Book Review

Multiple Pregnancy and Delivery

N Engl J Med 1996; 335:441-442August 8, 1996

Article

Multiple Pregnancy and Delivery
Edited by Stanley A. Gall. 335 pp., illustrated. St. Louis, Mosby, 1996. $65. ISBN: 0-8151-3406-1

Multiple pregnancies are on the rise. They now account for about 2 percent of all deliveries, up from 1 percent a decade ago. The principal reason for this increase is indisputable. Advances in the induction of ovulation and assisted reproductive techniques have resulted in an “epidemic” of multiple pregnancies. Unfortunately, the increase in twin and higher-order gestations has also increased maternal and perinatal risks. The editor of this timely textbook recognizes that multiple gestations are high risk and focuses on issues specific to such pregnancies.

From the opening chapter on the changing epidemiology of multiple pregnancies to the closing chapter on the short-term and long-term outcomes for the offspring, this book provides useful information for obstetricians. In addition to a review of common problems, there is an emphasis on problems particular to twin and higher-order pregnancies. For example, problems unique to monochorionic gestation, such as twin–twin transfusion syndrome, twin reverse arterial perfusion, monoamniotic gestation, and conjoined twins, are thoroughly discussed. The chapter on placentation provides an excellent explanation of the embryology and underlying etiology of these unique problems.

The disproportionate perinatal morbidity and mortality associated with multiple pregnancies give optimal obstetrical and neonatal management new importance as the incidence of multiple births increases. The chapter on assisted reproduction describes the strategies used to reduce the risk of multiple gestation when fertility therapies are used. Despite these efforts, patients with three or more fetuses continue to be seen by perinatologists. This book includes an excellent discussion of the issues surrounding multifetal pregnancy reduction.

The chapter on genetics and genetic counseling covers important issues relevant to multiple gestations. Monozygotic twins have a higher risk of congenital anomalies than dizygotic twins or singletons. Molecular genetics can be helpful in determining zygosity when twins discordant for various abnormalities are discovered and selective reduction is planned. The role of biochemical screening in twins is still being defined. This is of clinical importance because the risk of chromosomal abnormalities is higher in twins than in singletons.

A major controversy surrounding the intrapartum management of multiple gestations is the optimal route of delivery of twins when the first is in a vertex presentation and the second is in a nonvertex presentation. It is well discussed and referenced. The technique of external cephalic version and total breech extraction as well as the two most serious complications of total breech extraction, nuchal arm and head entrapment, are clearly described and beautifully illustrated.

The chapter on postpartum alterations includes a section on the potential problems of breast-feeding twins, a topic that receives little attention in most obstetrical textbooks. In addition to providing data on the increased risk of postpartum hemorrhage and infection, it would have been fitting to include some of the recent data on the psychological effect of giving birth to more than one infant at a time, although this topic is briefly addressed earlier in the book. Depression and psychological difficulties usually occur post partum, and physicians caring for new mothers need to be aware of this risk.

Despite the fact that perinatal mortality has decreased over the past 30 to 40 years, infants who are the products of multiple pregnancies continue to have poorer outcomes than singletons. There are many unique problems associated with twins that contribute to this higher morbidity and mortality, but the main one remains preterm labor and delivery. Prematurity has a substantial impact on short-term and long-term outcomes for these infants. The information in the chapter on outcome is useful for counseling couples expecting a multiple birth.

Multiple gestations are high risk and require specialized care. For clinicians looking after these patients, this textbook provides a readable and up-to-date reference. The editor's goal was to create a book that would assist “the obstetrician in caring for multiple gestation.” I believe he has achieved that goal.

Lynn L. Simpson, M.D.
New England Medical Center, Boston, MA 02111