Clinical features and short-term outcomes of triplet pregnancies in Japan

Successful intra-amniotic levothyroxine treatment for fetal goitrous hypothyroidism in a triplet pregnancy

We report an extremely challenging case of fetal goitrous hypothyroidism involving all three fetuses of a triplet pregnancy in which successful fetal treatment led to a favorable pregnancy outcome. The patient had a trichorionic, triamniotic triplet pregnancy and was referred to us at 24 weeks gestation after goiters affecting all three fetuses and polyhydramnios involving two fetuses were noted. Immediately before the conception, she underwent hysterosalpingography with an oil-soluble iodinated contrast medium. After the diagnosis of fetal hypothyroidism was made, intra-amniotic injection of levothyroxine was performed for two fetuses with polyhydramnios 3 times between 28 and 31 weeks gestation. The goiters shrunk and the polyhydramnios improved in response to the in utero treatment. No complications occurred. Cesarean section was performed at 33 weeks gestation. None of the three neonates developed respiratory insufficiency. Our experience suggested that successful intrauterine treatment is possible for fetal goitrous hypothyroidism, even in a triplet pregnancy. The indication, treatment timing, and diagnostic and assessment strategies should be carefully discussed to minimize puncture-related complications.

Maternal, Perinatal and Neonatal Outcomes of Triplet Pregnancies According to Chorionicity: A Systematic Review of the Literature and Meta-Analysis

Triplet pregnancies are rare events that affect approximately 93 in 100,000 deliveries in the world, especially due to the increased use of assisted reproductive techniques and older maternal age. Triplet pregnancies are associated with a higher risk of fetal and maternal morbidity and mortality compared to twins and singletons. Chorionicity has been proposed as a major determinant of perinatal and maternal outcomes in triplet pregnancies, although further evidence is needed to clarify the extent and real influence of this factor. Thus, the aim of this study was to conduct a systematic review of the literature and a meta-analysis of the maternal and perinatal outcomes of triplet pregnancies, evaluating how chorionicity may influence these results. A total of 46 studies with 43,653 triplet pregnancies and 128,145 live births were included. Among the main results of our study, we found a broad spectrum of fetal and maternal complications, especially in the group of monochorionic and dichorionic pregnancies. Risk of admission to NICU, respiratory distress, sepsis, necrotizing enterocolitis, perinatal and intrauterine mortality were all found to be higher in non-TCTA pregnancies than in TCTA pregnancies. To date, our meta-analysis includes the largest population sample and number of studies conducted in this field, evaluating a wide variety of outcome measures. The heterogeneity and retrospective design of the studies included in our research represent the main limitations of this review. More evidence is needed to fully assess outcome measures that could not be studied in this review due to scarcity of publications or insufficient sample size.

Are neonatal outcomes of triplet pregnancies different from those of singletons according to gestational age?

OBJECTIVES

Multiple pregnancies sustain the high pace of extreme prematurity. Little evidence is available about triplet gestation given the evolution in their management during the last decades. The aim of the study was to compare the neonatal outcomes of triplets with those of matched singletons in a cohort study.

METHODS

An observational retrospective cohort study of triplets and matched singletons born between 2004 and 2017 matched by gestational age was conducted. Additionally, the investigation performed in regard to data from the overall Greek population of interest. The primary outcome was mortality or severe neonatal morbidity based on pregnancy type.

RESULTS

A total of 237 triplets of 24-36 weeks' gestation and 482 matched singletons were included. No differences in the primary outcome between triplets and singletons were found. Rates of severe neonatal morbidities did not differ significantly between triplets and singletons. A threshold of 1000 gr for birthweight and 28 weeks' gestation for gestational age determined survival on triplets [OR: 0.08 (95% CI: 0.02-0.40, p=0.0020) and OR: 0.13 (95% CI: 0.03-0.57, p=0.0020) for gestational age and birthweight respectively]. In Greece stillbirths in triplets was 8 times higher than that of singletons (OR: 8.5, 95% CI: 6.9-10.5). From 3,375 triplets, 94 were stillborn, whereas in singletons, 4,659 out of 1,388,273. In our center 5 times more triplets than the expected average in Greece were delivered with no significant difference in stillbirths' rates.

CONCLUSIONS

No significant differences were identified in mortality or major neonatal morbidities between triplets and matched singletons highlighting the significance of prematurity and birthweight for these outcomes.

The Maternal Impact, Health Burden, and Postpartum Sequela in Triplet Pregnancies: A Retrospective Cohort

OBJECTIVE

The aim of the study is to describe the maternal health burden and perinatal outcomes in triplet pregnancies, and identify the maternal and pregnancy indicators associated with increased perinatal morbidity and mortality.

STUDY DESIGN

This is a retrospective cohort study of triplet pregnancies from 2007 to 2014. Maternal data were manually collected and assessed until 6 weeks postpartum, and neonatal data were assessed until hospital discharge or death.

RESULTS

Eighty-two triplet pregnancies were identified with 246 babies born. Mean gestational age at delivery was 32.3 (standard deviation [SD] ± 3.6) weeks and average birth weight was 1,726 g (SD ± 500). There were 12 perinatal deaths and 25 (10.2%) infants diagnosed with a congenital anomaly. Prior preterm birth and nulliparity had a negative impact on gestational age at delivery (p = 0.016) as compared with prior full-term births. Pregnancy complications (preeclampsia or hypertensive disorders [46.3%], gestational diabetes [28%], postpartum hemorrhage [9.8%], and blood transfusions [8.5%]) also impacted gestational age at delivery (33.0 vs. 34.0 weeks, p = 0.031). Spontaneous conception, chorionicity, and maternal medical problems did not have an impact on median gestational age.

CONCLUSION

Nulliparity and presence of pregnancy complications are pertinent to triplet outcomes. This study provides valuable information for anticipatory guidance and preconception counseling to patients considering artificial reproductive technology.

Perinatal outcomes of monochorionic diamniotic triplet pregnancies: a case series

Background

Triplet pregnancies are associated with higher fetal morbidity and mortality rates as well as life-threatening maternal complications. Monochorionic diamniotic (MCDA) triplet pregnancies are very rare compared to other types of triplet pregnancies.

Case presentation

We report three cases of MCDA triplet pregnancies between January 2012 and December 2017. Two of these MCDA triplet pregnancies received regular and intensive prenatal care, were diagnosed by ultrasonography during the first trimester or early second trimester, and had good perinatal outcomes. The case with irregular perinatal care had poor outcomes, and the MCDA triplet pregnancy was diagnosed intrapartum.

Conclusions

The possibility of continuing an MCDA triplet pregnancy should be recognized. Early diagnosis, regular antenatal care, close prenatal monitoring, and sufficient communication are recommended to obtain better perinatal outcomes in MCDA triplet pregnancies.

Neonatal Outcomes of Very Preterm or Very Low Birth Weight Triplets

OBJECTIVES

To compare the neonatal outcomes of very preterm triplets with those of matched singletons using a large international cohort.

METHODS

A retrospective matched-cohort study of preterm triplets and singletons born between 2007 and 2013 in the International Network for Evaluation of Outcomes in neonates database countries and matched by gestational age, sex, and country of birth was conducted. The primary outcome was a composite of mortality or severe neonatal morbidity (severe neurologic injury, treated retinopathy of prematurity, and bronchopulmonary dysplasia). Unadjusted and adjusted odds ratios with 95% confidence intervals (CIs) were calculated for model 1 (maternal hypertension and birth weight z score) and model 2 (variables in model 1, antenatal steroids, and mode of birth). Models were fitted with generalizing estimating equations and random effects modeling to account for clustering.

RESULTS

A total of 6079 triplets of 24 to 32 weeks' gestation or 500 to 1499 g birth weight and 18 232 matched singletons were included. There was no difference in the primary outcome between triplets and singletons (23.4% vs 24.0%, adjusted odds ratio: 0.91, 95% CI: 0.83-1.01 for model 1 and 1.00, 95% CI: 0.90-1.11 for model 2). Rates of severe neonatal morbidities did not differ significantly between triplets and singletons. The results were also similar for a subsample of the cohort (1648 triplets and 4944 matched singletons) born at 24 to 28 weeks' gestation.

CONCLUSIONS

No significant differences were identified in mortality or major neonatal morbidities between triplets who were very low birth weight or very preterm and matched singletons.

The Effect of Twin Birth on Neonatal and Infant Mortality Rates: A Systematic Review

Background and aims: Twin birth may account for higher mortality rates in infants and neonates. To investigate the potential relationship between twin birth and infant and neonatal mortality rates (NMRs), a systematic review was conducted. Methods: To gather the evidence for the relationship between twin birth and its potential effect on mortality during infancy and neonatal periods, a systematic review was conducted. The most important used databases were PubMed, Google Scholar, Web of Science, Scopus, ProQuest, Cochrane and Springer. Then, the databases were searched by appropriate keywords. After reviewing and evaluating the collected studies, trends in the different countries were compared. Results: A total of 13 790 related studies were found, of which 128 studies were selected in the first step. The studies which were not related to the subject, in addition to repetitive studies, were excluded from the search in the second step based on inclusion and exclusion criteria by reviewing the abstract and, in some cases, the full article. Finally, 7 studies entered the last step. Conclusion: This study showed that the mortality could be higher among twins than among non-twins, especially among boys.

Pre-pregnancy BMI-specific optimal gestational weight gain for women in Japan

Background

The Institute of Medicine (IOM) guidelines are the most widely used guidelines on gestational weight gain; however, accumulation of evidence that body composition in Asians differs from other races has brought concern regarding whether their direct application is appropriate. We aimed to study to what extent optimal gestational weight gain among women in Japan differs by pre-pregnancy body mass index (BMI) and to compare estimated optimal gestational weight gain to current Japanese and Institute of Medicine (IOM) recommendations.

Methods

We retrospectively studied 104,070 singleton pregnancies among nulliparous women in 2005–2011 using the Japanese national perinatal network database. In five pre-pregnancy BMI sub-groups (17.0–18.4, 18.5–19.9, 20–22.9, 23–24.9, and 25–27.4 kg/m²), we estimated the association of the rate of gestational weight gain with pregnancy outcomes (fetal growth, preterm delivery, and delivery complications) using multivariate regression.

Results

Weight gain rate associated with the lowest risk of adverse outcomes decreased with increasing BMI (12.2 kg, 10.9 kg, 9.9 kg, 7.7 kg, and 4.3 kg/40 weeks) for the five BMI categories as described above, respectively. Current Japanese guidelines were lower than optimal gains, with the lowest risk of adverse outcomes for women with BMI below 18.5 kg/m², and current IOM recommendations were higher than optimal gains for women with BMI over 23 kg/m².

Conclusion

Optimal weight gain during pregnancy varies largely by pre-pregnancy BMI, and defining those with BMI over 23 kg/m² as overweight, as proposed by the World Health Organization, may be useful when applying current IOM recommendations to Japanese guidelines.

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We estimated gestational weight gain that optimizes pregnancy outcomes in Japanese.

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Optimal gain was 12.2 kg/40 weeks for pre-pregnancy BMI 17.0–18.4 kg/m².

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Optimal gain was 4.3 kg/40 weeks for pre-pregnancy BMI 25.0–27.4 kg/m².

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Current national guidelines are too low for women with pre-pregnancy BMI < 18.5 kg/m².

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BMI > 23 kg/m² should be defined as overweight if applying IOM recommendations.

Prediction of perinatal mortality in triplet pregnancies

PURPOSE

To investigate predictors of perinatal mortality in triplet pregnancies.

METHODS

Retrospective cohort managed in a tertiary teaching hospital (1998-2012) including all pregnancies with tree live fetuses at the first ultrasound examination, performed after 11 weeks of gestation. Primary end-point was defined as the number of children alive at hospital discharge. Ordinal stepwise regression analysis examined the association with maternal age, parity, pregnancy chorionicity, gestational age at our first ultrasound evaluation, presence of maternal clinical, obstetrical and fetal complications and gestational age at delivery.

RESULTS

Sixty-seven triplet pregnancies were first seen at 18.5 ± 6.8 weeks, 33 (49.3 %) were trichorionic, obstetric complications occurred in 34 (50.7 %) and fetal complications were diagnosed in 17 (25.4 %). Perinatal mortality rate was 249 ‰ (95 % CI 189-317) and 138 (73 %) children were discharged alive from hospital (11 pregnancies with no survivors; single and double survival in ten cases each; all children alive in 36). Regression analysis showed that presence of fetal complications (OR 0.10, 95 % CI 0.03-0.36) and gestational age at delivery (OR 1.55, 95 % CI 1.31-1.85) are significant predictors of outcome (p < 0.001).

CONCLUSIONS

Perinatal mortality in non-selected triplet pregnancies is high and is related to the presence of fetal complications and gestational age at delivery.

Gestational weight gain according to number of fetuses in Japanese women

AIM

It is unknown whether weekly maternal weight gain differs between Japanese women with singleton, twin, and triplet pregnancies.

METHODS

Gestational weight gain defined as net weight gain during pregnancy was analyzed in 135,036 pregnant Japanese women, including 128,838 with singletons, 5573 with twins, and 132 with triplets, who gave birth at ≥22 weeks of gestation between 2007 and 2009. Weekly weight gain was defined as follows: gestational weight gain÷[gestational week (GW) at Delivery-2].

RESULTS

Length of gestation (weeks, mean±SD) decreased significantly (38.2±2.6, 35.3±3.0, and 32.7±2.8) with increasing number of fetuses, while overall gestational weight gain (kg) was significantly smaller in women with singletons than in those with either twins or triplets (9.6±4.4 vs. 10.9±4.8 or 10.9±5.2, respectively). Thus, weekly maternal weight gain (kg/week) increased significantly with increasing number of fetuses (0.26±0.12, 0.33±0.13, and 0.35±0.16). Among women with delivery at or after GW 34, difference in gestational weight gain (kg) was prominent between the three groups (9.8±4.4, 11.4±4.7, and 13.0±5.1 for singleton, twin, and triplet pregnancies, respectively, P<0.001 between any two groups).

CONCLUSIONS

Weekly maternal weight gain increases with increasing number of fetuses. Our figures may be useful for advising Japanese women with multifetal pregnancies regarding gestational weight gain.