Prevalence and outcome of higher order multiple pregnancies in Lagos, Nigeria.

OBJECTIVE: To determine the prevalence and outcome of higher order multiple (HOM) pregnancies in Lagos, Nigeria. METHODS: The mode of delivery, gestational age, pregnancy and neonatal outcome of babies delivered from HOM pregnancies were reviewed retrospectively from the labor ward and theater registers, neonatal unit admission records and medical notes in a tertiary referral centre from April 2009 to March 2012. RESULTS: Twenty-two (15, 6 and 1 set of triplets, quadruplets and quintuplet, respectively) of 6521 pregnancies delivered during the period were HOM pregnancies giving a prevalence of 3.37/1000. All the 74 babies except 12 were delivered by cesarean section. There were 18 perinatal deaths giving a perinatal mortality rate of 243 per 1000. Overall mortality was significantly associated with no antenatal booking (21 versus 5, OR: 21.0, 95% CI: 2.1-72.3, p = 0.000), gestational age ≤30 weeks (21 versus 5, OR: 46.2, 95% CI: 11.2-189.9, p = 0.000) and birth weight <1000 g for live births (p = 0.000). Mode of delivery and number of fetuses >3 were however not significantly associated with mortality. CONCLUSION: Reduction of early preterm births by proper antenatal care and close feto-maternal monitoring of HOM pregnancies will significantly reduce the resultant immediate poor outcomes for these pregnancies and their newborns.

Spontaneous fetal reduction and early pregnancy complications in multiple pregnancies following in vitro fertilization.

OBJECTIVE: To determine the incidence of spontaneous pregnancy reduction and early pregnancy complications among multiple pregnancies conceived via in vitro fertilization (IVF). METHODS: Spontaneous pregnancy reduction was assessed among multiple pregnancies conceived after IVF treatment in a private assisted reproduction center in Lagos, Nigeria, between January 2008, and June 2011. The pregnancies were diagnosed at 6-8 weeks of gestation by ultrasound scan, which was repeated at 11-14 weeks to determine the incidence of spontaneous reduction. RESULTS: The incidence of multiple pregnancies was 35.2%. There were 11 (20.0%) twin, 6 triplet (10.5%), and 2 quintuplet (3.6%) pregnancies. Spontaneous reduction occurred in 9 (47.7%) of these pregnancies, including 15.8% of twins, 21% of triplets, and 10.5% of quintuplets. Spontaneous reduction was significant among triplets and quintuplets (P<0.05). Six women (31.5%) older than 36 years had spontaneous reduction (P<0.05). Vaginal bleeding occurred in 3 (15.5%) women, 2 (66.7%) of whom had spontaneous abortion. In all instances of monochorionic placentation, spontaneous reduction resulted in spontaneous abortion. CONCLUSION: The incidence of spontaneous reduction among multiple pregnancies conceived after IVF was high. Vaginal bleeding was a warning sign of eventual abortion. Early pregnancy complications were fewer among pregnancies with dichorionic and trichorionic placentation.

[Neonatal outcome multiple pregnancies at the Neonatal Department of Research Institute of Polish Mother's Memorial Hospital]. / Wyniki leczenia noworodków urodzonych z ciaz o wyzszej krotnosci (> or = 3) leczonych w I "CZMP" w latach 1995-2002.

OBJECTIVES: The purpose of this study was to analyze the course of neonatal period among babies born from truly higher-order multiple pregnancies (> or = 3). DESIGN: The retrospective analysis included 81 infants born from multiple pregnancies (> or = 3), hospitalized in Neonatal Department of Research Institute of Polish Mother's Memorial Hospital between 1995-2001. MATERIALS AND METHODS: Studied population contained 63 babies delivered from 21 triplet pregnancies, 8 newborns from 2 quadruplet pregnancies and ten quintuplets. The groups were analyzed according to gestational age, birth weight, ventilation and hospitalization time as well as early and late consequences of prematurity. RESULTS: Among the multiples (> or = 3) the mean birth weight of triplets, quadruplets and quintuplets was respectively: 1656 g vs 1166 g vs 725 g, the diminished gestational age was also noticed: 32.4 vs 30 vs 26.5 GA. The cesarean section ratio in triplet deliveries was 95%, while quadruplets and quintuplets pregnancies were always delivered by operative interventions. The increase in number of fetuses was significantly associated with prolonged ventilation time (mean 9.5 vs 22.2 vs 57.5 days) as well as the hospitalization (mean 29.1 vs 64.1 s 79.6 days). The differences between mentioned above values reached statistical significance (p < 0.001). One out of three neonates born from triplet pregnancy required ventilatory support (36.6%), whereas in quadruplets and quintuplets this ratio reached 100%. The respiratory distress syndrome treated with surfactant was diagnosed in 7.9% (5/63) of triplets, 37.5% (3/8) quadruplets and 100% of quintuplets among whom 8 babies needed more than one dose of surfactant. The increased risk of unfavorable prematurity outcome (PDA, ROP, BPD, IVH) and neonatal death was highly related to plurality of pregnancy. CONCLUSIONS: Multiple pregnancies resulting from infertility treatment cause many medical problems. Undesirable outcome among neonates delivered from higher-order multiple pregnancies (> or = 3 fetuses) predestine to more judicious approach in the application of assisted reproductive techniques and multiple pregnancies prophylaxis.

Potentially preventable excess mortality among higher-order multiples.

OBJECTIVE: To estimate the level of potentially preventable excess mortality achievable by avoiding the creation of higher-order multiple gestation with assisted reproductive technologies. METHODS: This was a retrospective cohort study of multiple pregnancies delivered in the United States between 1995 and 1997 involving 304,466 twins, 16,068 triplets, 1448 quadruplets, and 180 quintuplets. We used the generalized estimating equation framework to compute adjusted relative risks for combined perinatal and infant mortality (early mortality). We then calculated potentially preventable excess mortality among higher-order gestations, using twins and triplets sequentially as the referent category. RESULTS: Early mortality increased significantly with each additional fetus in a dose-dependent fashion (P <.001), corresponding to relative risks (95% confidence interval) of 2.4 (2.2, 2.6) for triplets, 3.3 (2.5, 4.4) for quadruplets, and 10.3 (5.0, 21.4) for quintuplets. The creation of twin rather than quadruplet pregnancies would be associated with a substantially higher level of preventable excess mortality (70%) than the creation of triplet pregnancies (28%). By contrast, limiting quintuplets to twins or triplets did not exhibit a similar level of difference (89% versus 75%, respectively). CONCLUSIONS: Our findings support the need for regulating the number of transferred embryos that result in quadruplet and quintuplet pregnancies.

Multifetal gestation--maternal and perinatal outcome of 112 pregnancies.

PURPOSE: Multifetal pregnancy reduction is a widespread "therapy" to diminish the risk of prematurity and adverse outcome for the survivors in higher order multiple gestation. The aim of our study was to determine the maternal and neonatal outcome of multifetal pregnancies under a conservative pregnancy management. STUDY DESIGN: A retrospective review of 112 multifetal pregnancies is presented. All higher order multiple pregnancies delivered after 25 weeks of gestation and managed at a single institution between 1982 and 1999 are included. RESULTS: Triplets, quadruplets and quintuplets were delivered at a mean gestational age of 31 + 5, 29 + 5 and 28 + 4 weeks, respectively. The perinatal mortality was 14 for triplets and 36 for quadruplets. No quintuplet died in the perinatal period. Respiratory distress syndrome occurred in 23% of triplets, 65% of quadruplets and 75% of quintuplets, intracranial hemorrhage was diagnosed in 14% of triplets, 15% of quadruplets and 10% of quintuplets and retinopathy of prematurity was found in 10% of triplets, 9% of quadruplets and 25% of quintuplets. DISCUSSION: Despite a low neonatal mortality, morbidity of higher order multiple gestations remains significant. Mortality and morbidity are related to preterm delivery but do not exceed the rates of singletons or twins of an identical gestational age. Favorable prognostic landmarks are a gestational age >30 weeks and a number of fetuses per pregnancy < or =4. CONCLUSION: The risks of multifetal pregnancies are significant. Therefore, evidence-based counseling of couples seeking treatment for infertility and prevention of higher order multiple pregnancies through the prudent use of reproductive techniques attains paramount importance.

Incidence and outcome of multiple pregnancy after in vitro fertilization.

The aim of this study was to analyse the experience of IVF multiple pregnancies, in relation to the maternal morbidity and the neonatal morbidity and mortality. We considered 48 multiple pregnancies: 36 twins (group A), 8 triplets (group B), 2 quadruplets (group C), and 2 quintuplets (group D). The mean maternal age was 29.72 years and the mean gestational age was 36.83 weeks. Of the 36 patients with two babies, 20 (55.60%) had cesarean section, whereas 12 were delivered vaginally. All the triplets, quadruplets and quintuplets were delivered abdominally. Twenty-three cervical cerclage were placed. In group A 7 patients had premature rupture of the membranes (PROM), 2 had pregnancy-induced hypertension (PIH) and 14 had premature labour. In group B 4 patients had premature labour, 3 hadPROM and 2 had PIH. In group C one patient had premature labour. In group D 2 patients had premature labour and one also PIH. Multiple pregnancies lead to a high incidence of antenatal complications and extensive neonatal morbidity which translate into prolonged and expensive hospitalization for the neonates.

Incidence of handicaps in multiple births and associated factors.

This study investigated the degree of risk of handicap in twins, triplets, quadruplets and quintuplets and associated factors, and examined the clustering tendency of handicaps. The sample was recruited from the Kinki University Twin and Higher Order Multiple Birth Registry. This panel consisted of 705 pairs of twins (1410 twins), 96 sets of triplets (287 triplets excluding 1 infant death), 7 sets of quadruplets (27 quadruplets excluding 1 infant death), and 2 sets of quintuplets (10 quintuplets), all of whom were born after 1977. The incidence of handicap was 3.7% in twins, 8.7% in triplets, 11.1% in quadruplets, and 10.0% in quintuplets. The risk of producing at least 1 handicapped child was approximately 1 in 13 pairs of twins (7.4%), 1 in 4 or 5 sets of triplets (21.6%), and 1 in 2 sets of quadruplet and quintuplets (50%). There was a significantly higher clustering tendency of handicaps in twins and triplets compared with the expected frequency calculated from the incidence rate of handicap. Four significant risk factors for subsequent handicap were found by logistic regression: gestation number, shortening of gestational age, premature rupture of the membrane, and toxemia during pregnancy.

Triplets and higher-order multiple births. Time trends and infant mortality.

OBJECTIVES: To describe changes in rates of higher-order multiple births (triplets and higher) between 1972 and 1989, to compare infant mortality rates in infants of higher-order multiple births and singletons born from 1983 through 1985, and to compare infant mortality rates among higher-order multiples born from 1983 through 1985 with rates among those born in 1960. RESEARCH DESIGN: Population-based analysis of live births (1972 through 1989) and infant deaths (1960 and 1983 through 1985) in the United States. The rate of higher-order multiple births was calculated per 100,000 live births. DATA SOURCE: Computerized national natality files for 1972 through 1989 and national linked birth/infant death data sets for 1960 and 1983 through 1985 from the National Center for Health Statistics, Centers for Disease Control. POPULATION: Live births to white and black women in the United States. INTERVENTIONS: None. MAIN RESULTS: Between 1972 through 1974 and 1985 through 1989 the rate of higher-order multiple births increased by 113% among infants of white mothers and by 22% among infants of black mothers. In whites the increase was mostly age specific and was not due to the upward shift in the maternal age distribution. The increase was particularly large in white women aged 30 through 34 years (152%) and 35 through 39 years (165%) and in more highly educated mothers. In blacks the modest increase in the rate of higher-order multiple births was mostly due to an upward shift in the maternal age distribution. From 1983 through 1985, mortality of infants of higher-order multiple births was about 15 times that of singletons. This was due almost entirely to the lower birth weight distribution of infants of higher-order multiple births. Their weight-specific mortality compared favorably with that of singletons. At 500 through 999 g, mortality was about the same. In weight categories between 1000 and 1999 g, mortality rates in higher-order multiple births were much lower: weight-specific relative risks ranged from 0.30 to 0.73. Between 1960 and 1983 through 1985 infant mortality in higher-order multiple births declined by about 50%. CONCLUSIONS: It is likely that much of the increase in the incidence of higher-order multiple births is due to the rise in the use of ovulation-inducing drugs for the treatment of infertility. This increase and the decline in mortality risk have created a much greater need for medical and social services for infants of higher-order multiple births and their families.

Multiple births: trends and patterns in Canada, 1974-1990.

This paper examines Canadian trends and patterns in multiple births in relation to total confinements, singleton births, maternal age, parity, gestational age and birth weight using vital statistics from 1974 to 1990. Multiple-birth rates in Canada increased from 912.8 to 1,058.9 per 100,000 confinements between 1974 and 1990. The increase is especially noticeable for women over 30. The rate of triplet and higher-order births increased from 8.3 to 21.7 per 100,000 confinements between 1974 and 1990. The proportion of multiple-birth babies that were pre-term (< 37 weeks gestation period) increased from 32.8% in 1974 to 45.8% in 1990. Factors associated with the increase in multiple births may include the use of assisted pregnancy techniques, and the fact that women aged 30 and older, who are at higher risk of a multiple birth, and who postponed their child bearing, have increased their fertility. The sharp increase in multiple-birth rates has implications for maternal and child health and health care costs.

[Multiple pregnancies. Neonatal morbidity and mortality]. / Grossesses multifoetales. Morbidité et mortalité néonatales.

The increase in the number of multiple pregnancies and the high incidence of prematurity in this type of pregnancy justifies a pediatric evaluation. A retrospective study (1985-1989) compared the perinatal and neonatal characteristics of children resulting from 14 multifetal (at least 3 fetuses) pregnancies, with a gestational age of less than 34 weeks, with 27 children resulting from monofetal pregnancies of the same duration. Neonatal morbidity and mortality appeared to be similar in both groups. Thus at this very early time of onset of labour (mean gestational age of 30 weeks), fetal multiplicity expressed itself neither by any particular neonatal pathology nor by malnutrition.

Triplets and higher order multiple births in Japan.

Multiple birth rates in entire Japan were analyzed using vital statistics for 1951 to 1988. The triplet rate was nearly constant from 1951 to 1974, where the rate per million births was 58, then increased with the year up to 1982 (104), and decreased up to 1984, and suddenly increased thereafter (109 in 1987). The average rate of quadruplets per million births from 1951 to 1968 was 0.93, then increased with the year up to 1975 (7.5), and decreased until 1984 and suddenly increased thereafter (10.6 in 1987). The rate of quintuplets was 0.77 per million births during the period from 1975 to 1987. The higher multiple birth rate since 1975 was attributed to the higher proportion of mothers treated with ovulation-inducing hormones in Japan. Since 1985, higher multiple birth rates might be partially attributed to in vitro fertilization. The stillbirth rates for male triplets gradually decreased from 1960 to 1978 and thereafter remained constant at a little higher level except in 1988, whereas the rates for females gradually decreased with the year. The overall stillbirth rates decreased to 1/4 for triplets and to 1/5 for quadruplets during the 37-year period from 1951. The overall stillbirth rate of quintuplets was 0.60 (51/85) during the period 1975-1987.

Fetal deaths with birth defects among Japanese multiples, 1974.

Source of data is "Survey on Socio-Economic Aspects of Vital Events-Plural Births in 1975", including 12,392 twin pairs, 124 triplet sets, 7 quadruplet sets and 1 quintuplet set. Fetal deaths were 3,285 for twins, 141 for triplets, 17 for quadruplets, and 5 for quintuplets, among which the number of birth defects were 78, 3, 0, and 0 respectively. Concordant twin pairs with the same category of birth defect were 20 among 56 pairs (0.36). As for the remaining 36 pairs, 2 pairs had different category of birth defects, 27 pairs had liveborn cotwins, and 7 pairs were both fetal deaths among which a twin had birth defect. The second-born twins had birth defects more frequently than the first-born twins among fetal deaths (28 vs 6).