High-order pregnancies have become a challenge for ART centers given the complexity of their management and strict control that must be followed to prevent complications that can be expected in these cases (11) (12). Multiple pregnancies have a low incidence, especially quadruple pregnancies, occurring at an incidence of 1 of every 500,000 pregnancies, (13) estimating that about 90% of cases occur due to ART (7) (14).
Once pregnancy is established, the couple faces the dilemma of a high-order pregnancy and an attempt is made to continue with all fetuses, since the couple usually does not accept total interruption of the pregnancy, especially when they have a history of infertility (15). In Honduras, the law does not allow fetal interruption or reduction, a process that would improve the outcomes of these pregnancies (16), which leads to the association of inherent problems that will intervene in long-term survival and morbidity (5).
The patient underwent ovarian stimulation with follitropin alfa for artificial insemination, given the lack of success in the implementation of programmed intercourse plus the implementation of clomiphene and letrozole, reaching five mature follicles and under conditions suitable for ovulation. Patients undergoing ovarian stimulation have an increased risk of developing a multiple pregnancy due to the maturation of more than one egg, especially with the increasingly frequent use of ART in patients with infertility (13) (17) (18). Whenever ART is involved in the pregnancy planning process, there is a risk of high-order pregnancies; therefore, the risks of implementing ART must be weighed according to the benefits to be achieved: a successful pregnancy (19). The patient in this report successfully achieved a desired pregnancy, on two occasions after a primary infertility lasting more than two years of multiple pregnancy planning failures, ultimately requiring surgical intervention and ART and successfully achieving a resolved pregnancy on both occasions. The application of ART gave the couple the opportunity to procreate, and the risks were outweighed by the benefits achieved.
In the case presented, total success was achieved in every sense due to the mother's excellent physical condition and her perseverance in following the treatment indicated by her doctor. In gynecological-obstetric terms, this case represents an achievement in the clinical practice of ART not previously described in the country, with excellent maternal and perinatal results.
A high-order pregnancy predisposes the mother and fetuses to many complications; in the mother, there is an increased risk of preeclampsia, postpartum hemorrhage, polyhydramnios, preterm labor, caesarean section, gestational diabetes, premature rupture of membranes, placental detachment, placenta previa, and maternal death (by 2.5 times versus a single pregnancy) (20) (21). In newborns, there is an increased risk of prematurity (26 - 35 GW), low birth weight (mean 1046 - 1778 g) (14), cerebral palsy, death (22), and mortality (20 times higher in the first month of life) (11) (12) (19) (23) (24). The data presented in this case contrast the poor prognosis usually expected in this type of pregnancy; the mother and fetuses did not present any type of complication; the mother had a controlled pregnancy with blood pressures, ultrasound findings, and laboratory tests all within normal parameters and the cesarean section not showing alterations and being scheduled at term. During the intraoperative and postoperative periods, uterine atony was expected, and all oxytocics were available (ergometrine, oxytocin, carbetocin, prostaglandins, and Bakry balloon), and prepared for the eventuality of a hysterectomy. Only prophylactic carbetocin was used, and the uterus exhibited physiological tetanic hypertonia immediately upon evacuation, without the need for more medication.
Preterm birth is the most common maternal complication in high-order pregnancies, of which 90% of infants are born prematurely (25), with the average gestational age at delivery for quadruplets being at approximately 29 weeks and 5 days (26). The importance of this case lies in the success achieved in bringing the pregnancy to term at 37.2 GW, exceeding the usual range observed in quadruple pregnancies (14). In 2016, the United States reported that 93% of quadruplet pregnancies were delivered before 34 weeks of gestation (6).
In this study, the fetal weights were adequate (2600 g, 2740 g, 2380 g, and 1700 g) with better weighing than in other case series of high-order fetal pregnancies (14), It has been reported that 77.1% of quadruple pregnancy birth weights are below 1500 g and 96.2% are below 2500 g, and a limited nutrient supply could be responsible for low birth weight (27). The newborns were discharged together with the mother without early or late respiratory complications, did not present hyperbilirubinemia or other complications, and achieved the objective of all reproduction techniques: a healthy baby at home.
The patient attended 13 prenatal check-ups and was evaluated every week in recent months. There is no consensus about the periodicity of prenatal controls in high-order gestations, having a stricter and more exhaustive control in the last few weeks improves the maternal-fetal prognosis, avoids complications, and controls the weight of each fetus to enable the identification of discrepancies or alterations of the amniotic fluid (14) (28). It should be noted that the patient came from a rural area, where she had limited access to specialized health services, and it was necessary to transfer her to an urban area in the final few months of the pregnancy because of the possibility of premature rupture of membranes or pre-eclampsia that would accelerate the evacuation of the pregnancy.
In high-order pregnancies, the literature reports scheduled evacuations before term; in Honduras, neonatal units usually do not have the best resources to guarantee fetal well-being and decrease morbidity rates; therefore, the pregnancy was allowed to evolve until term. In this case, the well-being and comfort of the mother had great influence, as her quality of life was not affected by the quadruple pregnancy. The authors suggest that clinicians not intervene if a pregnancy continues without eventualities and allow its natural evolution as long as the fetal and maternal well-being tests provide adequate results.
The management of a high-order pregnancy is challenging for obstetricians in charge of the well-being of pregnant women and their fetuses. A key point is the close monitoring of maternal well-being, which could be the key to the full development of a successful pregnancy. The case presented here represents an achievement in every way.