Maternal and Neonatal Outcomes of Spontaneous Higher-Order Multiple Pregnancies: A Retrospective Case Series at Mbarara Regional Referral Hospital, Southwestern Uganda

Introduction: Higher-order multiple pregnancies (HOM) are rare but carry high maternal and neonatal risks. This retrospective case series describes maternal and neonatal outcomes of spontaneous HOM at MRRH, highlighting the challenges of managing these high-risk pregnancies. Methods We conducted a retrospective case series at MRRH by reviewing delivery records, operative logs, and patient files to identify women with spontaneous HOM (triplets or higher) managed between January 2024 and December 2024. Eligible cases were pregnancies involving three or more fetuses confirmed by antenatal ultrasound or intraoperative findings. Data on maternal demographics, antenatal history, mode of delivery, and complications were collected. Neonatal outcomes included gestational age, birth weight, Apgar scores, NICU admission, stillbirths, and early neonatal deaths (END). Findings were summarized descriptively. Results Four HOM cases were identified. Three were viable quadruplet pregnancies delivered at or beyond 32 weeks of gestation, while one triplet pregnancy resulted in spontaneous miscarriage at 23 weeks. All pregnancies were naturally conceived. The mothers had a median age of 29.5 years (IQR: 27.5–31.5) and included one primigravida and three multigravidae. All women were referrals from lower-level health facilities. Antenatal care attendance varied. Only one woman booked in the first trimester, while the remaining three booked in the second trimester, highlighting delays in early pregnancy optimization. Two women underwent emergency cesarean delivery, and one delivered vaginally while being prepared for surgery. Maternal complications included postpartum haemorrhage (n = 2) and puerperal sepsis (n = 1), with no maternal deaths. Among the three viable pregnancies, one intrauterine fetal death (IUFD) and two early neonatal deaths (END) occurred; nine neonates survived to discharge in good condition. All live-born infants were preterm, with a median gestational age of 33 weeks (IQR: 27.5–34.5), and all required NICU admission for complications of prematurity, including low birth weight and respiratory distress syndrome. Conclusion Spontaneous HOM pose substantial risks but can have favorable outcomes with timely, skilled, multidisciplinary care and improved antenatal and neonatal support systems.