MULTIPLE BIRTHS COMPLICATIONS
Category: Child Health
Abstract : multiple births complications: • Prematurity: Infants from multifetal
pregnancies are more likely to be born prematurely and to require neonatal
intensive care. Approximately 50% of twin deliveries occur before 37 weeks'
gestation. The length of gestation decreases inversely with the number of
fetuses present. Infants from multifetal pregnancies represent 20% of very low
bi
multiple births complications:
• Prematurity: Infants from multifetal
pregnancies are more likely to be born prematurely and to require neonatal
intensive care. Approximately 50% of twin deliveries occur before 37 weeks'
gestation. The length of gestation decreases inversely with the number of
fetuses present. Infants from multifetal pregnancies represent 20% of very low
birth weight infants.
• Hyaline membrane disease: Twins born at fewer
than 35 weeks' gestation are twice as likely to develop hyaline membrane disease
(HMD) as single birth infants born at fewer than 35 weeks' gestation are.
Prevalence of HMD is greater in monozygotic than in dizygotic twins. Concordance
rate for HMD (ie, both twins have HMD) is greater in monozygotic than in
dizygotic twins. If the twins are discordant for HMD, then the second twin is
more likely to develop HMD than the first twin.
• Birth
asphyxia/perinatal depression: Newborns from multiple gestation pregnancies have
an increased frequency of perinatal depression and birth asphyxia from a variety
of causes. Umbilical cord entanglement, locked twins, a prolapsed umbilical
cord, placenta previa, and uterine rupture can occur and result in asphyxiation
of an infant. Occurrence of cerebral palsy is 6 times more common in twin births
and 30 times more common in triplet births than in single births.
Monochorionic/monoamniotic twins are at highest risk for cord entanglement. The
second-born twin is at greatest risk for birth asphyxia/perinatal
depression.
• GBS infections: Early onset GBS infections in low birth
weight infants are nearly 5-fold greater than in average weight
singletons.
• Vanishing twin syndrome: Early ultrasound 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.
• Congenital
anomalies/acardia/twin reversed arterial perfusion sequence: Congenital
anomalies more commonly develop in twins than in a single fetus. CNS,
cardiovascular, and GI defects occur with increased frequency. Monozygotic twins
have increased prevalence of deformations secondary to intrauterine space
constraints. Common deformations in twins include limb defects, plagiocephaly,
facial asymmetry, and torticollis. Acardia is a rare anomaly unique to multiple
gestation. In this condition, one twin has an absent or rudimentary heart. Twin
reversed arterial perfusion (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 this 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.
• Twin-to-twin transfusion
syndrome:
This syndrome occurs in monochorionic/monoamniotic or
monochorionic/diamniotic twins. Vascular anastomoses in the monochorionic
placenta result in transfusion of blood from one twin (ie, donor) to the other
twin (ie, recipient). One classification scheme separates TTTS into severe,
moderate, and mild forms.
o Severe TTTS presents early in the second
trimester (16-18 weeks' gestation). A difference of more than 1.5 weeks'
gestational size between twins occurs. Severe TTTS has a 60-100% mortality rate.
Polyhydramnios develops in the sac of the recipient twin because of volume
overload and increased fetal urine output. Oligohydramnios develops in the sac
of the donor twin because of 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.
o Moderate TTTS develops
later at 24-30 weeks' gestation. Although a fetal size discrepancy of more than
1.5 weeks' gestation occurs, polyhydramnios and oligohydramnios do not develop.
The donor twin becomes anemic, hypovolemic, and growth retarded. The recipient
twin becomes plethoric, hypervolemic, and macrosomic. Either twin can develop
hydrops fetalis.
o Mild TTTS develops slowly in the third trimester.
Polyhydramnios and oligohydramnios usually do not develop. Hemoglobin
concentrations differ by more than 5g/dL. Twin sizes differ by more than 20%.
Polycythemic twins can develop hyperviscosity syndrome and hyperbilirubinemia
after birth.
• 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.
o Thoracopagus - Joined
at chest (40%)
o Xiphopagus/omphalopagus - Joined at abdomen (34%)
o
Pygopagus - Joined at buttocks (18%)
o Ischiopagus - Joined at ischium
(6%)
o Craniopagus - Joined at head (2%)
• Intrauterine growth
retardation:
Birth weights of twins, triplets, etc. are smaller than weights
of corresponding singletons. However, when combined, birth weights of twins are
greater than weights of corresponding singletons. Most of the deficit of birth
weight occurs in the final 8-11 weeks of pregnancy. Average birth weights are
similar between twins and singletons until 32 weeks of gestation. Average birth
weights are similar between triplets and singletons until 29 weeks of gestation.
Birth weight discrepancies of more than 20-25% are considered discordant.
Discordant birth weights occur in 10% of twins. The cause of discordant birth
weights among twins is the difference between each twin's placental surface area
or TTTS. Discordant birth weights among triplets are more common than discordant
birth weights between twins. Approximately 30% of pregnancies with triplets have
a birth weight discordance of more than 25%.
Prognosis:
• The
prognosis of infants born from multiple gestations depends upon the
complications that develop. Some studies have reported that the risks of death,
chronic lung disease, and grade III/IV intracranial hemorrhage were similar in
twins and singletons. Other studies have reported a higher prevalence of
complications such as necrotizing enterocolitis, retinopathy of prematurity, and
patent ductus arteriosus in infants from multiple gestation versus singletons.
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