Management of Comprehensive Care of multiple-birth infants from fetal to infancy period: challenges, training, strategies.

BACKGROUND: Prematurity escalates the crisis of the infants a susceptible group of the society. Multiple delivery further intensifies the susceptibility of both family and health system. A comprehensive care is, thus, necessary to ensure the optimal growth and development of such multiple-births. Accompanied by trainings, challenges, and strategies, the present study was conducted based on a two-year report of comprehensive care management experience on two sets of multiple infants. METHODS: A qualitative case study approach was used to survey these two sets of premature infants (quadruplet and quintuplet) and their families. The data were collected through medical files, interviews, questionnaire, field presence, phone call and WhatsApp application, and continued follow-ups. Content analysis was performed based on survey and interventions during a period of two years in Isfahan, Iran (2018-2020). RESULTS: Case presentation and comprehensive care management are the main areas resulted from this study. The results of the study were categorized in eight challenging areas (categories) and strategies including sterility and infertility period, transition from the intrauterine to neonatal intensive care unit (NICU), discharge process, physical and developmental status, home visit and home care, development of care plan, socio-economic support, and coronavirus nightmare. CONCLUSION: Based on challenges and strategies during these two years, the situation of the multiple-birth infants and their families' needs should be identified as the first prerequisites in an inter-professional approach and in collaboration with the health providers. Isfahan University of Medical Sciences, Welfare Organization, and the charities were the parties involved with this process in our study. It was also found that developing a separate specific package of comprehensive care management plan for multiple-births is a necessity.

Quintuplets: 5 Cases of NEC. Are There Other Risk Factors?

OBJECTIVE: To review a case of quintuplets with all babies developing necrotizing enterocolitis. METHODS: A retrospective study of preterm quintuplets all developing necrotizing enterocolitis. Clinical outcomes were reviewed. RESULTS: Quintuplets were born at 24 weeks gestation. Each baby developed NEC and was treated. One baby died. Currently the remaining 4 infants are on full enteral nutrition. CONCLUSION: Further studies are needed to better understand this emerging population of multiple birth pregnancy and the frequency of NEC development.

Quintuplets and a mother's determination to provide human milk: it takes a village to raise a baby--how about five?

This is the first published case of quintuplets who breastfeed and receive expressed mother's own milk and supplemental pasteurized donor human milk. In this case, all 5 babies receive exclusively human milk at 7 months. This result is achieved because of the mother's strong advocacy for human milk feedings and a remarkable support system of 200 individuals drawn from family, friends, and congregation.

Prenatal diagnosis of a spontaneous monochorionic five-amniotic quintuplet pregnancy.

OBJECTIVES: It is the aim of this study to report on the prenatal diagnosis and course of a spontaneous monochorionic (MC) 5-amniotic (5A) quintuplet pregnancy which is such a rare event that it has up to now never been described antenatally. CASE REPORT: A spontaneous MC 5A quintuplet pregnancy was diagnosed at 12 weeks by 2D ultrasound. Video tapes (2D and 4D) were made showing that 2D ultrasound still better documented simultaneous visualization of all quintuplets including their activities compared with 4D ultrasound, which, however, adds the information of space location. Variances of crown-rump length, nuchal translucency and nasal bone were evaluated. After informed consent and a second opinion of 2 centers performing invasive laser coagulation or occlusion of the umbilical cord, the parents decided to interrupt pregnancy. Pathologic evaluation confirmed MC 5A quintuplet pregnancy. CONCLUSION: The case demonstrates that splitting of 1 zygote into 5 embryos might even occur spontaneously. In view of the poor outcome and limited success of fetal reduction, pregnancy termination was finally part of the counseling.

Is peripartum hysterectomy more common in multiple gestations?

OBJECTIVE: To compare the occurrence of peripartum hysterectomy between singleton and multiple gestations. METHODS: This was a historical cohort study comparing the occurrence of peripartum hysterectomy between singleton and multiple gestations at Banner Good Samaritan Regional Medical Center, Phoenix, Arizona, from January 1, 1996, to December 31, 2001. RESULTS: During the study years, 42,595 singleton, 1,131 twin, 164 triplet, 35 quadruplet, and 2 quintuplet deliveries occurred. A total of 100 peripartum hysterectomies were performed. Of these hysterectomies, 88 occurred in singletons, 5 in twins, 6 in triplets, and 1 in quadruplets. The overall occurrence of peripartum hysterectomy was 2.28 per 1,000, and the occurrence of emergent peripartum hysterectomy was 1.73 per 1,000. Multiple gestations had a significantly greater risk of emergent peripartum hysterectomy than singletons (odds ratio [OR] 6.04, 95% confidence interval [CI] 3.28-11.11; P < .001). This difference was more pronounced among higher-order multiple gestations: twins (OR 2.95, 95% CI 1.22-7.13, P = .03), triplets (OR 25.22, 95% CI 11.02-57.77, P < .001), and quadruplets (OR 19.53, 95% CI 3.34-114.69, P = .04). When compared with singletons, higher-order multiple gestations had nearly a 24-fold increased risk of emergent peripartum hysterectomy (OR 23.97, 95% CI 11.05-51.99, P < .001). CONCLUSION: Multiple gestations have a significantly higher occurrence of emergent peripartum hysterectomy than singletons. This information should be used in counseling and managing patients with these pregnancies.

Monochorionic high-order multiple pregnancies and multifetal pregnancy reduction.

OBJECTIVE: To study the frequency and obstetric outcome of monochorionic multiple pregnancies in a population referred for fetal reduction. METHODS: Data charts of all patients with multifetal (> or =3) pregnancies referred for fetal reduction over the last 10 years were reviewed for the presence of monochorionic twin pairs or triplets. RESULTS: Twenty-nine of 239 high-order multiple pregnancies contained a monochorionic component (12.1%), eight of which were monochorionic triplets. Half of all naturally conceived pregnancies contained a monochorionic component. High-order multiple pregnancies with a monochorionic component resulted significantly more frequently from natural conceptions (7 of 29) than multichorionic pregnancies (7 of 210) (P =.001). Fetal reduction of the monochorionic twin pair in 21 pregnancies resulted in eight twin and 13 singleton pregnancies; mean gestational age at delivery was, respectively, 34.3 +/- 2.9 and 39.2 +/- 1.4 weeks. Pregnancy loss rate was one of 21 (4.8%). In the remaining eight multiple pregnancies with a monochorionic triplet present, three were complicated by a twin reversed arterial perfusion sequence, and two couples requested a first trimester termination of pregnancy. Fetal reduction of the monochorionic triplet in a dichorionic quadruplet pregnancy resulted in a normal pregnancy outcome. In two monochorionic triplet pregnancies, fetal reduction to monochorionic twin pregnancies with bipolar coagulation of the umbilical cord resulted in a favorable pregnancy outcome. CONCLUSION: Monochorionic twins or triplets are frequently part of naturally conceived high-order multiple pregnancies. Reduction of the monochorionic twin pairs improves pregnancy outcome. Monochorionic triplet pregnancies show a high complication rate, but may benefit from fetal reduction by cord coagulation.

Quintuplet pregnancy.

A quintuplet gestation after ovulation induction with clomiphene and HCG is described. This is the first quintuplet birth reported in Israel. The pregnancy was associated with ovarian hyperstimulation syndrome, toxemia of pregnancy, and pruritus gravidarum. Diagnosis and management of these cases pose a special problem for the obstetrician and neonatologist. The problem of multiple pregnancies and their control in the treatment of infertility with ovulation-inducing drugs is discussed.

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.

Multiple pregnancies following induction of ovulation.

PIP: This article reviews the cumulative data on multiple pregnancies which are the result of ovulation induction. Generally, those patients who require ovulation induction fall into 2 groups--those with primary or secondary amenorrhea, low levels of endogenous gonadotropins, and lack of endogenous estrogen activity, and those with anovulation due to menstrual disorders who have evidence of endogenous estrogen activity. The various ovulation-inducing preparations are discussed and they include gonadotropins ([hPG] human pituitary gonadotropin and [hMG] human menopausal gonadotropin), clomiphene, and agents which inhibit prolactin secretion. A variety of treatment schedules for gonadotropin administration have been advised and nearly all are based on the fact that hPG and hMG result in follicular growth and maturation and that ovulation can be induced by a triggering dose of hCG. A nonoverlapping regimen results in a significantly lower incidence of multiple pregnancies. Clomiphene administration must be varied according to the individual patient. Various combination therapies exist such as clomiphene and hMG or hPG or Parlodel and clomiphene or Parlodel and pergonal or LH-RH. Early diagnosis of multiple pregnancies is important since it enables the early institution of therapeutic measures which are likely to prevent maternal complications. Among the diagnostic methods are clinical examination, ultrasonography, radiography, and determinations of biochemical parameters. These multiple pregnancies can result in maternal complications and its effects on the fetus can be serious as well. Spontaneous abortion, premature delivery, perinatal mortality, and congenital malformations are some of the complications which can occur. There are attempts being made to reduce the incidence of multiple births by monitoring estrogens, monitoring follicular diameter measurements, selecting appropriate patients for therapy, and choosing a suitable regimen of treatment. Common measures taken in the management of multiple pregnancy include bed rest, myometrial relaxants, and suturing of the cervix.^ieng

Clinical course and systemic correlates of retinopathy of prematurity in quintuplets.

PURPOSE/METHODS: We studied clinical correlates of retinopathy of prematurity in four surviving quintuplets with similar low birth weights and gestational age of 27 weeks. Prospective serial ophthalmoscopic examinations and retrospective chart analysis were used. RESULTS/CONCLUSIONS: Retinopathy of prematurity varied among the neonates from stage 2 with total regression to threshold progressing to retinal detachment. Severity of eye disease correlated with duration of mechanical ventilation and of parenteral nutrition, as well as frequency of hypoglycemia and of hypercapnia. Poor outcome correlated inversely with weight gain.

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.

Group B streptococcus amnionitis with intact membranes associated with quintuplet delivery.

Chorioamnionitis is a frequent cause of premature labour and delivery, as well as of maternal and neonatal mortality. Group B streptococcus (GBS) has emerged over the past decade as a common pathogen in the etiology of neonatal sepsis. The case of chorioamnionitis reported here is unusual for three reasons: the premature labour was associated with intact membrane and amniotic fluid infected with GBS; all 5 infants were contaminated with GBS and all infants survived. Chorioamniotitis with intact membranes raises some questions regarding the antepartum use of steroids (potent anti-inflammatory agents), etc. The likelihood of chorioamnionitis in spite of cervical mucus, intact membranes, and the bacteriostatic activity of the amniotic fluid should alert the obstetrician to take special precautions, such as weekly vaginal cultures and appropriate vaginal antimicrobial treatment, in cases of imminent premature delivery.

Quintuplet pregnancies.

Five quintuplet pregnancies, following induction of ovulation with clomiphene and HMG-HCG, are the subject of this communication. In 3 women, pregnancy was associated with ovarian overstimulation, and two patients required emergency surgery because of torsion of an ovarian cyst. Two women aborted in mid-trimester, while the other 3 delivered by cesarean section at 33-35 wk gestation. 15 babies were born, weighing 700-2200 g. 8 infants suffered from respiratory distress syndrome and 5 babies were born with correctable malformations. 13 newborns survived, and all are mentally and physically well-developed. Four of the 5 women conceived again. The management of the patients during multiple gestation and the outcome of pregnancy are discussed.

Outcomes of quintuplet pregnancies.

OBJECTIVE: To review the obstetric and perinatal complications associated with quintuplet pregnancies in the United States. STUDY DESIGN: The databases of two large support groups for higher order multiple gestations, the Triplet Connection and Mothers of Super Twins, were accessed for quintuplet pregnancies. Each record contained information regarding maternal demographics, obstetric complications and perinatal outcomes. The data were analyzed by the Student t test and chi 2 test as indicated, with a P value < .05 for significance. RESULTS: Complete data were obtained for 36 quintuplet pregnancies. Preterm labor complicated all pregnancies. Six pregnancies delivered prior to 24 weeks' gestation, with no surviving infants. In the remaining 30 pregnancies, the mean gestational age at delivery was 28.9 weeks (SD +/- 2.0). There were trends toward later gestational ages at delivery in pregnancies with prophylactic cerclage placement and among multiparous women; however, these trends were not statistically significant. The perinatal mortality rate for the entire sample was 253/1,000. When adjusted for pregnancies delivered beyond 24 weeks' gestation, the perinatal mortality rate was 83/1,000. Minor and major neonatal morbidity affected 20% (26/132) and 10% (13/132) of quintuplet neonates, respectively. CONCLUSION: Quintuplet pregnancies are associated with high rates of obstetric complications and significant perinatal morbidity and mortality.

Clomiphene-induced quintuplets with a failed attempt at delayed-interval delivery.

Clomiphene citrate is widely used for ovulation induction. It is associated with a 6 to 17% incidence of multiple gestation. We report on a 27-year-old para 0010 patient who, after an initial evaluation for secondary infertility of 2 years' duration, was deemed to have oligo-ovulation. She conceived during the second cycle of clomiphene citrate administration. An early obstetric sonogram identified five fetuses with cardiac activity. The patient experienced preterm premature rupture of the membranes at 19 weeks gestation. A delayed-interval delivery was attempted, but all five fetuses were born over a period of 15 days. No maternal complications occurred. Multiple pregnancies of high order are commonly associated with human menopausal gonadotropins but rarely with clomiphene citrate. This is the seventh reported case of quintuplets related to clomiphene citrate, and possibly the first on whom no other fertility-enhancing medication was utilized. In this case, attempted delayed-interval delivery was not successful.

[Actual conditions of help and support of childcare in families with multiple birth children].

A mailed questionnaire survey was conducted on a population of 705 mothers of twins, 96 mothers of triplets, 7 mothers of quadruplets and 2 mothers of quintuplets to study the actual conditions of help and support of childcare in the families with multiple birth children. The following results were obtained. 1) In this study, 90.6% of the mothers of twins, 89.6% of the mothers of triplets, 100.0% of the mothers of quadruplets and 100.0% of the mothers of quintuplets had at least one relative and friend from whom they received practical help and regular support. However, 5.8% of the mothers of twins and 8.3% of the mothers of triplets did not have others from whom they received help and support. 2) Lack of time to take care of the other children was reported by approximately 90% of mothers with twins who did not have others from whom they received help and support for childcare. 3) Mothers who did not receive help and support from others for childcare reported severe fatigue, compared to mothers who received help and support from others: mothers of twins, especially reported severe mental fatigue and mothers of triplets or more, severe physical fatigue. 4) Mothers of twins who had no way to alleviate stress reported severe physical and mental fatigue, compared to mothers who had ways to alleviate stress. Mothers of triplets or more showed a similar tendency as mothers of twins. These mothers alleviated stress by talking with other mothers of multiple birth children, friends, their maternal mother or their husband.