**7. Delivery of a quadruplet or quintuplet pregnancy**

The delivery of high-order pregnancies is challenging for the mother, the obstetricians, and pediatricians. Malpresentations are common, while the babies often require intensive care and special treatment, considering that more than 90% of high-order pregnancies are born prematurely. Average gestational age at delivery is estimated around 29.5 weeks for quadruplets and 29 weeks for quintuplets [17], although term delivery has also been reported, mostly as case reports [20, 134, 135]. The rates of preterm birth in the USA at <37 weeks of gestation are estimated at 96.77% for quadruplets and 100% for quintuplets and more. When it comes at <34 weeks, the estimated rates are at 93.09% for quadruplets and 100% for quintuplets [12].

**Author details**

Stelios Fiorentzis1

Dimitrios P. Koutsoulis6

1 Agios Nikolaos Crete, Greece

6 General Panarcadian of Tripolis, Greece

1995;**29**(4):5-14. DOI: 10.3138/jcs.29.4.5

www.ncbi.nlm.nih.gov/pubmed/13792733

Chatzikosta, Ioannina, Greece

**References**

**41**:241

, Styliani Salta2,3, Michail Pargianas<sup>4</sup>

Cancérologie, Faculté de Médecine, Sorbonne Université, Paris, France

Assistance Publique Hôpitaux de Paris (AP-HP), Paris, France

\*Address all correspondence to: kosmasioannis@gmail.com

, Christodoulos Akrivis7

2 Cancer Biology and Therapeutics, Centre de Recherche Saint-Antoine, Institut National de la Santé et de la Recherche Médicale (INSERM) U938 and Institut Universitaire de

3 Service d'Hématologie Biologique Hôpital Tenon, Hôpitaux Universitaires Est Parisien,

4 Medical School, University of Ioannina, Obstetrics and Gynecology, Ioannina, Greece

5 Department of Obstetrics and Gynecology, University Hospital of Heraklion, Greece

[1] Aldwell A. Jane Smith, a fisherman's wife in Kinsale, had four boys at a birth. Cork Post Office General Directory. 1884-5. F. Jackson. p. 156. Available from: http://www. corkpastandpresent.ie/places/streetandtradedirectories/1844-5aldwellscountycitypogeneraldirectory/1844-5pages132to191/GeneralDirectory1844Pages156%20to%20161.pdf

[2] Wright C. They Were Five: The dionne quintuplets revisited. Journal of Canadian Studies.

[3] Hellin D. Die Ursache der Multiparität der Uniparen Tiere überhaupt und Zwillingsschwangerschaft beim Menschen insbesondere. Edinburgh Medical Journal. 1895;

[4] Zeleny C. The relative numbers of twins and triplets. Science. 1921;**53**(1368):262-263.

[5] Peller S. A new rule for predicting the occurrence of multiple births. American Journal of

[6] Allen G. A differential method for estimation of type frequencies in triplets and quadruplets. American Journal of Human Genetics. 1960;**12**:210-224. Available from: http://

Available from: http://science.sciencemag.org/content/53/1368/262.abstract

Physical Anthropology. 2005;**4**(1):99-106. DOI: 10.1002/ajpa.1330040110

7 Department of Obstetrics and Gynecology, Ioannina State General Hospital G.

, Artemis Pontikaki5

, Dimitrios Akrivis7

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http://dx.doi.org/10.5772/intechopen.80338

and Ioannis Kosmas7

Quadruplets and Quintuplets

\*

173

Cord prolapse, hemorrhage, and abruption of the placenta are undesirable possible complications for any vaginal delivery, but in a high-order pregnancy where the mother and the fetuses are more vulnerable are even more undesirable. While there are many reviews about the mode of delivery for twin and triplet gestations, this is not possible for quadruplet and quintuplet pregnancies. For quadruplet pregnancies, vaginal delivery has been reported [136]. Cesarean section is preferred if the obstetrician is not confident enough with vaginal delivery maneuvers [137], while on the same time when an elective cesarean is selected, it allows the optimal preparation and logistic conditions [138]. The time of the elective delivery is also to be considered, with Elliot reporting choosing the 34 + 0 weeks for quadruplets [17]. Finally, further research is needed in order to safely determine whether cesarean or vaginal delivery can affect the Apgar score of the newborns [139].

The most challenging cases of quadruplet and quintuplet pregnancies are the cases where preterm labor of at least one fetus has occurred and delayed interval delivery is considered an option in order to improve the chances of survival for the remaining fetuses. Such cases with at least one newborn surviving have been published, both for quadruplet [140, 141] and for quintuplet pregnancies [142]. For twin and triplet gestations, some authors consider delayed internal delivery a viable option [143, 144], while for quadruplet and quintuplet pregnancies, there are still not enough data.
