Multiple birth

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Triplet brothers at graduation. Identical triplets are extremely rare, something that occurs only once in every 500,000 births.

A multiple birth occurs when more than one fetus is carried to term in a single pregnancy. The preceding pregnancy is called a multiple pregnancy. Different names for multiple births are used, depending on the number of offspring. Common multiples are two and three, known as twins and triplets, respectively. These and other multiple births occur to varying degrees in most animal species, although the term is most applicable to placental species.

Multiple birth siblings are either monozygotic or polyzygotic. The former result from a single fertilized egg or zygote splitting into two or more embryos, each carrying the same genetic material (genes). Siblings created from one egg are commonly called identical. Since identical multiples share the same genetic material, they are always of the same sex. Polyzygotic (or fraternal) multiples instead result from multiple ova being ripened and released in the same menstrual cycle by a woman's ovaries, which are then fertilized to grow into multiples no more genetically alike than ordinary full siblings, sharing 50% of their genetic material. Multiples called "dizygotic" represent multiples from two eggs specifically. For example, a set of triplets may be composed of identical twins from one egg and a third non-identical sibling from a second egg.

The most common form of multiple births for humans is twins. Many placental species give birth to multiples as a matter of course, with the resulting group called a litter.

In the United States, it has been estimated that by 2011, 36% of twin births and 77% of triplet and higher-order births resulted from conception by assisted reproductive technology.[1]

Terminology[edit]

Fraternal twins at two weeks old. The technical term for "fraternal" is "polyzygotic".

Terms used for the order of multiple birth:

Higher order multiples[edit]

Identical triplets like these three sisters occur when a single fertilized egg splits in two and then one of the resulting two eggs splits again.

High orders of multiple births (three or more offspring in one birth) may result in a combination of fraternal (genetically different) and identical (genetically identical) siblings. The latter are also called super twins. For example, a set of triplets may consist of two identical siblings and one fraternal sibling. This happens when two eggs are fertilized and one of these subsequently divides into two fetuses. By analogy with monozygotic and dizygotic twins, such a combination is called dizygotic triplets. The Kübler triplets (see Elisabeth Kübler-Ross) were of this type.[2]

Identical triplets or quadruplets are very rare and result when the original fertilized egg splits and then one of the resultant cells splits again (for triplets) or, even more rarely, a further split occurs (for quadruplets).

Human multiple births[edit]

Fraternal twin sisters taking a nap. Nonidentical twins, the most common kind of multiple birth among humans, occur in about 1 out of every 80 pregnancies.

Twins are by far the most common multiples born live. Multiple births of as many as eight babies have been born alive, the first set on record to the Chukwu family in Texas in 1998; one died and seven survived. In 2009, a second set, the Suleman octuplets, was born in Bellflower, California. To date, all eight have survived.[3][4]

There have been a few sets of nonuplets (nine) in which a few babies were born alive, though none lived longer than a few days. There have been cases of human pregnancies that started out with ten, eleven, twelve or fifteen fetuses, but no instances of live births. The pregnancies of the 10, 11 and 15 fetuses have all resulted from fertility medications and assisted reproductive technology (ART). However there has been one documented case when 12 fetuses were conceived naturally.[5]

Multiple pregnancies in humans are usually born prior to 38 weeks of gestation[dubious ], the average length of pregnancy. Thirty-six weeks is average for twin births, thirty-two weeks for triplets and thirty weeks for quadruplets.

Quadruplets[edit]

Quadruplets are much rarer than twins or triplets. As of 2007, there were approximately 3500 sets recorded worldwide. Quadruplet births are becoming increasingly common due to fertility treatments. There are around 70 sets of all-identical quadruplets worldwide. Many sets of quadruplets contain a mixture of identical and fraternal siblings, such as three identical and one fraternal, two identical and two fraternal, or two pairs of identicals. One famous set of identical quadruplets was the Genain quadruplets, all of whom developed schizophrenia.

Quadruplets and quintuplets are sometimes referred to as "quads" and "quins" in Britain or "quints" in the USA.[6]

Causes and frequency[edit]

The frequency of N multiple births from natural pregnancies has been give as approximately 1:89N-1 (Hellin's law) and traditionally as about 1:80N-1 (1:80 means 1 time in 80).[7] This gives:

North American dizygotic twinning occurs about once in 83 conceptions, and triplets about once in 8000 conceptions. US figures for 2010 were:[8][9]

The Canadian Dionne sisters, seen in this 1947 photograph, were the first quintuplets known to survive infancy.

Human multiple births can occur either naturally (the woman ovulates multiple eggs or the fertilized egg splits into two) or as the result of infertility treatments such as IVF (several embryos are often transferred to compensate for lower quality) or fertility drugs (which can cause multiple eggs to mature in one ovulatory cycle).

For reasons that are not yet known, the older a woman is, the more likely she is to have a multiple birth naturally. It is theorized that this is due to the higher level of follicle-stimulating hormone that older women sometimes have as their ovaries respond more slowly to FSH stimulation.[10]

The number of multiple births has increased over the last decade. For example, in Canada between 1979 and 1999, the number of multiple birth babies increased 35%. Before the advent of ovulation-stimulating drugs, triplets were quite rare (approximately 1 in 8000 births) and higher-order births much rarer still.[citation needed] Much of the increase can probably be attributed to the impact of fertility treatments, such as in-vitro fertilization. Younger patients who undergo treatment with fertility medication containing artificial FSH, followed by intrauterine insemination, are particularly at risk for multiple births of higher order.

The Gosselin sextuplets with their parents and sisters, cover of KoreAm, May 2008

Certain factors appear to increase the likelihood that a woman will naturally conceive multiples. These include:

The increasing use of fertility drugs and consequent increased rate of multiple births has made the phenomenon of multiples more frequent and hence more visible. In 2004 the birth of sextuplets to Pennsylvania couple Kate and Jon Gosselin helped them to launch their television series, originally Jon & Kate Plus 8 and (following their divorce) Kate Plus 8, which became the highest-rated show on the TLC network.

Risks[edit]

Premature birth and low birth weight[edit]

Babies born from multiple-birth pregnancies are much more likely to result in premature birth than those from single pregnancies. 51% of twins and 91% of triplets are born preterm, compared to 9.4% in singletons.[11] 14% of twins and 41% of triplets are even born very preterm, compared to 1.7% in singletons.[11]

The preterm births also result in multiples tending to have a lower birth weight compared to singletons.

Some evidence[who?] indicates that only 1.10% of singletons are born with a very low birth weight and 10.12% twins and 31.88% triplets were found to be born with very low birth weight. This Study[who?] was conducted by looking at the statistics from the U.S. Natality Files (5).

Among the exceptions are the Kupresak triplets of Mississauga, Ontario, Canada; their combined weight at birth in 2008, of 17 lbs, 2.7 ounces, set a world record.[12]

Cerebral palsy[edit]

Cerebral palsy is more common among multiple births than single births, being 2.3 per 1,000 survivors in singletons, 13 in twins, and 45 in triplets in North West England.[13] This is likely a side effect of premature birth and low birth weight.

Incomplete separation[edit]

Multiples may become monochorionic, sharing the same chorion, with resultant risk of twin-to-twin transfusion syndrome. Monochorionic multiples may even become monoamniotic, sharing the same amniotic sac, resulting in risk of umbilical cord compression and entanglement. In very rare cases, there may be conjoined twins, possibly impairing function of internal organs..

Mortality rate (stillbirth)[edit]

Multiples are also known to have a higher mortality rate. It is more common for multiple births to be stillborn, while for singletons the risk is not as high. A literary review on multiple pregnancies shows a study done on one set each of septuplets and octuplets, two sets of sextuplets, 8 sets of quintuplets, 17 sets of quadruplets, and 228 sets of triplets. By doing this study, Hammond found that the mean gestational age (how many weeks when birthed) at birth was 33.4 weeks for triplets and 31 weeks for quadruplets. This shows that stillbirth happens usually 3–5 weeks before the woman reaches full term and also that for sextuplets or higher it almost always ends in death of the fetuses.[14] Though multiples are at a greater risk of being stillborn, there is inconclusive evidence whether the actual mortality rate is higher in multiples than in singletons.

Prevention in IVF[edit]

Today many multiple pregnancies are the result of in vitro fertilisation (IVF). In a study in 1997 of 2,173 embryo transfers performed as part of in vitro fertilisation (IVF), 34% were successfully delivered pregnancies.[15] The overall multiple pregnancy rate was 31.3% (24.7% twins, 5.8% triplets, and .08% quadruplets).[15] Because IVFs are producing more multiples, a number of efforts are being made to reduce the risk of multiple births- specifically triplets or more. Medical practitioners are doing this by limiting the number of embryos per embryo transfer to one or two. That way, the risks for the mother and fetuses are decreased.

The appropriate number of embryos to be transferred depends on the age of the woman, whether it is the first, second or third full IVF cycle attempt and whether there are top-quality embryos available. According to a guideline from The National Institute for Health and Care Excellence (NICE) in 2013, the number of embryos transferred in a cycle should be chosen as in following table:[16]

AgeAttempt No.Embryos transferred
<37 years1st1
2nd1 if top-quality
3rdNo more than 2
37–39 years1st & 2nd1 if top-quality
2 if no top-quality
3rdNo more than 2
40–42 years2

Also, it is recommended to use single embryo transfer in all situations if a top-quality blastocyst is available.[16]

Management of multiple pregnancy[edit]

Selective reduction[edit]

Another procedure that the medical world is using today is known as selective reduction, i.e. the termination of one or more, but not all, of the fetuses. This is often done in pregnancies with multiple gestations to increase the likelihood that one child may live a healthy life. Armour [17] found by looking at a review of a series of 1,000 selective reduction cases, there has had a loss rate of 5.4% in pregnancies. Many of the losses (15%) occurred within 4 weeks of the procedures and more than 50% occurred after 8 weeks. This suggests that the reduction was successful at reducing the embryos from multiple gestations to single.

Though selective reduction seems to be working, mothers of multiples who undergo this procedure are at a higher risk of miscarrying compared to that of an unreduced multiple pregnancy. A study done by looking at 158 pregnant women who underwent selective reduction from higher order multiples to twins showed that the mother had a 10.6% chance of miscarriage. Mothers of twin pregnancies without reduction only had a 9.5% chance of miscarriage. Antsaklis [18] shows that there is a small increase in mortality for reduced twin pregnancies versus unreduced twin pregnancies.

Competition among fertility clinics does not appear to increase rates of multiple births from fertility treatment by promoting more aggressive embryo transfer decisions.[19]

Cesarean section or vaginal delivery[edit]

A study in 2013 involving 106 participating centers in 25 countries came to the conclusion that, in a twin pregnancy of a gestational age between 32 weeks 0 days and 38 weeks 6 days, and the first twin is in cephalic presentation, planned Cesarean section does not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal disability, as compared with planned vaginal delivery.[20] In this study, 44% of the women planned for vaginal delivery still ended up having Cesarean section for unplanned reasons such as pregnancy complications. In comparison, it has been estimated that 75% of twin pregnancies in the United States were delivered by Cesarean section in 2008.[21] Also in comparison, the rate of Cesarean section for all pregnancies in the general population varies between 40% and 14%.[22]

Neonatal intensive care[edit]

Multiple-birth infants are usually admitted to neonatal intensive care immediately after being born. The records for all the triplet pregnancies managed and delivered from 1992-1996 were looked over to see what the neonatal statistics were. Kaufman [23] found from reviewing these files that during a five-year period, 55 triplet pregnancies, which is 165 babies, were delivered. Of the 165 babies 149 were admitted to neonatal intensive care after the delivery.

Cultural aspects[edit]

Certain cultures consider multiple births a portent of either good or evil.[24]

Mayan culture saw twins as a blessing, and was fascinated by the idea of two bodies looking alike. The Mayans used to believe that twins were one soul that had fragmented.

In Ancient Rome, the legend of the twin brothers who founded the city (Romulus and Remus) made the birth of twin boys a blessing, while twin girls were seen as an unlucky burden, since both would have to be provided with an expensive dowry at about the same time.

In Greek mythology, fraternal twins Castor and Polydeuces, and Heracles and Iphicles, are sons of two different fathers. One of the twins (Polydeuces, Heracles) is the illegitimate son of the god Zeus; his brother is the son of their mother's mortal husband. A similar pair of twin sisters are Helen (of Troy) and Clytemnestra (who are also sisters of Castor and Polydeuces). The theme occurs in other mythologies as well, and is called superfecundation.

In certain medieval European chivalric romances, such as Marie de France's Le Fresne, a woman cites a multiple birth (often to a lower-class woman) as proof of adultery on her part; while this may reflect a widespread belief, it is invariably treated as malicious slander, to be justly punished by the accuser having a multiple birth of her own, and the events of the romance are triggered by her attempt to hide one or more of the children.[25] A similar effect occurs in the Knight of the Swan romance, in the Beatrix variants of the Swan-Children; her taunt is punished by giving birth to seven children at once, and her wicked mother-in-law returns her taunt before exposing the children.[26]

See also[edit]

References[edit]

  1. ^ Kulkarni, A. D.; Jamieson, D. J.; Jones, H. W.; Kissin, D. M.; Gallo, M. F.; MacAluso, M.; Adashi, E. Y. (2013). "Fertility Treatments and Multiple Births in the United States". New England Journal of Medicine 369 (23): 2218. doi:10.1056/NEJMoa1301467.  edit
  2. ^ See Gill, Derek; Quest: The Life of Elisabeth Kübler Ross; p. 2 ISBN 0-06-011543-2
  3. ^ US woman gives birth to octuplets, BBC
  4. ^ Octuplets born in Bellflower, LA Times
  5. ^ Facts About Multiples
  6. ^ Oxford English Dictionary, 2nd ed.: "quada" used for "quadruplets" and and "quins" for "quintuplets" in various senses
  7. ^ Melissa Bush, MD, & Martin L. Pernoll, MD (2006). "Multiple Pregnancy". Pregnancy Health Center -Multiple Pregnancy (McGraw Hill Professional). Retrieved 2007-06-20. 
  8. ^ National Center for Health Statistics - Multiple Births
  9. ^ National Vital Statistics Reports, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Volume 61, Number 1 , August 28, 2012, Births: Final Data for 2010
  10. ^ Beemsterboer SN, Homburg R, Gorter NA, Schats R, Hompes PG, Lambalk CB. The paradox of declining fertility but increasing twinning rates with advancing maternal age. Hum Reprod. 2006 Jun;21(6):1531-2. Epub 2006 Feb 23. PubMed PMID 16497698.
  11. ^ a b Alexander G., Kogan M., Martin J., and Papiernik E. (1998). What are the fetal growth patterns of singletons, twins, and triplets in the United States? Clinical Obstetrics and Gynecology, 41(1), 114-125. Note: This study was done by looking at the 1991-1995 U.S. Natality Files, which were received from the National Center for Health Statistics
  12. ^ Le, Julia (26 July 2011). "Scale-tipping triplets set world record". Mississauga News (Mississauga ON). Retrieved 26 July 2011. ; note that the record wasn't confirmed until July 2011.
  13. ^ Pharoah PO., and Cooke T. (1996). Cerebral palsy and multiple births [abstract]. Archives of Disease in Childhood-Fetal and Neonatal Edition, 75, 174-177. Note: They conducted a study by looking at the registered births of babies born with cerebral palsy during the periods of 1982-1989 in the counties of Merseyside and Cheshire.
  14. ^ Hammond K. (1989). Multifetal pregnancy reduction. Journal of Obstetrics and Gynecological and Neonatal Nursing, 27(3), 338-343
  15. ^ a b Elsner C., Tucker M., Sweitzer C., Brockman W., Morton P., Wright G., and Toledo A. (1997). Multiple pregnancy rate and embryo number transferred during in vitro fertilization. American Journal of Obstetrics and Gynecology, 177(2), 350-355
  16. ^ a b Fertility: assessment and treatment for people with fertility problems. NICE clinical guideline CG156 - Issued: February 2013
  17. ^ Armour K., and Callister L. (2005). Prevention of triplets and high order multiples: Trends in reproductive medicine. Journal of Perinatal and Neonatal Nursing, 19, 103-111
  18. ^ Antsaklis A., Drakakis P., Vlazakis G., and Michalas S. (1998). Reduction of multifetal pregnancies to twins does not increase obstetrics or perinatal risks. Human Reproduction, 14(5) 1338-1340
  19. ^ Henne MB, Bundorf MK (April 2010). "The effects of competition on assisted reproductive technology outcomes". Fertil. Steril. 93 (6): 1820–30. doi:10.1016/j.fertnstert.2008.02.159. PMID 18442821. 
  20. ^ Barrett, J. F. R.; Hannah, M. E.; Hutton, E. K.; Willan, A. R.; Allen, A. C.; Armson, B. A.; Gafni, A.; Joseph, K. S.; Mason, D.; Ohlsson, A.; Ross, S.; Sanchez, J. J.; Asztalos, E. V.; the Twin Birth Study Collaborative Group (2013). "A Randomized Trial of Planned Cesarean or Vaginal Delivery for Twin Pregnancy". New England Journal of Medicine 369 (14): 1295–1305. doi:10.1056/NEJMoa1214939. PMID 24088091.  edit
  21. ^ Lee, H. C.; Gould, J. B.; Boscardin, W. J.; El-Sayed, Y. Y.; Blumenfeld, Y. J. (2011). "Trends in Cesarean Delivery for Twin Births in the United States". Obstetrics & Gynecology 118 (5): 1095. doi:10.1097/AOG.0b013e3182318651.  edit
  22. ^ Women can choose Caesarean birth - BBC article by James Gallagher. 2011.
  23. ^ Kaufamn GE., Malone FD., Harvey-Wilkes KB., Chelmow D., Penzias AD., and D’ Alton ME. (1998). Neonatal morbidity and mortality associated with triplet pregnancy. Obstetrics and Gynecologists, 91, 342-348
  24. ^ "Korea's 'lucky' triplets seized". Herald Sun (Fairfax). 2003-03-30. 
  25. ^ Laura A. Hibbard, Medieval Romance in England p295, 244 New York Burt Franklin,1963
  26. ^ Laura A. Hibbard, Medieval Romance in England p239, 243 New York Burt Franklin,1963

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