Triplet pregnancy: What do we tell the prospective parents.

Experience managing triplet pregnancies has increased over the past few decades as the incidence has changed related to assisted reproductive practices. Physicians caring for women carrying triplets cannot predict an individual outcome or pregnancy course but must educate patients about the challenges related to these high risk pregnancies. Obstetric providers can describe the wide range of risks associated with triplet gestations, and the general plan for management, but ultimately parents must make decisions with potentially lifelong consequences. Here, we present the diagnostic criteria, common complications, and management options for triplet pregnancies, to help obstetricians counsel patients on the medical and psychosocial consequences of triplet pregnancy, potential complications, and multifetal reduction.

Health-related quality of life and behavior of triplets at adolescent age.

OBJECTIVES: To assess health-related quality of life (HRQoL) and behavior of triplets compared with matched singletons at adolescent age and to identify medical and sociodemographic predictors of outcome. STUDY DESIGN: Fifty-four triplets (19 sets, mean [SD] gestational age 32.0 [2.4] weeks, birth weight 1580 [450] g) and 51 gestational age-, birth weight-, and sex-matched singleton controls self-rated their HRQoL at age 14.5 (0.3) years. Proxy reports about HRQoL and behavior were obtained by parents and teachers. HRQoL was measured with the Kidscreen-52 questionnaire child and parent form, and behavior with the Achenbach Child Behavior Checklist. RESULTS: Self- and parent-reported HRQoL values was similar in both groups except for the dimensions "mood and emotions" and "autonomy," which were better (P = .001, P = .03) in triplets. Parents reported significantly less behavioral problems in triplets compared with controls. Compared with community norms, both HRQoL and behavior measures in triplets were in the normal range. Parent-reported HRQoL was predicted by dichorionicity. CONCLUSIONS: HRQoL and behavioral outcome in adolescent triplets was good in our study and was, in some aspects, better than in matched singleton controls. Dichorionicity is an important outcome determinant.

[The cognitive development of triplets in school age and its impact on the quality of family life--a follow-up study from a perinatal centre]. / Die kognitive Entwicklung von Drillingen im Schulalter und ihr Einfluss auf die Qualität des Familienlebens--eine Follow-up Studie eines Perinatalzentrums.

OBJECTIVE: The aim of this study was to assess the developmental outcome of 7- to 9-year-old triplets and to determine parenting stress and quality of family life. METHODS: Cognitive development (Wechsler intelligence scales for children III, WISC III) and quality of family life (Kansas family life satisfaction scale, KFLSS; parenting stress index, PSI) of 48 triplets born between 1996 and 1998 at a perinatal centre were compared with controls born at a gestational age ≥37 weeks. Index and control children/mothers were matched by age (birthday: ±14 days/maternal age±2 years). RESULTS: Triplets and their families showed a mean IQ score and parenting satisfaction and stress within the normal range. Full IQ score (97 SD 16) as well as verbal and performance IQs (102 SD 16; 92 SD 19) were significantly lower than the controls' corresponding data (full IQ 111 SD 15, p<0.001; verbal IQ 116 SD 21, p<0.001; performance IQ 102 SD 17, p=0.001). Parents of triplets tended to show a higher total PSI score (222 SD 39) than the parents of the controls (205 SD 47). The differences reached statistical significance only in the parent domain (triplets 125 SD 24; controls 111 SD 27; p<0.01). Satisfaction with family life was good in triplet families and did not differ significantly in any of the subscales from control parents' satisfaction. CONCLUSIONS: This study demonstrates a favourable outcome of triplets with respect to their cognitive development and the quality of their families' lives at school age. The difference in children's IQ was statistically, but perhaps not clinically, significant, because the triplets' data were within the normal range.

Anorexia nervosa in identical triplets.

The cause of anorexia nervosa (AN) is unclear, but is likely multifactorial, including psychological, familial, environmental, societal, genetic, and other biological factors. This case report of identical 12-year-old female triplets simultaneously concordant for AN illustrates the importance of addressing all these components in evaluation and treatment, and the difficulty of determining the relative importance of each factor in the cause of an individual's eating disorder. An overly close relationship and competitiveness between the girls, treated at times as a triplet group rather than as individuals, as well as stressful family dynamics, were probably important antecedents to the girls' AN. The girls encouraged each other and competed to lose weight. Brief individual and family psychotherapy, parent counseling, nutritional counseling, and psychoeducation led to successful treatment. The triplets were encouraged in treatment to compete with and encourage each other to obtain treatment goals, including eating more healthily and achieving healthy weights. A literature review of AN twins studies is also presented, as these studies add to our understanding of the relative importance of shared genes and shared environment in the development of AN. These studies also add insight into treating individuals from families with multiple affected relatives.

The developmental origins of musicality.

The study of musical abilities and activities in infancy has the potential to shed light on musical biases or dispositions that are rooted in nature rather than nurture. The available evidence indicates that infants are sensitive to a number of sound features that are fundamental to music across cultures. Their discrimination of pitch and timing differences and their perception of equivalence classes are similar, in many respects, to those of listeners who have had many years of exposure to music. Whether these perceptual skills are unique to human listeners is not known. What is unique is the intense human interest in music, which is evident from the early days of life. Also unique is the importance of music in social contexts. Current ideas about musical timing and interpersonal synchrony are considered here, along with proposals for future research.

Genetic and environmental bases of childhood antisocial behavior: a multi-informant twin study.

Genetic and environmental influences on childhood antisocial and aggressive behavior (ASB) during childhood were examined in 9- to 10-year-old twins, using a multi-informant approach. The sample (605 families of twins or triplets) was socioeconomically and ethnically diverse, representative of the culturally diverse urban population in Southern California. Measures of ASB included symptom counts for conduct disorder, ratings of aggression, delinquency, and psychopathic traits obtained through child self-reports, teacher, and caregiver ratings. Multivariate analysis revealed a common ASB factor across informants that was strongly heritable (heritability was .96), highlighting the importance of a broad, general measure obtained from multiple sources as a plausible construct for future investigations of specific genetic mechanisms in ASB. The best fitting multivariate model required informant-specific genetic, environmental, and rater effects for variation in observed ASB measures. The results suggest that parents, children, and teachers have only a partly "shared view" and that the additional factors that influence the "rater-specific" view of the child's antisocial behavior vary for different informants. This is the first study to demonstrate strong heritable effects on ASB in ethnically and economically diverse samples.

Prenatal origin of schizophrenia in a subgroup of discordant monozygotic twins.

Neuropathological, obstetrical, and epidemiological evidence increasingly suggest that some cases of adult-onset schizophrenia have prenatal or neonatal etiological roots. We evaluated the developmental histories of 23 monozygotic twin pairs discordant for schizophrenia to determine when they markedly and permanently began diverging from each other in motor skills or unusual behavior. Seven of the twins (30%) who later developed schizophrenia had become permanently different from their cotwins by age 5 years. The early divergence group differed from the others by multivariate tests (p = 0.002) for within-twin pair effects and by univariate tests for physical anomaly scores (p = 0.01), total finger ridge counts (p = 0.001), family history of psychosis (p = 0.004), and serious perinatal complications or low birth weight (p = 0.05). It is concluded that some cases of adult-onset schizophrenia are associated with prenatal events, which may include neurodevelopmental abnormalities or specific insults such as anoxia or infectious agents.

Multiple birth versus neonatal brain lesions in children born prematurely as predictors of perceptuo-motor impairment at age 6.

Our primary objective in this study was to test the multiple birth hypothesis, which asserts that multiple gestation and delivery, per se, entail a greater likelihood of adverse outcome than for singletons. Our second objective was to assess the power of various neonatal risk indicators to predict developmental status at school age. In particular, we sought to weigh multiple birth as an indicator of outcome against brain lesions visualized by ultrasonography. Additional neonatal indicators included birth weight, gestational age, weight relative to gestational age, and gender. At 6 years of age, children were assessed on selected aspects of perceptuo-motor competence and verbal ability. Previous findings favoring the multiple birth hypothesis have been mostly confined to comparisons of unmatched groups of twins and singletons. This study limited investigation to children born prematurely (before 35 weeks gestation) and included comparison of multiplet-singleton pairs, matched on type and extent of any lesions, gestational age, and birth weight. The full sample comprised 124 singletons and 45 multiplets (twins, triplets, and quadruplets). About half exhibited brain lesions in the neonatal period. In this population, there was no tendency for singletons to do better than multiplets, either in the unmatched or matched samples, at 6 years of age. Lesions, supplemented by gestational age, were highly predictive of outcome on the selected measures. In contrast, the multiple birth factor was of no predictive utility.

Parent-infant synchrony and the social-emotional development of triplets.

To study the social-emotional development of triplets, 23 sets of triplets, 23 sets of twins, and 23 singleton infants (N=138) were followed from birth to 2 years. Maternal depression and social support were assessed in the postpartum period, mother-infant and father-infant interaction and the home environment were observed at 3 months, a separation-reunion episode and a maternal interview were conducted at 12 months, and infant behavior problems were evaluated at 24 months. Lower parent-infant synchrony was observed for triplets. Triplets showed less distress during maternal separation and less approach at reunion. Mothers reported lower adjustment and differentiation among siblings for triplets than for twins. Higher internalizing problems were reported for triplets, and the triplet with intrauterine growth retardation showed the poorest outcomes. Behavior problems were predicted by medical risk, maternal depression, parent-infant synchrony, infant approach, and mother adjustment. Discussion focuses on developmental risk when the exclusivity of the parent-infant relationship is compromised.

A view from the other side of the bed.

A unique perspective on multiple pregnancy is shared through the writings of an expectant mother of triplets during the 19 weeks she spent on strict bed rest, 15 of which were in the hospital. The expectant mother in this case is also a family physician, who finds herself on the opposite side of the patient bed to which she is accustomed. Through excerpts from her journal, the emotional ups and downs of a complicated pregnancy are revealed, along with the sources of strength and courage that kept her going. Commentary regarding the psychologic theory and developmental tasks of multiple pregnancy provide a foundation for suggesting effective nursing interventions for the psychosocial demands of these often high-risk pregnancies.

Triplets where monozygotic siblings are concordant for arson.

Triplets are described where the two genetically identical brothers are arsonists and both have sociopathic personality disorder rated using the Personality Assessment Schedule. The third, non-identical brother has not committed arson and does not have a personality disorder.

Shared kangaroo care for triplets.

The mother in this case study already had four children at home and was afraid she would be unable to bond to three additional babies. This article describes her experiences with shared kangaroo care (holding all three infants at once), how these experiences relieved her fears, and how kangaroo care was extended by co-bedding the triplets in a single pediatric crib. Clinical nurse specialists and advanced nurse practitioners can use the successful outcome reported here to promote kangaroo care for families with naturally occurring triplets as well as those families whose triplets result from treatment for infertility.

[Two-year follow-up cohort studies on triplets: development of children and mother-child relationship]. / Suivi à 2 ans d'une cohorte de triplés: développement des enfants et relations mères-enfants.

BACKGROUND: The number of triplets births has increased during the last 15 years. The psychomotor development of triplets, problems concerning long-term relationships between the mother and her children and between the children themselves are still incompletely studied. PATIENTS AND METHODS: Eleven families with triplets, consecutively born at the Clinique Baudelocque, were assessed at home for 2 years by the same psychologist. IQ was measured in each child at the age of 2 years using the Brunet-Lezine test. At this age, all mothers completed the Symptom-Check List allowing to assess eventual relationship difficulties between the mother and their children. RESULTS: The psychomotor development of the children (IQ = 100) was similar to the mean score in the general population. The mother reported great physical fatigue during the first year after birth and psychological difficulties during the second year. They mentioned behavioral problems and difficult relationships among the triplets. They complained of not being able to fulfill the children's demands. In four families, more severe difficulties, potentially damaging the psychological well-being of the children, required an intervention during the survey. CONCLUSIONS: Improved and prolonged help to families with triplets is necessary, requiring the participation of pediatricians, nurses, psychologists, social workers and specialized people.

A relação mãe e filho: vicissitudes de um (des)encontro para o laço simbólico / Mother-baby relationship: vicissitudes of the (dis)encounter for symbolic ties / La relación madre-bebé: vicisitudes de (des)encuentro para el lazo simbólico

A clínica da intervenção precoce nos convoca a refletir acerca da função materna no processo de construção do enlace com o Outro primordial e de como é possível ao analista intervir no (des)encontro mãe e filho, visando ao estabelecimento ou ao restabelecimento do circuito pulsional. Alguns bebês deparam com dificuldades para alcançar o estatuto de Sua Majestade, o Bebê, como dizia Freud. Qual será a situação em casos de trigêmeos? A partir da exposição de um caso clínico, pretendemos discutir as questões do laço simbólico entre mãe e bebê.

The clinic of child early intervention invites us to think about the mother's function as part of the construction of the ties with the Primordial Other and about how the analyst can intervene in the (dis)encounter between mother and child, aiming at the establishment or the re-establishment of the pulsion. Some babies are struggling to reach the status of His Majesty, the Baby, as Freud would say. How would it be in cases of triplets? Through the presentation of a clinical case, we intend to discuss the issues of the symbolic ties between mother and baby.

La clínica de la intervención precoz nos convoca a reflexionar sobre la función materna en el proceso de construcción del enlace con el Otro primordial y de cómo es posible la intervención del analista en el (des)encuentro madre e hijo, con el fin de establecer o de restablecer el circuito pulsional. Algunos bebés encuentran dificultades para alcanzar el estatuto de "Su Majestad, el Bebé", como decía Freud. ¿Cuál será la situación en caso de trillizos? A partir de la exposición de un caso clínico, pretendemos discutir las cuestiones del lazo simbólico entre madre y bebé.

Comparative study of the psychosocial risks associated with families with multiple births resulting from assisted reproductive technology (ART) and without ART.

OBJECTIVE: To determine whether the psychosocial risks associated with multiple births are increased as a consequence of the use of assisted reproductive technology (ART) in comparison with those not resulting from ART. DESIGN: Cross-sectional study. SETTING: Fertility units of a university hospital and a private hospital. PATIENT(S): Parents of single children and multiples (twins and triplets) between 6 months and 4 years of age (n = 636) were divided into two groups: those who conceived through ART (n = 265) and those who conceived through non-ART (n = 371). INTERVENTION(S): Administration of six scales, in office or by mail. MAIN OUTCOME MEASURE(S): Measurement scales of material necessities, social stigma, marital satisfaction, perceived stress, depression, quality of life, and their subscales. RESULT(S): The analysis of variance, Student's t-test, and χ(2)-test were applied. No effect was observed based on the use of ART in the psychosocial variables studied. Significant differences were obtained between the groups of single (SB) and multiple births (MB) with respect to material necessities, social stigma, marital satisfaction, depression, and quality of life. CONCLUSION(S): Having more than one child per birth, whether resulting from the use of ART or not, increases psychosocial risks for the parents. Assisted reproduction centers should include this information with the obstetric and neonatal risks, stressing the advantages of having one child per birth. Psychosocial risks are not increased as a result of having used ART, but the goal of avoiding the repeated use of ART does influence the desire to transfer the maximum number of embryos possible. Psychological counseling should be included before initiating ART, as well as when a multiple pregnancy is confirmed.

Psychosocial risks associated with multiple births resulting from assisted reproduction: a Spanish sample.

OBJECTIVE: To determine the psychosocial risks associated with multiple births (twins or triplets) resulting from assisted reproductive technology (ART). DESIGN: Transverse study. SETTING: Infertility units of a university hospital and a private hospital. PATIENT(S): Mothers and fathers of children between 6 months and 4 years conceived by ART (n = 123). The sample was divided into three groups: parents of singletons (n = 77), twins (n = 37), and triplets (n = 9). INTERVENTION(S): The questionnaire was self-administered by patients. It was either completed at the hospital or mailed to participants' homes. MAIN OUTCOME MEASURE(S): Scales measured material needs, quality of life, social stigma, depression, stress, and marital satisfaction. RESULT(S): Logistic regression models were applied. Significant odds ratios were obtained for the number of children, material needs, social stigma, quality of life, and marital satisfaction. The results were more significant for data provided by mothers than by fathers. CONCLUSION(S): The informed consent form handed out at the beginning of ART should include information on the high risk of conceiving twins and triplets and on the possible psychosocial consequences of multiple births. As soon as a multiple pregnancy is confirmed, it would be useful to provide information on support groups and institutions. Psychological advice should also be given to the parents.

Relationships among attachment styles, personality characteristics, and disordered eating.

OBJECTIVE: Insecure attachment styles and certain personality characteristics (i.e., high levels of neuroticism) have been associated with eating pathology. However, previous research has not examined these variables simultaneously and has not examined possible mediating relationships between attachment and personality characteristics for disordered eating. Because personality characteristics have emerged as some of the most robust predictors of disordered eating, it was predicted that the link between attachment and disordered eating might be through personality styles. METHOD: Participants included 85 female twins and triplets who took part in the Michigan State University Twin Study. Disordered eating, attachment style, and personality characteristics were assessed. Hierarchical linear models were used to examine relationships among the variables. RESULTS: Overall, neuroticism, and extraversion to a lesser extent, mediated the relationship between insecure-resistant attachment and disordered eating. Specifically, higher scores on the neuroticism scale predicted more disordered eating and explained the relationship between insecure-resistant attachment and disordered eating. CONCLUSION: These results suggest that relationships between attachment style and disordered eating are indirect, in that neuroticism fully mediates associations between insecure-resistant attachment and disordered eating.

Does a triplet birth pose a special risk for infant development? Assessing cognitive development in relation to intrauterine growth and mother-infant interaction across the first 2 years.

OBJECTIVE: To examine whether a triplet birth per se poses a risk to the development of infants' cognitive competencies and to the mother-infant relationship. METHODS: Twenty-three sets of triplets were matched with 23 sets of twins and 23 singleton infants (n = 138) with respect to gestational age, birth weight, and medical and demographic features. Infants with perinatal asphyxia, intraventricular hemorrhage of grade 3 or 4, periventricular leukomalacia, or central nervous system infection were excluded from the study. At 6, 12, and 24 months of age, mother-infant interaction was observed and infants' cognitive development was tested with the Bayley II test. RESULTS: Mothers of triplets displayed lower levels of sensitivity at 6, 12, and 24 months and infants were less socially involved at 6 and 24 months, compared with singletons and twins. Triplets scored lower than singletons and twins on the Bayley Mental Developmental Index at 6, 12, and 24 months. A weight discordance of >15% was found for 15 triplet sets (65.2%). The discordant triplets showed decreased cognitive skills at 12 and 24 months, compared with their siblings, and received the lowest scores for maternal sensitivity. Hierarchical multivariate regression analysis revealed that greater medical risk at birth, multiple-birth status, lower maternal sensitivity, and reduced infant social involvement in the first 2 years were each predictive of lower cognitive outcomes at 2 years (R2 = 0.33). CONCLUSIONS: Triplets appear to be at higher risk for cognitive delays in the first 2 years of life, and discordant infants are at especially high risk. This delay is related in part to the difficulty of providing sensitive mothering to 3 infants at the same time. The findings may assist practitioners in guiding prenatal and postpartum parental care and management.

Homosexual orientation in twins: a report on 61 pairs and three triplet sets.

Twin pairs in which at least one twin is homosexual were solicited through announcements in the gay press and personal referrals from 1980 to the present. An 18-page questionnaire on the "sexuality of twins" was filled out by one or both twins. Thirty-eight pairs of monozygotic twins (34 male pairs and 4 female pairs) were found to have a concordance rate of 65.8% for homosexual orientation. Twenty-three pairs of dizygotic twins were found to have a concordance rate of 30.4% for homosexual orientation. In addition, three sets of triplets were obtained. Two sets contained a pair of monozygotic twins concordant for sexual orientation with the third triplet dizygotic and discordant for homosexual orientation. A third triplet set was monozygotic with all three concordant for homosexual orientation. These findings are interpreted as supporting the argument for a biological basis in sexual orientation.

Decision making in multifetal pregnancy reduction for triplets.

The objective of this article is to examine the literature that forms the basis for counseling couples with higher order multiple gestation with regard to multifetal pregnancy reduction and present the data on expectant management of multiple gestations and multiple gestations managed with multifetal pregnancy reduction. The data sources for this article are computer-assisted search of the literature. Eighty-three articles, mainly published after 1989, and reporting on the natural history, management, and outcome of multifetal pregnancies, were reviewed. We analyze and present the data on expectant management of multiple gestations and multiple gestations managed with reduction to twins and then use the hypothetical patient-oriented questions listed below to organize the data. There is a general consensus that reducing triplets to twins results in significant secondary benefits: lower cost and fewer days in hospital and a decrease in a variety of moderate morbidities associated with prolonged hospitalizations and preterm delivery for mother and baby. However, it is not clear that couples are more likely to take home a healthy baby, if they undergo multifetal pregnancy reduction.