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Spontaneously conceived multiple pregnancies: A case series
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Received: ,
Accepted: ,
How to cite this article: Bedi M, Gupta M, Gilhotra S, Mann PK. Spontaneously conceived multiple pregnancies: A case series. Adesh Univ J Med Sci Res. 10.25259/AUJMSR_95_2025
Abstract
Spontaneous conceived multiple pregnancies arising without medical intervention represent a unique subset of obstetric phenomena with significant implication for maternal and fetal outcomes. These pregnancies occur due to a variety of factors, including maternal age, genetic predisposition, and certain ethnic background that increase the likelihood of hyper ovulation. Spontaneous multiples are associated with increased risks of complications such as preterm birth, preeclampsia, gestation diabetes, and fetal growth retardation. Management of these pregnancies requires specialized prenatal care to monitor and mitigate potential complication, emphasizing the need for early and regular ultrasound assessments as well as individualized birth planning. Advances in maternal fetal medicine have improved outcomes for both mothers and infants, yet spontaneous multiples continue to pose significant challenges. This abstract highlights the ecological factor, epidemiological trends, clinical implications, and management strategies associated with spontaneously conceived multiple pregnancies, underscoring the critical need for tailored obstetrics care to optimize maternal and neonatal health.
Keywords
Multifetal pregnancy reduction
Multiple pregnancy
Twins
INTRODUCTION
Spontaneous multiple pregnancies occur when a woman naturally conceives more than one fetus in a single pregnancy cycle without any fertility treatments. These pregnancies can involve twins, triplets, or higher-order multiples and result from two primary mechanisms, namely, polyovulation or zygotic splitting. The occurrence of spontaneous multiple pregnancies may be affected by factors such as maternal age, parity, ethnicity, and genetics.
Multiple pregnancy can be of two types: Dizygotic and monozygotic – dizygotic twins being more common. However, higher-order multiples like triplets and beyond can be a result from a combination of polyovulation and zygotic splitting. Spontaneous multiple pregnancies are associated with increased risks for both the mother and the fetuses, including – gestational hypertension, preeclampsia, and preterm labor in the mother while prematurity, low birth weight, and higher incidence of congenital abnormalities are observed in the fetus.
CASE SERIES
Case - 1
A 32-year-old G3P2L2, spontaneous conception, with previous lower segment cesarean section (LSCS) 2 years back referred at 27 weeks period of gestation (POG) with severe anemia (hemoglobin [Hb] 4 g/dL). She was thin, malnourished, markedly pale, with pulse 102/min, blood pressure 120/80 mmHg, and respiratory rate-36/min. Abdominal examination showed multiple pregnancy with relaxed uterus with no leaking/discharge.
Investigations revealed Hb 5 g/dL (microcytic hypochromic anemia); other parameters were normal. Ultrasound showed monochorionic quadramniotic pregnancy of 26+4 weeks (all breech). Estimated fetal weights were 800–900 g. Scar thickness was normal. The patient received corticosteroids for lung maturity and 4 units blood transfusion.
Five days later, she entered preterm labor. Assisted vaginal breech delivery of four fetuses with a common placenta was performed. Unexpectedly, a fifth fetus with its own placenta was delivered en-caul, confirming quintuplets (monochorionic quadramniotic with one additional sac).
Each newborn weighed 700–800 g and was admitted to neonatal intensive care unit (NICU) with surfactant support. Four neonates succumbed; one female (~800 g) survived. At 8-year follow-up, she shows normal growth and development.
Case - 2
A 22-year-old G5P2L1A1 presented as case of spontaneous conceived multiple pregnancy with pain lower abdomen radiating to the back at 27 + 5 weeks POG. Per abdomen (P/A) uterus two fetal heart sounds audible by Doppler with mild contractions. On per vaginum (P/V) examination – os 1 finger loose, early effaced. Patient delivered spontaneously. First fetus was cephalic and 2nd was breech weighing around 1.15 kg and 1.065 kg, respectively. However, only one fetus survived.
Case - 3
A 25-year-old G3P1L1A1 with 27 + 1 weeks POG (spontaneous conception) presented to emergency medical record (EMR) with pain in lower abdomen radiating to back since 1 day. Abdominal examination revealed over distended uterus with multiple fetal parts palpable. On P/V, os was closed, candid discharge present. Patient was admitted and investigated. Ultrasonography showed triplets of 22 weeks gestation, and average fetal weight 702 g. Steroid coverage tried for fetal lung maturity. Tocolytics were started but patient delivered spontaneously three female babies weighing 700 g, 900 g, and 850 g, respectively. However, out of three, two survived and both the babies are doing well.
Case - 4
A 25-year-old G2P1L1 with 26 + 1 weeks POG presented to EMR with leaking p/v and pain abdomen since 2 h. She had a previous normal vaginal delivery. On examination uterus was 26 weeks in size. relaxed and there was presence of 2 fetal heart sounds. On per speculum (P/S) examination, bleeding was present.
USG revealed twin pregnancy of 28 weeks with fetal discordance. Effective birth weight (EBW) of fetus 1 was 1102 g and fetus 2 was 879 g. Patient was managed as prelabor rupture of membranes. However, she went into preterm labor at 31 weeks. Both the babies were delivered vaginally. Fortunately, both the babies are doing well.
Case - 5
A 35-year-old G2P1L1 with 33 + 3 weeks POG presented to our outpatient department with spontaneously conceived twin pregnancy with c/o pain abdomen × 1 day. Patient went into pre-term labor and delivered two babies weighing 1.49 kg and 1.6 kg, respectively. Both the babies are doing well.
Case - 6
A 30-year-old, primigravida with 36 + 1 weeks POG, presented to our department with spontaneous conception and twin pregnancy. Soon after admission, patient went into labor and delivered vaginally. First baby was male with 2.37 kg weight and 2nd baby was a female with 1.60 kg weight, both with satisfactory appearance, pulse, grimace, activity, respiration (APGAR) score. Discordance of weight was noted; however, both babies are fine.
Case - 7
A 25-year-old female, primigravida with 25 + 4 weeks POG, presented to our department with spontaneous conception twin pregnancy. First twin is diagnosed with Tetralogy of Fallot, and the 2nd twin is normal. Pregnancy is presently ongoing.
RESULTS
Total seven cases were reported: Two out of seven were primigravida, and rest five were multiparous. It indicates that the incidence of preterm labor with multiple pregnancy is more common in multiparous females.
Out of seven, only two patients crossed 32 weeks of POG, and rest delivered in <28 weeks POG.
Baby weight was 900 g or below in most of the cases.
All babies required NICU admission.
Survival rate was thus found to be 6/12.
Perhaps, neonatal morbidity and mortality is higher with high-order multiples and with lower the period of gestation.
| Gravidarum (G) | Period of gestation (POG) in weeks | Multiples order | Outcome | Survival | Remarks | |
|---|---|---|---|---|---|---|
| Baby weight (in gm) | NICU admission | |||||
| G-5 | 27wks. + 5d | 5 | 700gm/800gm | Yes | 1 out of 5 | - |
| G-3 | 27wks. + 3d | 2 | 1100gm/1065gm | Yes | 1 out of 2 | - |
| G-3 | 27wks. + 1d | 3 | 700gm/900gm/850gm | Yes | 2 out of 3 | - |
| G-2 | 26wks. + 1d | 2 | 1005gm/1102gm | Yes | 2 out of 2 | PPROM, Discordance |
| G-2 | 33wks. | 2 | 1490gm/1600gm | Yes | 2 out of 2 | - |
| G-1 | 36wks. | 2 | 2300gm/1600gm | Yes | 2 out of 2 | Discordance |
| G-1 | 25wks. + 4d | 2 | On - going pregnancy | |||
NICU: Neonatal intensive care unit, PPROM: Preterm premature rupture of membranes.
DISCUSSION
Prematurity remains a major contributor to perinatal morbidity, mortality, and long-term neuro-developmental impairment, representing a global health challenge.[1] In 2020, India had the highest global incidence of preterm births, with 3.02 million cases, making up more than 20% of all such births worldwide. This was followed by Pakistan, Nigeria, China, Ethiopia, Bangladesh, the Democratic Republic of the Congo, and the United States.[2] Among these, multiple gestation births, which constitute 3–4.5% of all deliveries,[3,4] are significantly associated with an increased risk of prematurity.[5,6]
Despite the recognized correlation between multiple gestations and prematurity, data on morbidity and mortality in these cases remain inconsistent and at times contradictory. A comprehensive study by Kalikkot Thekkeveedu et al. (2021), analyzing a cohort of 22,853,125 newborns, revealed critical insights into this issue. Singletons comprised the vast majority (96.91%), followed by twins (2.96%) and triplets (0.13%).[6] Preterm birth rates showed a stark disparity across groups: 5.90% among singletons, 52.75% among twins, and 94.58% among triplets.
Mortality rates paralleled this trend. Among preterm infants, mortality rates were 3.01%, 2.65%, and 5.07% for singletons, twins, and triplets or higher-order multiples, respectively.[7] Notably, the adjusted odds ratio (OR) for mortality in triplet or higher-order gestations was significantly higher (OR: 1.33, 95% confidence interval: 1.128–1.575, P= 0.0008) when compared to singletons. Early interventions like fetal reduction have come up in modern obstetrics, which provides a better outcome as compared to the expectant management of multiple pregnancies.
In a systematic review by Raffe-Devine et al. (2021), fetal reduction was shown to improve multiple outcomes, including increased gestational age at birth, reduced preterm mortality, higher birth weights, and decreased rates of small-for-gestational-age and intrauterine growth restriction.[8-10] The review, encompassing 24 studies, also reported a significant reduction in LSCS rates following fetal reduction. Furthermore, one study highlighted a significant decrease in premature rupture of membranes rates with fetal reduction compared to expectant management (P < 0.001).[10]
Although this study is a step to sensitize care for multiple pregnancies, it also has its own limitations. As a case series with only seven cases, the findings are limited by the small sample size, reducing their generalizability to broader populations. It lacks the comparative power of cohort or randomized studies, which restricts the ability to establish causality or predict outcomes in diverse clinical settings. Finally, variations in clinical management across cases and settings may influence the outcomes, emphasizing the need for standardized protocols to validate the observations in larger populations.
Aiming to be stepping stone, this article invites future researches that should focus on larger, multicenter studies to assess the role of fetal reduction and its broader implications. Investigations should aim to elucidate its impact not only on fetal morbidity and mortality but also on maternal outcomes, including mental health, obstetric complications, and long-term reproductive health. Understanding how these interventions can be tailored to resource-limited settings will be essential to improving outcomes globally.
This discussion highlights the need for further research into tailored interventions and care protocols to address the challenges of multiple gestation births, particularly in resource- limited settings with high burdens of prematurity. Enhanced focus on preventative strategies, including fetal reduction where appropriate, and improvements in neonatal care are critical to reducing the global burden of prematurity and its associated risks
CONCLUSION
Multiple gestation pregnancies are associated with a substantially increased risk of prematurity and adverse perinatal outcomes, particularly in higher-order multiples. Fetal reduction may improve gestational age at delivery and neonatal outcomes when compared with expectant management in selected cases. Although limited by sample size, this study highlights the need for larger, multicenter research to establish standardized management protocols and optimize both fetal and maternal outcomes, especially in resource-limited settings with a high burden of prematurity.
Ethical approval:
The Institutional Review Board approval is not required.
Declaration of patient consent:
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for clinical information to be reported in the journal. The patient understands that the patient’s names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Nil.
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