Pregnancy after Multiple Birth of Triplets or More
By Lisa Glickstein, Ph.D, Triplet Mom
Originally printed in March 2004

Many TMM member families have experienced one or even several subsequent pregnancies
after their triplets or quads were born. Recently I've been asked if subsequent 
pregnancies are safe - "can my uterus handle it?" And what about other
medical issues that might arise?

"Should I have another baby?" Most of us have asked ourselves this question
at some point during our triplets or quads infancy. Reasons range from wanting a
"normal" singleton pregnancy, hoping for a boy or girl to complete the
family, wanting a large family, or seeking to implant frozen embryos. It is important
to note that there is no guarantee of fulfilling all hopes with a subsequent pregnancy
- one may again conceive multiples rather than the "normal" singleton,
or have another boy or another girl. Even if you are sure you want another baby,
it is important to consider your own motivations, alternatives to having another
child, and the impact on your family, in order to adequately prepare for a new addition.

"Can I get pregnant?" For some women, a spontaneous pregnancy may be a
pleasant surprise. Treatment for endometriosis or tubal damage may have temporarily
or permanently restored fertility. Pregnancy may also result because of ongoing 
treatment for an underlying condition causing infertility. For example, glucophage
treatment is now commonly prescribed for polycystic ovarian syndrome to regulate
associated insulin resistance (a prediabetic condition); it can help with weight
loss and also independently can restore ovulation. Others may actively seek treatment
for secondary infertility (fertility after a successful pregnancy outcome). Women
who have been treated for primary infertility may have a higher chance of getting
pregnant during subsequent treatment than newly diagnosed infertile patients. They
know they can respond to treatment. In fact, women who have conceived multiples 
with artificial reproductive treatment are at increased risk of doing so again, 
particularly with a diagnosis of polycystic ovarian syndrome. Conversely, younger
age is a strong indicator for treatment success, and women may not respond to secondary
treatment as well as they did even one to two years earlier. Increased fatigue and
stress from caring for young children, or significant weight gain, may also interfere
with treatment. These factors are highly individual and should be discussed with
your doctor. In addition, attitudes of family and friends may or may not be as supportive
as they were during your primary infertility. Ideally, one would enlist an understanding
support group prior to undertaking treatment. There are many resources for couples
experiencing secondary infertility, including Resolve and INCIID. Especially important
is conveying to family and friends the meaning of your struggle, which may include
failed treatment cycles or miscarriage. 

"Can my uterus take another pregnancy?" The short answer is, yes. There
is no evidence in the medical literature that higher-order multiple pregnancy weakens
the uterus with regard to carrying the pregnancy.

"Will I have the same complications I had with my triplet or quadruplet pregnancy?"
Women tend to repeat their pregnancy and delivery history. Therefore, if you had
hyperemesis gravidarum, high-blood pressure (preeclampsia), gestational diabetes,
HELLP syndrome, or preterm labor in your first pregnancy, you are at increased risk
of having these complications in your singleton pregnancy. However, this increased
risk is compared to other singleton pregnancies, in which the risk for these serious
complications is relatively small to begin with. Therefore the real rate of serious
complications is still low in subsequent pregnancies for mothers of higher order
multiples. It will still be important for you to be monitored for these complications,
particularly if you do become pregnant with twins or more. There is no increased
rate of complications in subsequent pregnancies for mothers who did not have these
complications in their triplet or quad pregnancy - in other words, having preeclampsia,
not having triplets or quads, increases the risk for future preeclampsia.

"Will I need to be on extended bedrest?" This depends on whether or not
you develop any complications. For example, if you anticipate that you will need
a cerclage, you needed bedrest for an earlier singleton pregnancy, or you become
pregnant with twins or more in your subsequent pregnancy, there is a high likelihood
that you would need bedrest. However, since the rate of complications is less in
singleton pregnancies, the chance of needing significant bedrest is also reduced.

"Will I deliver my subsequent pregnancy prematurely?" This is highly dependent
on the reason for your first preterm delivery. For example, if you lost a pregnancy
because of a problem with your cervix, and needed a cerclage for your triplet or
quad pregnancy, you may need one for a subsequent pregnancy as well. Premature rupture
of membranes may repeat, for unknown reasons, although antibiotic treatment for 
bacterial vaginosis in early pregnancy seems to reduce the risk. A subsequent pregnancy
of twins or more would obviously increase the likelihood of preterm delivery in 
and of itself without regard to a prior pregnancy outcome. However, most subsequent
singleton pregnancies are uncomplicated. No studies have looked at triplet or quadruplet
pregnancies, but two studies of preterm twin delivery found that delivery of twins
between 34-37 weeks did not significantly affect the duration of subsequent singleton
pregnancies, and delivery of the twins between 31-33 weeks only modestly increased
the risk of preterm delivery. Preterm delivery of twins prior to 30 weeks increased
the risk of subsequent prematurity 2-3.6 times. Even in the latter case, over 90%
of subsequent pregnancies delivered at or near term (beyond 37 weeks gestation).

"Can I have a vaginal delivery in my subsequent pregnancy?" Many women
want the experience of a vaginal delivery, especially if they have a subsequent 
singleton pregnancy. There is a chance during vaginal birth after C-section that
the scar can fail and cause the uterus to rupture (break open). This is not specific
to women who have carried triplets or quadruplets. Certain types of incision, or
a history of uterine rupture, are strong contraindications to vaginal birth after
C-section. For the bikini incision, and a singleton pregnancy, the risk of rupture
is relatively low in so-called "trial of labor" - in which you are given
a chance to deliver vaginally if you go into labor on your own. However, induction
with pitocin, and especially the use of prostaglandin gel on your cervix, greatly
increases the chance of uterine rupture. Many women do have a successful vaginal
delivery in a subsequent pregnancy. Repeated C-sections carry their own risks, including
near-term surgical complications and long-term risks for later pregnancies. Women
who want a larger family are advised to make this clear to their doctor. As I touched
on last month in this column, the medical community is currently leaning away from
vaginal birth after C-section. This is based on several recent studies, and in some
cases, has meant that smaller hospitals can no longer get insurance coverage to 
perform vaginal delivery after C-section. It is important to discuss this with your
doctor early in your pregnancy so there is time to make adjustments to expectations,
or to change doctors or hospitals, as appropriate.

"What about post partum depression?" Having a baby at any time can lead
to post partum depression. However, there are reasons to believe that mothers of
triplets 

or quads are at greater risk. First, prior history of post partum depression is 
a risk factor for subsequent post partum depression. Even if the depression in your
triplet or quadruplet pregnancy was triggered by the babies being in the hospital,
or the stress of caring for three or four infants, simply having depression elevates
the risk for future depression. This is especially true if the subsequent pregnancy
or new baby leads to marital, family or financial problems. If the pregnancy was
unwanted, or you find yourself having regrets, you are also more likely to become
depressed. Finally, fatigue alone is a significant risk factor for post partum depression,
and mothers of multiple toddlers or preschoolers are certainly likely to be tired!
Asking for help with your other children, the baby, or the housework, seeking psychotherapy
or antidepressant therapy, and adjusting expectations may all be significant preventive
techniques. Exercising gently and seeking social support are also helpful.

In summary, there is no evidence in the medical literature that triplet or quadruplet
pregnancies have any negative long-term consequences in and of themselves for later
pregnancies. However, the presence of complications, especially serious ones, in
the triplet or quadruplet pregnancy elevates the risk of the same complication in
a later pregnancy. C-section in the first pregnancy can make delivery choices more
complex. Undertaking treatment for secondary infertility and the added stress of
pregnancy and a new baby can certainly increase marital, family and financial problems.
Careful consideration of these issues both personally and in consultation with medical
professionals can ensure the best possible outcome when bringing another baby into
the family.