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PubMed2000

Maternal neonatal outcome in quadruplet and quintuplet versus triplet gestations.

OBJECTIVE: Examination and comparison of the natural histories of triplet versus quadruplet and quintuplet gestations. STUDY DESIGN: A retrospective study of sixty-four multifetal pregnancies (fifty-two sets of triplets, nine sets of quadruplets and three sets of quintuplets) cared for during past 12 years in our department. Quintuplets and quadruplets were compared with triplet pregnancies according to gestational age, birthweight, pregnancy complications and perinatal outcome. Student's t-test, Fisher exact test and chi2 test were used for statistical analysis, considering P value of <0.05 as statistically significant. RESULTS: Although mean gestational age at delivery between triplets and higher order gestations was not significantly different, birthweight of quadruplets and quintuplets was significantly lower. Pregnancy complications, including intrauterine growth retardation, were equally distributed between the groups. Early neonatal and perinatal mortality were significantly higher in quadruplets and quintuplets than in triplets. Surprisingly, survival of growth retarded fetuses was better than survival of their eutrophic counterparts. The spontaneous loss rate was 11.5% for entire triplet gestation and 16.7% for quadru- and quintuplet pregnancies. CONCLUSIONS: As the spontaneous loss rate of triplets and higher order pregnancies observed in our study is quite similar to pregnancy loss rate caused by multifetal pregnancy reduction, conservative management of multifetal pregnancies in specialised tertiary centers seems to be a prudent solution.

Birth Weight↗
PubMed2004

The cognitive, behavioral, and personality profiles of a male monozygotic triplet set discordant for sexual orientation.

The neurohormonal theory of sexual orientation proposes that homosexual men and homosexual women are exposed prenatally to a hormonal environment that is similar to that of the other sex. Prenatal exposure to an opposite-sex hormonal environment may lead the nervous system to develop in a manner consistent with the opposite sex. If this cross-sex exposure occurs, one prediction would be that the cognitive ability profile of homosexual men would be similar to that of heterosexual women. This study examined a set of male monozygotic triplets, aged 21 years, discordant for sexual orientation: 2 of the triplets were heterosexual, 1 was homosexual. The triplets were administered measures of 23 domains of cognitive ability, as well as measures of sexual orientation and masculinity/femininity. On the measures of cognitive ability, the triplets performed similarly, yet consistent differences were found between the 2 heterosexual triplets and the 1 homosexual cotriplet. Differences having the same pattern were found for the number of Schafer homosexuality signs on the Rorschach, and on a homosexuality scale derived from items on the Minnesota Multiphasic Personality Inventory--2 (MMPI-2). Responses from the homosexual triplet were in a more feminine direction than responses from his 2 heterosexual cotriplets on measures of masculinity-femininity, which included measures derived from Rorschach responses, the MMPI-2 Masculinity-Femininity scale, the Bem Sex Role Inventory, and the Boyhood Gender Conformity Scale. Responses to the 16 Personality Factor Questionnaire also distinguished the 1 homosexual triplet from the 2 heterosexual cotriplets. These findings support the view that the prenatal hormonal environment may have enduring effects on selected behavioral traits.

Adult↗
PubMed2004

Parent-infant synchrony and the social-emotional development of triplets.

To study the social-emotional development of triplets, 23 sets of triplets, 23 sets of twins, and 23 singleton infants (N=138) were followed from birth to 2 years. Maternal depression and social support were assessed in the postpartum period, mother-infant and father-infant interaction and the home environment were observed at 3 months, a separation-reunion episode and a maternal interview were conducted at 12 months, and infant behavior problems were evaluated at 24 months. Lower parent-infant synchrony was observed for triplets. Triplets showed less distress during maternal separation and less approach at reunion. Mothers reported lower adjustment and differentiation among siblings for triplets than for twins. Higher internalizing problems were reported for triplets, and the triplet with intrauterine growth retardation showed the poorest outcomes. Behavior problems were predicted by medical risk, maternal depression, parent-infant synchrony, infant approach, and mother adjustment. Discussion focuses on developmental risk when the exclusivity of the parent-infant relationship is compromised.

Adaptation, Psychological↗
PubMedDate not supplied

[Perinatal management of triplet pregnancies from 1997 to 2001].

BACKGROUND: Because of the trend for premature birth, multifetal pregnancies are at high risk for neonatal morbidity and mortality. This study presents our perinatal management scheme and the outcome of triplet pregnancies. PATIENTS AND METHODS: From 1997 to 2001 we studied 31 triplet pregnancies. Their management consisted of cervical measurement at 20 weeks, admission from 25 weeks onwards, regular ultrasound examinations, intravenous tocolysis with preterm contractions or cervical shortening, promotion of fetal lung maturation, antibiotic therapy with evidence of vaginal infection, delivery by caesarean section ideally at 33 weeks. RESULTS: In the studied group 4 triplet pregnancies were monochorionic, 6 dichorionic, and 21 (68 %) trichorionic. 2/31 triplet pregnancies finalized in late abortions. Furthermore, a single and a double intrauterine death occured in two triplet pregnancies. 6 (21 %) of triplet pregnancies were delivered before the 30th week and 23 (79 %) after the 30th week of gestation (median gestational age 31.5 weeks, median birth weight 1545g). Neonates of trichorionic pregnancies in comparison to those of mono- and dichorionic pregnancies were delivered two to three weeks later and presented with significantly higher birth weights (1660 g vs. 1245 g vs. 1240 g; p = 0.001 and 0.0009, respectively). 13/84 (15.5 %) of the neonates showed growth retardation. In 4/84 (4.1 %) children brochopulmonary dysplasia or cerebral haemorrhage was observed. Only one child developed enterocolitis. 19 % (16/84) of neonates showed evidence of retinopathy. No intrauterine death occured after 28 weeks and no child died after delivery. CONCLUSION/DISCUSSION: With our well defined management of triplet pregnancies from 20 weeks onwards we reach similar gestational ages at delivery but remarkably lower neonatal complication rates compared to previous studies.

Cesarean Section↗
PubMed1996

Delayed delivery of a triplet pregnancy without surgical intervention: a case report.

Multiple gestations have a significantly increased incidence of preterm labor and preterm rupture of membranes. This leads to an increase in neonatal morbidity and mortality due to prematurity. In this case, a 30-year-old woman achieved a triplet pregnancy by ovulation induction and intrauterine inseminations. Preterm premature rupture of membranes occurred at 21 6/7 weeks' gestation. At 24 weeks' gestation, preterm labor ensued and a vaginal delivery of the presenting triplet followed. Magnesium sulfate tocolysis was started after delivery. The patient was placed on bed rest, magnesium sulfate tocolysis, and weekly steroid injections. The second and third triplet delivered vaginally after a 46-day delay due to preterm labor. This is the first reported case of delayed delivery of the two remaining fetuses of a triplet pregnancy, after spontaneous preterm delivery of the presenting triplet, without surgical intervention. Although the first fetus expired 48 hours after delivery secondary to complications of prematurity, the other fetuses were subjected to tocolysis, bed rest, and steroids. This case illustrates that conservative management of a triplet pregnancy after preterm delivery of the presenting triplet may have a good outcome.

Adult↗
PubMed2002

Clinical implications of velamentous cord insertion in triplet gestations.

OBJECTIVE: The purpose of this study was to determine the incidence of velamentous cord insertion and to evaluate the association between velamentous cord insertion and small-for-gestational age infants in triplet gestations. STUDY DESIGN: We reviewed our computerized database to identify all cases of velamentous cord insertion in triplet gestations who were delivered at our institution from January 1995 through December 1999. Triplet gestations without velamentous cord insertion who were delivered during this period were used as control subjects. Birth weights and pregnancy outcomes were obtained from medical records. Data were analyzed with descriptive statistics, analysis of variance, and chi(2) with Fisher exact test, where appropriate. RESULTS: Thirty-nine sets of triplets (117 infants) were delivered during the study period. Of these, 11 sets of triplets (28.2%) had a velamentous insertion of at least one umbilical cord. Infants with velamentous cord insertion were more likely to be small-for-gestational age than infants without velamentous cord insertion (33% vs 8%, P =.02). There were no significant differences in the rates of pregnancy complications between the two groups. CONCLUSION: Velamentous cord insertion is found frequently in triplet gestations and is significantly associated with small-for-gestational age in triplet neonates.

Cesarean Section↗
PubMed2002

Total and individual triplet birth weights as a function of gestational age.

OBJECTIVE: Our purpose was to determine the relationship between gestational age and both the total and individual triplet birth weights. STUDY DESIGN: A 1988-2000 prospective cohort of 3238 live-born triplets in the United States was evaluated. The mean individual (heaviest, middle, and lightest) and total triplet birth weights were correlated with gestational age in nulliparous and multiparous patients. RESULTS: The mean total triplet birth weights significantly correlated with gestational age for both nulliparous women and multiparous women, but the respective regression lines were significantly different (P =.0018). The respective regression lines for individual triplets showed a significant linear correlation (R(2) = 0.996-0.998). Interparity and intraparity differences of the individual triplets' regression lines were also significantly different. CONCLUSIONS: The relationships support a model of two distinct growth periods for triplets: an age- and growth-promoting period until 33 weeks and an age-promoting growth-restricting period thereafter.

Adult↗
PubMed2002

Trichorionic triplet pregnancies at 10-14 weeks: outcome after embryo reduction compared to expectant management.

OBJECTIVE: To compare the outcome of trichorionic triplet pregnancies managed expectantly with those reduced to twins or singletons. METHODS: This was a retrospective study of trichorionic triplet pregnancies with three live fetuses at 10-14 (median 12) weeks' gestation referred to our unit for consideration of embryo reduction. Women were counselled as to the available options of either expectant management or embryo reduction. In those choosing reduction, a needle was inserted into the uterus transabdominally and potassium chloride was injected into the fetal heart. Using data derived from this study and from a review of studies reporting on survival and handicap by gestational age in singletons, the effects of embryo reduction on survival and handicap rates were estimated. Main outcome measures were miscarriage before 24 weeks of gestation, preterm delivery before 32 weeks, perinatal death and handicap rates. RESULTS: In total, there were 280 trichorionic triplet pregnancies and 125 of these were managed expectantly, 133 were reduced to two fetuses and 22 were reduced to one fetus. The rates of miscarriage were 3.2% for those managed expectantly, 8.3% for those reduced to twins and 13.6% for those reduced to singletons. The rates of early preterm delivery in those pregnancies that did not miscarry were 23.1%, 9.8% and 5.3%, respectively. The percentages for pregnancies with at least one survivor were 95.2%, 91.0% and 81.8%, respectively, and the median gestation at delivery was 34 weeks for the non-reduced, 36 weeks for those reduced to twins and 38 weeks for those reduced to singletons. From the published series on early preterm delivery, it was estimated that survival increases from about 27% at 24 weeks to about 98% at 32 weeks, and handicap decreases from 28% at 24 weeks to less than 5% at 32 weeks. From these estimates and the data on triplet pregnancies, it was calculated that, in triplets reduced to twins, compared to those managed expectantly, the chance of survival is similar (90.3% compared to 93.3%), but the risk of handicap may be lower (0.6% compared to 1.5% per fetus). CONCLUSIONS: In trichorionic triplet pregnancies, embryo reduction to twins does not improve the chance of survival but may reduce the rate of handicap. Reduction from triplets to singletons may reduce both the survival rate and the handicap rate among survivors.

Adult↗
PubMed1995

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.

Asphyxia Neonatorum↗
PubMed2004

Racial disparity in stillbirth among singleton, twin, and triplet gestations in the United States.

OBJECTIVE: We investigated the relationship between maternal race and stillbirth among singletons, twins, and triplets. METHODS: We conducted a retrospective cohort study on 14,348,318 singletons, 387,419 twins, and 20,953 triplets delivered in the United States from 1995 through 1998. We compared the risk of stillbirth between pregnancies of black and those of white mothers using the generalized estimating equations framework to adjust for intracluster correlation in multiples. RESULTS: The proportion of black infants was 16%, 18%, and 8% among singletons, twins, and triplets, respectively. Crude stillbirth rate among singletons was 6.6 per 1,000 and 3.5 per 1,000 for black and white fetuses, respectively. Among twins, 796 stillbirths (11.6 per 1,000) were recorded for black mothers versus 3,209 stillbirths (10.1 per 1,000) among white mothers, whereas among triplets there were 233 stillbirths, of which 39 stillbirths were black fetuses (24.6 per 1,000) and 194 stillbirths were white fetuses (10.0 per 1,000). Black singletons, twins, and triplets weighed 278 g, 186 g, and 216 g less than white fetuses, respectively (P <.001). Risk of stillbirth was elevated in black fetuses compared with white fetuses among singletons (adjusted odds ratio [OR] 2.9, 95% confidence interval [CI] 2.8-3.0) and twins (OR 1.3. 95% CI 1.2-1.4) but comparable among triplets (OR 1.2, 95% CI 0.7-2.1). This decreasing trend was significant (P for trend <.001). CONCLUSION: The disparity of stillbirths between black and white fetuses still persists among singletons and twins. Among triplet gestations, however, the 2 racial groups have a comparable risk level. Our findings highlight the need for a rigorous research agenda to elucidate causes of stillbirth across racial/ethnic entities in the United States. LEVEL OF EVIDENCE: II-2

Adult↗
PubMed2006

Impact of anomalous triplets on morbidity outcomes of normal in utero siblings.

OBJECTIVE: To evaluate the impact of number of anomalous fetuses on the prevalence of very preterm births (< 32 weeks), very low birth weight (< 1,500 g), and small for gestational age (SGA) infants among their normal cotriplets. METHODS: Cross-sectional study of United States triplet births from 1995 to 2000 using Matched Multiple Birth Files, comparing outcomes for triplet sets with no anomalous, 1 anomalous, and 2 anomalous fetuses. Chi-square test for trend and multiple logistic regression analyses, applying generalized estimating equations to account for correlation among cotriplets, were implemented. RESULTS: Of 34,881 matched triplets, 34,104 (97.8%) were nonanomalous (2.2% prevalence of fetal anomaly). Prevalence of very preterm birth (P < .001) and very low birth weight (P < .001), but not SGA (P = .52), among nonanomalous births increased significantly with number of anomalous cotriplets. The prevalence of very preterm birth was 44.1%, 54.8%, and 68.8%, respectively, as number of anomalous triplets per set increased from none to two. The prevalence of very low birth weight was 32.3%, 39.6%, and 62.0%, respectively. These trends remained unchanged after adjustment for correlation and potential confounding. CONCLUSION: Prevalence of triplet births with gestation less than 32 weeks and birth weight less than 1,500 g, but not SGA, among nonanomalous triplets increase linearly with number of anomalous members within triplet sets. LEVEL OF EVIDENCE: III.

Adult↗
PubMed2004

Maternal and neonatal outcome of 93 consecutive triplet pregnancies with 71% vaginal delivery.

BACKGROUND: The aim of this study was to investigate neonatal and maternal data in a large series of triplet pregnancies as a function of the decision regarding the route of delivery. METHODS: A retrospective series of 93 triplet pregnancies managed and delivered between 1989 and 2001 in a single perinatal department was analyzed. Seventy-eight women with triplet gestations who underwent a trial of labor were compared with 15 women with triplet gestations who delivered their infants by elective cesarean delivery. Neonatal outcomes assessed included respiratory distress syndrome, retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage and Apgar scores. Maternal outcomes assessed included preeclampsia, blood transfusion, endometritis and urinary tract infection. RESULTS: Sixty-six of 78 women (84%) who underwent a trial of labor had a successful vaginal delivery of all three neonates. The other 12 delivered their infants by cesarean delivery. Perinatal mortality referred to 104 triplet pregnancies was 48/1000. CONCLUSIONS: Our experience suggests that offering vaginal delivery is an acceptable management plan for triplet gestation in a center with a sufficient number of triplet deliveries.

Adult↗
PubMed2005

Monochorionic triplet pregnancy complicated by severe fetofetal transfusion.

We report two cases of fetofetal transfusion in monochorionic triamniotic triplet pregnancies. Case 1: At 23 weeks' gestation an amnioreduction was carried out. Three days later, the donor triplet died in utero. Immediately after that, a cardiotocogram of the triplet who had been thought to be unaffected by the fetofetal transfusion, showed a non-reassuring fetal status. Although cesarean section was carried out, none of the triplets survived. Case 2: At 24 weeks' gestation a woman was transferred to our center because of fetofetal transfusion in monochorionic triplets. Cesarean section was carried out. However, the recipient died on the 75th day after birth, and the others had neurological problems. Previous reports on fetofetal transfusion in triplets are very limited. The prognosis of this condition has been reported to be severe, irrespective of chorionicity, gestational age at delivery, maternal age, and parity. When managing a monochorionic or dichorionic triplet pregnancy, serial and careful ultrasound examination is mandatory to find early symptoms of this serious condition.

Adult↗
PubMedDate not supplied

Successful intrauterine management of severe feto-fetal transfusion in a monochorionic triplet pregnancy using bipolar umbilical cord coagulation.

Triplet-to-triplet transfusion is a rare clinical complication of monochorionic pregnancies. We present such a case in a monochorionic triamniotic triplet gestation. After a single fetal demise an ongoing twin-to-twin transfusion continued in the surviving triplets. The donor triplet had ultrasound evidence of secondary structural brain damage. The pregnancy was successfully managed with bipolar umbilical cord coagulation of the donor triplet and spontaneous vaginal delivery of the recipient triplet. The case highlights the clinical spectrum and diagnostic and management options that present themselves in these high-risk pregnancies.

Adult↗
PubMed2005

Early adequate maternal weight gain is associated with fewer small for gestational age triplets.

OBJECTIVE: To examine whether the recommended weight gain during the first 24 weeks reduces the frequency of SGA triplets. STUDY DESIGN: We used data collected by the Women's Health Division of Matria Healthcare, Inc (Marietta, GA). We studied the frequency of SGA triplets (birth weight <10th percentile by triplet standards) by weight gain, parity, and pregravid BMI category. Adequate weight gain was defined as >16.2 kg at 24 weeks and BMI categories were defined as underweight (<19.8), normal (19.8-26), and obese (BMI>26). RESULTS: We studied 2890 triplet sets. Adequate weight gain reduces the frequency of SGA triplets, irrespective of pregravid BMI category and parity, except for obese nulliparous women. However, the reduced frequency of SGA infants was significant only in underweight nulli-paras (OR 0.3, 95% CI 0.1, 0.9). CONCLUSION: Higher pregravid BMI and parity seem to reduce the occurrence of SGA triplets. However, lean mothers, especially nulliparas, may be the most important target population for nutritional intervention in triplet pregnancies.

Adult↗
PubMed2006

Early weight gain does not decrease the incidence of low birth weight and small for gestational age triplets in mothers with normal pre-gestational body mass index.

OBJECTIVE: To examine if the recommended weight gain of >680 g/week during the first 24 weeks of pregnancy decreases the frequency of adverse birth weight outcomes in triplet mothers with a normal pregravid BMI. STUDY DESIGN: Retrospective observational study of a large sample of triplet mothers with a normal (19.8-26) pregravid BMI. Adequate, average, and inadequate weight gains were defined as >680, 500-680, and <500 g/week. Outcome measures were the incidence of >or=1 SGA infant and total triplet birth weight <4500 g. RESULTS: Of the 1166 triplet mothers, 208 (17.8%) gained >680 g/week during their pregnancy. This presumed adequate weight gain did not reduce the incidence of SGA triplets or that of total birth weight <4500 g, irrespective of parity. These adverse birth weight outcomes were 2 to 3.5 times lower among multiparous compared to nulliparous mothers. CONCLUSION: Early weight gain of >680 g/week in triplet mothers with a normal pre-pregnancy BMI is not associated with a decrease in the incidence of adverse outcomes. Weight gain recommendations in triplet pregnancies should be realistic and associated with a low risk-benefit ratio.

Body Mass Index↗
PubMed2005

Does a triplet birth pose a special risk for infant development? Assessing cognitive development in relation to intrauterine growth and mother-infant interaction across the first 2 years.

OBJECTIVE: To examine whether a triplet birth per se poses a risk to the development of infants' cognitive competencies and to the mother-infant relationship. METHODS: Twenty-three sets of triplets were matched with 23 sets of twins and 23 singleton infants (n = 138) with respect to gestational age, birth weight, and medical and demographic features. Infants with perinatal asphyxia, intraventricular hemorrhage of grade 3 or 4, periventricular leukomalacia, or central nervous system infection were excluded from the study. At 6, 12, and 24 months of age, mother-infant interaction was observed and infants' cognitive development was tested with the Bayley II test. RESULTS: Mothers of triplets displayed lower levels of sensitivity at 6, 12, and 24 months and infants were less socially involved at 6 and 24 months, compared with singletons and twins. Triplets scored lower than singletons and twins on the Bayley Mental Developmental Index at 6, 12, and 24 months. A weight discordance of >15% was found for 15 triplet sets (65.2%). The discordant triplets showed decreased cognitive skills at 12 and 24 months, compared with their siblings, and received the lowest scores for maternal sensitivity. Hierarchical multivariate regression analysis revealed that greater medical risk at birth, multiple-birth status, lower maternal sensitivity, and reduced infant social involvement in the first 2 years were each predictive of lower cognitive outcomes at 2 years (R2 = 0.33). CONCLUSIONS: Triplets appear to be at higher risk for cognitive delays in the first 2 years of life, and discordant infants are at especially high risk. This delay is related in part to the difficulty of providing sensitive mothering to 3 infants at the same time. The findings may assist practitioners in guiding prenatal and postpartum parental care and management.

Analysis of Variance↗
PubMed2001

Development and behaviour of seven-year-old triplets.

UNLABELLED: The aim of this study was to assess the development and behaviour of 7-y-old triplets, who were followed from delivery to 7 y of age. The McCarthy Scales of Children's Abilities (MSCA) and Achenbach's Child Behaviour Checklist (CBCL) were used to assess and compare development and behaviour in the triplets and in a control group of singletons. The sample included 33 sets of triplets and 33 singletons, all 7-y-olds, and comparable for sex and fathers' social class. The triplets' scores on the MSCA were all within normal range. Although their mean scores for all subtests were below those of singletons, they did not differ significantly. The mean CBCL scores, based on mothers' reports, indicated that the triplets had significantly fewer behavioural problems than the controls. In half the triplet sets, one child stood out as having more behavioural problems than the others. CONCLUSION: Further assessments of the development of triplets are needed; these should be based on larger study samples and should use information from teachers and external observers as well as mothers.

Chi-Square Distribution↗