Obstetric management of high-order multiple pregnancies.

High-order multiples are increasingly common as a result of assisted reproductive technologies and represent pregnancies at exceptional risk. This article discusses the antepartum management of high-order multiples, which has in general been highly individualized and poorly studied. Care for high-order multiples should include preterm birth prevention education, the frequent assessment of maternal symptoms and cervical status by a consistent provider, individualized modification of activity, attention to maternal nutrition, ultrasonography for the assessment of fetal anatomy and intra-uterine growth and anticipation of maternal complications. Interventions such as prophylactic cerclage, uterine activity monitoring, prophylactic tocolysis or hospitalization have not improved outcome when used routinely, and guidelines for selective use will be presented. Specialized care for high-order multiples should be directed at identifying congenital anomalies, maximizing fetal growth and preventing early preterm birth, the effect of which will be to improve perinatal outcome for these exceptional pregnancies.