Journal of Clinical Neonatology

ORIGINAL ARTICLE
Year
: 2018  |  Volume : 7  |  Issue : 4  |  Page : 208--212

Multiple gestations and its outcome in a special care baby unit: Our experience in a resource-limited setting


Ibrahim Aliyu1, Teslim O Lawal2,  
1 Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano, Nigeria
2 Department of Paediatrics, Federal Medical Centre, Birnin Kebbi, Nigeria

Correspondence Address:
Dr. Ibrahim Aliyu
Department of Paediatrics, Aminu Kano Teaching Hospital, Bayero University Kano, Kano
Nigeria

Abstract

Introduction: multiple gestations occur worldwide; and it may be associated with complications such as prematurity and low birth weight, some warranting admission. Therefore, this study seeks to determine the pattern of illnesses seen among multiple gestations admitted to our special care baby unit and their outcome. Materials and Methods: This was a retrospective review of admissions of multiple gestations. Results: There were 111 cases of multiple gestation-related admission. There were 46 sets of twins, six sets of triplet, and a single second twin consisting of 51 (45.9%) males and 61 (54.1%) females. Most of the cases presented within the 1st day of life. Majority of the cases were <2.5 kg (76.6%). Varied severity of isolated low birth weight was the most common indication for admission followed by sepsis with low birth weight; however, most of the cases were discharged and 18 deaths were recorded. The deaths and signing against medical advice were recorded in those with low birth weight; also those with sepsis with low birth weight, while all the cases in the observation group, those with birth asphyxia, and those in the miscellaneous were successfully discharged. Conclusion: Managing multiple gestations is still challenging in a resource-limited setting. There was more twinning than higher-order multiple gestation in this study; expectedly low birth weight was common among the cases, but the majority were successfully discharged home.



How to cite this article:
Aliyu I, Lawal TO. Multiple gestations and its outcome in a special care baby unit: Our experience in a resource-limited setting.J Clin Neonatol 2018;7:208-212


How to cite this URL:
Aliyu I, Lawal TO. Multiple gestations and its outcome in a special care baby unit: Our experience in a resource-limited setting. J Clin Neonatol [serial online] 2018 [cited 2019 Jan 21 ];7:208-212
Available from: http://www.jcnonweb.com/text.asp?2018/7/4/208/243344


Full Text



 Introduction



Multiple gestations occur worldwide,[1] the advent of assisted reproductive technology and of anti-infertility drugs has increased the incidence of twinning and higher-order multiple gestation.[2]

Twinning may be monozygotic or dizygotic. Their incidence varies, while the incidence of monozygotic twinning is consistent at 3.9/1000 birth worldwide,[3] incidence of dizygotic twinning has a significant racial variability; it is reported to be more common among Blacks, especially in Nigeria, among the Yoruba extraction,[4],[5],[6] with an estimated incidence of 40.2/1000 birth.[7] Why this is so, is not completely understood, but the role of consumption local specie of yam with high clomiphene-like content (estrogenic) had been implicated.[8],[9] Multiple gestation have also been reported at a higher rate among East Indians and the Europeans while the least is among Asians of the Mongolian extraction.[10] Other established risk factors for dizygotic twinning include advanced maternal age, multiparity, and genetic and environmental factors. Triplet births are often rare and occur in 2/1000 live births among Hausa women,[11] which is higher than 1 in every 8000 live births witnessed among Caucasian women.

Multiple gestations are associated with pregnancy, delivery, and postdelivery complications often necessitating admission into the special care baby unit (SCBU); furthermore, they are at increased risk of congenital malformation;[12],[13],[14] among these complications are prematurity, low birth weight, birth asphyxia, sepsis, hypoglycemia, and hypothermia.[15] Therefore, the absence of a functional SCBU may result in poor survival outcome. This study, therefore, seeks to review the common clinical characteristics of multiple gestations, indications for admission, and their outcome in our SCBU.

 Materials and Methods



This was a retrospective review of cases of of multiple gestations admitted over a 3-year period from January 2011 to December 31, 2013. The records of cases of multiple gestations were retrieved, and relevant information was extracted such as their gestational age at delivery, birth weight, sex, and indication for admission and the outcome.

Data analysis

Obtained information was entered into SPSS version 16 (SPSS Inc, Chicago, Illinois, United State of America). Relevant statistical analysis such as the mean, standard deviation, and frequency tables was calculated for the quantitative and qualitative variables, respectively. The Fisher's exact test was adopted in comparing categorical variables and P < 0.05 was stated as statistically significant.

 Results



There were 111 cases of multiple gestation-related admissions out of a total 1240 admission over the 3-year period, constituting 9.0% of all admissions. These consisted of 46 sets of twins, six sets of triplet, and a single second twin. There were 51 (45.9%) males and 61 (54.1%) females with a ratio of 1:1.2.

Most of the cases presented within the 1st day of life [Table 1]. Majority of the cases were <2.5 kg (76.6%); however, the minimum weight was 0.56 kg, while the maximum weight was 3.12 kg, with a mean of 1.89 ± 0.61. Forty-nine of the cases (44.1%) were delivered at term while only 2 (1.8%) cases were <28 weeks; however, 62 (55.9%) were preterm. The minimum gestational age recorded was 25 weeks, while the maximum was 40 weeks with a mean age of 35.3 ± 3.4 [Table 2].{Table 1}{Table 2}

The mean weight distribution of the second twins was slightly higher than the first twins, while that of the first sets of the triplets were slightly higher than that of the second and third sets of triplets [Table 3].{Table 3}

There were 54 mothers involved in this study; their ages ranged from 15 to 41 years with a mean age of 26.0 ± 5.3. However, 36 (66.6%) which constituted the majority were of the 19–29 years age group [Table 4]. Ninety (81.1%) of the deliveries were in a tertiary center while the emergency cesarean section was the most common mode of delivery.{Table 4}

Ninety (81.1%) of the cases spent between 1 and 7 days on admission; however, the least duration of stay was 1 day while the maximum was 32 days, with a mean of 6.1 ± 5.1. Varied severity of low birth weight was the most common indication for admission followed by sepsis with low birth weight; however, most of the cases were discharged and only 18 deaths were recorded [Table 5].{Table 5}

The weight at admission and level of maturity with the admission outcome [Table 6] showed that only those who weighed <2.5 kg (Fisher's exact test = 12.395; P = 0.01) and also the preterm group recorded death and signing against medical advice (SAMA) (Fisher's exact test = 22.621; P = 0.001).{Table 6}

The deaths and SAMA were recorded in those with low birth weight; also those with sepsis with low birth weight, while all the cases in the observation group, those with birth asphyxia, and those in the miscellaneous were successfully discharged (Fisher's exact test = 24.472; P = 0.001) [Table 7].{Table 7}

 Discussion



The management of multiple gestations may pose significant challenges from the inception of pregnancy through delivery up to the neonatal period. This often requires expert management which may be scare in some resource-limited settings. Therefore, it is not surprising that there have been dismal survival pattern recorded with higher multiple gestation; Omoigberale et al.,[16] in their report on the management of quintuplet, gave a chronicle of the state of health facilities and how it had negatively impacted on the survival outcome of cases (quintuplet) of higher multiple gestations which none had survived before theirs. This is because most are delivered prematurely, with its attendant complications; furthermore, there is increased risk of congenital malformations in these babies further increasing the risk of morbidity and mortality.

Although multiple gestations are most common with multiparous older women, majority of the mothers in this study were between 19 and 29 years. They were younger than that reported by Attah et al.,[17] why this was so in our study was not completely understood; however, multiparity is a function of age at marriage, pregnancy, and commencement of delivery; therefore, early marriage with early deliveries may result in being multiparous even at a younger maternal age.

There were more females babies reported in this study, which was not surprising because it is a general knowledge that the higher the multiple gestation order, the higher the chances of female sex.

Multiple gestations are often complicated by premature deliveries,[2] but our study showed almost equal proportion of preterm to term babies with a ratio of 1.2:1; this may be due to better antenatal care and monitoring since majority of the pregnancies were delivered in the tertiary hospital, and this may also account for the higher cesarean section rate noted in this report when compared to previous reports.[4],[17] This disparity in our study may be related to the fact that majority of the cases were high risk pregnancies, hence the need for urgent intervention.

The mean gestational age of the cases was 35.3 ± 3.4 weeks, which was similar to that reported by Fitzsimmons et al.[18] but lower than that reported by Attah et al.[17] and Kuti et al.[19]

The mean weight of the babies was 1.89 ± 0.61 kg which portended a favorable survival outcome. Therefore, it was not surprising seeing that majority of the babies were admitted for observation spending <7 days in the SCBU. Although this was lower than that previously reported in Kano and Mallufashi, respectively.[17],[20] However, this study showed that the first twins weighted lower that the second twins, which was contrary to previous reports.[21],[22] This may be attributable to the smaller sample size in our study, but the first triplets were heavier than the second and third triplets.

The most common indication for admission was low birth weight; however, 30.6% of the babies were also admitted for observation, especially those whose mothers had emergency cesarean section; and those that their mean birth weight was favorable, with little or no complication. This explained why 81.1% of the babies spent less time on admission; therefore 74.8% of the cases were successfully discharged home. Eighteen deaths were recorded, especially among the extremely and very low birth weight preterm babies. These occurred within the first 24 h of admission. This highlights the need for further improvement on the availability of required facilities which will improve their survival.[16]

The obstetric and neonatal care is quite commendable in this report which explains the lower rate of complications such as birth asphyxia and hypoglycemia; more so a significant proportion of the pregnancies were carried to term; however, availability of special care for very preterm babies such as provision of surfactant, more functional incubators, and steady power supply will significantly improve their survival.

 Conclusion



Managing multiple gestations is still challenging in a resource-limited setting. There was more twinning than higher-order multiple gestation in this study; expectedly low birth weight was common among the babies, but majority were successfully discharged home. However, effective utilization of available resources and facilities could produce a favorable outcome as was seen in our study. Furthermore, health-care delivery is a continuous process; therefore, there is the need to train and retrain the stakeholders while ensuring that better equipment is provided to achieve the best practices obtainable in the developed countries.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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