Multiple pregnancy account for only 3% of all live births, however, they are responsible for a disproportionate share of all newborn morbidity and mortality in the United States.  Multiples give rise to 13% of all preterm births (<37 weeks); 15% of all early preterm births <32 weeks; 21% of all low birth weight (<2500 grams); and 25% of all very low birth weight (<1500 grams) deliveries.  As consequence of these high rates of both prematurity and low birth weight, twins are at an approximately fivefold greater risk of dying before their first birthday compared to singletons, while triplets are at almost a 14-fold greater risk.  Multiple births account for 16% of all newborn deaths in the United States.

Multiple pregnancies have rapidly become one of the most common high-risk conditions encountered in obstetrics.  Since 1980, the number of twins delivered in the United States has risen by more than 60% and now represents approximately one out of every 32 deliveries.  Triplets and higher order births, which formerly were statistical improbabilities, have increased 470% over the same time period and now occur with a frequency approaching one in every 1000 live births.  Two factors contribute most to this increasing frequency of multiple births.  The first is the emergence of assisted reproductive technologies, such as ovulation induction and in vitro fertilization, while the second is the societal trend toward delayed childbirth since twinning is more frequent in women over the age of 30. 

Among survivors, multiples experience increased risks of both mental and physical long-term handicaps.  Twin pregnancies result in a child with cerebral palsy 12 times more often than do singleton births, while one out of five triplet and half of all quadruplet pregnancies result in at least one child with a major long-term neurological disability. 

Not unexpectedly, multiples are also associated with significantly higher health care costs.  Prolonged neonatal intensive care unit admissions are required by one-fourth of twins, three-fourths of triplets, and virtually all quadruplets.  Women pregnant with multiples are at a six times higher risk of being hospitalized with antepartum complications, most frequently preterm labor, preterm PROM, and preeclampsia.

About the Prenatal Wellness Multiple Center Pregnancy Program:

Since its inception, more than a 1,000 twin gestations have been cared for and delivered through our program.  In addition, more than 100 triplet gestations, two sets of quadruplets, and one set of quintuplets have also been delivered.  A review of these pregnancies reveals significant improvement in outcomes including higher mean birth weight, fewer very low birth weight deliveries, fewer neonatal intensive care unit admissions, and a significantly lower perinatal mortality rate.

Why would a patient want to choose the Prenatal Wellness Center Multiple Pregnancy Program for their care?

1. Ultrasonographic surveillance: Early ultrasonographic evaluation is necessary to determine placentation and to exclude congenital anomalies.  Monochorionic (single placenta twins) pregnancies are at higher risk for complications, such as growth restriction, congenital anomaly, and fetal death.  Monoamniotic twins (twins that share the same sac) represent a pregnancy at extreme risk for fetal death due to cord entanglement.  Congenital malformations are also known to occur approximately twice as often in multiples.  The Prenatal Wellness Center offers the highest quality ultrasound capabilities in the region in addition to almost 20 years of experience in high-risk pregnancy surveillance.  The Prenatal Wellness Center is certified by the American Institute of Ultrasound in Medicine for advanced obstetrical ultrasound.  The Prenatal Wellness Center has a proven track record of accurately identifying both chorionicity and amnionicity as well as reliably identifying congenital malformations.  The Prenatal Wellness Center is one of four sites selected in the United States by the National Institute of Health (NIH) to particpate in the National Fetal Growth Study.

2. Nutritional counseling: One of the most important but least appreciated interventions that can improve outcomes for multiples is maternal nutrition.  Our emphasis on adequate nutrition and appropriate BMI-specific weight gain has contributed to improved fetal growth, prolongation of pregnancy, and lower rates of complications, such as growth retardation, preeclampsia, and premature rupture of the membranes.  To achieve these goals, frequent nutritional education is needed with continuous assessment of maternal weight with an emphasis on both early and mid pregnancy weight gain.  The nutritional demands of a multiple pregnancy greatly exceed that of a singleton and optimal outcomes cannot be achieved unless this fact is appreciated and maternal nutrition proportionately enhanced.

3. Prevention of prematurity:  Premature delivery is the leading cause of illness and death in multiple births.  The average gestational age at delivery is inversely related to the number of fetuses.  All patients are instructed in the signs and symptoms of premature labor and are empowered to request evaluation as needed for possible early labor.  Patients also undergo frequent cervical assessment using both ultrasound and digital examinations in order to identify women who are at increased risk for premature birth.  Some of the interventions used to reduce the risk of premature birth include cerclage placement to reinforce or close the cervix that is prematurely dilating, home uterine activity monitoring to identify early preterm labor, and various tocolytic drugs including both oral and subcutaneous infusion pump therapy to reduce excessive uterine activity.  These cervical assessments also help the physician know how to better recommend work, activity, and lifestyle modifications that are commonly employed in multiple pregnancies. 

4. Evaluation of fetal growth:  Next to premature delivery, abnormalities of fetal growth represent the second biggest contributor to illness and death among multiples.  Ultrasound plays a vital role as the only technique that allows assessment of each fetus individually.  Ultrasound examinations are typically done on a monthly basis.  Identification of a multiple gestation with growth restriction involving one or more fetuses well lead to antenatal surveillance of well-being or delivery in an effort to decrease the likelihood of fetal or newborn loss.  Ultrasound is also the only modality that can be used to identify other complications such as twin-to-twin transfusion syndrome or abnormalities of the amniotic fluid volume.  The Prenatal Wellness Center offers outstanding ultrasound technology as well as the experience to interpret the various fetal growth abnormalities that are identified.

5. Fetal surveillance:  A variety of fetal surveillance techniques are available through the Prenatal Wellness Center including fetal heart rate monitoring, ultrasound evaluation of fetal activity (the Biophysical Profile), Doppler monitoring of umbilical blood flow, and fetal kick counting.  These surveillance techniques are usually initiated in the third trimester and their interpretation allows care providers to decide on a weekly or bi-weekly basis as to the safety of continuing the pregnancy. 

6. Timing of delivery:  Appropriate timing of delivery in twin and triplet gestations is critical to optimizing outcome.  This decision involves simultaneous consideration of gestational age, estimated fetal weight, and fetal maturity.  Other factors that influence this decision include maternal conditions, such as preeclampsia, the adequacy of fetal growth, and the health of the fetus as determined by fetal surveillance techniques. 

Multiple gestations represent one of the most common, high-risk conditions faced in obstetrics.  The population attributable fetal and newborn risks are dramatic.  Prenatal care for multiples should be provided by an experienced and dedicated staff that can anticipate and manage the varied and complex problems presented by multiples.  This sort of specialized prenatal care for multiples provides the best opportunity to optimize intrauterine growth, identify congenital anomalies, prevent extremely preterm or very low birth weight deliveries, and identify fetal or maternal complications that may necessitate more intensive fetal surveillance or even delivery in order to prevent adverse perinatal outcomes.

The care provided at the Prenatal Wellness Center Multiple Pregnancy Program is provided by expert and experienced Maternal-Fetal Medicine specialists trained to provide this special antepartum care needed by women carrying multiples.  The director of the Multiple Pregnancy Program is Dr. Roger B. Newman, and its co-director is Amelia Rowland, RN, CNM.  Other Maternal-Fetal Medicine specialists providing care to multiples are Drs. Jill Mauldin, Scott Sullivan, Laura Goetzl and Charles Rittenberg. 

For further questions and information regarding your multiple gestation, please don’t hesitate to call the Prenatal Wellness Center Multiple Pregnancy Program at 135 Cannon Street and ask to speak to Amelia Rowland, RN, CNM, or Roger Newman, M.D. or our prenatal nurses Vivian Hugely, RN, Tabor Culbreth, RN and Renee Turner, LPN.

Best of luck with your multiple gestation. 

It is truly one of the most remarkable accomplishments of your life and the birth of your multiples will be an unforgettable life-changing event.

MUSC Online Health Library Resources:
 What is multiple pregnancy?

Other Online Resources:
Twins, Triplets, Multiple Births - Medlineplus
Preparing for Multiple Births - Nemours Foundation
Multiples Born to Older Moms Fare Same as or Better than Those Born to Younger Moms - National Institute of Child Health and Human Development
Multiples: Twins, Triplets and Beyond - March of Dimes
Pregnant with Multiples - Resolve National Infertility Association
More Multiple Births With Better Survival - American College of Obstetrics & Gynecology
What to Expect when Expecting Twins, Triplets or Quads - Dr. Barbara Luke
When do you deliver twins? - Contemporary Ob/Gyn