Quadruplets

Multiple births always attract attention and there is generally a great deal of fascination about the concept of more than one baby being born at the same time. But for parents of quadruplets, their initial responses can be far from what can be called exuberance, at least in the early stages. The practicalities of raising four babies to adulthood can seem utterly overwhelming, which is why experienced parents of higher order multiples (HOM) say it can help to just take things slowly at first and to allow the news to settle in, one steady day at a time.

The most common form of multiples are twins. Statistically 90% of all multiple births are made up of twins and the remaining 10% being shared between triplets, quadruplets and more. The most common variety of quadruplets is formed when four separate eggs are fertilized by four separate sperm. There are however, a range of possibilities when it comes to the different combinations of quadruplets and how they are conceived. Quadruplets may be identical, non identical or a combination of both.

As well as the four separate eggs and sperm variety, there is also the possibility that:

• One fertilized egg splits into four identical embryos.
• One fertilized egg splits into three identical embryos and another separate egg is fertilized by a separate sperm. This means there are identical triplets plus one.
• One set of Identical (monozygotic) twins occurs plus another two entirely separate embryos or another set of identical twins.
• Another possibility is that a set of non identical/fraternal twins are conceived plus a monozygotic pair form making a total of four embryos.

Quadruplet pregnancy is usually diagnosed on ultrasound. This is the most common time for parents to be told that four babies have been conceived and implanted. Seeing four little embryos on the screen can help the idea become a reality, but it’s very normal for expectant parents to leave the ultrasound rooms in a state of shock. If they have had fertility assistance then there is an increased risk of multiple birth so the possibility may already have been raised and discussed. Although rare, it is not unknown for quadruplets to be naturally conceived.

Tell us again how lucky we are

Different cultures view multiple births in diverse ways. For the Mayans, identical twins were seen as a blessing from God and a sign that they shared one soul which had been split between the two. In Roman culture twin boys were also viewed as a blessing, but unfortunately this belief did not extend to twin girls. They were seen as too much of a burden and the expense of raising two dowries instead of one overshadowed the “specialness” of two babies. Within Greek and other European mythology, twins and other higher order multiples all feature, with their existence being attributable to the blessing or alternately, a curse from an almighty God.

In some ancient cultures, multiple births were seen as an outward sign that a woman had been unfaithful to her husband and the existence of more than one baby was indisputable proof of this. Without any means of disproving this theory the poor women and their babies were often left to fend for themselves.

It goes without saying that we have much to be thankful for in terms of our current understanding of science and reproductive biology. But no matter how smart we have become and irrefutable evidence now supports our knowledge, there is still a little mystery and specialness surrounding multiple births.

Are quads as common as they used to be?

In the 1980s-1990s, multiple pregnancies were generally more common than at the present time. This decrease is thought to be due to overall advances in technology surrounding fertility assistance as well as the increased likelihood of these pregnancies being successful.

In the early days of assisted reproductive technology the general approach was to implant as many fertilized eggs as possible and therefore increase the chances of at least one of them implanting. But since there has been a greater understanding of the processes involved, as well as changes in the legislation surrounding the numbers of embryos which can be implanted, this has meant a reduction in the number of quadruplets being born.

There is an increased likelihood of quadruplets when:

• A mother has a family history of multiple births. If she is a multiple herself or her mother and/or sisters naturally conceived multiple babies, then she is more likely to as well. This is because there is a genetic link of hyper ovulation amongst the women in some families.
• Couples have had fertility assistance. Medication which increases the number of eggs supported towards maturity will increase the chances of multiple conception.
• Women whose diet is high in dairy foods and yams/sweet potato.
• Women are of African, especially Nigerian, descent.
• Women are already breastfeeding an older baby or toddler; they are more likely to conceive with multiples. But lactation and frequent breastfeeding can also have a contraceptive effect by stopping ovulation so this is a very individual process.
• Couples have regular sex during the woman’s fertile phases. This increases the overall chances of conception occurring.
• A woman conceives in her first cycle after ceasing the contraceptive pill. This is a time when her body is going through a readjustment phase of ovulation and menstruation and it can take a few months for her body to align back to a and normal reproductive cycle.
• Women are taller and have a higher Body Mass Index (BMI). Though this can also have a reverse effect, as women who are overweight can also have problems with regular ovulation.
• Women are older when they conceive rather than in a younger age group. Research has shown that women who are over 35 years are more likely to conceive with multiples. This tendency is thought to be due to what is known as a “fertility spike”, which occurs in women just before they enter peri-menopause. From a biological perspective, this is probably due to the naturally occurring phenomenon of nature maximizing the number of babies which can be born whilst women are still fertile.
• A woman has had many previous pregnancies. The more babies she has had and the more times she has ovulated the more likely she is to naturally conceive with multiples. This includes quadruplets.

Risks of quadruplet pregnancy

To the mother:

• Miscarrying one or all of the quadruplets. Genetic abnormalities account for a large percentage of early stage miscarriage. Even in a singleton pregnancy, the chances of miscarriage are 10-25% and these odds are increased for multiples.
• Increased risks of pregnancy complications overall including gestational diabetes, hypertension, placenta previa, ante and post partum hemorrhage and anemia.
• Uterine rupture and placental abruption.
• Need for caesarian section delivery. A normal vaginal delivery is not advisable for the birth of quadruplets as it is too stressful and risky for both the mother and her babies.
• Access to tertiary level neonatal services is essential. Women who are pregnant with quadruplets and who live in rural or regional areas are usually advised to relocate in their second or third trimester (at the latest) so they are close to the major city maternity hospital where their quads will be born.
• Restrictions around lifestyle, work, household and care of older children if there are any. The usual recommendations around working during pregnancy and taking maternity leave are usually different in the case of multiple pregnancy.
• Greater likelihood of having post natal depression and psychological adjustment disorders after the babies are born. Additional stress on the parent’s relationship is inevitable and the need for practical, financial and emotional support is great.

To the babies:

• Premature birth is always a risk factor in multiple births.
• Intra-uterine growth retardation and low birth weight. The average weight for a preterm individual quadruplet is around 1.3kgs but many weigh less than this and do not exceed 1kg when they are born.
• Cerebral palsy and jaundice. May need blood transfusions if there has been incompatibility issues or in cases of anemia and extreme jaundice.
• Breathing difficulties, problems maintaining their temperature and blood sugar levels.
• A generalized higher risk of physiological problems including hernia.
• Greater risk of developmental problems and global delays, including gross and fine motor skills, speech and language development, social and emotional development and visual acuity.

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