Quadruplet Pregnancies and Births in a Tertiary Center in Northern Nigeria: A Report of 2 Cases

Abdulrasheed. L1, Bature S.B2, Jibril U.3, Sarki U.S4

1Department of Obstetrics and gynecology, Barau Dikko Teaching Hospital, Kaduna State. 2. Department of

Obstetrics and gynecology, Barau Dikko Teaching Hospital, Kaduna State. 3Department of Obstetrics and

gynecology, Barau Dikko Teaching Hospital, Kaduna State. 4.Medical Officer, Department of Obstetrics and

gynecology, Barau Dikko Teaching Hospital, Kaduna State.

ABSTRACT

Correspondence

Dr Lubabatu Abdulrasheed,

Barau Dikko Teaching

Hospital, Kaduna

drlubabah@yahoo.com,

+234 (0) 8063346288.

Background: The occurrence of a quadruplet pregnancy is exceptionally rare and

profoundly remarkable which is often caused by ovulation induction, spontaneously or

by In vitro fertilization (IVF). Spontaneous pregnancies with more than two fetuses are

very rare. Currently, Quadruplet pregnancy has a prevalence of 1 in 512,000 to 1 in

677,000 births in spontaneous pregnancies however assisted reproduction has increased

it remarkably (1,2). Quadruplet pregnancy is considered a high-risk pregnancy due to

increase in maternal, fetal and neonatal morbidity and mortality (3) .Hence a

multidisciplinary approach is essential for a successful outcome. These case reports

capture both, a spontaneously conceived quadruplet pregnancy and an IVF pregnancy

in a tertiary center in northern Nigeria. Case Series: The First case was a 50-year-old

known hypertensive. G4P0+3 who had IVF with 4 embryos transferred and had

prophylactic cerclage at 18 weeks. She developed Gestational diabetes diagnosed at 28

weeks and was comanaged with the endocrinologist and cardiologist, and later booked

for an elective C/S at 34 weeks which was successfully done. All male neonates were

delivered with good Apgar scores and weighing between 1300 and 1600 grams. The

Second case was a 27-year-old G5P4+0 3 alive, a referral from a general hospital at 31

weeks’ gestation. She had an Emergency C/S, delivering 4 live male neonates with good

Apgar scores and weighing between 1400 and 1700 grams. It was confirmed pair of

monochorionic diamniotic. Management Summary: Management, initiated upon

diagnosis, included bed rest, high-protein diet, beta-mimetic agents, dexamethasone late

in the second trimester, selective cerclage and in particular the intensive

ultrasonographic controls with biophysical and Doppler parameters was important for

wellness and survey of the fetuses. The mean gestational age of 34 weeks when we

planned a Cesarean section and prenatal care has been shown to be effective in

improving outcomes in these multiple pregnancies. Conclusion: Spontaneous

conception of quadruplets pregnancy does occur. Successful supervision of Pregnancy

and delivery of quadruplet pregnancy with good outcome for mother and infants is

possible using a multidiscipline approach as demonstrated in these two cases.

Keyword: Quadruplets, Pregnancy Care, Delivery, Tertiary Health Center

INTRODUCTION

The occurrence of a quadruplet pregnancy is

exceptionally rare and profoundly remarkable which is

often caused by ovulation induction, spontaneously or

by In vitro fertilization (IVF).1 Spontaneous

pregnancies with more than two fetuses are very rare.

Hellin’s Law states that before the advent of fertility

methods, the natural occurrence of multiples would be

Twins 1 in 90 live births, Triplets 1 in 8,100 live births,

Abdulrasheed, et al. Quadruplet Pregnancies and Births

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

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quadruplets 1 in 729,000 live births and Quintuplets 1

in 65,610,000 live births but those numbers have

decreased to 1/38, with techniques of assisted

reproduction It is estimated that 60% of triplets are

from fertility treatments, 90% of quadruplets are from

fertility treatments, and 99% of quintuplets are due to

fertility treatments. 2

Currently, Quadruplet pregnancy has a

prevalence of 1 in 512,000 to 1 in 677,000 births in

spontaneous pregnancies however assisted

reproduction has increased it remarkably2,3. Quadruplet

pregnancy is considered a high-risk pregnancy due to

increase in maternal, fetal and neonatal morbidity and

mortality4.

As compared with singleton pregnancies,

quadruplets, are associated with a higher risks of

hypertension, incompetent cervix, premature rupture of

membranes, placenta previa, abruptio placenta, first-

trimester bleeding, preterm labour, anemia, stillbirths

and perinatal deaths. 5

Hence a multidisciplinary approach is

essential for a successful outcome. These case reports

capture both, a spontaneously conceived quadruplet

pregnancy and an IVF pregnancy in a tertiary center in

northern Nigeria.

CASE SERIES

The First case was a 50-year-old known hypertensive.

G4P0+3 who had IVF at a tertiary hospital in northern

Nigeria with 4 embryos transferred and had

prophylactic cerclage at 18 weeks. She developed

Gestational diabetes diagnosed at 28 weeks and was co-

managed with the endocrinologist and cardiologist with

appropriate medications, had uneventful antenatal

period with fortnightly ANC visit and later booked for

an elective C/S at 34 weeks which was successfully

done. All male neonates were delivered with good

APGAR scores and weighing between 1300 and 1600

grams.

Fig. 1. Spontaneous Quadruplets at 3 weeks

Fig. 2. Spontaneous Quadruplets at 6 months of age

Fig.3. IVF Quadruplets at 6 months

Fig. 4. IVF Quadruplets at 1 year

The Second case was a 27-year-old G5P4+0 3 alive, a

referral from a general hospital at 31 ‘weeks gestation

following the diagnosis of quadruplet pregnancy at the

same time, she was not offered a prophylactic cerclage

as at when due from the referral hospital, so she was

managed with bed rest and tocolysis. She was a rhesus

negative (unsensitized) patient with positive family

history of multiple gestation in her sisters. A diagnosis

of Pregnancy induced hypertension (PIH) was made at

31 weeks was made earlier on admission she was

booked for an elective C/S at 35 weeks, patient

however went into spontaneous labour at 34 weeks 5

days which necessitated an Emergency C/S, delivering

Abdulrasheed, et al. Quadruplet Pregnancies and Births

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

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4 live male neonates with good APGAR scores and

weighing between 1400 and 1700 grams. It was

confirmed pair of monochorionic diamniotic.

CLINICAL FINDINGS

The first case was a middle-aged woman with a weight

of 74.9kg and the height of 1.64m. Her blood pressure

throughout the pregnancy fluctuated between

100/60mmgh to 150/100mmhg while her fasting blood

sugar was controlled between 3.8mmol/l and

8.2mmol/l.

The second case was a young woman, with a

weight of 72.5kg and the height of 1.66m. Her blood

pressure fluctuated between 160/120mmhg and

110/75mmhg.

Diagnostic Assessments

Patient 1

PCV: 39%

Viral serologies: Negative

OGTT: Fasting – 5.7mmol/l

1HPP- 11.2mmol/l

2HPP- 9.6mmol/l

Patient 2

PCV: 33%

Viral serologies: Negative

Management Summary

Management, initiated upon diagnosis, included bed

rest, high-protein diet, beta-mimetic agents,

dexamethasone late in the second trimester, selective

cerclage and in particular the intensive

ultrasonographic controls with biophysical and

Doppler parameters was important for wellness and

survey of the fetuses.

The mean gestational age of 34 weeks when we

planned a Cesarean section and prenatal care has been

shown to be effective in improving outcomes in these

multiple pregnancies.

DISCUSSION

In the reported patients, pregnancy resulted from both

assisted reproduction and spontaneously with positive

family history, most cases of spontaneous quadruplet

pregnancies have reported a positive family history and

following ovulation induction. 1,2,5 However, few

reported no family history as in other studies3,6.

The spontaneous quadruplet pregnancy reached

the 3rd trimester without prophylactic cervical cerclage.

In 2018. Hafizi. L et al. reported a case of spontaneous

quadruplet pregnancy which was terminated at week 33

with 4 healthy neonates without prophylactic cerclage.

The problem of multiple gestation and its management

is becoming increasingly frequent due to current

methods of treating anovulatory patients.7-9 Multiple

pregnancy is considered a high-risk pregnancy as more

complications are observed with the increase in number

of fetuses. Higher order pregnancy needs a

multidisciplinary approach for the safe transition of a

pregnant women to motherhood. Not only obstetrician

but early involvement of neonatologists and

anesthesiologists for the assessment of such case is

essential for a successful obstetrics outcome. Both

patients benefited multidisciplinary management with

subsequent good outcome.

CONCLUSION

Spontaneous conception of quadruplets pregnancy does

occur. Successful supervision of Pregnancy and

delivery of quadruplet pregnancy with good outcome

for mother and infants is possible using a

multidiscipline approach as demonstrated in these two

cases. It is also important to note that the second patient

never had a prophylactic cerclage from the referring

facility which was the standard of care and because she

presented late tonus she did well on bed rest and

tocolysis

REFERENCES

1. Feldberg D, Laufer N, Dicker D, Goldman JA, DeCherney

A. Quadruplet pregnancy in IVF. Eur J Obstet Gynecol

Reprod Biol. 1986 Oct;23(1–2):101–6.

2. Shrestha D, Thapa B, Aryal S, Shrestha BK, Kalakheti B,

Panthee K. Successful Management of Quadruplet

Pregnancy following Spontaneous Conception. J Lumbini

Med Coll. 2016 Jun 30;4(1):46.

3. Hafizi L, Rezaii Asgarieh E, Taheri N, Ghomian N.

Successful Management of Spontaneous Quadruplet

Pregnancy: A Case Report. J Fam Reprod Health. 2018

Sep;12(3):173–6.

4. Lama LD, Das T, Neupane A, Lama R, Pandey R, Karki U.

Management of Quadruplet Pregnancy: A Case Report.

JNMA J Nepal Med Assoc. 2020 Feb;58(222):122–4.

5. Carrara S, Cavaliere A, Ermito S, Dinatale A, Pappalardo

EM, Militello M. Case report: successful of a spontaneous

quadruplet pregnancy. J Prenat Med. 2009 Jan;3(1):10–1.

6. Rathod S, Samal SK, Singh S, Swain S. Quadruplet

pregnancy following spontaneous conception: a rare case

report. J Clin Diagn Res JCDR. 2015 Apr;9(4):QD01-02.

7. Rasmussen MK, Kristensen SE, Ekelund CK, Sandager P,

Jørgensen FS, Hoseth E, et al. Quadruplet pregnancy

outcomes with and without fetal reduction: Danish national

cohort study 2008‐2018 and comparison with dichorionic

twins. Ultrasound Obstet Gynecol. 2023 Sep 24;uog.27497.

8. Ogunnowo T, Oluwole O, Aimakhu C, Ilesanmi A,

Omigbodun A. Term quadruplet pregnancy: a case report.

Niger J Surg Res [Internet]. 2010 May 27 [cited 2023 Oct

12];6(1–2). Available from:

http://www.ajol.info/index.php/njsr/article/view/54796

9. Vikranth, U., Borkar, N.V., Desai, S.K., Kania, P. and

Rangoonwala, N.H., 2007. A Quadruplet pregnancy. J Obstet

Gynecol India, 57(5), pp.439-41.

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