Iron Baby

https://vimeo.com/12125147!.?.!I did all the 3D for this video( modeling, Texturing, computer animation, Fx and so on) in 3dsMax 2011 and also rendered with Vray, for this extremely brief fake trailer i did simply for enjoyable with my pal Patrick Boivin that had the idea, did the online shooting, direction as well as compositing in Adobe After Effects. We wished to see the technical level we can reach together. I utilized CAT for the animation. The initial landing shot was done by

electronic camera projection( we had simply a photo for a fire and the background video ). I created all my HRDI pictures for the reflection making use of a fisheye lens. It took me alot of time to model the entire Iron Baby fit. I initially design the actual Iron Man and then flawed it to infant proportions. Making of readily available below: http://www.strob.net/2011/02/06/mon-making-of-du-iron-baby/ Version offered on Turbosquid: http://www.turbosquid.com/Search/Artists/Strob?referral=Strob.

Her Olympic Goal: Find Her Birth Parents

Her Olympic Goal: Find Her Birth Parents

Meehyun Lee was born in South Korea and adopted by a family in Pennsylvania when she was just 1. She returned to compete for South Korea in the Olympics, hoping her birth parents might be watching.

Nepal’s Chief Justice Sacked After He Is Accused of Faking Date of Birth

Gopal Parajuli, the chief justice of Nepal, was fired on Wednesday after a judicial council found that he had lied about his date of birth to remain in office.

Preterm birth

Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age.[1] These babies are known as preemies or premmies.[1] Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes or the leaking of fluid from the vagina.[8] Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and sight problems.[1] These risks are greater the earlier a baby is born.[1]

The cause of preterm birth is often not known.[2] Risk factors include diabetes, high blood pressure, being pregnant with more than one baby, being either obese or underweight, a number of vaginal infections, tobacco smoking and psychological stress, among others.[2][3] It is recommended that labor not be medically induced before 39 weeks unless required for other medical reasons.[2] The same recommendation applies to cesarean section.[2] Medical reasons for early delivery include preeclampsia.[9]

In those at risk, the hormone progesterone, if taken during pregnancy, may prevent preterm birth.[5] Evidence does not support the usefulness of bed rest.[5][10] It is estimated that at least 75% of preterm infants would survive with appropriate treatment, and the survival rate is highest among the infants born the latest.[2] In women who might deliver between 24 and 37 weeks, corticosteroids improve outcomes.[6][11] A number of medications, including nifedipine, may delay delivery so that a mother can be moved to where more medical care is available and the corticosteroids have a greater chance to work.[12] Once the baby is born, care includes keeping the baby warm through skin to skin contact, supporting breastfeeding, treating infections and supporting breathing.[2]

Preterm birth is the most common cause of death among infants worldwide.[1] About 15 million babies are preterm each year (5% to 18% of all deliveries).[2] Approximately 0.5% of births are extremely early periviable births, and these account for most of the deaths.[13] In many countries, rates of premature births have increased between the 1990s and 2010s.[2] Complications from preterm births resulted in 0.81 million deaths in 2015 down from 1.57 million in 1990.[7][14] The chance of survival at 22 weeks is about 6%, while at 23 weeks it is 26%, 24 weeks 55% and 25 weeks about 72%.[15] The chances of survival without any long-term difficulties are lower.[16]

Contents

  • 1 Classification
  • 2 Signs and symptoms
    • 2.1 Complications
      • 2.1.1 Mortality and morbidity
      • 2.1.2 Specific risks for the preterm neonate
  • 3 Risk factors
    • 3.1 Maternal factors
    • 3.2 Factors during pregnancy
    • 3.3 Infection
    • 3.4 Genetics
  • 4 Diagnosis
    • 4.1 Placental alpha microglobulin-1
    • 4.2 Fetal fibronectin
    • 4.3 Ultrasound
  • 5 Prevention
    • 5.1 Before pregnancy
    • 5.2 During pregnancy
      • 5.2.1 Screening of low risk women
      • 5.2.2 Self-care
    • 5.3 Reducing existing risks
      • 5.3.1 Reducing indicated preterm birth
      • 5.3.2 Reducing spontaneous preterm birth
        • 5.3.2.1 Antibiotics
        • 5.3.2.2 Progestogens
        • 5.3.2.3 Cervical cerclage
  • 6 Management
    • 6.1 Steroids
    • 6.2 Antibiotics
    • 6.3 Tocolysis
    • 6.4 Mode of delivery
    • 6.5 Neonatal care
  • 7 Prognosis
  • 8 Epidemiology
  • 9 Society and culture
    • 9.1 Economics
    • 9.2 Notable cases
  • 10 Ethics
  • 11 References
  • 12 External links

Classification[edit]

Stages in prenatal development, with weeks and months numbered from last menstruation.

In humans, the usual definition of preterm birth is birth before a gestational age of 37 complete weeks.[17] In the normal human fetus, several organ systems mature between 34 and 37 weeks, and the fetus reaches adequate maturity by the end of this period. One of the main organs greatly affected by premature birth is the lungs. The lungs are one of the last organs to mature in the womb; because of this, many premature babies spend the first days and weeks of their lives on ventilators. Therefore, a significant overlap exists between preterm birth and prematurity. Generally, preterm babies are premature and term babies are mature. Preterm babies born near 37 weeks often have no problems relating to prematurity if their lungs have developed adequate surfactant, which allows the lungs to remain expanded between breaths. Sequelae of prematurity can be reduced to a small extent by using drugs to accelerate maturation of the fetus, and to a greater extent by preventing preterm birth.

Signs and symptoms[edit]

A new mother holds her premature baby at Kapiolani Medical Center NICU in Honolulu, Hawaii

Preterm birth causes a range of problems.[18]

The main categories of causes of preterm birth are preterm labor induction and spontaneous preterm labor. Signs and symptoms of preterm labor include four or more uterine contractions in one hour. In contrast to false labour, true labor is accompanied by cervical dilatation and effacement. Also, vaginal bleeding in the third trimester, heavy pressure in the pelvis, or abdominal or back pain could be indicators that a preterm birth is about to occur. A watery discharge from the vagina may indicate premature rupture of the membranes that surround the baby. While the rupture of the membranes may not be followed by labor, usually delivery is indicated as infection (chorioamnionitis) is a serious threat to both fetus and mother. In some cases, the cervix dilates prematurely without pain or perceived contractions, so that the mother may not have warning signs until very late in the birthing process.

A review into using uterine monitoring at home to detect contractions and possible preterm births in women at higher risk of having a preterm baby found that it did not reduce the number of preterm births.[19] The research included in the review was poor quality but it showed that home monitoring may increase the number of unplanned antenatal visits and may reduce the number of babies admitted to special care when compared with women receiving normal antenatal care.[19]

Complications[edit]

Mortality and morbidity[edit]

In the U.S. where many neonatal infections and other causes of neonatal death have been markedly reduced, prematurity is the leading cause of neonatal mortality at 25%.[20] Prematurely born infants are also at greater risk for having subsequent serious chronic health problems as discussed below.

The earliest gestational age at which the infant has at least a 50% chance of survival is referred to as the limit of viability. As NICU care has improved over the last 40 years, the limit of viability has reduced to approximately 24 weeks.[21][22] Most newborns who die, and 40% of older infants who die, were born between 20 and 25.9 weeks (gestational age), during the second trimester.[13]

As risk of brain damage and developmental delay is significant at that threshold even if the infant survives, there are ethical controversies over the aggressiveness of the care rendered to such infants. The limit of viability has also become a factor in the abortion debate.[23]

Specific risks for the preterm neonate[edit]

Preterm infants usually show physical signs of prematurity in reverse proportion to the gestational age. As a result, they are at risk for numerous medical problems affecting different organ systems.

  • Neurological problems include apnea of prematurity, hypoxic-ischemic encephalopathy (HIE), retinopathy of prematurity (ROP),[24] developmental disability, transient hyperammonemia of the newborn, cerebral palsy and intraventricular hemorrhage, the latter affecting 25% of babies born preterm, usually before 32 weeks of pregnancy.[25] Mild brain bleeds usually leave no or few lasting complications, but severe bleeds often result in brain damage or even death.[25] Neurodevelopmental problems have been linked to lack of maternal thyroid hormones, at a time when their own thyroid is unable to meet postnatal needs.[26]
  • Cardiovascular complications may arise from the failure of the ductus arteriosus to close after birth: patent ductus arteriosus (PDA).
  • Respiratory problems are common, specifically the respiratory distress syndrome (RDS or IRDS) (previously called hyaline membrane disease). Another problem can be chronic lung disease (previously called bronchopulmonary dysplasia or BPD).
  • Gastrointestinal and metabolic issues can arise from neonatal hypoglycemia, feeding difficulties, rickets of prematurity, hypocalcemia, inguinal hernia, and necrotizing enterocolitis (NEC).
  • Hematologic complications include anemia of prematurity, thrombocytopenia, and hyperbilirubinemia (jaundice) that can lead to kernicterus.
  • Infection, including sepsis, pneumonia, and urinary tract infection [1]

A study of 241 children born between 22 and 25 weeks who were currently of school age found that 46 percent had severe or moderate disabilities such as cerebral palsy, vision or hearing loss and learning problems. 34 percent were mildly disabled and 20 percent had no disabilities, while 12 percent had disabling cerebral palsy.[27][28]

Risk factors[edit]

The exact cause of preterm birth is difficult to determine and it may be multi-factorial. The cause of 50% of preterm births is never determined.[29] Labor is a complex process involving many factors. Four different pathways have been identified that can result in preterm birth and have considerable evidence: precocious fetal endocrine activation, uterine overdistension (placental abruption), decidual bleeding, and intrauterine inflammation/infection.[30]

Identifying women at high risk of giving birth early would enable the health services to provide specialized care for these women to delay the birth or make sure they are in the best place to give birth (for example a hospital with a special care baby unit). Risk scoring systems have been suggested as a possible way of identifying these women. However, there is no research in this area so it is unclear whether the risk scoring systems would prolong pregnancy and reduce the numbers of preterm births or not.[31]

Maternal factors[edit]

A number of factors have been identified that are linked to a higher risk of a preterm birth such as being less than 18 years of age.[36] Maternal height and weight can play a role.[37]

Further, in the US and the UK, black women have preterm birth rates of 15–18%, more than double than that of the white population. Filipinos are also at high risk of premature birth, and it is believed that nearly 11-15% of Filipinos born in the U.S. (compared to other Asians at 7.6% and whites at 7.8%) are premature.[38] Filipinos being a big risk factor is evidenced with the Philippines being the 8th highest ranking in the world for preterm births, the only non-African country in the top 10.[39] This discrepancy is not seen in comparison to other Asian groups or Hispanic immigrants and remains unexplained.[36]

Pregnancy interval makes a difference as women with a six-month span or less between pregnancies have a two-fold increase in preterm birth.[40] Studies on type of work and physical activity have given conflicting results, but it is opined that stressful conditions, hard labor, and long hours are probably linked to preterm birth.[36]

A history of spontaneous (i.e., miscarriage) or surgical abortion has been associated with a small increase in the risk of preterm birth, with an increased risk with increased number of abortions, although it is unclear whether the increase is caused by the abortion or by confounding risk factors (e.g., socioeconomic status).[41] Increased risk has not been shown in women who terminated their pregnancies medically.[42] Pregnancies that are unwanted or unintended are also a risk factor for preterm birth.[43]

Adequate maternal nutrition is important. Women with a low BMI are at increased risk for preterm birth.[44] Further, women with poor nutrition status may also be deficient in vitamins and minerals. Adequate nutrition is critical for fetal development and a diet low in saturated fat and cholesterol may help reduce the risk of a preterm delivery.[45] Obesity does not directly lead to preterm birth;[46] however, it is associated with diabetes and hypertension which are risk factors by themselves.[36] To some degree those individuals may have underlying conditions (i.e., uterine malformation, hypertension, diabetes) that persist.

Women with celiac disease have an increased risk of the development of preterm birth.[35] The risk of preterm birth is more elevated when celiac disease remains undiagnosed and untreated.[4]

Marital status is associated with risk for preterm birth. A study of 25,373 pregnancies in Finland revealed that unmarried mothers had more preterm deliveries than married mothers (P=0.001).[34] Pregnancy outside of marriage was associated overall with a 20% increase in total adverse outcomes, even at a time when Finland provided free maternity care. A study in Quebec of 720,586 births from 1990 to 1997 revealed less risk of preterm birth for infants with legally married mothers compared with those with common-law wed or unwed parents.[47][needs update]

Genetic make-up is a factor in the causality of preterm birth. Genetics has been a big factor into why Filipinos have a high risk of premature birth as the Filipinos have a large prevalence of mutations that help them be predisposed to premature births.[38] An intra- and transgenerational increase in the risk of preterm delivery has been demonstrated.[48] No single gene has been identified.

Subfertility is associated with preterm birth. Couples who have tried more than 1 year versus those who have tried less than 1 year before achieving a spontaneous conception have an adjusted odds ratio of 1.35 (95% confidence interval 1.22-1.50) of preterm birth.[49] Pregnancies after IVF confers a greater risk of preterm birth than spontaneous conceptions after more than 1 year of trying, with an adjusted odds ratio of 1.55 (95% CI 1.30-1.85).[49]

Factors during pregnancy[edit]

The use of fertility medication that stimulates the ovary to release multiple eggs and of IVF with embryo transfer of multiple embryos has been implicated as an important factor in preterm birth. Maternal medical conditions increase the risk of preterm birth. Often labor has to be induced for medical reasons; such conditions include high blood pressure,[50] pre-eclampsia,[51] maternal diabetes,[52] asthma, thyroid disease, and heart disease.

In a number of women anatomical issues prevent the baby from being carried to term. Some women have a weak or short cervix[50] (the strongest predictor of premature birth)[53][54][55] Women with vaginal bleeding during pregnancy are at higher risk for preterm birth. While bleeding in the third trimester may be a sign of placenta previa or placental abruption – conditions that occur frequently preterm – even earlier bleeding that is not caused by these conditions is linked to a higher preterm birth rate.[56] Women with abnormal amounts of amniotic fluid, whether too much (polyhydramnios) or too little (oligohydramnios), are also at risk.[36] The mental status of the women is of significance. Anxiety[57] and depression have been linked to preterm birth.[36]

Finally, the use of tobacco, cocaine, and excessive alcohol during pregnancy increases the chance of preterm delivery. Tobacco is the most commonly abused drug during pregnancy and contributes significantly to low birth weight delivery.[58] Babies with birth defects are at higher risk of being born preterm.[59]

Passive smoking and/or smoking before the pregnancy influences the probability of a preterm birth. The World Health Organization published an international study in March 2014.[60]

Presence of anti-thyroid antibodies is associated with an increased risk preterm birth with an odds ratio of 1.9 and 95% confidence interval of 1.1–3.5.[61]

A 2004 systematic review of 30 studies on the association between intimate partner violence and birth outcomes concluded that preterm birth and other adverse outcomes, including death, are higher among abused pregnant women than among non-abused women.[62]

The Nigerian cultural method of abdominal massage has been shown to result in 19% preterm birth among women in Nigeria, plus many other adverse outcomes for the mother and baby.[63] This ought not be confused with massage conducted by a fully trained and licensed massage therapist or by significant others trained to provide massage during pregnancy, which has been shown to have numerous positive results during pregnancy, including the reduction of preterm birth, less depression, lower cortisol, and reduced anxiety.[64]

Infection[edit]

The frequency of infection in preterm birth is inversely related to the gestational age. Mycoplasma genitalium infection is associated with increased risk of preterm birth, and spontaneous abortion.[65]

Infectious microorganisms can be ascending, hematogeneous, iatrogenic by a procedure, or retrograde through the Fallopian tubes. From the deciduas they may reach the space between the amnion and chorion, the amniotic fluid, and the fetus. A chorioamnionitis also may lead to sepsis of the mother. Fetal infection is linked to preterm birth and to significant long-term handicap including cerebral palsy.[66]

It has been reported that asymptomatic colonization of the decidua occurs in up to 70% of women at term using a DNA probe suggesting that the presence of micro-organism alone may be insufficient to initiate the infectious response.

As the condition is more prevalent in black women in the US and the UK, it has been suggested to be an explanation for the higher rate of preterm birth in these populations. It is opined that bacterial vaginosis before or during pregnancy may affect the decidual inflammatory response that leads to preterm birth. The condition known as aerobic vaginitis can be a serious risk factor for preterm labor; several previous studies failed to acknowledge the difference between aerobic vaginitis and bacterial vaginosis, which may explain some of the contradiction in the results.[67]

Untreated yeast infections are associated with preterm birth.[68]

A review into prophylactic antibiotics (given to prevent infection) in the second and third trimester of pregnancy (13–42 weeks of pregnancy) found a reduction in the number of preterm births in women with bacterial vaginosis. These antibiotics also reduced the number of waters breaking before labor in full-term pregnancies, reduced the risk of infection of the lining of the womb after delivery (endometritis), and rates of gonococcal infection. However, the women without bacterial vaginosis did not have any reduction in preterm births or pre-labor preterm waters breaking. Much of the research included in this review lost participants during follow-up so did not report the long-term effects of the antibiotics on mothers or babies. More research in this area is needed to find the full effects of giving antibiotics throughout the second and third trimesters of pregnancy.[69]

A number of maternal bacterial infections are associated with preterm birth including pyelonephritis, asymptomatic bacteriuria, pneumonia, and appendicitis. A review into giving antibiotics in pregnancy for asymptomatic bacteriuria (urine infection with no symptoms) found the research was of very low quality but that it did suggest that taking antibiotics reduced the numbers of preterm births and babies with low birth weight.[70] Another review found that one dose of antibiotics did not seem as effective as a course of antibiotics but fewer women reported side effects from one dose.[71] This review recommended that more research is needed to discover the best way of treating asymptomatic bacteriuria.[70]

A different review found that preterm births happened less for pregnant women who had routine testing for low genital tract infections than for women who only had testing when they showed symptoms of low genital tract infections.[72] The women being routinely tested also gave birth to fewer babies with a low birth weight. Even though these results look promising, the review was only based on one study so more research is needed into routine screening for low genital tract infections.[73]

Also periodontal disease has been shown repeatedly to be linked to preterm birth.[74][75] In contrast, viral infections, unless accompanied by a significant febrile response, are considered not to be a major factor in relation to preterm birth.[36]

Genetics[edit]

There is believed to be a maternal genetic component in preterm birth.[76] Estimated heritability of timing-of-birth in women was 34%. However, the occurrence of preterm birth in families does not follow a clear inheritance pattern, thus supporting the idea that preterm birth is a non-Mendelian trait with a polygenic nature.[77]

Diagnosis[edit]

Placental alpha microglobulin-1[edit]

Placental alpha microglobulin-1 (PAMG-1) has been the subject of several investigations evaluating its ability to predict imminent spontaneous preterm birth in women with signs, symptoms, or complaints suggestive of preterm labor.[78][79][80][81][82][83][84] In one investigation comparing this test to fetal fibronectin testing and cervical length measurement via transvaginal ultrasound, the test for PAMG-1 (commercially known as the PartoSure test) has been reported to be the single best predictor of imminent spontaneous delivery within 7 days of a patient presenting with signs, symptoms, or complaints of preterm labor. Specifically, the PPV, or positive predictive value, of the tests were 76%, 29%, and 30% for PAMG-1, fFN and CL, respectively (P < 0.01).[85]

Fetal fibronectin[edit]

Fetal fibronectin (fFN) has become an important biomarker—the presence of this glycoprotein in the cervical or vaginal secretions indicates that the border between the chorion and deciduas has been disrupted. A positive test indicates an increased risk of preterm birth, and a negative test has a high predictive value.[36] It has been shown that only 1% of women in questionable cases of preterm labor delivered within the next week when the test was negative.[86]

Ultrasound[edit]

Further information: Cervical incompetence

Obstetric ultrasound has become useful in the assessment of the cervix in women at risk for premature delivery. A short cervix preterm is undesirable: A cervical length of less than 25 mm at or before 24 weeks of gestational age is the most common definition of cervical incompetence.[87]

Prevention[edit]

Historically efforts have been primarily aimed to improve survival and health of preterm infants (tertiary intervention). Such efforts, however, have not reduced the incidence of preterm birth. Increasingly primary interventions that are directed at all women, and secondary intervention that reduce existing risks are looked upon as measures that need to be developed and implemented to prevent the health problems of premature infants and children.[88] Smoking bans are effective in decreasing preterm births.[89]

Before pregnancy[edit]

Adoption of specific professional policies can immediately reduce risk of preterm birth as the experience in assisted reproduction has shown when the number of embryos during embryo transfer was limited.[88] Many countries have established specific programs to protect pregnant women from hazardous or night-shift work and to provide them with time for prenatal visits and paid pregnancy-leave. The EUROPOP study showed that preterm birth is not related to type of employment, but to prolonged work (over 42 hours per week) or prolonged standing (over 6 hours per day).[90] Also, night work has been linked to preterm birth.[91] Health policies that take these findings into account can be expected to reduce the rate of preterm birth.[88] Preconceptional intake of folic acid is recommended to reduce birth defects. There is significant evidence that long-term (> one year) use of folic acid supplement preconceptionally may reduce premature birth.[92][93][94] Reducing smoking is expected to benefit pregnant women and their offspring.[88]

During pregnancy[edit]

Healthy eating can be instituted at any stage of the pregnancy including nutritional adjustments, use of vitamin supplements, and smoking cessation.[88] Calcium supplementation in women who have low dietary calcium reduces the number of negative outcomes including preterm birth, pre-eclampsia, and maternal death.[95] The World Health Organization (WHO) suggests 1.5-2 g of calcium supplements daily, for pregnant women who have low levels calcium in their diet.[95] Supplemental intake of C and E vitamins have not been found to reduce preterm birth rates.[96] Different strategies are used in the administration of prenatal care, and future studies need to determine if the focus can be on screening for high-risk women, or widened support for low-risk women, or to what degree these approaches can be merged.[88] While periodontal infection has been linked with preterm birth, randomized trials have not shown that periodontal care during pregnancy reduces preterm birth rates.[88]

Screening of low risk women[edit]

Screening for asymptomatic bacteriuria followed by appropriate treatment reduces pyelonephritis and reduces the risk of preterm birth.[97] Extensive studies have been carried out to determine if other forms of screening in low-risk women followed by appropriate intervention are beneficial, including: Screening for and treatment of Ureaplasma urealyticum, group B streptococcus, Trichomonas vaginalis, and bacterial vaginosis did not reduce the rate of preterm birth.[88] Routine ultrasound examination of the length of the cervix identifies patients at risk, but cerclage is not proven useful, and the application of a progestogen is under study.[88] Screening for the presence of fibronectin in vaginal secretions is not recommended at this time in women at low risk.

Self-care[edit]

Self-care methods to reduce the risk of preterm birth include proper nutrition, avoiding stress, seeking appropriate medical care, avoiding infections, and the control of preterm birth risk factors (e.g. working long hours while standing on feet, carbon monoxide exposure, domestic abuse, and other factors). Self-monitoring vaginal pH followed by yogurt treatment or clindamycin treatment if the pH was too high all seem to be effective at reducing the risk of preterm birth.[98][99] Additional support during pregnancy does not appear to prevent low birthweight or preterm birth.[100]

Reducing existing risks[edit]

Women are identified to be at increased risk for preterm birth on the basis of their past obstetrical history or the presence of known risk factors. Preconception intervention can be helpful in selected patients in a number of ways. Patients with certain uterine anomalies may have a surgical correction (i.e. removal of a uterine septum), and those with certain medical problems can be helped by optimizing medical therapies prior to conception, be it for asthma, diabetes, hypertension and others.

Reducing indicated preterm birth[edit]

A number of agents have been studied for the secondary prevention of indicated preterm birth. Trials using low-dose aspirin, fish oil, vitamin C and E, and calcium to reduce preeclampsia demonstrated some reduction in preterm birth only when low-dose aspirin was used.[88] Interestingly, even if agents such as calcium or antioxidants were able to reduce preeclampsia, a resulting decrease in preterm birth was not observed.[88]

Reducing spontaneous preterm birth[edit]

Reduction in activity by the mother – pelvic rest, limited work, bed rest – may be recommended although there is no evidence it is useful with some concerns it is harmful.[101] Increasing medical care by more frequent visits and more education has not been shown to reduce preterm birth rates.[100] Use of nutritional supplements such as omega-3 polyunsaturated fatty acids is based on the observation that populations who have a high intake of such agents are at low risk for preterm birth, presumably as these agents inhibit production of proinflammatory cytokines. A randomized trial showed a significant decline in preterm birth rates,[102] and further studies are in the making.

Antibiotics[edit]

While antibiotics can get rid of bacterial vaginosis in pregnancy, this does not appear to change the risk of preterm birth.[103] It has been suggested that chronic chorioamnionitis is not sufficiently treated by antibiotics alone (and therefore they cannot ameliorate the need for preterm delivery in this condition).[88]

Progestogens[edit]

Progestogens, often given in the form of progesterone or hydroxyprogesterone caproate, relaxes the uterine musculature, maintains cervical length, and has anti-inflammatory properties, and thus exerts activities expected to be beneficial in reducing preterm birth. Two meta-analyses demonstrated a reduction in the risk of preterm birth in women with recurrent preterm birth by 40–55%.[104][105]

Progestogen supplementation also reduces the frequency of preterm birth in pregnancies where there is a short cervix.[106] However, progestogens are not effective in all populations, as a study involving twin gestations failed to see any benefit.[107]

Cervical cerclage[edit]

In preparation for childbirth, the woman’s cervix shortens. Preterm cervical shortening is linked to preterm birth and can be detected by ultrasonography. Cervical cerclage is a surgical intervention that places a suture around the cervix to prevent its shortening and widening. Numerous studies have been performed to assess the value of cervical cerclage and the procedure appears helpful primarily for women with a short cervix and a history of preterm birth.[106][108] Instead of a prophylactic cerclage, women at risk can be monitored during pregnancy by sonography, and when shortening of the cervix is observed, the cerclage can be performed.[88]

Management[edit]

About 75% of nearly a million deaths due to preterm deliver would survive if provided warmth, breastfeeding, treatments for infection, and breathing support.[109] If a baby has cardiac arrest at birth and is before 23 weeks or less than 400 gms attempts at resuscitation are not indicated.[110]

Tertiary interventions are aimed at women who are about to go into preterm labor, or rupture the membranes or bleed preterm. The use of the fibronectin test and ultrasonography improves the diagnostic accuracy and reduces false-positive diagnosis. While treatments to arrest early labor where there is progressive cervical dilatation and effacement will not be effective to gain sufficient time to allow the fetus to grow and mature further, it may defer delivery sufficiently to allow the mother to be brought to a specialized center that is equipped and staffed to handle preterm deliveries.[111] In a hospital setting women are hydrated via intravenous infusion (as dehydration can lead to premature uterine contractions).[112]

Steroids[edit]

Severely premature infants may have underdeveloped lungs because they are not yet producing their own surfactant. This can lead directly to respiratory distress syndrome, also called hyaline membrane disease, in the neonate. To try to reduce the risk of this outcome, pregnant mothers with threatened premature delivery prior to 34 weeks are often administered at least one course of glucocorticoids, a steroid that crosses the placental barrier and stimulates the production of surfactant in the lungs of the baby.[11] Steroid use up to 37 weeks is also recommended by the American Congress of Obstetricians and Gynecologists.[11] Typical glucocorticoids that would be administered in this context are betamethasone or dexamethasone, often when the pregnancy has reached viability at 23 weeks.

In cases where premature birth is imminent, a second “rescue” course of steroids may be administered 12 to 24 hours before the anticipated birth. There are still some concerns about the efficacy and side-effects of a second course of steroids, but the consequences of RDS are so severe that a second course is often viewed as worth the risk. A 2015 Cochrane review supports the use of repeat dose(s) of prenatal corticosteroids for women still at risk of preterm birth seven days or more after an initial course.[113]

Beside reducing respiratory distress, other neonatal complications are reduced by the use of glucocorticosteroids, namely intraventricular bleeding, necrotising enterocolitis, and patent ductus arteriosus.[114] A single course of antenatal corticosteroids could be considered routine for preterm delivery, but there are some concerns about applicability of this recommendation to low-resource settings with high rates of infections.[114] It remains unclear whether one corticosteroid (or one particular regimen) has advantages over another.[115]

Concerns about adverse effects of prenatal corticosteroids include increased risk for maternal infection, difficulty with diabetic control, and possible long-term effects on neurodevelopmental outcomes for the infants. There is ongoing discussion about when steroids should be given (i.e. only antenatally or postnatally too) and for how long (i.e. single course or repeated administration). Despite these unknowns, there is a consensus that the benefits of a single course of prenatal glucocorticosteroids vastly outweigh the potential risks.[116][117][118]

Antibiotics[edit]

The routine administration of antibiotics to all women with threatened preterm labor reduces the risk of the baby to get infected with group B streptococcus and has been shown to reduce related mortality rates.[119]

When membranes rupture prematurely, obstetrical management looks for development of labor and signs of infection. Prophylactic antibiotic administration has been shown to prolong pregnancy and reduced neonatal morbidity with rupture of membranes at less than 34 weeks.[120] Because of concern about necrotizing enterocolitis, amoxicillin or erythromycin has been recommended, but not amoxicillin + clavulanic acid (co-amoxiclav).[120]

Tocolysis[edit]

A number of medications may be useful to delay delivery including: NSAIDs, calcium channel blockers, beta mimetics, and atosiban.[121] Tocolysis rarely delays delivery beyond 24–48 hours.[122] This delay however may be sufficient to allow the pregnant woman to be transferred to a center specialized for management of preterm deliveries and give administered corticosteroids to reduce neonatal organ immaturity. Meta-analyses indicate that calcium-channel blockers and an oxytocin antagonist can delay delivery by 2–7 days, and β2-agonist drugs delay by 48 hours but carry more side effects.[88][123] Magnesium sulfate does not appear to be useful to prevent preterm birth.[124] It use before delivery however does appear to decrease the risk of cerebral palsy.[125]

Mode of delivery[edit]

The routine use of cesarean section for early delivery of infants expected to have very low birth weight is controversial,[88][126] and a decision concerning the route and time of delivery probably needs to be made on a case by case basis.

Neonatal care[edit]

After delivery, plastic wraps or warm mattresses are useful to keep the infant warm on their way to the NICU.[127] In developed countries premature infants are usually cared for in a neonatal intensive care unit (NICU). The physicians who specialize in the care of very sick or premature babies are known as neonatologists. In the NICU, premature babies are kept under radiant warmers or in incubators (also called isolettes), which are bassinets enclosed in plastic with climate control equipment designed to keep them warm and limit their exposure to germs. Modern neonatal intensive care involves sophisticated measurement of temperature, respiration, cardiac function, oxygenation, and brain activity. Treatments may include fluids and nutrition through intravenous catheters, oxygen supplementation, mechanical ventilation support, and medications. In developing countries where advanced equipment and even electricity may not be available or reliable, simple measures such as kangaroo care (skin to skin warming), encouraging breastfeeding, and basic infection control measures can significantly reduce preterm morbidity and mortality. Bili lights may also be used to treat newborn jaundice (hyperbilirubinemia).

Water can be carefully provided to prevent dehydration but no so much to increase risks of side effects.[128]

In a 2012 policy statement, the American Academy of Pediatrics recommended feeding preterm infants human milk, finding “significant short- and long-term beneficial effects,” including lower rates of necrotizing enterocolitis (NEC). [129]

Prognosis[edit]

The chance of survival at 22 weeks is about 6%, while at 23 weeks it is 26%, 24 weeks 55% and 25 weeks about 72%.[15] The chances of survival without long-term difficulties is less.[16] In the developed world overall survival is about 90% while in low-income countries survival rates are about 10%.[109]

Some children will adjust well during childhood and adolescence,[130] although disability is more likely nearer the limits of viability. A large study followed children born between 22 and 25 weeks until the age of 6 years old. Of these children, 46 percent had moderate to severe disabilities such as cerebral palsy, vision or hearing loss and learning disabilities, 34 percent had mild disabilities, and 20 percent had no disabilities. 12 percent had disabling cerebral palsy.[28]

As survival has improved, the focus of interventions directed at the newborn has shifted to reduce long-term disabilities, particularly those related to brain injury.[130] Some of the complications related to prematurity may not be apparent until years after the birth. A long-term study demonstrated that the risks of medical and social disabilities extend into adulthood and are higher with decreasing gestational age at birth and include cerebral palsy, intellectual disability, disorders of psychological development, behavior, and emotion, disabilities of vision and hearing, and epilepsy.[131] Standard intelligence tests showed that 41 percent of children born between 22 and 25 weeks had moderate or severe learning disabilities when compared to the test scores of a group of similar classmates who were born at full-term.[28] It is also shown that higher levels of education were less likely to be obtained with decreasing gestational age at birth.[131] People born prematurely may be more susceptible to developing depression as teenagers.[132] Some of these problems can be described as being within the executive domain and have been speculated to arise due to decreased myelinization of the frontal lobes.[133] Studies of people born premature and investigated later with MRI brain imaging, demonstrate qualitative anomalies of brain structure and grey matter deficits within temporal lobe structures and the cerebellum that persist into adolescence.[134] Throughout life they are more likely to require services provided by physical therapists, occupational therapists, or speech therapists.[130]

Despite the neurosensory, mental and educational problems studied in school age and adolescent children born extremely preterm, the majority of preterm survivors born during the early years of neonatal intensive care are found to do well and to live fairly normal lives in young adulthood.[135] Young adults born preterm seem to acknowledge that they have more health problems than their peers, yet feel the same degree of satisfaction with their quality of life.[136]

Beyond the neurodevelopmental consequences of prematurity, infants born preterm have a greater risk for many other health problems. For instance, children born prematurely have an increased risk for developing chronic kidney disease.[137]

Epidemiology[edit]

Disability-adjusted life year for prematurity and low birth weight per 100,000 inhabitants in 2004.[138]

  no data
  less than 120
  120-240
  240-360
  360-480
  480-600
  600-720
  720-840
  840-960
  960-1080
  1080-1200
  1200-1500
  more than 1500

Preterm birth complicates the births of infants worldwide affecting 5% to 18% of births.[68] In Europe and many developed countries the preterm birth rate is generally 5–9%, and in the USA it has even risen to 12–13% in the last decades.[139]

As weight is easier to determine than gestational age, the World Health Organization tracks rates of low birth weight (< 2,500 grams), which occurred in 16.5 percent of births in less developed regions in 2000.[140] It is estimated that one-third of these low birth weight deliveries are due to preterm delivery. Weight generally correlates to gestational age, however, infants may be underweight for other reasons than a preterm delivery. Neonates of low birth weight (LBW) have a birth weight of less than 2500 g (5 lb 8 oz) and are mostly but not exclusively preterm babies as they also include small for gestational age (SGA) babies. Weight-based classification further recognizes Very Low Birth Weight (VLBW) which is less than 1500 g, and Extremely Low Birth Weight (ELBW) which is less than 1000 g.[141] Almost all neonates in these latter two groups are born preterm.

Complications from preterm births resulted in 0.74 million deaths in 2013 down from 1.57 million in 1990.[14]

Society and culture[edit]

Economics[edit]

Preterm birth is a significant cost factor in healthcare, not even considering the expenses of long-term care for individuals with disabilities due to preterm birth. A 2003 study in the US determined neonatal costs to be $224,400 for a newborn at 500–700 g versus $1,000 at over 3,000 g. The costs increase exponentially with decreasing gestational age and weight.[142] The 2007 Institute of Medicine report Preterm Birth [143] found that the 550,000 preemies born each year in the U.S. run up about $26 billion in annual costs, mostly related to care in NICUs, but the real tab may top $50 billion.[144]

Notable cases[edit]

James Elgin Gill (born on 20 May 1987 in Ottawa, Ontario, Canada) was the earliest premature baby in the world, until that record was broken in 2014. He was 128 days premature (21 weeks and 5 days gestation) and weighed 1 pound 6 ounces (624 g). He survived.[145][146]

In 2014, a baby girl born in San Antonio became the youngest premature baby in the world. The daughter of Courtney Stensrud was born at 21 weeks 4 days and weighed 410 grams (less than a pound). Kaashif Ahmad resuscitated the baby after she was born. As of 2017, the girl was in preschool and on par with her peers.[147]

Amillia Taylor is also often cited as the most premature baby.[148] She was born on 24 October 2006 in Miami, Florida, at 21 weeks and 6 days gestation.[149] This report has created some confusion as her gestation was measured from the date of conception (through in vitro fertilization) rather than the date of her mother’s last menstrual period making her appear 2 weeks younger than if gestation was calculated by the more common method.[132] At birth, she was 9 inches (22.9 cm) long and weighed 10 ounces (283 grams).[148] She suffered digestive and respiratory problems, together with a brain hemorrhage. She was discharged from the Baptist Children’s Hospital on 20 February 2007.[148]

The record for the smallest premature baby to survive was held for a considerable amount of time by Madeline Mann, who was born in 1989 at 26 weeks weighing 9.9 oz (280 g) and 9.5 inches (24.1 cm) long.[150] This record was broken in September 2004 by Rumaisa Rahman, who was born in the same hospital[151] at 25 weeks gestation. At birth, she was eight inches (20 cm) long and weighed 244 grams (8.6 ounces). Her twin sister was also a small baby, weighing 563 grams (1 pound 4 ounces) at birth. During pregnancy their mother had suffered from pre-eclampsia, which causes dangerously high blood pressure putting the baby into distress and requiring birth by caesarean section. The larger twin left the hospital at the end of December, while the smaller remained there until 10 February 2005 by which time her weight had increased to 1.18 kg (2.6 lb).[152] Generally healthy, the twins had to undergo laser eye surgery to correct vision problems, a common occurrence among premature babies.

The world’s smallest premature boy to survive was born in February 2009 at Children’s Hospitals and Clinics of Minnesota in Minneapolis, Minnesota. Jonathon Whitehill was born at 25 weeks gestation with a weight of 310 grams (10.9 ounces). He was hospitalized in the Neonatal Intensive Care Unit for five months, and then discharged.[153]

Historical figures who were born prematurely include Johannes Kepler (born in 1571 at 7 months gestation), Isaac Newton (born in 1642, small enough to fit into a quart mug, according to his mother), Winston Churchill (born in 1874 at 7 months gestation), Anna Pavlova (born in 1885 at 7 months gestation),[154] Mark Twain (born 1835 two months early), Albert Einstein (born 1879 premature), and Stevie Wonder (born 1950 six weeks early).[155]

Ethics[edit]

The transformation of medical care means that extremely premature and very ill babies have better chances of survival than ever before. But it is difficult to predict which babies will die and which will live, though possibly with severe disabilities. As a consequence, families and health professionals have to make complex decisions about how much intervention is necessary or justifiable.

The most difficult decisions are about whether or not to resuscitate a premature baby and admit him or her to neonatal intensive care, or whether to withdraw intensive care and give the child palliative care.

This is discussed at great length in a report “Critical care decisions in fetal and neonatal medicine: ethical issues”[156] produced by the London-based Nuffield Council for Bioethics.

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  • ^ Mittal P, Romero R, Soto E, Cordoba M, Chang CL, Vaisbuch E, Bieda J, Chaiworapongsa T, Kusanovic JP, Yeo L, et al. A role for placental a-microglobulin-1 in the identification of women with a sonographic short cervix at risk for spontaneous rupture of membranes. Am J Obstet Gynecol, Supplement to December 2009.Vol 201, n86, pp S196–197.
  • ^ Lee SM, Lee J, Seong HS, Lee SE, Park JS, Romero R, Yoon BH (2009). “The clinical significance of a positive Amnisure test TM in women with term labor with intact membranes”. J Matern Fetal Neonatal Med. 22 (4): 305–310. doi:10.1080/14767050902801694. PMC 2744034 . CS1 maint: Multiple names: authors list (link)
  • ^ Lee SM, Yoon BH, Park CW, Kim SM, Park JW (2011). “Intra-amniotic inflammation in patients with a positive Amnisure test in preterm labor and intact membranes”. Am J Obstet Gynecol. 204 (1): S209. doi:10.1016/j.ajog.2010.10.543. CS1 maint: Multiple names: authors list (link)
  • ^ Lee MS, Romero R, Park JW, Kim SM, Park CW, Korzeniewski S, Chaiworapongsa T, Yoon BH (Sep 2012). “The clinical significance of a positive Amnisure test(™) in women with preterm labor”. J Matern Fetal Neonatal Med. 25 (9): 1690–8. doi:10.3109/14767058.2012.657279. PMC 3422421 . PMID 22280400. CS1 maint: Multiple names: authors list (link)
  • ^ Sukchaya K, Phupong V (Aug 2013). “A comparative study of positive rate of placental alpha-microglobulin-1 test in pre-term pregnant women with and without uterine contraction”. J Obstet Gynaecol. 33 (6): 566–8. doi:10.3109/01443615.2013.807786. PMID 23919851. 
  • ^ Nikolova T, Bayev O, Nikolova N, Di Renzo GC. Evaluation of a novel placental alpha microglobulin-1 (PAMG-1) test to predict spontaneous preterm delivery. J Perinat Med. 2013 Dec 13:1-5.
  • ^ Nikolova T, Bayev O, Nikolova N, Di Renzo GC. Comparison of a novel test for placental alpha microglobulin-1 with fetal fibronectin and cervical length measurement for the prediction of imminent spontaneous preterm delivery in patients with threatened preterm labor. J Perinat Med. 2015 Jan 6. [Epub ahead of print]
  • ^ Morice P, Lassau N, Pautier P, Haie-Meder C, Lhomme C, Castaigne D (2001). “Vaginal fetal fibronectin levels and spontaneous preterm birth in symptomatic women”. Obstetrics & Gynecology. 97 (2): 225–228. doi:10.1016/S0029-7844(00)01130-3. PMID 11165586. 
  • ^ Cervical incompetence Archived 7 March 2014 at the Wayback Machine. from Radiopaedia. Authors: Dr Praveen Jha and Dr Laughlin Dawes et al. Retrieved Feb 2014
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  • ^ Been JV, Nurmatov UB, Cox B, Nawrot TS, van Schayck CP, Sheikh A (May 3, 2014). “Effect of smoke-free legislation on perinatal and child health: a systematic review and meta-analysis”. Lancet. 383 (9928): 1549–60. doi:10.1016/S0140-6736(14)60082-9. PMID 24680633. 
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  • ^ Other Complications include:
    • Jaundice Of Prematurity
    • Atrial septal defects commonly seen in babies with bronchopulmonary dysplasia because their lungs are so fragile.
    • GER Gastroesophageal reflux
    • Patent Ductus Arterosis
    • Seizures
    • Immature GI system so feeding from an (NG) tube or nasogastric tube may help make feeding easier on the babies’ tummy. Also theirs[clarification needed] TPN feeding or Total Parenteral Nutrition is made up of lipids, calories, good fats calcium, magnesium sulfate and other vitamins including B and C. Neonatalogists work with the family as a whole instead of just the neonate or baby whose systems are to immature to actually swallow food so babies between 23-28 weeks are fed through a neonatal gastric tube from the babies nose to the stomach. In some neonates, there are disabilities from varying conditions of the baby this depends on the gestational age the babies delivered a.uUsually, women with severe enough preeclampsia will deliver earlier than normal and those mothers worry greatly because of all of their rumors about NICUs and babies needing wheelchairs glasses and also needing medicines for seizures and ADD/ADHD, Borderline Personality Disorder, anxiety disorders.

    Pompeii LA, Savitz DA, Evenson KR, Rogers B, McMahon M (2005). “Physical exertion at work and the risk of preterm delivery and small-for-gestational-age birth”. Obstetrics & Gynecology. 106 (6): 1279–1288. doi:10.1097/01.AOG.0000189080.76998.f8. PMID 16319253. 

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  • ^ Crowther, Caroline A.; McKinlay, Christopher J. D.; Middleton, Philippa; Harding, Jane E. (2015-07-05). “Repeat doses of prenatal corticosteroids for women at risk of preterm birth for improving neonatal health outcomes”. The Cochrane Database of Systematic Reviews (7): CD003935. doi:10.1002/14651858.CD003935.pub4. ISSN 1469-493X. PMID 26142898. 
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  • ^ Brownfoot, Fiona C.; Gagliardi, Daniela I.; Bain, Emily; Middleton, Philippa; Crowther, Caroline A. (2013-08-29). “Different corticosteroids and regimens for accelerating fetal lung maturation for women at risk of preterm birth”. The Cochrane Database of Systematic Reviews (8): CD006764. doi:10.1002/14651858.CD006764.pub3. ISSN 1469-493X. PMID 23990333. 
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  • ^ “Archived copy”. Archived from the original on 18 January 2017. Retrieved 18 July 2017. 
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  • ^ Schrag S, Gorwitz R, Fultz-Butts K, Schuchat A (2002). “Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC”. MMWR. Recommendations and Reports. 51 (RR-11): 1–22. PMID 12211284. 
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  • ^ Haas DM, Caldwell DM, Kirkpatrick P, McIntosh JJ, Welton NJ (Oct 9, 2012). “Tocolytic therapy for preterm delivery: systematic review and network meta-analysis”. BMJ (Clinical research ed.). 345: e6226. doi:10.1136/bmj.e6226. PMC 4688428 . PMID 23048010. 
  • ^ Simhan HN, Caritis SN (2007). “Prevention of Preterm Delivery”. New England Journal of Medicine. 357 (5): 477–487. doi:10.1056/NEJMra050435. PMID 17671256. 
  • ^ Li X, Zhang Y, Shi Z (February 2005). “Ritodrine in the treatment of preterm labour: a meta-analysis”. Indian J. Med. Res. 121 (2): 120–7. PMID 15756046. 
  • ^ Crowther CA, Brown J, McKinlay CJ, Middleton P (Aug 15, 2014). “Magnesium sulphate for preventing preterm birth in threatened preterm labour”. The Cochrane Database of Systematic Reviews. 8 (8): CD001060. doi:10.1002/14651858.CD001060.pub2. PMID 25126773. 
  • ^ Crowther, CA; Middleton, PF; Voysey, M; Askie, L; Duley, L; Pryde, PG; Marret, S; Doyle, LW; AMICABLE, Group. (October 2017). “Assessing the neuroprotective benefits for babies of antenatal magnesium sulphate: An individual participant data meta-analysis”. PLoS medicine. 14 (10): e1002398. doi:10.1371/journal.pmed.1002398. PMID 28976987. 
  • ^ Alfirevic, Zarko; Milan, Stephen J.; Livio, Stefania (2012-06-13). “Caesarean section versus vaginal delivery for preterm birth in singletons”. The Cochrane Database of Systematic Reviews (6): CD000078. doi:10.1002/14651858.CD000078.pub2. ISSN 1469-493X. PMC 4164504 . PMID 22696314. 
  • ^ McCall EM, Alderdice F, Halliday HL, Jenkins JG, Vohra S (Mar 17, 2010). “Interventions to prevent hypothermia at birth in preterm and/or low birthweight infants”. The Cochrane Database of Systematic Reviews (3): CD004210. doi:10.1002/14651858.CD004210.pub4. PMID 20238329. 
  • ^ Bell EF, Acarregui MJ (4 December 2014). “Restricted versus liberal water intake for preventing morbidity and mortality in preterm infants”. The Cochrane Database of Systematic Reviews. 12 (12): CD000503. doi:10.1002/14651858.CD000503.pub3. PMID 25473815. 
  • ^ American Academy of Pediatrics, Section on Breastfeeding (2012). “Breastfeeding and the Use of Human Milk”. Pediatrics. 129 (3): e827–e841. doi:10.1542/peds.2011-3552. PMID 22371471. Archived from the original on 27 July 2013. Retrieved 25 July 2013. Meta-analyses of 4 randomized clinical trials performed over the period 1983 to 2005 support the conclusion that feeding preterm infants human milk is associated with a significant reduction (58%) in the incidence of NEC. 
  • ^ a b c Saigal S, Doyle LW (2008). “An overview of mortality and sequelae of preterm birth from infancy to adulthood”. The Lancet. 371 (9608): 261–269. doi:10.1016/S0140-6736(08)60136-1. PMID 18207020. 
  • ^ a b Moster D, Lie RT, Markestad T (2008). “Long-Term Medical and Social Consequences of Preterm Birth”. New England Journal of Medicine. 359 (3): 262–273. doi:10.1056/NEJMoa0706475. PMID 18635431. 
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  • External links[edit]

    • Preterm Birth: Causes, Consequences and Prevention (PDF). Institute of Medicine. 

    Maternal care related to the
    fetus and amniotic cavity

    • amniotic fluid
      • Oligohydramnios
      • Polyhydramnios
    • Braxton Hicks contractions
    • chorion / amnion
      • Amniotic band syndrome
      • Chorioamnionitis
      • Chorionic hematoma
      • Monoamniotic twins
      • Premature rupture of membranes
    • Obstetrical bleeding
      • Antepartum
    • placenta
      • Circumvallate placenta
      • Monochorionic twins
      • Placenta praevia
      • Placental abruption
      • Twin-to-twin transfusion syndrome

    Labor

    • Amniotic fluid embolism
    • Cephalopelvic disproportion
    • Dystocia
      • Shoulder dystocia
    • Fetal distress
    • Locked twins
    • Obstetrical bleeding
      • Postpartum
    • Pain management during childbirth
    • placenta
      • Placenta accreta
    • Preterm birth
    • Postmature birth
    • Umbilical cord prolapse
    • Uterine rupture
    • Vasa praevia

    Puerperal

    • Breastfeeding difficulties
      • Low milk supply
      • Cracked nipples
    • Breast engorgement
    • Childbirth-related posttraumatic stress disorder
    • Diastasis symphysis pubis
    • Postpartum bleeding
    • Peripartum cardiomyopathy
    • Postpartum depression
    • Postpartum thyroiditis
    • Puerperal fever
    • Puerperal mastitis

    Other

    • Concomitant conditions
      • Diabetes mellitus
      • Systemic lupus erythematosus
      • Thyroid disorders
    • Maternal death
    • Sexual activity during pregnancy

    Length of gestation
    and fetal growth

    • Small for gestational age/Large for gestational age
    • Preterm birth/Postmature birth
    • Intrauterine growth restriction

    Birth trauma

    • scalp
      • Cephalhematoma
      • Chignon
      • Caput succedaneum
      • Subgaleal hemorrhage
    • Brachial plexus lesion
      • Erb’s palsy
      • Klumpke paralysis

    By system

    Infectious

    • Vertically transmitted infection
    • Neonatal infection
      • Congenital rubella syndrome
      • Neonatal herpes simplex
      • Mycoplasma hominis infection
      • Ureaplasma urealyticum infection
    • Omphalitis
    • Neonatal sepsis
      • Group B streptococcal infection
    • Neonatal conjunctivitis

    Other

    • Miscarriage
    • Perinatal mortality
      • Stillbirth
      • Infant mortality
    • Neonatal withdrawal


    Birth

    For other uses, see Birth (disambiguation) and Childbirth.

    Lambing: the mother licks the first lamb while giving birth to the second

    Birth is the act or process of bearing or bringing forth offspring.[1] In mammals, the process is initiated by hormones which cause the muscular walls of the uterus to contract, expelling the fetus at a developmental stage when it is ready to feed and breathe. In some species the offspring is precocial and can move around almost immediately after birth but in others it is altricial and completely dependent on parenting. In marsupials, the fetus is born at a very immature stage after a short gestational period and develops further in its mother’s womb’s pouch.

    It is not only mammals that give birth. Some reptiles, amphibians, fish and invertebrates carry their developing young inside them. Some of these are ovoviviparous, with the eggs being hatched inside the mother’s body, and others are viviparous, with the embryo developing inside her body, as in mammals.

    Contents

    • 1 Mammals
      • 1.1 Human childbirth
      • 1.2 Cattle
      • 1.3 Dogs
      • 1.4 Marsupials
    • 2 Other animals
    • 3 See also
    • 4 References
    • 5 Cited texts

    Mammals[edit]

    Large mammals, such as primates, cattle, horses, some antelopes, giraffes, hippopotamuses, rhinoceroses, elephants, seals, whales, dolphins, and porpoises, generally are pregnant with one offspring at a time, although they may have twin or multiple births on occasion. In these large animals, the birth process is similar to that of a human, though in most the offspring is precocial. This means that it is born in a more advanced state than a human baby and is able to stand, walk and run (or swim in the case of an aquatic mammal) shortly after birth.[2] In the case of whales, dolphins and porpoises, the single calf is normally born tail first which minimises the risk of drowning.[3] The mother encourages the newborn calf to rise to the surface of the water to breathe.[4]

    Most smaller mammals have multiple births, producing litters of young which may number twelve or more. In these animals, each fetus is surrounded by its own amniotic sac and has a separate placenta. This separates from the wall of the uterus during labor and the fetus works its way towards the birth canal.[citation needed]

    Large mammals which give birth to twins is much more rare, but it does occur occasionally even for mammals as large as elephants. In April 2018, approximately 8-month old elephant twins were sighted joining their mother’s herd in the Tarangire National Park of Tanzania, estimated to have been born in August 2017.[5]

    Human childbirth[edit]

    Main article: Childbirth
    Further information: Adaptation to extrauterine life

    An illustration of normal head-first presentation by the obstetrician William Smellie from about 1792. The membranes have ruptured and the cervix is fully dilated.

    Humans usually produce a single offspring at a time. The mother’s body is prepared for birth by hormones produced by the pituitary gland, the ovary and the placenta.[2] The total gestation period from fertilization to birth is normally about 38 weeks (birth usually occurring 40 weeks after the last menstrual period). The normal process of childbirth takes several hours and has three stages. The first stage starts with a series of involuntary contractions of the muscular walls of the uterus and gradual dilation of the cervix. The active phase of the first stage starts when the cervix is dilated more than about 4 cm in diameter and is when the contractions become stronger and regular. The head (or the buttocks in a breech birth) of the baby is pushed against the cervix, which gradually dilates until is fully dilated at 10 cm diameter. At some time, the amniotic sac bursts and the amniotic fluid escapes (also known as rupture of membranes or breaking the water).[6] In stage two, starting when the cervix is fully dilated, strong contractions of the uterus and active pushing by the mother expels the baby out through the vagina, which during this stage of labour is called a birth canal as this passage contains a baby, and the baby is born with umbilical cord attached.[7] In stage three, which begins after the birth of the baby, further contractions expel the placenta, amniotic sac, and the remaining portion of the umbilical cord usually within a few minutes.[8]

    Enormous changes take place in the newborn’s circulation to enable breathing in air. In the uterus, the unborn baby is dependent on circulation of blood through the placenta for sustenance including gaseous exchange and the unborn baby’s blood bypasses the lungs by flowing through the foramen ovale, which is a hole in the septum dividing the right atrium and left atrium. After birth the umbilical cord is clamped and cut, the baby starts to breathe air, and blood from the right ventricle starts to flow to the lungs for gaseous exchange and oxygenated blood returns to the left atrium, which is pumped into the left ventricle, and then pumped into the main arterial system. As result of these changes, the blood pressure in the left atrium exceeds the pressure in the right atrium, and this pressure difference forces the foramen ovale to close separating the left and right sides of the heart. The umbilical vein, umbilical arteries, ductus venosus and ductus arteriosus are not needed for life in air and in time these vessels become ligaments (embryonic remnants).[9]

    Cattle[edit]

    A cow giving birth

    Birthing in cattle is typical of a larger mammal. A cow goes through three stages of labor during normal delivery of a calf. During stage one, the animal seeks a quiet place away from the rest of the herd. Hormone changes cause soft tissues of the birth canal to relax as the mother’s body prepares for birth. The contractions of the uterus are not obvious externally, but the cow may be restless. She may appear agitated, alternating between standing and lying down, with her tail slightly raised and her back arched. The fetus is pushed toward the birth canal by each contraction and the cow’s cervix gradually begins to dilate. Stage one may last several hours, and ends when the cervix is fully dilated. Stage two can be seen to be underway when there is external protrusion of the amniotic sac through the vulva, closely followed by the appearance of the calf’s front hooves and head in a front presentation (or occasionally the calf’s tail and rear end in a posterior presentation).[10] During the second stage, the cow will usually lie down on her side to push and the calf progresses through the birth canal. The complete delivery of the calf (or calves in a multiple birth) signifies the end of stage two. The cow scrambles to her feet (if lying down at this stage), turns round and starts vigorously licking the calf. The calf takes its first few breaths and within minutes is struggling to rise to its feet. The third and final stage of labor is the delivery of the placenta, which is usually expelled within a few hours and is often eaten by the normally herbivorous cow.[10][11]

    Dogs[edit]

    Further information: Canine reproduction § Gestation and litters

    Birth is termed whelping in dogs.[12] Among dogs, as whelping approaches, contractions become more frequent. Labour in the bitch can be divided into 3 stages. The first stage is when the cervix dilates, this causes discomfort and restlessness in the bitch. Common signs of this stage are panting, fasting, and/or vomiting. This may last up to 12hrs.[12] Stage two is the passage of the offspring.[12] The amniotic sac looking like a glistening grey balloon, with a puppy inside, is propelled through the vulva. After further contractions, the sac is expelled and the bitch breaks the membranes releasing clear fluid and exposing the puppy. The mother chews at the umbilical cord and licks the puppy vigorously, which stimulates it to breathe. If the puppy has not taken its first breath within about six minutes, it is likely to die. Further puppies follow in a similar way one by one usually with less straining than the first usually at 15-60min intervals. If a pup has not been passed in 2 hrs a veterinarian should be contacted.[12] Stage three is the passing of the placentas. This often occurs in conjunction with stage two with the passing of each offspring.[12] The mother will then usually eat the afterbirth.[13] This is an adaption to keep the den clean and prevent detection of predators.[12]

    Marsupials[edit]

    See also: Marsupial § Reproductive system, and Marsupial § Early development

    A kangaroo joey firmly attached to a nipple inside the pouch

    An infant marsupial is born in a very immature state. The gestation period is usually shorter than the intervals between oestrus periods. The first sign that a birth is imminent is the mother cleaning out her pouch. When it is born, the infant is pink, blind, furless and a few centimetres long. It has nostrils in order to breathe and forelegs to cling onto its mother’s hairs but its hind legs are undeveloped. It crawls through its mother’s fur and makes its way into the pouch. Here it fixes onto a teat which swells inside its mouth. It stays attached to the teat for several months until it is sufficiently developed to emerge.[14] Joeys are born with “oral shields”; in species without pouches or with rudimentary pouches these are more developed than in forms with well-developed pouches, implying a role in maintaining the young attached to the mother’s nipple.[15]

    Other animals[edit]

    Many reptiles and the vast majority of invertebrates, most fish, amphibians and all birds are oviparous, that is, they lay eggs with little or no embryonic development taking place within the mother. In aquatic organisms, fertilization is nearly always external with sperm and eggs being liberated into the water (an exception is sharks and rays, which have internal fertilization[16]). Millions of eggs may be produced with no further parental involvement, in the expectation that a small number may survive to become mature individuals. Terrestrial invertebrates may also produce large numbers of eggs, a few of which may avoid predation and carry on the species. Some fish, reptiles and amphibians have adopted a different strategy and invest their effort in producing a small number of young at a more advanced stage which are more likely to survive to adulthood. Birds care for their young in the nest and provide for their needs after hatching and it is perhaps unsurprising that internal development does not occur in birds, given their need to fly.[17]

    Ovoviviparity is a mode of reproduction in which embryos develop inside eggs that remain in the mother’s body until they are ready to hatch. Ovoviviparous animals are similar to viviparous species in that there is internal fertilization and the young are born in an advanced state, but differ in that there is no placental connection and the unborn young are nourished by egg yolk. The mother’s body provides gas exchange (respiration), but that is largely necessary for oviparous animals as well.[17] In many sharks the eggs hatch in the oviduct within the mother’s body and the embryos are nourished by the egg’s yolk and fluids secreted by glands in the walls of the oviduct.[18] The Lamniforme sharks practice oophagy, where the first embryos to hatch consume the remaining eggs and sand tiger shark pups cannibalistically consume neighbouring embryos. The requiem sharks maintain a placental link to the developing young, this practice is known as viviparity. This is more analogous to mammalian gestation than to that of other fishes. In all these cases, the young are born alive and fully functional.[19] The majority of caecilians are ovoviviparous and give birth to already developed offspring. When the young have finished their yolk sacs they feed on nutrients secreted by cells lining the oviduct and even the cells themselves which they eat with specialist scraping teeth.[20] The Alpine salamander (Salamandra atra) and several species of Tanzanian toad in the genus Nectophrynoides are ovoviviparous, developing through the larval stage inside the mother’s oviduct and eventually emerging as fully formed juveniles.[21]

    A more developed form of viviparity called placental viviparity is adopted by some species of scorpions[22] and cockroaches,[23] certain genera of sharks, snakes and velvet worms. In these, the developing embryo is nourished by some form of placental structure. The earliest known placenta was found recently in a group of extinct fishes called placoderms, which are ancestral to mammals. A fossil from Australia’s Gogo Formation, laid down in the Devonian period, 380 million years ago, was found with an embryo inside it connected by an umbilical cord to a yolk sac. The find confirmed the hypothesis that a sub-group of placoderms, called ptyctodontids, fertilized their eggs internally. Some fishes that fertilize their eggs internally also give birth to live young, as seen here. This discovery moved our knowledge of live birth back 200 million years.[24] The fossil of another genus was found with three embryos in the same position.[25] Placoderms are a sister group of the ancestor of all living jawed fishes (Gnathostomata), including both chondrichthyians, the sharks & rays, and Osteichthyes, the bony fishes.

    Among lizards, the viviparous lizard Zootoca vivipara, slow worms and many species of skink are viviparous, giving birth to live young. Some are ovoviviparous but others such as members of the genera Tiliqua and Corucia, give birth to live young that develop internally, deriving their nourishment from a mammal-like placenta attached to the inside of the mother’s uterus. In a recently described example, an African species, Trachylepis ivensi, has developed a purely reptilian placenta directly comparable in structure and function to a mammalian placenta.[26] Vivipary is rare in snakes, but boas and vipers are viviparous, giving birth to live young.

    Female aphid giving birth

    The majority of insects lay eggs but a very few give birth to offspring that are miniature versions of the adult.[17] The aphid has a complex life cycle and during the summer months is able to multiply with great rapidity. Its reproduction is typically parthenogenetic and viviparous and females produce unfertilized eggs which they retain within their bodies.[27] The embryos develop within their mothers’ ovarioles and the offspring are clones of their mothers. Female nymphs are born which grow rapidly and soon produce more female offspring themselves.[28] In some instances, the newborn nymphs already have developing embryos inside them.[17]

    See also[edit]

    • Animal sexual behaviour
    • Breeding season
    • Dystocia
    • Foaling (horses)
    • Gestation
    • Kegel exercises
    • Lambing (sheep)
    • Mating system
    • Odon device
    • Reproduction
    • Reproductive system
    • Perineal massage
    • Episiotomy
    • Caesarean section
    • Forceps delivery
    • Ventouse

    References[edit]

  • ^ “birth”. OED Online. June 2013. Oxford University Press. Entry 19395 (accessed 30 August 2013).
  • ^ a b Dorit, R. L.; Walker, W. F.; Barnes, R. D. (1991). Zoology. Saunders College Publishing. pp. 526–527. ISBN 978-0-03-030504-7. 
  • ^ Mark Simmonds, Whales and Dolphins of the World, New Holland Publishers (2007), Ch. 1, p. 32 ISBN 1845378202.
  • ^ Crockett, Gary (2011). “Humpback Whale Calves”. Humpback whales Australia. Retrieved 2013-08-28. 
  • ^ “Trunk Twins : Elephant Twins Born in Tarangire | Asilia Africa”. Asilia Africa. 2018-04-06. Retrieved 2018-04-06. 
  • ^ NICE (2007). Section 1.6, Normal labour: first stage
  • ^ NICE (2007). Section 1.7, Normal labour: second stage
  • ^ NICE (2007). Section 1.8, Normal labour: third stage
  • ^ Houston, Rob (editor); Lea, Maxine (art editor) (2007). The Human Body Book. Dorling Kindersley. p. 215. ISBN 978-1-8561-3007-3. CS1 maint: Extra text: authors list (link)
  • ^ a b “Calving”. Alberta: Agriculture and Rural Development. 2000-02-01. Retrieved 2013-08-28. 
  • ^ “Calving Management in Dairy Herds: Timing of Intervention and Stillbirth” (PDF). The Ohio State University College of Veterinary Medicine Extension. 2012. Retrieved 2013-12-17. 
  • ^ a b c d e f Kustritz, M. (2005). “Reproductive behaviour of small animals”. Theriogenology. 64 (3): 734–746. doi:10.1016/j.theriogenology.2005.05.022. 
  • ^ Dunn, T.J. “Whelping: New Puppies On The Way!”. Puppy Center. Pet MD. Retrieved 2013-08-28. 
  • ^ “Reproduction and development”. Thylacine Museum. Retrieved 2013-08-28. 
  • ^ Yvette Schneider Nanette (Aug 2011). “The development of the olfactory organs in newly hatched monotremes and neonate marsupials”. J. Anat. 219 (2): 229–242. doi:10.1111/j.1469-7580.2011.01393.x. PMC 3162242 . 
  • ^ Sea World, Sharks & Rays; accessed 2013.09.09.
  • ^ a b c d Attenborough, David (1990). The Trials of Life. pp. 26–30. ISBN 9780002199124. 
  • ^ Adams, Kye R.; Fetterplace, Lachlan C.; Davis, Andrew R.; Taylor, Matthew D.; Knott, Nathan A. (January 2018). “Sharks, rays and abortion: The prevalence of capture-induced parturition in elasmobranchs”. Biological Conservation. 217: 11–27. doi:10.1016/j.biocon.2017.10.010. 
  • ^ “Birth and care of young”. Animals: Sharks and rays. Busch Entertainment Corporation. Archived from the original on August 3, 2013. Retrieved 2013-08-28. 
  • ^ Stebbins, Robert C.; Cohen, Nathan W. (1995). A Natural History of Amphibians. Princeton University Press. pp. 172–173. ISBN 978-0-691-03281-8. 
  • ^ Stebbins, Robert C.; Cohen, Nathan W. (1995). A Natural History of Amphibians. Princeton University Press. p. 204. ISBN 978-0-691-03281-8. 
  • ^ Capinera, John L., Encyclopedia of entomology. Springer Reference, 2008, p. 3311.
  • ^ Costa, James T., The Other Insect Societies. Belknap Press, 2006, p. 151.
  • ^ Dennis, Carina (2008-05-28). “Nature News: The oldest pregnant mum: Devonian fossilized fish contains an embryo”. Nature. 453 (7195): 575. Bibcode:2008Natur.453..575D. doi:10.1038/453575a. 
  • ^ Long, John A.; Trinastic, Kate; Young, Gavin C.; Senden, Tim (2008-05-28). “Live birth in the Devonian period”. Nature. 453 (7195): 650–652. Bibcode:2008Natur.453..650L. doi:10.1038/nature06966. PMID 18509443. 
  • ^ Blackburn DG, Flemming AF (2012). “Invasive implantation and intimate placental associations in a placentotrophic African lizard, Trachylepis ivensi (scincidae)”. J. Morphol. 273 (2): 137–59. doi:10.1002/jmor.11011. PMID 21956253. 
  • ^ Blackman, Roger L (1979). “Stability and variation in aphid clonal lineages”. Biological Journal of the Linnean Society. 11 (3): 259–277. doi:10.1111/j.1095-8312.1979.tb00038.x. ISSN 1095-8312. 
  • ^ Conrad, Jim (2011-12-10). “The aphid life cycle”. The Backyard Nature Website. Retrieved 2013-08-31. 
  • Cited texts[edit]

    • “Intrapartum care: Care of healthy women and their babies during childbirth”. NICE. September 2007. Archived from the original on 2014-04-26. 


    Several birth

    “Triplets” redirects here. For other uses, see Triplet.

    Identical triplet brothers at graduation. Identical triplets are extremely rare.

    A multiple birth is the culmination of one multiple pregnancy, wherein the mother delivers two or more offspring. A term most applicable to placental species, multiple births occur in most kinds of mammals, with varying frequencies. Such births are often named according to the number of offspring, as in twins and triplets. In non-humans, the whole group may also be referred to as a litter, and multiple births may be more common than single births. Multiple births in humans are the exception, and can be exceptionally rare in the largest mammals.

    Each single fertilized egg (zygote) may produce a single embryo, or it may split into two or more embryos, each carrying the same genetic material. Fetuses resulting from different zygotes are called fraternal and share only 50% of their genetic material, as ordinary full siblings from separate births do. Fetuses resulting from the same zygote share 100% of their genetic material, and are hence called identical and are always of the same sex (except in cases of Turner syndrome).

    A multiple pregnancy may be the result of the fertilization of a single egg that then splits to create identical fetuses, or it may be the result of the fertilization of multiple eggs that create fraternal fetuses, or it may be a combination of these two. A multiple pregnancy from a single zygote is called monozygotic, from two zygotes is called dizygotic, or from two or more zygotes is called polyzygotic.

    Similarly, the siblings themselves from a multiple birth may be referred to as monozygotic if they are identical, or as polyzygotic if they are fraternal.

    Contents

    • 1 Terminology
    • 2 Human multiple births
      • 2.1 Twins
      • 2.2 Triplets
      • 2.3 Quadruplets
      • 2.4 Quintuplets
      • 2.5 Sextuplets
      • 2.6 Very high-order multiple births
    • 3 Causes and frequency
    • 4 Risks
      • 4.1 Premature birth and low birth weight
      • 4.2 Cerebral palsy
      • 4.3 Incomplete separation
      • 4.4 Mortality rate (stillbirth)
      • 4.5 Prevention in IVF
    • 5 Management
      • 5.1 Selective reduction
      • 5.2 Care in pregnancy
      • 5.3 Nutrition
      • 5.4 Cesarean section or vaginal delivery
      • 5.5 Neonatal intensive care
    • 6 Society and culture
      • 6.1 Insurance coverage
      • 6.2 Cultural aspects
    • 7 See also
    • 8 References
    • 9 External links

    Terminology[edit]

    Fraternal twins at two weeks old. The technical term for “fraternal” is “polyzygotic”.

    Fraternal twin sisters taking a nap. Nonidentical twins, the most common kind of multiple birth among humans, occur in about 1 out of every 80 pregnancies.

    Terms used for multiple births or the genetic relationships of their offspring:

    • Monozygotic – multiple (typically two) fetuses produced by the splitting of a single zygote
    • Dizygotic – multiple (typically two) fetuses produced by two zygotes
    • Trizygotic – three or more fetuses produced by three zygotes
    • Polyzygotic – multiple fetuses produced by two or more zygotes

    Terms used for the number of offspring in a multiple birth:

    • Two offspring – twins
    • Three offspring – triplets
    • Four offspring – quadruplets
    • Five offspring – quintuplets
    • Six offspring – sextuplets
    • Seven offspring – septuplets
    • Eight offspring – octuplets
    • Nine offspring – nonuplets
    • Ten offspring – decuplets

    See List of Multiple Births

    Human multiple births[edit]

    In humans, the average length of pregnancy (two weeks fewer than gestation) is 38 weeks with a single fetus. This average decreases for each additional fetus: to thirty-six weeks for twin births, thirty-two weeks for triplets, and thirty weeks for quadruplets. With the decreasing gestation time, the risks from immaturity at birth and subsequent viability increase with the size of the sibling group. Only as of the twentieth century have more than four all survived infancy.

    Recent history has also seen increasing numbers of multiple births. In the United States, it has been estimated that by 2011, 36% of twin births and 78% of triplet and higher-order births resulted from conception by assisted reproductive technology.[1]

    Twins[edit]

    Main article: Twin

    Twins are by far the most common form of multiple births in humans. The U.S. Centers for Disease Control and Prevention report more than 132,000 sets of twins out of 3.9 million births of all kinds each year, about 3.4%, or 1 in 30.[2]

    Triplets[edit]

    Identical triplets like these three sisters occur when a single fertilized egg splits in two and then one of the resulting two eggs splits again.

    Play media

    Monoamniotic triplets as seen on ultrasound[3]

    Identical triplets come from a monozygotic pregnancy, three fetuses from one egg. The most common set, strictly fraternal triplets, comes from a polyzygotic pregnancy of three eggs. Between these types, triplets that include an identical (monozygotic) pair of siblings plus a fraternal sibling are the result of a dizygotic pregnancy, where one zygote divides into two fetuses and the other doesn’t.

    Triplets are far less common than twins, according to the U.S. Centers for Disease Control and Prevention, accounting for only about 4300 sets in 3.9 million births, just a little more than 0.1%, or 1 in 1000.[2] According to the American Society of Reproductive Medicine, only about 10% of these are identical triplets: about 1 in ten thousand.[2] Nevertheless, only 4 sets of identical triplets were reported in the U.S. during 2015, about one in a million.[2] According to Victor Khouzami, Chairman of Obstetrics at Greater Baltimore Medical Center, “No one really knows the incidence”.[2]

    Identical triplets or quadruplets are very rare and result when the original fertilized egg splits and then one of the resultant cells splits again (for triplets) or, even more rarely, a further split occurs (for quadruplets). The odds of having identical triplets is unclear. News articles and other non-scientific organizations give odds from one in 60,000 to one in 200 million pregnancies.[2][4][5][6][7][8]

    Quadruplets[edit]

    Quadruplets are much rarer than twins or triplets. As of 2007, there were approximately 3500 sets recorded worldwide. Quadruplet births are becoming increasingly common due to fertility treatments. There are around 70 sets of all-identical quadruplets worldwide. Many sets of quadruplets contain a mixture of identical and fraternal siblings, such as three identical and one fraternal, two identical and two fraternal, or two pairs of identicals. One famous set of identical quadruplets was the Genain quadruplets, all of whom developed schizophrenia. Quadruplets are sometimes referred to as “quads” in Britain.[9]

    Quintuplets[edit]

    The Canadian Dionne sisters, seen in this 1947 photograph, were the first quintuplets known to survive infancy.

    Quintuplets occur naturally in 1 in 55,000,000 births.[10] The first quintuplets known to survive infancy were the all-female Canadian Dionne Quintuplets, born in 1934. Quintuplets are sometimes referred to as “quins” in the UK and “quints” in North America.[11]

    Sextuplets[edit]

    Born in Liverpool, England on 18 November 1983, the Walton sextuplets were the world’s first all-female surviving sextuplets, and the world’s fourth known set of surviving sextuplets. Another well-known set of sextuplets is the Gosselin sextuplets, born May 10, 2004 in Hershey, Pennsylvania.[12] Reality television shows called Jon & Kate Plus 8 and later Kate Plus 8 have chronicled the lives of these sextuplets.

    Very high-order multiple births[edit]

    In 1997, the McCaughey septuplets were born in Carlisle, Iowa. Multiple births of as many as eight babies have been born alive, the first set on record to the Chukwu family in Texas in 1998; one died and seven survived. In 2009, a second set, the Suleman octuplets, were born in Bellflower, California.[13][14] The most recent report that all were still alive shortly before their fifth birthday.[15]

    There have been a few sets of nonuplets (nine) in which a few babies were born alive, though none lived longer than a few days. There have been cases of human pregnancies that started out with ten, eleven, twelve or fifteen fetuses, but no instances of live births. The pregnancies of the 10, 11 and 15 fetuses have all resulted from fertility medications and assisted reproductive technology (ART). However, there has been one documented case when 12 fetuses were conceived naturally.[16][not in citation given]

    Causes and frequency[edit]

    The frequency of N multiple births from natural pregnancies has been given as approximately 1:89N-1 (Hellin’s law) and as about 1:80N-1.[17] This gives:

    • 1:89 (= 1.1%) or 1:80 (= 1.25%) for twins
    • 1:892 (= 1:7921, about 0.013%) or 1:802 (= 1:6400) for triplets
    • 1:893 (= approx. 0.000142%, less than 1:700,000) or 1:803 for quadruplets

    North American dizygotic twinning occurs about once in 83 conceptions, and triplets about once in 8000 conceptions. US figures for 2010 were:[18][19]

    • Twins, 132,562, 3.31%
    • Triplets, 5,503, 0.14%
    • Quadruplets, 313, 0.0078%
    • Quintuplets and more, 37, 0.00092%

    Human multiple births can occur either naturally (the woman ovulates multiple eggs or the fertilized egg splits into two) or as the result of infertility treatments such as IVF (several embryos are often transferred to compensate for lower quality) or fertility drugs (which can cause multiple eggs to mature in one ovulatory cycle).

    For reasons that are not yet known, the older a woman is, the more likely she is to have a multiple birth naturally. It is theorized that this is due to the higher level of follicle-stimulating hormone that older women sometimes have as their ovaries respond more slowly to FSH stimulation.[20]

    The number of multiple births has increased over the last decade. For example, in Canada between 1979 and 1999, the number of multiple birth babies increased 35%. Before the advent of ovulation-stimulating drugs, triplets were quite rare (approximately 1 in 8000 births) and higher-order births much rarer still.[citation needed] Much of the increase can probably be attributed to the impact of fertility treatments, such as in-vitro fertilization. Younger patients who undergo treatment with fertility medication containing artificial FSH, followed by intrauterine insemination, are particularly at risk for multiple births of higher order.

    The Gosselin sextuplets with their parents and sisters, cover of KoreAm, May 2008

    Certain factors appear to increase the likelihood that a woman will naturally conceive multiples. These include:

    • mother’s age: women over 35 are more likely to have multiples than younger women[21]
    • mother’s use of fertility drugs: approximately 35% of pregnancies arising through the use of fertility treatments such as IVF involve more than one child

    The increasing use of fertility drugs and consequent increased rate of multiple births has made the phenomenon of multiples more frequent and hence more visible. In 2004 the birth of sextuplets, six children, to Pennsylvania couple Kate and Jon Gosselin helped them to launch their television series, originally Jon & Kate Plus 8 and (following their divorce) Kate Plus 8, which became the highest-rated show on the TLC network.

    Risks[edit]

    Premature birth and low birth weight[edit]

    Babies born from multiple-birth pregnancies are much more likely to result in premature birth than those from single pregnancies. 51% of twins and 91% of triplets are born preterm, compared to 9.4% in singletons.[22] 14% of twins and 41% of triplets are even born very preterm, compared to 1.7% in singletons.[22]

    At present, there is no way to stop twins being born early.[23] In women with single pregnancies drugs called betamimetics can relax the muscles of the uterus and delay birth.[24] Giving betamimetics can give more time to give steroids, for the baby’s lung development, or to transfer the mother to a hospital with a special care unit.[24]

    However, there is not enough evidence to say whether or not women with twin pregnancies should be given oral betamimetics to reduce the risk of preterm birth.[23] In some studies betamimetics have reduced the rate of preterm labour in twin pregnancies however the studies are too small to draw any solid conclusions.[23] Likewise, putting a stitch in the neck of the womb (a cervical suture) to prevent premature birth has not been shown to work in women carrying more than one baby due to the small sample sizes in the studies.[25]

    The preterm births also result in multiples tending to have a lower birth weight compared to singletons.

    Some evidence[who?] indicates that only 1.10% of singletons are born with a very low birth weight and 10.12% twins and 31.88% triplets were found to be born with very low birth weight. This study[who?] was conducted by looking at the statistics from the U.S. Natality Files (5).

    Among the exceptions are the Kupresak triplets of Mississauga, Ontario, Canada; their combined weight at birth in 2008, of 17 lbs, 2.7 ounces, set a world record.[26]

    Cerebral palsy[edit]

    Cerebral palsy is more common among multiple births than single births, being 2.3 per 1,000 survivors in singletons, 13 in twins, and 45 in triplets in North West England.[27] This is likely a side effect of premature birth and low birth weight.

    Incomplete separation[edit]

    Further information: Twin § Degree of separation

    Multiples may be monochorionic, sharing the same chorion, with resultant risk of twin-to-twin transfusion syndrome. Monochorionic multiples may even be monoamniotic, sharing the same amniotic sac, resulting in risk of umbilical cord compression and nuchal cord. In very rare cases, there may be conjoined twins, possibly impairing function of internal organs.

    Mortality rate (stillbirth)[edit]

    Multiples are also known to have a higher mortality rate. It is more common for multiple births to be stillborn, while for singletons the risk is not as high. A literary review on multiple pregnancies shows a study done on one set each of septuplets and octuplets, two sets of sextuplets, 8 sets of quintuplets, 17 sets of quadruplets, and 228 sets of triplets. By doing this study, Hammond found that the mean gestational age (how many weeks when birthed) at birth was 33.4 weeks for triplets and 31 weeks for quadruplets. This shows that stillbirth happens usually 3–5 weeks before the woman reaches full term and also that for sextuplets or higher it almost always ends in death of the fetuses.[28] Though multiples are at a greater risk of being stillborn, there is inconclusive evidence whether the actual mortality rate is higher in multiples than in singletons.

    Prevention in IVF[edit]

    Today many multiple pregnancies are the result of in vitro fertilisation (IVF). In a study in 1997 of 2,173 embryo transfers performed as part of in vitro fertilisation (IVF), 34% were successfully delivered pregnancies.[29] The overall multiple pregnancy rate was 31.3% (24.7% twins, 5.8% triplets, and .08% quadruplets).[29] Because IVFs are producing more multiples, a number of efforts are being made to reduce the risk of multiple births- specifically triplets or more. Medical practitioners are doing this by limiting the number of embryos per embryo transfer to one or two. That way, the risks for the mother and fetuses are decreased.

    The appropriate number of embryos to be transferred depends on the age of the woman, whether it is the first, second or third full IVF cycle attempt and whether there are top-quality embryos available. According to a guideline from The National Institute for Health and Care Excellence (NICE) in 2013, the number of embryos transferred in a cycle should be chosen as in following table:[30]

    Also, it is recommended to use single embryo transfer in all situations if a top-quality blastocyst is available.[30]

    Management[edit]

    Bed rest has not been found to change outcomes and therefore is not generally recommended outside of a research study.[31]

    Selective reduction[edit]

    Main article: Selective reduction

    Selective reduction is the termination of one or more, but not all, of the fetuses in a multiple pregnancy. This is often done in pregnancies with multiple gestations to increase the likelihood that one child may live a healthy life. Armour[32] reported a loss rate of 5.4% in a review of 1,000 cases of selective reduction. Fifteen percent of the losses occurred within 4 weeks of the procedures and more than 50% occurred after 8 weeks. This suggests that the reduction was successful at reducing the embryos from multiple gestations to single.

    Though selective reduction seems to be effective, mothers of multiples who undergo this procedure are at a higher risk of miscarrying compared to that of an unreduced multiple pregnancy. A study done by looking at 158 pregnant women who underwent selective reduction from higher order multiples to twins showed that the mother had a 10.6% chance of miscarriage. Mothers of twin pregnancies without reduction only had a 9.5% chance of miscarriage. A study by Antsaklis[33] showed a small increase in mortality for reduced twin pregnancies versus unreduced twin pregnancies.

    However, there is a lack of good quality research on the risks and benefits of selective reduction procedures.[34] Many parents often find the suggestion of selective termination upsetting particularly if the pregnancy is a result of IVF or they have had difficulty getting pregnant in the past. Background, religious or personal beliefs can all play a part in effecting whether parents want to go through with the procedure and could be the reason why research in this area is scarce.[34]

    Competition among fertility clinics does not appear to increase rates of multiple births from fertility treatment by promoting more aggressive embryo transfer decisions.[35]

    Care in pregnancy[edit]

    Women with a multiple pregnancy are usually seen more regularly by midwives or doctors than those with singleton pregnancies because of the higher risks of complications.[36] However, there is currently no evidence to suggest that specialised antenatal services produce better outcomes for mother or babies than ‘normal’ antenatal care. [37]

    Nutrition[edit]

    As preterm birth is such a risk for women with multiple pregnancies, it has been suggested that these women should be encouraged to follow a high-calorie diet to increase the birth weights of the babies. Evidence around this subject is not yet good enough to advise women to do this because the long term effects of the high-calorie diets on the mother are not known.[38]

    Cesarean section or vaginal delivery[edit]

    A study in 2013 involving 106 participating centers in 25 countries came to the conclusion that, in a twin pregnancy of a gestational age between 32 weeks 0 days and 38 weeks 6 days, and the first twin is in cephalic presentation, planned Cesarean section does not significantly decrease or increase the risk of fetal or neonatal death or serious neonatal disability, as compared with planned vaginal delivery.[39] In this study, 44% of the women planned for vaginal delivery still ended up having Cesarean section for unplanned reasons such as pregnancy complications. In comparison, it has been estimated that 75% of twin pregnancies in the United States were delivered by Cesarean section in 2008.[40] Also in comparison, the rate of Cesarean section for all pregnancies in the general population varies between 40% and 14%.[41]

    Fetal position (the way the babies are lying in the womb) usually determines if they are delivered by caesarean section or vaginally. A review of good quality research on this subject found that if the twin that will be born first (i.e. is lowest in the womb) is head down there is no good evidence that caesarean section will be safer than a vaginal birth for the mother or babies.[42]

    Monoamniotic twins (twins that form after the splitting of a fertilised egg and share the same amniotic fluid sac) are at more risk of complications than twins that have their own sacs. There is also insufficient evidence around whether to deliver the babies early by caesarean section or to wait for labour to start naturally while running checks on the babies’ wellbeing.[43] The birth of this type of twins should therefore be decided with the mother and her family and should take into account the need for good neonatal care services.[44]

    Cesarean delivery is needed when first twin is in non cephalic presentation or when it is a monoamniotic twin pregnancy.

    Neonatal intensive care[edit]

    Multiple-birth infants are usually admitted to neonatal intensive care immediately after being born. The records for all the triplet pregnancies managed and delivered from 1992-1996 were looked over to see what the neonatal statistics were. Kaufman[45] found from reviewing these files that during a five-year period, 55 triplet pregnancies, which is 165 babies, were delivered. Of the 165 babies 149 were admitted to neonatal intensive care after the delivery.

    Society and culture[edit]

    A women bearing 9 or 11 children, Prodigiorum ac ostentorum chronicon, 1557, by Conrad Lycosthenes

    Insurance coverage[edit]

    A study by the U.S. Agency for Healthcare Research and Quality found that, in 2011, pregnant women covered by private insurance in the United States were older and more likely to have multiple gestation than women covered by Medicaid.[46]

    Cultural aspects[edit]

    Certain cultures consider multiple births a portent of either good or evil.[47]

    Mayan culture saw twins as a blessing, and was fascinated by the idea of two bodies looking alike. The Mayans used to believe that twins were one soul that had fragmented.[citation needed]

    In Ancient Rome, the legend of the twin brothers who founded the city (Romulus and Remus) made the birth of twin boys a blessing, while twin girls were seen as an unlucky burden, since both would have to be provided with an expensive dowry at about the same time.

    Beatrix with her seven swan-children, in the Knight of the Swan romance (Talbot Shrewsbury Book)

    In Greek mythology, fraternal twins Castor and Polydeuces, and Heracles and Iphicles, are sons of two different fathers. One of the twins (Polydeuces, Heracles) is the illegitimate son of the god Zeus; his brother is the son of their mother’s mortal husband. A similar pair of twin sisters are Helen (of Troy) and Clytemnestra (who are also sisters of Castor and Polydeuces). The theme occurs in other mythologies as well, and is called superfecundation.

    In certain medieval European chivalric romances, such as Marie de France’s Le Fresne, a woman cites a multiple birth (often to a lower-class woman) as proof of adultery on her part; while this may reflect a widespread belief, it is invariably treated as malicious slander, to be justly punished by the accuser having a multiple birth of her own, and the events of the romance are triggered by her attempt to hide one or more of the children.[48] A similar effect occurs in the Knight of the Swan romance, in the Beatrix variants of the Swan-Children; her taunt is punished by giving birth to seven children at once, and her wicked mother-in-law returns her taunt before exposing the children.[49]

    See also[edit]

    • Biological reproduction
    • Conjoined twins
    • The Loud House a 2016 animated series, the character Rita Loud was the mother of eleven children.
    • Half a Dozen Babies a 1999 drama film, about the 1993 born Dilley sextuplets.
    • List of multiple births
    • List of twins
    • Only child
    • Superfecundation (multiple pregnancy resulting from separate sexual intercourses)
    • Twin
    • Feodor Vassilyev

    References[edit]

  • ^ Kulkarni AD, Jamieson DJ, Jones HW, Kissin DM, Gallo MF, Macaluso M, Adashi EY (2013). “Fertility Treatments and Multiple Births in the United States”. New England Journal of Medicine. 369 (23): 2218–2225. doi:10.1056/NEJMoa1301467. PMID 24304051. 
  • ^ a b c d e f Cohn, Meredith (October 23, 2015). “Rare identical triplets born to Baltimore couple”. Baltim. Sun. Retrieved October 23, 2015. 
  • ^ “UOTW #19 – Ultrasound of the Week”. Ultrasound of the Week. 23 September 2014. Retrieved 27 May 2017. 
  • ^ Keating, Caitlin (January 10, 2015). “1 in a Million Chance: Minnesota Mom Welcomes Identical Triplets”. People. Retrieved January 15, 2015. 
  • ^ “Rare identical triplets born in Austria”. Vienna. Reuters. August 8, 2007. Retrieved January 15, 2015. 
  • ^ Mohney, Gillian (December 5, 2013). “Identical Triplets, Conceived without Fertility Drugs, are ‘One in a Million'”. ABC News. Retrieved January 15, 2015. 
  • ^ Fierro, Pamela Prindle (December 15, 2014). “Identical Triplets”. About.com. Retrieved 15 January 2015. 
  • ^ “Mothers of Supertwins: Supertwins Statistics”. Archived from the original on January 18, 2015. Retrieved January 15, 2015. 
  • ^ Oxford English Dictionary, 2nd ed.: “quads” used for “quadruplets”
  • ^ Multiples in pregnancy – twins triplets quads identical and fraternal development information. Baby2see.com. Retrieved on 2015-04-15.
  • ^ Oxford English Dictionary, 2nd ed.: “quads” used for “quadruplets” and “quins” for “quintuplets” in various senses
  • ^ http://news.psu.edu/story/215904/2004/05/10/day-after-mothers-day-gosselin-sextuplets-arrive
  • ^ US woman gives birth to octuplets, BBC
  • ^ Octuplets born in Bellflower, LA Times
  • ^ 8 facts about ‘Octomom’ Nadya Suleman
  • ^ Facts About Multiples
  • ^ Melissa Bush, MD, & Martin L. Pernoll, MD (2006). Multiple Pregnancy. Pregnancy Health Center -Multiple Pregnancy. McGraw Hill Professional. Retrieved 2007-06-20. CS1 maint: Multiple names: authors list (link)
  • ^ National Center for Health Statistics – Multiple Births
  • ^ National Vital Statistics Reports, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, Volume 61, Number 1, August 28, 2012, Births: Final Data for 2010
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  • ^ “Multiple Pregnancy – ACOG”. www.acog.org. Retrieved 2016-01-13. 
  • ^ a b Alexander G., Kogan M., Martin J., Papiernik E. (1998). “What are the fetal growth patterns of singletons, twins, and triplets in the United States?”. Clinical Obstetrics and Gynecology. 41 (1): 114–125. CS1 maint: Multiple names: authors list (link) Note: This study was done by looking at the 1991–1995 U.S. Natality Files, which were received from the National Center for Health Statistics
  • ^ a b c Yamasmit, W; Chaithongwongwatthana, S; Tolosa, JE; Limpongsanurak, S; Pereira, L; Lumbiganon, P (8 December 2015). “Prophylactic oral betamimetics for reducing preterm birth in women with a twin pregnancy”. The Cochrane Database of Systematic Reviews. 12: CD004733. doi:10.1002/14651858.CD004733.pub4. PMID 26645888. 
  • ^ a b Neilson, JP; West, HM; Dowswell, T (5 February 2014). “Betamimetics for inhibiting preterm labour”. The Cochrane Database of Systematic Reviews. 2: CD004352. doi:10.1002/14651858.CD004352.pub3. PMID 24500892. 
  • ^ Rafael, TJ; Berghella, V; Alfirevic, Z (10 September 2014). “Cervical stitch (cerclage) for preventing preterm birth in multiple pregnancy”. The Cochrane Database of Systematic Reviews. 9: CD009166. doi:10.1002/14651858.CD009166.pub2. PMID 25208049. 
  • ^ Le, Julia (26 July 2011). “Scale-tipping triplets set world record”. Mississauga News. Mississauga ON. Retrieved 26 July 2011. ; note that the record wasn’t confirmed until July 2011.
  • ^ Pharoah PO, Cooke T (1996). “Cerebral palsy and multiple births”. Arch. Dis. Child. Fetal Neonatal Ed. 75 (3): F174–7. doi:10.1136/fn.75.3.f174. PMC 1061194 . PMID 8976682. Note: They conducted a study by looking at the registered births of babies born with cerebral palsy during the periods of 1982-1989 in the counties of Merseyside and Cheshire. 
  • ^ Hammond KR (1998). “Multifetal pregnancy reduction”. J Obstet Gynecol Neonatal Nurs. 27 (3): 338–43. doi:10.1111/j.1552-6909.1998.tb02657.x. PMID 9620827. 
  • ^ a b Elsner CW, Tucker MJ, Sweitzer CL, Brockman WD, Morton PC, Wright G, Toledo AA (1997). “Multiple pregnancy rate and embryo number transferred during in vitro fertilization”. Am. J. Obstet. Gynecol. 177 (2): 350–5; discussion 355–7. PMID 9290450. 
  • ^ a b Fertility: assessment and treatment for people with fertility problems. NICE clinical guideline CG156 – Issued: February 2013
  • ^ McCall, CA; Grimes, DA; Lyerly, AD (June 2013). “”Therapeutic” bed rest in pregnancy: unethical and unsupported by data”. Obstetrics and gynecology. 121 (6): 1305–8. doi:10.1097/aog.0b013e318293f12f. PMID 23812466. 
  • ^ Armour KL, Callister LC (2005). “Prevention of triplets and higher order multiples: trends in reproductive medicine”. J Perinat Neonatal Nurs. 19 (2): 103–11. doi:10.1097/00005237-200504000-00006. PMID 15923959. 
  • ^ Antsaklis A, Drakakis P, Vlazakis G, Michalas S (1998). “Reduction of multifetal pregnancies to twins does not increase obstetrics or perinatal risks”. Human Reproduction. 14 (5): 1338–1340. doi:10.1093/humrep/14.5.1338. 
  • ^ a b Dodd, JM; Dowswell, T; Crowther, CA (4 November 2015). “Reduction of the number of fetuses for women with a multiple pregnancy”. The Cochrane Database of Systematic Reviews. 11: CD003932. doi:10.1002/14651858.CD003932.pub3. PMID 26544079. 
  • ^ Henne MB, Bundorf MK (April 2010). “The effects of competition on assisted reproductive technology outcomes”. Fertil. Steril. 93 (6): 1820–30. doi:10.1016/j.fertnstert.2008.02.159. PMID 18442821. 
  • ^ Dodd, JM; Dowswell, T; Crowther, CA (6 November 2015). “Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes”. The Cochrane Database of Systematic Reviews. 11: CD005300. doi:10.1002/14651858.CD005300.pub4. PMID 26545291. 
  • ^ Dodd JM, Dowswell T, Crowther CA (2015). “Specialised antenatal clinics for women with a multiple pregnancy for improving maternal and infant outcomes”. Cochrane Database Syst Rev (11): CD005300. doi:10.1002/14651858.CD005300.pub4. PMID 26545291. 
  • ^ Bricker, L; Reed, K; Wood, L; Neilson, JP (24 November 2015). “Nutritional advice for improving outcomes in multiple pregnancies”. The Cochrane Database of Systematic Reviews. 11: CD008867. doi:10.1002/14651858.CD008867.pub3. PMID 26599328. 
  • ^ Barrett JF, Hannah ME, Hutton EK, Willan AR, Allen AC, Armson BA, Gafni A, Joseph KS, Mason D, Ohlsson A, Ross S, Sanchez JJ, Asztalos EV (2013). “A Randomized Trial of Planned Cesarean or Vaginal Delivery for Twin Pregnancy”. New England Journal of Medicine. 369 (14): 1295–1305. doi:10.1056/NEJMoa1214939. PMC 3954096 . PMID 24088091. 
  • ^ Lee HC, Gould JB, Boscardin WJ, El-Sayed YY, Blumenfeld YJ (2011). “Trends in Cesarean Delivery for Twin Births in the United States”. Obstetrics & Gynecology. 118 (5): 1095–101. doi:10.1097/AOG.0b013e3182318651. PMC 3202294 . PMID 22015878. 
  • ^ Women can choose Caesarean birth – BBC article by James Gallagher. 2011.
  • ^ Hofmeyr, GJ; Barrett, JF; Crowther, CA (19 December 2015). “Planned caesarean section for women with a twin pregnancy”. The Cochrane Database of Systematic Reviews. 12: CD006553. doi:10.1002/14651858.CD006553.pub3. PMC 4110647 . PMID 26684389. 
  • ^ Shub, A; Walker, SP (23 April 2015). “Planned early delivery versus expectant management for monoamniotic twins”. The Cochrane Database of Systematic Reviews. 4: CD008820. doi:10.1002/14651858.CD008820.pub2. PMID 25906204. 
  • ^ Shub, A; Walker, SP (23 April 2015). “Planned early delivery versus expectant management for monoamniotic twins”. The Cochrane Database of Systematic Reviews. 4: CD008820. doi:10.1002/14651858.CD008820.pub2. PMID 25906204. 
  • ^ Kaufman GE, Malone FD, Harvey-Wilkes KB, Chelmow D, Penzias AS, D’Alton ME (1998). “Neonatal morbidity and mortality associated with triplet pregnancy”. Obstet Gynecol. 91 (3): 342–8. doi:10.1016/s0029-7844(97)00686-8. PMID 9491857. 
  • ^ Moore JE, Witt WP, Elixhauser A (April 2014). “Complicating Conditions Associate With Childbirth, by Delivery Method and Payer, 2011”. HCUP Statistical Brief #173. Rockville, MD: Agency for Healthcare Research and Quality. 
  • ^ “Korea’s ‘lucky’ triplets seized”. Herald Sun. Fairfax. 2003-03-30. 
  • ^ Laura A. Hibbard, Medieval Romance in England p295, 244 New York Burt Franklin,1963
  • ^ Laura A. Hibbard, Medieval Romance in England p239, 243 New York Burt Franklin,1963
  • External links[edit]

    • Facts About Multiples
    • HFEA consultation on multiple births after IVF
    • D. L. Ashliman, Multiple Births in Legend and Folklore
    • Twins and Multiple Births Association

    Childbirth

    Postpartum

    Obstetric history

    • Gravidity
    • Parity
    • TPAL


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