Multiple Gestations - 3 - Common Complications
Friday, January 02, 2009
Kenneth F. Trofatter, Jr., MD, PhD
The incidence of twins has increased steadily over the past two decades in the U.S. Although assisted reproductive technologies have contributed to an increase in all multiples and, especially, high order multiples, better monitoring of the infertility patient and general agreement among reproductive endocrinologists to recommend the transfer of no more than two embryos in in vitro fertilization cycles, has stabilized the rise in the latter in recent years. Specific issues related to ‘placentation’ as discussed for twins in the previous post also apply to higher order multiples as do proportionate increases in pregnancy complications.
The most common fetal and neonatal complications in multiple gestations are related to premature delivery. The mean gestational age for delivery of twins is about 35 weeks, triplets about 32 weeks, and quadruplets about 29 weeks. In the U.S., as we mentioned previously, multiples account for about 3% of all deliveries, but they also contribute to about 25% of the very low birth weight (VLBW; < 1500 g) babies that are born. In 2001, 57% of twins and 92% of triplets were born at less than 37 weeks compared to only 10% of singletons. In that same year, 10% of twins, 35% of triplets, and more than 70% of higher order multiples resulted in VLBW babies. Martin and colleagues (National Center for Health Statistics Report 2003;42) reviewed birth weight data from 2002 and found the mean birth weight for singletons was 3,332 g, whereas that for twins was 2,347 g, triplets 1,687 g, and quadruplets 1,309 g. It is significant to note that 80% of the triplets and higher pregnancies were the results of the ‘successes of infertility programs throughout the country. It is also interesting to note that women who require infertility treatment to conceive are at even greater risk for preterm and low birth weight babies than women who spontaneously conceive multiple gestations (Schieve, et al., NEJM 2002;346:741; Dhont, et al., Am J Obstet Gynecol 1999;181:688; McElrath, et al., Obstet Gynecol 1997;90:600).
Early gestational age at delivery, low birth weight, and intrauterine growth restriction at these early gestational ages contribute to the morbidity and mortality accompanying multiple gestations. U.S. Vital Statistics data indicate that twins are about 7 times more likely than singletons to die during the first month of life (and 5 times more likely to die during the first year) and triplets are about 20 times more likely to die in the first month (and 12 times more likely during the first year). Multiple gestations require a high rate of admission to neonatal intensive care units and are at risk for all of the common complications of prematurity, both acute and chronic, such as respiratory distress syndrome, necrotizing enterocolitis, intraventricular hemorrhage, retinopathy of prematurity, and chronic lung disease. Despite the dramatic advances that have been made in early neonatal care, worldwide data suggests that multiples are 4 to 10 times more likely to result in cerebral palsy and permanent handicaps than singleton pregnancies. The short- and long-term costs of health care for multiples are staggering when compared on a per baby basis to singleton pregnancies.
Maternal complications during pregnancies with multiples also contribute to morbidity, mortality, and health care costs above that seen for singletons at every stage of pregnancy. There are greater risks for miscarriage in first and second trimesters, severe nausea and vomiting of pregnancy (hyperemesis gravidarum), bladder and kidney infections, iron deficiency anemia (and frank maternal malnutrition with higher order pregnancies), thromboembolic complications, gestational diabetes, hypertensive disorders of pregnancy, including severe preeclampsia syndromes, acute fatty liver of pregnancy, as well as premature rupture of membranes, early, and cesarean deliveries. Abnormalities of placentation and uterine overdistention increase the risk for bleeding complications both during the pregnancy and at the time of delivery. If a woman with multiples has previously had a cesarean delivery, she may also be at greater risk for uterine rupture prior to the onset of, or during, labor. Multiple, and sometimes prolonged, hospitalizations related to any of these complications contribute to the increased costs of health care for these pregnancies and are characteristic of high order multiples. Indeed, the higher the order of the multiple pregnancy, the greater the risk for each of these complications…
Labels: Multiple gestations, triplets, twins
10 Comments:
At Mon Jan 05, 10:27:00 PM 2009,
Anonymous said…
Dr.T, I am writing in the hope that you will actually be able to read this. I have been doing research for over two years now on CMV and just came across your previous article listed here: http://www.healthline.com/blogs/pregnancy_childbirth/2007/11/cytomegalovirus-cm
v-reprise.html This was very helpful. I have a 2.5 yr old son who was born with CMV. Research for me is ongoing to learn how children like him develop in their later years, however there seems to be nothing after around 6mos of age. Do you know of any links/resources to assist in this? My son has bilateral deafness (however received a cochlear implant a few months ago and is slowly responding), and is developmentally delayed( depending on the "test" he is assessed from 18mo skill to 6mo skill, so all over the charts). I believe "Lana" from your blog above has started an awareness page on "myspace". Not many know of it, but it sounds as if it could be her (from Australia anyway). There are about thirty families on there now and we just keep pushing the awareness out there. Thanks for your research, and providing this blog.
At Fri Jan 09, 11:28:00 PM 2009,
Vanessa W said…
Dr Trofatter,
my question is actually unrelated to the issue of multiple pregnancy, but posting it here will make it easier for me to find your response.
I actually tried to post a question related to nuchal translucency screening during the time that Blogger was experiencing problems, and my message got lost. At 13 weeks, I had an NT scan with an abnormal result of 3.2mm for a CRl of 6.7mm (1.88 MoM). First-trimester blood screening was not available to me here in New Zealand, and I was given a risk of 1:33 for Trisomie 21 and about the same for congenital heart defect.
As you can imagine, this cause quite a bit of concern and stress at the time. Thankfully, all subsequent tests have ruled out chromosomal and cardiac defects, and the fetus appears average in just about every way (good news in the world of high-risk obstetrics).
However, these results also make me question the advisability of NT scans, especially in the absence of additional screening tools, and I can't help but wonder what I would do in any future pregnancies.
My question is if the NT measurements of subsequent pregnancies in women who had an abnormal NT measurement, but normal fetus in their first pregnancies have been studied. In other words, has anyone looked at whether some people just tend to grow fetuses with higher than normal NTs in the absence of abnormalities associated with increased NT?
Thank you very much for any information you may have on this issue. I very much appreciate the care and detail with which you discuss obstetrical issues in general, and patient questions in particular!
At Tue Jan 13, 02:54:00 AM 2009,
nadia1265sunshine said…
Hi..My name is Nadia.. Im 21 years of age..
I did not find out i was pregnant until i was 15w & 5 days pregnant... I just got off depo going on a year at the time so I had what I thought was a period...I had some bleeding in my second month..(but did not know at the time i was expecting)..When i found out I was expecting I enformed my doctor of the bleeding and she said that was normal, and that some woman bleed threw theyre entire pregnancy..which i never knew that! I also enformed her at around 16years of age I had 2 leaps done...My ultra sound at 15w, was normal...I&the baby also passed all test they gave me as well..At 20weeks i went in for my ultra sound and to check my cervix length..Everything was great at that time aswell, and my cervix was exceptionaly long, even with the two leeps done...she said they would just watch for it during my pregnancy...Well at 22weeks i started having contractions and went to the hospital by the time I arrived I was fully dialated and was delievering before i knew it..(Everything happend within 1-2hours contraction to water breaking to delievering)I lost my son shortly after delivery.. I also went to my family doctor before i went to the obgyn to confirm that my at home pregnancy was correct..at that time he did a vaginal exam...he found a slight iregularity in my discharge.. he gave me a prescription for some vaginal medication, i enformed my obgyn of that medication and she told me not to use it we would only use it if the discharge started to bother me...( it was my first time expecting and i trusted the obgyn)i have been reading peoples problems and your answers so i was just wondering if you could tell me what went wrong so i can cope with my loss and what EXACTLY i can do next time to prevent this from happening...thank you soooo much
(Also i was taking prenatual vitamins as soon as i found out about expecting and was eating very healthy, no sodas)I hope to hear a response soon...
At Sat Jan 17, 05:25:00 AM 2009,
Caspar said…
Dear Doctor Trofatter, my question is not regarding multiple gestations, but I couldn't find the right place to post it. I had a blighted ovum in october 2008 (hcg only when up to 720 at 6weeks, progesterone was 27 and then started to drop). I got pregnant again in december 2008. On the 29th Dec. I got my blood test results with hCG 2111 and Progesterone 39. My lmp was on 23rd november 2008. I retested blood on the 10th Jan.09; hCG 60493 and Prog 31. Retested again 6 days after (16th Jan) and hCG was 122645 and Prog 29.16. My question is, why my progesterone keeps on dropping? Isn't it supposed to increase?. Does it mean that this pregnancy will not make it? Should I worry at all?. My doctor prescribed progest 200mg, but it produces an abdominal rush and I don't feel comfortable using it. Is it a must to use it? or am I attempting against my baby if I don't?. I've been having "all day sickness" for 2 weeks now, and since yesterday the symptoms have decreased a bit. I feel nauseaous and dizzy but not as bad as it was before, is it normal that the symptoms subside at this stage? (My guess is I'm about to start week 8). I would appreciate your help. I haven't had an ultrasound yet and my first appt with my doctor is on Monday 19th.
At Sat Jan 17, 08:15:00 AM 2009,
nunnthewiser said…
I know this is posted on an unrelated topic, but I was unable to post my comment/question on the pai-1 thread. i hope this is ok.
Here is my history:
2004 pregnancy, live birth, mild preeclampsia.
2005 miscarriage at 10 weeks, saw heartbeat.
2005 blighted ovum
2006 miscarriage at 6 weeks
2007 pregnancy. big clot shown in uterus w/fetus, eventually disappeared. preeclampsia. placental abruption. pre-term delivery (34 weeks) due to HELLP syndrome.
blood work in 2008:
protein c deficiency
pai-1 deficiency
I see a lot about too MUCH pai-1, very little about the opposite. That, added to the protein c deficiency, apparently makes me a weirdo. I can't find ANYTHING on the internet. :(
we want to try for a 3rd child, but not if it is too dangerous.
My doctors are torn, and give very conflicting advice. Neither of them know enough about these disorders. I have an appointment with a hematologist, just wondering if you had any insight.
sara.nunn@gmail.com
nunnthewiser.wordpress.com
At Mon Jan 19, 05:50:00 AM 2009,
Anonymous said…
Dr. Trofatter,
You were very helpful to me early in my pregnancy when I received a positive first trimester screening with an increased risk for Down Syndrome. I elected not to have a CVS or amniocentesis due to the risk for miscarriage. I am happy to report that my son was born healthy with no evidence of chromosomal disorder. However, he did have some interesting findings on his placenta. He had a velementous (sp?) cord insertion and an extra lobe. Would this have caused the false positive on the screening? Is there an increased risk of these problems in a subsequent pregnancy? Should these issues have been identified on the Level II Ultrasound?
Thank you in advance for your thoughts!
At Mon Jan 19, 08:51:00 PM 2009,
scoffman said…
My daughter was diagnosed with MTHFR after her stroke at the age of 14, she is now 17. The Dr's that diagnosed her with MTHFR, said that this caused her stroke, she has both mutations. I have since had on Dr disagree in that the MTHFR had nothing to do with her stroke, even though the literature states that it can increase your risk of clotting, which she had a blood clot. Her right carotid artery is 100% blocked. She is currently taking baby aspirin, Plavix, Folic Acid and Multi Vitamins, is this good? Or should she take more concerning the MTHFR? She also talks of having her own children, I disagree and think she should never take birth control?
At Tue Jan 27, 12:38:00 PM 2009,
Sandi said…
Dr.T,
I am 37, 18 weeks pregnant (on thursday) with ID twins through IVF (own eggs, husbands sperm). The first part of my sequential screen came back great. Don't have my measurements (asking them to be faxed). The second part came back elevated HCG 2.5 MOM. Was told other markers came back fine. Placing my risk factor for DS at 1/175 higher than the age risk factor as I will be 38 at time of delivery in June. I am really stressed because when I asked if I could just do one I was told I'd have to do amnios because even though my RE identified my twins as identical and my perinatologist says it really looks like it but there is no way to be 100% sure until they are delivered and the membrane can be measured. I was told my chances of something going wrong with the amnios are 1/1000 for both and more like 1/1600 for one, which I am not having. My questions:
1. Being that hcg are higher in multiple pregnancies...Do you know if the sequential screen calcs factor in twin pregnancy hcg levels when looking at what is normal and what is not?
2. Would having a targeted sonogram at 18-20 weeks really lower my risk for having twins with DS?
3. Do I need to have my doctor monitor my hcg long after the amnios since it came back high? Meaning are there other things I should be concerned about?
4. Based on the fact that I only had a single marker come back abnormal would you recommend amnios??
Thank you so very much.
At Thu Jan 29, 09:24:00 AM 2009,
Anonymous said…
I actually had a question and I couldn't find where to ask it in the web site. I have a missed period, I actually thought I had it the other day because of the spottinng. But that wa it I spotter only once when I urinated and that's it. I don't have any pain in my abdomen or my back or anywhere. But I am extremely scared right now because I had a tubal ligation done during my las c-section which was 1 yr and a half ago. I'm in perfect health and I have 3 kids which were all c-sections. I've never had this problem before and the only thing that I am doing differently is that I am exercising. I've always had a normal period never missed one unless I was pregnant. I've had a lot of complications during pap- smear tests and so I'm petrified of them and no I haven't taken a home pregnancy test. My question is if I am pregnant and I have no pain or bleeding does this mean that I have a normal pregancy or does it mean that I have an ectopic pregnancy? Like I said I have no pain or bleeding but I am experiencing a lot of urination, like I have to pee way more than normal. Any answers will be greatly appreciated. Thank You
At Wed Feb 04, 11:49:00 AM 2009,
Anonymous said…
Hi Dr T. my wife is 13wks pregnant with triplets (IVF, 26year old), we found yesterday (via ultrasound) that one of the babies have chromosomal abnormalities (appears to be Monosomy X and Trisomy 13). We had an initial IVF attempt (2 embryos, only one took), and the baby did have some sort of abnormality because it never had a heartbeat (it only made it to 6weeks), and it miscarried in 2 weeks later.
Now with this new pregnancy, we have made it farther than the prvious one. The MFM and the OB doctors estimate that it should stop heart bitting up to 6 weeks from now. The other 2 babies are good and healthy. Also, each baby has its own placenta. They indicated that this fetus will not make it.
My questions are: if the baby in question doesn't terminate itself, why the doctors are waiting until week-16 to make a choice? and, if the have to intervene in order to save the other 2 babies, would that procedure harm the good babies? what are the probabilities that they will be harmed?
Thanks in advance for your feedback.
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