Triplet, quadruplet and quintuplet pregnancies. Management and outcome

Variable outcome in quintuplets pregnancy based on obstetric care

The incidence of multiple pregnancies has increased dramatically over the last few years in developed countries, largely attributed to delayed childbearing and the increasing use of assisted reproduction technologies and ovulation inducing hormones. Relatively few countries have population-based statistics covering birth statistics. Of those that do, the numbers of quintuplet pregnancies rose sharply in the nineties while, at the same time, their delivery rates decreased greatly because of the use of fetal reduction. Fetal reduction is not possible or legal in some countries, Poland being one of them, and therefore obstetricians are faced with the challenges of quintuplet deliveries. Conservative treatment and management is difficult, and outcomes often vary greatly. Despite this, expert care provided at tertiary care centers can positively influence outcomes. The objective of this article is to present different care options and their consequences in two illustrative cases, as well as to establish a set of obstetric care and management goals that would allow prolongation of the gestation time. Quintuplet pregnancy is rare but poses relevant clinical problems to both the obstetrician and the neonatologist. It should be managed with close cooperation between all concerned. Due to the extreme and invariable risk of premature delivery associated with quintuplet pregnancies, we recommend early diagnosis, adequate prenatal care at one tertiary medical center, routine hospitalization and bed rest, repeated ante partum ultrasound surveillance with tests of fetal well-being, tocolytic therapy at first signs of the risk of premature labor, and specialized neonatology care after delivery.

The risks for very low birth weight infants from multiple pregnancies

Advances in perinatal and neonatal care in recent years have resulted in dramatic improvements in the rate of intact survival of preterm infants. As a result, neonatologists have focused on the new challenge of bringing about similar advances for the tiniest infants who are born at or near the current limits of viability. Although these tiny infants comprise only a small proportion of all births, the ravages of prematurity make them by far the most challenging group of infants who require our attention in the neonatal intensive care unit.

Prophylactic cerclage in the management of triplet pregnancies

OBJECTIVE

The purpose of this study was to determine if prophylactic cerclage improves pregnancy outcome in women with triplet pregnancies without a history of cervical insufficiency.

STUDY DESIGN

Triplet pregnancies with > or = 1 day of outpatient surveillance beginning before 32 weeks' gestation were identified from a database of women in the US who received outpatient preterm labor surveillance services between January 1990 and May 2004. Triplet pregnancies managed with prophylactic cerclage were compared with triplet pregnancies in which cerclage was not placed. Patients with a diagnosis of cervical insufficiency in a previous or in the index pregnancy were excluded from analysis. The primary outcome was incidence of preterm birth before 32 weeks. Groups were compared using Fisher exact test, and Student t test with 2-sided P values < .05 considered statistically significant.

RESULTS

Three thousand two hundred seventy-eight triplet pregnancies met criteria for inclusion, of which 248 women (7.6%) received prophylactic cerclage. No significant differences were seen in mean gestational age at delivery, incidence of preterm birth before 32 weeks, birth weight, or neonatal days in the hospital. This study had 80% power to detect a 30% reduction in the primary outcome.

CONCLUSION

Prophylactic cerclage did not result in improved pregnancy or neonatal outcomes in triplet pregnancies without a history of cervical insufficiency.

Nutrition in multiple gestations

Multiple pregnancies represent a state of magnified nutritional requirements, resulting in a greater nutrient drain on maternal resources and an accelerated depletion of nutritional reserves. Maternal weight gain to 20 weeks and between 20 and 28 weeks has the greatest effect on birthweight in twin and triplet pregnancies, particularly among underweight women. Parity, which most likely represents a higher proportion of body fat, has a positive effect on pregnancy outcome, with an average 7 to 10 days longer gestation for multiparous versus nulliparous women. In addition to being the nutrients most often lacking in a woman's diet, calcium, magnesium, and zinc have been identified as having the most potential for reducing pregnancy complications and improving outcomes.

Neonatal morbidity of very low birth weight infants from multiple pregnancies

The epidemic of multiple births has translated into a marked rise in very low birth weight infants, who are at risk for major neonatal morbidity and mortality. Gestational age-adjusted comparisons of outcome between singletons and multiples have shown conflicting results. Comparisons that corrected for relevant confounding variables show that twins and singletons have similar risks for early morbidity and mortality. Very low birth weight triplets may have increased risk for neonatal mortality, however. Second-born very low birth weight twins seem to be at risk for increased respiratory morbidity, even in the era of routine antenatal corticosteroids and postnatal surfactant therapy.

Antepartum management and neonatal outcome of triplet pregnancies

MATERIALS AND METHODS

The maternal and neonatal outcome of 27 triplet and 1 quadruplet gestations was studied at the University Hospital of Verona.

RESULTS

Mean maternal age was 31.7+/-3.7 years; 24 women (85.7%) were nulliparous. Six (21.4%) patients had conceived spontaneously. Common maternal complications were: preterm labor (78.6%), anemia (57.1%), preeclampsia (25.0%). Thirteen patients (46.4%) had cervical cerclage, 21(75%) received tocolysis, 20 (71.4%) corticosteroid prophylaxis, 4 (14.3%) unfractionated heparin. All patients underwent Caesarean section with mean gestational age of 32+/-2.5 weeks and mean postoperative stay was 9 days. Three patients were treated in ICU after delivery, 1 was hysterectomized and 6 received blood transfusions. The live newborns were 80, the stillborns 5. Mean birth weight was 1,520+/-516 g (range 650-2,665), 95.0% being LBW. The following neonatal complications were observed: RDS (28.7%), cerebral hemorrhage (26.2% of II degrees and 1.2% of III degrees ), anemia (20%), PDA (12.5%), ROP (6.5%), polyglobulia (3.75%), NEC (2.5%). Mean hospitalization time was 30.6 days (range 2-132).

DISCUSSION

Iatrogenic multiple births are increasing as the use of assisted conception techniques expands. Gynecologists should be aware of maternal complications and neonatal outcome of triplet pregnancies and infertility management strategies should try to avoid iatrogenic multiple gestations.

Triplets and quadruplets in Switzerland: comparison with singletons, and evolution over the last decade

AIMS

Main objectives were 1) to determine the incidence of higher multiple births from 1995 to 1998 in Switzerland, and 2) to evaluate neonatal mortality and morbidity. Secondary objectives were 3) to compare the results with those of matched singletons, and 4) to compare the present data to the first Swiss study (1985-1988).

METHODS

Retrospective analysis of maternal and neonatal data obtained from all Swiss hospitals.

RESULTS

The incidence of triplet births was 1/3247 and that of quadruplet births 1/81,186. The median gestational age was 32 5/7 weeks for triplets, and 28 6/7 weeks for quadruplets. The median birth weight was 1665 g for triplets and 1076 g for quadruplets. Perinatal mortality was 6% for triplets and 19% for quadruplets. Respiratory distress syndrome was the major morbidity as diagnosed in 52% of triplets and 81% of quadruplets. A comparison of triplets with matched singletons showed no significant differences in morbidity and mortality. Compared with the first Swiss study, the mortality rate decreased, while the incidence of triplets increased but decreased for quadruplets.

CONCLUSION

The incidence of higher-order multiple births in Switzerland dropped for quadruplets in the last decade but has increased for triplets. The mortality and morbidity of triplets is comparable to that of singletons with a similar gestational age.

Intrapartum management of multifetal pregnancies

Over the past several decades advances in assisted-reproductive technologies have resulted in a dramatic increase in the number of multifetal gestations. Concomitant with this increase there has been a gradual rise in the overall preterm birth rate, as well as other pregnancy complications related to these pregnancies. Twin, triplet, and other high-order multifetal gestation pregnancies pose a number of important issues related to antepartum and intrapartum management. Antepartum issues include ultrasound determination of zygosity, management and prevention of preterm labor, maternal/fetal surveillance for complications, and specific interventions focused on prevention of adverse maternal and/or fetal outcomes. Intrapartum issues include those related to timing of delivery, labor management, anesthesia options, and determination of an optimal delivery modality. Clearly, these issues related to the management of multifetal pregnancies are of paramount importance to optimize pregnancy outcome. As many of the issues related to antepartum care for women with multifetal gestations have been reviewed elsewhere, we have restricted the focus of this article to intrapartum management. Thus, this article reviews salient issues related to the intrapartum management of multifetal gestations, including twins, triplets, and other high-order pregnancies.

Perinatal outcome in 41 sets of triplets in Jordan

BACKGROUND

Triplet births, which have increased greatly throughout the world in recent years, have a much greater risk of poor birth outcome than singleton births. The purpose of this study was to determine the perinatal outcome associated with triplet pregnancies and to compare abdominal delivery with vaginal delivery.

METHODS

We conducted a retrospective study of 41 sets of triplets born between January 1, 1994, and June 30, 1999, at the Princess Badee'a Teaching Hospital in Amman, Jordan. The primary outcome measures were perinatal mortality and early neonatal complications.

RESULTS

Of these sets, 21 triplets were delivered vaginally and 20 triplets were delivered by cesarean section. The perinatal mortality rate was 260 per 1000 live births in this series, primarily due to respiratory distress syndrome. The perinatal deaths occurred to infants whose birthweights were primarily 500 to 1500 g (90.6%). Breech presentation was associated with a significantly higher perinatal mortality rate than vertex presentation (62.5% vs 37.5%). Cesarean delivery was associated with a higher perinatal mortality rate than vaginal delivery (30.0% vs 22.2%).

CONCLUSIONS

These results suggested that cesarean delivery in triplets is not superior to vaginal delivery in terms of fetal and early neonatal outcome. The perinatal mortality rate was significantly higher than that in other recent series due to limited resources in Jordan.

Controversies in the intrapartum management of twin gestations

Advances in reproductive endocrine technology have helped to make twin gestations commonplace; however, as this article suggests, many unanswered questions and areas of controversy about the intrapartum management of twin gestations remain. Continued research in this area and the performance of prospective studies will shed further light on many of these topics.

Planned abdominal compared with planned vaginal birth in triplet pregnancies

OBJECTIVE

To compare a policy of planned abdominal delivery with a policy of planned vaginal delivery in triplet pregnancies.

DESIGN

Retrospective study.

SETTING

Two Dutch university hospitals, each having a different approach to the planned mode of delivery in triplet gestations.

SUBJECTS

Thirty women giving birth to triplets in the hospital in Leiden, who favoured planned abdominal delivery, compared with 39 from the Medical Centre in Amsterdam who favoured vaginal delivery.

MAIN OUTCOME MEASURES

Perinatal mortality and early neonatal complications.

RESULTS

Both centres were equally successful in achieving their planned policies: in Leiden 80% of women were delivered by caesarean section but in Amsterdam 87% of women were delivered vaginally. Compared with vaginal delivery, planned abdominal delivery was associated with a significantly higher perinatal mortality rate (P = 0.02), primarily due to respiratory distress syndrome, and a higher recorded neonatal complication rate (P = 0.03), especially sepsis, respiratory distress syndrome, and necrotising enterocolitis.

CONCLUSIONS

A policy of planned abdominal delivery in triplets is not superior to a policy of planned vaginal delivery in terms of fetal and early neonatal outcome.

Delivery of uncomplicated triplet pregnancies: is the vaginal route safer? A case-control study

OBJECTIVE

Our purpose was to evaluate the safety of vaginal delivery of triplets.

STUDY DESIGN

A retrospective case-control study on 69 consecutive triplet pregnancies delivered in the same institution between 1981 and 1992. Vaginal delivery was attempted in 23 otherwise uncomplicated triplet pregnancies, which form the study group. They were compared with 23 controls undergoing routine cesarean section and matched for gestational age at birth. Maternal hospital stay, neonatal mortality, hospitalization in the neonatal intensive care unit, and 5-minute Apgar scores were compared by means of paired t tests.

RESULTS

In the vaginal delivery group there was one neonatal death related to prematurity (32 weeks) after intrapartum cesarean section for failure to progress. However, neonatal mortality was not significantly increased in comparison with controls (1 of 69 vs 0). In the study group Apgar scores were significantly higher (9.5 vs 8.4) and hospitalization in the neonatal care intensive unit was significantly shorter (6 vs 18 days) than in the cesarean section group (p < or = 0.002).

CONCLUSION

In carefully selected cases vaginal delivery of triplets may be safe.

Obstetrical implications in multiple pregnancies

In the present study 90 multiple pregnancies were examined. These were subdivided on the basis of the number of embryos involved (74 twins, 10 triplets, 6 quintuplets) and on whether they were followed at our clinic for the entire pregnancy or not. In each group we analysed certain variables, calculating the respective mean values and standard deviations. We used the ANOVA test to discriminate the eventual differences in the means of the variables analysed, operating a p < 0.05 significance value. In addition, significant differences were analysed by the test of Contrasts (Scheffe F-test). The concept that emerged from the data investigated is that careful management of these pregnancies, carried out in high-level structures, can reduce the incidence of complications on both the maternal and fetal side and thus prevent "minimal brain damage" in the newborn.