Prediction of Time to Delivery Week-by-Week in Women with a Triplet Pregnancy

Abstract

Objective Some clinicians advise prophylactic administration of antenatal steroids for fetal lung maturation in women with a triplet pregnancy. However, the effect of corticosteroids is limited to 10 to 14 days after administration. The aim of this study was to assess the natural course of triplet pregnancies to allow a better anticipation for administration of corticosteroids.

Study Design We collected data on all triplet pregnancies in the Netherlands from 1999 to 2007 from the Netherlands Perinatal Registration. We calculated time to delivery, the risk of delivery in 2-week intervals at different gestational ages, and the time frame between hospital admission and delivery of the first child.

Results Median gestational age at delivery of 494 women with a triplet pregnancy was 33⁺⁴ weeks (interquartile range of 31–35⁺¹ weeks). Twenty-one women (4.3%) delivered between 22 and 24 weeks and 146 women (29.6%) delivered before 32 weeks. At a gestational age of 24 weeks, the chance to deliver within the next week was 0.6%. For 26, 28, 30, 31, and 32 weeks, these risks were 2.4, 2.5, 8.1, 7, and 16.7%, respectively.

Conclusion Before 32 weeks of gestation, prophylactic administration of steroids is not indicated as the risk to deliver within 7 days is < 10%.

Keywords

triplet pregnancy - preterm birth - antenatal steroid treatment - neonatal outcome

Note

This study was presented as a poster presentation at the 32nd World Congress of the Society of Maternal Fetal Medicine (SMFM), Dallas, 2012.

• References

• 1 Kupka MS, Ferraretti AP, de Mouzon J , et al; European IVF-Monitoring Consortium, for the European Society of Human Reproduction and Embryology. Assisted reproductive technology in Europe, 2010: results generated from European registers by ESHRE. Hum Reprod 2014; 29 (10) 2099-2113
• 2 Luke B, Brown MB. Maternal morbidity and infant death in twin vs triplet and quadruplet pregnancies. Am J Obstet Gynecol 2008; 198 (4) 401.e1-401.e10
• 3 Blondel B, Kogan MD, Alexander GR , et al. The impact of the increasing number of multiple births on the rates of preterm birth and low birthweight: an international study. Am J Public Health 2002; 92 (8) 1323-1330
• 4 Tandberg A, Bjørge T, Nygård O, Børdahl PE, Skjaerven R. Trends in incidence and mortality for triplets in Norway 1967-2006: the influence of assisted reproductive technologies. BJOG 2010; 117 (6) 667-675
• 5 Revello R, De la Calle M, Moreno E, Duyos I, Salas P, Zapardiel I. Maternal morbidity on 147 triplets: single institution experience. J Matern Fetal Neonatal Med 2013; 26 (2) 193-196
• 6 Petterson B, Nelson KB, Watson L, Stanley F. Twins, triplets, and cerebral palsy in births in Western Australia in the 1980s. BMJ 1993; 307 (6914) 1239-1243
• 7 Zanconato G, Poggi S, Ruffo R, Gazzoni A, Padovani EM, Franchi M. Antepartum management and neonatal outcome of triplet pregnancies. Arch Gynecol Obstet 2005; 271 (4) 320-324
• 8 Ziadeh SM. The outcome of triplet versus twin pregnancies. Gynecol Obstet Invest 2000; 50 (2) 96-99
• 9 Kraemer B, Becker S, Kagan KO , et al. Twenty-six triplet pregnancies: a retrospective analysis. Arch Gynecol Obstet 2009; 279 (4) 455-461
• 10 Blickstein I. How and why are triplets disadvantaged compared to twins?. Best Pract Res Clin Obstet Gynaecol 2004; a; 18 (4) 631-644
• 11 Weissman A, Ulanovsky I, Burke Y, Makhoul IR, Blazer S, Drugan A. Triplet pregnancies—a three-decade perspective: do we fare better?. Eur J Obstet Gynecol Reprod Biol 2013; 170 (1) 82-84
• 12 Joseph KS, Marcoux S, Ohlsson A , et al; Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System. Preterm birth, stillbirth and infant mortality among triplet births in Canada, 1985-96. Paediatr Perinat Epidemiol 2002; 16 (2) 141-148
• 13 Roberts D, Dalziel S. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2006; (3) CD004454
• 14 Ramin KD, Ogburn Jr PL, Mulholland TA, Breckle RJ, Ramsey PS. Ultrasonographic assessment of cervical length in triplet pregnancies. Am J Obstet Gynecol 1999; 180 (6 Pt 1) 1442-1445
• 15 To MS, Skentou C, Cicero S, Liao AW, Nicolaides KH. Cervical length at 23 weeks in triplets: prediction of spontaneous preterm delivery. Ultrasound Obstet Gynecol 2000; 16 (6) 515-518
• 16 Poggi SH, Ghidini A, Landy HJ, Alvarez M, Pezzullo JC, Collea JV. Predictive value of transvaginal cervical length in triplet pregnancies for spontaneous preterm delivery at < or = 32 weeks. J Matern Fetal Neonatal Med 2002; 12 (1) 46-49
• 17 Fox NS, Rebarber A, Roman AS, Klauser CK, Peress D, Saltzman DH. Combined fetal fibronectin and cervical length and spontaneous preterm birth in asymptomatic triplet pregnancies. J Matern Fetal Neonatal Med 2012; 25 (11) 2308-2311
• 18 Elimian A, Figueroa R, Nigam S, Verma U, Tejani N, Kirshenbaum N. Perinatal outcome of triplet gestation: does prophylactic cerclage make a difference?. J Matern Fetal Med 1999; 8 (3) 119-122
• 19 Rebarber A, Roman AS, Istwan N, Rhea D, Stanziano G. Prophylactic cerclage in the management of triplet pregnancies. Am J Obstet Gynecol 2005; 193 (3 Pt 2) 1193-1196
• 20 Caritis SN, Rouse DJ, Peaceman AM , et al; Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), Maternal-Fetal Medicine Units Network (MFMU). Prevention of preterm birth in triplets using 17 alpha-hydroxyprogesterone caproate: a randomized controlled trial. Obstet Gynecol 2009; 113 (2 Pt 1) 285-292
• 21 Pons JC, Charlemaine C, Dubreuil E, Papiernik E, Frydman R. Management and outcome of triplet pregnancy. Eur J Obstet Gynecol Reprod Biol 1998; 76 (2) 131-139
• 22 NICE Guideline. Multiple pregnancy: the management of twin and triplet pregnancies in the antenatal period. National Collaborating Centre for Women's and Children's Health. London: RCOG; 2011: 143-149
• 23 Bricker L. Optimal antenatal care for twin and triplet pregnancy: the evidence base. Best Pract Res Clin Obstet Gynaecol 2014; 28 (2) 305-317
• 24 PRN. The Dutch Perinatal Registry. Available at: www.perinatreg.nl . Accessed November 6, 2014
• 25 NVOG. The Dutch College of Obstetrics and Gynecology. Guideline threatened preterm labor (dreigende vroeggeboorte). Available at: http://nvog-documenten.nl . Accessed November 6, 2014
• 26 Wilms FF, Vis JY, Pattinaja DAPM , et al. Relationship between the time interval from antenatal corticosteroid administration until preterm birth and the occurrence of respiratory morbidity. Am J Obstet Gynecol 2011; 205 (1) 49.e1-49.e7
• 27 Crowther CA, McKinlay CJD, Middleton P, Harding JE. Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes. Cochrane Database Syst Rev 2011; (6) CD003935
• 28 Asztalos EV, Murphy KE, Willan AR , et al; MACS-5 Collaborative Group. Multiple courses of antenatal corticosteroids for preterm birth study: outcomes in children at 5 years of age (MACS-5). JAMA Pediatr 2013; 167 (12) 1102-1110
• 29 D'Amore A, Ahluwalia J, Cheema I, Prentice A, Kaptoge S, Kelsall W. The effect of antenatal corticosteroids on fetal growth, survival, and neurodevelopmental outcome in triplet pregnancies. Am J Perinatol 2004; 21 (1) 1-8
• 30 Kawaguchi H, Ishii K, Yamamoto R, Hayashi S, Mitsuda N ; Perinatal Research Network Group in Japan. Perinatal death of triplet pregnancies by chorionicity. Am J Obstet Gynecol 2013; 209 (1) 36.e1-36.e7
• 31 Spencer JV, Ingardia CJ, Nold CJ, Borgida AF, Herson VC, Egan JFX. Perinatal and neonatal outcomes of triplet gestations based on placental chorionicity. Am J Perinatol 2009; 26 (8) 587-590