Introduction
High risk pregnancies are always at risk of complications.
Hence, additional antenatal follow ups, vigilant monitoring, in utero transfer to tertiary care center and timely intervention makes the journey fruitful.
The incidence of higher order multiple pregnancy cases has increased recently mainly due to the assisted reproductive techniques, but they do happen spontaneously. Expertise in obstetric care and well-equipped NICU together can drastically improve the perinatal outcome.
Case Report
Here is a case report of high risk pregnancy: 23 years old G2P1L1 with 28.4 weeks of gestation, referred to us with H/O PPROM since 3 days. She conceived during lactational amenorrhea when the first baby was 4 months old. UPT confirmed pregnancy. Ultrasound showed five gestational sacs!
Couple was counselled about anticipated problems and complications of multiple pregnancy i.e. miscarriage antepartum hemorrhage, PPROM, preterm labor, PPH and discussed about termination of pregnancy/foetal reduction, but the patient opted to continue the pregnancy on religious grounds. Cervical encerclage was done at 16 weeks, steroids were given at 25 weeks.
On examination, her vitals were normal.
Pallor was present. Per speculum showed frank leaking. High vaginal swab was suggestive of E. coli. Antibiotics were given.
Next day, patient developed fever and tachycardia with raised WBC, CRP and procalcitonin levels indicating early chorioamnionitis. Sonography showed severe oligohydramnios in the lowest sac, suggestive of leaking. Hence, couple was counselled for caesarean section to salvage other babies from infection. Risks of surgery and anticipated complications were explained to the couple.
Extensive preparations made, included five sets of ventilators and mock drills practised to ensure uneventful surgery.
Planned caesarean section was done under spinal anesthesia.
Five male babies were delivered in a span of 3 min weighing 850–930 g. There were no intrapartum and postpartum complications. All babies were ventilated immediately after the delivery.
Four babies went home after spending 2 months in NICU with average weight of around 2.2 kg. Unfortunately, baby housed in the leaking sac succumbed to sepsis.
This was the first reported Indian case of spontaneous quintuplets delivered at this period of gestation. It was possible only due to timely referral to tertiary care center, team with expertise and liaison between doctors (Obstetrician, Neonatologist, Anesthetist and Radiologist), besides good NICU care with better infrastructure and technology.
Discussion
Quintuplet pregnancies are associated with high incidence of obstetric complications and significant perinatal morbidity and mortality. Women with multiple pregnancies should be offered extra care during antenatal period with specific objectives of early diagnosis and timely treatment of complications [1]. Hence, tertiary care management can drastically improve the perinatal outcome.
It was heartening to know that all babies were born alive at 28.4 weeks of gestation and four babies did well. Ours was the first case in India and seventeenth in the world to have spontaneously conceived; all live born male Quints delivered at the highest period of gestation.
Quintuplets Facts
First set of surviving quints are identical Dionnes of Canada [2].
First set of all male Quints: In the US.
Compliance with ethical requirements and Conflict of interest
An ethical clearance has been taken from the institutional ethical committee. The authors of the article Jatinder Kaur, Suchitra N Pandit, Maya PL Gade declare that they have no conflict of interest.
Jatinder Kaur
did her post graduation (DNB, DGO) from Dr. Balabhai Nanavati Hospital, Mumbai. She is currently working as Clinical Associate at Kokilaben Dhirubhai Ambani Hospital, Mumbai. She is an active member of youth council, MOGS, and FOGSI, and has been involved in many academic and health awareness programs. She had received awards to her credit: (1) MOGS—Dr. Pramila Bhatia “Young Scientist Award”; (2) MOGS—Dr. S. D. Upasani Prize for best paper presentation; (3) FOGS—Dr. C. S. Dawn Prize for best paper on “New Armamentarium in Contraception—Nuvaring”; and (4) first runner up in “GEM’s award (Going The Extra Mile) in the category of Best Young Doctors” at Kokilaben Dhirubhai Ambani Hospital. She had also participated as “Sub-investigator” in the study of Contraceptive vaginal ring in Indian women.
References
- 1.Francois K, Alperin A, Elliot JP. Outcomes of quintuplet pregnancies. J Reprod Med. 2001;46:1047–1051. [PubMed] [Google Scholar]
- 2.Whalen J. The Whalen quintuplets homepage [Internet]. Quintuplet facts Available from http://www.whalenquintuplets.com/projecthome.htm. Reprinted in Clay MM. Quadruplets and higher multiple births. Cambridge University Press; 1991. p. 6.