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Neonatal complications, outcome, and management of multiple births

George T Mandy, MD
Section Editor
Leonard E Weisman, MD
Deputy Editor
Melanie S Kim, MD


Multiple births are increasing in the United States and contribute disproportionately to perinatal and neonatal mortality and morbidity. (See "Perinatal mortality", section on 'Multifetal pregnancies'.)

The complications, outcome, and pediatric management of multiple births are reviewed here. The antenatal management of twins and triplets, and monoamniotic twin pregnancy are discussed separately. (See "Twin pregnancy: Prenatal issues" and "Twin pregnancy: Labor and delivery" and "Monoamniotic twin pregnancy" and "Triplet pregnancy: Mid and late pregnancy complications and management" and "Triplet pregnancy: Early pregnancy management".)


Twins and triplets naturally occur in approximately 1 in 80 and 1 in 8000 pregnancies, respectively, in the United States [1,2]. The incidence of spontaneous twins varies by country and is lower in Canada and South China [3,4].

Multiple pregnancies has comprised an increasing proportion of the total pregnancies in the developed world due to older maternal age at childbirth and the expanded use of fertility treatments [5,6]. In the United States, 36 percent of twin pregnancies and 77 percent of triplet and higher order pregnancies occur after infertility treatment [5]. (See "Twin pregnancy: Prenatal issues", section on 'Prevalence and epidemiology'.)

In the United States, twin births account for 3.4 percent of live births and over 96 percent of multiple births [7]. The number of twin pregnancies increased by 76 percent from 1980 through 2009 and stabilized with a birth rate of 33.7 per 1000 births in 2013 [7]. The peak incidence of triplets, quadruplets, or higher order pregnancies occurred in 1998 with a rate of 193.5 per 100,000 live births in 1998, and has decreased to a rate of 119.5 per 100,000 births in 2013 [7]. The decline in triplet and higher order multiple birth rates is due to changes in assisted reproductive technology. (See "Strategies to control the rate of high order multiple gestation", section on 'Limiting the multiple gestation risk of ART' and "In vitro fertilization", section on 'Embryo transfer'.)


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Literature review current through: Oct 2015. | This topic last updated: Aug 19, 2015.
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  1. Benirschke K, Kim CK. Multiple pregnancy. 1. N Engl J Med 1973; 288:1276.
  2. Benirschke K, Kim CK. Multiple pregnancy. 2. N Engl J Med 1973; 288:1329.
  3. Lu X, Zhang J, Liu Y, et al. Epidemiology of twin births in southeast China: 1993-2005. Twin Res Hum Genet 2013; 16:608.
  4. Fell DB, Joseph K. Temporal trends in the frequency of twins and higher-order multiple births in Canada and the United States. BMC Pregnancy Childbirth 2012; 12:103.
  5. Kulkarni AD, Jamieson DJ, Jones HW Jr, et al. Fertility treatments and multiple births in the United States. N Engl J Med 2013; 369:2218.
  6. Tandberg A, Bjørge T, Nygård O, et al. Trends in incidence and mortality for triplets in Norway 1967-2006: the influence of assisted reproductive technologies. BJOG 2010; 117:667.
  7. Martin JA, Hamilton BE, Osterman MJ, et al. Births: final data for 2013. Natl Vital Stat Rep 2015; 64:1.
  8. Gezer A, Rashidova M, Güralp O, Oçer F. Perinatal mortality and morbidity in twin pregnancies: the relation between chorionicity and gestational age at birth. Arch Gynecol Obstet 2012; 285:353.
  9. Spellacy WN, Handler A, Ferre CD. A case-control study of 1253 twin pregnancies from a 1982-1987 perinatal data base. Obstet Gynecol 1990; 75:168.
  10. Roberts WE, Morrison JC, Hamer C, Wiser WL. The incidence of preterm labor and specific risk factors. Obstet Gynecol 1990; 76:85S.
  11. Bodeau-Livinec F, Zeitlin J, Blondel B, et al. Do very preterm twins and singletons differ in their neurodevelopment at 5 years of age? Arch Dis Child Fetal Neonatal Ed 2013; 98:F480.
  12. Arlettaz Mieth R, Ersfeld S, Douchet N, et al. Higher multiple births in Switzerland: neonatal outcome and evolution over the last 20 years. Swiss Med Wkly 2011; 141:w13308.
  13. Blondel B, Kogan MD, Alexander GR, et al. The impact of the increasing number of multiple births on the rates of preterm birth and low birthweight: an international study. Am J Public Health 2002; 92:1323.
  14. Rydhstroem H, Heraib F. Gestational duration, and fetal and infant mortality for twins vs singletons. Twin Res 2001; 4:227.
  15. Donovan EF, Ehrenkranz RA, Shankaran S, et al. Outcomes of very low birth weight twins cared for in the National Institute of Child Health and Human Development Neonatal Research Network's intensive care units. Am J Obstet Gynecol 1998; 179:742.
  16. Yeo KT, Lee QY, Quek WS, et al. Trends in Morbidity and Mortality of Extremely Preterm Multiple Gestation Newborns. Pediatrics 2015; 136:263.
  17. Ribicic R, Kranjcec I, Borosak J, et al. Perinatal outcome of singleton versus twin late preterm infants: do twins mature faster than singletons? J Matern Fetal Neonatal Med 2015; :1.
  18. Petit N, Cammu H, Martens G, Papiernik E. Perinatal outcome of twins compared to singletons of the same gestational age: a case-control study. Twin Res Hum Genet 2011; 14:88.
  19. Hamilton BE, Martin JA, Ventura SJ. Births: preliminary data for 2005. Natl Vital Stat Rep 2006; 55:1.
  20. Fox NS, Rebarber A, Klauser CK, et al. Intrauterine growth restriction in twin pregnancies: incidence and associated risk factors. Am J Perinatol 2011; 28:267.
  21. Manzanares S, Sanchez-Gila M, Moreno-Martinez MD, et al. Perinatal outcomes in preterm growth-restricted twins: effects of gestational age and fetal condition. Twin Res Hum Genet 2013; 16:727.
  22. Hartley RS, Hitti J, Emanuel I. Size-discordant twin pairs have higher perinatal mortality rates than nondiscordant pairs. Am J Obstet Gynecol 2002; 187:1173.
  23. Demissie K, Ananth CV, Martin J, et al. Fetal and neonatal mortality among twin gestations in the United States: the role of intrapair birth weight discordance. Obstet Gynecol 2002; 100:474.
  24. Branum AM, Schoendorf KC. The effect of birth weight discordance on twin neonatal mortality. Obstet Gynecol 2003; 101:570.
  25. Victoria A, Mora G, Arias F. Perinatal outcome, placental pathology, and severity of discordance in monochorionic and dichorionic twins. Obstet Gynecol 2001; 97:310.
  26. Blickstein I, Kalish RB. Birthweight discordance in multiple pregnancy. Twin Res 2003; 6:526.
  27. Blickstein I, Jacques DL, Keith LG. A novel approach to intertriplet birth weight discordance. Am J Obstet Gynecol 2003; 188:1026.
  28. Breathnach FM, Malone FD. Fetal growth disorders in twin gestations. Semin Perinatol 2012; 36:175.
  29. Schinzel AA, Smith DW, Miller JR. Monozygotic twinning and structural defects. J Pediatr 1979; 95:921.
  30. Sebire NJ, Snijders RJ, Hughes K, et al. The hidden mortality of monochorionic twin pregnancies. Br J Obstet Gynaecol 1997; 104:1203.
  31. Bermúdez C, Becerra CH, Bornick PW, et al. Placental types and twin-twin transfusion syndrome. Am J Obstet Gynecol 2002; 187:489.
  32. Zosmer N, Bajoria R, Weiner E, et al. Clinical and echographic features of in utero cardiac dysfunction in the recipient twin in twin-twin transfusion syndrome. Br Heart J 1994; 72:74.
  33. Jones KL. Smith's recognizable patterns of human malformation, 6th ed, Elsevier Saunders, Philadelphia 2006.
  34. Coulam CB, Wright G. First trimester diagnosis of acardiac twins. Early Pregnancy 2000; 4:261.
  35. Su LL. Monoamniotic twins: diagnosis and management. Acta Obstet Gynecol Scand 2002; 81:995.
  36. Suzuki S, Kaneko K, Shin S, Araki T. Incidence of intrauterine complications in monoamniotic twin gestation. Arch Gynecol Obstet 2001; 265:57.
  37. Spitz L, Kiely EM. Conjoined twins. JAMA 2003; 289:1307.
  38. Métneki J, Czeizel A. Conjoined twins in Hungary, 1970-1986. Acta Genet Med Gemellol (Roma) 1989; 38:285.
  39. Spencer R. Anatomic description of conjoined twins: a plea for standardized terminology. J Pediatr Surg 1996; 31:941.
  40. Mackenzie TC, Crombleholme TM, Johnson MP, et al. The natural history of prenatally diagnosed conjoined twins. J Pediatr Surg 2002; 37:303.
  41. Cywes S, Millar AJ, Rode H, Brown RA. Conjoined twins--the Cape Town experience. Pediatr Surg Int 1997; 12:234.
  42. Spitz L, Kiely E. Success rate for surgery of conjoined twins. Lancet 2000; 356:1765.
  43. Morikawa M, Yamada T, Yamada T, et al. Prospective risk of intrauterine fetal death in monoamniotic twin pregnancies. Twin Res Hum Genet 2012; 15:522.
  44. Fernández-Miranda Mde L, Cruceyra Bertriu M, Rodríuez-González R, et al. [Twin pregnancy with intrauterine death of one fetus: maternal and neonatal outcome of surviving fetus]. Ginecol Obstet Mex 2012; 80:254.
  45. Fichera A, Zambolo C, Accorsi P, et al. Perinatal outcome and neurological follow up of the cotwins in twin pregnancies complicated by single intrauterine death. Eur J Obstet Gynecol Reprod Biol 2009; 147:37.
  46. Hillman SC, Morris RK, Kilby MD. Single twin demise: consequence for survivors. Semin Fetal Neonatal Med 2010; 15:319.
  47. Glinianaia SV, Pharoah PO, Wright C, et al. Fetal or infant death in twin pregnancy: neurodevelopmental consequence for the survivor. Arch Dis Child Fetal Neonatal Ed 2002; 86:F9.
  48. Taylor CL, de Groot J, Blair EM, Stanley FJ. The risk of cerebral palsy in survivors of multiple pregnancies with cofetal loss or death. Am J Obstet Gynecol 2009; 201:41.e1.
  49. Aydın B, Dilli D, Zenciroğlu A, et al. Can intrauterine death of a co-twin result in renal failure in the survivor? Ren Fail 2013; 35:544.
  50. Giannantonio C, Semeraro CM, Fioretti M, et al. Renal failure of the surviving fetus after intrauterine death of the co-twin. Fetal Pediatr Pathol 2012; 31:336.
  51. Friedman S, Flidel-Rimon O, Lavie E, Shinwell ES. The effect of prenatal consultation with a neonatologist on human milk feeding in preterm infants. Acta Paediatr 2004; 93:775.
  52. Czeszyńska MB, Kowalik K. Multiple pregnancy: factors contributing to early infant's breast-feeding--own experience. Acta Genet Med Gemellol (Roma) 1998; 47:191.
  53. Flidel-Rimon O, Shinwell ES. Breast feeding twins and high multiples. Arch Dis Child Fetal Neonatal Ed 2006; 91:F377.
  54. Damato EG, Dowling DA, Standing TS, Schuster SD. Explanation for cessation of breastfeeding in mothers of twins. J Hum Lact 2005; 21:296.
  55. Berlin CM. "Exclusive" breastfeeding of quadruplets. Breastfeed Med 2007; 2:125.
  56. Mead LJ, Chuffo R, Lawlor-Klean P, Meier PP. Breastfeeding success with preterm quadruplets. J Obstet Gynecol Neonatal Nurs 1992; 21:221.
  57. Saint L, Maggiore P, Hartmann PE. Yield and nutrient content of milk in eight women breast-feeding twins and one woman breast-feeding triplets. Br J Nutr 1986; 56:49.
  58. Leonard LG. Breastfeeding higher order multiples: enhancing support during the postpartum hospitalization period. J Hum Lact 2002; 18:386.
  59. Leonard LG. Breastfeeding rights of multiple birth families and guidelines for health professionals. Twin Res 2003; 6:34.
  60. Leonard LG. Depression and anxiety disorders during multiple pregnancy and parenthood. J Obstet Gynecol Neonatal Nurs 1998; 27:329.
  61. Choi Y, Bishai D, Minkovitz CS. Multiple births are a risk factor for postpartum maternal depressive symptoms. Pediatrics 2009; 123:1147.
  62. Ellison MA, Hotamisligil S, Lee H, et al. Psychosocial risks associated with multiple births resulting from assisted reproduction. Fertil Steril 2005; 83:1422.
  63. Harrigan R, Naber MM, Jensen KA, et al. Perinatal grief: response to the loss of an infant. Neonatal Netw 1993; 12:25.
  64. Bryan E. The impact of multiple preterm births on the family. BJOG 2003; 110 Suppl 20:24.
  65. Malone FD, Chelmow D, Athanassiou A, D'Alton ME. Impact of gestational age at delivery of the economics of triplet pregnancy. J Matern Fetal Med 1999; 8:256.
  66. Robin M, Josse D, Tourrette C. Forms of family reorganization following the birth of twins. Acta Genet Med Gemellol (Roma) 1991; 40:53.
  67. Matthews TJ, MacDorman MF. Infant mortality statistics from the 2010 period linked birth/infant death data set. Natl Vital Stat Rep 2013; 62:1.
  68. Lorenz JM. Neurodevelopmental outcomes of twins. Semin Perinatol 2012; 36:201.
  69. Wadhawan R, Oh W, Vohr BR, et al. Neurodevelopmental outcomes of triplets or higher-order extremely low birth weight infants. Pediatrics 2011; 127:e654.
  70. Feldman R, Eidelman AI. Triplets across the first 5 years: the discordant infant at birth remains at developmental risk. Pediatrics 2009; 124:316.
  71. Natalucci G, Iten M, Hofmann J, et al. Health-related quality of life and behavior of triplets at adolescent age. J Pediatr 2012; 161:495.