Quadruplets

Multiple births always attract attention and there is generally a great deal of fascination about 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 happy, at least in the early stages. The practicalities of raising four babies to adulthood can seem utterly overwhelming, which is why other  parents of multiples  advise to just take things slowly at first and allow the news to settle in, one steady day at a time.

The most common form of multiples is twins. Statistically, over 90% of all multiple births are made up of twins, and the remaining 10%  are shared between triplets, quadruplets and more.

The most common variety of quadruplets is formed when four separate eggs are fertilised 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 fertilised egg splits into four identical embryos.
• One fertilised egg splits into three identical embryos and another separate egg is fertilised 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 room in a state of shock. If they have had fertility treatment then there is an increased risk of multiple births, 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 2 babies.

Within Greek and other European mythology, twins and other higher order multiples all feature, with their existence being attributable to a 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 1 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 how much 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 present. This decrease is thought to be due to overall advances in technology surrounding fertility treatment, 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 fertilised 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 that 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 who have had fertility assistance. Medication, which increases the number of eggs supported towards maturity, will increase the chances of multiple conception.
• Women that are of African descent.
• Couples having regular sex during the woman’s fertile phases. This increases the overall chances of conception occurring.
• Women that are taller and have a higher Body Mass Index (BMI). Though this can also have a reverse effect, as women that are overweight can also have problems with regular ovulation.
• Women who are older when they conceive rather than in a younger age group. Research has shown that women 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 maximising the number of babies which can be born while women are still fertile.
• A woman who 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 15% and these odds are increased for multiples.
• Increased risks of pregnancy complications overall, including gestational diabetes, hypertension, placenta praevia, ante-and postpartum haemorrhage and anaemia.
• Uterine rupture and placental abruption.
• Need for caesarean 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 a high level of neonatal services is essential. Women that are pregnant with quadruplets and live in rural or regional areas are usually advised to relocate in their second or third trimester (at the latest) so that they are close to the 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 postnatal depression and psychological adjustment disorders after the babies are born. Additional stress on the parents’ 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 1.4 kg but many weigh less than this
• Cerebral palsy and jaundice (may need blood transfusions if there has been incompatibility issues or anaemia and extreme jaundice)
• Breathing difficulties, problems maintaining their temperature and blood sugar levels
• A generalised higher risk of physiological problems including hernias
• 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

For more information:

Multiples 2 Multiples - Association for Parents and Families with Multiple Children. http://www.multiples2multiples.org/index.php