triplet pregnancy approaches

1. Triplet pregnancy
Notes

2. INTRODUCTION
• The rate of triplet and higher-order multiple births is higher than the naturally-occurring
rate due to medically assisted conception, particularly in vitro fertilization and controlled
ovarian hyperstimulation with gonadotropins, in countries where this technology is
widely available.
• Increasing maternal age at conception has also contributed to the increased rate of triplet
gestations.
• Triplet and higher-order births accounted for 103.6 per 100,000 births in the United
States in 2015 but only 32.3 per 100,000 births in 1977 (before in vitro fertilization).
• The rate of higher-order pregnancies has declined from its peak (193.5/100,000 in 1998)
as a result of transfer of fewer embryos and an increase in fetal reduction procedures.

3. INTRODUCTION
• Higher-order multiple gestations are associated with significantly increased risks of
maternal and neonatal morbidity compared with twin and singleton gestations,
primarily because almost all triplets are born preterm and at an earlier mean
gestational age (mean gestational age of delivery for triplets, twins, and singletons:
31.9, 35.3, and 38.7 weeks, respectively.

4. ANTEPARTUM MANAGEMENT
• Women with triplet pregnancies should be counseled about the specific issues and risks associated with
these pregnancies, management of complications, and the high probability of cesarean birth.
• An ultrasound is performed in the first or early second trimester to ascertain if the triplet pregnancy is
trichorionic, fully monochorionic, or has a monochorionic twin pair to help guide counseling and
management.
• Surveillance of triplet pregnancies includes more frequent ultrasound examinations and frequent office
visits (discussed below), particularly after 20 weeks of gestation, due to the increased risk of maternal
morbidity and perinatal morbidity and mortality.
• In the second half of pregnancy, these pregnancies are at increased risk for preterm delivery, preeclampsia,
and fetal growth discordance when compared with singletons.
• Delivery planning with an onsite level III neonatal intensive care unit should be considered for women with
triplet pregnancies.
• However, many other issues are the same as in any pregnancy.

5. Basic care
• Weight gain and nutrition — Evidenced-based weight gain and nutritional guidelines for triplet
pregnancies are lacking. We use the following gestational weight gain targets, which reflect the
higher end of Institute of Medicine (IOM) provisional gestational weight gain guidelines for twin
pregnancies that go to term :
• ●Body mass index (BMI) 18.5 to 24.9 kg/m2 (normal weight): 25 kg (54 lbs)
• ●BMI 25.0 to 29.9 kg/m2 (overweight): 23 kg (50 lbs)
• ●BMI ≥30.0 kg/m2 (obese): 19 kg (42 lbs)
• Some physicians believe that IOM weight gain targets are too high, particularly for obese women.
• For obese women with singleton gestations, gestational weight gain lower than that recommended
by the IOM may be associated with better maternal and perinatal outcomes, and this may also be
true for obese women with triplet gestations.

6. Basic care
• Our recommendations for daily micronutrient supplementation are also based on
existing data for twin pregnancies: calcium 2000 to 2500 mg, vitamin D 1000
international units, zinc 14 to 45 mg, and folic acid 1 mg.
• Nonanemic women are prescribed 30 mg of elemental iron daily, which is increased
to 60 to 120 mg/day if the serum ferritin level is less than 15 mg.

7. Timing and frequency of ultrasound examination
• Diagnosis of triplet pregnancy is based on ultrasound examination, which is generally
initially performed for assessment of gestational age.
• Determination of amnionicity and chorionicity, which is ideally performed in the first
trimester, is critical for risk assessment, counseling, and pregnancy management.
• First-trimester ultrasound examination may detect abnormalities associated with adverse
outcome.
• These include congenital anomalies, crown-rump length discordance (associated with
aneuploidy, twin-twin transfusion syndrome [TTTS]), and enlarged nuchal translucency
(associated with aneuploidy, congenital anomalies, TTTS).

8. Timing and frequency of ultrasound examination
• In all triplet pregnancies, we perform a detailed ultrasound to survey the fetal
anatomy at approximately 20 weeks of gestation.
• We base timing and frequency of other second- and third-trimester ultrasound
examinations on amnionicity and chorionicity.

9. Triamniotic dichorionic triplets
• Monochorionic placentation in any multiple gestation places the involved fetuses at high risk for TTTS and discordant
growth .
• We follow a protocol similar to that commonly used for managing monochorionic twin pregnancies.
• Starting at about 16 weeks, ultrasound examination is performed every two weeks to determine the maximum vertical
amniotic fluid pocket for each sac and to visualize the bladder of each fetus.
• Fetal growth is assessed every two to four weeks.
• Oligohydramnios and polyhydramnios sequence suggests TTTS; nonvisualization of the bladder of the donor twin is a sign
of more severe disease.
• In pregnancies with discordant amniotic fluid volume or fetal growth, we also perform umbilical artery Doppler
assessment.
• Some centers routinely perform middle cerebral artery peak systolic velocity (MCA-PSV) Doppler to monitor for twin
anemia polycythemia sequence in these pregnancies, but there is no proven benefit from such monitoring.
• We do not monitor MCA-PSV in this setting, in agreement with recommendations from the Society for Maternal-Fetal
Medicine specialists

10. Monoamniotic or diamniotic triplets
• Monoamniotic placentation in any multiple gestation places the involved fetuses at high risk of cord
entanglement and death from cord compression.
• They are also at risk of TTTS.
• Doppler velocimetry to detect altered flow has been proposed as suggestive of compression of cord vessels.
• High blood velocity in the umbilical vein, a notch in the umbilical artery waveform, or persistent absent end
diastolic flow were reported as suggesting the fetoplacental circulation is compromised.
• However, given the poor specificity of these findings without associated adverse effects, the use of Doppler
for routine monitoring of monoamniotic twins is not recommended.
• Instead, at about 26 weeks of gestation, the patient is admitted to the hospital for one hour of continuous
fetal heart rate monitoring every eight hours.
• Ultrasound monitoring for TTTS is the same as that described above for triamniotic dichorionic triplets.

11. Triamniotic trichorionic triplets
• Triamniotic trichorionic placentation is associated with better perinatal outcomes
than shared placentation; growth restriction is the major concern.
• Starting at 20 weeks, ultrasound examination is performed every three to four
weeks to monitor fetal growth.

12. Office visits
• In the first half of pregnancy, office visits can be scheduled per usual obstetric
standards for singleton pregnancy.
• However, we see patients weekly beginning at 24 weeks of gestation to closely
monitor for signs/symptoms of preeclampsia and preterm labor.
• There is limited evidence that weekly visits improve outcomes, so visits every two
to four weeks are also reasonable.

13. Biophysical profile
• There are no evidence-based guidelines for when and how often antepartum fetal testing should be
performed.
• If monitoring is indicated, the biophysical profile is our first-line testing strategy because it allows us to
identify and access each fetus and avoid technical difficulties encountered with performing non-stress test
in higher-order multiples, similar to what has been reported by others.
• We implement fetal testing based on the type of chorionicity (discussed below).
• When results of fetal monitoring of a singleton preterm fetus are nonreassuring, the decision to intervene is
determined by whether the fetus' risk from remaining in utero exceeds that from premature delivery.
• In multiple gestations, an ethical dilemma arises when one fetus is in jeopardy but the others are not.
• These decisions are complex, and should be made jointly with, at a minimum, the parents, a maternal-fetal
medicine specialist, and a neonatologist.

14. Triamniotic dichorionic triplets
• For triamniotic dichorionic triplets, we obtain a weekly biophysical profile score
starting at 28 weeks because all of these pregnancies are at high risk for fetal
complications.
• Non-stress tests are a reasonable alternative.

15. Triamniotic trichorionic triplets
• For triamniotic trichorionic triplets, we only initiate antepartum fetal testing (eg,
biophysical profile score, nonstress test) if the pregnancy is complicated by a
maternal or fetal disorder such as preeclampsia or fetal growth restriction.
• The frequency of testing depends on the clinical scenario.

16. Monoamniotic or diamniotic triplets
• Monoamniotic or diamniotic triplets are hospitalized at about 26 weeks of gestation
and monitored three times daily with one hour of continuous fetal heart rate
monitoring, rather than by the biophysical profile, because we are looking for
decelerations, which suggest cord entanglement with cord compression.

17. Monitoring for preterm labor
• We educate patients about the signs and symptoms of preterm labor but do not perform
routine digital cervical examination, fetal fibronectin screening, or home uterine activity
monitoring as these interventions have no proven benefit on pregnancy outcome.
• We do not measure cervical length in triplet pregnancies although this is a common
screening test for prediction of preterm birth in singleton pregnancies.
• Cervical length measurement is not a sensitive screening test for prediction of preterm
birth in multiple gestations, and there is no strong evidence that any intervention (eg,
progesterone supplementation, cerclage) is beneficial for preventing preterm birth in
women with multiple gestation and short cervical length.

18. Physical and sexual activity
• There is no consensus about physical activity for women carrying triplets given a lack of
definitive data.
• Our exercise recommendations are, in general, similar to those for women with singleton
gestations, especially prior to 20 weeks of gestation.
• After about 20 weeks of gestation, many women with uncomplicated triplet pregnancy
will want to limit physical activity because of fatigue and physical discomfort; in the mid
to late second trimester, the uterus enlarges to a size comparable to that of a singleton at
term.
• These patients can rest and reduce activity in and outside of the home, as needed.
• Sexual intercourse does not appear to increase the risk of preterm birth ; abstinence is
not necessary.

19. Potential first-trimester complications
• Spontaneous reduction — A substantial number of multiple gestations undergo spontaneous loss
of one sac in the first trimester, which is referred to as a "vanishing twin."
• The rate of loss is correlated with the initial number of gestational sacs.
• In one study, fetal loss occurred in 20 to 50 percent of twin pregnancies, 53 percent of triplet
pregnancies, and 65 percent of quadruplet pregnancies diagnosed before 12 weeks.
• In the triplet gestations, most losses occurred prior to the ninth gestational week; loss of all three
sacs occurred in 6 percent of triplet pregnancies.
• Triplet pregnancies that experienced spontaneous reduction delivered earlier than unreduced
pregnancies with the same number of fetuses (eg, triplets-to-singletons delivered 10 days earlier
than unreduced singletons, triplets-to-twins delivered four days earlier than unreduced twins).

20. Screening for neural tube defects
• Serum screening for neural tube defects with maternal serum alpha-fetoprotein has
not been validated in triplets.
• Therefore it is prudent that all triplets undergo a focused anatomical survey in the
second trimester.

21. Aneuploidy
• The risk of aneuploidy in a trizygotic triplet pregnancy is higher than in a singleton
or dizygotic twin pregnancy since there are three fetuses, each of whom is at risk.
• The Down syndrome risk of a 28-year old woman carrying a trizygotic triplet
pregnancy is similar to that of a 35-year-old woman carrying a singleton pregnancy.
• We suggest that all women with triplet gestations be offered genetic counseling to
discuss their risk of aneuploidy in one or more fetuses.

22. Prenatal aneuploidy screening
• No serum marker or cell-free DNA screening test for aneuploidy has been validated in
triplet gestations.
• The distribution of nuchal translucency measurements is the same in triplets as it is in
singletons.
• In triplets, increased nuchal translucency (defined as greater than the 95th percentile for
gestational age) has been validated as a screening test for trisomy 21 and trisomy 18 but
not for trisomy 13.
• In this study, five of six aneuploid fetuses had increased nuchal translucency (three cases
of trisomy 21, one of trisomy 18, and one of monosomy of chromosome X; a
mosaic 45,X/46,XX was missed).

23. Prenatal (fetal) diagnosis
• Chorionic villus sampling (CVS) is one option for prenatal diagnosis of aneuploidy.
• This technique is particularly useful for women with high age-related risk of fetal
aneuploidy who are planning multifetal pregnancy reduction.
• Because karyotype results should be available prior to the reduction procedure, it would
be possible to identify and selectively reduce an aneuploid fetus.
• However, CVS is more difficult in triplet than singleton gestations, and the patient must
understand that it can be difficult to be certain that all three placentas have been
sampled rather than one placenta being sampled twice and another missed altogether.
• The risk of a sampling error in triplets and higher order gestations was 1.2 percent in one
study.

24. Prenatal (fetal) diagnosis
• Amniocentesis is another option for prenatal diagnosis and is performed similar to
singleton gestations.
• The procedure-related pregnancy loss rate is probably similar to that after genetic
amniocentesis in singleton pregnancy.

25. Potential second and third trimester complications
• Fetal demise — The rate of fetal demise after 22 weeks of gestation is related to
chorionicity; in one study, fetal demise occurred in 0.8 percent of trichorionic triplet
pregnancies (12/1521)versus 2.7 percent of monochorionic triamniotic triplet
pregnancies (4/150).
• Although no study has specifically examined the outcomes of survivors of co-triplet
demise, this risk likely depends on whether they shared or had separate placentas from
the demised triplet.
• For example, monochorionic survivors of a co-twin fetal demise have higher rates of
subsequent demise, preterm birth, and neurodevelopmental impairment than dichorionic
survivors of a co-twin fetal demise.

26. Potential second and third trimester complications
• After demise of one or two triplets with monochorionic placentation, injury to the
surviving fetus or fetuses occurs instantaneously; thus, immediate delivery will not
prevent adverse outcomes related to this event.
• We base delivery timing on the usual standards for the remaining twin or singleton
gestation but implement fetal surveillance with weekly biophysical profiles
(nonstress tests are a reasonable alternative) and serial ultrasound growth scans.

27. Cord compression in monoamniotic multiples
• Monoamniotic placentation in any multiple gestation places the involved fetuses at
high risk of cord entanglement and death from cord compression.
• To reduce this risk, we admit these patients to the hospital at 26 weeks of gestation
for intensive fetal heart rate monitoring (one hour of continuous monitoring every
eight hours), administer a course of antenatal corticosteroids, and deliver them by
cesarean at 32 to 33 weeks of gestation.

28. Fetal growth restriction or discordant growth
• Fetal growth is monitored by ultrasound examination; initiation and frequency are guided
by the type of placentation, as described above.
• We diagnose fetal growth restriction by the same criteria used for singleton pregnancies.
• Because triplet growth starts to deviate from singleton growth in the third trimester , use
of these criteria may over-diagnose impaired fetal growth.
• For this reason, several authors have published growth tables specific for triplet
pregnancies (medians, 10th and 90th percentiles).
• However, whether these tables perform better for detecting fetuses at increased risk of
adverse fetal/neonatal outcome is unknown.

29. Fetal growth restriction or discordant growth
• Discordant growth of multiples is usually defined as a 20 to 25 percent difference in
sonographic estimated fetal weight (EFW) of the smaller compared with the larger
fetus (difference of larger minus smaller EFW divided by larger EFW). Discordance
may be a marker for structural or genetic anomalies, infection, TTTS, or placenta-
mediated disease.
• Based on twin studies, evidence of growth restriction of one or both fetuses is a
stronger predictor of adverse neonatal outcome than growth discordance alone.
• Management of growth restriction and growth discordance is based on the etiology.

30. Twin-twin transfusion
• Discordant amniotic fluid volume (polyhydramnios/oligohydramniossequence) with
dichorionic triamniotic placentation suggests TTTS.
• Laser coagulation is an effective treatment even in triplets.

31. Preterm birth
• Preterm delivery is the most common cause of death and morbidity in triplet
gestations.
• In 2015, 98.6 percent of triplets delivered before 37 weeks of gestation in the
United States, and 37.1 percent delivered before 32 weeks of gestation.
• Ninety-six percent of triplets were low birth weight (<2500 g) and 36 percent were
very low birth weight (<1500 g).
• By comparison, 1.2 percent of singletons delivered before 32 weeks and 1 percent
weighed <1500 g.

32. Potentially useful interventions
• Multiple interventions have been investigated to reduce the risk for preterm
delivery.
• None have proven efficacious; however, administration of corticosteroids
and magnesium sulfate may reduce neonatal morbidity.

33. Antenatal corticosteroids
• As discussed above, we admit triplets with monoamniotic placentation to the hospital at about 26 weeks of
gestation for intensive fetal heart rate monitoring and routinely administer a course of antenatal
corticosteroids at that time if not given previously.
• For diamniotic and triamniotic triplets, we administer a course of betamethasone between 23+0and
33+6 weeks of gestation only if there is an increased risk for delivery (eg, ruptured membranes, preterm
labor, maternal or fetal disorder) within seven days.
• We use standard doses; there is no convincing evidence that the dose should be increased with an
increasing number of fetuses.
• The value of this therapy is well-established in singleton pregnancies, but neonatal outcomes after in utero
exposure to corticosteroids have not been examined in randomized trials of triplet gestations, and the
magnitude of benefit in these pregnancies is less clear.
• In the United States, the National Institutes of Health recommends administration of one course of
antenatal corticosteroids (unless contraindicated) irrespective of the fetal number.

34. Antenatal corticosteroids
• In our practice, we offer a second course of antenatal corticosteroids if it has been
more than a week since the prior course, the patient is at increased risk for preterm
birth within the next seven days, and the pregnancy is less than 34 weeks.
• We do not administer steroids after 34 weeks as no data are available on efficacy in
multiple gestations late in gestation.

35. Magnesium sulfate
• We offer magnesium sulfate for neuroprotection to those triplet pregnancies at risk
for imminent delivery (ie, within 24 hours) between 23+0 and 31+6 weeks.
• We use the Marret regimen (4 g magnesium sulfate bolus over 30 minutes with no
continuous infusion ) because omitting the continuous infusion may reduce the risk
for pulmonary edema.
• Other regimes (eg, 4 g bolus with 1 g/hour continuous infusion) can also be used.

36. Unproven interventions
• Prophylactic cerclage — Prophylactic cerclage in women with a triplet gestation without a history
of cervical insufficiency does not prolong gestation or improve neonatal outcomes and should be
avoided.
• No randomized trials examining prophylactic cerclage in triplet pregnancy have been performed.
The largest study used a national database to compare the outcome of triplet pregnancies with
cerclage (n = 248) with those without cerclage (n = 3030) .
• Both groups had similar rates of preterm birth <28 and <32 weeks.
• There were no significant differences between groups in gestational age at delivery, live birth, birth
weight, very low birth weight, neonatal intensive care unit admission, or neonatal hospital days.
• A limitation of this study was that only patients who reached 23 to 24 weeks of gestation were
entered into the database; thus, any effects of cerclage on early pregnancy loss were not measured.
Smaller studies have reported mixed results.

37. Prophylactic pessary
• In the largest randomized trial of 808 women, the use of prophylactic pessaries in
unselected multiple gestations was not shown to decrease the incidence of poor
perinatal outcomes and therefore is not recommended.

38. Bedrest
• There is no convincing evidence that bed rest improves pregnancy outcome, and it
may be harmful due to the risk for thrombosis and deconditioning.
• In a 2010 systematic review of seven randomized trials that compared outcomes in
women with a multiple pregnancy and their infants who were offered bed rest in
hospital with women only admitted to the hospital if complications occurred,
routine bed rest in hospital for multiple pregnancy did not reduce the risk of
preterm birth or perinatal mortality.

39. Progesterone supplementation
• The administration of progesterone supplementation is not recommended.
• In placebo-controlled multicenter randomized trials, routine progesterone
supplementation in triplet pregnancies did not reduce the frequency of fetal loss or
spontaneous preterm birth.
• Progesterone supplementation has also been associated with a significant increase
in the rate of midtrimester fetal loss in triplets.

40. Prophylactic tocolytics
• There is no role for the prophylactic use of tocolytic agents in any multiple gestation
including triplets.
• There has been no proven benefit on the incidence of preterm delivery, low birth
weight, or neonatal mortality.
• Moreover, the prolonged use of beta mimetics has been linked to increased risk of
adverse maternal cardiovascular events including maternal death.

41. Tocolytics
• The author does not use tocolytic drugs to treat preterm contractions or preterm labor in patients
with triplets.
• No tocolytic has been proven to improve neonatal outcomes when compared with placebo and
tocolytic use in multiple gestations results in a higher incidence of adverse events, such as
pulmonary edema .
• Others may administer a tocolytic for 48 hours to allow for administration of betamethasone.
• A calcium channel blocker or nonsteroidal anti-inflammatory drug, depending on gestational age, is
the preferred tocolytic.
• Use of magnesium sulfate has been associated with maternal pulmonary edema. In one study of 15
women with triplet pregnancies complicated by pulmonary edema, 14 had received magnesium
sulfate because of preeclampsia or preterm labor.

42. Preeclampsia
• The frequency of preeclampsia is higher in triplet pregnancies (10 percent) than in
singleton gestations (6.5 percent).
• Preeclampsia occurs earlier and is more severe in multiple gestations, and HELLP
syndrome (Hemolysis, Elevated Liver enzymes, Low Platelet count) is more likely.

43. Prevention of preeclampsia
• We offer low-dose aspirin (60 to 150 mg/day), initiated between 12 and 28 weeks
of gestation, to reduce the occurrence of preeclampsia and its associated
complications of preterm birth and intrauterine growth restriction in patient
populations with an absolute risk for preeclampsia of at least 8 percent, such as
triplet pregnancy .
• We prescribe 81 mg/day.

44. Gestational diabetes
• Gestational diabetes has been reported in up to 22 percent of triplet gestations
versus about 10 percent of singletons.

45. Screening and management
• Since there is no strong evidence on which to base recommendations for the best time for
screening for gestational diabetes mellitus (GDM), medical management, or obstetric management
in triplet pregnancies, we use ACOG guidelines for diagnosis and treatment of gestational diabetes
in this population with minor modifications .
• Since these patients are at high risk for early GDM, we suggest screening in the first trimester. Either
of two tests can be considered: (1) fasting blood glucose followed by a 75 gram glucose load and
two-hour plasma glucose measurement or (2) a 50 gram oral glucose challenge test and, if
abnormal, follow-up with a three-hour glucose tolerance test.
• If results of the early screen are negative, follow-up screening using the two-step screening process
at 24 to 28 weeks should be performed.
• If gestational diabetes is diagnosed, medical nutritional therapy is begun; patients who remain
hyperglycemic should be treated with insulin.

46. Other complications
• Other pregnancy complications more common in triplet pregnancy include the following. Diagnosis and management are
similar to that in singleton pregnancies with the same complication.
• ●Nausea and vomiting of pregnancy.
• ●Abruption placenta has been reported in 1.6 percent of triplet pregnancies versus <1 percent of singleton pregnancies .
• ●Thrombocytopenia occurs in up to one-third of triplet gestations.
• The most common cause is preeclampsia.
• ●Acute fatty liver has been reported in up to 7 percent of triplet pregnancies versus 1 in 10,000 singleton pregnancies.
• ●Intrahepatic cholestasis is observed more commonly in multiple gestations.
• ●Multiple gestation is a risk factor for uterine atony resulting in hemorrhage, transfusion, and possibly hysterectomy.
• ●Postpartum depression and other psychological disorders are more common after a multiple birth.

47. INTRAPARTUM CARE
• Delivery timing — Delivery timing is based on the type of amnionicity, irrespective
of lung maturity.
• We suggest the following:
• Monoamniotic or diamniotic triplets — Monoamniotic and diamniotic triplets are
delivered by cesarean at about 32+4weeks of gestation (ie, between 32+0 to 32+6
weeks) based on extrapolation of the finding that the in utero risk of fetal demise of
a monoamniotic twin fetus exceeds the risk of a postnatal nonrespiratory
complication at this gestational age.

48. Delivery timing
• Triamniotic triplets — Uncomplicated triplet pregnancies with three amniotic sacs,
whether monochorionic, dichorionic, or trichorionic, are delivered between 35+0
and 35+6 weeks of gestation.
• In a review commissioned by the National Institute for Health and Clinical
Excellence, the risk of fetal demise increased in uncomplicated triplets beyond
36+0 weeks .
• Earlier delivery is indicated in complicated pregnancies; timing depends on the
individual clinical scenario.

49. Route of delivery
• Cesarean delivery is the preferred route of delivery for triplet gestations.
• A review of data from a national database found that vaginal delivery of triplets was
associated with an increased risk for stillbirth and neonatal and infant deaths as
compared with cesarean delivery.
• This finding was supported by a multi-center retrospective United States cohort
Study that reported the rate for successful attempted vaginal delivery was only 16.7
percent (four triplet sets), and vaginal delivery was associated with a higher risk of
maternal transfusion and neonatal mechanical ventilation, as well as a trend toward
increased composite neonatal morbidity.

50. Anesthesia
• Neuroaxial anesthesia is recommended.
• It is particularly useful for those few women with triplets attempting a vaginal birth
as it helps to facilitate operative delivery, external or internal version, and total
breech extraction.
• It is also important to prepare for significant hemorrhage at the time of delivery
because multiples are at increased risk for uterine atony, postpartum hemorrhage,
and emergent hysterectomy.

51. PERINATAL MORTALITY AND MORBIDITY
• Preterm delivery and low birth weight are the most common causes of death and
morbidity in triplet gestations.
• The infant mortality rate in triplet pregnancies is 52 percent compared with 5
percent in singleton gestations.
• The cerebral palsy rate is 28 per 1000 live births versus 1.6 per 1000 live births in
singleton gestations.