Protocols for Monitoring of Multiple Pregnancies: A Literature Review.

Charalampos Tsimpoukelis 1 , Sofoklis Stavros 2 , Despoina Mavrogianni 1 , Peter Drakakis 1,2

1. First Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece.

2. Third Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Attikon Hospital, Athens, Greece.

Corresponding Author: Charalampos Tsimpoukelis, First Department of Obstetrics and Gynecology, National and Kapodistrian University of Athens, Alexandra Hospital, Athens, Greece.

Copy Right: © 2023 Charalampos Tsimpoukelis, This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: April 13, 2023

Published Date: May 10, 2023

Abstract

Introduction The incidence of multiple pregnancies has increased over the past decades, mainly due to the use of assisted reproduction methods and increased maternal age at childbirth. Indicatively in the United States, the birth rate of multiple pregnancies has increased dramatically since 1980, reaching a peak in 2014, with a slight decrease since then, reaching 33 per 1000 births in 2019. From 1980 to 2009, the twin birth rate rose 76%, with little fluctuation until 2019, when it was 32.1 per 1,000 births. The triplet and higher order multiple birth rate increased more than 400% from 1980 to 1998. In 2019, it stood at 0.87 per 1,000 births, a 55% decrease from the peak in 1998, due to fewer embryos being transferred during IVF and an increase in fetal reduction procedures. In terms of the mechanisms of generation and risk factors of multiple pregnancies, there are differences between monozygotic and dizygotic twins. In monozygotic twins, depending on the period when the spontaneous division of the incipient developing embryo occurs, different combinations of amnionicity and chorionicity arise. Their creation is due to random non-hereditary factors. Their prevalence is relatively stable and is not affected by patient-specific factors, except for pregnancies resulting from IVF techniques, which appear to increase the risk of zygote cleavage. In contrast, dizygotic twins result from the independent fertilization of two ova during one ovulatory cycle. Their prevalence varies between populations. Risk factors for dizygotic twin pregnancies include black race, advanced maternal age, increased maternal weight and height, multiparity, family history of multiple pregnancies, high levels of follicle-stimulating hormone (FSH), and infertility treatment with techniques of multiple ovulation in combination with multiple embryo transfer.

Objectives-Methods: The aim of this paper is to review the issues and complications associated with twin and triplet pregnancies and to present an evidence-based approach to the management and monitoring of these pregnancies according to chorionicity and amnionicity. A literature review was performed including studies up to June 2022. The following electronic databases were searched to identify articles for the systematic review: MEDLINE, PubMed-NCBI, Cochrane Library, Cochrane Central Register of Controlled Trials, EMBASE and Scopus. In addition, guidelines relevant to the topic of the work were searched in the following: ACOG, NICE, ISUOG, and HSOG. Results: This paper first analyzed both the initial prenatal assessment and prenatal care in the second and third trimesters for singleton pregnancies and then reviewed twin and triplet pregnancies. In regard to multiple pregnancies, the way of diagnosis, determination of the gestational age and the chorionicity and amnionicity, and labeling of the fetuses was initially presented. Subsequently, a distinction was made between maternal, including preeclampsia and gestational diabetes mellitus, perinatal, and fetal complications of multiple pregnancies. In the latter, a further division was made into complications that characterize all multiple pregnancies (preterm birth, growth restriction and discordance, congenital anomalies), complications that occur exclusively in monochorionic multiple pregnancies [twin-twin transfusion syndrome (TTTS), twin anemia polycythemia sequence (TAPS), twin reversed arterial perfusion (TRAP), and selective fetal growth restriction (sFGR)], and complications which concern only monoamniotic multiple pregnancies (intertwin cord entanglement, conjoined twins). At the same time, reference was made to the management of the above complications. Then, special mention was made of how to deal with single fetal demise in twin and triplet pregnancies, and of the cases of multifetal pregnancy reduction and selective termination. Consequently, an attempt was made to record and present prenatal care in twin and triplet pregnancies as completely as possible. In more detail, the issue of education and promotion of pregnant women's health was initially touched upon.

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