Twinning rates were studied in Swedes, Åland Islanders, Finns, Germans, and Dutch during years of starvation when death rates were two to three times higher than average. In contrast to the situation among some animals, this study suggests that nutrition above a certain threshold is unimportant for human reproduction, including twinning. The twinning rates for these different populations display marked temporal differences, but low values in the twinning rate are not consistently associated with periods of epidemics, famine, or similar nutritional stress. After years of privation and/or separation of spouses, a rapid “catch-up effect” can often be seen in the twinning rates, as well as marriage and birth rates. Psychoendocrine factors and interparental immunological conditions that may be involved in this phenomenon are discussed.

Changes in the management of 1120 twin pregnancies delivered in Tampere University Central Hospital during the years 1964-1985 were studied, together with changes in the pattern of perinatal deaths. Perinatal mortality decreased from 7.4% in 1964-68 to 3.5% in 1981-85. There were no significant changes in stillbirths. The decrease of perinatal mortality resulted from a reduction in early neonatal deaths, mainly those due to respiratory distress syndrome. Changes in obstetric management include earlier diagnosis by ultrasound, intrapartum monitoring, and an increase in cesarean section rate from 4% to 32%. There is still a need for a reduction in the number of very early preterm births, and for more effective intrauterine supervision of twin pregnancies.

The frequency of triplets in the U.S. white population may have reached an all-time low around 1964, at 78 sets per million deliveries. One-fourth of those were monozygotic as estimated by the difference method, or 18% by Bulmer's theoretical model. By 1983 the frequency of triplets had nearly doubled, the increase presumably occurring in dizygotic and trizygotic types. In Belgium most triplet pregnancies now result from artificial induction of ovulation, which is expected to occur mainly in older mothers. In the U.S., however, triplets have increased as much in young mothers as in older mothers, proportionally. This age distribution of the increase may be partly explained by a decrease in parity in older mothers since 1964.

The results of the Bene Anthony Family Relations Test on 53 pairs of twins and 30 older siblings, as well as an analysis of personality inventories from their parents, are presented. It is shown that weight and birth order can affect not only personality and the way in which twins interact with each other, but can also affect family interaction. Particular attention has been given to the effect on and of the preceding sibling.

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.

The rise in twinning rates previously reported for U.S. between 1964 and 1987 after adjustment for maternal age and birth order occurred in each of the nine conventional geographic divisions except the Pacific States. Differences and consistencies in rank order among the divisions with respect to crude and adjusted twinning rates and other demographic parameters may hold clues to yet unidentified influences in twinning.

This three-year study was based on individual interviews of over 200 bereaved MZ and DZ adult twins. Its purpose was to record the Ione twins' response to the loss of their twin and to investigate factors that correlated with either the severity or amelioration of the loss.

Fourteen triplet deliveries conducted between 1 January 1981 and 30 June 1986 at the principal teaching hospitals of Northwestern University Medical School are reviewed. Maternal demographic characteristics are listed, as are the obstetric outcomes, including mode of delivery, and the fetal outcome. The recent literature of triplet delivery is reviewed.

The rate of triplet delivery in our study was 0.37 per 1,000 live births. About two-thirds of the pregnancies resulted from the use of fertility-inducing agents. Ultrasonic confirmation was available in all cases. The majority of women were delivered by cesarean section (85%). No consistent pattern of presentation was seen. The mean weight of all 42 infants was 1,779 g (± 594). Unlike-sex triplets accounted for most of the sets (77%). The mean 5-min Apgar score of all infants was 9 and had no association with the order of deliveries. The weight differences by sex regardless of birth order were clinically insignificant. Neonatal mortality was 2.3%

The grief process is examined within the framework of multifetal pregnancy in a variety of demise situations. The case studies examined were obtained from approximately 120 lettere and interviews with families predominantly of higher order multiple births, who have experienced either partial or total loss in their pregnancy or afterwards. Objective and subjective factors were addressed. Results indicate the steps of the grief response are worked through in the same order as a singleton demise, but differ in intensity, duration, and frequency, depending on the individual circumstances, type of loss, gestational age, and the parents' backgrounds, expectations and beliefs. A unique feature discovered is that the entire grieving process, from shock through acceptance, appears to be completely experienced twice, with a large percentage of parents experiencing all of the stages three or more times. The general conclusion of the study is that the grieving pattern in multifetal death indeed follows a cycle and pattern of its own and requires special considerations.

The perinatal outcome of twin births in Australia is described from 1973 to 1980. Over that period, the perinatal mortality rate declined more slowly in twins that singletons. The stillbirth rate actually increased in twins due to a rise in antepartum deaths. An increasing proportion of monozygotic twins may have contributed to this trend. The overall perinatal mortality rate was 82.85/1,000 for twins and 16.49/1,000 for singletons, giving a relative risk of 5.0.

In a retrospective survey of 336 mothers of recently born multiples, 71% reported suspicions of twin pregnancy prior to medical confirmation. Primiparous and multiparous reports of symptoms may be utilized to significantly increase the early diagnosis of the presence of multiples.

The influence of maternal age and congenital malformations on perinatal mortality in twins in Australia from 1973 to 1980, is described. Stillbirths and neonatal deaths in twins fell with advancing maternal age. For teenage mothers, the twin perinatal mortality rate was 127.15/1,000. The sex ratio in twins is closer to unity than in singletons. Perinatal mortality due to malformation fell as maternal age increased up to 35 years. The role of zygosity and the distribution of birth weight with maternal age are discussed.

Limited data suggest that cesarean section (CS) may be the preferred method of delivery for triplets. Despite this, it is also felt that the third triplet is at great risk at delivery. We reviewed our experience of 14 triplet pregnancies at Northwestern University between 1981 and 1985. All deliveries were attended by neonatal teams in sufficient number to resuscitate each infant. Of the 14 pregnancies, two ended in previable loss. Thirty-six infants were born from 12 pregnancies of a mean gestational age of 33 weeks (28-38 weeks). The overall survival was 97.3%. Two women delivered vaginally. While the first was successful, the second resulted in vaginal delivery of the first two triplets followed by emergency CS for the third. That infant had a cord blood pH of 6.96(BE-19), was resuscitated and survived. All 10 CS were successful. The mean cord blood gas tensions and pH were normal. In addition, Apgar scores, the requirement for mechanical ventilation or supplemental oxygen, and mortality did not differ between the first and thirdborn triplet. These observations suggest that CS was beneficial. Our very low mortality rate supports the concept that CS delivery and aggressive neonatal resuscitation and therapy greatly enhances survival.

Studies of developmental progress in high-risk twins have disparate findings. In this study, we report the outcome of 45 twin pairs born between 26 and 37 weeks gestation, and whose birthweights ranged from 840 to 2000 g. No significant differences were found for weight, risk and birth order. However, earlier preterm infants were found to have significantly lower mental scores on the Bayley Scales of Infant Development at 24 months, and lower IQ scores on the Stanford Binet Intelligence Scale at 36 months. These findings imply that gestational age is a powerful variable in determining developmental outcome.

Parents of multiples suffer unique stresses which can severely impair family health and welfare. Access to information, counseling, and community resources increase parents' abilities to cope, and reduce the risk of child and spousal abuse. Twinline, a social service agency in Califormia, provides a variety of free and low-cost nonmedical perinatal services to meet the needs of a heterogeneous population of over 1,000 multiple birth families and parents expecting multiples in the urban and rural counties of the San Francisco Bay Area.

A study of perinatal mortality in multiple pregnancy over a period of 12 years, 1972 to 1984, showed prematurity and low birthweight as the major causes of fetal loss. The highest risk was found at 28 to 30 weeks gestation (306/1,000). There was a significantly greater risk to babies delivered by the breech (136/1,000), and likewise in the second twin when compared with the first, ratio 1:1.4. A significant drop in the perinatal mortality rate, from 98/1,000 to 39/1,000, was observed between 1972-1978 and 1979-1984. Ultrasound has facilitated the earlier diagnosis of twins and provides more accurate serial fetal assessment. Bedrest, more vigilant antenatal care, intrapartum surveillance and improved neonatal care, are required to maintain and further reduce the perinatal mortality rate. When regional analgesia was employed in labour, the number of babies lost was 41/1,000, vs 93/1,000 in patients not receiving regional analgesia. External cephalic version and vertex delivery of the second twin is preferable to internal version and breech extraction. It should also be contemplated, as an alternative to elective cesarean section for a transverse lie or brrech presentation of the second fetus.

Nation-wide data in Japan on the 112 sets of conjoined twins from fetal deaths and from postnatal deaths during 1979-1985 were analysed. Female conjoined twins accounted for 60% of cases. The incidence rate of conjoined twins remained Constant except in 1985. Overall incidence rate was 10 per million births. Maternal age effect was found in mothers over the age of 40, where the highest incidence rate was obtained. The incidence rate of conjoined twins increased with birth order. There was no seasonal variation in the time of conception.

Data concerning 16 triplet and higher-order deliveries (resulting in a total of 56 infants) are reviewed. The vaginal delivery rate was 81%. Maternal morbidity was more serious after abdominal delivery. Prematurity (< 36 weeks gestation) rate amounted to 68%. Overall perinatal and neonatal mortalities for infants born after 28 weeks gestation and weighing at least 1000 g were 7% and 3%, respectively. We doubt that neonatal outcome could have been markedly improved by performing more cesareans. The importance of antenatal care is stressed.

Based on the outcome of 21 triplet pregnancies from Antoine Béclère Hospital, early diagnosis in the major requirement for improving rates of fetal survival in multiple pregnancies. The outcome was better in mothers with spontaneous ovulation than in those with induced ovulations. Elective cesarean section in proposed.