This document presents a case report of a 25-year-old woman managed for an early preterm triplet pregnancy complicated by antepartum fetal loss of one triplet, chronic hypertension, and urinary tract infection. She underwent an emergency cesarean section at 29 weeks gestation, delivering two live male infants weighing 1.3kg and 0.9kg, and one female infant weighing 1.4kg. Both the mother and neonates were discharged in stable condition, with the neonates requiring care for extreme prematurity. Management of multifetal gestations involves increased antenatal surveillance and monitoring for complications like preterm labor and fetal growth discordance.

1. Case presentation on a patient managed
for early preterm triplet pregnancy +
AFSOL + chronic hypertension + UTI
By dr. wondmeneh
Moderator: Dr.

2. Content
 Case summary
 Discussion
 Scientific background
 Comment
 Take home message
 Reference
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3. Identification
 Name: L/S
 Age: 25 years
 Marital status: married
 Address :Jimma
 DOA :13/05/14
 DOD:17 /05/14
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4. Senior resident evaluation at labor ward
• G2P1(alive ,VD) mother
• GA: 29wks from U/S=16+6 weeks(28/10/21)
• ANC follow up at FGA 3 times and told to have
triplet and on follow up
• Referred from there with the diagnosis of “preterm
labor + twin pregnancy + chronic hypertension”
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5. • BP from referral: 150/100
• Presented with pushing down pain 4 hrs duration but
no passage of liquor
• Has no headache,blurring of vision or epigastric pain
• No known other medical illness
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6. P/E
 G/A: in labor pain
 V/S: BP: 145/100 PR:100 RR: 22 T: 36.4 c
 HEENT: Pink conjunctiva, non icteric sclera
 LGS: NSLAP
 Chest: NAD
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7.  Abdomen: -
Term sized gravid
uterus
Multiple fetal parts
palpable
Has contraction
FHB: positive
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U/S:- Triplet IUPX
-FHB: Positive for all
-TA&B-cephalic TC-
breech
-no GCA for all
Index:3rd TM triplet px
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8. • GUS: -Cervix is 4cm dilated, 80% effaced
–Membrane intact and bulged
–Vertex presentation
–Station: -1
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9. • Assessment: Early preterm triplet pregnancy + AFSOL +
chronic hypertension
• Plan:
• Prepare for emergency c/s
• CBC, BG/RH, RFT,LFT U/A
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10. Operation note
• After informed written consent taken patient
prepared and transferred to OR
• Under SA abdomen cleaned, draped and entered
through pfannesteil incision
• Finding:
• Intact gravid uterus
• Healthy looking ovaries,tubes and urinary
bladder
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11. • Done:
• Bladder flap created ,LUSTC/S done to effect
delivery of Triplets:-TA:-M-1.3KG-APGAR: 7/9
-TB:-M-0.9KG-APGAR: 6/8
-TC:-F-1.4KG-APGAR: 7/9
• Pitocin 10IU IM given, placenta delivered and is
dichorionic diamniotic placentation
• Uterus mopped closed in layers using catgut no 2
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12. • Hemostasis secured
• Correct counts of instruments, packs and gauze made
• Fascia and skin closed using vicryl no 2 and 3/0
respectively
• EBL-600ML
• TOLAC possible in next pregnancy
• The mother transferred to recovery with stable vital sign
and the neonates transferred to NICU for evaluation
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13. Post op Order
 P: Immediate postop day after LUST C/S done Early
preterm triplet pregnancy + AFSOL + chronic
hypertension
 C: subcritical
 A: encourage early ambulation
 D: keep NPO until bowel sound is active
 N/C: follow V/S, uterine tone and excessive vaginal
bleeding every 15min for first 2hrs then every 30min for
next 4hrs.
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14. • Treatment:
• Put on 2/3 maintenance fluid
• Tramadol 50 IV TID
• Remove foley catheter after 8hrs.
• HCT after 8 hrs
• Hydralazine 5mg if BP>=160/110mmHg
every 20min –maximum 5 doses
• Cephalexin 500mg PO TID
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15. Investigation chart
date investigation result
13-5-14 CBC WBC-12600 NE-80.4
HGB-13.1 HCT-38.6%
PLT-165000
RFT CR-0.68
UREA-6.4
LFT AST-22.2
ALT-17.7
BG/RH B+
VDRL Negative
HBsAg Negative
U/A Ketone:+2
Blood: +2
Nitrite: positive
Glucose & protein: negative
RBC: Many
WBC:1-5
Many bacterias
Postop HCT 36%
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16. POST OP V/S FOLLOW UP
date Time Time PR RR TEMP
13-5-14 112/64 100 20 35.3
120/77 96 20 35.3
140/95 88 22 35.4
143/75 88 22 35.4
150/90 92 22 35.7
145/85 88 22 35.4
145/90 84 22 35.3
150/95 84 20 35.7
145/90 80 20 36.2
150/90 85 22 36.6
140/90 86 22 36.2
140/90 92 20 36.5
140/80 85 22 36.7
140/90 85 20 36.9
140/90 85 20 36.5
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17. Date BP PR RR TEMP
14/5/14 SBP:130-140
DBP:90-100
86-90 20-22 36-36.7
15/5/14 SBP:130-132
DBP:80-90
84-92 20-24 36-36.8
16/5/14 SBP:125-150
DBP:85-90
78-92 20-23 36.3-36.5
17/5/14 SBP:130-140
DBP:80-90
80-82 20-22 36-36.2
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18. Discharge summary
• P2(1alive by VD, triplet by CD) mother on her 2nd post op
day after LUST C/S was done for an indication of Early
preterm triplet pregnancy + AFSOL + chronic hypertension
+ UTI
• She passes flatus and Ambulating
• All the 3 neonates are complicated by ENND
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19. Plan up on discharge
• Advised about breast care(tight bra, cold compress)
• Counseled about FP ; opted for implanon and she
want to take after a month
• Cephalexin 500mg po BID
• Ibuprofen 400mg po PRN
• BP 2X/week
• To start early ANC in next pregnancy
• Advised on danger signs(bleeding, headache,RUQ
pain)
• Appointments: after 1 week at medical OPD and after
6wks at ANC
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20. Problems identified
• Triplet pregnancy
• PTL
• Chronic HTN
• UTI
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21. DISCUSSION
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22. INTRODUCTION
• Multiple pregnancy is a development of more
than one fetus in utero.
• Could be: twins, Triplet, Quadruplets,
Quintuplet, etc
• Maternal morbidity and mortality rates are much
higher in multiple pregnancy than in singleton
pregnancy
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23. Genesis of multifetal gestation
• MFG result from:-
• Two or more fertilization events
• A single fertilization followed by a splitting
of the zygote
• A combination of both
• Triplets can be : Monozygotic, Dizygotic or Trizygotic
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24. INCIDENCE
• Incidence of multiple pregnancies is approximated
using: Helen’s Formula :1: 80n-1 Triplets 1: 802 =
1:6400
• The incidence of triplet and higher order multi fetal
gestation has risen several hundred percent since 1980
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25. DIAGNOSIS
History
Physical examination
Investigation
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26. History
• Exaggerated pregnancy symptoms
• Unusual rate of abdominal growth
• Excessive fetal movement
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27. PHYSICAL EXAMINATION
• Elevated BP
• Futures of anemia
• Increased weight gain unrelated to PE and obesity
• Big for date uterus
• ballottement Multiple fetal parts
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28. ULTRASOUND
Diagnosis of MG
Determination of:-
Chorionicity
Gestational age
Viability
Fetal anomalies
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29. CHRIONOCITY
Trichorionic
Dichorionic
triamniotic
Dichorionic
Diamniotic
Monochorionic
Triamniotic
Monochorionic
Diamniotic
Monochorionic
Monoamniotic
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30. Complications
• Maternal
• Fetal
• Neonatal
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31. Maternal
complication
Hyperemesis gravidarum
Abortion
Maternal anemia
Preterm labor
Gestational DM
PIH(PE)
APH
Malpresentation
PPH
Postpartum Depression
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32. Fetal and newborn complications
• Low birth weight
• Malformations
• Discordant
• Cord accident
• Polyhydramnios
• Perinatal mortality
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33. Approach to Management of triplet pregnancy
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34. ANC
• Number of ANC visit
• Uncomplicated TATC: 9 visits
• DCTA/MCTA: 11 Visits
• Those with shared amnion(DCDA,DCMA,MCMA):
Individualized care at territory hospital
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35. Monitoring of fetal growth
• At each U/S scan from 24weeks, offer women
fetal weight estimation for discordance:
• (EFW of larger fetus - EFW of smaller fetus)/EFW
of larger fetus
• (EFW of larger fetus - EFW of middle fetus)/EFW
of larger fetus
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36. Preterm labor
• 75 to 100 percent of triplets are born prematurely
• 95 percent of triplets have birth low birthweight
• 35 percent are very low birthweight
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38. Average GA and Average birth weightat
time of delivery
Type of pregnancy Average GA at time
of delivery
Average birth
weight
Singleton 38.6 weeks 3300gms
Twin 35 weeks 2300gms
Triplet 32 weeks 1660gms
Quadruplet 30 weeks 1300gms
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