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Case report: successful of a spontaneous quadruplet pregnancy
Abstract
Objective:
To report a rare case of successful pregnancy and delivery of two pair of monozygotic twins (quadruplets).
Methods:
We reported a Case Report of a 32-year-old nulligravida, who had had a previous twin pregnancy and was herself a twin assisted hatching. Prophylactic cervical cerclage sec. McDonald in the 23st week of pregnancy, hospitalization, and intensive care of pregnancy were performed.
Results:
Successful pregnancy and delivery of two male and two female twins in the 34th week of pregnancy.
... In 2009, Carrara et al. reported another case of quadruplet pregnancy in which the patient had had a previous twin pregnancy and was herself a twin herself. Preterm labour at week 34 of gestation had resulted in 4 healthy neonates (10). In the case report by Rathod et al. in 2015, one case of spontaneous quadruplet pregnancy was mentioned following spontaneous conception with no family history of multiple pregnancies (11). ...
... Shrestha et al. in 2016 reported another case of spontaneous quadruplet pregnancy, it had terminated at week 33 with 4 healthy neonates (3). Carrara et al. in 2009 reported a case of spontaneous quadruplet pregnancy in which despite prophylactic cervical cerclage at 23 weeks, the contractions had initiated at week 33 resulting in cesarean section at 34 weeks (10). Nevertheless, in some papers even spontaneous quadruplet pregnancies with no signs of premature labour had undergone an elective cesarean section at term (6,12). ...
Objective: Triplet or higher-order multiple pregnancies are often caused due to ovulation induction. Spontaneous quadruplet pregnancy is a rare phenomenon which is associated with maternal and fetal complications. Here in, we report a spontaneous quadruplet pregnancy with no family history and as a result of an unwanted pregnancy.
Case report: The patient was a 34-year-old, G4 L2 Ab1. She noticed being pregnant during breastfeeding, a spontaneous quadruplet pregnancy. There was no case of multiple pregnancies in her or her husband's family. In week 29 she was hospitalized due to the diagnosis of preterm labour. At 32 weeks and 4 days of gestation, because of the restart of labour contractions and dilatation development, she underwent a cesarean section. The outcome was the birth of 4 healthy neonates weighing between 1800 to 2100 gram and normal Apgar score.
Conclusion: Quadruplet pregnancy can rarely occur spontaneously even unintentionally, and can reach the third trimester without prophylactic cerclage.
... Others include placenta praevia, abruptio placentae, stillbirth and perinatal death. The risk of medical complications in pregnancy is also high in such pregnancies [6]. Of all the challenges in the management of higher order multiples; preterm labour and delivery have been the most pressing. ...
Background: High order multiple gestations are an uncommon occurrence. The incidence of multiple gestation continues to decrease as the number of fetuses increase as calculated using Hellin’s rule: incidence = 1:80n-1 births, where n is the number of fetuses. Thus, the expected incidence of quadruplets is estimated at 1 in 512,000 births. All these have changed with the advent of reproductive technology. However, the occurrence of quadruplets as a natural process has remained rare globally. Objective: To report a case of a successful spontaneously conceived quadruplet with the death of one of the fetuses and delivery of 3 live fetuses and a twin papyraceous fetus at the 36th week of gestation. Methods: We report a case of a 28-year-old para-2 woman who had a spontaneous conception resulting in a quadruplet. She had an ultrasound diagnosis of death of one of the fetuses at 25 weeks of gestation. She was admitted twice in the course of the pregnancy and subsequently delivered at the 35th week of gestation. Results: A successful caesarean delivery of 2 fem ales and 1 male with a male papyraceous fetus.
... There have also been multiple reports of prophylactic cerclages placed to prolong gestation in higher order multiple pregnancy. A case report by Carrara et al. described a quadruplet pregnancy with a prophylactic cerclage placed at 23 weeks, and delivered at 34 weeks [7]. In this patient, despite symptomatic preterm contractions with cerclages in place, the pregnancy was further prolonged for approximately five weeks from the onset of uterine contractions. ...
Introduction: The incidence of multiple pregnancies has increased tremendously over the last 3–4 decades due to the advent of assisted reproductive technology treatment. Generally, multifetal pregnancy is associated with increase in maternal and perinatal morbidity and mortality, which are directly proportional with increasing numbers of fetuses in higher order multiple pregnancies. Case Report: We present a case of a 26-year-old G1P0104 female with a 3-year history of anovulatory infertility. After the third cycle of ovarian stimulation with clomiphene citrate, she became pregnant with quadruplets. She had no significant past medical or surgical history. The pregnancy was a tetrachorionictetraamniotic quadruplet and it was relatively uncomplicated during the first and second trimesters. However, the patient had prolonged antepartum admission from 25w6d due to symptomatic preterm uterine contractions. At 31w3d, the patient underwent primary cesarean section due to non-reassuring fetal heart tracing and biophysical profile of quadruplet A. Four viable neonates were delivered, three females and one male. All four quadruplets were admitted to the Neonatal Intensive Care Unit (NICU) with varying degrees of neonatal complications due to prematurity, but they were discharged home between 8 and 9 weeks of life. The placental pathology showed Tenney-Parker changes, but it did not adversely affect the outcome of these infants. Conclusion: Higher-order multifetal pregnancies can pose serious management challenges because of increased preterm delivery. Hence, management should be in a tertiary medical center with a multi-disciplinary team that includes an Obstetrician, Perinatologist, and Neonatologist.
... Others include placenta praevia, abruptio placentae, stillbirth and perinatal death. The risk of medical complications in pregnancy is also high in such pregnancies [6]. Of all the challenges in the management of higher order multiples; preterm labour and delivery have been the most pressing. ...
Background: High order multiple gestations are an uncommon occurrence. The incidence of multiple gestation continues to decrease as the number of fetuses increase as calculated using Hellin's rule: incidence = 1:80 n-1 births, where n is the number of fetuses. Thus, the expected incidence of quadruplets is estimated at 1 in 512,000 births. All these have changed with the advent of reproductive technology. However, the occurrence of quadruplets as a natural process has remained rare globally.
... A published the first case of spontaneous quintuplet pregnancy in Africa was published in 1888 in Duffle in present-day Uganda in A. J. Mounteney-Jephson [5]. In the literature, cases of spontaneous quintuplet pregnancies have been reported in India, Pakistan, and Germany [3,6] [4,7,9]. ...
Introduction and importance:
Quintuplets conceived spontaneously are a rare occurrence. As compared with singleton pregnancies, quintuplets are associated with high rates of obstetric complications and significant prenatal morbidity and mortality. To our knowledge, here we reported the first case of spontaneous quintuplet pregnancy faced by a practicing clinician in an underdeveloped country (Somalia) with a Successful outcome.
Case presentation:
A 32-year-old woman presented in her third trimester of gestation at 30 weeks feeling pain and uterine contractions.
Clinical findings and investigations:
Ultrasound examination showed multiple pregnancies with four alive intrauterine pregnancies, but quintuplets could not be ruled out. Fetal heart activities were present, and the amniotic fluid was normal in amount.
Interventions and outcome:
Extensive preparations made included four sets of ventilators. We did an emergency cesarean section under spinal anesthesia: five alive infants, three boys and two girls delivered in cephalic and breech presentations.
Conclusions:
Quintuplet pregnancy is rare but poses relevant clinical problems to both the obstetrician and the neonatologist.
Relevance and impact:
The takeaway lesson from this case would be that Pregnancy with multiples is considered a high-risk pregnancy; with more complications observed as the number of fetuses increases, their effective follow-up requires early diagnosis with regular monitoring. Through this case, we would like to highlight the urgent need to focus on the delivery of women's health care services in Somalia, along with the need to recognize the importance of receiving antenatal care in the community so that the burden of thousands of lives that are lost each year could be reduced. This case report has been reported according to the SCARE Criteria (Agha et al., 2020).
... Historically the incidence is one in 512,000 [15]. There are case reports of spontaneous quadruplet pregnancies ending in live birth but almost each case had experienced obstetric and perinatal complications [4,[15][16][17][18][19]. All quadruplets in our study resulted from fertility treatment. ...
High order multiple pregnancy (HOMP) is defined as presence of three or more fetuses in utero. These pregnancies are often met with increased maternal and perinatal complications. The incidence of HOMP has been rising considerably with increasing usage of assisted reproductive techniques (ART). Multifetal pregnancy reduction (MFPR) is a standard procedure aimed to minimise maternal–fetal complications by converting high order multiples into twins or singletons. While the procedure has been well researched in triplets, literature is sparse for quadruplets. This is a case series of 20 consecutive cases of MFPR followed up till delivery. All procedures were performed between 11 and 14 weeks of gestation (mean 11.9+/− 0.94) in a dedicated fetal medicine unit by a single operator through transabdominal route. The primary outcome measure was to assess procedure related miscarriage. The study also looked at neonatal outcomes at delivery and various maternal complications like antepartum hemorrhage (APH) and prelabour premature rupture of membranes (PPROM). There was no pregnancy loss before 24 weeks but the rate of preterm delivery was very high (90%). Only two out of 20 women were delivered after 37 weeks. All (100%) ended in live births. There were two cases of neonatal deaths where one twin died from each pair. The mean birthweight (+/− SD) was 1754.75 (+/− 514.75) g (range 700–2600 g). Quadruplet pregnancies can happen with fertility treatment. Transabdominal MFPR in the first trimester is a safe procedure for quadruplets.
... Compared to single pregnancies, quintuplet pregnancies are associated with a high risk of hypertension, cervical incompetence, premature rupture of membranes, abruption placenta, placenta previa, first trimester bleeding, premature birth, anemia, stillbirths and perinatal deaths [11]. For our patient, we found pre-eclampsia at 24 weeks, and premature rupture of membranes at 33 weeks + 5 days. ...
Theorems, proofs, laws and rules are commonly named according to the presumed investigator, but often earlier investigators have contributed substantially to the findings. One example of this is Hellin's law, which was named after Hellin, although he was not the first to discover it. In research on twinning and higher multiple maternities, the law has played a central role because it is approximately correct, despite showing discrepancies that are difficult to explain or eliminate. Several improvements to this law have been proposed. In this study, we re-examine some old papers to provide an overview of the scientists who have contributed to the genesis and the improvements of this law. In addition, we consider more recent contributions in which Hellin's law has been discussed and evaluated. It has been mathematically proven that Hellin's law does not hold as a general rule. However, most studies are based on empirical rates of multiple maternities, ignoring random errors. Such studies can never confirm the law, but only serve to identify errors too large to be characterized as random.
To estimate the effect of parity on gestational age (GA) at birth in multifetal pregnancies.
Birth data from the public-access Matched Multiple Birth File produced by the National Center for Health Statistics from 1995 to 2000 were analyzed following IRB approval. GA, parity and demographic data were analyzed with parametric and nonparametric tests, including regression analysis, using SPSS.
Data from women with twin (n=316,983), triplet (n=11,981), and quadruplet (n=766) pregnancies were analyzed. A significantly higher proportion of nulliparous versus parous women were Caucasian (twins: 82 versus 77%; triplets: 91 versus 87%) and had more than 15 years of education (twins: 39 versus 24%; triplets: 55 versus 39%; quadruplets: 53 versus 35%). Mean GA was 5.6 days longer for twins, 5.4 days longer for triplets and 6.8 days longer for quadruplets born to parous versus nulliparous women. Caucasian and African-American parous women pregnant with twins or triplets delivered their babies at a later GA than their nulliparous counterparts at each level of education. GA at delivery increased as a function of age of the mother in nulliparous and parous women of twins or triplets, and at every age level, parous women delivered their babies at a later GA. A higher proportion of nulliparous women delivered before 24 weeks (twins: 2.9 versus 1.2%; triplets: 5.9 versus 2.5%; quadruplets: 8.3 versus 2.6%). The percentage of twins born at or after 32 weeks was 84.9% for nullipara and 90.1% for parous women; for triplets, corresponding figures were 61.4 and 69.6%; and for quadruplets the figures were 33.2 and 44.2%. The percentage of births at or after 36 weeks for nulliparous and parous women pregnant with twins was 54.8 and 63.2%, respectively. The majority of the gain in GA was observed between women who had no previous births and those who had one previous birth. In regression analysis, the effect of parity remained after controlling for demographic and risk factors known to affect GA.
GA at delivery is significantly increased in parous women carrying a multifetal gestation after controlling for other factors that affect GA at birth.
Objective To review the maternal morbidity and neonatal morbidity and mortality associated with in vitro fertilization (IVF) multiple pregnancies. Design Retrospective analysis of data collected from office and hospital records and from questionnaires sent to patients, their obstetricians, and pediatricians. Setting Patients (all with private insurance carriers) enrolled in an academic IVF program (The Jones Institute for Reproductive Medicine). Patients, Participants All IVF pregnancies resulting in one or more gestational sacs on the initial ultrasound at 6 to 7weeks were reviewed. Main Outcome Measures The frequency and severity of obstetrical and neonatal complications and the perinatal mortality of IVF twins, triplets, and quadruplets were compared. These were also compared with non-IVF multiple pregnancies. Results From 1982 to 1990, 629 IVF pregnancies progressed beyond 20weeks; 115 twins (18.3%), 15 triplets (2.4%), and 4 quadruplets (0.6%). There was a high incidence of antenatal complications such as abortions (30.3%, 42%, and 20%), premature labor (41.5%, 92.3%, and 75%), pregnancy-induced hypertension (17.0%, 38.6%, and 50%), and gestational diabetes mellitus (3.1%, 38.5%, and 25%) for twins, triplets, and quadruplets, respectively. The mean gestational age at delivery was 35.5±3.7, 31.8±2.7, and 31.0±1.7weeks, respectively. There was also a proportionate progressive increase in neonatal complications. The mean weights were 2,473±745, 1,666±441 and 1,414±368g, respectively. Twins (22.7%), 64.1% of triplets, and 75% of quadruplets needed admission to the neonatal intensive care unit and remained for an average of 12.0±2.3, 17.4±14.0, and 57.8±17.9days, respectively. There was no difference in the mean Apgar scores or the incidence of congenital malformations in the three groups. The corrected perinatal mortality rates were 38.5, 0.0, and 0.0 per thousand live births, respectively. Conclusion Triplet and quadruplet IVF pregnancies have increased obstetrical and neonatal complications compared with IVF twins. The perinatal mortality and the incidence of congenital malformations are, however, comparable in all three groups.
To report a unique case of successful pregnancy and delivery of two pair of monozygotic twins (quadruplets) after intracytoplasmic sperm injection (ISCI) and transfer of two blastocysts.
Case report.
University medical center.
A 30-year-old nulligravida, who had first ISCI, assisted hatching, and fresh embryo transfer because of a male factor of infertility (severe olygoasthenozoospermia).
Prophylactic cervical cerclage sec. McDonald in the 21st week of pregnancy, hospitalization, and intensive care of pregnancy, ending with delivery by planned Cesarean section (CS) in the 34th week of pregnancy.
Successful pregnancy and delivery of two male and two female twins in the 34th week of pregnancy.
Two blastocysts were divided and four embryos developed. After extensive counseling the couple decided to keep all embryos. In the 21st week prophylactic cerclage was preformed. During hospitalization the ultrasound examination was performed every 2 weeks, and from the 30th week on a cardiotocogram was recorded. At the 33rd week her blood pressure increased and she received antihypertensive therapy. At the 34th week planned CS was performed and four newborns (two male monochorionic monoamniotic twins, and two female monochorionic biamniotic twins) weighted between 1,300 and 2,170 g were born.
Even without embryoreduction, intensive care throughout pregnancy including prophylactic cerclage, bed rest, prophylactic anticoagulant, and antihypertensive therapy results in delivery of four healthy newborns.
Multi-fetal gestations are associated with increased frequency of maternal, fetal and neonatal complications. Data on the prognosis of multi-fetal pregnancies are of particular importance when the option of selective termination is considered. The present study details the obstetric management, neonatal outcome, and follow-up of seven quadruplet pregnancies in a french university center. The perinatal mortality was 250/1000. The neonatal mortality was 214/1000. The incidence of respiratory distress syndrome was 38%, bronchopulmonary dysplasia 19% and intraventricular hemorrhage 9.5%. Follow-up from one to 16 years shows that no child is handicapped. Our specific management for higher order multi-fetal pregnancies include early diagnosis, meticulous follow-up, early decrease of maternal activity, midwives at home, psychological care, delivery by cesarean section and a neonatalogist for each baby at the time of delivery.
To review the maternal morbidity and neonatal morbidity and mortality associated with in vitro fertilization (IVF) multiple pregnancies.
Retrospective analysis of data collected from office and hospital records and from questionnaires sent to patients, their obstetricians, and pediatricians.
Patients (all with private insurance carriers) enrolled in an academic IVF program (The Jones Institute for Reproductive Medicine).
All IVF pregnancies resulting in one or more gestational sacs on the initial ultrasound at 6 to 7 weeks were reviewed.
The frequency and severity of obstetrical and neonatal complications and the perinatal mortality of IVF twins, triplets, and quadruplets were compared. These were also compared with non-IVF multiple pregnancies.
From 1982 to 1990, 629 IVF pregnancies progressed beyond 20 weeks; 115 twins (18.3%), 15 triplets (2.4%), and 4 quadruplets (0.6%). There was a high incidence of antenatal complications such as abortions (30.3%, 42%, and 20%), premature labor (41.5%, 92.3%, and 75%), pregnancy-induced hypertension (17.0%, 38.6%, and 50%), and gestational diabetes mellitus (3.1%, 38.5%, and 25%) for twins, triplets, and quadruplets, respectively. The mean gestational age at delivery was 35.5 +/- 3.7, 31.8 +/- 2.7, and 31.0 +/- 1.7 weeks, respectively. There was also a proportionate progressive increase in neonatal complications. The mean weights were 2,473 +/- 745, 1,666 +/- 441 and 1,414 +/- 368 g, respectively. Twins (22.7%), 64.1% of triplets, and 75% of quadruplets needed admission to the neonatal intensive care unit and remained for an average of 12.0 +/- 2.3, 17.4 +/- 14.0, and 57.8 +/- 17.9 days, respectively. There was no difference in the mean Apgar scores or the incidence of congenital malformations in the three groups. The corrected perinatal mortality rates were 38.5, 0.0, and 0.0 per thousand live births, respectively.
Triplet and quadruplet IVF pregnancies have increased obstetrical and neonatal complications compared with IVF twins. The perinatal mortality and the incidence of congenital malformations are, however, comparable in all three groups.
This article reviews the epidemiology, management, and outcome of 71 quadruplet pregnancies that occurred between 1980 and 1989. A study of detailed medical questionnaires and medical records revealed that 67 (94%) of the pregnancies followed ovulation induction therapy. A majority of the pregnancies were diagnosed by 9.3 weeks' gestation and bed rest was instituted by 16.7 weeks; 14% of women had cervical cerclages. Tocolytic agents were used in 59 (83%) of the group beginning at 24.5 weeks' gestation. The mean gestational age at delivery was 31.4 weeks and the mean birth weight was 1482 gm. Cesarean sections were performed in 89% of the cases. The average maternal weight gain was 45.8 pounds. Of the 284 fetuses, there were six first-trimester losses (including one ectopic pregnancy), 10 stillbirths and 33 neonatal deaths, resulting in a stillbirth rate of 29 per 1000, and corrected neonatal and perinatal mortality rates of 37 per 1000 and 67 per 1000, respectively. Other than premature labor, the most common maternal complications were first-trimester bleeding (35%), toxemia (32%), and anemia (25%). The quadruplet fetal growth curve parallels the singleton 25th percentile until 34 weeks, when it drops below the 10th percentile. These data suggest that a majority of quadruplets are delivered after 28 weeks and a viable outcome is expected. Because of retarded growth after 34 weeks, delivery should be considered at 34 weeks in most cases.
The main complication in multiple gestation with more than two fetuses is prematurity, with its concomitant increase in perinatal mortality and morbidity. Clearcut indications as to management of these pregnancies are lacking, and the efficiency of elective cerclage is controversial.
Twelve triplets and three quadruplets out of 27 multiple pregnancies were electively sutured and compared to 10 triplets and two quadruplets without this procedure. Otherwise, both groups were managed uniformly regarding bed-rest, beta-mimetic drugs and dexamethazone for the enhancement of fetal lung maturity.
Mean duration of pregnancy in patients with cerclage was 35 weeks, significantly longer than those who did not undergo this procedure (30.7 weeks) (p<0.01).
Furthermore, in the former group, the mean neonatal weight was significantly higher (p<0.01), mean Apgar scores were better, significantly lower rates of respiratory distress syndrome occurred (p<0.05), perinatal mortality rate was significantly reduced (p<0.01) and the mean hospitalization period was shorter (p< 0.025).
It seems that elective cervical suture is a definite contribution to the successful management of multiple pregnancies with more than two fetuses.
The rate of multiple pregnancies with more than 2 fetuses has significantly increased since the introduction of ovulation induction agents. From 1970 through 1978, there were 19 triplets and 6 quadruplets in the authors' department, incidences of 1:696 and 1:5370, respectively. Eighteen (72%) of the 25 multiple pregnancies followed treatment with ovulation induction agents and 7 were spontaneous. The diagnosis of more than 2 fetuses was made earlier in the induced than in the uninduced pregnancies. Management, initiated upon diagnosis, included bed rest, high-protein diet, beta-mimetic agents, progestins, dexamethasone late in the second trimester, and selective cerclage. The mean gestational age was 34 weeks in the triplets and 35 weeks in the quadruplets. Forty-four percent of the deliveries were by cesarean section and the remainder were by vaginal delivery. The mean weight of the neonates was 1807 g in the triplets and 1950 g in the quadruplets. The mean overall Apgar score was 8.16, and the perinatal mortality was 185 per 1000, corrected (more than 28 weeks) to 137 per 1000. The main neonatal complications resulted from prematurity, and maternal complications noted were postpartum hemorrhage necessitating hysterectomy in 2 patients. The preferable mode of delivery cannot be stated dogmatically. Fetal outcome was similar in vaginal and cesarean deliveries among the various gestational age groups.
Twins and triplets are at higher risk of cerebral palsy than singletons. This study investigated the degree of risk for cerebral palsy in twins, triplets and quadruplets, and identified factors associated with the increased risk.
The subjects were recruited from the Kinki University Twin and Higher Order Multiple Births Registry.
The subjects were 705 twins pairs (1410 twins), 96 sets of triplets (287 triplets excluding one infant death), and 7 sets of quadruplets (27 quadruplets excluding one infant death), who were born after 1977. The prevalence of cerebral palsy was 0.9% among 1410 twins, 3.1% among 287 triplets, and 11.1% among 27 quadruplets. Furthermore, the risks of producing at least one child with cerebral palsy were 1.5%, 8.0%, 42.9% in twin, triplet, quadruplet pregnancies, respectively. After adjusting for each associated factor using logistic regression, the risk of cerebral palsy was significantly associated with decrease in gestational age and asphyxia. The odds ratio indicated that infants whose gestational age was < 32 weeks were 20 times more likely to develop cerebral palsy than infants whose gestational age was > or = 36 weeks.
The prevalence of cerebral palsy in triplets and quadruplets was higher than that in twins. Lower gestational age was associated with a greater risk of cerebral palsy.