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In antepartum management of multiple gestation, this review discusses studies covering the outcome of bedrest, use of ultrasound to assess fetal outcome, management of monoamniotic twins, and outcome of higher-order gestation. Studies comparing modes of delivery are also discussed.

Diabetic pregnancies complicated by preeclampsia are of concern because of poor perinatal outcome. However, with improved maternal and fetal surveillance the impact of preeclampsia in diabetic pregnancies is declining. This prospective controlled study compared the incidence of preeclampsia and maternal-fetal outcome in 334 diabetic pregnancies and 16,534 nondiabetic pregnancies. The incidence of preeclampsia was 9.9% (33/334) in diabetic pregnancies compared with 4.3% (716/16,534) in nondiabetic controls. The incidence of preeclampsia rose with increasing severity of diabetes by White classification, but was still 8.9% after exclusion of diabetic patients with nephropathy or chronic hypertension. The perinatal mortality rate per 1000 births was 60 for preeclamptic diabetic patients compared with 3.3 for normotensive diabetic patients. Parity, maternal age, and blood glucose control were similar in preeclamptic diabetic patients compared with normotensive diabetic patients. We conclude that preeclampsia is twice as common in diabetic pregnancies compared with normal controls.

1. The use of ultrasound may improve perinatal outcome in twin pregnancy. 2. Singleton growth curves for FL, BPD, and AC may be used to assess fetal growth prior to 28 weeks gestation. 3. After 28 weeks gestation, specific twin growth curves should be used. However, increased morbidity may be seen when fetal weight falls from the normal singleton predictive curves. 4. Amnionicity and chorionicity frequently can be determined. This should be attempted early in the second trimester so that appropriate monitoring can be offered for the monoamnionic and monochorionic gestations. 5. Serial assessment of fetal growth should be performed. In the authors' institutions, growth scans are performed in twins every 2 weeks after 24 weeks gestation. 6. Evidence on ultrasound examination of discordant growth suggests either fetal growth retardation or TTS. In the presence of a dichorionic placentation, growth retardation of one twin is the usual diagnosis. If placentation is monochorionic, it is difficult to differentiate between growth retardation and TTS. The presence of polyhydramnios, a stuck twin, or fetal hydrops are suggestive of TTS. 7. The value and safety of cordocentesis and the management of twin pregnancy and diagnosis of TTS have not been established. 8. Doppler ultrasound may be useful in the assessment of the IUGR twin fetus. The use of Doppler in the identification of TTS is not yet clear.

Fifteen cases were reviewed over a five-year period at a perinatal centre with intrauterine demise of one member of a multiple gestation. Nine cases were monozygotic twin pairs, two were dizygotic, and two were triples . Gestational age ranged from 27 to 39 weeks. The management protocol consisted of delivery in all cases after confirmation of the diagnosis. In 4 cases delivery was immediate because of spontaneous labor. In the other cases elective delivery was performed if the gestational age was 37 weeks or greater or there was evidence of preeclampsia or if amniocentesis revealed a mature lecithinsphingomyelin (L/S) ratio. Steroids were given if the L/S was immature or the attempt at amniocentesis was unsuccessful and delivery was performed 48 hours after initiation of steroid therapy. Cesarean section was the mode of delivery in 14 of the 15 cases. All of the cotwins and cotriplets survived. One survivor of a monozygous twin pair has multicystic encephalomalacia possibly implicating perinatal arterial occlusion or in utero disseminated intravascular coagulation (DIC). The intrauterine deaths are categorized into possibly avoidable deaths (2/15), unavoidable due to congenital anomalies (3/15), and unknown or unavoidable deaths (8/15).

The embryology and onset time of gastroschisis are poorly understood. This paper reviews 22 cases of the condition seen at the Children's Hospital of Eastern Ontario between 1975 and 1986. Sixteen cases were judged to be of the perinatal and 6 of the early type. Ultrasonography revealed the actual time of development in one case and the probable time in another. In 20 cases the defect was closed primarily and in 2 by a staged procedure (Silon pouch). Nineteen infants (86.4%) survived. In all cases the umbilical vasculature was normal and all were right-sided. Other anomalies were rare and less important. Two clear examples of rupture of the umbilical ring are documented. Ultrasonography had been performed in 10 infants, usually for intrauterine growth retardation, and gastroschisis was diagnosed in 4 of these. Delivery was by cesarean section in six. Marked meconium staining occurred in 16 (73%), 7 of whom had subglottic aspiration of meconium. The average birth weight was 2480 g. Ultrasonography is recommended in all cases of intrauterine growth retardation with careful examination of the umbilical area to establish the presence and time of onset of gastroschisis. Vaginal delivery appears to be the route of choice for delivery.

Dystocia continues to be the leading indication for caesarean birth. The active management of labour as developed in Dublin is one approach that could be applied to the problem. It is not generally appreciated, however, that the word 'active' describes the active involvement of the consultant obstetrician and not medical intervention with oxytocin infusions. In this article, the Dublin protocol is reviewed in broad perspective and is compared to more traditional North American methods of dealing with dysfunctional labour.

Two cases of acute polyhydramnios complicating twin pregnancies were treated with repeated amniocentesis for the relief of extreme abdominal discomfort and to prevent imminent premature labor. The procedure was found to be safe and resulted in prolonging the pregnancies by 14 to 11 days respectively. This management, with the addition of tocolysis and close fetal surveillance (which resulted in 2/4 living children) can offer some hope in an otherwise hopeless situation.

In a prospective study of 69 consecutive twin gestations, chorionicity was assessed ultrasonographically, by the new technique of counting the number of layers visualized in the dividing membrane. For purposes of the study the antenatal categorization of chorionic type was based only on the number of layers observed. The pregnancy was classified as monochorionic when only two layers were identified and as dichorionic if three or four layers were seen. Confirmation of chorionic type was obtained after delivery by histopathologic examination of the placenta. The ultrasonographic technique used correctly determined chorionicity in 68 of 69 twin pregnancies. The predictive accuracy was 100% for 51 pregnancies designated by ultrasonography as dichorionic and 94.4% for 18 pregnancies considered to be monochorionic. These results suggest that counting the number of layers seen in fetal membranes by ultrasonography examination is an accurate way of determining chorionicity in twin gestation.

Fetal pulmonary maturity is generally determined by analyzing amniotic fluid for surfactants. This task is accomplished by lipid extraction of the fluid and resolution, identification and quantitation of the isolated lipids with thin-layer chromatography. These methods are lengthy, cumbersome and often not available on demand. A quick, simple, reliable and economical test therefore would be highly desirable. We have been able to correlate an optical density (OD) reading of amniotic fluid at 650 nm greater than or equal to 0.15 with the absence of hyaline membrane disease (HMD). For 428 fluids in which an OD reading of greater than or equal to 0.15 was found and delivery occurred within 48 hours, HMD was present in only two infants. The accuracy of the test was 99.53% , with a false-positive rate of 0.47%. With the use of this simple and accurate test one can satisfy the requirement of an on-demand test to determine fetal pulmonary maturity.

Ultrasonographic measurement of fetal foot length is useful in the assessment of gestational age. Two hundred twenty-three postpartum and 224 ultrasonographic measurements were performed between 11 and 43 weeks' gestation; 207 postpartum and 160 ultrasonographic measurements met our requirements of secure dates and no physical anomaly or maternal disease. Mean foot length at each week of gestation compared favorably with Streeter's data, based on pathologic specimens, described in 1920. Comparison of curvilinear regression of foot length versus gestational age demonstrated a strong correlation with an R2 value of 0.981; 95% confidence intervals at each week compared favorably with both biparietal diameter and femur length data. Fetal foot length is a reliable parameter for use in the assessment of gestational age and is particularly useful when other parameters do not accurately predict gestational age, for example, hydrocephalus, anencephaly, short limb dysplasia.

A 38-year-old woman, gravida 5, para 3, with a triplet pregnancy discordant for anencephaly, is reported. The diagnosis was made prenatally by ultrasound. Autopsy of the anencephalic member revealed small adrenal glands with absent fetal cortex, and a coincidental tetralogy of Fallot. Studies of the histocompatible lymphocyte antigens of both parents were performed and they failed to demonstrate HLA B-27. The literature on anencephaly in triplets is summarized. The association of congenital heart disease and HLA B-27 with anencephaly is discussed.