The challenges of expecting, delivering and rearing triplets.

Twenty-one couples with complete sets of triplets aged between four and six years were interviewed about their experiences of being "triplet parents". The diagnosis of triplets had been a shock for most. All triplets were born prematurely, the mean birth weight being 2,000 g. The first time at home was chaotic for most of the parents. They spent more time organizing and arranging their day and less time on emotional care than did parents of single infants. Growing up as a triplet, with constant competition for attention, stimulation and love from the mother (parents), differed a great deal from the situation for singletons and twins. The early relationship between mothers and triplets must be managed differently from that between mothers of singletons and twins. The study shows how important it is for obstetricians, paediatricians and other professionals to understand the specific needs of these families.

Physical and mental development in 4-6-year-old triplets.

A total of 21 families with complete sets of triplets, born within 200 km of Stockholm, were invited to participate in a follow-up study with the aim of assessing the physical and mental development of their triplets at 4-6 years of age. Four families declined to participate in the study and thus the study group consisted of 17 sets of triplets who were born at 33-36 gestational weeks from 1986 to 1989. Mean birth weight was 2104 g (range 1310-2670 g) for the boys and 1882 g (range 1290-2590 g) for the girls. At birth, none of the 51 triplets showed any malformations. No asphyxia or other major complications were noted to have occurred at delivery. The children were examined in their homes with a neurological examination and the Griffiths mental development scales (GMDS). No major physical disabilities were found. In a group of triplets born small for dates, the total GMDS score and most of the subscale scores were significantly lower than for their siblings. In contrast to what has been found in singletons and twins, the differences in mental development between triplet boys and girls were not significant. On the whole, physical and mental development did not differ from what has been found in twins and singletons of the same age and with the same birth weight.

Maternal, fetal and amniotic fluid prolactin levels in term and post-term pregnancies.

Prolactin (PRL) levels in maternal serum, amniotic fluid and mixed cord blood from 11 women with post-term pregnancies and 64 women with normal term pregnancies were measured by immunoenzymetric assay in order to investigate their possible role in the onset of labor. No differences were found between term and post-term pregnancies, and it is concluded that PRL probably has no function in triggering labor.

Grand multiparity as an obstetric risk factor; a prospective case-control study.

In a socio-economically stable community with free access to medical care, a prospective comparison was made of pregnancy, delivery and neonatal data concerning 480 grand multiparas (> or = 5 deliveries) and 325 controls. The mean diastolic blood pressure was slightly higher (79.8 vs. 77.8 mmHg) among the grand multiparas and the rates of episiotomy differed greatly (5.8% in the grand multiparas vs. 45.7% in the controls). The main clinical difference was a slightly higher incidence of placental complications-i.e., praevia, abruptio and retentio (3.4% vs. 0.9%; P < 0.05) in the grand multiparas. The differences had no effect on neonatal outcome. Grand multiparity should be regarded as an obstetrical risk factor, mainly because of the higher frequency of placental complications. With good obstetric care there should be no adverse effects on the mother or the newborn.

Prolactin and amniotic fluid electrolytes.

Prolactin (PRL) levels and Na+, K+, Cl-, Ca++ concentrations in maternal serum and amniotic fluid from 64 women in normal term pregnancy were measured by immunoenzymetric assay and flame photometry. The mean amniotic fluid PRL concentration was 597.7 (SE 31.5) ng/ml and the mean amniotic fluid Na+, K+, Cl- and Ca++ levels were 125.6 (SE 0.9) mmol/l, 4.5 (SE 0.1) mmol/l, 109.3 (SE 1.3) mmol/l and 2.0 (SE 7.5 E-02) mmol/l, respectively. There was no correlation between PRL levels in maternal serum and amniotic fluid, and the electrolyte concentrations in amniotic fluid. A close correlation was found between the concentrations of Na+ and Cl- in maternal serum and amniotic fluid. Thus, even though PRL may participate in the regulation of electrolytes in the amniotic fluid compartments, our findings provide indirect evidence for the existence of other regulatory mechanisms.

The fate of "small twins": a four-year follow-up study of low birthweight and prematurely born twins.

This follow-up study of twins includes 35 families from the Stockholm area. One section concerns the physical and mental development of the twins. The other sections compare the development of the children with their parents' expectations of them and the parents' feelings about the delivery. Seven twin pairs (20%) in the total group were born before 37 complete gestational weeks. Thirty-seven of the twins weighed less than 2,500 g at birth; of these, 23 (9 boys and 14 girls) weighed less than 2,500g, although they were born after 37 gestational weeks. At four years of age, 22 of the 68 twins still showed some impairment of locomotor, language/speech and emotional development, as assessed by the Griffiths Mental Development Scales. All the prematurely born and small-for-date infants were in this group. There also seems to be a relationship between developmental problems and the mother's negative or ambivalent expectations concerning the twin pregnancy.

Four-year follow-up of locomotor and language development in 34 twin pairs.

A group of 34 twin pairs was studied at four years of age. Characteristics of the group were a homogeneous social background, good parental interrelationship and conscientious care during pregnancy, delivery and the neonatal period. All the children were tested with the Griffiths' Mental Development Scales. The girls generally showed a higher development quotient than the boys. Birth weight seemed to be the most important factor; at 4 years of age, the twins with a birth weight of less than 2500 grams had a significantly lower locomotor quotient. The language quotient showed a similar trend. This difference was, however, not significant. No significant differences in either locomotor or language development could be observed between MZ and DZ twins.

Acute polyhydramnios in twin pregnancy. A retrospective study with special reference to therapeutic amniocentesis.

Acute polyhydramnios in monozygotic twin pregnancy causes severe maternal discomfort and carries a high risk of premature labor. During the years 1980 to 1987, 36 patients with this complication were delivered in Sweden, giving an incidence of 1/20,000 births, or 1/200 twin births. In 18 patients (group A) who were treated with one or more amniotic taps, the delivery was postponed by 2 weeks, as compared with one week in 18 conservatively treated patients (group B). The peri- and neonatal death rate was 47% in group A and 58% in group B. Our own experience is that amniotic taps are safe if the amniotic fluid is removed slowly under prophylactic tocolysis. It gives symptomatic relief to the mother and may postpone labor until the gestational age of the twins is more compatible with survival.

Hemostasis in cold-knife conization. Effects and side effects of Glypressin, a long-acting analogue of lysine-vasopressin.

In a double-blind, randomized study, 50 patients undergoing conization were treated with either lysine-vasopressin (LVP) or its longer-acting analogue Glypressin. Bleeding during the operation and side effects were studied. The hemostatic effect appeared better with LVP than with Glypressin. One postoperative bleeding occurred in the whole series, in a patient treated with Glypressin. The effect on the general circulation, especially with respect to pallor of the skin, was less prominent with Glypressin than with LVP (with the concentrations used in this study).

Postpartum perforation of the colon due to endometriosis.

A case is reported of a ruptured endometriotic lesion following childbirth. Immediately after her second delivery, the 34-year-old parturient developed acute abdominal pain. At operation a ruptured left-sided ovarian abscess with a fistula to the colon was found. Endometriosis was present in the ovarian wall and the adjacent colon. Endometriosis as a cause of acute abdominal pain during pregnancy should be kept in mind.

Urinary bile acids in women treated with contraceptive steroids. A study using computerized gas chromatography-mass spectrometry.

Twenty-five different bile acids were determined by gas chromatography-mass spectrometry in 24 hour urine specimens before and during treatment with a commercial contraceptive drug. Neither excretion pattern nor individual amounts of bile acids showed any change during treatment of 4 healthy women. One woman with a history of recurrent cholestasis of pregnancy showed a slight increase in the levels of S-ALAT and total amount of urinary bile acids one day before she stopped taking the pill because of generalized itching. Another patient had a normal pattern of urinary bile acids after one year with a daily intake of 10 mg of estradiol valerate.

Radioimmunoassay of serum bile acids in normal pregnancy and in recurrent cholestasis of pregnancy.

Radioimmunoassay has been used to quantitate the conjugates of cholic and chenodeoxycholic acid in venous blood from women in different stages of normal pregnancy and in patients with recurrent intrahepatic cholestasis of pregnancy (RCP). The levels of cholic and chenodeoxycholic acid were shown to be within normal limits throughout uncomplicated pregnancy, and elevated in RCP. Because of RIAs simplicity and reliability, it is suggested that this method can be used to detect and follow the course of RCP and to assess the possible influence of treatment, e.g. diet.

Urinary bile acids during development of recurrent cholestasis of pregnancy.

The pregnancies of two patients with mild intrahepatic cholestasis of pregnancy (RCP) were followed with detailed analyses of bile acids in urine. About twenty-five different bile acids were determined by GC/MS following separation according to mode of conjugation. The results were collated with the clinical course of the disease. The first detectable change in bile acid excretion was the appearance of tetrahydroxylated bile acids at about the 30th gestational week. Somewhat later and concomitant with the rise in urinary oestriol, the total bile acid excretion started to increase. In one of the patients, who had a maximum total excretion of 84 mumol/24 h, deoxycholic acid was a major constituent, comprising about 40% of the total. The same patient had only slightly elevated levels of tetrahydroxylated bile acids and serum amino-transferases. The possible effect of low-fat diet on these results is discussed. Monohydroxylated bile acids were present throughout the pregnancies in small amounts and their role as aetiological factors is discussed. The care of RCP patients is outlined, and the need for simple, specific and quantitative methods for following the course of RCP is pointed out.

Urinary bile acids in late pregnancy and in recurrent cholestasis of pregnancy.

The metabolic profiles of urinary bile acids in pregnant women in the last trimester and patients with recurrent intrahepatic cholestasis of pregnancy (RCP) were studied. Following separation according to mode of conjugation, about thirty different bile acids were quantitatively analysed by gas chromatography-mass spectrometry. In all patients the sulphate fraction comprised 50--90% of the total bile acids. In RCP a shift from glycine to taurine conjugation was noted to together with a slight relative increase in sulphation. A ten- to hundred-fold increase in cholic and chenodeoxycholic acids was seen in RCP, the increase being mainly in the sulphate fraction. Tetrahydroxylated bile acids, tentatively regarded as 1- and 6-hydroxylated products of cholic acid, were quantitatively important in patients with RCP. The relative amounts of the secondary bile acids, deoxycholic and lithocholic acids, decreased with increasing cholestasis. Metabolites hydroxylated at C-6 were common, and the excretion of hydroxylated at C-6 were common, and the excretion of hyocholic acid was positively correlated to that of chenodeoxycholic acid. An increase in the excretion of 5 alpha-configurated bile acids in RCP was noted. A positive correlation between the excretion of 3 beta-hydroxy-5-cholenoic acid and 3 beta,12 alpha-dihydroxy-5-cholenoic acid indicates a metabolic relationship between the two compounds. Because of the relatively small amounts of lithocholic and 3 beta-hydroxy-5-cholenoic acids in patients with RCP, these compounds do not seem to be of pathogenetic importance in this type of cholestasis.