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Purpose: The purpose of this survey was to study anxiety and associated factors in the mothers of twins or triplets as compared with the mothers of singleton children., Methods: The subjects were 130 mothers of twins or triplets aged 3 or under and 860 mothers of similarly aged singleton children. The Japanese version of State-Trait Anxiety Inventory (STAI) was used to evaluate their anxiety states., Results: 1. Mothers of twins or triplets showed significantly higher STAI state anxiety scores than those of singleton children. However, there was no significant difference in STAI trait anxiety between mothers with twins or triplets and those with singleton children. 2. Mothers of twins or triplets showed greater anxiety during pregnancy than those of singleton children. There were also higher rates of cases where stress could not be alleviated in mothers of twins or triplets than in those with singleton children. STAI state anxiety of mothers was associated with anxiety during pregnancy, anxiety for future child-rearing, problems with stress alleviation, maternal health conditions, poor sleeping conditions and having siblings., Conclusion: This study indicated a tendency for mothers of twins or triplets to show greater anxiety as compared with those having singleton children. It is important to improve the child-rearing environment to reduce anxiety felt by mothers of twins or triplets.

A 30-year-old woman in her 25th week of gestation with triplets complained of severe pain due to a hemorrhoid. The patient felt it was difficult to continue childbearing. First we performed caudal epidural block with 0.25% bupivacaine 20 ml and morphine hydrochloride 2 mg once a day, for 12 days without inserting a catheter because there were signs of infection. After the signs of infection had disappeared, we inserted a caudal epidural catheter and administered 0.125% bupivacaine 1-2 ml x hr(-1) for 6 days, up to the day of cesarean section. Liver function and blood bupivacaine levels of the mother were acceptable in the perioperative periods. The babies' Apgar scores and neurologic findings of the babies were normal. Blood bupivacaine levels of the babies were below the limit of measurement.

Extreme premature triplets were scheduled for PDA ligation through median sternatomy. Anesthesia was maintained with fentanyl, ketamine, pancuronium and sevoflurane or isoflurane with N2O, oxygen and air. During operation, steady ventilation with low oxygen concentration was maintained. Monitoring size and contraction of hearts in the face, 5% albumine solution could be administered safely for hypotension after PDA ligation. PDA ligation through median sternatomy might be a less invasive surgical procedure.

Purpose: The purpose of this survey was to study child-rearing problems and necessary community welfare and health services in the families with twins or triplets as compared with families with singleton children., Methods: The subjects were 205 mothers of twins or triplets aged less than 6 and 911 mothers of similarly aged singleton children., Results: 1. Concerning maternal feeling when informed of a pregnancy, a significant difference was observed between the mothers with twins or triplets and the mothers with singleton children: 1.3% of the mothers with singleton children were not delighted when informed of a pregnancy, while the rate for mothers with twins or triplets was 12.4%. Mothers of twins or triplets showed significantly greater anxiety when informed of a pregnancy, and also after delivery, greater anxiety for child-rearing. 2. Mothers of twins or triplets were more likely to feel they could not get information regarding pregnancy and child-rearing. 3. There were higher rates of child-rearing problems with regard to economic burden, attending a hospital when a child become ill, shortage of hands for medical examinations or preventive injections, going out with children, shortage of cooperators for child-rearing, lack of time and difficulty for feeding methods for twins or triplets. 4. Community welfare and health services that mothers of twins or triplets wished for were an allowance for child-rearing in 77.0% of cases, helper or baby-sitter for medical examinations or preventive injections in 59.8%, and meeting for mothers of multiple children in 52.0%., Conclusion: This study indicated a tendency for mothers of twins or triplets to show greater anxiety during pregnancy, greater anxiety for child-rearing after delivery, and harder to get information regarding pregnancy and child-rearing as compared with those having singleton children. Mothers of twins or triplets had more child-rearing problems with regard to shortage of cooperators, economic burden and feeding methods for plural infants.

Objective: This study was conducted to assess the birth weight and height in triplets, and to identify associated factors., Method: The subjects were 371 sets of triplets (1,113 triplets), who were born after 1986. Data on birth weight, birth height, gender, birth order, mode of delivery, gestational age, maternal weight gain at delivery, and infertility treatment were obtained. Pregravidic body mass index (BMI) was computed to evaluate maternal physique., Results: Mean triplet birth weight was 1,763.3 +/- 420.6 g and mean birth height was 42.2 +/- 3.36 cm. Overall, 96% were low birth weight newborn, 24.4% were very low birth weight newborn, and 4.9% had less than 1,000 g weight. The triplet birth weight was significantly associated with gender (male > female), sex combination (opposite-sexed sets > same-sexed sets), mode of delivery (vaginal delivery > caesarean section), and pregravidic body mass index (BMI) (more than 26.0 kg/m2 > less than 19.8 kg/m2). There was a significant correlation coefficient between maternal weight gain at delivery and birth weight. The triplet birth height was significantly associated with gender (male > famale), sex combination (opposite-sexed sets > same-sexed sets), and pregravidic BMI (more than 26.0 kg/m2 > less than 19.8 kg/m2). Moreover, the birth height was associated with maternal weight gain at delivery and infertility treatment., Conclusion: The birth weight and birth height in triplets are much lower than those for singletons and twins. Triplet birth weight is associated with gender, birth order, pregravidic body mass index, mode of delivery, and maternal weight gain at delivery, taking into account gestational age. Birth height is associated with gender, pregravidic body mass index, and infertility treatment.

Unlabelled: Multiple births are associated with an increased risk of child abuse and neglect. It is reported that only one child is abused in almost cases, and most abusers are the mothers. Maternal partiality regarding attachment has been suggested as the reason for this tendency. This study investigated the prevalence of this phenomenon in families with multiple birth children and identified factors associated with increased risk. The subjects were 231 mothers of multiple birth children. The following results were obtained. 1. Overall, 10.0% of mothers with multiple birth children reported that they didn't equally attach themselves to all their offspring. 2. Mothers who didn't equally attach themselves exhibited significantly poor health conditions and a higher frequency of upper respiratory infections, compared with mothers who demonstrated no partiality. Moreover, they were more likely to complain of severe fatigue (physical and mental) and poor sleeping conditions. 3. The mothers who didn't equally attach themselves to all their multiple birth children had a higher rate of handicapped children., Conclusion: Mothers who do not equally attach themselves to all their multiple birth children show poor health conditions and a higher frequency of upper respiratory infections, and complain of severe fatigue and poor sleeping conditions. They also have a higher rate of handicapped children.

Our purpose was to evaluate the association between maternal weight gain patterns and pregravid body mass index (BMI), toxemia of pregnancy, birthweight, intrartum asphyxia, preterm rupture of membrane, mode of delivery and handicaps, and to make specific recommendations for maternal weight gain in twin and triplet pregnancy. The subjects were 1,436 mothers of twins and 227 mothers of triplets aged from 20 to 34. The following results were obtained. 1) In twin pregnancies, maternal weight gain was significantly lower in overweight women than in under- and normal-weight women. In triplet pregnancies, there was no significant difference in maternal weight gain by BMI. However, gestational week at delivery and birthweight was significantly lower in underweight women than in the normal weight women. The number of babies weighing under 1,500 g was significantly higher in underweight women than in the normal weight women. 2) In twin pregnancies, the risk of toxemia of pregnancy, baby weighting under 1,500 g, intrapartum asphyxia and preterm rupture of membrane was significantly associated with maternal weight gain. Moreover, in triplet pregnancies, toxemia of pregnancy and baby weighing under 1,500 g was significantly associated with maternal weight gain. 3) In twin pregnancies, the mean maternal weight gain in mothers without toxemia of pregnancy, and with baby weighing at least 1,500 g, was 6.2 kg at 36-37 weeks of delivery in overweight women, 12.0 kg at 37 weeks in normal women, and 12.4 kg at 36-37 weeks in the underweight women. The approximate birthweight of twins in those mothers was from 2,300 to 2,500 g. Moreover, in triplet pregnancies, the mean maternal weight gain in mothers without toxemia of pregnancy, and with baby weighing at least 1,500 g, was 12.2 kg at 35 weeks of delivery in normal weight women and 11.8 kg at 34-35 weeks in underweight women. The approximate birthweight of triplets in those mothers was from 1,800 to 2,100 g.

A 29-year-old woman with a triplet pregnancy received emergency caesarean section in the 33rd week of pregnancy. She lost 2 babies, one of whom was a fetal death and the other a neonatal death. Three weeks before delivery, she was admitted to hospital suffering from vomiting, diarrhea and polyuria. There were no laboratory abnormalities such as a slightly elevated levels of liver enzymes, nor any clinical symptoms of preeclampsia. At the end of the operation, disseminated intravascular coagulation (DIC) occurred and HELLP syndrome was diagnosed. However, the hemoglobin level was in the normal range at this point. On the 2nd postoperative day, hemolytic anemia developed in spite of the resolution of other problems. We suggested that the hemolysis, which may have been caused by a latent hemoconcentration and a membrane disorder of the red cells, was an osmotic hemolysis. This case was unique for the following reasons; 1) a lack of symptoms of hypertension, proteinuria and edema, 2) complications due to diabetes insipidus, 3) postpartum severe hemolysis following latent hemoconcentration, and 4) slow progress of the condition after onset. Early detection of HELLP syndrome is difficult. It should be considered in the management of patients with unrecognizable hemoconcentration and nonspecific complications.

A mailed questionnaire survey was conducted on a population of 705 mothers of twins, 96 mothers of triplets, 7 mothers of quadruplets and 2 mothers of quintuplets to study the actual conditions of help and support of childcare in the families with multiple birth children. The following results were obtained. 1) In this study, 90.6% of the mothers of twins, 89.6% of the mothers of triplets, 100.0% of the mothers of quadruplets and 100.0% of the mothers of quintuplets had at least one relative and friend from whom they received practical help and regular support. However, 5.8% of the mothers of twins and 8.3% of the mothers of triplets did not have others from whom they received help and support. 2) Lack of time to take care of the other children was reported by approximately 90% of mothers with twins who did not have others from whom they received help and support for childcare. 3) Mothers who did not receive help and support from others for childcare reported severe fatigue, compared to mothers who received help and support from others: mothers of twins, especially reported severe mental fatigue and mothers of triplets or more, severe physical fatigue. 4) Mothers of twins who had no way to alleviate stress reported severe physical and mental fatigue, compared to mothers who had ways to alleviate stress. Mothers of triplets or more showed a similar tendency as mothers of twins. These mothers alleviated stress by talking with other mothers of multiple birth children, friends, their maternal mother or their husband.

A mailed questionnaire survey was conducted on a population of 123 mothers of twins and 96 mothers of triplets to study problems in the families and maternal fatigue symptoms. The following results were obtained. 1) The prevalence rate of handicap was 9.7 per 100 for triplets, and 4.9 per 100 for twins. The risk of handicap in triplet pregnancy was approximately 25%, and in twin pregnancy was approximately 10%. Therefore 1 in 4 mothers with triplets and 1 in 10 mothers with twins had one and more handicapped children. 2) Mothers with triplets aged 0-11 months reported significantly poorer sleep quality than mothers with triplets aged one year or more with shorter sleeping time, greater frequency of awakening during the night, and more complaints of inadequate sleep. Mothers with twins aged 0-11 months showed a greater tendency for poor sleep quality than mothers with twins aged one year or more. 3) Approximately 70% of mothers with twins and triplets aged up to two reported lack of time to care for the other children. When the age of twin was 3 or more, lack of time to take care of other children was reported by only 13.3% of mothers, while it was 41.7% for mothers with triplets. 4) Mothers of twins and triplets who did not receive assistance from others for childcare reported severe physical fatigue, compared to mothers who received assistance from others. Mothers of twins and triplets aged 3 or more showed a tendency of less physical fatigue, compared to mothers of twins and triplets aged up to two.

This study was conducted to investigate the prevalence rates of handicaps in twins and triplets. The subjects were 252 twins and 287 triplets. The following results were obtained. 1) The prevalence rates of the handicapped were 8.7 per 100 triplets, and 4.4 per 100 twins. The risk of producing at least one handicapped child was approximately 22% in triplet pregnancy and 9% in twin pregnancy. This means that one in 4 or 5 sets of triplets had at least one handicapped child, as did one in 11 pairs of twins. 2) Cerebral palsy was the most frequent handicap in twins and triplets. The risks of producing a child with cerebral palsy were 2.0% and 3.1% in twins and triplets, respectively. 3) The prevalence rates of congenital anomalies (congenital heart disease, limb anomalies, and others) were 2.4% in twins and 4.5% in triplets. Approximately 45% of the handicaps in twins and triplets resulted from congenital anomalies. 4) The prevalence rate of the handicapped in twins and triplets was not associated with maternal age, but was associated with the years of delivery in triplets, and was higher in babies with shorter gestation periods.

A mailed questionnaire survey was conducted on 96 mothers of triplets to study antenatal complications in triplet pregnancies and birth weights of triplets, and compared to 122 controls recruited from mothers of twins. The following results were obtained. 1) Antenatal complications occurred in approximately 80% of both triplet and twin pregnancies. In the triplet pregnancies the incidence of toxemia of pregnancy and anemia was 25.0% and 47.9%, respectively. There was no significant difference in the incidence of antenatal complications, toxemia of pregnancy and anemia between triplet and twin pregnancies. On the other hand, the incidence of preterm labor and threatened miscarriage was higher in triplets (70.8% and 34.4% respectively) than in twin pregnancies (45.9% and 12.3% respectively). 2) The mean birth weight was 1831.7 g for each individual triplet and 5495.0 g for each triplet set. In triplets, 94.7% were low in birth weight (< 2500 g). 3) The antenatal complications of preterm labor and threatened miscarriage in triplet pregnancies have increased since 1990 in Japan. The frequency of toxemia of pregnancy and anemia did not particularly change significantly during the surveyed years. However, mean birth weight for each individual triplet showed a tendency to decrease from year to year (1978-1989, 1934.5 g; 1990-1991, 1900.3 g; 1992-1993, 1741.1 g).

Selective beta-sympathomimetic drugs are frequently used for tocolysis. But, since these drugs exhibit some beta-1 activity as well, they may bring about pulmonary edema, myocardial ischemia, cardiac arrhythmia and others as side effects. A 29 year-old female with a triplet pregnancy had premature contraction at 26 weeks of gestation. High doses of IV ritodrine were given for tocolysis for 8 weeks until caesarean section. One hour after caesarean section at 35 weeks of gestation, she complained of dyspnea. Urinary output decreased and chest X-ray showed pulmonary edema. She was intubated and artificial ventilation with PEEP was performed in ICU. Echocardiogram showed left ventricular dilatation. ECG showed inverted T waves on all leads. We diagnosed her as suffering from acute heart failure, pulmonary edema and acute renal failure. Hemodialysis was performed for 6 hrs but PCWP was still 18 mmHg. So CVVH was added to hemodialysis. Five hrs after the start of CVVH, her symptoms gradually started to subside. Total fluid removal was 5.8 l over 16 hrs. Three days after admission she was extubated and five days later returned to her ward. We concluded that pulmonary edema, heart failure and renal failure were induced by the long-term high dose medication of ritodrine, resulting in volume overload and myocardial dysfunction.

Fetal weight estimation was tried in each fetus in 16 cases of twins and 2 cases of triplets using the formula derived from the regression analysis of fetal biometric data and actual neonatal weights in 26 cases of singleton pregnancies. The fetal biometric data used were biparietal diameter (BPD), abdominal antero-posterior diameter (APD), abdominal transverse diameter (TD), abdominal circumference (AC) and fetal femur length (FFL). The correlation between the estimated and actual weight was significant (r = 0.926) and the estimation error in neonates smaller than 2,500 g was less than 10% of the birth weight. Estimated weight differences in 16 pairs of twin pregnancies correlated well with the actual weight differences (r = 0.678). A sensitivity of 70% and specificity of 100% were revealed in the diagnosis of IUGR using the estimation formula and the intrauterine fetal growth curve. These results showed how the estimation formula derived from ultrasonically measured fetal biometric parameters, can be applied clinically but two kinds of formula with or without BPD are necessary for fetal weight estimation in multiple pregnancies as only 53% of BPD were available for fetal weight estimation.