Contributor: Carolina Bibbo, MD
Carolina Bibbo, MD, is a maternal-fetal medicine specialist in the Division of Maternal-Fetal Medicine in the Department of Obstetrics and Gynecology at Brigham and Women's Hospital.
News of a pregnancy is especially joyful after a couple has overcome obstacles to conceive. When the good news involves a multiple pregnancy, hopeful parents immediately face a new challenge: Finding the right care. This is especially true when triplets are expected. As the news settles in, parents may feel overwhelmed by the prospect of triplet pregnancy, birth and newborn care.
“Most patients who carry triplets have used either medications to induce ovulation or in vitro fertilization and understand that this technology increases the risk of multiple pregnancy. Even so, many patients are still surprised when they hear that they are carrying triplets,” says Carolina Bibbo, MD, an obstetrician/gynecologist in the Division of Maternal-Fetal Medicine (also known as High-Risk Obstetrics) at Brigham and Women’s Hospital, where she runs a clinic for women expecting multiple births. “As shocking as it is to be pregnant with triplets, for many patients it also feels like a blessing — with some potential complications.”
Birth of triplets and high-order multiples rose fourfold during the 1980s and 1990s in the United States, due largely to increased use of fertility-enhancing therapies, according to the US Centers for Disease Control and Prevention. Then rates dropped as improvements in treatments made it possible to achieve pregnancy using fewer embryos. Nationally, the twin birth rate has slowly continued to rise. The vast majority of multiple births are twins.
At Brigham and Women’s Hospital, more than 6,300 babies are born annually, which typically includes nearly 200 women giving birth to twins, triplets or quadruplets each year.
For an expectant mother, the difference between twins and triplets is a matter of degree: The same concerns apply, just more so. A triplet pregnancy generally calls for the expertise of specialists in high-risk pregnancy, along with the emotional support and knowledge of an entire team – maternal-fetal physicians (obstetricians), newborn specialists (neonatologists), nurses, nutritionists, and social workers.
“Despite the challenges of a triplet pregnancy, it is a time of great joy for the parents, and we work together to bring the best health possible for mother and babies,” says Dr. Bibbo.
A woman pregnant with triplets is at risk of the same complications as one having twins – gestational diabetes, hypertensive disorders and anemia — but at a higher rate. Triplet moms also experience more general discomfort, such as prolonged back pain and nausea.
The biggest risk of any multiple pregnancy is preterm delivery – and the more babies a woman carries, the greater the risk. For a singleton, birth typically occurs around 39 weeks gestational age; for twins approximately 36 weeks; and for triplets 32 weeks. In preterm babies, body systems and organs may not be fully matured, making the newborn more vulnerable to complications.
The earlier an infant is born, the longer their hospital stay will typically be, with babies often ready for discharge to home around their original due date. With a multiple birth, the babies may not be ready to go home at the same time.
Birth between 34 and 37 weeks is considered “late prematurity,” with risks related mainly to breathing independently, feeding, and regulating blood sugar and body temperature. These issues are generally not life-threatening or long-lasting, but often require admission to a neonatal intensive care unit (NICU) or special care nursery (SCN). Babies born before 34 weeks may need breathing assistance and several weeks of NICU care, as they grow and develop the ability to eat by mouth, breathe and stay warm on their own. Birth prior to 28 weeks, carries greater potential risks, including long-term lung-disease, infection associated with an immature immune system and higher rate of long-term neurological complications including cerebral palsy.
The Brigham’s clinic for women expecting multiples, run by Dr. Bibbo and Julian N. Robinson, MD, brings together leaders in fetal diagnosis and pediatric specialists who offer expertise in assessing and managing the risks associated with multiples. This supportive clinic also coordinates the extra prenatal visits and ultrasounds that may be recommended. Because women expecting twins and triplets find it challenging to keep up with the nutritional demands, each patient at the Brigham’s multiples clinic has access to a nutritionist for guidance on how to get enough protein and other nutrients.
Due to risk of early labor and birth, Dr. Bibbo recommends choosing an obstetrician who is experienced in multiple births and delivers at a hospital with a Level 3 NICU.
1. Your obstetrician — and the entire obstetrical team — should be experienced in delivering multiple babies.
The preferred route for triplet delivery is Caesarean section, due to potential risks of maternal and fetal complications.
To prepare for the birth, parents in the Brigham’s multiples clinic meet with the entire birth and newborn team in advance, ideally before hospitalization. But because many triplet moms are admitted to the hospital for observation and assistance delaying a very preterm delivery, this meeting may occur in the hospital.
At the time of a triplet delivery at Brigham and Women’s Hospital, a designated NICU team is assembled and waiting, staying in close communication with the team handling the birth. Each baby is assigned a full team of newborn specialists (usually two or three nurses or doctors) that is devoted solely to each newborn.
2. A Level 3 NICU may be needed to optimize the health of a fragile newborn immediately after birth.
The rare triplet mom who doesn’t go into labor until week 35 or 36 may be able to deliver safely in a smaller hospital, and her babies may not need NICU care. But given the likelihood of early labor with triplets, planning for birth in a hospital with a Level 3 NICU eliminates the need for transfer should complications arise.
Given the likelihood of early labor with triplets, planning for birth in a hospital with a Level 3 NICU eliminates the need for transfer should complications arise.
With multiple birth also comes the possibility that babies will be smaller and less developed than their gestational age suggests. Babies born before 34 weeks may need breathing assistance or advanced brain monitoring to detect seizures or irregular blood flow. A Level 3 NICU has access to the necessary pediatric specialists and technology appropriate to care for a hospital’s smallest patients.
Dr. Bibbo emphasizes the importance of choosing a hospital with a NICU that can accommodate three newborns at once. This tends to be large hospitals that also train specialists.
In the most modern NICUs, including a newly-expanded NICU at Brigham and Women’s Hospital, the space is designed to be soothing, to help fragile newborns heal, grow and develop. The Brigham NICU includes private and semi-private rooms where parents and babies can be together. As babies require less intensive therapy, they move to the Growth and Development Unit, specifically designed to promote appropriate neurodevelopment. Enhanced services there include physical and occupational therapy and specialized feeding help from speech and language therapists. Triplets, depending on how early they are born, are likely to remain in the NICU for weeks to reach appropriate maturity to be able to go home.
Alongside the technical expertise of experienced physicians and nurses and a top-notch medical center, triplet parents need emotional support. Medical staff who work regularly with multiple pregnancies are familiar with their specific needs and concerns.
“We see a lot of high-risk patients, so we understand their struggles,” says Dr. Bibbo. “A nurse who sees all the patients in the multiples clinic is used to answering the questions that these mothers have.”
Multiples patients tend to have frequent visits with their medical team during the pregnancy, which fosters a close relationship. Their caregivers know that twin and triplet mothers may be more vulnerable to depression as they face a complex pregnancy, plus new family dynamics, financial concerns, and other anxieties.
“Patients build a rapport with our clinic, so they are comfortable reaching out to us if they feel overwhelmed,” Dr. Bibbo says.
All babies who have been in the Brigham and Women’s Hospital NICU can join the outpatient NICU Follow-Up Program, starting immediately after discharge. The program monitors children through toddler years, providing ongoing assessments and connecting parents with services to help keep growth and development on track.
We understand that you may have concerns and want to assure you that we are steadfast in our commitment to safely providing the care you need. Our maternal-fetal medicine specialists are available to connect with you in person and with Virtual Visits. To request an appointment, call 617-732-5130 or submit the form below.
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