Nineteen women attending a special multiple pregnancy antenatal clinic with a triplet pregnancy were randomly allocated to either bed rest in hospital from 24 weeks gestation onwards until delivery, or to continue conventional outpatient management. Conclusions are limited by the trial size, but the study suggests that routine hospitalization for bed rest decreases the incidence of preterm delivery and light-for-gestational age infants and reduces the need for intensive neonatal care. Although still compatible with change variation, the observations, if confirmed in a larger randomized study, would have considerable implications for clinical practice. The policy needs further evaluation in a large multicentred collaborative study.

During the 10-year period, 1975-1984, 105 triplet pregnancies were delivered at Harare Maternity Hospital, Zimbabwe, among 286,338 pregnancies in the Greater Harare Unit, giving an incidence of triplets of 1:2,727. The mean gestational age at delivery was 32.5 wk with 81 women (77.1%) delivering before 37 wk. Primigravidas delivered at a significantly earlier mean gestational age (P < 0.05) and had a higher perinatal mortality (P < 0.001) compared with grand multigravidas. Of the 315 babies, 277 (87.9%) weighed < 2500 g. The overall perinatal mortality rate was 327‰, with a pernital mortality rate of 146‰ for infants weighing ≥ 1000 g. Women hospitalised for bed rest during the antenatal period had fewer perinatal deaths compared with those diagnosed during the antenatal period, but not hospitalised for bed rest (P < 0.02). No difference was found in the mean gestational age at delivery or the mean birth weights between these two groups. Among infants ≥ 28 wk gestation there were fewer perinatal deaths in triplets delivered by cesarean section compared with triplets delivered vaginally (P < 0.0004). This suggests that cesarean section may offer the optimal mode of delivery in triplet pregnancy.

Recent clinical literature on the causes of twin pregnancy and specific areas of antenatal care are reviewed. Controversial aspects of clinical management are discussed.

The international literature on triplet births is surveyed. No definitive work on triplet gestations exists. The relatively few articles on this subject are divided into three categories: 1) national data; 2) local, regional or hospital series; 3) case reports. Clinical concerns, such as prematurity, low birth weight, bed rest, and tocolysis, are discussed with specific reference to literature citations.

During the years 1979-1980, a prospective study was carried out to evaluate the value and efficacy of routine hospital bed rest in the prevention of premature birth and pregnancy complications in twin gestation. This was done by comparing hospital bed rest to special antenatal care at outpatient clinic. Since the results did not support the idea of using routine hospital bed rest, this was abandoned. Because the material was rather small, the results of the changed policy of management were controlled in the present follow-up study. The material consists of 102 twin pregnancies diagnosed during the years 1982-1983. The number of deliveries before the 34th gestational week and of < 1500 g weighing infants were still decreasing (9.0% and 3.0%). Perinatal mortality after the 24th gestational week was 2.0%. The follow-up study confirmed the unefficacy of routine hospital bed rest. Early diagnosis is the basis of the management of twin pregnancy. This allows counselling of the pregnant women, regular examinations to detect pregnancy complications, and also planning of the delivery.

A total of 146 twin pregnancies were studied to evaluate the importance of bed rest. A significantly reduced frequency of preterm delivery was found after bed rest in hospital as compared to bed rest at home or no bed rest at all. An increase in gestational age and in birth weight was seen after bed rest. No effect was found on the intrauterine increase of fetal weight per time. Early routine ultrasound is recommended, so that effective bed rest may be instituted in due time.

A survey of triplet pregnancies in Linköping, Sweden, 1973-1981, showed a low perinatal mortality (4%) and low morbidity possibly due to prophylactic bed rest and tocolytic treatment. All children were followed at child health clinics. In one child, a persistent growth retardation was recorded at 4 years of age. No psychomotor deviations were found in the group. An interview concerning social and economic factors after delivery was carried out. The answers revealed considerable strain in daily life for all families.

During 1973/1978, more than 90% of the pregnant women in Malmö, Sweden, were examined by ultrasound to improve the early diagnosis of twin pregnancy. This screening programme detected 90% of the twin pregnancies delivered during this period, 105 were subjected to a preventive treatment with bed rest in hospital, usually from the 29th to the 37th week (mean: 55 days). This study evaluates the outcome of these pregnancies, compared with those not treated with bed rest and with all twin pairs born a decade earlier (1963/1965). All twins of this group born up to 1 May 1977 were also monitored by regular postpartum check-ups until at least 18 months of age. Perinatal mortality was reduced to 0.5% in the group with bed rest, but remained as high (8%) as ten years earlier in the group without bed rest. The bed rest group, compared with the group without bed rest and the group of twins born 1963/1965, also showed a significantly reduced frequency of deliveries before the 37th week; also, the incidence of twins born light-for-gestational age and with birth weight below 1500 g was reduced. The incidence of twins born with cerebral palsy, mental retardation, and late development was 3% in 1973/1977 and 8.1% in 1963/1965. The reduction of mortality and morbidity of twins paralleled the improved obstetric and neonatal care. The fact that perinatal mortality and preterm delivery were reduced only among twins subjected to special antenatal supervision suggests that large gains are to be made by early detection and antenatal hospitalization. The lower CNS morbidity provides evidence of the quality improvement among the twin survivers.