Triplet Deliveries Research Articles

The maternal and neonatal outcome of triplet gestations

OBJECTIVE: Our purpose was to determine the contemporary maternal and neonatal outcome of triplet gestations. STUDY DESIGN: A retrospective review of 57 triplet deliveries between April 1, 1989, and July 31, 1994, was performed. RESULTS: The mean gestational age at delivery was 33.0 ± 2.7 weeks, and the mean birth weight was 1820 ± 513 gm. The most common maternal complications were preterm labor (86.0%), anemia (58.1%), preeclampsia (33.3%), preterm premature rupture of the membranes (17.5%), postpartum hemorrhage (12.3%), and HELLP (hemolysis, elevated liver enzymes, and low platelets) syndrome (10.5%). Neonatal complications included hyaline membrane disease (29.6%), transient tachypnea of the newborn (20.1%), intraventricular hemorrhage (7.7%), and major congenital anomalies (7.1%). The perinatal mortality was 41 per 1000. Birth order had no significant effect on the incidence of neonatal complications. CONCLUSION: Perinatal mortality rates have improved in recent years but remain higher than for singleton gestations. Despite increasing experience with triplets, the rate of maternal complications is high. (A M J O BSTET G YNECOL 1996;174:1551-6.)

Delayed Delivery of a Triplet Pregnancy Without Surgical Intervention: A Case Report

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

Planned abdominal compared with planned vaginal birth in triplet pregnancies.

To compare a policy of planned abdominal delivery with a policy of planned vaginal delivery in triplet pregnancies. Retrospective study. Two Dutch university hospitals, each having a different approach to the planned mode of delivery in triplet gestations. Thirty women giving birth to triplets in the hospital in Leiden, who favoured planned abdominal delivery, compared with 39 from the Medical Centre in Amsterdam who favoured vaginal delivery. Perinatal mortality and early neonatal complications. Both centres were equally successful in achieving their planned policies: in Leiden 80% of women were delivered by caesarean section but in Amsterdam 87% of women were delivered vaginally. Compared with vaginal delivery, planned abdominal delivery was associated with a significantly higher perinatal mortality rate (P = 0.02), primarily due to respiratory distress syndrome, and a higher recorded neonatal complication rate (P = 0.03), especially sepsis, respiratory distress syndrome, and necrotising enterocolitis. A policy of planned abdominal delivery in triplets is not superior to a policy of planned vaginal delivery in terms of fetal and early neonatal outcome.

Delivery of uncomplicated triplet pregnancies: Is the vaginal route safer?: A case-control study

OBJECTIVE: Our purpose was to evaluate the safety of vaginal delivery of triplets. STUDY DESIGN: A retrospective case-control study on 69 consecutive triplet pregnancies delivered in the same institution between 1981 and 1992. Vaginal delivery was attempted in 23 otherwise uncomplicated triplet pregnancies, which form the study groupo. They were compared with 23 controls undergoing routine cesarean section and matched for gestational age at birth. Maternal hospital stay, neonatal mortality, hospitalization in the neonatal intensive care unit, and 5-minute Apgar scores were compared by means of paired tests. RESULTS: In the vaginal delivery group there was one neonatal death related to prematurity (32 weeks) after intrapartum cesarean section for failure to progress. However, neonatal mortality was not significantly increased in comparison with controls (1 of 69 vs 0). In the study group Apgar scores were significantly higher (9.5 vs 8.4) and hospitalization in the neonatal care intensive unit was significantly shorter (6 vs 18 days) than in the cesarean section group ( p ≤ 0.002). CONCLUSION: In carefully selected cases vaginal delivery of triplets may be safe.

Outcome of triplet pregnancies after assisted reproductive techniques: How frequent are the vanishing embryos?

To assess the incidence of spontaneous embryo reduction as well as the obstetric and neonatal outcome of triplet gestations after assisted reproductive techniques (ART). We analyzed the spontaneous outcome of 38 pregnancies in which three gestational sacs were identified with vaginal ultrasound between 21 and 28 days after ART. Weekly follow-up visits were scheduled during the first trimester until referral to a high-risk obstetrician. After delivery, each patient was interviewed individually and, if necessary, the obstetrician was contacted. The triplets delivery rate was 47.4%, whereas 31.6% delivered twins, 18.4% delivered singletons, and only one patient miscarried all three cases (2.6%). Finding three fetal heart beats was associated with a triplet delivery rate of 69.2%, a twin incidence of 19.2%, and a singleton birth rate of 11.6%. Embryo resorptions were observed mainly during the first 7 weeks of gestation and did not occur beyond the 14th week. The mean gestational age at delivery and neonatal birth weight were significantly lower among triplets (32.8 weeks and 1,740 g versus 35.3 weeks and 2,352 g in twins and 39.1 weeks and 3,122 g for singletons). Triplets had a 100% prematurity and cesarean section rate compared with 67% and 75% in twins and 0% and 43% in singletons, respectively. Hospitalization at the Neonatal Intensive Care Unit was required in 83% of newborn triplets, 29% of twins, and 0% of singletons, with a mean stay of 34 and 21 days for triplets and twins, respectively. One stillbirth and no neonatal deaths were reported, with an overall perinatal mortality rate of 11.9 per 1,000. Spontaneously, approximately 50% of triplet pregnancies will experience at least one embryo resorption. The ongoing triplets demand a complex and more expensive perinatal management, a strong argument to consider limiting the number of oocytes-embryos transferred in ART.

Handicaps in twins and triplets

This study was conducted to investigate the prevalence rates of handicaps in twins and triplets. The subjects were 252 twins and 287 triplets. The following results were obtained. 1) The prevalence rates of the handicapped were 8.7 per 100 triplets, and 4.4 per 100 twins. The risk of producing at least one handicapped child was approximately 22% in triplet pregnancy and 9% in twin pregnancy. This means that one in 4 or 5 sets of triplets had at least one handicapped child, as did one in 11 pairs of twins. 2) Cerebral palsy was the most frequent handicap in twins and triplets. The risks of producing a child with cerebral palsy were 2.0% and 3.1% in twins and triplets, respectively. 3) The prevalence rates of congenital anomalies (congenital heart disease, limb anomalies, and others) were 2.4% in twins and 4.5% in triplets. Approximately 45% of the handicaps in twins and triplets resulted from congenital anomalies. 4) The prevalence rate of the handicapped in twins and triplets was not associated with maternal age, but was associated with the years of delivery in triplets, and was higher in babies with shorter gestation periods.

Perinatal Outcome in Vaginally Delivered Triplet Pregnancies: A Case Control Study and Review of the Literature

Objective: to determine if there is a significant difference in immediate perinatal morbidity and mortality in triplets selected for delivery vaginally compared to delivery by Caesarean section.Study Design: over a ten-year period, 57 triplet pregnancies were delivered at the B.C.’s Women’s Hospital. In four cases, vaginal delivery of triplets was attempted. Criteria for attempted vaginal delivery included: (i) gestational age greater than 33 weeks, (ii) triplet A with a cephalic presentation, (iii) no evidence of fetal distress, A case controlled study was performed comparing the four vaginal deliveries to eight triplet pregnancies delivered by Caesarean section, matched for: (i) fetal presentation, (ii) multiparity, (iii) gestational age. Outcome variables compared included: (i) birthweight, (ii) Apgar scores at one and five minutes, (iii) length of stay in the Special Care Nursery (SCN) and evidence of trauma associated with delivery. Maternal outcome characteristics included: post-partum haemorrhage, infection, and maternal length of stay. Means were compared by student t-test and categorical variables were compared using chi-squared analysis.Results: our study revealed no significant difference in perinatal outcome between the triplets (A, B or C) delivered vaginally as compared to Caesarean section. However, a statistically significant increase in estimated maternal bleeding (875cc versus 600) and hospital stay (6 versus 4 days) for the Caesarean section group compared with the vaginal group were noted.Conclusion: in selected cases with gestational age greater than 33 weeks and triplet A cephalic, attempted vaginal delivery is not associated with any increase in adverse perinatal outcome and may be offered.

Trends in multiple deliveries and infertility treatments in France

To point out the association between infertility treatments and the increasing number of multiple deliveries. Comparison over time of the incidence of multiple deliveries, the proportion of deliveries resulting from assisted conception (AC), and ovulation inductor sales. Use of existing statistics: vital statistics, surveys of AC centres and ovulation inductor sales. Between 1972 and 1989 the incidence of twin deliveries rose from 8.8/1000 to 11.2/1000, and the incidence of triplet deliveries from 0.9/10,000 to 4.4/10,000. This upward trend was particularly remarkable among women aged 30 to 39. Since 1978, the triplet delivery rates and the sales of Human Menopausal Gonadotrophin have been rising similarly. Between 1985 and 1989, 26 per cent of the triplet deliveries followed assisted conception and nearly 50 per cent were estimated to be due to ovulation inductor agents. The results suggest a strong influence of infertility treatments and especially ovulation inductor agents in the dramatic increase of triplet deliveries.

Actocardiotocographic monitoring of triplets during vaginal delivery

A case is reported in which fetal monitoring during vaginal delivery of triplets was performed with the MT 430 actocardiotocograph. This method provides optimal monitoring of multiple pregnancies because the fetal heart rate tracings of three fetuses, together with recordings of fetal movements and uterine contractions, can be visualized on one display.

Triplets are not so rare any more

Triplet gestations present a considerable management challenge due to a high rate of antenatal, intrapartum and neonatal complications. The introduction of ovulation inducing agents resulted in a marked increase of these pregnancies. Consequently, triplet conceptions are not considered a rare phenomenon and have become almost routine high risk pregnancies. In our department the triplet gestation frequency increased 2-4 times in a 10 year period from a rate of 0.07-0.14% during 1978-84 to 0.28% of all deliveries in 1987. This high incidence of triplet deliveries results in a threefold increase in the frequency of triplet neonates and their associated complications. It is reasonable to assume that the wide application of various assisted reproductive techniques will result in continuous increase in the incidence of triplets which will in turn require coordinated management of a high risk pregnancy unit, delivery room and neonatal intensive care unit.

Preterm delivery of a first triplet at 26 weeks and delivery of second and third triplets 8 days later, with survival of all babies

Preterm delivery of a first triplet at 26 weeks and delivery of second and third triplets 8 days later, with survival of all babies

Delayed interval delivery in a triplet pregnancy; a case report

A case report is presented in which a triplet pregnancy ended in an immature delivery of triplet A at 20 weeks gestation, followed by a successful delay in delivery of 49 days of triplets B and C by means of a cervical cerclage and tocolysis. This is the first reported case in which two living infants could be vaginally delivered after a preceding vaginal delivery of the third infant in a triplet pregnancy.

Triplets with conjoined twins: A Nigerian Midwife's case report

This article is a case report of a spontaneous vaginal delivery of live triplets, which included conjoined twins joined at the buttocks. The birth was conducted by an experienced midwife in a rural maternity in the Anambra State of Nigeria. The case illustrates the difficulties faced by rural Nigerian midwives when patients need referral to larger hospitals. There is a scarcity of diagnostic equipment, medical back-up, and the transportation that could facilitate an effective referral network. In addition, patients are reluctant to leave their home villages to give birth in a far-away hospital. For these reasons, many difficult births take place in rural maternity centers. The successful outcome of this high-risk delivery demonstrates the skill of the local Nigerian midwife, who is frequently faced with unusual complications of childbirth, ones that she must resolve herself.

The Northwestern University Triplet Study. II: Fourteen triplet pregnancies delivered between 1981 and 1986.

Fourteen triplet deliveries conducted between 1 January 1981 and 30 June 1986 at the principal teaching hospitals of Northwestern University Medical School are reviewed. Maternal demographic characteristics are listed, as are the obstetric outcomes, including mode of delivery, and the fetal outcome. The recent literature of triplet delivery is reviewed. The rate of triplet delivery in our study was 0.37 per 1,000 live births. About two-thirds of the pregnancies resulted from the use of fertility-inducing agents. Ultrasonic confirmation was available in all cases. The majority of women were delivered by cesarean section (85%). No consistent pattern of presentation was seen. The mean weight of all 42 infants was 1,779 g (+/- 594). Unlike-sex triplets accounted for most of the sets (77%). The mean 5-min Apgar score of all infants was 9 and had no association with the order of deliveries. The weight differences by sex regardless of birth order were clinically insignificant. Neonatal mortality was 2.3%.

The Northwestern University Triplet Study. III: Neonatal outcome.

Limited data suggest that cesarean section (CS) may be the preferred method of delivery for triplets. Despite this, it is also felt that the third triplet is at great risk at delivery. We reviewed our experience of 14 triplet pregnancies at Northwestern University between 1981 and 1985. All deliveries were attended by neonatal teams in sufficient number to resuscitate each infant. Of the 14 pregnancies, two ended in previable loss. Thirty-six infants were born from 12 pregnancies of a mean gestational age of 33 weeks (28-38 weeks). The overall survival was 97.3%. Two women delivered vaginally. While the first was successful, the second resulted in vaginal delivery of the first two triplets followed by emergency CS for the third. That infant had a cord blood pH of 6.96 (BE-19), was resuscitated and survived. All 10 CS were successful. The mean cord blood gas tensions and pH were normal. In addition, Apgar scores, the requirement for mechanical ventilation or supplemental oxygen, and mortality did not differ between the first and third-born triplet. These observations suggest that CS was beneficial. Our very low mortality rate supports the concept that CS delivery and aggressive neonatal resuscitation and therapy greatly enhances survival.

Amniotic Fluid Embolism-Reply

In Reply.— About an hour before the morning mail, which brought a copy of the letter by Drs Rodgers and Heymach for my review, I received a telephone call from a man in the Midwest, who had lost his wife to AFE in the early part of May, nine hours after the cesarean delivery of triplets. Now, left with six children, he is trying to understand the event that took his wife so suddenly and sought to offer the information about her clinical course to me in order that some other life might be someday saved. I was therefore heartened to read their communication relating the successful treatment of a case of AFE with cryoprecipitate, to accomplish fibronectin repletion. As the mortality of AFE is so high (despite all known methods of support), and its occurrence so uncommon, it is clear that a sequential, controlled trial of new therapeutic modalities

The World Collaborative Report on in Vitro Fertilization and Embryo Replacement: Current State of the Art in January 1984a

A questionnaire was sent to potential participants of the III World Congress of in Vitro Fertilization and Embryo Transfer, held in Helsinki in 1984, concerning their current practice in and results with IVF to the end of January 1984. Sixty-five teams reported information concerning 10,028 cycles. Embryo replacement was performed in 7993 cycles to yield 600 infants to date from 523 confinements; 572 continuing pregnancies; 324 clinical abortions; and 19 ectopic and 285 "biochemical" pregnancies. The best success rates were seen in couples where the woman was less than 30 years of age (13.6%) compared with those where the woman was over 40 years of age (7.2%); where normal semen was used; where higher numbers of embryos were replaced per patient (9.7% with one, 14.6% with two, 19.3% with three, and 24.1% with four or more); and where the women presented with secondary infertility. Of the 523 confinements reported, 457 were singleton deliveries; 57 twin deliveries (10.9%); 7 triplet deliveries (1.3%); and two quadruplet deliveries (one set was born after January 1984). The cesarean section rate was 49%. No infant was reported to be born with a chromosomal abnormality. Nine conceptuses from spontaneous abortions were reported to have a chromosomal abnormality, but this is likely to be an underestimate since not all underwent chromosome analysis. There were 9 other severe fetal defects, including intrauterine fetal death (1.5%). Results of this collaborative study show that in vitro fertilization is widely accepted as a method for the treatment of infertility and does not carry a higher than normal risk of fetal abnormalities.

Effects of inappropriate laws in developing countries—An illustrative case

Laws in developing countries are frequently archaic and unrevised. This is particularly true of those laws governing abortion, sterilization, and suicides. Even those laws controlling new and/or harmful drugs are lacking, inappropriate, or irrelevant to patterns of living, socioeconomic, political and environmental constraints, and the realities of communities which they purport to serve. The traditional practices of the indigenous peoples are frequently out of step with the changes taking place in society as a result of industrialization and urbanization. The poor suffer most during the transitional stages. The wealthy can evade legal obstacles, going abroad if necessary to obtain a service, or buying the services locally if they require. In most developing countries, one has to have money to get a safe abortion by a qualified practitioner (expecially in countries where the laws are not liberalized). In the city of Nairobi with a population of 700,000 and a growth rate of about 6.5%/year, there is not 1 program for the pregnant teenager. As in many other developing countries, their situation is still determined by the traditional cultural framework. This paper describes the case of a pregnant 17-19 year old unmarried girl from Kenya who has a primary level education, no definite religion, is unemployed and living with her father, a watchman. Private practitioners can charge between US$75 to US$175 depending upon the particular doctor's sense of risk-taking. Unable to pay for a safe abortion and realizing the risks of self-induced abortion, or treatment from a local "quack," she carries the pregnancy to term, giving birth to triplets. Subsequent health services visits reveal the lack of effective and suitable family planning advice by the health visitor and social worker. High parity in a young mother produces high risk. The factors involved are nutritional deficits, poverty, inadequate health care, the short length of time between the 1st delivery of (triplets) and subsequent conception, and insufficient prenatal visits during the 2nd pregnancy. This case study emphasizes the need for: 1) liberal abortion law; 2) social workers, and health visitors trained in counseling and contraception; 3) co-ordination of various agencies; plus 4) more experienced legal personnel.

Conjoined twins.

During the years 1960 to 1970 inclusive, six conjoined twins were delivered out of a total of 403 441 deliveries including 3 276 twins and 37 triplet deliveries, an incidence of 1 in 67 241 deliveries and 1 in 655 twin deliveries. A seventh conjoined twin was delivered in late January 1971; inclusion of this case as well as the deliveries in January 1971 would lead to an incidence of 1 in 57 975 deliveries and 1 in 546 twin deliveries. Four of the twins were thoracopagus, one craniopagus, one dicephalus tripus tetrabrachius and one syncephalus. One of the thoracopagus twins occurred in a triplet pregnancy. All except two were delivered alive; four died within a few hours to a few days. One thoracopagus survived till 3 months of age; surgical separation was then attempted resulting on one survival who has developed normally and is now 7 years old. Antenatal diagnosis is necessary if the survival rate is to be improved.

FILM review of the month: Normal delivery of triplets

FILM review of the month: Normal delivery of triplets