Diagnosis and Management Challenges of Spontaneous Quadruplet Pregnancy in a Resource-Limited Setting: A Case Report

Kevin Dominique Tjandraprawira,1 Dhanny Primantara Johari Santoso,2 Hartanto Bayuaji,1 Annisa Dewi Nugrahani,2 Dadan Susandi2 1Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, Indonesia; 2Department of Obstetrics and Gynecology, Dr. Slamet General Hospital, Garut, IndonesiaCorrespondence: Kevin Dominique Tjandraprawira, Department of Obstetrics and Gynecology, Faculty of Medicine, Universitas Padjadjaran – Dr. Hasan Sadikin General Hospital, Bandung, Indonesia, Email [email protected]: Higher-order pregnancy is considered as a high-risk pregnancy, followed by various maternal and foetal complications. The diagnosis and management of higher order pregnancy have abundant and complex challenges, especially in rural areas where antenatal care (ANC) is often inadequate. Late booking and low awareness of complications necessitates priority management and referral to a tertiary center for fetal medicine expertise. This is our experience managing a spontaneously conceived quadruplet pregnancy delivered prematurely in a low-resource setting.Case Presentations: A 27-years-old primigravida of 7.5 months of gestation presented with preterm labor. Her membrane was intact, and she noted active fetal movements. Her history was notable due to her pregnancy being spontaneously conceived and that her antenatal consultations had mistakenly identified her pregnancy as a triplet pregnancy. At presentation, her fundal height was 49 cm, and her cervix was 5– 6 cm dilated. As she was in active labor, she underwent an emergency caesarean section. Four neonates were delivered but only two were transferred to the neonatal intensive care unit due to infrastructure limitations. She made an uneventful recovery and was discharged 2 days later. However, only two of four neonates eventually survived. This quadruplet pregnancy signified the pertinent complications of multifetal pregnancy: misidentification of chorionicity; preterm delivery; and early neonatal deaths due to prematurity.Conclusion: Higher order pregnancies present their own challenges for diagnosis and treatment. Preterm delivery and its associated neonatal complications are well-known complications, and a multidisciplinary management is crucial.Keywords: case report, multiple pregnancy, pregnancy, quadruplet