Higher order multiple births in Nigeria: Experiences, challenges and neonatal outcomes in a private health facility.

OBJECTIVES: The aim of this study is to describe the experience and outcome of higher order multiple (HOM) births in a private tertiary health facility in Nigeria. MATERIALS AND METHODS: This was a retrospective review of records of HOM over 3 years in a private tertiary health facility in Nigeria. Relevant data on HOM births were extracted from both the patients' case notes, admission registers and maternity ward and delivery records of the hospital using a predesigned pro forma. Data were analyzed using Statistical Package for Social Sciences Version 22.0. RESULTS: The prevalence of HOM births was 0.72% of 1950 births over the 3 years study period; while for triplets, quadruplets, and quintuplets were 0.56%, 0.1% and 0.05%, respectively. The mean gestational age was 32 ± 3 weeks, and all except three sets of triplets were by Assisted Reproductive Technology (ART). Respiratory distress syndrome, neonatal jaundice, and neonatal sepsis accounted for more than 80% of the neonatal complications noted in HOM births. However, there was no significant difference between neonatal survival of HOM as compared to twin deliveries, P = 0.08. CONCLUSION: HOM is becoming increasingly common in Nigeria. The strongest risk factor is ART, and neonatal complications are common reinforcing the need to streamline ART protocols in Nigeria.

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.

[Births and children after assisted reproductive technologies. A retrospective analysis with special regard to multiple pregnancies at the Department of Obstetrics and Gynecology, Paracelsus Medical University Salzburg (2000-2009) with an extrapolation for Austria]. / Geburten und Kinder nach assistierter Fortpflanzungshilfe. Eine retrospektive Analyse unter besonderer Berücksichtigung von Mehrlingsschwangerschaften an der Universitätsklinik für Frauenheilkunde und Geburtshilfe Salzburg (2000-2009) mit einer Hochrechnung für Österreich.

BACKGROUND: Austria still lacks a baby-take-home rate after assisted reproductive technologies (ART) and therefore an adequate quality management of ART. PATIENTS AND METHODS: This paper extrapolates data about births/infants after ART at the University Clinic of Obstetrics and Gynaecology (PMU/SALK) in Salzburg for Austria, especially in regard to multiple births/infants collected between 2000 and 2009. RESULTS: On average 2 271 infants were born per year during the last 10 years. Among them, 76 infants (3.34% of all children) were born after ART. Of all children conceived by ART and born (759) at the University Clinic of Obstetrics and Gynaecology 368 are multiples. This is 48.5% of all children born after ART. 31.6% of all multiples born were conceived through ART. DISCUSSION: The extrapolation of data concerning multiples results in 1 255 multiples/year after ART for Austria. CONCLUSION: Without a baby-take-home rate, serious quality management of reproductive medicine is impossible. Online registration of deliveries and infants is the only adequate approach. The data of this statistical extrapolation from a single perinatal center not only provide a survey about the situation in Austria, but also support the claim of a quantitative (numbers) as well as qualitative (condition of infants) baby-take-home rate after ART.

Spontaneous embryonic loss following in vitro fertilization: incidence and effect on outcomes.

OBJECTIVES: The purpose of this study was to determine the early spontaneous loss rate in multiple pregnancies following assisted reproductive technology (ART). STUDY DESIGN: Analysis of pregnancies following ART as related to the initial number of embryos and maternal age was performed. RESULTS: At least one spontaneous loss was observed in 47.0% (95% CI 29.8-64.9) of quadruplets, 59.3% (95% CI 48.2-69.8) of triplets, and 35.2% (95% CI 29.6-41.2) of twins. The increased loss rates in mothers > or =35 years was related to early twin pregnancies, but not to early triplet and quadruplet gestations. We could not find an effect of the starting number of embryos on either gestational age or birth weight characteristics. CONCLUSION: Our observations did not identify a clear relation between early spontaneous loss of multiple gestations and either initial number of embryos or maternal age. Other factors might be involved in the outcome of ART multiple pregnancies.

[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.

Higher order multiple pregnancies in New South Wales 1990-1999.

OBJECTIVE: To examine higher order multiple pregnancy and birth rates in NSW, and to describe trends in the characteristics and management of these births. DESIGN: Cross-sectional analytic study. SETTING: New South Wales, Australia. POPULATION: Two hundred and ninety-one women who gave birth to triplets, quadruplets or quintuplets (880 babies) from 1 January 1990 to 31 December 1999. METHODS: Data were obtained from the NSW Midwives Data Collection and rates over time were calculated. MAIN OUTCOME MEASURES: Higher order multiple birth and pregnancy rates (> or = 20 weeks), place of birth, mode of delivery, fetal death rates and Apgar scores. RESULTS: There was no significant change in the number or rate of higher order multiple births in NSW during the 1990s with an average annual rate of 10.3/10,000 births or 3.5/10,000 pregnancies > or = 20 weeks. Among women with higher order multiple pregnancies, those aged > or = 35 years increased from 19% in 1990 to 47% in 1999. There was also a trend towards delivery in a perinatal centre from 56% to 70%, and vaginal birth from 18% to 28%. There were no significant changes in infant outcomes. CONCLUSIONS: The increases in higher order multiple pregnancies observed in Australia in the 1980s, and into the 1990s in other countries, have not persisted in NSW, suggesting that guidelines for limiting the number of embryos/oocytes transferred in assisted reproductive technologies have been widely adopted.

[Choice of delivery method in multiple pregnancy: twins, triplets and quadruplets]. / Izbor i metod na rodorazreshenie pri mnogoplodna bremennost - dve-, tri- i chetiriplodna bremennost.

From February 1996 tice May 1998 year 7 patients (5 with trigemini and 2 with quadrigemini) were delivery at the State University Hospital "Majchin Dome" The methods applied for delivery were: per vies naturalis--1 pregnancy with trigemini in 32 gestation wick and 1 spontaneous abortion due to hydramnions on guadrigemini in 23 g.w.; by cesarean section--4 pregnancies with trigemini in 29 g.w.--1, 32 g.w.--2 and in 36 g.w.--1 patients and 1 pregnancy with guadrigemini in 32 g.w. The trigemini delivery per vies naturalis was discharged from Hospital alive. From delivered by cesarean section (1 in 32 g.w. was fetus mortus), the rest--live, but this delivered in 29 g.w.--prematurely III and IV grade died up to 26 hour after delivery in spite off neonatal care. The remaining were discharged from Hospital alive. The guardigemini in 32 g.w. delivered by cesarean section were discharge from Hospital alive. The authors consider that by trigemini and quadrigemini after 32 g.w. the prefer method for delivery is cesarean section.

Establishing a twin register in Sri Lanka.

Nearly all twin registers are based in developed countries and there is no twin register in the developing world. Our objectives were to initiate the process of establishing a nationwide twin register in Sri Lanka by starting a volunteer register first and working towards a population-based register. Regular newspaper advertisements, feature articles, radio talks, and television programmes were used to publicise a competition for twins, their parents/relatives and friends requesting them to participate by sending in details of twins. The competition ran from 28 March 1997 for a period of 3 months. It offered prizes for three winners selected by drawing lots. Advertisements highlighted the objective of the competition as establishing a twin register for future research and emphasised that informed consent would be obtained for individual research projects. Those who registered comprise 4602 twin pairs (same sex: male--1564, female--1885; different sex--1153), 80 sets of triplets (same sex: male--17, female--31; different sex--42) and two sets of quadruplets (different sex). The oldest twins, triplets, quadruplets are 85, 46, and 5 years old, respectively; 88.0% of twins are less than 30 years old. Although others have previously used media publicity to enrol twins in twin registers, we believe this to be the first time that twins have been enrolled through competition. We have more young twins, and our gender and zygosity proportions after applying Weinburg's rule do not match the proportions expected from a volunteer twin sample. Establishing a twin register for research purposes has proved possible in a developing country.

Constant multiple birth rates in the Czech Republic and the Slovak Republic until recently, 1972-1995.

Using vital statistics, yearly changes in the twinning and triplet rates by zygosity were investigated in the Czech Republic and the Slovak Republic during the period 1972-1995. Monozygotic (MZ) twinning rates in both countries had remained nearly constant (about 3 per 1000 total births) during that period. With a few exceptions, the dizygotic (DZ) twinning rates remained constant from 1972 to 1994, and increased in 1995 for both countries. MZ twinning rates for both countries were the lowest in Europe. As for triplet rates, overall rates increased significantly year by year in the Czech Republic, but not in the Slovak Republic. The triplet rate was significantly higher in 1995 than in the period 1972-1982 for both countries. The MZ triplet rate remained constant during that period in the Czech Republic. The trizygotic (TZ) triplet rates increased 3-fold for the Czech Republic and 4-fold for the Slovak Republic in 1972-1976 and 1992-1995. In the later period, the TZ rate was 1.5-fold higher in the Czech Republic than in the Slovak Republic. The quadruplet rate increased 2.3-fold from 2.9 per million births in 1982-1986 to 6.7 in 1992-1995 in the Czech Republic. The corresponding values were 2.7, 2.20 and 5.9-fold in the Slovak Republic. Both the Czech and the Slovak Republics were not affected by fertility drugs and assisted reproductive techniques until recently.

Prevalence of cerebral palsy in twins, triplets and quadruplets.

BACKGROUND: Twins and triplets are at higher risk of cerebral palsy than singletons. This study investigated the degree of risk for cerebral palsy in twins, triplets and quadruplets, and identified factors associated with the increased risk. METHODS: The subjects were recruited from the Kinki University Twin and Higher Order Multiple Births Registry. RESULTS: The subjects were 705 twins pairs (1410 twins), 96 sets of triplets (287 triplets excluding one infant death), and 7 sets of quadruplets (27 quadruplets excluding one infant death), who were born after 1977. The prevalence of cerebral palsy was 0.9% among 1410 twins, 3.1% among 287 triplets, and 11.1% among 27 quadruplets. Furthermore, the risks of producing at least one child with cerebral palsy were 1.5%, 8.0%, 42.9% in twin, triplet, quadruplet pregnancies, respectively. After adjusting for each associated factor using logistic regression, the risk of cerebral palsy was significantly associated with decrease in gestational age and asphyxia. The odds ratio indicated that infants whose gestational age was < 32 weeks were 20 times more likely to develop cerebral palsy than infants whose gestational age was > or = 36 weeks. CONCLUSIONS: The prevalence of cerebral palsy in triplets and quadruplets was higher than that in twins. Lower gestational age was associated with a greater risk of cerebral palsy.

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.

The frequency of multiple births in central Anatolia.

The purposes of the present study were to contribute additional data regarding the frequency of multiple births in Ankara, and to reassess both the relation between maternal age and twinning, and the inter-relation between twinning and seasonality. The frequency of twinning was found to be 0.0084858 +/- 0.00028 (0.85%), triplets 0.0001087 +/- 0.000031 (0.011%), and quadruplets 0.000009 (0.0009%). It is observed that there is a correlation between the frequency of twinning, maternal age and parity, and that the rate of twinning increases with maternal age. The twinning rate varies according to the month of the year in which birth takes place. Accordingly, the frequency of twin births is greater between May and August, and lower between September and December.

Triplets and quadruplets born in Victoria between 1982 and 1990. The impact of IVF and GIFT on rising birthrates.

OBJECTIVES: To examine the perinatal characteristics of all higher order multiple births (133 sets of triplets and six sets of quadruplets) in the State of Victoria between 1982 and 1990. To compare the rising higher order multiple birth rates in Victoria with those in the other States of Australia, and to assess the impact of in-vitro fertilisation (IVF) and gamete intrafallopian transfer (GIFT) on these rising birth rates. DESIGN: Retrospective review of all higher order multiple births registered in Victoria and other States of Australia between 1982 and 1990, and in particular those resulting from IVF and GIFT. DATA SOURCES: Victorian Perinatal Data Collection Unit, Australian Bureau of Statistics, National Perinatal Statistics Unit, data from Victorian IVF and GIFT units. MAIN OUTCOME MEASURES: Higher order multiple birth rates and perinatal mortality rates. RESULTS: The higher order multiple birth rates in Victoria rose from 3.5 per 10,000 in 1982 to 10.9 per 10,000 in 1990. The average perinatal mortality rates for the Victorian triplets and quadruplets born during this period were 10.8% and 25.0%, respectively. The rates of caesarean section were 70% and 83%; the proportions of deliveries in level III hospitals, 75% and 100%; and the mean maternal lengths of stay in hospital, 32 and 57 days, respectively. Endotracheal intubation was performed at birth in 18.5% of all infants. The proportions of triplet and quadruplet pregnancies in Victoria owing to IVF and GIFT rose during this period, reaching a peak of 42% in 1990. In the other States, the birth rates for higher order multiples increased at 1.8 times the rate observed for Victoria, with IVF and GIFT contributing to an estimated 43% of these conceptions between 1985 and 1989. CONCLUSION: Restrictions on the numbers of embryos/oocytes transferred during IVF and GIFT should reduce the frequency of higher order multiple births.

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.