Nadya Suleman, dubbed Octomom by the international media, brought the world’s attention to Higher Order Multiples when she gave birth to octuplets, in January 2009. Her story is wrought with controversy and led to an investigation into the field of assisted reproductive therapy by the Medical Board of California.
Following the investigation in 2011, fertility specialist Dr Michael Kamara had his medical license revoked. It was later revealed Ms Suleman already had six children, was unemployed, and on public assistance programs when she underwent IVF treatment to conceive the octuplets.
The chance of conceiving octuplets naturally is virtually impossible, so needless to say unless you have a fertility specialist on your payroll who is willing to sacrifice his or her career and induce superovulation or implant eight embryos, your chance of being the next Octomom is zero. However, since you’re listening to this podcast chances are you’re carrying more than two, three, or even four babies. Congratulations!
But what does that mean?
Chair in Obstetrics and Gynaecology and Professor Fetal Medicine, Head of Discipline Obstetrics and Gynaecology at the University of Newcastle and John Hunter Hospital Professor Craig Pennell talks us through the types of Higher Order Multiples and what it means for your pregnancy.
Definition of a Higher Order Multiple (HOM) pregnancy
“A higher order multiple pregnancy is where you have more than two babies in a uterus at any point in time,” explains Professor Craig Pennell.
“A higher order multiple pregnancy is where you have more than two babies in a uterus at any point in time.”
~Professor Craig Pennell~
A HOM pregnancy can be:
Triplets when there are three babies (which is what most higher order multiples are);
Quadruplets when there are four babies (which is rare), and
Quintuplets when there are five babies (which is very rare given that the rules about IVF and embryo transfer numbers have changed).
Professor Pennell says that oftentimes the diagnosis of a HOM pregnancy is missed due to the use of poor quality imaging used by many obstetricians. He advocates visiting a specialist imaging centre that has the latest ultrasound equipment to get higher quality images for a clearer diagnosis.
“There’s a bit of reluctance to doing transvaginal scans in women in the early part of pregnancy, and often the images you can obtain trans-abdominally are quite poor,”
“Therefore, you can have a second sac hiding behind a first sac, and it’s only when you get better-quality images that you can see an additional sac or sacs,” says Professor Pennell.
Types of HOMs
Associate Professor Pennell explains that there are three patterns of combinations with triplets.
- Three eggs that are fertilised by three different sperm known as a Trichorionic Triamniotic pregnancy.
- Monochorionic twins and a singleton, known as a Dichorionic Triamniotic pregnancy.
- Monochorionic triplets, known as a Monochorionic Triamniotic.
For quadruplet pregnancies, most are where four eggs are fertilised by four different sperm, known as a Quadrachorionic Quadramniotic pregnancy, however, you can also have twins and two singletons. It’s also theoretically possible to have two sets of identical twins but it’s extremely rare, according to Associate Professor Craig Pennell.
“Assessing a Higher Order Multiple pregnancy gets more difficult as the weeks progress,”
“When there are three placentas, which are the size of a bread plate, and in the third trimester the size of a dinner plate, you can imagine that placentas cover most of the uterine wall. Therefore, dividing the placentas up is much more difficult,” explains Professor Pennell.
Risks with HOMs
According to Professor Pennell, there is a greater chance of miscarrying one or all of the babies in a HOM pregnancy than in a twin pregnancy, simply because there are more embryos to lose.
“The rate of prematurity is also dramatically higher and with prematurity comes complications,”
“The one complication that causes the greatest degree of fear is Cerebral Palsy,”
“With twins, the risk is 1.5 percent of having a child with Cerebral Palsy, which is .75 percent for each fetus, with triplets it goes up to eight percent, and with quads, it goes up to 40 percent,” says Professor Pennell.
“With twins, the risk is 1.5 percent of having a child with Cerebral Palsy, which is .75 percent for each fetus, with triplets it goes up to eight percent, and with quads, it goes up to 40 percent.”
~Professor Craig Pennell~
He goes on to explain that when you start talking to people about the risks of Cerebral Palsy, they start asking questions about their options, and the option that is taken by some women who have higher order multiples is a fetal reduction or pregnancy reduction.
“The procedure is one where, under ultrasound guidance, a very fine needle is inserted into one of the pregnancy sacs very early in pregnancy, and that will stop the embryo growing and developing,”
“The triplet pregnancy will become a twin pregnancy or the quads may become triplets or twins,” Professor Pennell explains.
When this procedure is carried out, however, there is a small risk of losing the entire pregnancy and the risk of preterm birth for the surviving pregnancy is increased.
For twins, the current evidence recommends that non-identical or Dichorionic twins are delivered in their 37th week of gestation, while identical or Monochorionic twins are delivered in their 36th week, and Monochorionic Monoamniotic twins are delivered in their 32nd week of gestation.
When it comes to triplets, they’re delivered at around 34-weeks’ gestation, that is of course if they haven’t delivered already.
“This timing relates to the risks of stillbirth, which goes up quite dramatically after that particular point,”
“Also, by the time you’re getting to 34-weeks’ gestation there is usually one twin whose growth has stopped and when you’re trying to measure three heads, three abdomens, three legs, three cords, three sets of brain flows, heart flows, cord flows it’s quite easy to get them mixed up,” admits Professor Pennell.
The latest research also suggests that in terms of Monochorionic Triamniotic triplets they would certainly be delivered around 32-34 weeks.
“With this type of pregnancy, you can get Triplet-to-Triplet-to-Triplet Transfusion Syndrome, which is extraordinarily difficult to manage,”
“Identical triplets are rare and incredibly difficult but with specialist care, and being managed by a group who are familiar with this situation, you can get very good outcomes, it just needs very regular and careful review,” suggests Professor Pennell.
“Identical triplets are rare and incredibly difficult but with specialist care, and being managed by a group who are familiar with this situation, you can get very good outcomes, it just needs very regular and careful review.”
~Professor Craig Pennell~
In terms of quadruplets and quintuplets, the aim is to get as close to 30-weeks’ as possible.
“In that situation, you’re going to have a massively expanded uterus, uterine contractions, irritability, and difficulty assessing the babies,” says Professor Pennell.
Laura Sarubin was basking in the glow of her first pregnancy and was planning her future around the arrival of her baby, however, at her eight-week dating scan, the sonographer found two heartbeats.
“And, then there was a bit of a look of panic on the sonographer’s face and she told us don’t be alarmed but I think we can see another heartbeat,” says Laura.
Laura explains that following the triplet diagnosis she was really worried about the future of the babies, how she would cope with the pregnancy, and if they’d arrive safely. Her husband also started worrying about all the logistical things like the car and would they have to move house.
“It was exciting telling our news to everybody, but I also felt like I needed to be cautious, I still felt like there were lots of risks involved”
~Triplet mum, Laura Sarubin~
“It was exciting telling our news to everybody, but I also felt like I needed to be cautious, I still felt like there were lots of risks involved,”
” Fortunately, one of my friends has triplets and I leaned on her a lot for support,” says Laura.
Because two of the babies were sharing a placenta, Laura and her husband went back to their obstetrician at 16-weeks’ gestation, where they found out they were having girls. Originally, they thought the identical twin girls were MoMo, however, eventually, a dividing membrane was found, which meant there was a set of Monochorionic-Diamniotic twins and a singleton.
It was at about 30-weeks when Laura started developing preeclampsia, and at 31-weeks she had to be admitted to hospital.
Her platelet levels dropped to a dangerous level and the triplets were born safely by caesarean section at 32-weeks’ gestation.
Jannelle Snaddon and her husband Matt had been trying for a year to conceive but nothing was happening.
“We’d been together eight years, we’d been married for about a year, and then decided that kids were on the agenda,” says Jannelle.
Like most people, Jannelle didn’t expect it to happen overnight but thought it would happen at some point, however, after about a year of trying and nothing happening, she started asking questions. It turned out that there was a problem for Jannelle falling pregnant, which she didn’t expect.
“I know it happens to lots of people but for myself, I hadn’t been around it with anyone close to me, so this was a whole new world,” says Jannelle
Jannelle and Matt tried natural therapies first to see if that would help but unfortunately, that wasn’t successful due to a much bigger issue that Jannelle wasn’t aware of. That’s when they headed to the IVF clinic to start the process.
Jannelle and Matt had been with the IVF clinic for about a year before they got to the stage where they could attempt an implant. Before that could happen, Jannelle had to undergo hormone therapy to produce eggs, however, the first attempt was unsuccessful.
The next step would be to undertake intrauterine insemination(IUI), which is considered less invasive than in vitro fertilisation(IVF).
“They did say they didn’t think it would work but it was our choice,”
“Matt and I went to Perth and had the process done, Matt drove home and I stuck my feet up on the dashboard all the way home because I was like this is gonna work,” says Jannelle.
“I stuck my feet up on the dashboard all the way home because I was like this is gonna work.”
~Jannelle Snaddon’s IVF journey~
After about 3-or-4 weeks Jannelle received the phone call informing her that she was pregnant. Immediately, her mum started teasing her about having twins.
It wasn’t until Jannelle was about 8-weeks’ pregnant that she went in for what she thought would be a routine scan.
“He was searching my belly, but I could tell he was covering a lot of ground, and he kept circling and going everywhere,”
“And, then all of a sudden he grabbed my hand and said, ‘well, you’re definitely pregnant and there’s four’,” says Jannelle.
Jannelle met her Maternal-Fetal Medicine Specialist when she was 15-weeks’ pregnant, which was the first appointment she attended without Matt. Thankfully, she had her mum and brother with her because at that appointment the doctor had to explain about selective reduction, which is a conversation that’s had with all women carrying HOMs.
With the way the babies scanned, Jannelle was told that she couldn’t reduce from four to three, she would have to reduce to two.
“Obviously, the doctor had to explain about reducing, which is a conversation you have to have when people are carrying multiple births, but we decided to take the plunge into growing four.”
~Quadruplet mum, Jannelle Snaddon~
“I decided that no, this had all happened to me for a reason and everything was going well and I wanted to give them every chance, so we decided to take the plunge into growing four,” says Janelle.
Jannelle went inpatient at 26-weeks’ gestation, mainly due to the more than 200-kilometre distance she lived from the closest hospital that was equipped to cater for the imminent preterm arrival of the quadruplets.
The babies were delivered at 30-weeks-and-four days gestation.
Enjoy Your Pregnancy and Ask For Help
The trick with HOMs is that you want to do as much as you can early on. You’ll want to sort out the type of HOM you’ve got, make sure you’ve got great care and great imaging, and that you’re optimising the situation in terms of your haemoglobin, so ensuring you have enough iron, calcium, and vitamins, suggests Professor Pennell.
“My advice is to buy a second or third freezer and whenever someone offers to help you say it would be great if you could make me a few frozen casseroles, and you just fill those freezers up such that you’ve got all these resources for later,”
“If you’re in a good situation physically and metabolically by the time you get to 22-24 weeks, and you’re being cared for by a great team then you can feel confident that you will get through the situation,” says Professor Pennell.
Professor Pennell insists that if you’re one of the unlucky people who starts contracting early, bleeding, or has some complications, seek medical help quickly. In this situation, you will be transferred to a tertiary centre, if you’re not already there, and you’ll be given steroids which optimises the outcomes for each of the babies.
“The benefit of being administered corticosteroid at 23-weeks is that it reduces the mortality by 50 percent,” says Professor Pennell.
It’s important to be realistic and understand that there will be tough times. You are going to have good days and bad days.
“If you are showing signs of post-natal depression, get onto it, get it treated, seek help, see a psychologist, start taking medication if you need it,”
“Know that it’s a hiccup in time for the first year where there’s going to be chaos, but once you get through that, you’ve got yourself a ready-made family,” says Professor Pennell
“If you are showing signs of post-natal depression, get onto it, get it treated, seek help, see a psychologist, start taking medication if you need it.”
~Professor Craig Pennell~
Until next time …
I wish yo Double Happiness … Multiplied.
Monochorionic Triamniotic, or identical triplets, are delivered around 32-34 weeks.
In terms of quads and quins, the aim is to get as close to 30-weeks’ gestation as possible.
The benefits of being administered corticosteroid at 23-weeks’ gestation are that it reduces the mortality by 50 percent.
Between 8-and-12 weeks’ gestation is the best time to formally classify Higher Order Multiples.
There is a greater chance of miscarrying one or all of the babies in a HOM pregnancy than a twin pregnancy, simply because there are more embryos to lose.
Disclaimer: The content contained within this article is purely informative and educational in nature and should not be construed as medical advice. Please use the content only in consultation with an appropriately certified medical or healthcare professional.
Australian Multiple Birth Association
Perth & Districts Multiple Birth Association
International Council of Multiple Birth Organisations (ICOMBO)
Multiples of America
Twins & Multiple Births Association
The Multiple Births Foundation
Irish Multiple Births Association
Multiple Births Canada
South African Multiple Birth Association