European Journal of Cardiovascular Medicine

The rarity of plural birth in women and the increased danger to the mother and offspring in these circumstances renders such an event in a certain limited sense a disease or an abnormality"- Mathew Duncan, 1865.

Multifetal pregnancies have been celebrated throughout human history. Multifetal pregnancy refers to the development of more than one fetus in the uterus at the same time. Twins are two fetuses developing in the uterus at the same time, whereas triplets, quadruplets, pentuplets, and so on vary in the number of fetuses.¹

Multifetal pregnancies, an object of fascination from before the stories of Cain and Abel, Romulus and Remus and in Hindu mythology the twins Luv and Kush are the sons of Lord Ram, continue to present a unique challenge for clinicians today.² Multifetal births are far more common today than they were previously. According to the US Department of Health and Human Services, the rate of twin birth has climbed by more than 75% since 1980, with triplet, quadruplet, and high-order multifetal births increasing even faster. Multifetal births are becoming increasingly common nowadays, because more women are undergoing infertility treatment, which increases the risk of multifetal pregnancy.³ However, since the first publication in 1998 of the American Society for Reproductive Medicine’s (ASRM’s) Guidelines on Number of Embryos Transferred, the number of treatment-related pregnancies with triplets or more has decreased dramatically.⁴

The incidence of multifetal frequency is approximately 1 per 89 live births, but there is significant variation amongst different countries and different populations.

Hellin’s Rule states that the following incidences of multifetal pregnancy:⁵

• Twins- 1:89
• Triplets- 1:89²
• Quadruplets- 1:89³
• Quintuplets- 1:89⁴

Multifetal pregnancy is also connected with significantly higher maternal morbidity and health-care expenses. Women who have Multifetal are roughly 6 times more likely to be hospitalised. Medical complications are more common in women with multifetal gestations than with singleton gestations. These include abortion, hyperemesis, gestational diabetes mellitus, hypertensive disorders of pregnancy, anaemia, preterm labor, preterm premature rupture of membranes, placental abruption, pyelonephritis, and postpartum haemorrhage, postpartum depression. Other complications are fetal malpresentation, polyhydramnios, cord prolapse, cord entanglement, urinary tract infection, retained second twin and operative vaginal delivery.  More frequent and serious complication increases as the number of foetus increase. Hypertensive disorder of pregnancy are more common in women who are carrying multiple foetuses. Singletons have a 6.5% chance of developing hypertensive problems, twins have a 12.7% chance, and triplets have a 20.0% chance.⁶

Keeping the above facts in mind a prospective observational study is be conducted in the Obstetrics and gynecology department of Jorhat Medical College & hospital, in order to improve the maternal outcomes for patients with multifetal pregnancies, the current study will analyze the maternal morbidity associated with multifetal gestation. It will also highlight the importance of routine antenatal checkups.

AIMS AND OBJECTIVES

• To determine the maternal outcome in multifetal gestation.

The prospective study was carried in the department of obstetrics and gynaecology, Jorhat Medical College and Hospital, Assam from August, 2023 to January, 2024 included 50 women with multifetal gestation with gestational age of 28 weeks or more. All cases of multifetal gestation either admitted from antenatal clinics or from emergency labour room were included in the study.

INCLUSION CRITERIA –

• Primigravida or Multigravida.
• Booked and unbooked cases.
• Women admitted in Labour room or Antenatal ward with Clinical or ultrasound diagnosis of multifetal pregnancy after 28 weeks of gestation.
• Willing to participate in the study.

EXCLUSION CRITERIA-

• Singleton pregnancy.
• Pregnant women of less than 28 weeks of gestation.
• Not willing to participate in the study.

There were 50 multifetal pregnancy deliveries amongst 4744 total deliveries in the specific time period out of which 49 were twin pregnancies and 1 was triplet pregnancy. Twin pregnancy is most common multifetal pregnancy, incidence decreases with further higher order multifetal pregnancies.

Incidence of multifetal pregnancies in our hospital is 1.05%

Following results were analysed at the end of the study.

Table-1

Age wise Distribution of multifetal pregnancies

Table-1 shows majority of women are in age group of 21-29 years, accounting for 62% followed by 18% in the age group of 30-39 years.

Table-2

Gestational age wise distribution of Multifetal Pregnancies

Table-2 shows that most of the women at the time of admission were in 33-36 weeks which is 54% and followed by 42% in ³37 weeks. Thus the majority of multifetal gestation delivered at less than 36 weeks (58%), which is earlier than singleton pregnancies, while only one triplet in our study delivered prematurely at 33 weeks.

Figure-1

Distribution of women according to ANC status

In this current study among 50 cases, most of the women were unbooked which is 80% and rest were Booked showed in Fig-1

Figure-2

Distribution of by Types of multifetal gestation

In our study we found 49 twin pregnancies and only 1 triplet pregnancy out of 50 showed in Fig-2.

Table-3

Parity wise distribution of women with multifetal pregnancies

In our study maximum number of women were primigravida which is 62% followed by second parity and third parity which is depicted in Table-3.

Figure-3

Distribution of women based on mode of conception

In Fig-3 we found that 88% women conceive spontaneously and 12% women conceive after Infertility treatment.

Table-4

Distribution of women according to chorionicity

From above Table-4 in respect with chorionicity most common type of placentation among twin pregnancies were diachorionic diamniotic which is 64% followed by monochorionic diamniotic 20% and monochorionic monoamniotic being the least common. The triplet in our study had Dichorionic triamniotic placentation.

Table-5

Table:5A- Distribution of women according to fetal presentation in labour

Table:5 B- In Triplet distribution of fetal presentation in labour

In our study cephalic-cephalic fetal presentation is most common presentation at the time of delivery which is 38% followed by Breech-Vertex 22% and transverse-transverse only 2%. In the triplet all the 3 fetuses are in transverse lie.

Table-6

Table:6A- Distribution by mode of delivery in twins

Table:6B- Distribution by Mode of delivery in triplet

Figure-5

From the above Table 6A, 6B in twin pregnancies 19 twin-1 and 18 twin-2 had vaginal delivery and 30 twin-1, 31 twin-2 delivered by LSCS and only one triplet which delivered by LSCS. Only one case 1^st baby delivered Vaginally and 2^nd baby delivered by Caesarean section. Fig-5 showed out of 50 women 62% underwent LSCS and 38% delivered by vaginally.

Table:7

Distribution of women by indication for LSCS

From above Table-7 we found that malpresentation is the most common cause for LSCS accounting 43.6% followed by fetal distress (19.3%) and patient is previous LSCS also account for 12.9%, APH contributes for 9.6% The presence of breech or transverse lie in any of the fetus increase the chance of LSCS. Only 1 patient underwent LSCS for cord prolapse in our study.

Figure-6

Distribution of maternal complications in multifetal pregnancies

From the above figure-6 it is determined that among maternal risk in multifetal anaemia 62% and Preterm labour 58% are the most common complication , 14% women had Gestational Hypertensive disorder out of which 1 patient had eclampsia, PPROM and PROM complicated for 14% and 12% respectively, APH account for 6% cases. One patient with dichorionic twin pregnancy had single intrauterine fetal demise at 1^st trimester and delivered one healthy fetus and one dead fetus of weighing 300grms at 3^rd trimester.

Table-9

Intrapartum maternal complications encountered among patients and outcome

From the above table-9 there is no maternal death in our study. One patient underwent Hysterectomy for Placenta accrete spectrum and 1 patient need ICU admission. 14 patient out of 50 received blood transfusion.

The current study included 49 twin pregnancies and 1 triplet, resulting in an incidence rate of 1.03% and 0.02% respectively. In 2015, Rajshree D K et al. documented that the occurrence of twin pregnancies was 1.35%, whereas the occurrence of triplet pregnancies was 0.02%⁷. The incidence of twins was found to be 1.7% by Sanjay P et al in 2016⁸.

The study revealed that 62% of women with multifetal pregnancy were between the ages of 21 to 29. According to Shivali B et al.'s research, 56% of the participants were between the ages of 21 and 30, which is consistent with our own findings⁹. In our study 54% of women gave birth within the gestational period of 33-36 weeks. Gajera et al found similar outcomes, with the majority of patients (46%) delivering babies between 33 and 36 weeks of gestation¹⁰. In this study, 80% of the cases were unbooked, while the remaining 20% were booked instances. A study conducted by Pandey MR et al in 2015 found that 95.7% of the patients were unbooked¹¹. Our study found that the majority of women, specifically 62%, were primipara. These results align with the findings of Sahu B et al, who reported that 50.7% of cases were primipara¹². Our analysis found that 64% of the instances involved dichorionic-diamniotic twins, 20% involved monochorionic-diamniotic twins, and 6% involved monochorionic-monoamniotic twins. The results of our investigation are similar to those of Erdemoglu et al. which demonstrated that 69.3% of cases were dichorionic-diamniotic¹³. In our study vertex-vertex presentation, accounting for 38% of cases. Gajera et al. (60%) and Yeasmin et al. (48.21%) found that the most frequent way the condition was presented was at the vertex^10,14. In this study was caesarean section, accounting for 62% of cases. The study done by Shivali et al. found that 54% of participants underwent a caesarean section⁹. Our research revealed that malpresentation is the primary factor leading to the need for a lower segment caesarean section (LSCS), accounting for 43.6% of cases. This is consistent with the results reported by Bhalla S et al. (48.14%)⁹. In our analysis, the most prevalent maternal problems were anaemia (62%), pre-term labour (58%), premature rupture of membranes (PPROM) (14%), rupture of membranes (PROM) (12%), hypertensive disorders of pregnancy (14%). In the study conducted by Bangal et al, the prevalence of anaemia was found to be 84%. Our findings are similar to this. The prevalence of anaemia was 37% in the Hada et al study, 39.88% in the Yeasmin et al trial, and 26% in the Chowdhury et al investigation^14,15,16. The occurrence of anaemia was 7% in the study conducted by Gajera et al and 9.4% in the study conducted by Spellacy et al^10,17. The rates of preterm birth were higher in the study conducted by Gajera et al. (74%) and Bangal et al. (88%). Yeasmin et al. (51.44%) and Chowdhury et al. (43.4%) also found that preterm labor is a common issue among mothers, which aligns with previous studies^10,14,15,18. Among the 50 instances examined in our study, 5 patients (10%) experienced postpartum haemorrhage. Two of these patients had low lying placenta, while one patient had placenta accreta spectrum. Simi et al. which reported a rate of 17%. Chowdhury et al. also found a comparable occurrence of postpartum haemorrhage (PPH) in pregnancies with multiple fetuses, specifically 18.9%^18,19.

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