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PubMed2004

Longitudinal changes in plasma glucose values of the 75-g glucose tolerance test in triplet pregnancies.

We evaluated longitudinal changing patterns of 75 g glucose tolerance test (GTT) in triplet pregnancies. Eight triplet pregnancies were prospectively studied. All triplet pregnancies were fertilized with artificial reproductive techniques; patients showed no glucosuria or fasting hyperglycemia > 100 mg/dL before pregnancy. The 75-g GTT was performed at first, second, and third trimester, as well as at postpartum. Longitudinal changes in glucose levels at fasting, 1 hour, and 2 hours were compared by one-way repeated-measure analysis of variance (ANOVA) and Bonferroni/Dunn test ( p < 0.05). Values were expressed as mean +/- standard deviation. Each of the 3-point values of 75-g GTT decreased after 28 weeks of gestation in triplet pregnancies. During the third trimester, fasting values were significantly decreased compared with postpartum values (65.5 +/- 13.4 versus 74.6 +/- 4.0 mg/dL), and 2-hour values were significantly decreased from those of second-trimester 75-g GTT (116.3 +/- 19.5 versus 99.6 +/- 17.1 mg/dL). Longitudinal glucose values of 75-g GTT improve during third trimester in triplet pregnancies, suggesting that fetoplacental fuel drain may counterbalance maternal insulin resistance.

Adult↗
PubMed2005

Changes in antithrombin activity and platelet counts in the late stage of twin and triplet pregnancies.

It is possible that women with triplet pregnancies are more likely to exhibit pregnancy-induced antithrombin deficiency, gestational thrombocytopenia, and perinatal elevation in serum aspartate aminotransferase (AST) than women with twin pregnancies. We retrospectively reviewed changes in antithrombin activity, platelet count, and blood chemistry in 23 twin and seven triplet pregnancies in which the mothers received antenatal care and gave birth in our hospital during 1999 and 2001. Both antithrombin activity and platelet counts gradually decreased until delivery, then promptly increased after delivery in both twin and triplet pregnancies. A significantly larger number of women developed gestational thrombocytopenia of < 100 x 10 (9)/L (43% [three of seven] versus 4.3% [one of 23]; p < 0.01) and pregnancy-induced antithrombin deficiency of < 60% of normal activity (57% [four of seven] versus 17% [four of 23]; p < 0.05) in triplet than in twin pregnancies. Eight women with pregnancy-induced antithrombin deficiency, including three women with gestational thrombocytopenia, were significantly more likely to develop perinatal elevations of AST, lactate dehydrogenase, serum creatinine, fibrin/fibrinogen degradation products, and D-dimer than were those without pregnancy-induced antithrombin deficiency. These findings suggest that women with triplet pregnancies are at an increased risk of the HELLP syndrome and acute fatty liver of pregnancy compared with women with twin pregnancies.

Adult↗
PubMed1997

The rate of severe preeclampsia is increased in triplet as compared to twin gestations.

The objective of this study was to determine if the rate of preeclampsia is increased in triplet as compared to twin gestations. Fifty-three triplet pregnancies between 1986 and 1993 at The New York Hospital-Cornell Medical Center were reviewed. These were matched for maternal age, parity, and race to twin gestations (N = 53) from the same population. Severe preeclampsia was defined by standard criteria. Student's t-test, Fisher exact test, and Chi-square were used for statistical analysis. The rate of severe preeclampsia was increased significantly in the triplet group 12 of 53 (22.6%) as compared with the twin group 3 of 53 (5.7%) (OR = 4.9, 95% CI 1.2-23.5, p = 0.02). The rate of overall preeclampsia was not significantly different in the triplet 18 of 53 (33.96%) or twin 12 of 53 (22.6%) groups. In this retrospective, case-controlled study, the rate of severe pre-eclampsia was significantly increased in triplet gestations as compared to twins although the overall rate of preeclampsia was not. This information may be useful in counseling patients with high order multifetal gestations.

Adult↗
PubMed1993

Elective suture of uterine cervix in triplets.

The incidence of triplet pregnancies has increased several times due to the widespread use of ovulation induction agents. Premature delivery is the main complication of triplet gestations. In twin conceptions it was shown definitely that elective cervical suture does not prolong these pregnancies. However, in higher order multifetal gestations the uterus is extremely overdistended and the application of cerclage is equivocal. This work intended to assess the value of elective cervical sutures in prolonging triplet pregnancies. Twelve of 35 women with triplet conceptions hospitalized at our high-risk pregnancy unit underwent an elective cerclage at 12 to 14 weeks and 23 women served as control subjects. None of them had any history or physical findings of cervical incompetence prior to the procedure. The gestational age (weeks) at delivery was 33.0 +/- 5.1 and 34.7 +/- 2.8 (mean +/- SD) for the sutured and noncerclage groups, respectively. The birthweight (grams) of the neonates was 1833.0 +/- 524.5 and 1884 +/- 455.5 (mean +/- SD) for the cerclage and nonsutured women, respectively. It seems that triplet gestations as such do not benefit from an elective cervical suture.

Birth Weight↗
PubMed2002

Outcomes of dichorionic triplet pregnancies.

OBJECTIVE: The objective of this study was to describe outcomes in a series of dichorionic triplet pregnancies. STUDY DESIGN: All triplet pregnancies evaluated in our obstetric sonography unit from 1993 to 2000 were identified. Those containing a monochorionic twin pair were included. Prenatal and neonatal records were reviewed. Statistical comparison was performed by using Wilcoxon matched-pairs signed-ranked sum test. RESULTS: Seventeen cases met inclusion criteria. Two pregnancies (11.8%) were delivered spontaneously before viability, at 22 and 21 weeks. Twin-twin transfusion syndrome was diagnosed in the second trimester in the monochorionic pair in 3 pregnancies (17.6%). In the remaining 12 pregnancies, mean gestational age at delivery was 33.5 +/- 2.3 weeks. The median birth weight of 23 neonates from individual monochorionic twin pairs was 1810 g (interquartile range, 1540-2180 g), which was significantly lower than the median birth weight of 12 triplets supplied by a separate placenta, 2125 g (interquartile range, 1762-2390 g) (P =.01). CONCLUSION: Twin-twin transfusion syndrome or spontaneous loss before viability complicated approximately 30% of dichorionic triplet pregnancies. Lower birth weights were noted in triplets from monochorionic twin pairs.

Abortion, Spontaneous↗
PubMed2003

Comparison of morbidity among twins and triplets.

This study aims to compare morbidity indicators between twins and triplets. This was a retrospective, observational study, and involved a review of twins and triplets born in Basildon Hospital between 1991 and 2000. The main outcome measures were mean birth weight, gestational age at delivery, mode of delivery and length of stay in the intensive care unit. The mean birth weight is comparable between twins and triplets (1.877 kg at 33+4 weeks of gestation vs. 1.905 kg at 34+4 weeks of gestation). Triplets stayed a longer period in the intensive care baby unit. In this study birth weight in multiple pregnancies was as expected for gestational age. Triplets required longer neonatal intensive care.

Birth Weight↗
PubMed2002

Anti-neutrophil cytoplasmic autoantibody (ANCA) profiles in propylthiouracil-induced lupus-like manifestations in monozygotic triplets with hyperthyroidism.

We describe the ANCA profile of two monozygotic triplets (A and B) treated with propylthiouracil (PTU) for hyperthyroidism who developed LE-like manifestations. Triplet C also developed hyperthyroidism but was not treated with PTU and never experienced LE-like symptoms. Triplet A and B showed a marked rise in P-ANCA titer to 1:1280 after PTU was introduced whereas triplet C never had a titer higher than 1:80. Consecutive sera were investigated for ANCA to six different neutrophil granule proteins. Triplet A and B, but not C, both developed a strongly positive elastase-ANCA. Our results confirm the importance of a genetic factor influencing the susceptibility to drug-induced LE.

Antibodies, Antineutrophil Cytoplasmic↗
PubMed2002

Comparative outcome study between triplet and singleton preterm newborns.

AIM: To evaluate the outcome of triplet versus singleton preterm newborns. METHODS: The study population included 64 sets of preterm triplet (gestational age 25-34 wk) and 64 singleton controls. Data on prenatal and perinatal findings, neonatal complications, duration of hospitalization, and neonatal mortality were collected by chart review. RESULTS: Mothers of triplets were more likely to receive prenatal tocolytic treatment and more antenatal steroids for foetal lung maturation, and to be delivered by caesarean section. No differences were found between the groups in perinatal parameters (cord pH, Apgar score, respiratory support after birth), respiratory parameters (severity of acute and chronic lung disease, use and duration of oxygen treatment and assisted ventilation), or neonatal complications (patent ductus arteriosus, intraventricular haemorrhage, periventricular leukomalacia, necrotizing enterocolitis, retinopathy of prematurity, meningitis, sepsis and jaundice). This was also true for duration of hospitalization and neonatal mortality. No differences were recorded by birth order among the triplets for any of these parameters. CONCLUSION: The study indicates that good prenatal care can lead to a good outcome for preterm triplets, close to that of preterm singleton infants. Families and physicians should consider this information when foetal reduction is offered.

Female↗
PubMed2001

The anesthetic management of triplet cesarean delivery: a retrospective case series of maternal outcomes.

UNLABELLED: Spinal anesthesia for the cesarean delivery of triplets is associated with an increased incidence of maternal hypotension and placental hypoperfusion. We performed a retrospective case series analysis between January 1992 and June 2000 to evaluate the effects of regional anesthetic techniques for cesarean delivery in triplet pregnancies on maternal and neonatal outcome. Spinal and epidural anesthesia were compared with respect to intraoperative hemodynamics and neonatal outcomes. Ninety-six triplet pregnancies were delivered by cesarean section, of which 91 received regional anesthesia. A statistically significant decrease in systolic blood pressure was demonstrated immediately after the induction of spinal as compared with epidural anesthesia. The total volume of IV crystalloid used was significantly larger in the Spinal Anesthesia group. The number of patients receiving more than 15 mg of ephedrine and the cumulative dose of ephedrine was significantly larger in the Spinal group compared with the Epidural group. There were no differences in the rate of perioperative complications between the Spinal and Epidural Anesthesia groups. Neonatal Apgar scores were similar in both groups. The data suggest that both epidural and spinal anesthesia for triplet cesarean delivery are safe techniques, but the latter is associated with a larger initial decrease in systolic blood pressure. This decreasing of systolic blood pressure, however, remained within the physiological range and did not seem to be clinically significant. The need for more crystalloid fluids and ephedrine should be anticipated when spinal anesthesia is used for these cases. IMPLICATIONS: A large retrospective case series of the effects of spinal and epidural anesthesia on maternal hemodynamic profile during cesarean delivery for triplet gestation was performed. Our findings suggest that spinal anesthesia results in outcomes comparable to epidural anesthesia for both mother and newborns.

Adult↗
PubMed2003

Outcome of triplets and high-order multiple pregnancies.

PURPOSE OF REVIEW: To present data related to the outcome of triplets and high-order multiple pregnancies. RECENT FINDINGS: Current frequencies of high-order multiple pregnancies in most developed countries range between 400 and 800% above the rates observed in the late 1970s. Of particular importance is the striking increase in pregnancies in older mothers. These epidemiological trends are the result of modern infertility treatments. The improved outcome of triplets may be attributed to close antenatal and perinatal care, both of which are more likely to be implemented in patients who can afford treatment for infertility. The overall odds of delivering at least one triplet infant weighing less than 1000 g is approximately 10%. The neonatal complications among triplets weighing less than 1500 g at birth are not much different from those among twins or singletons, except for a higher neonatal mortality rate. Despite this, the frequency of cerebral palsy bears a significant exponential relationship to the number of fetuses, and iatrogenic multiple births are clearly implicated in the increased cerebral palsy rate. In the past few years the perinatal mortality rate for triplets has been approximately 110/1000, three-quarters of which represent neonatal deaths. SUMMARY: Available data imply that in order to improve outcomes further, all multiple pregnancies deserve optimal perinatal care, something that is not always obtainable.

Adult↗
PubMed2006

Triplet ultrasound growth parameters.

OBJECTIVE: To create ultrasound growth curves for normal growth of fetal triplets using statistical methodology that properly accounts for similarities of growth of fetuses within a mother as well as repeated measurements over time for each fetus. METHODS: In this longitudinal study, all triplet pregnancies managed at a single tertiary center from 1992-2004 were reviewed. Fetuses with major anomalies, prior selective reduction, or fetal demise were excluded. Data from early and late gestation in which there were fewer than 30 fetal measurements available for analysis were excluded. We used multilevel models to account for variation in growth within a single fetus over time, variations in growth between multiple fetuses within a single mother, and variations in fetal growth between mothers. Medians (50th), 10th, and 90th percentiles were estimated by the creation of multiple quadratic growth models from bootstrap samples adapting a previously published method to compute prediction intervals. Estimated fetal weight was derived from Hadlock's formula. RESULTS: One hundred fifty triplet pregnancies were identified. Twenty-seven pregnancies were excluded for the following reasons: missing records (23), fetal demise (3), and fetal anomaly (1). The study group consisted of 123 pregnancies. The gestational age range was restricted to 14-34 weeks. Figures and tables were developed showing medians, 10th and 90th percentiles for estimated fetal weight, femur length, biparietal diameter, abdominal circumference, and head circumference. CONCLUSION: Growth curves for triplet pregnancies were derived. These may be useful for identification of abnormal growth in triplet fetuses. LEVEL OF EVIDENCE: III.

Anthropometry↗
PubMed2004

Maternal and neonatal outcomes in 54 triplet pregnancies managed in an Australian tertiary centre.

BACKGROUND: To provide current data on maternal and neonatal outcomes in triplet pregnancies in an Australian population. METHODS: Retrospective case note review of all triplet pregnancies managed within a single Australian tertiary centre. RESULTS: Fifty-four sets of triplets were managed from January 1996 to October 2002. A total of 59% resulted from the use of assisted reproductive technologies. The median gestation at delivery was 32.5 weeks (range: 21-36 weeks); 14% delivered prior to 28 weeks and 43% delivered before 32 weeks. Preterm labour and preterm rupture of membranes were the most common antenatal complications occurring in 57 and 22% of pregnancies, respectively. A total of 93% of pregnancies were delivered by Caesarean section and 37% of mothers experienced at least one post-partum complication. A total of 96% of neonates were liveborn, with a median birthweight of 1644 g (range: 165-2888 g). The two most common neonatal complications were jaundice and hypoglycaemia in 52 and 43% of liveborn neonates, respectively. A total of 28% of neonates were below the 10th centile for gestational age and sex. A total of 8% of neonates demonstrated congenital anomalies. The perinatal mortality at a gestational age of 20-24 weeks was 100%, 22% at 25-28 weeks and zero for those babies born at 29 weeks or beyond. CONCLUSION: Assisted reproductive technologies contribute significantly to the incidence of triplet pregnancies. Gestational age at delivery and perinatal mortality is comparable to published international data. Triplets born in a tertiary centre beyond 28 weeks gestation have a very favourable prognosis in the newborn period.

Adult↗
PubMed2002

Fundal height as a predictor of early preterm triplet delivery.

The purpose of this study was to create graphs of fundal height parameters in triplet pregnancies compared with those in twin pregnancies, and to investigate whether larger fundal heights in triplet pregnancies would predispose them to earlier delivery (before 34 weeks). The subjects were 727 twin pregnant women and 133 triplet pregnant women, who delivered after 1984. Triplet pregnancies showed significantly higher fundal heights compared with twin pregnancies at each gestational age (weeks). In triplet pregnancies, a single fundal height measurement above the 90th percentile before 34 weeks yielded a sensitivity of 31.3% and specificity of 82.4% for delivery before 34 weeks, with a positive predictive value of 50.0% and a negative predictive value of 68.0%. After adjusting for each associated factor using logistic regression, the risk of preterm labour was not significantly associated with a single fundal height measurement above the 90th percentile recorded before 34 weeks.

Anthropometry↗
PubMed1977

Monozygotic triplets with discordance for diabetes mellitus and diabetic microangiopathy.

A set of monozygotic triplets (PE.K., P.K., S.K.) has been studied. There is no diabetes in first-degree relatives. PE.K. developed insulin-requiring (60 U. NPH) diabetes at the age of 13 years. Over a period of 11 years since that time, numerous studies of insulin and growth-hormone secretion were performed on P.K. and S.K., including multiple oral glucose tolerance tests (OGTTs), cortisone-primed oral glucose tolerance tests (C-OGTTs), intravenous glucose tolerance tests (IVGTTs), and intravenous tolbutamide tests (IVTTs). The results of each test were compared with age- and sex-matched control subjects. P. K. developed insulin-requiring (56 U. NPH) diabetes after remaining discordant for eight years. Glucose, insilin, and growth-hormone responses during all tests were normal except during the IVGTT performed four months prior to the onset of diabetes. This last IVGTT revealed a glucose disappearance rate of 0.98 per cent per minute, and the slope of the regression line of serum-insulin response (IRI) on blood glucose (BG) was markedly decreased to 0.005 micronU./ml. IRI/mg./dl. BG (controls 0.340 +/- 0.04; mean +/- S.E.M.). The insulin responses in P.K. and S.K. were similar during all OGTTs, C-OGTTs, and IVTTs. S.K. has continued to maintain normal glucose tolerance and normal insulin and growth-hormone responses during all tests. The histocompability antigen studies have revealed HLA-A2, AW24, BW15, and BW40 phenotype in these monozygotic triplets. Muscle capillary basement membranes of the nondiabetic triplet were normal, whereas both diabetic triplets manifested evidence of capillary basement membrane thickening. The clinical and biochemical profiles in these triplets and the capillary basement membrane data lend strong credence to the role of "nongenetic" determinants in the development of "genetic" diabetes as well as diabetic microangiopathy in juvenile-onset-type diabetes.

Adolescent↗
PubMed1997

A comparison of the expressive communication skills of triplet, twin and singleton children.

Few studies have focused on the language acquisition of higher multiple birth sets. In this study, the communication skills of 51 triplet children are described. The measures used were: mean length of utterance; type-token ratio; conversational acts; phoneme repertoire; and number of different types of phonological processes used. The data gained were used to compare the communication skills of triplets with those of twins, singletons and normative data available in the literature. Siblings within triplet sets were also compared using language samples obtained from adult-child interactions and when the three children were playing together. The results indicated that the triplets' early communication skills were different from those of both singletons and twins. The triplets' difficulties included delayed syntactic development, limited use of different language functions and delayed phonological development. In contrast, twins' communication profile is characterised by disordered phonological development.

Child, Preschool↗
PubMed2004

Feasibility of nuchal translucency in triplet pregnancies.

OBJECTIVE: To assess the feasibility of nuchal translucency in triplets compared with singletons. METHODS: Nuchal translucency thickness as part of routine first-trimester screening in the general population was compared between 3128 singleton pregnancies and 51 triplets (153 fetuses). Crown-rump length was also noted. The 5th, 50th, and 95th percentiles were determined and compared between the 2 groups, and regression curves of nuchal translucency measurements plotted against crown-rump length were drawn. RESULTS: The mean nuchal translucency thickness was 1.23 mm for singletons and triplets. The 5th and 95th percentiles were also the same between the 2 studied groups. The regression curves of 5th, 50th, and 95th percentiles of nuchal translucency plotted against crown-rump length of triplets and singletons overlapped. CONCLUSIONS: Nuchal translucency values and distribution are the same in triplets and singletons, validating the utility of the cutoff values.

Adult↗
PubMed2004

Cervical length in the early second trimester for detection of triplet pregnancies at risk for preterm birth.

OBJECTIVE: Preterm triplet delivery is common and has a tremendous impact on neonatal mortality and morbidity. We aimed at assessing early second-trimester cervical length as a means of detecting triplet pregnancies at risk for preterm birth. METHODS: Cervical length was measured in triplet pregnancies during weeks 14 to 20. Cervical length of less than 25 mm was used as a cutoff to divide individuals into 2 groups. Perinatal outcome parameters were compared between the 2 groups and included gestational age at delivery, birth weights, and neonatal intensive care unit admission rates. Sensitivity, specificity, and positive and negative predictive values were calculated for cervical length as a screening method for preterm birth. RESULTS: We evaluated 36 triplets during weeks 14 to 20. Cervical length of less than 25 mm was measured in 14 (group I), 12 of which were delivered before 32 weeks (mean +/- SD, 28.4 +/- 3.1 weeks). Four of 22 women with cervical length of greater than 25 mm (group II) had delivery before 32 weeks (mean, 30.1 +/- 1.8 weeks). The mean gestational age at delivery for all parturients from group II was 33.1 +/- 2.1 weeks (P < .05). Group I neonates had lower birth weights (972 versus 1889 g; P < .001) and higher rates of low 5-minute Apgar scores and neonatal intensive care unit admissions compared with group II neonates. The sensitivity of a shorter cervix as a predictor of preterm labor was 75%, with specificity of 90%, a positive predictive value of 83%, and a negative predictive value of 81%. CONCLUSIONS: Cervical length of less than 25 mm at 14 to 20 weeks' gestation is associated with preterm delivery and adverse perinatal outcome in triplet pregnancies.

Adult↗
PubMedDate not supplied

Triplet pregnancies and their aftermaths. Part I: Basic considerations.

Until recently, triplets were an infrequent occurrence. With the development of ovulation-inducing medications and then assisted reproductive technology (ART), the triplet birth rate in maternal age ranges over 24 years has multiplied three- to fiftyfold. The first review of the clinical aspects of triplet pregnancies was published in 1988. Since then, more data reported on such births have revealed a consistent triad of preterm delivery, low birth weight, and very low birth weight, plus increased maternal risks. This article details comparative risks to mothers and children using population-based data comparing differential outcomes in singletons, twins, and triplets; an extensive review of recent triplet publications is provided in the references.

Birth Rate↗