Fetal and maternal outcome of higher-order multiple pregnancies in a tertiary hospital: A 5-year single-center observational study from Nigeria

Objective: The aim of this study was to determine the pattern and outcomes of higher-order multiple pregnancies in a tertiary hospital in Nigeria Methods: This is a retrospective review of all cases of higher-order multiple pregnancies that were managed between 1 January 2012 and 31 December 2016 in Alex Ekwueme Federal University Teaching Hospital Abakaliki, Nigeria. Data obtained were represented with frequency tables, percentages, bar charts, and odds ratio. Results: There were 22 higher-order multiple pregnancies over the study period and 12,002 deliveries, giving a higher-order multiple prevalence rate of 0.2%. Five of the mothers (four triplets and one quadruplet) had in vitro fertilization (0.4 per 1000 deliveries), while other mothers conceived naturally. Many of the women (12, 54.6%) were in the 30–34 years age group, and more than half (16, 72.7%) were multiparas. More than half of the neonates were delivered preterm (13, 59.1%). Being booked is associated with better neonatal outcomes although not significant (odds ratio = 3.06. 95% confidence interval: 0.55–16.83, p = 0.197). Anemia was common in the antepartum and postpartum periods. Half of the women (11, 50%) were delivered by elective cesarean section and 7 (31.8%) by emergency cesarean section (C/S), while 4 (18.2%) had a spontaneous vaginal delivery. The neonates had a mean birth weight of 2.14 ± 0.35 kg. Overall, 61 neonates (91.0%) were born alive and 6 (9.0%) suffered perinatal deaths, giving a perinatal mortality rate of 89.8 neonates per 1000 live births. Conclusion: Our study shows that higher-order multiple pregnancies are high-risk pregnancies that are associated with fetal and maternal complications. Anemia is the commonest complication seen in our study. The majority had preterm delivery. Proper antenatal care and close feto-maternal monitoring are important in reducing adverse outcomes associated with these pregnancies. This is a retrospective cross-sectional study of HOM pregnancies managed in the Obstetrics and Gynaecology Department of AEFUTHA between 2012 and 2016. This retrospective cross-sectional study was carried out in the Department of Obstetrics and Gynaecology of AEFUTHA Ebonyi state. Ebonyi state is one of the states in southeast Nigeria and is populated mainly by Igbos’. It is estimated that the population of Abakaliki as of 2021 is about 1,179,280. Ebonyi is primarily an agricultural region and about 75% of the population dwell in rural areas with farming as their major occupation. AEFUTHA is the only teaching hospital in the state, receiving a referral from primary, secondary, private, and mission hospitals in the state and neighboring states. The Department of Obstetrics and Gynaecology is one of the departments in the hospital. It is managed by consultant obstetricians and resident doctors with the help of trained midwives and nurses. Both antenatal and booking clinics hold daily from Mondays through Fridays which are run by consultant obstetricians with their team of resident doctors. The average antenatal attendee in AEFUTHA is 100 women per week and the delivery rate is 155 deliveries per month, with a C/S rate of 34.3%. A woman is said to have booked in the center if she has attended two or more antenatal visits and has done the baseline investigations which must have been reviewed by an obstetrician. Unbooked women are those who have no prenatal care in our facility or those who registered at our hospital but has less than two antenatal visits. During antenatal class, interactive health talk is provided to the women by the midwives before the women are allowed to see their obstetrician. It lasts for about 60 min. The topic discussed includes nutrition, diet, personal hygiene and danger signs in pregnancy, the labor experience, care of the newborn, exclusive breastfeeding, and immunization. Other health issues, such as hypertension, diabetes mellitus, malaria, anemia, HIV/AIDS, and family planning, are also discussed. Routine services following the health talk include weight and height measurement, blood pressure estimation, urinalysis, and hemoglobin estimation. Following this, the women are called in by their doctors. History taking, examination, and appropriate investigations are requested. Some of the investigations requested include blood group, genotype, pack cell volume, fasting blood sugar, HIV screening—after due counseling and offered routinely with an option to opt-out, hepatitis B virus screening, venereal disease research laboratory test, and urinalysis. Ultrasound examination is not done routinely but on an indication. However, it is expected that a third-trimester ultrasound should be carried out to access the fetal well-being, fetal weight, placental localization, and biophysical profile before delivery. For HIV-positive women, other investigations requested include viral load, CD4 count, hepatitis C virus screening, liver function test, kidney function test, full blood count, and platelet. The women are counseled on birth preparedness and complication readiness. Drugs given at routine visits include folic acid, ferrous sulfate, and multivitamins. Other drugs are also prescribed depending on clinical findings. HIV-positive pregnant women are given highly active anti-retroviral therapy and Septrin as a routine in addition to other drugs; at delivery, anti-retroviral prophylaxis is commenced for the neonates using nevirapine or nevirapine and zidovudine depending on the risk of vertical transmission. The labor ward is managed by a team of resident doctors led by a senior registrar under the supervision of a labor ward consultant. They are assisted by trained midwives. Parturients in labor are admitted in the labor ward when the cervical dilatation is 4 cm and above, while those for induction of labor are admitted when the Bishop score 13 is 6 and above. They were managed with individualized partograph according to the departmental protocol. However, pregnant women who were booked for C/S are admitted into the antenatal ward 24 h before the day of surgery. Blood and urine samples were collected for pack cell volume, grouping and typing of blood, and urinalysis as a routine. Other investigations would be requested based on the clinical finding from the patient. The anesthetist and neonatologist were informed to review her and to be present during the delivery process. The case files of all women who had HOM pregnancies at the hospital (AEFUTHA, Ebonyi State, Nigeria) from 1 January 2012 to 31 December 2016 were retrieved and reviewed. HOM pregnancies occur when more than two fetuses are present in the uterus at the same time. The diagnosis was made through an ultrasound investigation. Women included in the study were all parturient who was delivered of three or more neonates in the facility during the study period irrespective of the outcome. Those excluded were parturients who were delivered of singleton or twin fetuses. The emergency room, postnatal, theater, and labor ward records were used to identify the cases of HOM pregnancies and deliveries in the facility over the study period. The hospital numbers were compiled making sure that double-entry was avoided. It was used to retrieve the case notes from the record department. Using a data collection form, the following information was obtained from each case note: sociodemographic parameters (maternal age, parity, occupation, level of education, marital status, and religion), gestational age, booking status, mode of delivery (Figure 1), antepartum complication—anemia, hypertension, preterm labor, premature rupture of membrane, neonatal sex, Apgar score, 10 neonatal weight, and postpartum complication (Table 1). Mode of delivery of women. As shown in Figure 1, half of the women (11, 50.0%) delivered through elective cesarean section, 7 (31.8%) had emergency cesarean section, while 4 women (18.2%) delivered through spontaneous vaginal delivery. In total, 32 neonates (47.8%) were female, while 35 (52.2%) were male. Sociodemographic characteristics of the women. As shown in Table 1, the majority of the women (12, 54.6%) were in the 30–34 years age group and the mean maternal age was 31.23 ± 4.48 years with a range of 20–40 years. The majority of the women (16, 72.7%) were multiparas, while 4 (18.2%) were primiparas. More than half (13, 59.1%) of the women delivered preterm with a mean gestational age of 35.82 ± 2.24 weeks. The minimum gestational age was 31.5 weeks, while the maximum was 40 weeks. Secondary education is the commonest (10, 45.5%) form of education attained by women with the majority (20, 90.9%) being Christian. Most of the women (16, 72.7%) booked for antenatal care in the facility and 40.9% (9) of those who carried their pregnancy beyond 36 weeks belonged to this group. The data obtained were analyzed using IBM SPSS Statistics version 20 (IBM Corp., Armonk, NY, USA). The results were expressed using odds ratio (OR), bar charts, frequency tables, percentages, mean, and standard deviation. The OR was classified into OR <1 and OR >1. OR <1 represents decreased chances of bad neonatal outcomes occurring, while OR >1 represents increased chances of the neonates having bad outcomes. Ethical approval was obtained from the Health Research and Ethics Committee of AEFUTHA, Ebonyi state. The ethical approval number is FETHA/REC/VOL1/2017/539. Informed consent was waived by the Institutional Review Board due to the retrospective nature of the study.