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PubMed1995

Incidence of handicaps in multiple births and associated factors.

This study investigated the degree of risk of handicap in twins, triplets, quadruplets and quintuplets and associated factors, and examined the clustering tendency of handicaps. The sample was recruited from the Kinki University Twin and Higher Order Multiple Birth Registry. This panel consisted of 705 pairs of twins (1410 twins), 96 sets of triplets (287 triplets excluding 1 infant death), 7 sets of quadruplets (27 quadruplets excluding 1 infant death), and 2 sets of quintuplets (10 quintuplets), all of whom were born after 1977. The incidence of handicap was 3.7% in twins, 8.7% in triplets, 11.1% in quadruplets, and 10.0% in quintuplets. The risk of producing at least 1 handicapped child was approximately 1 in 13 pairs of twins (7.4%), 1 in 4 or 5 sets of triplets (21.6%), and 1 in 2 sets of quadruplet and quintuplets (50%). There was a significantly higher clustering tendency of handicaps in twins and triplets compared with the expected frequency calculated from the incidence rate of handicap. Four significant risk factors for subsequent handicap were found by logistic regression: gestation number, shortening of gestational age, premature rupture of the membrane, and toxemia during pregnancy.

Cluster Analysis↗
PubMedDate not supplied

Multifetal gestation--maternal and perinatal outcome of 112 pregnancies.

PURPOSE: Multifetal pregnancy reduction is a widespread "therapy" to diminish the risk of prematurity and adverse outcome for the survivors in higher order multiple gestation. The aim of our study was to determine the maternal and neonatal outcome of multifetal pregnancies under a conservative pregnancy management. STUDY DESIGN: A retrospective review of 112 multifetal pregnancies is presented. All higher order multiple pregnancies delivered after 25 weeks of gestation and managed at a single institution between 1982 and 1999 are included. RESULTS: Triplets, quadruplets and quintuplets were delivered at a mean gestational age of 31 + 5, 29 + 5 and 28 + 4 weeks, respectively. The perinatal mortality was 14 for triplets and 36 for quadruplets. No quintuplet died in the perinatal period. Respiratory distress syndrome occurred in 23% of triplets, 65% of quadruplets and 75% of quintuplets, intracranial hemorrhage was diagnosed in 14% of triplets, 15% of quadruplets and 10% of quintuplets and retinopathy of prematurity was found in 10% of triplets, 9% of quadruplets and 25% of quintuplets. DISCUSSION: Despite a low neonatal mortality, morbidity of higher order multiple gestations remains significant. Mortality and morbidity are related to preterm delivery but do not exceed the rates of singletons or twins of an identical gestational age. Favorable prognostic landmarks are a gestational age >30 weeks and a number of fetuses per pregnancy < or =4. CONCLUSION: The risks of multifetal pregnancies are significant. Therefore, evidence-based counseling of couples seeking treatment for infertility and prevention of higher order multiple pregnancies through the prudent use of reproductive techniques attains paramount importance.

Delivery, Obstetric↗
PubMed2003

[Neonatal outcome multiple pregnancies at the Neonatal Department of Research Institute of Polish Mother's Memorial Hospital].

OBJECTIVES: The purpose of this study was to analyze the course of neonatal period among babies born from truly higher-order multiple pregnancies (> or = 3). DESIGN: The retrospective analysis included 81 infants born from multiple pregnancies (> or = 3), hospitalized in Neonatal Department of Research Institute of Polish Mother's Memorial Hospital between 1995-2001. MATERIALS AND METHODS: Studied population contained 63 babies delivered from 21 triplet pregnancies, 8 newborns from 2 quadruplet pregnancies and ten quintuplets. The groups were analyzed according to gestational age, birth weight, ventilation and hospitalization time as well as early and late consequences of prematurity. RESULTS: Among the multiples (> or = 3) the mean birth weight of triplets, quadruplets and quintuplets was respectively: 1656 g vs 1166 g vs 725 g, the diminished gestational age was also noticed: 32.4 vs 30 vs 26.5 GA. The cesarean section ratio in triplet deliveries was 95%, while quadruplets and quintuplets pregnancies were always delivered by operative interventions. The increase in number of fetuses was significantly associated with prolonged ventilation time (mean 9.5 vs 22.2 vs 57.5 days) as well as the hospitalization (mean 29.1 vs 64.1 s 79.6 days). The differences between mentioned above values reached statistical significance (p < 0.001). One out of three neonates born from triplet pregnancy required ventilatory support (36.6%), whereas in quadruplets and quintuplets this ratio reached 100%. The respiratory distress syndrome treated with surfactant was diagnosed in 7.9% (5/63) of triplets, 37.5% (3/8) quadruplets and 100% of quintuplets among whom 8 babies needed more than one dose of surfactant. The increased risk of unfavorable prematurity outcome (PDA, ROP, BPD, IVH) and neonatal death was highly related to plurality of pregnancy. CONCLUSIONS: Multiple pregnancies resulting from infertility treatment cause many medical problems. Undesirable outcome among neonates delivered from higher-order multiple pregnancies (> or = 3 fetuses) predestine to more judicious approach in the application of assisted reproductive techniques and multiple pregnancies prophylaxis.

Female↗
PubMedDate not supplied

Multifetal pregnancies: evolution of methods of initiation and impact of REI certification for patients seeking reduction.

OBJECTIVE: Multifetal pregnancy as a result of ovulation induction (OI) and assisted reproductive technologies (ART) correlate with Board certification in reproductive endocrinology and infertility (REI). DESIGN: Retrospective chart analysis of 304 patients referred to Wayne State University (WSU) and Thomas Jefferson University (TJU) for multifetal pregnancy reduction (MFPR) from March 1986 to January 1995 compared to 275 patients referred from January 1 to December 31, 2000 at MCP Hahnemann University. MATERIAL AND METHODS: Chart review for fetal number, pregnancy generation (OI or ART) and physician REI Board certification from the American Board of Specialties Obstetrics and Gynecology. Information was available on 296 of 304 patients studied in the 1986-1995 WSU cohort and 275 patients studied from the MCP Hahnemann 2000 cohort. RESULTS: Analysis of 296 multifetal pregnancies at WSU and TJU for REI Board status showed non-REI Board-certified (NREI) physicians generated 174 pregnancies with quadruplets or more compared to 122 quadruplets or more by REI Board-certified physicians. Board certification did not impact quadruplet or more rates for OI or ART (p < 0.368). Of 275 patients with triplets or more at MCP Hahnemann, 156 (56.7%) were from ARTs versus 41.2% from 1986-1995 (chi(2) = 13.1, p < 0.001). Quintuplets or more decreased from 18.5 to 9.7% (chi(2) = 8.3, p = 0.004), and for REIs from 22.1 to 9.6% (chi(2) = 4.7, p < 0.01), while 14.4% of cases coming from non-REIs had quintuplets versus 9.6% from REIs (p = NS). CONCLUSIONS: Cases of MFPR from ARTs have risen, while percentage of cases with quintuplets have fallen in half. We found no difference in quintuplets between REIs and non-REIs overall, but REI quintuplets fell significantly, and NREI has not.

Adult↗
PubMed2003

Potentially preventable excess mortality among higher-order multiples.

OBJECTIVE: To estimate the level of potentially preventable excess mortality achievable by avoiding the creation of higher-order multiple gestation with assisted reproductive technologies. METHODS: This was a retrospective cohort study of multiple pregnancies delivered in the United States between 1995 and 1997 involving 304,466 twins, 16,068 triplets, 1448 quadruplets, and 180 quintuplets. We used the generalized estimating equation framework to compute adjusted relative risks for combined perinatal and infant mortality (early mortality). We then calculated potentially preventable excess mortality among higher-order gestations, using twins and triplets sequentially as the referent category. RESULTS: Early mortality increased significantly with each additional fetus in a dose-dependent fashion (P <.001), corresponding to relative risks (95% confidence interval) of 2.4 (2.2, 2.6) for triplets, 3.3 (2.5, 4.4) for quadruplets, and 10.3 (5.0, 21.4) for quintuplets. The creation of twin rather than quadruplet pregnancies would be associated with a substantially higher level of preventable excess mortality (70%) than the creation of triplet pregnancies (28%). By contrast, limiting quintuplets to twins or triplets did not exhibit a similar level of difference (89% versus 75%, respectively). CONCLUSIONS: Our findings support the need for regulating the number of transferred embryos that result in quadruplet and quintuplet pregnancies.

Adult↗
PubMed2000

Motor performance status in 10 to 17-year-old Estonian girls.

The improvement of motor abilities is associated with the periodical acceleration of changes in adolescents of both sexes. The present cross-sectional study is aimed at establishing smooth curves of motor performance status in 10 to 17-year-old girls. Motor performance was tested in 902 girls with the aid of 30 m dash, standing long jump, vertical jump, pushing a stuffed ball (2 kg), standing quintuplet jump, isometric strength of back extensor muscles, trunk forward flexion and 1-min ergocycling at the highest possible rate. Statistically significant differences of all studied motor abilities between the age groups of 10-12 were indicated. In height and body mass the most pronounced differences (on average 6.5 cm and 7.7 kg, respectively) appeared between the age groups of 12 and 13. At the age of 13 the group results were statistically higher than those at 12 in pushing a stuffed ball, vertical jump, quintuplet jump, strength of back extensors muscle, 30 m dash and ergocycling test, but not in standing long jump and trunk forward flexion. At the age of 14 the performance was not higher than at 13, except in the vertical jump and quintuplet jump. From 14 to 16 years of age differences reappeared in the results of vertical jump, quintuplet jump, pushing a stuffed ball, 1-min cycling and trunk forward flexion but not in the 30 m dash and standing long jump. The lack of significant differences between the age groups of 16 and 17 indicated the final stabilization of tested motor abilities. The obtained results suggest the existence of several periods in motor performance status in 10 to 17-year-old Estonian girls: 1) The biggest differences in the mean results of the tests on motor abilities occurred between ages 10-11, 11-12 and 12-13, which coincide with the biggest differences in height and weight at the same age. 2) The differences in the mean results of most tests on motor abilities stabilized between the age groups of 13 and 14. The mean results of 14-year-old girls were lower in some tests compared to the results of 13-year-olds. 3) The positive differences in the mean results remained between the age groups of 14-15 and 15-16 (excluding the sprint velocity and standing long jump). 4) The final stabilization of motor abilities occurred at the age of 16 to 17.

Adolescent↗
PubMed2000

Force-frequency relationship and potentiation in mammalian skeletal muscle.

Repetitive activation of a skeletal muscle results in potentiation of the twitch contractile response. Incompletely fused tetanic contractions similar to those evoked by voluntary activation may also be potentiated by prior activity. We aimed to investigate the role of stimulation frequency on the enhancement of unfused isometric contractions in rat medial gastrocnemius muscles in situ. Muscles set at optimal length were stimulated via the sciatic nerve with 50-micros duration supramaximal pulses. Trials consisted of 8 s of repetitive trains [5 pulses (quintuplets) 2 times per second or 2 pulses (doublets) 5 times per second] at 20, 40, 50, 60, 70, and 80 Hz. These stimulation frequencies represent a range over which voluntary activation would be expected to occur. When the frequency of stimulation was 20, 50, or 70 Hz, the peak active force (highest tension during a contraction - rest tension) of doublet contractions increased from 2.2 +/- 0.2, 4.1 +/- 0.4, and 4.3 +/- 0.5 to 3.1 +/- 0.3, 5.6 +/- 0.4, and 6.1 +/- 0.7 N, respectively. Corresponding measurements for quintuplet contractions increased from 2.2 +/- 0.2, 6.1 +/- 0.5, and 8.7 +/- 0.7 to 3.2 +/- 0.3, 7.3 +/- 0.6, and 9.0 +/- 0.7 N, respectively. Initial peak active force values were 27 +/- 1 and 61.5 +/- 5% of the maximal (tetanic) force for doublet and quintuplet contractions, respectively, at 80 Hz. With doublets, peak active force increased at all stimulation frequencies. With quintuplets, peak active force increased significantly for frequencies up to 60 Hz. Twitch enhancement at the end of the 8 s of repetitive stimulation was the same regardless of the pattern of stimulation during the 8 s, and twitch peak active force returned to prestimulation values by 5 min. These experiments confirm that activity-dependent potentiation is evident during repeated, incompletely fused tetanic contractions over a broad range of frequencies. This observation suggests that, during voluntary motor unit recruitment, derecruitment or decreased firing frequency would be necessary to achieve a fixed (submaximal) target force during repeated isometric contractions over this time period.

Animals↗
PubMed1998

Multifetal pregnancy reduction of both fetuses of a monochorionic pair by intrathoracic potassium chloride injection of one fetus.

The purpose of this study was to determine if a monochorionic pair of fetuses in a higher-order multiple gestation can be reduced by injecting only one fetus with potassium chloride. Three quadruplet and two quintuplet gestations, each with a monochorionic pair of fetuses, were referred for pregnancy reduction. In each case, reduction was performed by injecting one of the monochorionic pair with potassium chloride. Patients returned for a follow-up sonogram within 1 week of the procedure. The reductions were performed at an average 12.1 weeks' gestation, with a range of 10.7 to 14.0 weeks. Follow-up scans 4 to 7 days after the procedure showed that both monochorionic fetuses were dead and all other fetuses were alive. One quintuplet pregnancy underwent a second reduction procedure to twins. One quintuplet and two quadruplet pregnancies that were reduced to twins resulted in the birth of live twins between 30.8 weeks and 36.8 weeks' gestations. The third quadruplet pregnancy reduced to twins is still ongoing; the mother is pregnant with twins at 20 weeks' gestation. The quintuplet pregnancy reduced to triplets resulted in delivery of live triplets at 24.1 weeks' gestation, but two of the neonates died in the first few days of life. Reduction of both fetuses of a monochorionic pair in a higher-order multiple gestation can be accomplished by intrathoracic injection of potassium chloride into only one of the pair.

Female↗
PubMed1998

Ultrasonographic measurement of crown-rump length in high-order multifetal pregnancies.

The objective of the study was to evaluate the crown-rump length (CRL) in high-order multifetal pregnancies (three or more fetuses). The records of patients who underwent multifetal pregnancy reduction were reviewed. The following parameters were defined: the mean CRL (CRLMEAN) and the difference between the largest and smallest CRL (CRLRANGE) for each pregnancy. CRLMEAN was plotted versus gestational age (GA) and the line of best fit was derived. The residual for each CRL (CRLRES) was calculated by subtracting the value predicted by the regression line from the individual CRL (CRLIND). Regression lines for single-tons with confirmed GA from four previously reported studies were used for comparison. A total of 82 patients were included (29 triplets, 38 quadruplets and 15 quintuplets; mean GA 10.7 +/- 0.78 weeks). CRLMEAN correlated with GA (CRLMEAN = 38.88 - 8.78(GA) + 0.82(GA)2; R = 0.83; R2 = 0.70). This second-degree polynomial remained within the range for singletons. No significant differences in maternal age, GA and CRLMEAN were noted between the patients with different numbers of fetuses. The median CRLRANGE was largest in quintuplets, followed by quadruplets and triplets. The CRLRANGE correlated poorly with GA. The mean CRL in multifetal pregnancies increases with GA similarly to that in singletons. The variability of individual measurements increases with the number of fetuses and CRLs are lower in quintuplets.

Adult↗
PubMed1992

Spontaneous fetal reduction in multiple gestations assessed by transvaginal ultrasound.

OBJECTIVE: To assess the occurrence of disappearance of one or more of the fetuses in pregnancies which start as multiple gestation. DESIGN: Observational study. SETTING: Infertility section, Rambam Hospital, Haifa. SUBJECTS: 88 women with multiple gestations, established after ovulation induction (54 twin, 26 triplet, five quadruplet, and three quintuplet) and diagnosed by transvaginal ultrasound at 5-6 weeks, in all of whom absorption of at least one gestation sac was detected at follow-up ultrasound scan. INTERVENTIONS: Follow-up by serial transvaginal and later abdominal ultrasound scan throughout pregnancy. RESULTS: Of the 54 twin gestations, 51 ended in the birth of a singleton and three in miscarriage. Of the 26 pregnancies starting as triplets, 12 ended in singleton births, 12 in twins and two miscarried. The five quadruplet gestations resulted in one singleton birth, one set of twins, two triplets, and one ended in late miscarriage. Of the three quintuplet pregnancies, two resulted in the birth of triplets, one of them after spontaneous, the other after iatrogenic fetal reduction. In the third quintuplet pregnancy, one fetus vanished spontaneously and another was subject to iatrogenic reduction, two fetuses survived and were liveborn. Of the 221 fetuses identified 107 (48%) vanished spontaneously. CONCLUSION: Iatrogenic fetal reduction should be delayed until 12 weeks gestation in quadruplet or higher multiple gestations, but is probably not indicated in twin and triplet gestations.

Adult↗
PubMed1994

Perinatal mortality in single and multiple births in Japan, 1980-1991.

Perinatal mortality rates (PMR) decreased significantly per year in single, twin, triplet, quadruplet and quintuplet births during the period 1980-1991. The PMRs were 7.7 per 1000 livebirths for singletons, 45.6 for twins, 89.0 for triplets, 116.8 for quadruplets, and 476.2 for quintuplets during the 12 years. The relative risks of perinatal death in multiplets vs. singletons were 6 for twins, 12 for triplets, 15 for quadruplets and 62 for quintuplets. The PMR was significantly higher in males than females for singletons and twins, but there was no sex differential in PMRs for higher order of multiple births. The PMR increased with birth order in twins and triplets, whereas there was no birth order effect on the PMR for quadruplets. An increasing proportion of multiple births among perinatal deaths may be related to the increasing multiple birth rate in Japan.

Birth Order↗
PubMed2001

Estimated number of multiplets under 16 years using two sets of census data in Japan: 1990 and 1995.

Data for sets of multiples under 16 years of age were obtained from the population censuses of Japan in 1990 and 1995. These numbered 147,188 twin pairs, 1410 sets of triplets, 59 sets of quadruplets, and 3 sets of quintuplets in 1990, with the corresponding numbers in 1995 being 141,354, 2,211, 136 and 12, respectively. The total number of sets of multiples was 148,660 in 1990 and 143,713 in 1995. Twinning, triplet, quadruplet and quintuplet rates were estimated for each age. Rates of monozygotic twins and triplets remained constant age by age up to 15 years, while the dizygotic twinning rate, and rates of di- and tri-zygotic triplets decreased over the same period. Quadruplet and quintuplet rates also decreased. The accuracy of estimating number of multiples from census data is discussed using data on vital statistics.

Adolescent↗
PubMed2002

Maternal and neonatal outcome of high order gestation.

OBJECTIVE: To study maternal and neonatal outcome of triplets, quadruplets and quintuplets gestations. METHOD: This retrospective review of 21 triplet, 3 quadruplet and 3 quintuplet deliveries between 1(st) January 1990 and 31(st) of August 2001. RESULTS: Preterm labor was the most common maternal complication (96%). The 27 high order gestation resulted in 88 live births and two stillbirths. The early neonatal mortality rate for the entire group was 91, late neonatal deaths 45 and infant deaths 57. Of the 88 live born infants, 71(81%) survived to discharge. The incidence of respiratory distress syndrome was 69.3%, and mechanical ventilation was necessary also in 70% of the newborns, patent ductus arteriosus was diagnosed in 8% of cases. Intraventricular hemorrhage was diagnosed in 14% of cases. Nercotizing enterocolitis occurred in 8 cases. Neonatal sepsis was diagnosed in 24 cases (27%). CONCLUSION: Early diagnosis, meticulous antenatal care, early hospitalization, frequent evaluation of fetal well being, delivery by cesarean section and on site availability of trained neonatologists and a highly functional intensive care unit are essential for better outcome.

Adult↗
PubMed1983

Fetal movements in multiple pregnancy.

Fetal activity in multiple pregnancies, as expressed by maternal daily fetal movement recordings, was compared with that in singleton pregnancies. It was found that the mean fetal activity in 33 cases of twins, six cases of triplets, one case of quadruplets, and one case of quintuplets was generally higher than that obtained during singleton pregnancies. In most cases, fetal movements of triplets, quadruplets, and quintuplets were even higher than the movement of twins.

Female↗
PubMed1996

Essential fatty acid status measured in umbilical vessel walls of infants born after a multiple pregnancy.

The essential fatty acid (EFA) status of full-term infants born after an uneventful, singleton pregnancy has been reported to be marginal. If this low EFA status is caused by a limiting maternal EFA supply, the higher total fetal EFA demand associated with a multiple pregnancy would result in an even lower EFA status of the infants born after a multiple pregnancy. Therefore, we compared the EFA status at birth of 30 pairs of twins, seven sets of triplets, and one set of quintuplets with that of 94 infants (51 preterm, 43 full-term) born after a singleton pregnancy. Phospholipid-associated EFA profiles of the umbilical vessel walls, considered a longer-term reflection of the fetal EFA status, were studied. After correction for gestational age at birth, levels of n-6 and n-3 EFAs were generally lower, while levels of EFA-deficiency indicating n-9 polyunsaturated fatty acids were significantly higher both in the draining umbilical arteries and the supplying veins of infants born after a multiple pregnancy. EFA profiles of twins and triplets were similar, but the average EFA status of the set of quintuplets was lower than that of twins and triplets. In conclusion, the observation that the EFA status of infants born after a multiple pregnancy is lower than that of infants born after a singleton pregnancy supports the view that the maternal EFA supply to the fetus is limiting. Considering the importance of EFAs and their longer chain derivatives for proper growth and development, this finding warrants further studies of the adequacy of the maternal EFA intake during pregnancy.

Adult↗
PubMed1990

Triplets and higher order multiple births in Japan.

Multiple birth rates in entire Japan were analyzed using vital statistics for 1951 to 1988. The triplet rate was nearly constant from 1951 to 1974, where the rate per million births was 58, then increased with the year up to 1982 (104), and decreased up to 1984, and suddenly increased thereafter (109 in 1987). The average rate of quadruplets per million births from 1951 to 1968 was 0.93, then increased with the year up to 1975 (7.5), and decreased until 1984 and suddenly increased thereafter (10.6 in 1987). The rate of quintuplets was 0.77 per million births during the period from 1975 to 1987. The higher multiple birth rate since 1975 was attributed to the higher proportion of mothers treated with ovulation-inducing hormones in Japan. Since 1985, higher multiple birth rates might be partially attributed to in vitro fertilization. The stillbirth rates for male triplets gradually decreased from 1960 to 1978 and thereafter remained constant at a little higher level except in 1988, whereas the rates for females gradually decreased with the year. The overall stillbirth rates decreased to 1/4 for triplets and to 1/5 for quadruplets during the 37-year period from 1951. The overall stillbirth rate of quintuplets was 0.60 (51/85) during the period 1975-1987.

Adult↗
PubMed1990

Fetal deaths with birth defects among Japanese multiples, 1974.

Source of data is "Survey on Socio-Economic Aspects of Vital Events-Plural Births in 1975", including 12,392 twin pairs, 124 triplet sets, 7 quadruplet sets and 1 quintuplet set. Fetal deaths were 3,285 for twins, 141 for triplets, 17 for quadruplets, and 5 for quintuplets, among which the number of birth defects were 78, 3, 0, and 0 respectively. Concordant twin pairs with the same category of birth defect were 20 among 56 pairs (0.36). As for the remaining 36 pairs, 2 pairs had different category of birth defects, 27 pairs had liveborn cotwins, and 7 pairs were both fetal deaths among which a twin had birth defect. The second-born twins had birth defects more frequently than the first-born twins among fetal deaths (28 vs 6).

Congenital Abnormalities↗
PubMed2006

The changing risk of infant mortality by gestation, plurality, and race: 1989-1991 versus 1999-2001.

OBJECTIVE: Our aim was to quantify contemporary infant mortality risks and to evaluate the change by plurality, gestation, and race during the most recent decade. PATIENTS AND METHODS: The study population included live births of 20 to 43 weeks' gestation from the 1989-1991 and 1999-2001 US Birth Cohort Linked Birth/Infant Death Data Sets, including 11,317,895 and 11,181,095 live births and 89,823 and 67,129 infant deaths, respectively. Adjusted odds ratios and 95% confidence intervals were calculated to evaluate the change in risk by plurality and gestation and to compare the change with that for singletons. RESULTS: Overall, the infant mortality risk decreased significantly for singletons, twins, and triplets but nonsignificantly for quadruplets and quintuplets. Compared with singletons, significantly greater reductions were experienced by twins overall and at <37 weeks and triplets at <29 weeks. The largest reduction was for triplets at 20 to 24 weeks and for quadruplets and quintuplets at 25 to 28 weeks. For white infants, significant reductions were achieved overall for singletons, twins, and triplets and at every gestation. For black infants, significant reductions occurred for singletons overall and at every gestation, for twins at <37 weeks, and for triplets at 25 to 28 weeks. Compared with white infants, black infants had significantly lower risks before and higher risks after 33 weeks, although between 1989-1991 and 1999-2001 this survival advantage at earlier ages diminished, and the risk at later gestations increased. CONCLUSIONS: The improvements in survival were greater for multiples versus singletons and for white versus black infants. Within each plurality, at each gestation the racial disparity in mortality has widened.

Adult↗