Higher-order (triplet or more) multiple pregnancies occur when more than two fetuses are present in the uterus at the same time. (1) (2)
High order multiple pregnancies (HOMP) are uncommon, the reported incidence range from 0.01% to 0.07% of all pregnancies.(1) (2) (3)
Spontaneous quadruplet pregnancy is rare with an incidence rate of 1 in 512000 to 1 in 677, 000 births (2)
The incidence of multiple pregnancies has increased dramatically in the last 25 years (4) (5)
In United States it is documented that HOMP has increased fourfold during the 1980s and 1990s (6), due to infertility treatments like Assisted Reproductive Techniques (ART) and ovulation-inducing treatments (7) (8)
The lack of insurance coverage for ART in most of the United States, as well as competition among ART programs, has generated pressure to achieve success in a minimal number of cycles, one strategy has been to increase the number of embryos transferred per IVF procedure. (9)
An analysis of 1998 Society of Assisted Reproductive Technology (SART) data demonstrated that providers in states without insurance coverage for IVF transferred more embryos per cycle, had a higher percentage of cycles resulting in pregnancy, and encountered an increased frequency of high order gestations compared to providers in states with IVF insurance coverage (9).
HOMP is considered a high-risk pregnancy as it has many complications on the mother and the fetuses with marked psychosocial and economical implications.
Prenatal morbidities as prematurity ( more than 90% deliver prematurly) (2), intrauterine growth restriction, low-birth weights for these babies, congenital malformation have been showing to be more common in HOMP (7) . Long term consequences for these fetuses as cerebral palsy and learning disabilities are demonstrated.(8)
Complications of prematurity as Intraventricular hemorrhage, periventricular leukomalacia, cerebral palsy, necrotizing enterocolitis, retinopathy of prematurity, and respiratory distress syndrome which can result in permanent injuries, including cerebral palsy, mental retardation, chronic lung disease, and loss of vision and hearing. (5)□ maternal mortality associated with multiple births is 2.5 times that for singleton births (10)
Maternal morbidities such as pre-eclampsia, anaemia, postpartum haemorrhage which is more than 500 ml blood loss.. etc.. are higher in HOMP and up to three to seven times more common than singleton pregnancies (8), and these complications usually associated with consequently prolonged hospitalization.□
It is difficult for the parents to take care of four or five babies at the same time, and it was found that depression is more common in mothers of multiple births, and they are more emotionally and physically exhausted than a singleton pregnancy. (11) . These pregnancies constitute a huge financial burden for the hospitals, data shows that the average cost per multiple gestation delivery is greater than the average cost of in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) cycles (8).
A study by (12) showed that the mean hospital costs of a singleton, twin, and HOMP child to age 5 years were $2730, $8993, and $24 411 (in 2009-2010 US dollars), respectively, with cost differences concentrated in the neonatal period and during the first year of life. Almost 15% of inpatient costs for multiple births could have been avoided if ART twins and HOMP had been born as singletons. (12)
Avoiding HOMP is important, therefore changes in assisted reproductive technologies (ART) practices, such as reducing the number of embryos transferred in ART procedures, using lower doses of ovulation induction medications or if multiple mature follicles seen during ovulation induction the cycle will be cancelled , all these modifications have been associated with the decline in higher-order multiple births (8) if primary prevention of HOMP failed, the fetal reduction is an ethically acceptable procedure (13) and its appropriate alternative to decrease the perinatal morbidity and mortality and to increase survival and well-being of high order pregnancy (14)
The term selective reduction means the selective termination of one or more embryos, using a trans-abdominal or trans-vaginal approach, under careful real-time ultrasonographic monitoring. The operation usually is performed late in the first trimester or early in the second trimester, commonly, no more than two embryos are terminated at one session, and occasionally a second intervention is indicated.
In United States the triplet and higher-order birth rate declined from about 1 in 515 births in 1998 to one in 880 births in 2014 and that decline was around 41% (6)
National Vital Statistics System data in United States of 2015 reported the number of quadruplet births were 228 and the number of quintuplets and other higher-order births were 24 ,with the rate of triplet or higher-order birth were: 103.6 per 100,000 live births, while in 2018 they reported that the number of quadruplets were 217 , higher-order multiple birth rate was 101.4 per 100,000 births for 2016, a non-significant decline from 2015 (15), but with the marked decline in HOMP since the peak 1998 (16)
The outcome of HOMP was determined by the gestational age at delivery,(5), the mean gestational age at delivery for quadruplet pregnancies was reported to be 31.4 weeks (5)
HOMP are best to be managed in a tertiary centre, and with aim of prolongation the gestation time as much as possible, thereby allowing the medical team to deliver the fetuses safely and to have advanced neonatal intensive care unit. (4)
Term delivery is rare in quadruplet pregnancies because of the increased risk of preterm delivery and other pregnancy complications such as pre-eclampsia and preterm premature rupture of fetal membranes . (2) , It is stated that the average gestational age at delivery for twins is 35 weeks, triplets 32.2 weeks quadruplets 29.9 weeks, and quintuplets 28.5 weeks (2)
Prevention and management of HOMP, therefore, poses a great challenge to the obstetrician as there is no clear evidence-based approach to its management and prevention, bed rest, beta mimetic drugs, progestogens, and elective cervical cerclage have all been reported to have a beneficial effect in prolonging pregnancy in some literature, but the results are yet to be substantiated by controlled trials. (2)
There are limited studies are reviewing obstetric outcomes following fetal reduction.□
Our aim retrospectively to review the outcomes of fetal reduction in HOMP in reducing the risk of post partum haemorrhage ( PPH) and preterm labour in quadruplets and quantuplets pregnancies.