European Journal of Obstetrics & Gynecologv and Reproductive Biology, 35 (1990) 159-171

Elsevier

159

EUROBS 00926

Triplet and quadruplet pregnancies - a forthcoming challenge also for the ‘general’ obstetrician

Per Olofsson Department of Obstetrics and Gynecology, University Hospital, Lund, Sweden

Accepted for publication 17 August 1989

Summary

Data from 14 triplet and 2 quadruplet pregnancies (50 infants) during the period 1974-1988 were analysed. The perinatal mortality rate was only 68, despite a

preterm delivery rate of 88%. Preterm delivery was more common in young (I 29

years) multiparous women. Perinatal complications were, as expected, strongly

associated with immaturity. Respiratory problems of the infants occurred signifi- cantly more often among women delivered by elective Cesarean section than among

those planned for vaginal delivery, but the mean gestational duration was 1 week longer in the latter group. Few problems arise in infants weighing 2000 g or more, or

at delivery at 34 weeks or later, and under optimal conditions it would therefore seem safe to allow these women to give birth vaginally. Nor did birth order affect

the outcome for infants born vaginally. It is recommended that quadruplets be delivered by Cesarean section because of the difficulty of ensuring satisfactory fetal surveillance in labor.

Triplet pregnancy; Quadruplet pregnancy; Perinatal outcome; Selective abortion

Introduction

The frequency of multiple pregnancies has increased during the last decade (Table I), both for twins and in pregnancies with more than two fetuses (Table II).

The likelihood that the ‘general’ obstetrician may encounter a pregnancy with more than two fetuses has therefore increased, yet most obstetricians have no substantial experience in managing such multiple gestations.

Correspondence: Per Olofsson, MD, Department of Obstetrics and Gynecology, University of Lund, General Hospital, S-21401 Malm8, Sweden.

0028-2243/90/$03.50 0 1990 Elsevier Science Publishers B.V. (Biomedical Division)

160

TABLE I

The numbers of infants born in singleton and multiple pregnancies in Sweden compared over the S-year

periods 1977-1981 and 1982-1986 [l]. Chi-square test with Yates’ correction was used for statistical

comparison

Period

1977-1981

1982-1986

Singletons Multiple

(n) (n)

470114 8783

471047 9689

Chi-square = 41.7.

p < 0.001.

TABLE II

Frequencies of twins and triplets (or more) during the period 1977-1986 in Sweden [l]

Year Twins/1000 infants Triplets or more/1000 infants

1977 16.4

1978 17.8

1979 19.3

1980 18.1

1981 18.4

1982 18.4

1983 19.4

1984 20.3

1985 19.7

1986 21.0

0.25

0.35

1 ?i =18.0 0.47

0.31 0.29

0.35

0.30

1 x=19.8 0.41

0.24

0.49

’ z = 0.36

TABLE III

A selection of reports on perinatal mortality rate in triplet and quadruplet pregnancies

Authors Period n Perinatal mortality (%I)

Kurtz et al. [6]

kkowic [7]

Syrop and Vamer [8]

Daw [S]

Holcberg et al. [9]

Loucopoulos and

Jewelewicz [lo]

Deale and Cronje [ll] 1967-1976 Ron-El et al. 1121 1970-1978

1931-1956

1946-1976

1946-1983

1958-1977

1960-1979

1965-1981

21x3

59x3

20x3

14x3

31x3

27x3

7x4

1x5

367X3

19x3

6x4

33.3

23.2

21.6

30.9

23.2

14.8

18.2

18.5

Berg et al. [13] 1973-1981 8x3 4.0 McFee et al. [4] 1974 2x4 12.5

Goldman et al. [14] 1987 1x4 0

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The use of artificial stimulation of ovulation and in vitro fertilization (IVF) with embryo transfer is a major reason for the above-mentioned trend. The multiple

pregnancy rate occurring after ovulatory stimulation or IVF is approximately 20-25% [2,3].

Pregnancies with a higher fetal number occurring after treatment for infertility is

regarded as a complication. The risks are similar to those of twin pregnancies, but

are often more serious because of a more pronounced ‘intra-uterine crowding’.

Abdominal discomfort, pre-eclampsia, intra-uterine growth retardation (IUGR),

premature labor, uterine inertia, fetal malpresentation, etc., are all common compli- cations [4,5]. The perinatal mortality is high (Table III) and most often associated

with immaturity, but has declined from approximately 20-30% to 4-19% during the

last four decades.

So, the number of pregnancies with a high fetal number is growing and the

present study was therefore carried out in order to elucidate the current problems, e.g., what advice should be offered to the general obstetrician?

Material and methods

This study comprised all triplet and quadruplet pregnancies managed during the period 1974-1988 at the University Hospital of Lund. Miscarriages prior to 25

completed weeks were excluded. No pregnancy with more than four fetuses reached this gestational age.

Maternal and perinatal data are shown in Table IV. Fifty babies were born in 14

triplet and 2 quadruplet pregnancies. All were diagnosed antepartum. Five women were treated with stimulation of ovulation prior to conception: two with clomiphene

alone and three with human chorionic gonadotropin (hCG) in addition. Both

quadruplet pregnancies were induced by clomiphene and hCG, and one of them was also treated with gamete intrafallopian transfer (GIFT). One woman suffered from

asthma, one from diabetes mellitus, and one developed hypertension during preg- nancy. Median maternal age was 29.5 years and those eight women of 29 years or

younger were compared with those eight of 30 years or older. Hospitalization and tocolysis (usually terbutaline) was initiated in cases of

impending preterm delivery (n = 14). Steroids for acceleration of fetal pulmonary maturation was given when indicated (n = 13).

Respiratory distress syndrome (RDS) was defined as neonatal respiratory distress with rising right-left shunt during the first 24 h of life and characteristic X-ray findings, excluding transient tachypnea, aspiration and pneumonia. Pulmonary maladaptation (PMA) was defined as respiratory distress with normal PO,, but with

characteristic X-ray findings. Course of pregnancy and fetal outcome were analysed with respect to maternal

age, artificial fertilization, maternal complications, parity, delivery week and birth

weight, sex, mode of delivery, and fetal presentation and birth order. In order to analyse the mode of delivery, women primarily scheduled for vaginal

delivery (n = 9) were compared with women scheduled for elective Cesarean section (CS) (n = 7). An anesthesiologist was present also during vaginal delivery. Three of the nine women in the former group underwent an emergency abdominal delivery

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TABLE IV

Maternal and perinatal data on 14 triplet and 2 quadruplet pregnancies (50 infants) analysed especially

in relation to mode of delivery

Women (N = 16)

Infants (n = 50)

Scheduled for

vaginal delivery

(N=9)

(n = 27)

Elective CS

(N=7)

(n = 23)

Total

(N = 16)

(n = 50)

vaginal

delivery

(N=6)

(n = 18)

acute CS

(N=3)

(n = 9)

Maternal age (yrs) Jz

mean

range

Artificial

fertilization

29.4

23-39

5

29.3. 28.4 26.7

25-34 23-30

2 1

parity

nullipara

multipara

Tocolysis

Steroids

Preterm PROM

5 1 1

11 5 2

I4 6 2

13 5 2

I 2 1

Completed weeks

at delivery

mean

range

Stillbirth

32.8

26-38

2

32 Y

34.2 34.0 33.7

31-38 32-35

1

Apgar score l-6 at

lmin

Smin

10 min

13/48 3 4 6

9/48 4 5

2/48 _ 2

Perinatal

mortality

SGA

RDS + PMA

Hyperbilirubinemia

3/50 1 2

7/50 2 2 3

15/48 3 12

11/48 4 1 6

30.7

23-39

2

32.8

26-34

1

CS, cesarean section; PROM, premature rupture of the membranes; SGA, small-for-gestational age;

RDS, respiratory distress syndrome; PMA, pulmonary maladaptation.

163

(due to umbilical cord prolapse, impending fetal asphyxia, and abruptio placentae,

respectively).

Since the study was retrospective and spanned a 15year period, it is difficult to give any standardized selection criteria for choosing vaginal delivery, but three rules

were applied during the whole period: a gestational age of at least 31 weeks; first

triplet in vertex presentation; absence of other complications.

The Chi-square test, Fisher’s exact probability test, and Wilcoxon two-sample test were used for statistical analyses.

Results Maternal age. Perinatal mortality comprised one case in the young (I 29 years)

and two cases in the older group (2 30 years). Both stillbirths occurred in the older

group. The mean delivery week was 31.5 weeks (range 26-35) in the young group

and 34.1 weeks (range 31-38) in the older, but the difference was statistically not significant (Wilcoxon two-sample test). Regarding the incidence of preterm prema- ture rupture of the membranes (PROM), CS, low Apgar scores, small-for-gestational

age (SGA), respiratory problems and hyperbilirubinemia, there were no differences between the groups.

Artificial fertilization. No specific maternal complication differing from the rest of the material was found among the five artificially induced pregnancies.

Three women were delivered by Cesarean section and among them both quadruplet pregnancies.

The five induced pregnancies resulted in 17 infants, born between 31 and 35 weeks of gestation. The mean delivery week (33.6) did not differ from the average in

the series as a whole. All infants survived and only one had a 1-min Apgar score of

< 7, whereas all had normal scores at 5 and 10 min. One infant was SGA and five

developed PMA. In summary, there was no neonatal complication rate that differed from the

average.

Maternal complications. The woman with diabetes was delivered at 26 weeks of pregnancy, the women with asthma at 31 weeks, and the woman with pregnancy-in- duced hypertension at 34 weeks. All three pregnancies had occurred naturally. Of the nine infants borne by these women, one fetus died in utero in the 34th week (hypertension) and one infant (diabetes, born in the 27th week) died on the 4th day of life due to RDS and intracranial hemorrhage (ICH). Another infant of the diabetic mother also developed RDS and suffered from hydrocephalus. Among the

seven surviving infants, only one did not develop any respiratory problems. One

infant got RDS, one bronchopulmonary dysplasia, and four PMA. Purity. Mean maternal age was fairly uniform among both nulli- and multi-

paras. The nulliparas were delivered later - mean gestational week 34.0, compared with 32.3 for the multiparas; difference statistically not significant (Wilcoxon

two-sample test). The mean gestational age at delivery of altogether six multiparous women 29 years or younger was 30.5 weeks. The delivery week of nulliparous

women 29 years or younger, 30 years or older, and of multiparas aged 30 or more, was 33.7-34.5 (mean). The two women with the earliest deliveries overall, at 26 and 27 weeks respectively, were 29 and 33 years old.

164

25

20

15

10

5

0 I I b

26 26 30 32 34 36 38, 40 Bsftional

Fig. 1. The cumulative number of cases of respiratory distress syndrome (RDS) and pulmonary maladaptation (PMA) in relation to gestational age at delivery in 14 triplet and 2 quadruplet pregnancies

(48 liveborn infants).

All seven cases of preterm PROM occurred in multiparous women. Four out of five nulliparas were delivered by CS, including the two quadruplet pregnancies. Both stillbirths occurred among the nulliparas. On the other hand, in this group only two infants had a low Apgar score at 1 and 5 min and none at 10 min, which

should be compared with the multiparas’ figures of 11, 7 and 2, respectively. The

only case of neonatal death occurred in this latter group. Regarding the frequencies

of SGA, respiratory problems and hyperbilirubinemia, there were no differences

between the groups. Delivery week and birth weight. The prematurity rate (delivery < 36 completed

weeks) was 14/16 (87.5%). The cumulative frequencies of RDS and PMA in relation to gestational week at delivery are shown in Fig. 1. The altogether five cases of RDS occurred in three pregnancies, in weeks 26, 27 and 33, respectively. The woman of 33 weeks gave birth vaginally. Three out of six infants born before 28 weeks suffered from RDS and another from PMA. In two of the cases of RDS, there were signs of intrapartum hypoxia. None of the 12 infants born after 34 completed weeks had any respiratory problems .

The perinatal complications in relation to birth weight are shown in Table V. Of

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TABLE V

Perinatal complications in relation to birth weight of 50 infants born in 14 triplet and 2 quadruplet

pregnancies. The figures denote number of infants

Birth weight (g) n Stillbirth PNM Apgar 1-6 RDS PMA SGA

1’ 5’ 10’

(500 1 1 1 _ _ _ 1 500-749 _ _ _ _

750-999 6 - 1 4 3 1 2 1 1

1000-1499 7 1 1 4 4 1 1 _ 4

1500-1999 18 - _ 3 1 - 1 8 1 200%2499 12 - _ 1 1 - _ 1 _

2 2500 6 - _ 1 - - 1 _ _

Total 50 2 3 13 9 2 5 10 7

PNM, perinatal mortality; RDS, respiratory distress syndrome; PMA, pulmonary maladaptation; SGA,

small-for-gestational age.

the seven infants weighing less than 999 g, one fetus was severely growth-retarded

(310 g) in the 35th week and died in utero and another infant weighing 950 g of 26

weeks’ gestation died due to prematurity and RDS. Its sibling of 950 g also had a low 10 min Apgar score and suffered from bronchopulmonary dysplasia, ICH, and developed hydrocephalus.

A SGA infant of 1470 g died in utero in the 35th week. Another infant (1080 g, week 27, RDS) had a low 10 min Apgar score, but has done well.

Four out of altogether 12 infants born alive and weighing less than 1499 g, got

respiratory problems. In the group 1500-1999 g, nine out of 18 infants got respiratory problems. Of infants weighing more than 2000 g, two got respiratory

problems.

Of the 50 fetuses and infants, seven (14%) were growth retarded (according to the Swedish standards for singleton pregnancies; curves for normal growth of triplet

and quadruplet pregnancies are lacking). Both cases of intra-uterine death were

SGA (one severely; weight 310 g, compared with 2140 and 1210 g for its siblings).

Also another fetus was severely growth-retarded (820 g in the 32nd week, weighing 49% of its largest sibling’s birth weight), but was born vaginally as number three in

order and did well despite pneumonia. The pregnancy course and neonatal period of the five surviving SGA infants was otherwise uneventful: intrapartum hypoxia occurred in one case, low Apgar score at 1 min in two cases and at 5 min in one

case, one case of hyperbilirubinemia and one of hypocalcemia. No SGA infant was born earlier than 31 weeks.

Sex. Thirty-four of the 50 infants were boys and 16 girls (ratio 2.1). All perinatal deaths happened to boys. Mean gestational week for boys born alive was

32.8 and for girls, 30.9. Of the 48 infants born alive, lo/32 (31%) of boys and 3/16 (19%) of girls had a low Apgar score at 1 min; 22% and 13%, respectively, at 5 min;

3% and 6%, respectively, at 10 min. Of the boys 9% developed RDS and 19% PMA, compared with 13% and 25%, respectively, of the girls. The incidence of SGA was

the same among boys as in girls.

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TABLE VI

P&natal outcome of six vaginally delivered women with triplet pregnancies (18 infants) in relation to

birth order

Birth order of infant

No. 1 No. 2 No. 3

(n) (n) (n)

Fetal presentation

vertex

breech

transverse

Stillbirth

Apgar score < 1

lmin

Smin

10 min

Perinatal mortality

SGA

RDS

PMA

Hyperbilirubinemia

6 5

1

1 _

3

2

1

2

_ 1 _

1

1

2

SGA, small-for-gestational age; RDS, respiratory distress syndrome; PMA, pulmonary maladaptation.

Mode of delivery. As shown in Table IV, mean maternal age was lower, parity higher and delivery week later, among the women scheduled for vaginal delivery,

compared with the elective CS group. Regarding perinatal complications, there was no case of severe hypoxia (low

Apgar score at 10 min) in the group scheduled for vaginal delivery, despite serious

intrapartum complications (cord prolapse, abruptio placentae), whereas there were

cases of severe hypoxia in the elective CS group. Respiratory problems (RDS and PMA) of at least one sibling occurred in six of seven women in the elective CS

group and in two of nine women in the group scheduled for vaginal delivery

(Fisher’s exact test; p < 0.025). Fetal presentation and birth order. The importance of fetal presentation and

birth order could of course be analysed only for the six women (18 infants, all triplets) who gave birth vaginally. The outcome of these pregnancies is shown in Table VI.

All first-born infants were in vertex presentation. Few problems occurred among these infants.

Of the six infants born second in order, five were in vertex presentation. One of

these had a low 1 min Apgar score. It was born 7 min after the first triplet, which was equal to a mean delay of 6.5 min between the first and second triplet in the whole series of infants born vaginally.

Of the infants born third in order, two had a low 1 min Apgar score. These two were born 16 and 20 min, respectively, after the first sibling (mean 14 min in the whole series) and 11 and 13 min, respectively, after the second (mean 7.5 mm).

No infant had a low Apgar score at 5 or 10 min.

167

Discussion

This study suggests that perinatal mortality in triplet pregnancies is approaching an acceptably low rate. This decline is a trend seen in high-risk pregnancies in

general and can to a great extent be attributed to the improved survival of very

immature infants.

Prematurity is the most common and serious complication in multiple fetal

pregnancies. The figures in the literature range between 57% and 100% [5-9,12,13].

Daw [5] and Ron-El et al. [12] have reported the lowest figures. The perinatal

mortality figures in their series were 31% and 198, respectively. The present study

and another Swedish study [13] indicate that it is possible to achieve a low perinatal

mortality (6% and 4%, respectively) despite a high preterm delivery rate (88% and

lOO%, respectively).

Both Swedish studies were made in tertiary care university hospitals and it can be assumed that the quality of the perinatal care had a considerable influence on the

good outcome. Although these series are small, and comparison with clinics on a lower level and with even smaller series is impossible, the results raise the question:

should pregnancies with a high fetal number be managed at a level lower than tertiary clinics? The importance and availability of experienced obstetricians and

neonatologists have been emphasized previously [lo]. Fetal pulmonary maturation is closely related to gestational age. Respiratory

distress due to immaturity seems to be the primary cause of death in multifetal pregnancies [lo]. The present study showed that all infants suffering from RDS were

born before 34 weeks. Furthermore, none of the infants born after 34 weeks had any respiratory problems. Other authors report the same experience [ll].

Although maturation is a better measure than birth weight when considering the

risk of developing neonatal complications, weight must also be discussed, because of the uncertain dating in many studies. Previous studies have revealed that the outcome is poor when the birth weight is below 1000 g, but excellent when it

exceeds 1800-2000 g [5,6,11]. By and large, this statement could be confirmed in the present study, though the survival rate was still 4/7 for infants weighing less than

1000 g. In summary, in the present study the outcome was good in newborns weighing at least 2000 g, or when born after 34 weeks.

The frequency of SGA was 14% (seven cases). Growth retardation could be identified in utero, as the pregnancies were monitored with serial ultrasound fetometry. Both of the two stillborn fetuses were SGA, but no SGA infant was born earlier than 31 weeks of gestation. It seems unethical to consider terminating a multiple pregnancy at an earlier gestational stage on behalf of one growth-retarded

fetus in jeopardy, and thereby venture the health of the other fetus(es). It was found in the present study that young multiparous women gave birth

earlier in pregnancy. Kurtz et al. [6] believe that the young multiparous woman is

prone to ignore the risks in the interest of her family. Maybe these women should be

offered better support by the social welfare system. No specific maternal (except infertility) or neonatal stigmata were found in the

artificially induced pregnancies. Holcberg et al. [9] found that women with artifi- cially accomplished fertilization had a longer pregnancy duration, which they

168

attributed to the more careful antenatal management with early diagnosis, hospitali- zation, and scheduled delivery by CS. Syrop and Vamer [8] found, conversely, that

spontaneous ovulations were associated with a later delivery. @kowic [7] found the

same perinatal mortality rate whether the pregnancy occurred naturally or not. The

crucial point seems to be an early diagnosis, which has also vigorously been

advocated [6,11,15]. Pregnancy-induced hypertension and pre-eclampsia are well-known complica-

tions of multiple pregnancy (range 8-46% in triplet and quadruplet pregnancies)

[7-9,121. Hypertension is to some degree avoided by bedrest. In multifetal preg-

nancy, the topic of bedrest or not is controversial. Most women in this study were

hospitalized due to impending preterm delivery, and there was only one case of

hypertension. Some authors believe bedrest to have a beneficial effect on the

duration of pregnancy [8,9], while others deny this [5,12]. Daw [15] and LOUCOPOU-

10s and Jewelewicz [lo] found no effect upon duration of pregnancy, but prefer to recommend it anyway. In a study of twins, no difference in delivery week was found

when comparing hospitalization and rest at home with sick leave [16]. Due to the conflicting opinions, it would seem judicious to recommend at least sick leave and

some restriction of activities from the late second trimester. Nine out of altogether 16 women in the present series were scheduled for vaginal

delivery. Despite three cases of potentially serious complications during labor,

resulting in emergency CS, the outcome was in all respects better than for women

who underwent elective CS. The presence of an anesthesiologist also at vaginal

delivery and the possibilities to rapidly perform a CS was then mandatory. The frequency of respiratory problems was significantly lower in the group scheduled for

vaginal delivery (Table IV). However, it should be borne in mind that in this group delivery was 1 week later. The comparison is therefore uncertain, but a cautious

conclusion would be that the outcome was satisfactory for women at least 31 weeks pregnant when they were allowed to go into labor.

The importance of fetal presentation and birth order could be analysed only in the six women who actually gave birth vaginally. The outcome for the second and

third baby was just as good as that for the first. It should be remembered, however, that all first-boms were in vertex presentation, which is ideal and fortunately also most common [15]. Unless the size of the second or third fetus is not significantly larger than that of the first, it is difficult to understand why the presentation of the

fetuses next in order should play any role, as long as they come in a longitudinal lie. Breech delivery of the second or third triplet is not similar to breech delivery of the

first. Under optimal conditions, delivery of triplets can be managed as we have suggested for twins [18].

Many authors have recommended abdominal delivery [5,11,12], as they have

experienced an inverse relation between birth order and fetal survival [6,7], an impaired outcome in connection with malpresentation [5,8], or generally a better outcome of abdominally delivered babies [7,9,11,12]. Loucopolous and Jewelewicz [lo] have claimed that the mode of delivery does not seem to play any particular role in fetal outcome. There seems to be no general opinion in the literature. Deale and CronjC [ll], who have collected a large series, can conceive of the possibility of vaginal delivery under ideal conditions: good antenatal care, absence of maternal

169

ailments, gestation lasting 34 weeks or more, birth weight above 2000 g, continuous

monitoring in labor, a speedy and atraumatic delivery, and adequate neonatal facilities. To this can be added the opinions of Daw [5], that there is no correlation between birth time interval and fetal outcome, and of Kurtz et al. [6] that internal

podalic version and extraction should be abandoned.

The arguments used in triplet (and twin) pregnancy regarding delivery mode

cannot be automatically applied to quadruplet pregnancy. The cases of quadruplet pregnancy reported in the literature are so few that no general opinion seems to

have been established. Collection of data from case reports is not reliable, as it can be assumed that one is reluctant to report unsuccessful cases. Since a close and

continuous fetal monitoring during labor is mandatory in all multiple pregnancies,

the optimal mode of delivery of quadruplets should be a CS. McFee et al. [4] claim, however, that ‘vaginal delivery seems not to be contraindicated’, after having

managed two quadruplet pregnancies (of 30 and 35 weeks’ gestation respectively)

vaginally, resulting in seven surviving infants. Furthermore, in a recommendation

for delivery of triplets, Loucopoulos and Jewelewicz [lo] also include quadruplets

and quintuplets and have actually managed such pregnancies vaginally. They add,

however, that CS is the best mode of delivery if the obstetrician is not confident

with the intrapartum manoeuvers.

It is obvious that the outcome of multiple pregnancies is related directly to the number of fetuses - the greater the number, the greater the risk. A new attitude to

management of pregnancies of higher fetal number has therefore recently been discussed. Berkowitz et al. [19] have selectively aborted ‘supernumerary’ fetuses in

an attempt to improve the prospects for the remaining fetuses. The authors recommend that this procedure be offered to women carrying four or more fetuses, but not in the case of twins. In their opinion, triplets are in a grey zone where a selective abortion is doubtful. In the four triplet pregnancies reported, the authors

had no choice, however, since all four women had decided to interrupt the pregnancy if they were denied selective abortion.

Feldberg et al. [20] have reported a case of quadruplets following IVF, tragically

culminating in an artificial abortion due to hyperemesis and anxiety (physician’s anxiety also?). It is suggested that the number of embryos transferred at an IVF

procedure should be limited to three or four and excessive embryos frozen and used

in subsequent natural cycles [14,20]. It is easy to agree with Berkowitz et al. [19] and Hobbins [21] that in a society

with an unhindered right to legal abortion and where the decision is solely the woman’s, the selective feticide procedure requires no additional rationale and is simply a variation of a first-trimester abortion. It seems unjustified to recommend a

selective abortion in triplet pregnancy, however, since perinatal mortality now approaches an acceptable figure and the morbidity rate is also fairly low. It is the quadruplets that are in the grey zone, in which more experience is needed.

Recommendations

I. Quadruplet pregnancy is in a grey zone in which antenatal counselling on the selective abortion procedure is dependent upon the obstetrician’s experience, local

170

facilities for neonatal intensive care, and the expectant couple’s own capability. A

close fetal monitoring is mandatory in all multiple pregnancies during labor, but seems unattainable in the case of quadruplets and therefore necessitates a CS in

these cases.

II. With appropriate antenatal care, the outcome in triplet pregnancy is fairly good and selective abortion should not routinely be recommended. Selective abortion

should be offered in a triplet pregnancy only when the option is a total termination

of pregnancy.

III. Triplet pregnancy can be managed in a way similar to twin pregnancy: - Early diagnosis and dating with sonographic fetometry.

- A liberal attitude to sick leave from the late second trimester.

- Evaluation of cervical status every week from the late second trimester in order to

early diagnose and prevent impending preterm birth.

- Sonographic fetometry every second or third week throughout the last trimester

in order to diagnose intra-uterine growth retardation. _ A liberal attitude to hospitalization. _ Cesarean section on common obstetrical indications. - Abdominal delivery before 33 completed weeks. _ Vaginal delivery from 34 weeks onwards when the first triplet is in vertex

presentation. The presentations of the other fetuses should not influence the choice of mode of delivery.

- Vaginal delivery considered from 34 weeks onwards when the first triplet is in breech presentation, provided all other circumstances are optimal.

- Vaginal delivery managed as previously described for twins [18]. Most important is ensuring a longitudinal position of the triplet next in order by using ultrasound

and external manipulation; fundus pressure for engagement of the presenting

part into the fully dilated cervix; augmentation of labor; rupture of the mem- branes not until the presenting part is firmly down in the birth channel.

- Delivery at a tertiary care center, at least when before 33 weeks.

- The ultimate decision regarding mode of delivery is dependent upon the skill and experience of the obstetrician - if there is any doubt, the ‘choice’ must be

abdominal delivery.

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