Virology & Mycology Infectious Diseases
 
   Publications A-Z
A
»Accounting & Marketing
» Addiction Research & Therapy
» Advanced Chemical Engineering
»Advances in Automobile Engineering
»Advances in Crop Science and Technology
»Advances in Dairy Research
»Advancements in Genetic Engineering
»Advances in Pharmacoepidemiology & Drug Safety
»Advances in Robotics & Automation
»Advanced Techniques in Biology & Medicine
»Advance Research in Meteorological Sciences
»Aeronautics & Aerospace Engineering
»Aging Science
»Agrotechnology
»AIDS & Clinical Research
»Alcoholism and Drug Dependence
»Allergy & Therapy
»Alternative & Integrative Medicine
»Air & Water borne Diseases
»Alzheimers Disease & Parkinsonism
»Analytical & Bioanalytical Techniques
»Anaplastology
»Anatomy & Physiology
»Ancient Diseases & Preventive Remedies
»Andrology-Open Access
»Anesthesia & Clinical Research
»Angiology: Open Access
»Antivirals & Antiretrovirals
»Anthropology
»Applied & Computational Mathematics
»Applied Mechanical Engineering
»Aquaculture Research & Development
» Arabian Journal Business and Management Review
»Architectural Engineering Technology
»Arthritis
»Arts and Social Sciences Journal
» Astrobiology & Outreach
»Astrophysics & Aerospace technology
»Autacoids
»Automatic Control of Physiological State and Function
»Autism-Open Access
  
B
»Bacteriology & Parasitology
»Bioanalysis & Biomedicine
»Bioceramics Development and Applications
»Biochemistry and Analytical Biochemistry
»Biochemistry & Pharmacology: Open Access
»Biochips & Tissue Chips
»Biodiversity & Endangered Species
»Bioenergetics: Open Access
»Bioengineering & Biomedical Science
»Bioequivalence & Bioavailability
»Biosafety & Health Education
»Biofertilizers & Biopesticides
»Biometrics & Biostatistics
»Biomimetics Biomaterials and Tissue Engineering
»Biomolecular Research & Therapeutics
» Biomusical Engineering
»Biochemistry & Physiology: Open Access
»Biological Systems- Open Access
»Biology and Medicine
»Bioprocessing & Biotechniques
»Bioremediation & Biodegradation
»Biosafety
»Biosensors & Bioelectronics
» Biosensors Journal
»Biotechnology & Biomaterials
»Bioterrorism & Biodefense
»Blood Disorders & Transfusion
»Blood & Lymph
»Bone Marrow Research
»Brain Disorders & Therapy
»Business and Economics Journal
»Business and Financial Affairs
  
C
»Cancer Science & Therapy
»Climatology & Weather forecasting
»Carcinogenesis & Mutagenesis
»Cardiovascular Diseases & Diagnosis
»Cardiovascular Pharmacology: Open Access
»Cell & Developmental Biology
»Cell Science & Therapy
»Chemical Engineering & Process Technology
»Chemical Sciences Journal
»Chemotherapy: Open Access
»Child and Adolescent Behavior
»Chromatography & Separation Techniques
»Civil & Environmental Engineering
»Civil & Legal Sciences
»Clinical & Cellular Immunology
»Clinical Case Reports
»Clinical & Experimental Cardiology
»Clinical & Experimental Dermatology Research
»Clinical & Experimental Ophthalmology
»Clinical & Experimental Pathology
»Clinical & Experimental Pharmacology
»Clinical Microbiology: Open Access
»Clinical Pharmacology & Biopharmaceutics
»Clinical Research & Bioethics
»Clinical Research on Foot & Ankle
»Clinical Toxicology
»Clinical Trials
»Clinics in Mother and Child Health
»Cloning & Transgenesis
»Community Medicine & Health Education
»Communication Disorders, Deaf Studies & Hearing Aids
»Computer Science & Systems Biology
» Current Synthetic & Systems Biology
»Cytology & Histology
D
»Data Mining in Genomics & Proteomics
»Defense Management
»Dentistry
»Depression and Anxiety
»Developing Drugs
»Diabetes & Metabolism
»Drug Designing
»Drug Metabolism & Toxicology
  
E
»Earth Science & Climatic Change
»Ecosystem & Ecography
»Endocrinology & Metabolic Syndrome
»Entomology, Ornithology & Herpetology
»Environmental & Analytical Toxicology
»Epidemiology: Open Access
»Emergency Medicine
»Ergonomics
»Electrical & Electronics
»Enzyme Engineering
»Entrepreneurship & Organization Management
  
F
»Family Medicine & Medical Science Research
»Fermentation Technology
»Fertilization: In Vitro - IVF-Worldwide
»Fisheries and Aquaculture Journal
»Fisheries & Livestock Production
»Food Processing & Technology
»Forensic Biomechanics
»Forensic Research
»Forest Research: Open Access
»Fundamentals of Renewable Energy and Applications
»Fungal Genomics & Biology
  
G
»Gastrointestinal & Digestive System
»Genetic Syndromes & Gene Therapy
»Gene Technology
»Generalized Lie Theory and Applications
»Glycobiology
»Glycomics & Lipidomics
»Gynecology& Obstetrics
»General Medicine
»General Practice
»Geography & Natural Disasters
»Geology & Geosciences
»Geophysics & Remote Sensing
»Gerontology & Geriatric Research
»Global Economics
»Global Journal of Technology and Optimization
  
H
»Hair : Therapy & Transplantation
»Hematology & Thromboembolic Diseases
»Health Care : Current Reviews
»Health & Medical Informatics
»Hereditary Genetics
»Homeopathy & Ayurvedic Medicine
»Horticulture
»Hotel & Business Management
»Human Genetics & Embryology
»Hydrology: Current Research
»Hypertension- Open Access
  
I
»Industrial Engineering & Management
»Irrigation and Drainage Systems Engineering
»Infectious Diseases and Therapy
»Information Technology & Software Engineering
»Intellectual Property Rights: Open Access
»Integrative Oncology
»Internal Medicine
»International Journal of Accounting Research
»International Journal of Advanced Innovations, Thoughts & Ideas
»International Journal of Biomedical Data Mining
»International Journal of Economics and Management Science
»International Journal of Sensor Networks and Data Communications
»International Journal of Swarm Intelligence and Evolutionary Computation
»International Journal of waste resources
»International Journal of Genomic Medicine
»International Journal of Physical Medicine & Rehabilitation
»Innovative Energy Policies
»Immunome Research
  
J
»JBR Journal of Interdisciplinary Medicine and Dental Science
»JBR Journal of Clinical Diagnosis and Research
»JBR Journal of Young Scientist
  
L
»Liver
» Leukemia
» Lovotics
  
M
»Marine Science: Research & Development
»Malaria Chemotherapy, Control & Elimination
»Mass Communication & Journalism
»Material Sciences & Engineering
»Medicinal Chemistry
»Medicinal & Aromatic Plants
»Medical Diagnostic Methods
»Medical Microbiology & Diagnosis
»Medical & Surgical Urology
»Membrane Science & Technology
»Metabolic Syndrome
»Metabolomics:Open Access
»Microbial & Biochemical Technology
»Modern Chemistry & Applications
»Molecular Biology
»Molecular Biomarkers & Diagnosis
»Molecular and Genetic Medicine
»Molecular Imaging & Dynamics
»Molecular Pharmaceutics & Organic Process Research
»Mycobacterial Diseases
N
»Natural Products Chemistry & Research
»Nanomedicine & Biotherapeutic Discovery
»Nanomedicine & Nanotechnology
»Neonatal Biology
»Nephrology & Therapeutics
»Neurology & Neurophysiology
»Neuroinfectious Diseases
»Neurological Disorders
»Novel Physiotherapies
»Nuclear Medicine & Radiation Therapy
»Nutrition & Food Sciences
»Nutritional Disorders & Therapy
»Nursing & Care
  
O
»Obesity & Weight Loss Therapy
»Oceanography-Open Access
»Occupational Medicine & Health Affairs
»OMICS Journal of Radiology
»Osteoporosis and Physical Activity
»Oral Health and Dental Management
»Oral Hygiene & Health
»Organic Chemistry: Current Research
»Orthopedic & Muscular System: Current Research
»Otolaryngology
  
P
»Pain & Relief
»Palliative Care & Medicine
»Pancreatic Disorders & Therapy
»Pediatrics & Therapeutics
»Petroleum & Environmental Biotechnology
»Pharmaceutica Analytica Acta
»Pharmaceutical Regulatory Affairs: Open Access
»Pharmacogenomics & Pharmacoproteomics
»Pharmacovigilance
»Physical Chemistry & Biophysics
»Physical Mathematics
»Plant Pathology & Microbiology
»Plant Biochemistry & Physiology
»Pollution Effects & Control
»political Sciences & public affairs
»Poultry, Fisheries & Wildlife Sciences
»Powder Metallurgy & Mining
»Primatology
»Primary Health Care: Open Access
»Probiotics & Health
» Phylogenetics & Evolutionary Biology
»Proteomics & Bioinformatics
»Phylogenetics & Evolutionary Biology
»Psychology & Psychotherapy
»Psychological Abnormalities in Children
»Pulmonary & Respiratory Medicine
  
R
»Reproductive System & Sexual Disorders
»Research and Development
»Review of Public Adminstration and Management
»Rheumatology: Current Research
»Rice Research: Open Access
  
S
» Single Cell Biology
»Sleep Disorders & Therapy
»Socialomics
»Sociology and Criminology-Open Access
»Sports Medicine & Doping Studies
»Spine
»Stem Cell Research & Therapy
»Steroids & Hormonal Science
»Stock & Forex Trading
»Surgery: Current Research
  
T
»Telecommunications System & Management
»Textile Science & Engineering
»Theoretical and Computational Chemistry:Open Access
»Thermodynamics & Catalysis
»Thyroid Disorders & Therapy
»Tissue Science & Engineering
»Translational Medicine
»Transplantation Technologies & Research
»Transcriptomics: Open Access
»Trauma & Treatment
»Tropical Diseases
»Tropical Medicine and Surgery
»Tourism & Hospitality
  
V
»Vaccines & Vaccination
»Vascular Medicine & surgery
»Veterinary Science & Technology
»Virology & Mycology
»Vitamins & Minerals
»Vortex Science and Technology
  
W
»Women's Health Care
  
Y
»Yoga & Physical Therapy
 
   Browse by Subjects
Clinical
» AIDS & Clinical Research
» Anesthesia & Clinical Research
» Angiology
» Cancer Science & Therapy
» Carcinogenesis & Mutagenesis
» Cell Science & Therapy
» Chemotherapy
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» Clinical & Cellular Immunology
» Clinical Case Reports
» Clinical & Experimental Cardiology
» Clinical & Experimental Dermatology Research
» Clinical & Experimental Ophthalmology
» Clinical & Experimental Pharmacology
» Clinical & Experimental Pathology
» Clinical Microbiology: Open Access
» Clinical Research & Bioethics
» Clinical Research on Foot & Ankle
» Clinical Toxicology
» Clinical Trials
»Clinics in Mother and Child Health
» Communication Disorders, Deaf Studies & Hearing Aids
» Cytology & Histology
» Forensic Research
»Forensic Biomechanics
» Integrative Oncology
»Immunome Research
»JBR Journal of Clinical Diagnosis and Research
» Neurology & Neurophysiology
» Pulmonary & Respiratory Medicine
» Stem Cell Research & Therapy
» Transplantation Technologies & Research
   
Pharmaceutical Sciences
» Advances in Pharmacoepidemiology & Drug Safety
» Alcoholism and Drug Dependence
» Bioanalysis & Biomedicine
» Biochemical Pharmacology
» Bioequivalence & Bioavailability
» Cardiovascular Pharmacology: Open Access
» Clinical Pharmacology & Biopharmaceutics
» Developing Drugs
» Drug Designing
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» Pharmaceutica Analytica Acta
» Pharmaceutical Regulatory Affairs
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Chemistry
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» Theoretical and Computational Chemistry:Open Access
   
Environmental
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» Earth Science & Climatic Change
» Ecosystem & Ecography
» Environmental & Analytical Toxicology
» Fisheries & Livestock Production
»Fundamentals of Renewable Energy and Applications
» Geography & Natural Disasters
» Hydrology: Current Research
»Innovative Energy Policies
»International Journal of waste resources
» Oceanography-Open Access
» Petroleum & Environmental Biotechnology
» Pollution Effects & Control
» Poultry, Fisheries & Wildlife Sciences
   
Omics
» Data Mining in Genomics & Proteomics
»Ergonomics
» Glycomics & Lipidomics
» Health & Medical Informatics
»JBR Journal of Young Scientist
» Metabolomics:Open Access
» OMICS Journal of Radiology
» Pharmacogenomics & Pharmacoproteomics
» Phylogenetics & Evolutionary Biology
» Proteomics & Bioinformatics
» Transcriptomics
   
Life Sciences
» Advanced Techniques in Biology & Medicine
»Advancements in Genetic Engineering
»Advances in Crop Science and Technology
»Advances in Dairy Research
» Aging Science
» Agrotechnology
» Air & Water Borne Diseases
» Antivirals & Antiretrovirals
» Autism-Open Access
» Bacteriology & Parasitology
» Biochemistry & Physiology
» Biochemistry and Analytical Biochemistry
» Bioenergetics
» Bioengineering & Biomedical Science
» Biofertilizers & Biopesticides
» Biological Systems
» Biometrics & Biostatistics
»Biomimetics Biomaterials and Tissue Engineering
» Biomolecular Research & Therapeutics
» Bioremediation & Biodegradation
» Biosafety
» Biosafety & Health Education
» Biosensors & Bioelectronics
» Biosensors Journal
» Biotechnology & Biomaterials
» Bioterrorism & Biodefense
» Cell & Developmental Biology
» Current Synthetic & Systems Biology
» Entomology, Ornithology & Herpetology
» Enzyme Engineering
» Fermentation Technology
» Fertilization: In Vitro - IVF-Worldwide
» Fisheries and Aquaculture Journal
» Forest Research
» Fungal Genomics & Biology
» Gene Technology
» Glycobiology
» Horticulture
» Homeopathy & Ayurvedic Medicine
»International Journal of Swarm Intelligence and Evolutionary Computation
» Marine Science: Research & Development
» Membrane Science & Technology
» Microbial & Biochemical Technology
» Molecular Biology
» Molecular Imaging & Dynamics
» Nanomedicine & Biotherapeutic Discovery
» Nanomedicine & Nanotechnology
» Nutrition & Food Sciences
» Plant Pathology & Microbiology
» Primatology
» Probiotics & Health
» Rice Research: Open Access
» Single Cell Biology
» Sociology and Criminology-Open Access
» Tissue Science & Engineering
» Tropical Diseases
» Veterinary Science & Technology
» Vitamins & Minerals
»Virology & Mycology
   
Engineering
» Advances in Automobile Engineering
» Advances in Robotics & Automation
» Aeronautics & Aerospace Engineering
» Applied & Computational Mathematics
» Applied Mechanical Engineering
» Architectural Engineering Technology
» Astrophysics & Aerospace technology
» Biochips & Tissue Chips
» Bioprocessing & Biotechniques
» Chemical Engineering & Process Technology
» Civil & Environmental Engineering
» Computer Science & Systems Biology
» Electrical & Electronics
» Food Processing & Technology
» Geology and Geosciences
» Geophysics & Remote sensing
»Global Journal of Technology and Optimization
» Industrial Engineering & Management
» Information Technology & Software Engineering
» International Journal of Advance Innovations, Thoughts & Ideas
»International Journal of Sensor Networks and Data Communications
» Irrigation and Drainage Systems Engineering
»Generalized Lie Theory and Applications
» Lovotics
» Material Sciences & Engineering
»Physical Mathematics
» Powder Metallurgy & Mining
» Telecommunications System & Management
» Textile Science & Engineering
»Vortex Science and Technology
   
Medical Sciences
» Addiction Research & Therapy
» Allergy & Therapy
» Alternative & Integrative Medicine
» Alzheimers Disease & Parkinsonism
» Anaplastology
» Anatomy & Physiology
» Ancient Diseases & Preventive Remedies
» Andrology
» Arthritis
» Autacoids
»Automatic Control of Physiological State and Function
» Bioceramics Development and Applications
» Biology and Medicine
» Biomusical Engineering
» Blood & Lymph
» Blood Disorders & Transfusion
» Bone Marrow Research
» Brain Disorders & Therapy
» Cardiovascular Diseases & Diagnosis
» Cloning & Transgenesis
» Community Medicine & Health Education
» Dentistry
» Depression and Anxiety
» Diabetes & Metabolism
» Emergency Medicine
» Endocrinology & Metabolic Syndrome
» Epidemiology: Open Access
» Family Medicine & Medical Science Research
» Gastrointestinal & Digestive System
» General Medicine
» General Practice
» Genetic Syndromes & Gene Therapy
» Gynecology& Obstetrics
» Gerontology & Geriatrics Research
» Hematology & Thromboembolic Diseases
» Hair: Therapy & Transplantation
» Health Care : Current Reviews
» Hereditary Genetics
» Human Genetics & Embryology
» Hypertension-Open Access
» Infectious Diseases & Therapy
» International Journal of Genomic Medicine
» Internal Medicine
»International Journal of Biomedical Data Mining
» International Journal of Physical Medicine & Rehabilitation
»JBR Journal of Interdisciplinary Medicine and Dental Science
» Leukemia
» Liver
»Malaria Chemotherapy, Control & Elimination
» Medical & Surgical Urology
» Medical Diagnostic Methods
» Medical Microbiology & Diagnosis
» Metabolic Syndrome
» Molecular Biomarkers & Diagnosis
» Molecular and Genetic Medicine
» Mycobacterial Diseases
» Neonatal Biology
» Nephrology & Therapeutics
»Neuroinfectious Diseases
» Neurological Disorders
» Novel Physiotherapies
» Nuclear Medicine & Radiation Therapy
» Nursing & Care
» Nutritional Disorders & Therapy
» Obesity & Weight Loss Therapy
» Occupational Medicine & Health Affairs
» Oral Health and Dental Management
» Oral Hygiene & Health
» Orthopedic & Muscular System
» Osteoporosis & Physical Activity
» Otolaryngology
» Pain & Relief
» Palliative Care & Medicine
» Pancreatic Disorders & Therapy
» Pediatrics & Therapeutics
» Primary Health Care
» Psychological Abnormalities in Children
» Psychology & Psychotherapy
» Reproductive System & Sexual Disorders
»Research and Development
» Rheumatology: Current Research
» Sleep Disorders & Therapy
» Spine
» Sports Medicine & Doping Studies
» Steroids & Hormonal Science
» Surgery: Current Research
» Thyroid Disorders & Therapy
» Translational Medicine
» Trauma & Treatment
» Tropical Medicine and Surgery
» Vascular Medicine & surgery
» Women's Health Care
» Yoga & Physical Therapy
 
Management
» Accounting & Marketing
» Arabian Journal Business and Management Review
» Arts and Social Sciences Journal
» Business and Economics Journal
» Business and Financial Affairs
» Civil & Legal Sciences
» Defense Management
» Entrepreneurship & Organization Management
» Global Economics
» Hotel & Business Management
» Intellectual Property Rights: Open Access
»International Journal of Accounting Research
» International Journal of Economics & Management Sciences
» Mass Communication & Journalism
» political Sciences & public affairs
»Review of Public Adminstration and Management
» Socialomics
» Stock & Forex Trading
» Tourism & Hospitality
 
   Conferences
Upcoming Conferences
»2nd International Conference and Exhibition on Pathology, August 05-07, 2013 Las Vegas, USA
»International Conference on Integrative Biology Summit, August 05-07, 2013 Las Vegas, USA
»2nd International Conference on Translational Medicine, August 05-07, 2013 Chicago, USA
»International Conference on Predictive, Preventive and Predictive, Preventive and Personalized Medicine & Molecular Diagnostics, August 05-07, 2013 Chicago, USA
» 2nd International Conference on Biodiversity & Sustainable Energy Development, August 12-14, 2013 Raleigh, USA
» International Conference on Genetic Engineering & Genetically Modified Organisms, August 12-14, 2013 Raleigh, USA
» 4th World Congress on Diabetes & Metabolism, August 14-16, 2013 Chicago, USA
»International Conference on Radiology and Imaging, August 14-16, 2013 Chicago, USA
»2nd International Conference and Exhibition on Orthopedics & Rheumatology, August 19-21, 2013 Las Vegas, USA
»International Conference on Dental & Oral Health, August 19-21, 2013 Las Vegas, USA
»International Conference and Exhibition on Physical Medicine & Rehabilitation, August 19-21, 2013 Las Vegas, USA
»International Conference on Molecular Epidemiology and Evolutionary Genetics, August 21-23, 2013 Miami, USA
»International Conference on Oceanography, August 21-23, 2013 Orlando, USA
»International Conference on Biodefense & Natural Disasters, August 21-23, 2013 Miami, USA
» World Congress on Endocrinology, August 26-28, 2013 Raleigh, USA
»2nd International Conference on Hydrology and Groundwater Expo, August 26-27, 2013 Raleigh, USA
» 2nd International Conference on Tissue Science & Regenerative Medicine, August 26-28, 2013 Raleigh, USA
» International Conference on Omics Studies, September 04-06, 2013 Orlando-FL, USA
»International Symposia on Entomology, September 04-06, 2013 Miami, USA
»2nd International Conference on Surgery and Anesthesia, September 16-18, 2013 Las Vegas, USA
»2nd International Conference on Clinical Microbiology & Microbial Genomics, September 16-18, 2013 Las Vegas, USA
»2nd International Conference and Exhibition on Biowaivers & Biosimilars, September 23-25, 2013 Raleigh, USA
»4th World Congress on Biotechnology, September 23-25, 2013 Raliegh, USA
»International Conference on Hematology & Blood Disorders, September 23-25, 2013 Raliegh, USA
»International Conference on Psychology, Autism and Alzheimer's Disease, September 30-October 01, 2013 San Antonio, USA
»International Conference and Exhibition on Mechanical & Aerospace Engineering, September 30-October 02, 2013 San Antonio, USA
»2nd International Summit on Toxicology, October 07-09, 2013 Las Vegas, USA
»International Conference and Exhibition on Biochemical & Molecular Engineering, October 07-09, 2013 San Antonio, USA
»International Conference and Exhibition on Lasers, Optics & Photonics, October 7-9, 2013 San Antonio, USA
»2nd International Conference and Exhibition on Materials Science & Engineering, October 07-09, 2013 Las Vegas, USA
»2nd International Conference on Forensic Research & Technology, October 07-09, 2013 Las Vegas, USA
»2nd International Conference on Clinical & Cellular Immunology, October 15-17, 2013 Las Vegas, USA
»2nd International Conference on Medicinal Chemistry & Computer Aided Drug Designing, October 15-17, 2013 Las Vegas, USA
»4th International Conference and Exhibition on Analytical & Bioanalytical Techniques, October 15-17, 2013 Las Vegas, USA
»International Conference and Exhibition on Pharmacognosy, Phytochemistry and Natural Products, October 21-23, 2013 Hyderabad, India
» 3rd World Congress on Cancer Science & Therapy, October 21-23, 2013 California, USA
»3rd International Conference on Pharmaceutical Regulatory Affairs, October 21-23, 2013 California, USA
»2nd International Conference and Exhibition on Cell & Gene Therapy, October 23-25, 2013 Orlando, USA
»2nd International Conference and Exhibition on Probiotics & Functional Foods, October 23-25, 2013 Orlando, USA
»International Conference on HIV/AIDS, STDs, & STIs, October 24-25, 2013 Orlando-FL, USA
» International Conference on Fermentation Technology, Bioprocess and Cell Culture, October 28-30, 2013 Kansas City, USA
»2nd International Conference and Exhibition on Food Processing & Technology, October 28-30, 2013 Kansas City, USA
»International Conference on Functional and Comparative Genomics & Pharmacogenomics, November 12-14, 2013 Chicago, USA
»2nd International Conference and Exhibition on Cosmetology & Trichology, November 12-14, 2013 Chicago, USA
»2nd International Summit on GMP, QA & QC, November 12-14, 2013 Chicago, USA
»2nd International Summit on GLP, GCP & Clinical Pharmacology, November 12-14, 2013 Chicago, USA
»2nd International Conference and Exhibition on Pharmacovigilance & Clinical Trials, November 18-19, 2013 San Antonio, USA
»International Summit on Clinical Pharmacy & Dispensing, November 18-20, 2013 San Antonio, USA
»World Congress on Petrochemistry and Chemical Engineering, November 18-20, 2013 San Antonio, USA
»3rd World Congress on Virology, November, 20-22, 2013 Baltimore, USA
»International Congress on Bacteriology and Infectious diseases, November 20-22, 2013 Baltimore, USA
»3rd World Congress on Cell Science & Stem Cell Research, November 20-22, 2013 San Antonio, USA
»2nd International Conference and Exhibition on Obesity & Weight Management, December 02-04, 2013 Las Vegas, USA
»International Conference on Nursing & Emergency Medicine, December 02-04, 2013 Las Vegas, USA
»3rd International Conference on Nanotek & Expo, December 02-04, 2013 Las Vegas, USA
»International Conference and Exhibition on Traditional & Alternative Medicine, December 09-11, 2013 Hyderabad, India
»2nd International Conference on Agricultural & Horticultural Sciences, February 03-05, 2014 Hyderabad, India
Previous Conferences Organized/Co-organized
»2nd International Conference on Nephrology & Therapeutics, July 29-31, 2013 Las Vegas, USA
»3rd International Conference on Vaccines & Vaccination, July 29-31, 2013 Las Vegas, USA
»2nd International Conference on Earth Science & Climate Change, July 22-24, 2013 Las Vegas, USA
»2nd International Conference and Exhibition on Addiction Research & Therapy, July 22-24, 2013 Las Vegas, USA
»International Conference on Animal & Dairy Sciences, July 23-24, 2013 Las Vegas, USA
»3rd International Conference on Proteomics & Bioinformatics, July 15-17, 2013 Philadelphia, USA
»2nd International Conference and Exhibition on Nutritional Science & Therapy, July 15-17, 2013 Philadelphia, USA
»4th International Conference on Biomarkers & Clinical Research, July 15-17, 2013 Philadelphia, USA
»2nd International Conference and Exhibition on Biosensors & Bioelectronics, June 17-19, 2013 Chicago, USA
»2nd International Conference and Exhibition on Neurology & Therapeutics, June 17-19, 2013 Chicago, USA
»2nd International Conference on Gastroenterology & Urology, June 10-12, 2013 Chicago, USA
»2nd International Conference and Exhibition on Biometrics & Biostatistics, June 10-12, 2013 Chicago, USA
»2nd International Conference and Exhibition on Occupational Health & Safety, May 21-22, 2013 Beijing, China
»4th World Congress on Bioavailability & Bioequivalence, May 20-22, 2013 Beijing, China
»3rd International Conference on Clinical & Experimental Ophthalmology, April 15-17, 2013 Chicago, USA
»3rd International Conference on Clinical & Experimental Cardiology, April 15-17, 2013 Chicago, USA
»3rd International Conference on Clinical & Experimental Dermatology, April 15-17, 2013 Chicago, USA
»2ndInternational Conference and Exhibition on Metabolomics & Systems Biology, April 08-10, 2013 Chicago, USA
»3rd International Conference and Exhibition on Pharmaceutics & Novel Drug Delivery Systems, April 08-10, 2013 Chicago, USA
»International Exhibition and Conference on Water Technologies, Environmental Technologies & Renewable Energy, February 13-14, 2013 Mumbai, India
»International Summit on GMP & GCP: USA, Europe, Japan, Asia Pacific December 03-05, 2012 DoubleTree by Hilton Philadelphia Center City, USA
»International Conference on QA, QC and Validation, December 03-05, 2012 DoubleTree by Hilton Philadelphia Center City, USA
»2nd International Conference on Nanotek and Expo, December 03-05, 2012 DoubleTree by Hilton Philadelphia Center City, USA
»International Conference and Exhibition on Obesity and Weight Management, December 03-05, 2012 at DoubleTree by Hilton Philadelphia, USA.
»International conference on Hair Transplantation and Trichology November 26-28, 2012 San Antonio, USA.
»International Conference on Anesthesia & Perioperative Care during November 26-28, 2012 San Antonio, USA.
»International Toxicology Summit & Expo November 26-28, 2012 Hilton San Antonio Airport, USA
»International Conference and Exhibition on Surgery & Transplantation November 26-28, 2012 Hilton San Antonio Airport, USA.
»International Conference and Exhibition on Food Processing and Technology November 22-24, 2012 Hyderabad, India.
»3rd International Conference and Exhibition on Analytical & Bioanalytical Techniques November 22-24, 2012 Hyderabad International Convention Center, India
»2ndInternational Conference and Exhibition on Pharmaceutical Regulatory Affairs November 23-24, 2012 HICC Hyderabad, India
»International Conference and Exhibition on Cosmetology & Cosmetics November 23-24, 2012 HICC Hyderabad, India.
»International Conference on Genetic Syndromes & GeneTherapy November 19-21, 2012 Hilton San Antonio Airport, USA
»Global Biofuels and Bioproducts Summit November 19-21, 2012 San Antonio, USA.
»International Conference and Exhibition on Probiotics-2012, November 1921, 2012, Hilton San Antonio Airport, USA.
»2nd World Congress on Cell Science and Stem Cell Research, November 12-14, 2012 Hilton San Antonio Airport, USA.
»International Conference on Regenerative and Functional Medicine, November 12-14, 2012 at San Antonio, Texas, USA.
»International Conference on Clinical Microbiology & Microbial Genomics November 12-14, 2012 San Antonio, USA.
» International Confeernce on Pulmonary & Respiratory Medicine October 29 - 31, 2012 Chicago, USA
»International Conference and Exhibition on Computer Aided Drug Design & QSAR October 29-31, 2012, Chicago, USA.
»International Conference on Clinical and Cellular Immunology October 22-24, 2012 Las Vegas, USA.
»International Conference and Expo on Material science and Engineering October 22-24, 2012 DoubleTree by Hilton Chicago-North Shore, USA.
» International Expo and Conference on Analytrix & HPLC October 22-24, 2012 Hilton Northbrook, Chicago, USA.
»International Conference on Forensic Research & Technology October 15 - 17, 2012 DoubleTree by Hilton Chicago - Northshore, USA.
»International Conference and Exhibition on Otolaryngology October 15 - 17, 2012 DoubleTree by Hilton Chicago - Northshore, USA.
»International conference on Biothreats and Biodefense October 15 - 17, 2012 DoubleTree by Hilton Chicago - Northshore, USA.
»International Conference on Tissue Science and Engineering October 1-3, 2012 DoubleTree by Hilton Chicago-North Shore, USA.
»International conference and Exhibition on Pharmacovigilance and Clinical Trials October 1-3, 2012 DoubleTree by Hilton Chicago-North Shore, USA.
»International Conference on Emerging Cell Therapies October 1-3, 2012 DoubleTree by Hilton Chicago-North Shore, USA.
»3rd World Congress on Diabetes & Metabolism which is to be held on September 24-26, 2012 Marriott Convention Center, Hyderabad, India.
»2nd International Conference on Pediatrics & Gynecology September 24-26, 2012, Hyderabad Marriott Hotel & Convention Centre , Hyderabad, India.
»International Conference on Translational medicine-2012, September 17-19, 2012 Holiday Inn San Antonio, Texas, USA.
»3rd World Congress on Biotechnology September 13-15, 2012 HICC, Hyderabad, India
»International Conference on Biodiversity & Sustainable Energy Development September 14-15, 2012 Hyderabad, India.
» International Conference on Agricultural & Horticultural Sciences September 14-15, 2012 Hyderabad International Convention Center, India
» International Conference on Hotel and Business Management September 14-15, 2012 Hyderabad International Convention Center, India
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Journal of Neonatal Biology Video Journal of Neonatal Biology Linkedin - Journal of Neonatal Biology Twitter - Journal of Neonatal Biology Facebook - Journal of Neonatal Biology Journal of Neonatal Biology Blog
Research Article Open Access
Study of a Population of Triplet Pregnancies: Maternal and Neonatal Outcomes
1Department of Woman Health and Territory’s Medicine, University of Rome Sapienza, S. Andrea Hospital, Rome, Italy
2Neonatal Unit of San Pietro FBF Hospital, Rome, Italy
*Corresponding author: Donatella Caserta
University of Rome Sapienza
Department of Woman Health and Territory’s Medicine
S. Andrea Hospital
Via di Grottarossa 1035-1039 00189 Rome, Italy
Tel: +390633775696
Fax: +390633776660
E-mail: donatella.caserta@uniroma1.it
 
Received January 26, 2012; Accepted March 14, 2012; Published March 18, 2012
 
Citation: Caserta D, Bordi G, Stegagno M, Filippini F, Podagrosi M, et al. (2012) Study of a Population of Triplet Pregnancies: Maternal and Neonatal Outcomes. J Neonatal Bio 1:104. doi:10.4172/2167-0897.1000104
 
Copyright: 2012 Caserta D, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
 
Abstract
 
Objective: To describe maternal complications, perinatal mortality and neonatal morbidity in triplet pregnancies.
 
Methods: Retrospective analysis of maternal and neonatal records of 21 triplet pregnancies delivered from January 2008 to June 2011 at San Pietro FBF Hospital of Rome, a tertiary medical center.
 
Results: The incidence of triplet pregnancies was one in 690 births. Among the 21 triplet pregnancies, only one was conceived spontaneously and 20 were the result of assisted reproductive techniques. Mean maternal age was 34.4 ± 5 years. There was one case of a selective foeticide of a foetus with an encephalocele. Preterm delivery occurred in all the remaining 20 pregnancies. Other frequent complications were premature rupture of membranes (40%) and cervical incompetence (35%). There was no maternal mortality in any of the studied pregnancies. The mean length of maternal hospitalization was 15 ± 5.9 days. The mean gestational age was 31.8 weeks, with a mean birth weight of 1590 ± 590 grams. The neonatal mortality was 5%. The incidence of congenital anomalies was 16.7%. Respiratory distress syndrome occurred in 53% of cases and 75.6% of newborns required intensive care. Other common neonatal complications were jaundice (66.7%), anaemia (28.9%), patent ductus arteriosus (24.4%), apnea of prematurity (17.8%), sepsis (13.3%), neurological complications (11.1%) and bronchopulmonary dysplasia (11.1%). The mean length of newborns hospitalization was 33.6 ± 23.3 days. There was no significant difference in neonatal mortality and morbidity based on birth order.
 
Conclusions: This series of triplet pregnancies demonstrated an excellent survival rate and a relatively low major morbidity, despite the 100% incidence of prematurity. Although perinatal outcomes in triplet gestations have improved in recent years, higher-order multiple pregnancies continued to be associated with great medical problems for both mothers and infants. All methods of assisted reproduction should aim for the prevention of multifetal pregnancies.
 
Keywords
 
Triplet; Maternal outcomes; Perinatal outcomes; Assisted reproductive technology.
 
Introduction
 
The incidence of multiple gestations in developed world has increased over recent decades. In Italy, the rate of twin pregnancies and triplet and higher-order multiple pregnancies has been reported to be 12 per 1,000 and 0.52 per 1,000 respectively [1]. This increase is not limited to Italy, but it is a world-wide issue. The incidence of triplet and higher-order multiples pregnancies in the United States has increased from 0.37 per 1,000 live births in 1980 to 1.48 per 1,000 in 2008 [2].
 
The increase in the triplet birth rate has been most marked in women aged 40 years and over, with an increase of more than 1000%. Conversely, in women aged 30 to 40 years the multiple birth rate has risen by 30% and in women aged under 20 by only 13% [3].
 
This steep rise is attributed to the trend to delay in the childbearing and notably to the growing use and improvement in infertility therapies and assisted reproductive techniques (ART) [4,5]. Over the past few years the maternal and neonatal impact of multiple pregnancies has led to a more conservative embryo transfer policy [6]. Nevertheless, ART continues to contribute to multiple birth rates, particularly to the incidence of triplet and higher-order pregnancies.
 
The risk of adverse short- and long-term birth outcome increases with the number of foetuses in a multigestation pregnancy. Neonatal outcome among higher-order multiples is largely determined by gestational age at birth and correlating birth weight [7]. Literature reports the mean gestational age for triplets at about 32 weeks and the rate of growth restriction at 50-60% [8].
 
The rate of preterm births in triplets is very different from that in twins or singletons. For example, the USA National Vital Statistics Report describes a rate of very preterm births (<32 weeks of gestation) of 38.5%, 3.3 times more than for twins and 24.1 times more than for singletons [2].
 
Multiple-pregnancy births are associated with major medical problems for both mother and infants such as preterm delivery, preeclampsia, intrauterine growth retardation, increased cesarean rates, prematurity complications, disabilities and death [9].
 
The socioeconomic and the emotional demands that may accompany the birth of three or more premature babies at the same time may overwhelm the mother and her family [10]. Beyond of these factors, the effects of significantly increased medical expenses on the healthcare system must also be considered. While carrying a multiple pregnancy, women are more likely to generate extra medical costs due to longer period of bed-rest, hospitalization, administration of medication to prevent preterm labour and surgical procedures such as emergency caesarean section and cervical cerclage. Compared with singleton, obstetric care costs are 1.94 and 3.96 times higher for twin and triplet pregnancies, respectively. The ratio of neonatal singleton versus twins and triplets costs is 1:16 and 1:109 respectively [11]. Lifetime costs for chronic medical care, rehabilitation and special education related to extreme prematurity also have to be taken into account [12].
 
Because of decisions such as abortion, embryo reduction, life style changes and other therapeutic interventions based on these concerns, it is critical to have contemporary and accurate data on the outcomes of the neonates from multiple births [13].
 
The aim of our study is to evaluate maternal outcomes, perinatal mortality and neonatal morbidity in triplet pregnancies.
 
Materials and Methods
 
From January 1, 2008 to June 30, 2011, there were 14,499 deliveries at San Pietro FBF Hospital of Rome, a tertiary medical center with an University affiliated Obstetric Unit dealing with high risk cases. This study concentrated on twenty-one women with triplet pregnancy, from their antenatal care to delivery at San Pietro Hospital during above the period.
 
Institutional ethical committee approval was not required as this study was an observational analysis and no intervention was introduced.
 
The gestational age was calculated by adding two weeks to the day of oocyte retrival for assisted conception triplet pregnancies and in the one patient who spontaneously conceived, from the last menstrual period.
 
From the medical records of these patients, the following data were collected: age at delivery, mode of conception, type of infertility treatment, gravity and parity status, systemic diseases, gynaecologic surgery, smoking habit and weight gain during pregnancy, gestational age at the time of delivery, mode of delivery, antenatal, intrapartum and postpartum complications, antenatal admission, corticosteroids administration (defined as receipt of maternal steroid within 7 days of the delivery), antenatal admission, admission to an intensive-care unit (ICU) and length of hospitalization. The data extracted from neonatal charts included: birth weight, length, head circumference, Apgar score at 1 and 5 minutes after birth, congenital anomalies, neonatal mortality, neonatal complications, admission to neonatal intensive care unit (NICU) and length of stay in hospital. Additional information was obtained by personal communication with parents to analyze the current health status of the neonates.
 
Low birth weight (LBW), very low birth weight (VLBW) and extremely low birth weight (ELBW) were defined as a birth weight <2500, <1500 and <1000 g, respectively.
 
Antenatal corticosteroids were administrated to women at risk of iatrogenic or spontaneous preterm birth up to 34+6 weeks of gestation, according to the guidelines of Royal College of Obstetricians and Gynaecologists (RCOG) [14].
 
Neonatal mortality was defined as the number of deaths within 28 days after birth per 1000 live births. Respiratory distress syndrome (RDS) was diagnosed on the basis of clinical parameters, chest radiography and blood gas values. Bronchopulmonary dysplasia was diagnosed by the need for supplemental oxygen after 28 days and the typical changes found in chest X-rays. Diagnosis of apnea of prematurity was determined when infants stopped breathing for more than 15 seconds. Ultrasound imaging diagnosed intraventricular hemorrhage (IVH). Patent ductus arteriosus (PDA) was confirmed by echocardiogram. Gastroesophageal reflux was diagnosed based on regurgitation of feeds, neck arching and posturing with feedings. Jaundice was determined by high bilirubin levels which required phototherapy. A diagnosis of anaemia was made when red cells transfusions were performed. Sepsis was diagnosed by clinical parameters and a positive blood culture. Necrotising enterocolitis was diagnosed by clinical values confirmed by radiographical pneumatosis intestinalis.
 
Statistics: Chi-square with Yates corrections for categorical variables and t-test (or non-parametric Mann-Withney-U test) for continuous variables were used to compare neonatal outcomes based on birth order. A value of p < 0.05 was considered as statistically significant.
 
Results
 
The study population included 21 women with triplet pregnancy who delivered at San Pietro FBF Hospital of Rome. The incidence of triplets was 0.145% or one in 690 of all births.
 
With regard to the method of conception, only one woman conceived spontaneously, whereas five pregnancies were obtained by in vitro fertilization (IVF), twelve by intacytoplasmatic sperm injection (ICSI), one by intrauterine insemination (IUI), one by gamete intrafallopian transfer (GIFT) and one by ovulation induction. All women who conceived after infertility treatments had undergone controlled ovarian stimulation.
 
Mean maternal age was 34.4 ± 5 years. All women were nulliparous, except one patient who conceived spontaneously and already had two sons. History of previous miscarriage had been reported in five patients (23.8%) and among these, one (4.8%) had recurrent miscarriage.
 
Nine women (42.9%) had systemic diseases, including endometriosis, hypothyroidism, diabetes and thrombophilia. Eight patients (38.1%) underwent gynaecological surgery: three patients underwent ovarian cystectomy, two myomectomy, two endometrial polypectomy and one hysteroscopic resection of uterine septum.
 
Only one woman (4.8%) smoked during pregnancy. The mean weight gain during pregnancy was 16.2 ± 8.9 kg. Five patients (23.8%) underwent invasive prenatal diagnosis: amniocentesis was performed in four cases and villocentesis in one case.
 
In one triplet pregnancy, a 40-year-old woman who conceived a triplet pregnancy after undergoing ICSI, a selective foeticide of a foetus with an encephalocele was performed. An ultrasound examination at 22 weeks of gestation showed an encephalocele in one foetus and a thick septae compatible with trichorionic triamniotic triplets. Selective foeticide was performed at 23 weeks of gestation by transamniotic injection of potassium chloride into the heart of the abnormal foetus. The procedure was without complications and the following ultrasound examinations showed that the other two twins were morphologically normal. The woman delivered at 37 weeks by elective caesarean section. The surviving twins were both boys, with an Apgar score of 8 at 1 minute and 9 at 5 minutes and weighing 2860 g and 2300 g respectively. They had no major neonatal complications and they were discharged 8 days after birth. Triplet 3 was a small macerated abortus.
 
All the remaining 20 triplet pregnancies were complicated by preterm delivery. Eight (40%) sets of triplet were delivered before 32 weeks of gestation. The mean gestational age was 31.8 ± 3.4 weeks, and it ranged from 22.3 to 35.9 weeks. In addition to preterm delivery, the most common complications were premature rupture of membranes (PROM), that occurred in eight triplet pregnancies (40%) and cervical incompetence that occurred in seven cases (35%) and required cervical cerclage. Other complications were oligohydramnios in 30% of cases, first trimester bleeding in 25%, obstetric cholestasis in 20%, pregnancy-induced hypertension in 15%, placental abruption in 10%, gestational diabetes in 10%, anaemia in 5% and hyperemesis gravidarum in 5%.
 
Ten patients (50%) were admitted to the antenatal unit because of pregnancy complications and prenatal corticosteroids (12 mg of betamethasone repeated for a total of two doses) were administrated to eighteen women (90%).
 
Three patients (15%) suffered postpartum hemorrhage which required a blood transfusion. Postpartum blood transfusion was also required in other two patients with low haemoglobin. One patient underwent peripartum hysterectomy and was transferred to intensive care unit. There was no maternal mortality in any of the studied pregnancies. The mean length of maternal hospitalization was 15 ± 5.9 days.
 
Eighteen sets of triplet (90%) were delivered by caesarean section. Among these, two-thirds were emergency caesareans. Two patients progressed very fast in labour at 22.3 and 26 week’s gestation respectively and delivered vaginally. The leading foetus was cephalic in 12 (60%) and breech in 8 (40%) cases.
 
The percentage of male infants was 40%. The mean birth weight was 1590 ± 506 grams. Mean birth length and head circumference were 41.7 ± 3.9 and 29.6 ± 2.7 cm respectively. All the newborns were LBW, whereas the global rate of VLBW and ELBW was 18.3 % and 16.6% respectively. Seven newborns (11.6%) were small for gestational age (SGA) and two of them were under the 3th percentile in weight. The remaining appropriate for gestational age (AGA) newborns was between the 10th and 75th percentiles in weight. No triplet was large for gestational age (LGA).
 
The percentage of neonates with low Apgar score (<7) at 5 minutes was 30%. Thirteen neonates (21.7%) required tracheal intubation. As the triplet delivered at 22.3 weeks of gestation died shortly after birth, the neonatal mortality rate was 5%. With regard to congenital anomalies, we observed ten cases (16.7%) of birth defects, including two cases of bilateral cryptorchism, two of ventricular septal defect, four of pyelectasis and two of hypospadias.
 
Twelve neonates were transferred to another hospital because of capacity problems and nine of them were admitted to NICU of the new hospital because of respiratory problems. None of the transferred newborns died. Of the remaining 45 neonates, 34 (75.6%) of them required NICU admission and 11 (24.4%) needed for mechanical ventilation.
 
Table 1 depicts neonatal morbidity according to gestational age. Respiratory distress syndrome occurred in twenty-four neonates (53%) and five newborns (11.1%) were affected by bronchopulmonary dysplasia and needed for ventilation for more than two months. Other neonatal complications were jaundice in 66.7% of cases, metabolic acidosis in 35.6%, anaemia in 28.9%, patent ductus arteriosus in 24.4%, apnea of prematurity in 17.8%, sepsis in 13.3%, hypoglycemia in 13.3%, hyperglycemia in 11.1%, gastroesophageal reflux in 8.9%, patent foramen ovale in 6.7% and necrotizing enterocolitis in 4.4%. Neurological complications were diagnosed in 11.1% of cases and included cerebral intraparenchymal or and posthemorrhagic hydrocephalus. The mean length of stay for the birth admission was 33.6 ± 23.3 days and it ranged from 9 to 95 days.
 
Table 1: Distribution of major neonatal complications according to gestational age.
 
There was no significant difference in terms of neonatal morbidity or mortality based on birth order (Table 2). With regard to birth characteristics, mean birth weights of triplet A, B and C were 1627 ± 550, 1572 ± 467 and 1516 ± 518 grams respectively. Mean birth length and head circumference were 41.3 and 29.9, 42 and 29.7, 41.8 and 29.3 cm respectively.
 
Table 2: Neonatal outcomes of triplet A vs. triplet B vs. triplet C.
 
Discussion
 
According to Hellin’s rule, the natural rate for spontaneous twin pregnancies is 1/80, the rate for triplet is 1/80² (1/6,400) and the rate for quadruplets is 1/80³ (1/512,000) [15].
 
Nevertheless, the incidence of triplet pregnancies in our hospital (which represents a reference center for high-risk gestations, including multiple pregnancies and ART pregnancies) was of one in 690 deliveries (0.145%). This notable rise is regarded mainly as a consequence of developments in assisted reproductive technologies (ART) which account for approximately 95% of triplet pregnancies [16]. This percentage is alarming and it could be explained by the attempts to increase pregnancy rates in women of further and further advanced age. Italy is one of the European countries with the highest maternal age at the first child and the lowest fertility rate [17]. The agerelated decline of the biological capacity of a woman to reproduce is well established and the current trend to postpone childbearing until later in life often requires more aggressive infertility treatments, thus increasing the risk of multiple pregnancy.
 
Neonatal morbidity and mortality increase with the number of foetuses in a pregnancy, but simultaneously the term of the pregnancy decreases so that problems associated with premature birth gain importance.
 
The incidence of preterm delivery in triplet pregnancies has been reported in literature to be approximately 90% [2]. In accordance with other Italian research [18], all triplet pregnancies in our study population ended preterm. The optimal gestational age at birth for triplet pregnancies is reported to be 34-35 weeks, at a weight of 1,900- 2,200 g [19]. The mean gestational age at delivery in our study was 31.8 weeks, with a mean birth weight of 1590 g. These values are comparable with data in the literature [20-24].
 
Gestational age represents the main factor affecting birth weight, which correlates with morbidity and survival rate [4,25]. Alexander and colleagues [26] described how triplet growth does not follow the growth curves of singleton and twins, but after 26 weeks there is a decrease in triplet growth that is about 20% less than that of singleton. This finding is due to blood flow alteration in uterus and placenta and notably to the restricted intrauterine space that represents also the main cause of preterm labour.
 
In our study, incidence of caesarean section delivery was 90% and it was comparable with other studies [13,27]. It is well known that caesarean section triplets have a lower perinatal mortality and morbidity versus vaginally delivered triplets. Triplet vaginal births are associated with higher risk of cord prolapse, foetal collision, reduced placental perfusion and haemorrhage from separating placentae [10]. For these reasons, our gynecologists operated caesarean section for all triplet pregnancies except for two patients who delivered vaginally at 22.3 and 26 weeks respectively. This occurred because the triplets were all extremely low birth weight and their severe immaturity caused the death of the first triplet set and major morbidity of the second one.
 
Although previous studies have reported a higher neonatal morbidity and mortality in the third born triplet [28], we found no difference in outcome according to the birth order, which was probably due to the policy of delivering all triplet pregnancies by caesarean section.
 
Several studies compared the perinatal outcome of triplets with twins and singletons matched for gestational age. The most of these studies have not shown significant differences in mortality rates, neonatal complications and survival without significant morbidity, although birth weight was lower in triplets [13,22,29]. Thus, the adverse neonatal outcome in multiple births seems to be due primarily to prematurity, as confirmed in our study by the distribution of major morbidity in the categories of lower gestational age. In this contest, it is apparent that efforts aimed at reducing prematurity and avoiding complications should be our primary focus for these patients.
 
Infants of triplet gestation constitute a significant proportion of NICU admissions [29]. In our study about ¾ of newborns required intensive care. The neonatal morbidity of higher-order multiples is mainly marked by respiratory problems, occurring in approximately two-thirds of our triplets.
 
Twelve infants required postnatal transfer because of capacity problems in the primary NICU encountered by the sudden arrival of three or more premature infants. This reflects a critical management of perinatal care due to insufficient availability of intensive therapy beds compared to the incoming demand. As a consequence, premature neonates very often cannot be cared for in the medical center of birth but they have to be transferred to another hospital, which certainly increases risks of death and of long-term sequelae.
 
It is reported in literature that the risk of cerebral palsy is significantly higher in infants resulting from multiple gestations than from singleton births, and increases exponentially with the number of foetuses [30]. The characteristic of this study limited to the neonatal period does not allow us to obtain data on motor and long-term sequelae. No doubt, it is observed that neurological complications affected 11% of all infants were affected by neurological complications (including intraventricular hemorrhage or posthemorrhagic hydrocephalus), that could be considered markers of risk for neurologic sequelae.
 
Despite the small sample, our study adds more information to the limited available studies regarding higher-order gestations and supports the view expressed in the general literature that perinatal mortality in triplet pregnancies have improved in recent years. Well-equipped neonatal units having adequate supportive therapy have decreased the perinatal mortality rate in higher-order multiple pregnancies. In the care of triplet pregnancies, coordination between obstetrical and neonatal staff is essential. Probably this has contributed to the fact that in our sample, although the incidence of prematurity has been 100%, we observed an extremely low mortality rate (5%) and relatively low serious associated morbidity.
 
Nevertheless, maternal and neonatal morbidity in triplet pregnancies remains higher compared with singleton pregnancies. The majority of these pregnancies are conceived by infertility treatments. This demonstrates that the attitude to prevent multiple pregnancies needs to be implemented and that ART should be managed by specialists who not only decide if a pregnancy is possible, but also choose the most appropriate treatment for every infertile couple. Finally, both maternal and neonatal risks should be carefully discussed with these patients when they are counselled.
 
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