Multiple pregnancies are inherently higher risk than singletons. They carry elevated rates of preterm birth, growth restriction, hypertensive disorders, gestational diabetes, and perinatal morbidity. For a surrogate the physical burden increases, as does the necessity for more intensive monitoring, interventions, and support.

In the surrogacy context, additional considerations come into play:

• The agreement and contract must anticipate higher risks, complications, and possibly fetal reduction decisions.

• The intended parents, surrogate, and medical team must be in alignment about contingencies (e.g., selective reduction, preterm delivery).

• Insurance, liability, and cost arrangements must cover more possibilities.

• Coordination among fertility specialists, maternal-fetal medicine (MFM) specialists, obstetricians, and neonatal teams is critical.

Because assisted reproductive technologies (ART) often contribute to multiple gestations (via multiple embryo transfers), many multiple pregnancies in surrogacy result from ART. Clinical guidelines for ART typically emphasize minimizing multiple gestation risk where possible. But if a multiple pregnancy occurs, robust management is required.

Core Principles of Antepartum Surveillance and Monitoring

One of the first critical tasks is to identify whether the fetuses are monochorionic, dichorionic, monoamniotic, or higher combinations. Chorionicity (shared placenta) and amnioticity influence risk profiles and guide surveillance protocols. Early ultrasound, preferably in the first trimester, is used to define placental sharing, twin signs (lambda sign, T-sign), and membrane structure.

Because complications may evolve quickly, women with multiple gestations generally require more frequent prenatal visits, surveillance, and imaging than in a singleton pregnancy

Delivery Planning, Obstetric Decisions, and Postnatal Management

Deciding when and how to deliver multiples involves balancing the risks of prematurity and the risks of continuing the pregnancy (stillbirth, growth restriction, placental insufficiency). In uncomplicated dichorionic twins, many guidelines suggest delivery around 37&38 weeks. For monochorionic twins, earlier delivery (32&37 weeks, depending on complications) may be warranted. Monoamniotic twins often require planned cesarean delivery earlier (e.g., 32&34 weeks) due to cord entanglement risk.

In cases when one fetus is delivered prematurely while the others remain in utero (rare but occasionally feasible), a strategy called delayed-interval delivery may be considered to prolong gestation for the remaining fetus(es).

Multiples are more often born preterm and at low birth weight, requiring neonatal intensive care. The surrogacy team must ensure neonatal plans: NICU capacity, immediate resuscitation readiness, and communication with intended parents.

Specific Considerations in the Surrogacy Context

Given the added risks, the surrogacy contract should explicitly cover possible scenarios unique to multiples:

• Whether selective reduction is allowed, under what circumstances, and what consent procedures.

• How costs and insurance cover multiple fetuses, NICU stays, and extended hospital stays.

• Decision authority in emergencies (e.g., which fetal compromise triggers early delivery).

• Psychological support for surrogate and intended parents in the event of fetal loss or complications.

Having these contingencies spelled out in advance helps avoid crisis decision-making under duress.

One preventive measure is to limit the number of embryos transferred in IVF to reduce the chance of multiple gestations in the first place. Many fertility programs now aim for elective single embryo transfer (eSET) or double only in selected cases. And when multiple embryos are transferred, the contract and care plan should anticipate multiple gestations and risks.