Challenge posed by multiple births

Globally, the incidence of twin births and multiple pregnancies have increased astronomically as a result of Assisted Reproductive Techniques. It is well known that Nigeria, the southern part of the country in particular, has the highest number of naturally occurring twin births world-wide, possibly due to peculiar diets in the area.

The introduction of ART has further increased multiple pregnancies in the country. This poses a lot of challenge to the care givers because of the increased number of complications and the significant physical, emotional and financial burden on the parents and family members.

Multiple gestations, such as twins and three or more fetuses, are by far the ones that have most complications than the single ones.

Early in the first trimester, pregnancy symptoms are exaggerated, such as Hyper emesis gravidarum, a condition that results in excessive vomiting and electrolyte imbalance, which necessitates hospital admission. Bleeding per vagina is part of the symptoms and signs of miscarriage are common.

Obstetric challenges associated with multiple and multiple pregnancies include increased incidence of pre-eclampsia, gestational diabetes, preterm labour and delivery, placenta praevia, placental abruption, anaemia, difficulty in breathing, malpresentation, intra uterine growth restriction, intra uterine fetal death and increased operative delivery.

A phenomenon known as “vanishing twin syndrome” – in which there is an arrested development of one or more embryos or fetuses and the continued development of the other, could occur. In other words, an apparent singleton in second trimester may end up as multiple, postpartum hemorrhage and, in some cases, death. The list is not exhaustive.

Most of the problems associated with multiple pregnancies include preterm birth and its attendant consequences.

There is increased perinatal morbidity and perinatal mortality from prematurity as a result of preterm birth. On the average, twins, triplets and quadruplets are delivered between 36 and 37 weeks, 33 and 34 weeks, as well as from 30 to 31 weeks, respectively. fetal lung matures by 34 weeks, hence the increased respiratory difficulties experienced by these fetuses born before this gestational age.

The emotional and financial burden associated with the period of pregnancy poses a lot of stress to the mother, spouse and family members, considering the cost of admission, delivery and the financial implications of the babies staying in a neonatal intensive care unit when they are delivered preterm.

It is important to constitute an obstetric/ neo-natal team, with an adequately staffed and equipped obstetric and neo-natal facility (to ensure prompt and efficient service delivery, as well as to manage these recognised complications of obstetric and neo-natal challenges highlighted above when they occur). Essentially, a neo-natal intensive care unit with an absolute zero tolerance for infection, a ventilator to support the respiratory difficulty often encountered in these babies and the use of surfactant, a sterile environment with dedicated neo-natologists and neo-natal nurses will greatly improve neo-natal outcome.

Find below a case report and a three-year review of ART and multiple births in Medical Art Center/Mart Medicare in Lagos, Nigeria.

Our records in Medical Art Center indicate that the incidence of multiple births was high for twins, triplets, quadruplets and quintuplets in our earlier data Nigerian Quarterly Journal of Hospital Medicine, 2012 when we transferred up to four embryos.

Current data indicate no more incidents of quadruplet and quintuplet since we started transferring three or fewer embryos following AFRH guidelines published in 2013. However, we still have a high incidence of twins and rarely triplets.

Case report:

Mrs. A.O, 32 year-old Nigerian, who had IVF + ET. Early Ultrasound revealed three gestational sacs at four weeks gestation. She was subsequently enrolled in our early pregnancy and high-risk obstetric monitoring unit where a weekly trans vaginal scan was done.

At nine weeks gestation, she had an episode of bleeding per vagina. She was reviewed and brought in for a bed rest. Ultrasound on admission revealed three viable fetuses with marginal bleeding at the placenta edge. She was advised to continue progesterone support for 13 weeks. The bleeding subsided completely after a few weeks on admission and she was subsequently discharged to be seen forthnightly in the antenatal clinic.

The patient’s antenatal care was uneventful. She was placed early on folic acid one and iron gluconate 300mg thrice daily. She had two doses of tetanus toxoids at 20 weeks and 24 weeks. She was also given sulphadoxine and pyrimethamine at 18 weeks and 24 weeks.

She was admitted for bed rest till delivery from 24 weeks. She wore pressure stockings throughout the admission period to prevent blood clots in the legs. On admission, complete blood count was done every four weeks so as to identify any form of abnormal blood parameter prevalent with higher order multiple gestation. At 28 weeks, her haemoglobin level was found to be 8g/dl. Blood film revealed mild iron deficiency anaemia. Stool for ova and parasite done for any worm infestation was negative.

She was also found to have difficulty in breathing at this time. However, her chest was clinically clear. She was subsequently transfused with two pints of packed cells. She also had two doses of 12mg dexamethasone 12 hourly.

Ultra sound scan was subsequently done fortnightly and fetal weights and growths were satisfactory. She had an emergency Caesarean Section at 33 weeks on account of preterm prelabour rupture of membrane and was successfully delivered of a set of triplets.

Baby A was 2.1kg, B 2. 1kg and C 1.8kg

The babies were delivered to the mother and there was no need to admit in neo-natal intensive care unit.

Mother was discharged home on the 5th day post-operative. She had five days course of thrombo prophylaxis with low molecular weight heparin.

Mother and babies are alive and well and this is strongly attributed to God’s help and the presence of skilled members of staff.

PUNCH.