Antepartum care in multiple gestation.

Multiple gestation carries a significant risk of perinatal complications and mortality. Often twin neonates are delivered small and early with a perinatal mortality rate five to seven times that of singleton neonates. Increased morbidity and mortality is due to an increased incidence of antepartum complications, monozygotic pathology, preterm labor, and uteroplacental insufficiency. The key to management is early diagnosis, risk assessment, serial ultrasonography for fetal growth, and antepartum testing from 28 weeks until delivery. Prophylactic cerclage or tocolysis have not proven valuable. Reduction of maternal activity (bedrest) has theoretical advantages and is supported by retrospective studies, but not by prospective trials. The timing of delivery is based on the usual considerations. Third trimester uteroplacental insufficiency is identified by serial ultrasonographic exam and antepartum testing. Discordant fetal testing creates a dilemma: the risk of continued hypoxic damage to the sicker twin and the risks of premature delivery in the healthy twin. The management of this dilemma should be based on as much information as possible, ie, oxytocin challenge testing, biophysical profile and fetal lung maturity studies, and as much experience as possible, ie, a perinatal center, equipped to handle very sick premature infants.