Anemia of Prematurity - Portal Neonatal

• Delivery room management of infants from multifetal pregnancies requires adequate
personnel skilled in neonatal resuscitation. Infants from multifetal pregnancies are at
increased risk of birth asphyxia and respiratory distress syndrome (RDS). Such infants may
require bag mask ventilation and endotracheal intubation in the delivery room.
• Partial exchange transfusion may be necessary in donor or recipient twins from TTTS.
o Partial exchange transfusions are used to increase hemoglobin concentrations in
anemic donor twins while maintaining euvolemia. Small aliquots (5-15 cc) of packed
red blood cells (RBCs) are infused (usually via an umbilical venous catheter) following
removal of an equal volume of the infant's blood until a desired hemoglobin is
attained. The transfused packed RBCs should be appropriately cross-matched,
cytomegalovirus (CMV) negative, and irradiated.
o Partial exchange transfusions are used to decrease hemoglobin concentrations in
polycythemic recipient twins while maintaining euvolemia. Small aliquots (5-10 cc) of
fresh frozen plasma are infused (usually via an umbilical venous catheter) following
removal of an equal volume of the infant's blood until a desired hemoglobin is
attained.
Consultations: A woman with multiple gestation pregnancy may benefit from a consultation with a
perinatologist. A neonatologist may be involved in the postnatal care of multiple birth infants,
particularly if the births are premature or if congenital anomalies are present.
FOLLOW-UP Section 6 of 9
Complications:
• Prematurity: Infants from multifetal pregnancies are more likely to be born prematurely and to
require neonatal intensive care. Approximately 50% of twin deliveries occur before 37 weeks'
gestation. The length of gestation decreases inversely with the number of fetuses present.
Infants from multifetal pregnancies represent 20% of very low birth weight infants.
• Hyaline membrane disease: Twins born at fewer than 35 weeks' gestation are twice as likely
to develop hyaline membrane disease (HMD) as single birth infants born at fewer than 35
weeks' gestation are. Prevalence of HMD is greater in monozygotic than in dizygotic twins.
Concordance rate for HMD (ie, both twins have HMD) is greater in monozygotic than in
dizygotic twins. If the twins are discordant for HMD, then the second twin is more likely to
develop HMD than the first twin.
• Birth asphyxia/perinatal depression: Newborns from multiple gestation pregnancies have an
increased frequency of perinatal depression and birth asphyxia from a variety of causes.
Umbilical cord entanglement, locked twins, a prolapsed umbilical cord, placenta previa, and
uterine rupture can occur and result in asphyxiation of an infant. Occurrence of cerebral palsy
is 6 times more common in twin births and 30 times more common in triplet births than in
single births. Monochorionic/monoamniotic twins are at highest risk for cord entanglement.
The second-born twin is at greatest risk for birth asphyxia/perinatal depression.
• GBS infections: Early onset GBS infections in low birth weight infants are nearly 5-fold greater
than in average weight singletons.
• Vanishing twin syndrome: Early ultrasound diagnosis has revealed that as many as one half of
all twin pregnancies result in the delivery of only a single fetus. The second twin vanishes.
Intrauterine demise of one twin can result in neurologic sequelae in the surviving twin. Acute
exsanguination of the surviving twin into the relaxed circulation of the deceased twin can result
in intrauterine CNS ischemia.
• Congenital anomalies/acardia/twin reversed arterial perfusion sequence: Congenital
anomalies more commonly develop in twins than in a single fetus. CNS, cardiovascular, and
GI defects occur with increased frequency. Monozygotic twins have increased prevalence of
deformations secondary to intrauterine space constraints. Common deformations in twins
include limb defects, plagiocephaly, facial asymmetry, and torticollis. Acardia is a rare
anomaly unique to multiple gestation. In this condition, one twin has an absent or rudimentary