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PubMed2004

Survival of triplets who are born to teen mothers in the United States.

OBJECTIVE: The purposes of this study were to assess survival among triplets who are born to teen mothers and to determine whether fetal number influences the mortality rates of the offspring of teen mothers when compared with the offspring of older women. STUDY DESIGN: A retrospective cohort study of 354 triplet births to teenage mothers and 6858 to young mature mothers (20-29 years) who were delivered from 1995 through 1998. We compared the occurrence of stillbirth and neonatal and infant mortality rates between the 2 categories by means of the generalized estimating equation. Similar analyses were conducted for singleton pregnancies and twin pregnancies. RESULTS: Triplets of teenage mothers experienced a higher level of stillbirth (odds ratio, 3.24; 95% CI, 1.44-7.24), neonatal mortality (odds ratio, 2.00; 95% CI, 1.11-3.61), and infant death (odds ratio, 1.66; 95% CI, 1.01-2.87). Moreover, as the plurality increased from singleton infant to triplet, the offspring of teenagers fared progressively worse ( P < .0001). CONCLUSION: This study confirms the association between teenage motherhood and feto-infant death and indicates that this mortality relationship varies in a dose-dependent fashion.

Adolescent↗
PubMed2007

Long-term neurodevelopmental outcome of triplets.

OBJECTIVE: To analyze the incidence of neurodevelopmental disabilities in triplets and to find out possible connection between the outcome and perinatal events. DESIGN: Retrospective cohort study of 94 triplets and their outcome at 24-144 months of age correlated with gestational age, birth weight, pregnancy complications, early neonatal period, neonatal cranial ultrasound, period of birth (1985-1995, 1996-2000) and type of antenatal care. RESULTS: Sixty-two triplets are healthy, 15 suffer cerebral palsy (CP) and 17 minimal cerebral dysfunction (MCD). Adverse outcome correlates significantly with prematurity, low birth weight and maternal age. In multivariate analysis, both cerebral palsy and minor disabilities correlate significantly with early neonatal complications, neonatal cranial ultrasound with later CP (p<0.01), and MCD with preterm rupture of membranes (p=0.047). Children conceived spontaneously do worse than those born after assisted reproduction (p=0.004), those born in the time period 1996-2000 do better than those born before (p=0.021). Seventy-seven percent (77%) of newborns delivered in the time period 1996-2000 and after level 1 antenatal care was introduced, compared with 54% being delivered in the time period before 1996 and with less meticulous types of antenatal care, remain healthy (p=0.015). CONCLUSION: Triplets are still at high risk for long-term neurodevelopmental complications. Stringent perinatal care might appear important determinant of their long-term outcome.

Birth Weight↗
PubMed1999

Comprehensive fetal ultrasonographic growth measurements in triplet gestations.

OBJECTIVE: Our purpose was to create tables and graphs of ultrasonographically derived fetal growth parameters in longitudinally studied triplet gestations from a single center. STUDY DESIGN: All triplet pregnancies managed by our division from 1987 through 1998 were identified. All had first-trimester dating sonograms and complete obstetric sonograms obtained by means of 3.5- or 5.0-MHz curvilinear transducers with freeze-freeze capability and on-screen calipers. Sonograms to assess fetal growth were obtained every 2 to 4 weeks, from 16 to 18 weeks' gestation until delivery. Fetal parameters obtained with each sonogram included biparietal diameter; head circumference; bicerebellar diameter; abdominal circumference; femur, humerus, tibia, and fibula lengths; estimated fetal weight; and head circumference/abdominal circumference ratio. Regression analysis was performed with JMP and Cricket Graph software packages, and lines of best fit with 95% confidence intervals were generated. RESULTS: A total of 443 ultrasonographic examinations were performed for 33 triplet pregnancies (99 fetuses). Each had between 3 and 6 sonograms obtained, all between 16 and 35 weeks' gestation. Scatterplots of each of the fetal growth parameters against gestational age were created with regression lines of best fit and 95% confidence intervals. All growth parameters were dependent on gestational age. CONCLUSION: A comprehensive set of fetal growth measurements in triplets from the United States is now available and can be used to assess longitudinal fetal growth.

Birth Weight↗
PubMed1999

Multifetal pregnancy reduction in cases of threatened abortion of triplets.

OBJECTIVE: To investigate the course of pregnancy and fetal outcome after first-trimester multifetal pregnancy reduction (MFPR) in patients with triplet pregnancies and uterine bleeding. DESIGN: Case series of patients with threatened triplet pregnancies considered for MFPR. SETTING: Department of Obstetrics and Gynecology, Rabin Medical Center, Petah-Tiqva, Israel. PATIENT(S): Forty-two patients with triplet pregnancies and first-trimester uterine bleeding. INTERVENTION(S): At 10-15 weeks' gestation, MFPR with intracardiac injection of potassium chloride was performed. The procedures were performed 7-10 days after cessation of bleeding (9-13 weeks) or in the presence of minimal uterine bleeding (14-15 weeks). In patients with heavy uterine bleeding, MFPR was postponed. MAIN OUTCOME MEASURE(S): Early- and late-pregnancy complications related to the procedure, pregnancy outcome, and fetal survival. RESULT(S): Performance of MFPR at 14-15 weeks was associated with a higher abortion rate (38.5%), lower mean gestational age at delivery (30.6 weeks), and lower mean twin birth weight (1,376+/-218 g and 1,014+/-202 g) than was performance of MFPR at 10-13 weeks (18.8%, 33.2 weeks, and 1,720+/-245 g and 1,596+/-170 g, respectively). Abortion occurred in four of the five patients with moderate to heavy uterine bleeding who did not undergo MFPR; the fifth patient gave birth prematurely at 28 weeks, and two of the newborns died. CONCLUSION(S): Pregnancy outcome and fetal mortality and morbidity in triplet pregnancy after MFPR are directly correlated with duration and amount of first-trimester bleeding.

Abortion, Threatened↗
PubMed2002

Survival of other fetuses after a fetal death in twin or triplet pregnancies.

OBJECTIVE: To estimate the frequency of fetal death in multifetal pregnancies and the probability of survival to age 1 year for twins or triplets in which at least one fetal death occurred at 20 weeks' gestation or more. METHODS: We used the Matched Multiple Birth File from the US National Center for Health Statistics, which included 152,233 sets of twins and 5356 sets of triplets registered from 1995 to 1997. The Cox proportional hazards model was used to estimate the adjusted relative risk of death before age 1 year for remaining twins and triplets. RESULTS: Fetal death at 20 weeks' gestation or later was uncommon, occurring in 2.6% of twin and 4.3% of triplet gestations. After adjustment for confounders, the survival of the remaining fetuses was inversely related to the time of the first fetal demise. Same-sex twins were two times more likely than opposite-sex twins to die after an intrauterine demise at 25-32 weeks' gestation and were more than three times more likely to die after a death at 33 weeks' gestation or more. CONCLUSION: After a fetal death in a multifetal pregnancy at 20 weeks' gestation or later, the survival of the remaining fetuses is inversely related to the time the death occurred. Among twins, survival also depends on sex concordance, with opposite-sex twins more likely than same-sex twins to survive.

Female↗
PubMed1998

Acute fatty liver of pregnancy in triplet gestation.

BACKGROUND: Acute fatty liver is reported to be more common in twin than in singleton pregnancies. We report three cases of biopsy-proven acute fatty liver in triplet gestations. CASES: In all three cases of acute fatty liver complicating triplet pregnancies, the presenting features were vague abdominal complaints with elevated hepatic aminotransferase levels. A liver biopsy was performed in each case, and cesareans were performed immediately after the diagnosis was confirmed histologically. Clinical resolution occurred in all cases, and all infants did well in the neonatal period. CONCLUSION: Patients with triplet gestations should be monitored closely for the early signs of acute fatty liver. Triplet gestations may contribute to the onset of acute fatty liver by further stressing the fatty acid oxidation capabilities of the susceptible woman.

Acute Disease↗
PubMed1996

Reducing fetal deaths in multiple births: optimal birthweights and gestational ages for infants of twin and triplet births.

The objective of this study was to determine the birthweight and gestational age associated with the lowest fetal mortality for twins and triplets. The study design was a population-based analysis of all live births and fetal deaths in the US between 1983-88. Fetal mortality was compared by categories of birthweight and gestational age, for twins and triplets versus singletons, and within each plurality by the lowest rate compared to all other rates as relative risks +/- 95% Cls. The overall versus lowest fetal death rate per 1,000 conceptions for singletons was 4.3 versus 0.9 at 3700-4000 g and 40-41 weeks; for twins, 15.5 versus 3.3 at 2500-2800 g and 36-37 weeks; and for triplets, 21.0 versus 5.2 at 1900-2200 g at 34-35 weeks. Beyond these plurality-specific lowest ranges, the risk of fetal death increased, more for twins than singletons, and most for triplets. To conclude, fetal death rates can be reduced by 75-80% with attainment of birthweight and gestational age within a plurality-specific ideal range.

Birth Weight↗
PubMed1989

Surveillance of triplets with umbilical artery velocimetry waveforms.

Doppler arterial velocimetry waveforms was used as a method of antenatal surveillance for triplets. Six sets of triplet pregnancies were studied. Each fetus was identified by real-time-ultrasound scanning and the peak systolic/end diastolic (S/D) ratio was calculated. In one set of triplets two fetuses showed absent end diastolic flow. Both subsequently suffered from necrotising enterocolitis and had major bowel resection. The five other sets of triplets maintained a normal S/D ratio. Three had a normal outcome and two delivered prematurely.

Adult↗
PubMed2003

Risk factors for pulmonary edema in triplet pregnancies.

OBJECTIVE: Multiple gestations are known to be at increased risk for pulmonary edema. Our objective was to characterize this morbidity in a cohort of triplet pregnancies. STUDY DESIGN: Charts from triplet pregnancies managed by the Georgetown University Hospital Maternal-Fetal Medicine service were abstracted for demographic information and complications. Cases who developed pulmonary edema were compared with those who did not using Fisher exact test, chi(2) and Student's t-test with p <0.05 considered significant. RESULTS: Of 66 triplet pregnancies with complete records, 15 (22.7%) were complicated by pulmonary edema. Patients developing this condition were more likely to be receiving magnesium sulfate therapy than those who did not [14/15 (93.3%) vs 32/51 (62.7%) p=0.049]. There was no difference between patients developing pulmonary edema and those who did not in terms of maternal age (mean+/-SD: 34.5+/-6.8 vs 34+/-4.3 years, p=0.8) or gestational age at delivery (33.3+/-2.3 vs 32.8+/-3.5 weeks, p=0.6), but the former group had smaller babies than the latter (1739+/- 369 vs 1891+/-538 g, p=0.04). Among the patients treated with magnesium sulfate, those who developed the more severe form of pulmonary edema were more likely than those who did not to have been treated for pre-eclampsia than preterm labor (6/10 (60%) vs 7/33 (21.2%), p=0.04). CONCLUSIONS: Pulmonary edema is a common complication of triplet pregnancy. Patients receiving magnesium sulfate, having pre-eclampsia or fetal growth restriction are at increased risk for pulmonary edema, particularly in its worst clinical presentation.

Adult↗
PubMed2000

Pruritic urticarial papules and plaques of pregnancy in twin and triplet pregnancies.

BACKGROUND: Pruritic urticarial papules and plaques of pregnancy (PUPPP) is a common dermatosis of unknown aetiology. Multiple pregnancies occur frequently in most reported series of PUPPP and increased abdominal distension has been considered a factor in its causation. OBJECTIVES: To determine the frequency of PUPPP in twin and triplet pregnancies. METHODS: A retrospective review of all the records of patients delivered of twin or triplet pregnancies over an 18-month period at a busy general maternity hospital. RESULTS: One hundred and thirty-eight women delivered twins, four of whom developed PUPPP (2.9%). Fourteen women delivered triplet pregnancies, two of whom developed PUPPP (14%). Four of these six multiple pregnancies were conceived by in vitro fertilization. CONCLUSIONS: The reported rate of PUPPP in single pregnancies is 1 in 200 (0.5%). Our findings suggest that multiple pregnancies are at a higher risk of developing this cutaneous eruption with 2.9% of twin and 14% of triplet pregnancies affected in our study.

Adult↗
PubMed2004

The effect of antenatal corticosteroids on fetal growth, survival, and neurodevelopmental outcome in triplet pregnancies.

Triplet pregnancies have increased as a result of infertility therapy. The objectives of this study are to review the outcome of triplet pregnancies and to determine the effect of different antenatal corticosteroid treatments on fetal growth, survival, and neurodevelopmental outcome. A retrospective case note review of infant and maternal records from a single tertiary neonatal unit was performed from January 1, 1986, through December 31, 1999; 173 live births from 60 triplet pregnancies were divided into groups according to maternal antenatal corticosteroid exposure. Logistic regression model showed only gestation had a significant effect on survival. There was no adverse effect of steroid exposure on weight or head circumference at birth. Ninety percent of live births survived to discharge. Of 143 survivors, only five infants had documented neurodevelopmental problems. Survival rate in triplet pregnancy is high. In this analysis of cohort data repetitive antenatal steroids were not associated with adverse outcome.

Adrenal Cortex Hormones↗
PubMed1998

Maternal morbidity associated with triplet pregnancy.

The objective of this article is to describe maternal morbidity in a large cohort of triplet pregnancies managed by a single Maternal-Fetal Medicine group over a short period of time. Records from all triplet pregnancies managed and delivered from 1992 to 1996 were reviewed for maternal outcome data. Pregnancies delivered prior to 20 weeks were excluded. During the 4-year study period, 55 triplet pregnancies were managed and delivered at this center. The most common maternal complication was preterm labor, which occurred in 42 cases (76%). Preterm premature rupture of membranes occurred in 11 cases (20%). Pregnancy-induced hypertensive complications occurred in 15 cases (27%), which included severe preeclampsia 13 (24%), hemolysis, elevated liver function tests, and low platelets (HELLP) syndrome 5 (9%), and eclampsia 1 (2%). Other maternal antenatal complications included anemia 15 (27%), acute fatty liver of pregnancy 4 (7%), gestational diabetes 4 (7%), supraventricular tachyarrhythmias 2 (4%), dermatoses 2 (4%), urinary tract infection 2 (4%), and acute disc prolapse requiring surgery in 1 case (2%). Postnatal complications occurred in 18 cases (33%), including endometritis 13 (24%), postpartum hemorrhage 5 (9%), pneumonia 2 (4%), urinary tract infection 2 (4%), and diastasis of rectus muscles requiring surgery in 1 (2%). There were no maternal deaths. Antenatal and postnatal maternal complications occur in almost all triplet gestations, suggesting that such pregnancies be managed at centers that have appropriate multidisciplinary expertise available.

Cohort Studies↗
PubMed1993

Discordancy in triplets.

Discordancy in twins is generally described as a weight difference between the fetuses of 15 to 25% and its prevalence in normal twin gestations is estimated at 15 to 29%. The present study was performed in order to determine the frequency of discordant newborns in uncomplicated triplet gestations. One hundred and fourteen normal triplet newborns were delivered during a period of 11 years. Their birthweight ranged from 493 to 2533 gm, with a mean of 1894.2 +/- 468.5 gm (+/- sd). In 58% of these 38 sets of triplets the difference in weight between the largest and smallest newborn was more than 15%. About a quarter of the newborns had a greater than 25% dissimilarity in their birthweights. There was no substantial fetal-fetal transfusion or difference in the Apgar scores between the discordant fetuses. It may be concluded that triplet newborns have a rate of discordancy double that of twins. Discordance per se does not necessarily mark an underlying complication of pregnancy or a bad perinatal outcome.

Birth Weight↗
PubMed1993

A comparison of sonographic growth curves of triplet and twin fetuses.

Sonographic growth curves of 47 normal triplet pregnancies were compared with those of 71 uncomplicated twin gestations. Starting from the 25th week, the biparietal diameter in triplets was found to lag progressively compared with that of twins, reaching a mean difference of 2 weeks at 36 weeks gestation. Similarly, a significant difference was found between the femur length and head to abdomen circumference ratio growth curves of triplets and twins. It is concluded that as pregnancy continues from the 25th to the 36th gestational week, there is a significant delay in the growth patterns of normal triplet pregnancies compared with twin gestations.

Age Factors↗
PubMed1991

Management of triplet pregnancies in the 1980s--are we doing better?

The incidence of triplet pregnancies has increased with the introduction of ovulation induction agents and is expected to further increase with the implementation of multiple embryo transfer in the in vitro fertilization programs. We review our experience with 29 triplet pregnancies in the last 10 years. Despite early sonographic diagnosis, close follow-up, increased use of tocolytics, and prophylactic cervical suture, we could not document prolongation of pregnancy, increased infants' weight, or a significantly decreased perinatal mortality, which still remains about 14%. Furthermore, the use of cesarean section as the delivery method of choice did not change the well-documented unfavorable relationship between birth order and fetal outcome. There is an urgent need for prospective assessment of the value of different treatment modalities, which nowadays becomes possible with the increasing incidence of triplet pregnancies. The prevention of triplet pregnancies or treatment by selective fetal reduction deserves a second thought.

Adult↗
PubMed1986

[Induction of secondary labor in triplet pregnancy].

After premature birth of the first triplet we successfully delayed the delivery of the remaining triplets for 21 days until the 29th week of gestation. The 36 year-old patient from Africa (Uganda) was suffering secondary sterility due to bilateral salpingectomy. After transfer of four in-vitro fertilised eggs, triplets were diagnosed ultrasonographically in the 7th week of gestation. In the 26th week, despite tocolysis, premature labour led to the delivery of a 740 g female foetus who died 2 days later. Immediately after delivery cerclage was performed under halothane anaesthesia. Further treatment consisted of tocolytics, antiseptics locally, antibiotics systemically, and rest in bed. In the 29th week a caesarean section had to be performed because of uncontrollable contractions and threatening asphyxia of the second triplet. Both infants, 1100 and 1150 g, were female, both survived without handicaps.

Adult↗
PubMed2003

Pre-natal, clonal origin of acute lymphoblastic leukaemia in triplets.

A unique case of ALL in three monozygotic triplets diagnosed at the age of 24, 27 and 37 months is described. Archived bone marrow smears were available for molecular analysis of immunoglobulin heavy chain (IGH) and IGK genes and T-cell receptor (TCR)-delta and gamma gene rearrangements. A shared IGH rearrangement was found in triplets "A" and "B", and an identical rearrangement of TCR-delta in triplets "B" and "C". These data suggest a common, monoclonal initiation of ALL in one of these three triplets, followed by dissemination of clonal progeny to the other twins via vascular anastomoses within the single, monochorionic placenta that they shared in utero. Differences in IGH rearrangements in diagnostic samples also indicates divergent subclonal evolution of the original "pre-leukaemic" clone.

Adult↗
PubMed2004

Embryo reduction versus expectant management in triplet pregnancies.

OBJECTIVE: In triplet pregnancies, to compare pregnancy outcome of expectant management with that after embryo reduction to twins. METHODS: Retrospective study of 255 trichorionic triplet pregnancies, of which 185 had embryo reduction to twins (reduced group) and 70 were managed expectantly (non-reduced group). RESULTS: Median birth weight was higher by about 500 g and gestation prolonged by about 3 weeks in the reduced pregnancies compared with the expectantly managed pregnancies (2300 vs. 1760 g; 36 vs. 33 weeks). The rates of preterm delivery were significantly lower in the reduced group (11.17 vs. 36.76% for delivery at < or = 32 weeks and 40.58 vs. 83.82% for delivery at < or = 35 weeks, reduced vs. non-reduced group). The percentage of infants born with low birth weight was significantly higher in the expectantly managed triplets (10.98 vs. 28.44% for birth weight < or = 1500 g and 68.55 vs. 92.89% for birth weight < or = 2500 g, reduced vs. non-reduced group). Total fetal loss was significantly higher in the reduced group than in the non-reduced group (15.41 and 4.76%, respectively) and the difference was mainly due to the higher miscarriage rate in the reduced group (8.11 vs. 2.86% in the non-reduced group). With the expected rates of handicap in preterm infants, we would anticipate 0.63% of severely handicapped children due to extreme prematurity in the reduced group and 1.64% in the non-reduced group. CONCLUSION: In triplet pregnancies, embryo reduction to twins significantly reduces the risk of severe preterm delivery and very low birth weight by about one-third, at the expense of a significant increase in total fetal loss, by about one-quarter. The procedure is likely to reduce the risk of having a severely handicapped child due to extreme prematurity.

Abortion, Spontaneous↗