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Triplet pregnancy: Mid and late pregnancy complications and management

David C Jones, MD
Section Editor
Charles J Lockwood, MD, MHCM
Deputy Editor
Vanessa A Barss, MD, FACOG


Triplet pregnancy is associated with significantly increased risks of maternal and neonatal morbidity compared with twin pregnancy. In a study that compared outcomes of 12,193 triplet pregnancies with 316,696 twin pregnancies, triplet pregnancies had significantly higher frequencies of diabetes, anemia, amniotic fluid abnormalities, pregnancy-associated hypertension, eclampsia, cervical insufficiency, uterine bleeding, use of tocolysis, cesarean delivery, abruption, and placenta previa [1].

The management of triplet gestations and pregnancy complications during mid to late pregnancy will be reviewed here. The incidence, diagnosis, and early prenatal care of triplet pregnancy are discussed separately. (See "Triplet pregnancy: Early pregnancy management".)


Preterm delivery is a common, serious complication of triplet gestation: 75 to 100 percent of triplets are born prematurely. The average duration of gestation for singletons, twins, and triplets is 39, 35, and 32 weeks, respectively [2]. About 95 percent of triplets have birth weights <2500 grams (ie, low birth weight [LBW]) and 35 percent <1500 grams (ie, very low birth weight [VLBW]). By comparison, the rates of LBW and VLBW in singletons are 6.5 and 1.1 percent, respectively. A previous pregnancy resulting in the term birth of an appropriately grown neonate is predictive of longer gestation and higher birth weight in a subsequent triplet pregnancy [3].

The primary cause of preterm birth in triplet pregnancy is spontaneous preterm labor, with or without preterm premature rupture of membranes (PPROM). Preeclampsia and fetal growth restriction are the most common causes of indicated preterm birth. These complications are more common in multiple gestations than in singleton gestations and account for a large proportion of the excess rate of preterm birth in multiples.

Overview of monitoring and intervention — No intervention has been proven effective in reducing the incidence of spontaneous preterm birth in triplets. We perform sonographic cervical length measurement at 19 to 20 weeks of gestation to identify women at highest risk of developing preterm labor. While the optimum cervical length threshold for cervical shortening in triplet gestations has not been established, a cervical length of ≤25 mm before 25 weeks in triplet pregnancies appears to be predictive of an increased risk for birth prior to 28 to 32 weeks of gestation and is the threshold we use [4-8]. We also see our patients every other week in the office starting at 24 weeks of gestation to ask about symptoms of preterm labor and perform digital examination and/or cervical length ultrasound if they are symptomatic. In patients over 24 weeks with equivocal findings, we obtain a fetal fibronectin test. Alternatively, one can simply obtain a cervical length every two weeks or a fetal fibronectin every two weeks. The combination of both a positive fetal fibronectin result and a short cervical length on ultrasound examination is more predictive of preterm birth within seven days than either test alone [9,10]. (See "Second-trimester evaluation of cervical length for prediction of spontaneous preterm birth" and "Diagnosis of preterm labor and overview of preterm birth".)


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Literature review current through: Jan 2016. | This topic last updated: May 1, 2014.
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  1. Luke B, Brown MB. Maternal morbidity and infant death in twin vs triplet and quadruplet pregnancies. Am J Obstet Gynecol 2008; 198:401.e1.
  2. Martin, JA, Hamilton, BE, Ventura SJ, et al. Births: Final data for 2009. Natl Vital Stat Rep 2009. http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_01.pdf (Accessed on November 29, 2011).
  3. Luke B, Nugent C, van de Ven C, et al. The association between maternal factors and perinatal outcomes in triplet pregnancies. Am J Obstet Gynecol 2002; 187:752.
  4. Ramin KD, Ogburn PL Jr, Mulholland TA, et al. Ultrasonographic assessment of cervical length in triplet pregnancies. Am J Obstet Gynecol 1999; 180:1442.
  5. Guzman ER, Walters C, O'reilly-Green C, et al. Use of cervical ultrasonography in prediction of spontaneous preterm birth in triplet gestations. Am J Obstet Gynecol 2000; 183:1108.
  6. Poggi SH, Ghidini A, Landy HJ, et al. Predictive value of transvaginal cervical length in triplet pregnancies for spontaneous preterm delivery at < or = 32 weeks. J Matern Fetal Neonatal Med 2002; 12:46.
  7. Fait G, Har-Toov J, Gull I, et al. Cervical length, multifetal pregnancy reduction, and prediction of preterm birth. J Clin Ultrasound 2005; 33:329.
  8. Maslovitz S, Hartoov J, Wolman I, et al. Cervical length in the early second trimester for detection of triplet pregnancies at risk for preterm birth. J Ultrasound Med 2004; 23:1187.
  9. Roman AS, Pessel C, Fox N, et al. Vaginal fetal fibronectin as a predictor of spontaneous preterm delivery in triplet gestations. J Matern Fetal Neonatal Med 2012; 25:1921.
  10. Fox NS, Rebarber A, Roman AS, et al. Combined fetal fibronectin and cervical length and spontaneous preterm birth in asymptomatic triplet pregnancies. J Matern Fetal Neonatal Med 2012; 25:2308.
  11. Moragianni VA, Aronis KN, Craparo FJ. Biweekly ultrasound assessment of cervical shortening in triplet pregnancies and the effect of cerclage placement. Ultrasound Obstet Gynecol 2011; 37:617.
  12. Roman AS, Rebarber A, Pereira L, et al. The efficacy of sonographically indicated cerclage in multiple gestations. J Ultrasound Med 2005; 24:763.
  13. Rebarber A, Roman AS, Istwan N, et al. Prophylactic cerclage in the management of triplet pregnancies. Am J Obstet Gynecol 2005; 193:1193.
  14. Yost NP, Owen J, Berghella V, et al. Effect of coitus on recurrent preterm birth. Obstet Gynecol 2006; 107:793.
  15. Crowther CA, Han S. Hospitalisation and bed rest for multiple pregnancy. Cochrane Database Syst Rev 2010; :CD000110.
  16. Blickstein I, Reichman B, Lusky A, et al. Plurality-dependent risk of severe intraventricular hemorrhage among very low birth weight infants and antepartum corticosteroid treatment. Am J Obstet Gynecol 2006; 194:1329.
  17. Blickstein I, Shinwell ES, Lusky A, et al. Plurality-dependent risk of respiratory distress syndrome among very-low-birth-weight infants and antepartum corticosteroid treatment. Am J Obstet Gynecol 2005; 192:360.
  18. Goldman GA, Dicker D, Peleg D, Goldman JA. Is elective cerclage justified in the management of triplet and quadruplet pregnancy? Aust N Z J Obstet Gynaecol 1989; 29:9.
  19. Bernasko J, Lee R, Pagano M, Kohn N. Is routine prophylactic cervical cerclage associated with significant prolongation of triplet gestation? J Matern Fetal Neonatal Med 2006; 19:575.
  20. Young CM, Stanisic T, Wynn LB, et al. Use of cerclage in triplet pregnancies with an asymptomatic short cervix. J Ultrasound Med 2014; 33:343.
  21. Moragianni VA, Cohen JD, Smith SJ, et al. The role of ultrasound-indicated cerclage in triplets. Ultrasound Obstet Gynecol 2009; 34:43.
  22. Pregnancies and births resulting from in vitro fertilization: French national registry, analysis of data 1986 to 1990. FIVNAT (French In Vitro National). Fertil Steril 1995; 64:746.
  23. Adams DM, Sholl JS, Haney EI, et al. Perinatal outcome associated with outpatient management of triplet pregnancy. Am J Obstet Gynecol 1998; 178:843.
  24. Holcberg G, Biale Y, Lewenthal H, Insler V. Outcome of pregnancy in 31 triplet gestations. Obstet Gynecol 1982; 59:472.
  25. Albrecht JL, Tomich PG. The maternal and neonatal outcome of triplet gestations. Am J Obstet Gynecol 1996; 174:1551.
  26. Alamia V Jr, Royek AB, Jaekle RK, Meyer BA. Preliminary experience with a prospective protocol for planned vaginal delivery of triplet gestations. Am J Obstet Gynecol 1998; 179:1133.
  27. Day MC, Barton JR, O'Brien JM, et al. The effect of fetal number on the development of hypertensive conditions of pregnancy. Obstet Gynecol 2005; 106:927.
  28. Chasen ST, Al-Kouatly HB, Ballabh P, et al. Outcomes of dichorionic triplet pregnancies. Am J Obstet Gynecol 2002; 186:765.
  29. Kawaguchi H, Ishii K, Yamamoto R, et al. Perinatal death of triplet pregnancies by chorionicity. Am J Obstet Gynecol 2013; 209:36.e1.
  30. Matalliotakis IM, Makrigiannakis AS, Giannakopoulou CC, et al. Delayed interval delivery and survival of the two fetuses after second trimester loss of one triplet. Eur J Obstet Gynecol Reprod Biol 1998; 80:159.
  31. Berghella V, Davis GH, Macones GA, Wapner RJ. Prolongation of pregnancy and survival of remaining fetuses after operative evacuation of one triplet at 18 weeks' gestation. Obstet Gynecol 1996; 88:665.
  32. Ziegler WF, Welgoss J. Delayed delivery of a triplet pregnancy without surgical intervention: a case report. Am J Perinatol 1996; 13:191.
  33. Benden D, Miller M, Hatoum N. 39-day delay in delivery of twins. A case report. J Reprod Med 2001; 46:1071.
  34. Peeters SH, Middeldorp JM, Lopriore E, et al. Monochorionic triplets complicated by fetofetal transfusion syndrome: a case series and review of the literature. Fetal Diagn Ther 2012; 32:239.
  35. Davidoff DF, Dickinson JE, Warner T, Pennell CE. Twin-twin transfusion syndrome and twin anemia-polycythemia sequence in a monochorionic triamniotic pregnancy. Twin Res Hum Genet 2013; 16:716.
  36. Konnikova L, Harvey-Wilkes K, Marino T, et al. Clinical dilemma in triplet pregnancy: when is it appropriate to intervene for a jeopardized fetus? J Perinatol 2003; 23:229.
  37. Newman RB, Hamer C, Miller MC. Outpatient triplet management: a contemporary review. Am J Obstet Gynecol 1989; 161:547.
  38. Johnson CD, Zhang J. Survival of other fetuses after a fetal death in twin or triplet pregnancies. Obstet Gynecol 2002; 99:698.
  39. Børlum KG. Third-trimester fetal death in triplet pregnancies. Obstet Gynecol 1991; 77:6.
  40. Elliott JP, Finberg HJ. Biophysical profile testing as an indicator of fetal well-being in high-order multiple gestations. Am J Obstet Gynecol 1995; 172:508.
  41. Rodis JF, Arky L, Egan JF, et al. Comprehensive fetal ultrasonographic growth measurements in triplet gestations. Am J Obstet Gynecol 1999; 181:1128.
  42. Glinianaia SV, Skjaerven R, Magnus P. Birthweight percentiles by gestational age in multiple births. A population-based study of Norwegian twins and triplets. Acta Obstet Gynecol Scand 2000; 79:450.
  43. Vignal J, Daures JP, Vergnes C, et al. Assessment of triplet fetal growth by using cross-sectional analysis of the birth weight. Fetal Diagn Ther 1999; 14:31.
  44. Min SJ, Luke B, Min L, et al. Birth weight references for triplets. Am J Obstet Gynecol 2004; 191:809.
  45. Elster AD, Bleyl JL, Craven TE. Birth weight standards for triplets under modern obstetric care in the United States, 1984-1989. Obstet Gynecol 1991; 77:387.
  46. Blickstein I, Jacques DL, Keith LG. Total and individual triplet birth weights as a function of gestational age. Am J Obstet Gynecol 2002; 186:1372.
  47. Jacobs AR, Demissie K, Jain NJ, Kinzler WL. Birth weight discordance and adverse fetal and neonatal outcomes among triplets in the United States. Obstet Gynecol 2003; 101:909.
  48. Blickstein I, Jacques DL, Keith LG. A novel approach to intertriplet birth weight discordance. Am J Obstet Gynecol 2003; 188:1026.
  49. Feldman DM, Borgida AF, Trymbulak WP, et al. Clinical implications of velamentous cord insertion in triplet gestations. Am J Obstet Gynecol 2002; 186:809.
  50. Shoshani M, Rhea DJ, Keith LG, Blickstein I. Comparison between singleton- and triplet-specific "growth" curves to detect growth restricted triplet infants. J Perinat Med 2007; 35:322.
  51. Ezra Y, Jones J, Farine D. Umbilical artery waveforms in triplet and quadruplet pregnancies. Gynecol Obstet Invest 1999; 47:239.
  52. Kahn B, Lumey LH, Zybert PA, et al. Prospective risk of fetal death in singleton, twin, and triplet gestations: implications for practice. Obstet Gynecol 2003; 102:685.
  53. Luke B. Reducing fetal deaths in multiple births: optimal birthweights and gestational ages for infants of twin and triplet births. Acta Genet Med Gemellol (Roma) 1996; 45:333.
  54. Vintzileos AM, Ananth CV, Kontopoulos E, Smulian JC. Mode of delivery and risk of stillbirth and infant mortality in triplet gestations: United States, 1995 through 1998. Am J Obstet Gynecol 2005; 192:464.
  55. Wildschut HI, van Roosmalen J, van Leeuwen E, Keirse MJ. Planned abdominal compared with planned vaginal birth in triplet pregnancies. Br J Obstet Gynaecol 1995; 102:292.
  56. Grobman WA, Peaceman AM, Haney EI, et al. Neonatal outcomes in triplet gestations after a trial of labor. Am J Obstet Gynecol 1998; 179:942.
  57. Bakos O. Birth in triplet pregnancies. Vaginal delivery--how often is it possible? Acta Obstet Gynecol Scand 1998; 77:845.
  58. Dommergues M, Mahieu-Caputo D, Mandelbrot L, et al. Delivery of uncomplicated triplet pregnancies: is the vaginal route safer? A case-control study. Am J Obstet Gynecol 1995; 172:513.
  59. Stutchfield P, Whitaker R, Russell I, Antenatal Steroids for Term Elective Caesarean Section (ASTECS) Research Team. Antenatal betamethasone and incidence of neonatal respiratory distress after elective caesarean section: pragmatic randomised trial. BMJ 2005; 331:662.
  60. Mordel N, Ezra Y, Benshushan A, et al. Transverse versus longitudinal uterine incision in cesarean delivery of triplets. J Reprod Med 1993; 38:695.
  61. Keith LG, Ameli S, Depp OR, et al. The Northwestern University Triplet Study. II: Fourteen triplet pregnancies delivered between 1981 and 1986. Acta Genet Med Gemellol (Roma) 1988; 37:65.
  62. Syrop CH, Varner MW. Triplet gestation: maternal and neonatal implications. Acta Genet Med Gemellol (Roma) 1985; 34:81.
  63. Weissman A, Jakobi P, Yoffe N, et al. Sonographic growth measurements in triplet pregnancies. Obstet Gynecol 1990; 75:324.
  64. Malone FD, Kaufman GE, Chelmow D, et al. Maternal morbidity associated with triplet pregnancy. Am J Perinatol 1998; 15:73.
  65. Guilherme R, Drunat S, Delezoide AL, et al. Zygosity and chorionicity in triplet pregnancies: new data. Hum Reprod 2009; 24:100.
  66. DeJesus Allison SO, Javitt MC, Glanc P, et al. ACR Appropriateness Criteria® Multiple gestations. Ultrasound Q 2012; 28:149.
  67. Raju TN, Mercer BM, Burchfield DJ, Joseph GF Jr. Periviable birth: executive summary of a joint workshop by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Academy of Pediatrics, and American College of Obstetricians and Gynecologists. Am J Obstet Gynecol 2014; 210:406.