Obstetric Management and Neonatal Implications of Higher-Order Multiple Pregnancies

Triplet and higher-order multifetal pregnancies are associated with significant obstetric complexity and neonatal morbidity. The rise of multifetal gestations is mostly attributed to advances in assisted reproductive technology; however, more recent practice changes aim to reduce the incidence given the associated risks. Recommendations for enhanced antepartum care include additional screening for obstetric complications, tailored ultrasonography surveillance, and counseling regarding interventions for risk reduction, including multifetal pregnancy reduction. Chorionicity remains the primary determinant of risk of perinatal mortality, with additional surveillance required for monochorionic twin pairs because of the complexity of shared placentation. Neonatal outcomes are largely driven by complications associated with prematurity, including respiratory distress syndrome, intraventricular hemorrhage, necrotizing enterocolitis, feeding immaturity, and prolonged neonatal intensive care unit hospitalization. Infants from monochorionic pairs within higher-order gestations may require specialized evaluation for cardiovascular compromise, anemia, and other sequelae of shared placentation. Delivery planning requires coordination across obstetric, neonatal, and other indicated specialty teams, with anticipation of simultaneous resuscitation and stabilization of multiple preterm infants. This review summarizes current evidence and consensus recommendations from the American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, and American Academy of Pediatrics to guide the comprehensive management of higher-order multifetal pregnancies and optimize neonatal outcomes.