Management of Triplet Pregnancy

Objective: This manuscript represents a retrospective observational cohort of 22 triplet pregnancies and a d d resses the impact of antenatal hospitalization, p rophylactic cervical cerclage, tocolytic therapy and mode of delivery on the obstetric and neonatal outcomes. Study Design: All triplet pregnancies that progressed beyond 22 weeks of gestation during the period 1988 to 1995 at King Khalid University Hospital, Riyadh, Saudi Arabia were included. The data was analyzed using Chisquare and student paired two-tailed T-test. R e s u l t s : The incidence of triplet pregnancy in the present study is 0.8 per 1000 deliveries. The mean gestational age at delivery was 33 ± 4 weeks (range 23-38 weeks), 50% of deliveries occurred between 34 and 38 weeks. The mean birth weight was 1766 ± 644 grams. There was no statistically significant difference in the mean gestational age and birth weight between triplet p regnancies that were managed with pro p h y l a c t i c cervical cerclage, hospitalization and tocolysis and those who were not. Six patients had pre-term labor (27.2%) <37 weeks of gestation. Three had pregnancy-induced Lulu A Al-Nuaim, Turki M. Al-Kharfy, Mohammed S Mustafa , Zeinab M Abotalib, Fahmida Banu Departments of Obstetrics and Gynecology and Pediatrics King Khalid University Hospital Riyadh, Saudi Arabia hypertension (13.6%). Otherwise no significant antenatal complications were noted. Nineteen sets of triplet pregnancies (86.4%) were delivered by lower segment cesarean section (LSCS); 15 were emergency and four were elective. There were seven perinatal deaths (12.3%) among the triplets who were delivered by C.S. compared to none in the vaginally delivered group. C o n c l u s i o n : Our study, though small, showed no significant difference in obstetric and neonatal outcomes among those triplet pregnancies managed with tocolysis and those who were not. Triplet pregnancies delivered by LSCS, whether elective or emergency, had higher neonatal mortality than those delivered vaginally, though the number was only three. This is due to the rarity of triplets and higher multiple pregnancies. We feel that future prospective multi-center studies are needed to answer the questions of the optimal antenatal management as well as the best and safest mode of delivery for triplet pregnancies and higher multi-fetal pregnancies. INTRODUCTION Triplet pregnancies are associated with an i n c reased risk of maternal and neonatal complications. The incidence of fetal and neonatal mortality and morbidity in triplets is higher than in singletons. Owing to the relatively low incidence of naturally occurring high order births, in general, and the infrequency of triplet pregnancies in specific, information on the best management of triplets appears to be inadequate. Many studies have been hampered because they had to span a number of years in order to accumulate a reasonable sample size. However, since the introduction of ovulation induction and assisted reproduction, the incidence of multiple gestation has risen substantially . Obstetricians are increasingly challenged with the questions of how to manage triplet p regnancies as they are often faced with limited information on which to base their management decision. On the basis of uncontrolled studies, routine cesarean section has been advocated to i m p rove the perinatal outcome, particularly for the second and third triplet [ 1 , 7 , 8 . At pre s e n t , h o w e v e r, there appears to be no substantial evidence to suggest that the advantages are s i g n i f i c a n t 9 , 1 0 . On the other hand, it has been recently shown that multi-fetal pregnancies place an important burden on medical care re s o u rc e s and carry much higher social and economic costs than singleton pre g n a n c i e s 11 , 1 2 . We report our experience in a university hospital on the management of 22 triplet pregnancies. The study evaluates the course of pregnancy with particular emphasis on prenatal management, mode of delivery and neonatal outcome. It also discusses the perinatal mortality and morbidity.