Increased severe maternal morbidity with multiple gestation pregnancies

1. Women with multiple gestation pregnancies (e.g. twins, triplets) were more likely to experience ICU admission, hemorrhage and maternal death.

2. Older age, nulliparity, and fertility treatments were associated with increased risk of severe maternal morbidity.

Evidence Rating Level: 2 (Good)           

Study Rundown: The incidence of multiple births is increasing in the United States, largely due to increased utilization of assisted reproductive technologies (ART) treatments. It is known that infants of multiple gestation pregnancies are more likely to experience complications including preterm birth, fetal growth restriction, and various congenital abnormalities. While extensive work has been done to study neonatal morbidity in multiple gestation pregnancies, less is known about maternal morbidity in this population. Prior studies identified increased incidence of preeclampsia, anemia, cesarean delivery and postpartum hemorrhage in these women. In the present work, authors studied the combined relative risk of severe acute maternal morbidity (SAMM) in women in the Netherlands. They found that multiple gestation pregnancies were associated with increased risk for SAMM, specifically ICU admission, eclampsia, hemorrhage, and death; they also found that age, use of ART, and need for labor induction were associated with greater risk for SAMM. Findings highlight increased maternal risks of multiple pregnancies and identify women at greatest risk for complications who may require closer monitoring during pregnancy and labor.

Strengths of the study included a large, nation-wide population database and evaluation of both individual and combined maternal outcomes. The study was limited primarily by inability to adjust for possible confounders. Additional prospective studies are needed to confirm findings and inform possible interventions to reduce maternal morbidity in this growing population.

Click to read the study in AJOG

Relevant Reading: Maternal morbidity and mortality associated with multiple gestations

In-Depth [prospective cohort]: This study assessed the incidence of SAMM in singleton (n = 358 369) and multiple (n = 7225) pregnancies. SAMM outcomes of interest included ICU admission, uterine rupture, eclampsia, major obstetric hemorrhage, and a miscellaneous morbidities category.

Women with multiple pregnancies were more likely to experience SAMM (RR 4.3, CI 3.7-5.0), including ICU admission, eclampsia, major hemorrhage and death. Compared to women with singleton pregnancies experiencing SAMM, those with multiple pregnancies were more likely to be older (p < 0.05), nulliparous (p < 0.001) and have conceived through ART (p < 0.001).

Image: PD

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