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PubMed2004

The likelihood of adverse outcomes in triplet pregnancies estimated by pregravid maternal characteristics.

OBJECTIVE: To estimate the likelihood of adverse outcomes in triplet pregnancies by a score comprising pregravid maternal characteristics. DESIGN: A cross-sectional study. SETTING: Triplets database collected by Matria Healthcare, Inc. PATIENT(S): A scoring system was constructed, assigning 1 point for the presence of a risk factor (nulliparity, stature <165 cm, and age <35 years) and 0 for the absence of a risk factor. Data related to 2,887 triplet sets were analyzed. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Total triplet birth weight <4,500 and delivery at 27-32 weeks. RESULT(S): We identified 18% of triplets' mothers (score 3) in whom the likelihood for adverse results is 50%-90% higher and the likelihood for optimal results is 40% to 70% lower than background rates. CONCLUSION(S): A pregravid maternal profile could estimate the likelihood of adverse outcomes and be used for consulting patients at risk of having or carrying a triplet pregnancy.

Birth Weight↗
PubMed2005

Comparison of pregnancy course and outcome with color and radiographic angiography of the placenta in a monochorionic triplet pregnancy.

A patient with spontaneous monochorionic (MC) triamniotic triplet pregnancy developed symptoms of feto-fetal-transfusion-syndrome (FFTS) at 18 weeks of gestation with one donor (oligohydramnios) and one receptor (polyhydramnios) triplet. The patient "received" a diet enriched with proteins. Amniotic-fluid volume returned to normal after 24 weeks. At 32 weeks, a Cesarean section was performed due to intra-uterine growth restriction of the donor triplet. Post partum color injection and computer angiograms showed arterio-arterial (AA) anastomoses between all triplets. Deep arterio-venous (AV) anastomoses between the two triplets who had demonstrated with oligo- and polyhydramnios between 18 and 26 weeks were revealed by computer angiography that were not seen by placental color angiogram. Detailed analysis of placental vascular communications by use of color injection angiogram of the chorionic plate and computer angiogram demonstrating deep anastomoses beneath the chorionic plate helps to understand the individual pathophysiology and clinical course in patients with FFTS, which is even more complex in MC triplet compared to MC twin pregnancies.

Adult↗
PubMed1998

Neonatal outcomes in triplet gestations after a trial of labor.

OBJECTIVE: This study aimed to compare neonatal outcomes in a cohort of triplet gestations undergoing a trial of labor with those of a similar cohort delivered by elective cesarean delivery. STUDY DESIGN: Thirty-three women with triplet gestations who underwent a trial of labor were compared with a matched cohort of 33 women with triplet gestations who were delivered of their infants by elective cesarean delivery. Neonatal outcomes assessed included respiratory distress syndrome, retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage, Apgar scores, and birth trauma. RESULTS: Twenty-nine of 33 women (87.9%) who underwent a trial of labor had a successful vaginal delivery of all 3 neonates. One patient was delivered of her first triplet vaginally but then required a cesarean delivery for abruptio placentae; 3 other patients were delivered of their infants by cesarean section for active-phase arrest of labor. There were no differences in neonatal outcomes between the 2 groups, although triplet neonates delivered by elective cesarean section demonstrated a trend toward a greater incidence of respiratory distress syndrome (P = .09). CONCLUSION: Our experience suggests that offering vaginal delivery is an acceptable management plan for triplet gestations.

Adult↗
PubMed2002

Hospitalization vs. outpatient care in the management of triplet gestations.

OBJECTIVE: To compare the course and outcome of triplet gestations under a preventive care strategy that includes hospitalization, surveillance, bed rest, and daily specialized care from the beginning of the second trimester, with pregnancies managed according to the Croatian standard outpatient care protocol for multiplets. METHODS: A retrospective study of 79 triplet pregnancies. Preventive hospitalization from the beginning of the second trimester, with complete bed rest and all necessary interventions, was chosen by 55 women (Group I). The remaining 24 women (Group II) elected the standard outpatient protocol for multiple pregnancies. Outpatient management with prophylactic bed rest was initiated at home as soon as the multiple pregnancy was diagnosed. After 28 weeks of gestation, all outpatients were hospitalized until delivery irrespective of symptoms. RESULTS: There was no difference between the groups regarding maternal age, race, pre-pregnancy weight and height, weight gain during the first 24 weeks of pregnancy, or the proportion of pregnancies achieved with assisted reproductive technology. Four out of 55 women (7.2%) from Group I and 4 out of 24 women (12.5%) from Group II had monochorionic triplet pregnancies (P=n.s.). Nulliparity was more frequent in Group I than in Group II (P=0.006). Elective cesarean delivery was significantly more frequent in Group I (46 out of 55 gestations, 72.7%) than in Group II (9 out of 24 gestations, 37.5%), P=0.024. Gestational age at delivery and mean birth weight were significantly higher in Group I than in Group II (P<0.001). Deliveries up to 28 weeks of pregnancy were infrequent in Group I (P=0.02). Thirty-three gestations in Group I (60%) and 6 (25%) in Group II had a duration of 33-36 weeks (P<0.001). Two out of 55 triplet gestations in Group I (3.6%) and 4 out of 24 in Group II (16.7%) ended in spontaneous abortion (P=0.053). The survival of the three triplets was more frequent in Group I than in Group II (P=0.048). For gestations reaching 24 weeks or more, the fetal and perinatal death rate was significantly lower in Group I (P<0.001). In Group I the intrauterine death rate for fetuses weighing 1500 g or less was also significantly lower (P=0.007), and the early neonatal death rate was almost half (15.8 vs. 28.9%, P=0.157). There were no differences in other pregnancy complications between the two groups except significantly more frequent preterm premature rupture of membranes and preterm labor requiring parenteral tocolysis in Group II (P=0.042 and 0.036, respectively), and significantly more frequent fetal growth retardation in Group I (P<0.001). CONCLUSION: Preventive hospitalization offers a better outcome for triplets even though prolonged hospitalization and all other procedures necessary to achieve optimal pregnancy outcome are also offered in the Croatian standard outpatient care protocol for multiplet pregnancies.

Ambulatory Care↗
PubMed2004

Premature rupture of membranes and early mortality among triplets in the United States.

OBJECTIVES: We investigated the relationship between premature rupture of the membranes (PROM) and early mortality among triplets in the United States. STUDY DESIGN: Analysis was conducted on matched and linked triplet sets born to mothers in the United States between 1995 and 1997. The generalized estimating equation framework was used to generate odds ratios after capturing the effects of sibling correlations within triplet clusters. RESULTS: Triplets exposed to PROM were twice as likely to experience stillbirth (OR=2.17, 95% CI [1.26-3.41]), neonatal death (OR=2.23, 95% CI [1.70-3.0]) and infant death (OR=2.21, 95% CI [1.72-2.85]), as compared to those who did not. The population-attributable risk for early mortality due to PROM was 11-12%. CONCLUSIONS: Triplets associated with PROM had a significantly higher level of early mortality than those without. Assuming a causal relationship, 11-12% of all early deaths among triplets in the United States are accounted for by PROM.

Adult↗
PubMed1997

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.

Child↗
PubMed2003

A comparative study of zygotic twinning and triplet rates in eight countries, 1972-1999.

Annual changes in twinning and triplet rates by zygosity were investigated in eight countries during the period 1972-1999 using vital statistics. The monozygotic (MZ) twinning rates in Denmark, Switzerland and the Slovak Republic remained more or less constant throughout this period, whereas those in England and Wales, the Federal Republic of Germany (Germany), the Netherlands, the Czech Republic and Japan increased significantly year by year. With the exception of the Slovak Republic, the dizygotic (DZ) twinning rate increased significantly year by year in each country. It was 2.9 times higher in Denmark and 1.5 times higher in Germany in 1999 than in 1972, and within the same range in the other countries. With two exceptions, the MZ triplet rates remained more or less constant in each country. On the other hand, the DZ and trizygotic (TZ) triplet rates increased significantly year by year in each country. The TZ rate increased 30-fold in Germany, 16.6-fold in Japan, 11.7-fold in Switzerland, 9.7-fold in the Czech Republic, 8.7-fold in the Netherlands, 6.4-fold in Denmark, 5.6-fold in England and Wales and 3.5-fold in the Slovak Republic. The higher DZ twinning rate and higher DZ and TZ triplet rates since 1983 have been attributed to the higher proportion of mothers being treated with ovulation-inducing hormones and in vitro fertilization (IVF) in Denmark, England and Wales, Germany, the Netherlands, Switzerland and Japan. After the introduction of fertility drugs and IVF, variations in the DZ twinning and triplet rates and the TZ triplet rates were not only due to biological factors, but also depended on the popularity of fertility drugs and IVF in each country. In the Slovak Republic, where human fertility might not be affected by some adverse environmental factors, the DZ:MZ ratio remained constant during the period 1972-1999.

Adult↗
PubMed2002

Preterm birth, stillbirth and infant mortality among triplet births in Canada, 1985-96.

Recent increases in the frequency of multiple births and simultaneous increases in preterm birth among multiple births have focused attention on such births. However, most previous studies have examined twins rather than higher-order multiples. We carried out a study to examine rates and trends in preterm birth and in gestational age-specific fetal and infant mortality among triplet births in Canada. We used data from the stillbirth, live birth and mortality files of Statistics Canada for the years 1985-97. All births in Canada (excluding those occurring in Ontario and Newfoundland) were included in the study, with two periods (1985-90 vs. 1991-96) being contrasted for assessing temporal change. Changes were estimated using relative risks, 95 confidence intervals [CI] and two-tailed P-values. The rate of preterm birth among triplet live births increased by 6 (95 CI 3, 9) from 90.4 in 1985-90 to 96.0 in 1991-96. Stillbirth rates among triplets did not change significantly and were 30.3 per 1000 total births in 1985-90 and 33.8 per 1000 total births in 1991-96. Infant mortality among triplets declined from 112.7 per 1000 live births in 1985-90 to 73.8 per 1000 live births in 1991-96. In spite of temporal reductions in infant mortality, triplet births continue to be associated with very high rates of preterm birth and fetal and infant mortality. Fetal mortality among triplets has not changed over the last ten years.

Birth Weight↗
PubMed2000

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.

Adult↗
PubMed2004

The relationship between paternal age and early mortality of triplets in the United States.

We sought to determine the impact of advanced paternal age on the birth outcomes of triplets in a retrospective cohort study on 15,156 triplets born in the United States from 1995 to 1997. The study group comprised fathers aged > or = 40 years. Two control groups consisting of mature (30 to 39 years) and younger (20 to 29 years) fathers were constructed for comparison of main end points. We applied the generalized estimating equation framework to obtain relative risk estimates after capturing the effect of sibling correlations within triplet clusters. Stillbirths were 35% and 26% higher among triplets of mature and older men, respectively, whereas neonatal mortality was 28% and 23% lower among infants of mature and older fathers, respectively, using younger fathers as the referent category. Although only the relative risk for neonatal mortality comparing triplets of mature and younger fathers was statistically significant, these results constitute high indices that represent an important burden of excess early mortality at the population level. Our findings demonstrate a "shifting phenomenon" whereby a higher level of intrauterine demise was compensated by a higher rate of extrauterine survival among triplets born to older fathers.

Adult↗
PubMed1993

Sonographic growth curves of triplet conceptions.

The diagnosis of inappropriate intrauterine fetal growth in triplet pregnancies requires normal standard sonographically determined growth curves. The aim of the present study was to establish such nomograms. The biparietal diameter (BPD), femur length, head and abdominal circumferences (HC, AC) were once in 3 weeks sonographically evaluated in 108 normal triplet fetuses. The resulting growth curves were compared with those of normal singleton fetuses. The data showed that, compared with singletons, the mean triplet fetal BPD progressively lags to a maximum of 2 1/2 weeks as pregnancy continuous from the 25th to the 36th gestational week. Similarly, mean femur length of triplet fetuses gradually shortfalls to the greatest of 2 weeks as gestation advances from the 25th to the 36th week. HC to AC ratio of the triplet fetuses does not differ from the singletons curve. It may be concluded that a normal fetal growth curve in triplet pregnancies demonstrates a 1- to 3-week delay compared with singleton gestations.

Embryonic and Fetal Development↗
PubMed2004

Maternal and sibling microchimerism in twins and triplets discordant for neonatal lupus syndrome-congenital heart block.

OBJECTIVE: Neonatal lupus syndrome-congenital heart block (NLS-CHB) is an acquired autoimmune disease in which maternal autoantibodies are necessary but not sufficient for disease. Maternal myocardial cells have been found in the hearts of patients with NLS-CHB, suggesting that maternal microchimerism may also play a role. In this study we asked whether levels of microchimerism in the blood are associated with NLS-CHB in discordant twins and triplets. METHODS: Human leucocyte antigen (HLA)-specific and Y-chromosome-specific real-time quantitative polymerase chain reaction (PCR) was used to quantitatively assay maternal and sibling microchimerism in peripheral blood. Because of HLA allele sharing in families, it was not always possible to distinguish between multiple sources of microchimerism. RESULTS: In one family, maternal and/or sibling microchimerism was detected in two triplets who had CHB, but not in the triplet with transient hepatitis. Levels ranged from 4 to 948 genome-equivalents of foreign deoxyribonucleic acid per million host genome-equivalents (gEq/million). Over the first year levels of sibling microchimerism decreased in the triplet with complete CHB and increased in the triplet who progressed from first- to second-degree CHB. In a second family, maternal and/or sibling microchimerism was detected in the healthy twin (1223 gEq/million) but not in the twin with CHB. CONCLUSIONS: Maternal and/or sibling microchimerism was detectable in the blood of infant twins and triplets discordant for NLS. Microchimerism in the blood was not specific for NLS-CHB, although in one family levels correlated with disease. Thus, microchimerism in the blood and/or tissues may be involved in the pathogenesis or progression of NLS-CHB, but additional factors must also contribute. Further investigation is warranted.

Chimerism↗
PubMed2005

Stillbirth and infant mortality among Hispanic singletons, twins, and triplets in the United States.

OBJECTIVE: We estimate the impact of increasing fetal number on fetal and infant mortality among Hispanic mothers. METHODS: Retrospective cohort study involving singletons, twins, and triplets delivered in the United States from 1995 through 2000, except for the analysis on infant mortality in singletons (1995 through 1999). Main outcome measures were stillbirth (> or = 20 weeks) and infant mortality (< 365 days). RESULTS: A total of 37,489,600 individual births were reviewed, consisting of 36,840,704 singletons, 613,930 twins, and 34,966 triplets. Hispanics accounted for 6,848,027 (18.6%) singletons, 85,887 (14.0%) individual twins, and 2,725 (7.8%) individual triplets. Among singletons, stillbirth (odds ratio [OR] 0.91, 95% confidence interval [CI] 0.90-0.92) and infant mortality (OR 0.85, 95% CI 0.84-0.86) were both lower in Hispanics than in whites. Among twins, Hispanics had a lower risk for infant mortality (OR 0.93, 95% CI 0.88-0.97) but a comparable risk for stillbirth (OR 1.06, 95% CI 0.98-1.13). Although the risk for infant mortality in Hispanic triplets was comparable to that of whites (OR 1.20, 95% CI 0.94-1.54), Hispanic triplets had a 50% higher likelihood of dying in utero (OR 1.50, 95% CI 1.06-2.14). CONCLUSION: Although Hispanic infants generally show better or comparable survival indices compared with whites, the risk for fetal and infant death in Hispanics increases in fetal number in a dose-dependent fashion, thereby obliterating the Hispanic advantage. The elevated risk for stillbirth among Hispanic triplets is particularly noteworthy and underscores the need for caution in making generalizations of favorable birth outcomes in Hispanics.

Cohort Studies↗
PubMed1994

A review of 19 sets of triplets: the positive results of vaginal delivery.

The outcome of 19 triplet pregnancies delivered at Waikato Women's Hospital is analyzed, with particular regard to the mode of delivery. During the period 1981-1992 the incidence of triplets was 1:1,945. Twelve sets of triplets were delivered by Caesarean section (63%) with 6 perinatal deaths occurring in this group, compared to none in 7 sets of triplets delivered vaginally (37%). All triplet pregnancies were correctly diagnosed antenatally by ultrasound examination at a mean gestational age of 19 weeks (range 11-28 weeks). The most common antenatal complications were preterm labour in 18 pregnancies (95%) and preeclampsia in 4 (21%). The mean gestation at delivery was 33 weeks (range 25-39 weeks). The outcome of triplet pregnancies was better in the group that delivered vaginally than those delivered by Caesarean section. Greater maturity of the infants delivered vaginally appeared to be the major factor for the lower neonatal morbidity and mortality.

Birth Weight↗
PubMed1995

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.

Child↗
PubMed2000

Perinatal outcome in 41 sets of triplets.

OBJECTIVE: To determine the perinatal outcome associated with triplet pregnancies and to compare abdominal delivery with vaginal delivery. METHODS: Retrospective analysis of maternal and neonatal medical records of 41 triplets. 21 were delivered vaginally and 20 were delivered by cesarean section. MAIN OUTCOME: To measure perinatal mortality and early neonatal complications. RESULTS: Between January 1, 1994, and June 30, 1999, there were 41 triplets delivered at our institution. Of these 21 triplets were delivered vaginally and 20 triplets were delivered abdominally. The perinatal mortality rate was 32/123 (26.0%), primarily due to the respiratory distress syndrome. The perinatal deaths are mainly at a birth weight of 500-1,500 g (29/32; 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: Abdominal delivery in triplets is not superior to vaginal delivery in terms of fetal and early neonatal outcome. The perinatal deaths are increased with low birth weight (500-1,500 g) and with breech presentation. The main cause of neonatal mortality is the respiratory distress syndrome.

Cesarean Section↗
PubMedDate not supplied

Assessment of triplet fetal growth by using cross-sectional analysis of the birth weight.

OBJECTIVE: To model the growth of triplets. METHOD: Statistical analysis using data of a consecutive series of 76 triplet gestations (223 livebirths). RESULTS: The best model to describe the growth was linear regression (r = 0.76; r2 = 0.577; p < 0.0001; y = -2,858.05 + 139.66x). 34.2% of the sets had an intratriplet discordance rate of at least 25%, and 11.8% of the triplets had a maximum discordance rate over 40%. CONCLUSIONS: (1) Triplet fetal growth is strongly related to the gestational age; (2) the growth of each triplet in a same set may considerably differ, and (3) the use of singleton curves for triplet growth assessment is inadequate.

Adolescent↗
PubMed2004

Monochorionic triplets following intracytoplasmic sperm injection: a report of two consecutive cases.

Monochorionic triplet pregnancies are very rare. Here we report 2 cases of multiple pregnancies with monochorionic triplets following intracytoplasmic sperm injection (ICSI) and day 3 embryo transfer. The 2 women concomitantly underwent controlled ovarian hyperstimulation due to male factor infertility. Following oocyte retrieval, ICSI and assisted hatching (AH) were performed, and the 2 women conceived consecutively. One patient had a quadruplet pregnancy, which included monochorionic triplets, while the other had monochorionic triplets. Selective embryo reduction by intracardiac KCl injection targeted at 2 of the triplets was performed on the patient with the quadruplet pregnancy, but the third triplet also died. The gestation continued as a singleton pregnancy, and the patient gave birth to a healthy female baby at 38 weeks. The other patient gave birth to 3 healthy female babies at 34 weeks. Possible etiologic factors for the formation of monozygotic splitting among women undergoing assisted reproduction treatment are discussed.

Adult↗