/vertex presentation with the possibility of interlocking twins
o Monoamniotic twins
o Conjoined twins
o Congenital anomalies that threaten increased neonatal morbidity in a twin
o Delayed interval delivery of remaining fetuses in multifetal pregnancy at the border of viability is becoming more common. Before 30 weeks of gestation, delayed delivery for 2 or more days is associated with improved survival in the second twin.

• Delivery room management of infants from multifetal pregnancies requires adequate personnel skilled in neonatal resuscitation. Infants from multifetal pregnancies are at increased risk of birth asphyxia and respiratory distress syndrome (RDS). Such infants may require bag mask ventilation and endotracheal intubation in the delivery room.

• Partial exchange transfusion may be necessary in donor or recipient twins from TTTS.
o Partial exchange transfusions are used to increase hemoglobin concentrations in anemic donor twins while maintaining euvolemia. Small aliquots (5-15 cc) of packed red blood cells (RBCs) are infused (usually via an umbilical venous catheter) following removal of an equal volume of the infant's blood until a desired hemoglobin is attained. The transfused packed RBCs should be appropriately cross-matched, cytomegalovirus (CMV) negative, and irradiated.
o Partial exchange transfusions are used to decrease hemoglobin concentrations in polycythemic recipient twins while maintaining euvolemia. Small aliquots (5-10 cc) of fresh frozen plasma are infused (usually via an umbilical venous catheter) following removal of an equal volume of the infant's blood until a desired hemoglobin is attained.

Consultations: A woman with multiple gestation pregnancy may benefit from a consultation with a perinatologist. A neonatologist may be involved in the postnatal care of multiple birth infants, particularly if the births are premature or if congenital anomalies are present.