Hello, rufus3!
You have asked a fascinating question. Much of the research on
triplets revolves around those born to mothers who have undergone
assistive fertilization. However, I have also found excellent
information pertaining to naturally-occuring multiple births.
SOME BASIC STATISTICS ON TRIPLET BIRTH RATES
=============================================
From "Multiple Births: Looking Beyond the Technology,"by Donna
Launslager, POMBA Canada.
http://www.iaac.ca/english/articles/multiplebirths.asp
"In a 1997, British study it was found that 25 - 30% of multiple
births occur naturally and the remaining 70 - 75% are a result of
fertility treatments. It is estimated that 60% of triplets, 90% of
quadruplets and 99% of quintuplets result from these treatments. The
incidence of triplets and higher order multiple births has risen even
more dramatically in other countries. Experts have concluded that the
widespread and largely unregulated use of ovulation induction drugs is
responsible for a significant number of dizygotic (fraternal twinning)
triplets and higher order multiples."
GESTATIONAL AGE, WEIGHT AND MORTALITY
======================================
From "Multiple births - their risks and how to prevent them. Science
Blog. July 2002 http://www.scienceblog.com/community/older/2002/F/20022305.html
A study synopsis:
"French fertility experts have carried out an analysis of nearly
25,000 pregnancies that has clearly demonstrated that babies who are
part of a multiple pregnancy face major risks to their life and
health."
"They studied 24,989 pregnancies resulting in 32,389 babies born using
reproductive technologies in France between 1986 and 1998. Main health
markers -- gestational age, weight and mortality - were compared for
single babies (18,235), twins (11,905) and triplets (1,772)."
"Lead investigator Professor Emile Papiernik from Hôpital Port Royal
in Paris, said that prematurity (under 37 weeks gestation) was
strongly related to multiple pregnancy, with nearly 87% of triplets
and over 42% of twins being premature compared with just over 8% of
single babies. More than 5% of babies were born before 33 weeks of
pregnancy with over 28% of these very premature babies being triplets,
nearly 8% being twins and less than 2% being singletons."
"Over 57% of the babies who were small for their gestational age were
triplets, nearly 43% were twins and just over 17% were singletons."
"Deaths in the period around birth were five times as frequent for
triplets as for single babies (a rate of nearly 40 per 1,000 compared
with under 8 per 1,000 for single babies)"
"Professor Papiernik concluded: "Multiple pregnancy is a very
important risk factor for the babies' health, particularly in assisted
reproduction where it represents over 40% of the newborns but 70% to
80% of the pathologies."
(Read original Abstract, titled "Multiple Pregnancy outcome after
assisted reporductive technology. A 25,000 deliveries Fivnat study,"
presented by Papiernik El, Sage J.C., Pouly J.L. , Mourouvin A., and
de Mouzon J. Humreprod Abstracts 200w MS. Num. V-0790, 07/04/02)
http://conf.eshre.com/PDF/O-014.pdf
TRIPLETS BORN TO OLDER MOTHERS MAY FACE LESS RISK
==================================================
From "Multiples Born to Older Moms Fare Same as or Better than Those
Born to Younger Moms." National Institute of Health. (Realeased
Friday, September 10, 2002)
http://www.nih.gov/news/pr/sep2002/nichd-10.htm
Findings in Brief:
------------------
"In contrast to the pattern seen with singleton births, twins born to
older mothers do not appear to have a greater risk of birth
complications than do twins born to younger mothers, according to a
recent study by researchers at the National Institute of Child Health
and Human Development (NICHD) and the University of Kansas.
** The study also found that triplets born to older mothers actually
fare better than triplets born to younger mothers."
Implications:
-------------
"Twin and triplet pregnancies are riskier than singleton pregnancies
at any age. ** However, the greater risks faced by infants born to
older mothers may be offset in twin and triplet pregnancies by the
fact that many older mothers pregnant with more than one baby conceive
through the use of assisted reproductive technology (ART).
"Multiples conceived through the use of ART are less likely than those
conceived naturally to be identical. This is important because
non-identical multiples have a smaller risk of poor birth outcomes
than do identical multiples. Additionally, mothers who conceive
multiples via ART tend to be monitored more closely than are mothers
who conceive multiples naturally."
Read more.....
==
For further discussion of the above research, see:
Age of Mom Not Risky for Twins, Triplets," by Ross Grant. Personal MD. 2002
http://www.personalmd.com/news/n0916055708.shtml
One important point brought out in this second article is that older
women are often using assistive technology to conceive. Their economic
status and particular concern for prenatal health may be different
than that of the mother who conceives multiples naturally.
"Zhang admits his research leaves out critical information about the
mothers of twins and triplets, since it focused mainly on the health
of the babies. Because of limitations in the records, the researchers
weren't able to evaluate all aspects of birth by older women."
(This is a factor that must be considered in the lack of risk.)
"Zhang's data, collected between 1995 and 1997 by the National Center
for Health Statistics, probably will reassure older mothers about the
safety of pregnancy. However, understanding why twins and triplets
born to older women are safer than had been thought is a complex
issue.
"The paradoxical phenomenon is due to a combination of medical and
socioeconomic factors," he says. For example, older women who use
assisted reproductive technology or drugs are usually monitored more
closely than younger mothers who conceive naturally. They are also
more likely to get counseling or prenatal tests than young women."
*** "Another reason is that natural twins and triplets, who often
come from a single egg splitting, generally share the same placenta or
amniotic sac. This leads to greater risks of them sharing infections,
defects or other complications. By contrast, twins and triplets born
through assisted technologies usually come from different eggs." ***
Impact of Paternal Age
-----------------------
"The relationship between paternal age and early mortality of triplets
in the United States." Salihu HM, Aliyu MH, Alexander GR. Am J
Perinatol. 2004 Feb;21(2):99-107.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15017474
Abstract only:
"We sought to determine the impact of advanced paternal age on the
birth outcomes of triplets in a retrospective cohort study on 15,156
triplets born in the United States from 1995 to 1997. The study group
comprised fathers aged > or = 40 years. Two control groups consisting
of mature (30 to 39 years) and younger (20 to 29 years) fathers were
constructed for comparison of main end points. We applied the
generalized estimating equation framework to obtain relative risk
estimates after capturing the effect of sibling correlations within
triplet clusters. Stillbirths were 35% and 26% higher among triplets
of mature and older men, respectively, whereas neonatal mortality was
28% and 23% lower among infants of mature and older fathers,
respectively, using younger fathers as the referent category. Although
only the relative risk for neonatal mortality comparing triplets of
mature and younger fathers was statistically significant, these
results constitute high indices that represent an important burden of
excess early mortality at the population level. Our findings
demonstrate a "shifting phenomenon" whereby a higher level of
intrauterine demise was compensated by a higher rate of extrauterine
survival among triplets born to older fathers."
OVERVIEW OF RISKS TO MOTHERS AND BABIES
========================================
From "Fact Sheet: Risks of In Vitro Fertilization." American Society
for Reproductive Medicine. (12/1996)
http://www.asrm.org/Patients/FactSheets/RisksIVF-Fact.pdf
"Multiple pregnancies are complicated by an increased risk of
premature labor, premature delivery, maternal hemorrhage, cesarean
delivery, pregnancy-induced high blood pressure, and gestational
diabetes."
==
From "Multiples: Twins, Triplets and Beyond." March of Dimes Fact
Sheet. October 2002 http://www.marchofdimes.com/professionals/681_4545.asp
"The more babies a woman carries at once, the greater her risk of complications."
"Close to 60 percent of twins, over 90 percent of triplets and
virtually all quadruplets and higher multiples are born preterm. The
length of gestation decreases with each additional baby. On average,
most singleton pregnancies last 39 weeks; for twins, 36 weeks; for
triplets, 32 weeks; for quadruplets, 30 weeks; and for quintuplets, 29
weeks."
"Most preterm multiples weigh less than 5 1/2 pounds (2,500 grams),
which is considered low birthweight. Low-birthweight babies,
especially those born before 32 weeks of gestation and/or weighing
less than 31/3 pounds (1,500 grams), are at increased risk of health
complications in the newborn period as well as lasting disabilities,
such as mental retardation, cerebral palsy and vision and hearing
loss."
"Women who are pregnant with multiples also face an increased risk of
pregnancy-related forms of high blood pressure (preeclampsia) and
diabetes. ** More than half of triplet pregnancies are complicated by
preeclampsia. ** With proper treatment, these disorders usually do
not pose a major risk to mother or baby."
"..when a woman is carrying three or more babies, a cesarean delivery
is usually recommended because it is safer for the babies."
Read more for recommendations concerning weight gain, activity and
medical visits...
=
From "Multiple Births." Human Fertilisation and Embryology Society.
http://www.hfea.gov.uk/PressOffice/Backgroundpapers/MultipleBirths
"Some prospective parents may see a multiple birth as a way of having
the family they want all in one go without the need for further IVF
treatment, but having twins or triplets can have serious health
consequences for both the mother and the children and long term
consequences for the family as a whole.
The medical risks for the mother are:
* increased risk of early and late miscarriage
* raised blood pressure
* pre-eclampsia
* higher rate of caesarean section
* increased chance of hospitalisation before the birth
The medical risks for the baby are:
* being born prematurely and needing intensive care
* dying before birth or in the first year of life
* physical disability and learning difficulties e.g. cerebral palsy
See Chart of Mortality Rates - England and Wales - 1988.
==
From "Management of Multiple Gestations," by Peter S. Bernstein, MD,
MPH. The Triplet Connection.
http://www.tripletconnection.org/gestations.html
"Dr. L.G. Keith,[1] Northwestern University, The Feinberg School of
Medicine, Center for Study of Multiple Birth, Chicago, Illinois,
started his presentation on iatrogenic multiple pregnancies and their
impact on prenatal care by stating that multiple gestations increase
markedly the incidence of preterm birth and low-birth-weight
deliveries and that this is directly related to the number of fetuses
present.
** "For example, the incidence of extreme preterm birth (delivery
between 20 and 27 weeks of gestation) for triplets is twice the rate
for twins and 12 times the rate for singleton gestations. These
differences are even more evident for infants delivering between 28
and 32 weeks of gestation; delivery at this point in pregnancy in
triplet gestations is 3.9 times greater than in twin gestations and
18.6 times greater than in singleton pregnancies."
** "This same dataset of infertility practices in France also
demonstrated that these higher rates of preterm birth and low birth
weight translated into higher rates of neonatal morbidity and
mortality among infants who were the products of multiple
gestations.[2] Those infants who survive to discharge who were born
prematurely or had low birth weight continue to require significant
outpatient clinical services, have recurrent hospitalizations, and are
at risk for long-term disabilities."
Risks to mother:
"Dr. Keith also noted that, in addition to the risks that multiple
gestation conferred on the newborns, there were also greater risks for
the pregnant woman. These include hypertensive disorders,
complications of treatments for preterm labor, and operative delivery;
each of these complications increase risks for maternal mortality.
Some authors have even suggested that these risks may be magnified in
iatrogenically conceived as compared with spontaneously conceived
multiple gestations. For example, Nyriati and colleagues[4] reported
on 232 spontaneously conceived multiple gestations and compared them
with 98 twin gestations and 16 triplet gestations that were all
medically induced pregnancies. They noted that the rate of
pregnancy-induced hypertension was higher among the twin pregnancies
that were induced compared with those that were spontaneous and that
the rate of preeclampsia was greater among those triplet pregnancies
that were induced compared with those that were spontaneously
conceived. Dr. Keith suggested that these trends in maternal
complications during pregnancy may worsen given increasing use of
reproductive technologies in older gravidas. Luke has observed that
the birth rate among women in their twenties has remained relatively
stable, while it is rising in women in their thirties and forties.
These women are at higher risk for complications during their
pregnancies, especially given that the proportion of multiple births
among these mothers has risen dramatically in the past 25 years."
==
From "IVF Treatment - Risks and other issues." IVF Australia.
http://www.ivf.com.au/htmlpages/ivf_risks.html#congenital
Of major concern is the 27 fold increased risk of * cerebral palsy in
triplets, * hence we rarely transfer 3 embryos."
==
From Abstract: "Multifetal gestation--maternal and perinatal outcome
of 112 pregnancies." Strauss A, Paek BW, Genzel-Boroviczeny O,
Schulze A, Janssen U, Hepp H. Fetal Diagn Ther. 2002
Jul-Aug;17(4):209-17.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12065948
"The aim of our study was to determine the maternal and neonatal
outcome of multifetal pregnancies under a conservative pregnancy
management."....
"A retrospective review of 112 multifetal pregnancies is presented.".....
RESULTS: "Triplets, quadruplets and quintuplets were delivered at a
mean gestational age of 31 + 5, 29 + 5 and 28 + 4 weeks, respectively.
The perinatal mortality was 14 for triplets and 36 for quadruplets. No
quintuplet died in the perinatal period. Respiratory distress syndrome
occurred in 23% of triplets, 65% of quadruplets and 75% of
quintuplets, intracranial hemorrhage was diagnosed in 14% of triplets,
15% of quadruplets and 10% of quintuplets and retinopathy of
prematurity was found in 10% of triplets, 9% of quadruplets and 25% of
quintuplets."
==
From "Multiple Births: Looking Beyond the Technology,"by Donna
Launslager, POMBA Canada.
http://www.iaac.ca/english/articles/multiplebirths.asp
"Since a significant percentage of multiple birth babies are born
prematurely and/or of low birth-weight, the babies are at a higher
risk of neonatal mortality, birth defects, SIDS and developmental
disabilities. Five times more likely, in fact."
"The average cost of neonatal care for a triplet infant is estimated
to be 24 times higher than a single baby, and a quadruplet infant 42
times more than a singleton. Furthermore, there are substantial
obstetrical health service costs associated with the pregnancy itself
(ie. prolonged hospital stay, ultrasound scans, cesarean section
operation etc)."
==
From "Multiple Gestations," by Jan Marie Benanti, M.D. / J. Gerald
Quirk, M.D., Ph.D. Legal Commentary: Gary D. Fox, J.D.
http://www.stfblaw.com/CM/Articles/articles26.asp
(This is a lengthy article which focuses primarily on twins, but has
some references to triplets and multiple births in general)
* Perinatal mortality for triplets is approximately 200 per 1000 births (2).
Birth Order
-----------
"Birth order, prematurity, and growth abnormalities are the risk
factors most commonly associated with poor outcome.
** As an example, the last-born infant of a triplet gestation carries
double the mortality risk of the firstborn infant; the middle birth
displays an intermediate risk (4).
Maternal Risks that increase with each fetus
---------------------------------------------
"Farooqui and coworkers reported a 13% occurrence of preeclampsia in
women pregnant with twins (25). Other studies have reported
hypertensive disorders in up to 37% of these women (41). Severe
preeclampsia is increased fivefold in primigravidas with twin
gestations (42). *** Hypertensive complications also become more
frequent as the number of fetuses increases (41)."
"Maternal anemia is seen four times as frequently and to a more severe
degree in multiple gestations compared to single gestations (43). This
anemia is related to the increased fetal requirements for iron and
folate as well as compensation for the exaggerated increase in
maternal plasma volume. Importantly, twin pregnancies are at increased
risk of maternal hemorrhage secondary to placenta previa, abruptio
placentae, uterine atony, and operative delivery."
"Other maternal complications observed with increased frequency in
multiple gestations include pyelonephritis and cholestasis (26). In
higher numbers of multiple gestations, the increased uterine volume
also results in pronounced maternal respiratory compromise, increased
reflux esophagitis, and chronic constipation. Varicosities and edema
of the vulva and lower extremities, resulting from obstruction of
venous return, are likewise more common in multiple pregnancies."
(See article for footnote references.)
==
Abstract Only:
From "A case of body stalk anomaly arising in the second baby of a
triplet pregnancy after in-vitro fertilization and embryo transfer."
Hirokawa S, Uotani H, Futatani T, Sasaki Y, Ogawa J, Sakai M, Tsukada
K, Saito S. Pediatr Surg Int. 2003 May;19(3):223-5. Epub 2003 Mar 29.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12811483
"We report a case of body stalk anomaly arising in the second baby of
a triplet pregnancy after in-vitro fertilization and embryo transfer
(IVF-ET). Body stalk anomaly or limb-body wall complex is a rare
congenital anomaly with a series of similar clinical manifestations
and poor prognosis."
===
Abstract:
"Neonatal outcome of triplet versus twin and singleton pregnancies: a
matched case control study." Ballabh P, Kumari J, AlKouatly HB, Yih M,
Arevalo R, Rosenwaks Z, Krauss AN. Eur J Obstet Gynecol Reprod Biol.
2003 Mar 26;107(1):28-36.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12593890
"During a 7-year period 116 sets of triplet pregnancies were reviewed.
Of 116 sets of live born triplets (348 newborns), 70.67% triplets were
born between 33- and 36-week gestation, 28.44% between 28 and 32 weeks
and 0.86% less than 28 weeks. Triplets were smaller in weight than
singletons but not twins. Apgar score, use of prenatal steroid and sex
ratio were similar in the three groups. Incidence of respiratory
distress syndrome (RDS), use of surfactant, infants requiring
intubation, pneumothorax, patent ductus arteriosus, sepsis,
intraventricular hemorrhage, periventricular leucomalacia, retinopathy
of prematurity, necrotizing enterocolitis, gastroesophageal reflux and
jaundice requiring phototherapy were not statistically different among
the three groups. Incidence of major and minor congenital anomalies,
percent neonatal intensive care unit (NICU) admissions, and mean
duration of NICU stay were also similar. There was no influence of
birth order on neonatal outcome of triplet pregnancy and outcome did
not significantly change over 7 years of the study period.
CONCLUSIONS: Triplets have a similar outcome to twins and singletons
when matched for gestational age. Since outcome is dependent on
gestational age, the closer the gestational age is to term the better
is the outcome."
STRESS ON THE PARENTS
=======================
From "Multiple Gestations," by Jan Marie Benanti, M.D. / J. Gerald
Quirk, M.D., Ph.D. Legal Commentary: Gary D. Fox, J.D.
http://www.stfblaw.com/CM/Articles/articles26.asp
"Because early loss and perinatal mortality are increased
significantly in multiple gestations, parents must often cope with the
loss of one or more of their offspring. Parents tend to regard each
member of the gestation as a separate individual early in gestation;
thus, when the loss of one fetus occurs, the grief can be as intense
as that which occurs with the loss of a single pregnancy (97)."
"As discussed previously, myriad antepartum and intrapartum
complications are possible in multiple pregnancies. Parents often
require assistance to cope with these problems and the related changes
in life-style. Frequent antepartum hospitalizations, the imposition of
strict bed rest, curtailing sexual activity, and other restrictions
may impose stress on the relationship between partners and other
family members."
"The intense intrapartum surveillance may make the parents feel "out
of control" of the birth process. A "surprise" cesarean delivery for
the onset of fetal distress or other obstetrical indications may
result in a sense of failure on the part of the mother and engender
regret or situational depression."
"Being the parents of multiple babies places serious demands on the
family. Many are familiar with the time demands and mental and
physical exhaustion of caring for just one infant. If these demands
are multiplied and complicated by health problems in one or more
neonate(s), the parents may experience tremendous stress. Groothius
and coworkers demonstrated that the incidence of child abuse was
approximately eight times higher in families with twins than in
matched single controls. The needs and demands of a multiple
gestation, superimposed on preexisting family problems, can be
devastating (98)."
(See article for footnote references.)
==
From "From "Multiple Births: Looking Beyond the Technology,"by Donna
Launslager, POMBA Canada. (no date)
http://www.iaac.ca/english/articles/multiplebirths.asp
"No parent can carry three babies at the same time, and only with
great difficulty can they feed or transport them on their own. An
Australian study found that mothers with infant triplets expends,
between herself and paid or volunteer assistance, an average of 197
hours per week out of a possible 168 on the care and management of her
children and home. These hours did not contemplate time in the day for
the mother to bathe, dress, sleep, eat, relax or even talk to her
husband."
"In 1988, The Parents of Multiple Births Association of Canada (POMBA)
prepared a first year cost comparison between a three person family
with one infant and families with triplets, quadruplets and
quintuplets. POMBA Canada's study revealed that the first year 'start
up' costs of having triplets are $8,000 higher than giving birth to a
single baby. Similarly, the cost of having quadruplets is $11,000
higher and quintuplets $16,000 higher than giving birth to a single
baby. The cost comparison did not allow for the cost of transportation
needs (example - purchase of a larger vehicle to properly facilitate
three, four or five infant car seats safely), housing needs or the
cost for part time help (P.O.M.B.A. 1989). With the extraordinary time
commitments involved in caring for three, four or five babies at once,
a high percentage of families with triplets and higher-order multiples
find it necessary to give up the security of a second income, yet
assume these extraordinary costs. All of these unique and overwhelming
stresses put the family unit at risk."
ADDITIONAL REFERENCES
=====================
"Selective reduction of multifetal pregnancies to twins improves
outcome over nonreduced triplet gestations." Smith-Levitin M, Kowalik
A, Birnholz J, Skupski DW, Hutson JM, Chervenak FA, Rosenwaks Z. Am J
Obstet Gynecol. 1996 Oct;175(4 Pt 1):878-82.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=8885740
=
"Loss of an Older Multiple." Center for Loss in Multiple Birth
http://www.climb-support.org/enabled/index.html?older
=
Also from "The Center for Loss in Multiple Birth.
http://www.climb-support.org/enabled/index.html?introjs&bothorall
"About one-third of our members have lost both or all of their babies.
While statistics seem not to be kept, we think that total loss is not
much less common than the loss of one twin, or loss of one or more but
not all triplets or higher. There seems to be a high rate of
miscarriage in the first trimester, and many more parents are aware of
it now because of the prevalence of early ultrasound. Besides
miscarriage, the most common cause of the death of both or all of the
babies seems to be prematurity, often between 20 and 24 weeks in what
had been good pregnancies, from a variety of causes or no known cause.
For some, it came after the difficult decision earlier to undergo
"selective reduction" (multifetal pregnancy reduction) in order to
give the remaining babies a better chance; and for others, after the
decision not to have reduction."
"Others have lost each of their triplets to prematurity at different
times over a period of months."
=
"Multiple births and fertility treatment." BBC News. Dec. 1998
http://news.bbc.co.uk/1/hi/health/medical_notes/239741.stm
=
"Early mortality among triplets in the United States: black-white
disparity." Salihu HM, Williams AT, McCainey TN, Kirby RS, Alexander
GR. Am J Obstet Gynecol. 2004 Feb;190(2):477-84.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14981393
===
I hope the information I have compiled is helpful. While research on
this subject could go on and on, I have tried to stay within the
confines of the price posted. If you would like to pursue another
aspect of this topic in the future, I would be happy to go into
further depth!
Sincerely,
umiat
Google Search Strateg
research on risks +triplets
"management of multiple gestations"
triplets AND birth defects
long term birth defects from multiple births OR triplets
PubMed search on "triplets" or "triplets and birth defects" |
