Perinatal care improves the outcome of triplets

How much have the perinatal outcomes of triplet pregnancies improved over the last two decades?

Objective

This study was conducted to demonstrate the temporal trends in perinatal outcomes of triplet pregnancies over the last two decades.

Methods

The medical records of patients with triplet pregnancies at two Korean tertiary-care hospitals from 1992 to 2012 were retrospectively reviewed in regard to maternal and neonatal outcomes. The study was divided into two periods for analysis: period I (1992-2001) and period II (2003-2012).

Results

Over a 21-year period, 65 women with triplet pregnancies and 185 neonates were analyzed. Period II, when compared with period I, was associated with improved maternal outcomes, characterized by a decreased incidence of preeclampsia (31.8% vs. 2.3%, P=0.002) and anemia (68.2% vs. 30.2%, P=0.003) during pregnancy. Regarding neonatal aspects, the composite morbidity of period II was significantly decreased compared with that of period I, as assessed with a generalized estimating equation for logistic regression (26.2% vs. 8.1%, P=0.03). Multivariable analysis revealed that the gestational age at delivery and the period were significantly associated with the composite neonatal morbidity (P<0.001 and 0.007, respectively).

Conclusion

Improved neonatal morbidity was associated with a higher gestational age at delivery and with the more recent decade.

Adverse perinatal outcomes related to the delivery mode in women with monochorionic diamniotic twin pregnancies

AIMS

The association between the planned delivery mode and adverse perinatal outcomes of monochorionic diamniotic (MCDA) twin pregnancies at ≥36 weeks' gestation was evaluated.

METHODS

This retrospective cohort study included uncomplicated MCDA twin pregnancies delivered after 36 weeks' gestation during a 10-year period. Cases were classified into the trial of labor (TOL) or cesarean section (CS) group according to the planned delivery mode. The primary outcome was a composite of adverse outcomes for at least one twin, including intrauterine fetal death (IUFD) after 36 weeks, neonatal death, umbilical artery pH<7.1, 5-min Apgar scores<7, hypoxic ischemic encephalopathy (HIE), meconium aspiration syndrome (MAS), respiratory distress syndrome (RDS), or acute feto-fetal hemorrhage (AFFH). The relationship between outcomes and the planned delivery mode was evaluated using a multiple logistic regression analysis.

RESULTS

We included the 310 pregnancies delivered after 36 weeks' gestation. After excluding 15 patients, the final analysis included 295 MCDA pregnancies: 63% had delivered through TOL and 37% through CS. The incidences of composite adverse outcomes in the TOL and CS groups were 4.3% and 1.9%, respectively. No IUFD, neonatal death, MAS, RDS, or AFFH was observed; two infants in each group developed HIE. Adverse outcomes were not significantly associated with any risk factor, including delivery through TOL.

CONCLUSION

TOL may not influence the perinatal outcomes of MCDA twin pregnancies delivered at ≥36 weeks' gestation.

Perinatal death of triplet pregnancies by chorionicity

OBJECTIVE

The purpose of this study was to evaluate the perinatal risk of death by chorionicity at >22 weeks of gestation of triplet pregnancies.

STUDY DESIGN

In a retrospective cohort study, the perinatal data were collected from triplet pregnancies in Japanese perinatal care centers between 1999 and 2009. We included maternal characteristics and examined the following factors: prenatal interventions, pregnancy outcome, and neonatal outcome. The association between fetal or neonatal death of triplets and chorionicity was evaluated by logistic regression analysis.

RESULTS

After the exclusion of 253 cases, the study group comprised 701 cases: 507 trichorionic triamniotic (TT) triplet pregnancies, 144 diamniotic triamniotic (DT) triplet pregnancies, and 50 monochorionic triamniotic (MT) triplet pregnancies. The mortality rate (fetal death at >22 weeks of gestation; neonatal death) in triplets was 2.6% and included 2.1% of TT triplet pregnancies, 3.2% of DT triplet pregnancies, and 5.3% of MT triplet pregnancies. No significant risk of death was identified in DT triplet pregnancies; however, MT triplet pregnancies had a 2.6-fold greater risk (adjusted odds ratio, 2.60; 95% confidence interval, 1.17-5.76; P = .019) compared with TT triplet pregnancies. Prophylactic cervical cerclage did not reduce the perinatal mortality rate at >22 weeks of gestation in triplets.

CONCLUSION

The risk of death for MT triplet pregnancies is significantly higher than that of TT triplet pregnancies; however, the risk of death for DT triplet pregnancies is not.

Perinatal factors associated with the neurologic impairment of children born preterm

OBJECTIVE

To determine the perinatal risk factors of long-term neurologic impairment for preterm infants.

METHODS

A case-control study was conducted with 60 neurologically impaired and 60 healthy children, all born prematurely.

RESULTS

There was no relation between neurologic impairment and maternal pregnancy complications or prenatal steroid administration, bacteriologic content of cervical smear, fetal presentation, fetal heart rate, or mode of delivery. Cerebral palsy was associated with early neurologic signs, perinatal asphyxia, neonatal septicemia, abnormal brain ultrasound findings, prolonged interval between rupture of membranes and delivery, and multiple placental lesions. Children with minimal cerebral dysfunction were more frequently first born. Multiple placental lesions, neonatal septicemia, abnormal brain ultrasound findings, and perinatal asphyxia were independently correlated with long-term neurologic impairment.

CONCLUSION

Perinatal infection, perinatal asphyxia, and abnormal brain ultrasound findings seem to be risk factors for cerebral palsy whereas primigravidity seems to be correlated with minimal cerebral dysfunction.

Maternal morbidity and infant death in twin vs triplet and quadruplet pregnancies

OBJECTIVE

The purpose of this study was to calculate nationally representative, population-based estimates of maternal and neonatal risks in triplet and quadruplet pregnancies compared with twin pregnancies.

STUDY DESIGN

The study population included 316,696 twin, 12,193 triplet, and 778 quadruplet pregnancies from the 1995-2000 Matched Multiple Birth Data Set. Adjusted odds ratios (AORs) and 95% CIs estimated the risk of complications and were controlled for maternal age, race, parity, and smoking status.

RESULTS

Compared with mothers of twins, mothers of triplets and quadruplets were more likely to be diagnosed with preterm premature rupture of membranes (AORs, 1.53, 1.74, respectively), pregnancy-associated hypertension (AORs, 1.22, 1.27), and excessive bleeding (AORs, 1.50, 2.22), to require tocolysis (AORs, 2.85, 5.03), and to be delivered by cesarean (AORs, 6.55, 7.38) at < 29 weeks of gestation (AORs, 3.76, 7.96), and to have > or = 1 infants die (AORs, 3.02, 4.07).

CONCLUSION

Triplet and quadruplet pregnancies have significantly higher risks than twin pregnancies for most maternal and neonatal complications. Maternal anthropometric, nutritional, and previous reproductive factors may be particularly important in the reduction of these excess risks and improvement of outcomes in multiple births.

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.

Neuropsychological Outcomes of Preterm Triplets Discordant for Birthweight: A Case Report

Multiple gestation is associated with a higher incidence of preterm birth and preterm birth often results in later neurocognitive and behavioral problems that persist into adulthood. The medical, neurobiological, familial, and socio-environmental factors determinant for an individual are unpredictable. We present neuropsychological data for fraternal triplets discordant for birthweight whose school-age outcome was inconsistent with the low birthweight literature and for whom neurobiological variables appeared especially pertinent. Preterm infants may achieve optimal outcomes, although etiological factors leading to such outcomes may depend heavily on care center variables that limit or avoid intracerebral and other medical complications of prematurity.

The maternal and neonatal outcome of high order gestation at King Abdulaziz University Hospital

OBJECTIVE

To review the outcome of high-order gestations at King Abdulaziz University Hospital (KAUH).

METHODS

A retrospective chart review of all high order multiple pregnancy delivered at KAUH. The ante partum and postpartum complications and the neonatal outcome had been studied.

RESULTS

Thirty-six triplets, five quadruplets, and one set of quintuplets delivered during the period (1985-2005). The mean maternal age was 28.5 +/- 5 years. The mean gestational age at delivery was 33.9 +/- 2.5 weeks. The maternal complications included: first trimester bleeding 7 (15.4%), pre-eclampsia 5(19.2%), gestational diabetes 2 (3.8%), anemia 12 (23.1%), and preterm labor 29 (65.4%). Of 133 fetuses there were three stillbirths, seven neonatal deaths, six early neonatal deaths, and one late neonatal death, and all died because of extreme low birth weight. Fifteen babies had low APGAR score of < 7 at 5 min. Three babies had congenital anomalies.

CONCLUSION

The outcome of high order gestations at our center is comparable to others, prematurity and extreme low birth weight being major determinants.

Comparative study of perinatal outcome of dichorionic and trichorionic iatrogenic triplets

OBJECTIVE

The purpose of this study was to compare the perinatal outcome of dichorionic and trichorionic triplets who were conceived by assisted reproductive techniques.

STUDY DESIGN

In this retrospective study, the maternal, neonatal, and chorionicity data were collected from 106 sets of trichorionic triamniotic and 34 sets of dichorionic triamniotic triplet pregnancies who were conceived by assisted reproductive techniques between January 1986 and December 2000. Perinatal and neonatal data were evaluated in relation to chorionicity and intertriplet birth weight discordance.

RESULTS

The dichorionic triamniotic triplets have an 8-fold higher risk of perinatal death than trichorionic triamniotic gestations (odds ratio, 7.9; 95% CI, 4.4-14.0; P < .001). This is attributed to a higher risk of very low birth weight (P < .01), delivery at < 30 weeks of gestation (P < .001), and premature rupture of membrane (P < .001) in dichorionic triamniotic triplets compared with trichorionic triamniotic pregnancies. Twin-twin transfusion syndrome (odds ratio, 11.5; 95% CI, 4.8-27.7; P < .001), delivery at < 30 weeks of gestation (odds ratio, 40.5; 95% CI, 16.9-97; P < .01), premature rupture of membrane (odds ratio, 6.7; 95% CI, 3.8-11.9; P < .01), and nulliparity (odds ratio, 3.1; 95% CI, 1.6-6.1; P < .05) had independent effects on perinatal loss rate.

CONCLUSION

The dichorionic triplets have an 8 times higher perinatal mortality rate than trichorionic triamniotic pregnancies.

How and why are triplets disadvantaged compared to twins?

The current epidemic of triplets, a result of the widespread use of assisted reproduction, started less than two decades ago. Its full impact has been appreciated only recently. Triplets are disadvantaged from every perinatal perspective compared to twins--preterm birth, low birth weight, morbidity and mortality--because the human uterus probably is better equipped to carry twins than triplets. Although modern neonatal care has improved survival rates of preterm as well as low-birth-weight triplets, other complications remain and are of great clinical importance. The alternative to carrying triplets--multifetal pregnancy reduction--is associated with improved outcomes, as expected from comparing twin to higher-order multiples. However, the improved outcomes of triplets in recent years might call for second thoughts about the frequent recommendation of multifetal pregnancy reduction of triplets to twins.

Maternal and neonatal outcome of 93 consecutive triplet pregnancies with 71% vaginal delivery

BACKGROUND

The aim of this study was to investigate neonatal and maternal data in a large series of triplet pregnancies as a function of the decision regarding the route of delivery.

METHODS

A retrospective series of 93 triplet pregnancies managed and delivered between 1989 and 2001 in a single perinatal department was analyzed. Seventy-eight women with triplet gestations who underwent a trial of labor were compared with 15 women with triplet gestations who delivered their infants by elective cesarean delivery. Neonatal outcomes assessed included respiratory distress syndrome, retinopathy of prematurity, necrotizing enterocolitis, intraventricular hemorrhage and Apgar scores. Maternal outcomes assessed included preeclampsia, blood transfusion, endometritis and urinary tract infection.

RESULTS

Sixty-six of 78 women (84%) who underwent a trial of labor had a successful vaginal delivery of all three neonates. The other 12 delivered their infants by cesarean delivery. Perinatal mortality referred to 104 triplet pregnancies was 48/1000.

CONCLUSIONS

Our experience suggests that offering vaginal delivery is an acceptable management plan for triplet gestation in a center with a sufficient number of triplet deliveries.