The Quadruplet Pregnancies and birth in a tertiary Centre in northern Nigeria: A Report of 2 Cases

quadruplet pregnancy case report

Abstract

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).(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, 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)

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 labor, 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 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 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 and an elective C/S was booked at 35 weeks was planned, patient however went into spontaneous labor at 34 weeks 5 days which necessitated 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.
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  she did well on bed rest and tocolysis

KEYWORDS; quadruplets, pregnancy care, delivery, diamniotic monochorionic