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Medical complications associated with multifetal gestation include hyperemesis, hypertension, gestational diabetes, acute fatty liver, anemia, hemorrhage, increased risk of cesarean delivery and postpartum depression.

  • Hyperemesis: The etiology is unclear but may be secondary to higher levels of human chorionic gonadotropin. Treatment for hyperemesis should be the same as with a singleton pregnancy.

  • Hypertensive disorders of pregnancy and preeclampsia

    • Prevalence/etiology: Gestational hypertension and preeclampsia range from 10% to 20% in twins, 25% to 60% in triplets, and up to 90% in quadruplet pregnancies. This is thought to be in part secondary to the larger placental mass. Often, preeclampsia is more atypical in presentation in higher order multiple gestation, occurring earlier in pregnancy and is often more severe.

    • Management: Low-dose aspirin is recommended for preeclampsia prevention in multifetal gestation, starting in the first trimester between 12 weeks and 28 weeks, and ideally prior to 16 weeks. Delivery timing for indication of hypertensive disorders of pregnancy is the same as with singleton pregnancies.

  • Gestational diabetes

    • Prevalence/etiology: There are no official guidelines regarding the timing of screening of gestational diabetes in multiple gestation; however, some experts suggest screening around 20 to 24 weeks given increased incidence of gestational diabetes with multifetal gestation.

    • Management is the same as with a singleton pregnancy, with insulin often preferred as first-line treatment if dietary changes and exercise are not sufficient to achieve euglycemia.

  • Acute fatty liver of pregnancy. Multiple gestation is a risk factor for acute fatty liver and should be considered in a differential when a woman with multiple gestation presents with hepatic dysfunction. Acute fatty liver is one of the imitators of HELLP syndrome. The typical onset is from 27 to 40 weeks' gestation. Symptoms may include malaise, anorexia, nausea, vomiting, and epigastric pain. Physical examination findings include jaundice, hypertension, proteinuria, and/or bleeding from coagulopathy. Typical lab findings include abnormal coagulation factors, elevated creatinine, and/or bilirubin. Maternal morbidity was previously reported as high as 70% but now is thought to be <10% secondary to higher supportive care. Perinatal morbidity and mortality are both increased. Treatment includes supportive care and delivery.