1
|
Pasteau C, Bettahar K, Weingertner AS, Bouhanna P, Sananès N. [Embryo reduction in twin pregnancy on maternal request: A French practice study]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2024:S2468-7189(24)00298-8. [PMID: 39341569 DOI: 10.1016/j.gofs.2024.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/26/2024] [Accepted: 09/23/2024] [Indexed: 10/01/2024]
Abstract
INTRODUCTION In France, embryo reduction is controversial in twin pregnancy, especially when there is no underlying pathology. The objective of this study was to establish the status of this practice in France and to depict the ethical issues around this problematic. STUDY DESIGN A questionnaire drafted by Maternal and Fetal Medicine physicians and family planning teams of the University Hospital from Strasbourg was distributed to the 48 French Multidisciplinary Prenatal Diagnosis Centers, among which 28 answered (58,3%). RESULTS Embryo reduction in twin pregnancy on maternal request has already challenged 71% of the centers; 29% have performed such a reduction. The overall position of the centers to these requests is negative (3.1/10), with very mixed levels of in-team agreement. The main arguments against this practice are that twin pregnancy is not a pathology, that embryo reduction exposes to the risk of loosing the entire pregnancy, the feeling of being held hostage with the alternative of abortion of the whole pregnancy, and the lack of legal framing. On the contrary, the arguments in favor of the reduction are: that the reduction can avoid an abortion, that this type of reduction can be related to a partial abortion, that it responds to women's rights and that mental health is an integral part of women's health. CONCLUSION There is no consensus about how to respond to patients requesting for embryo reduction in twin pregnancy. However, the majority of Centers have been confronted with it and it would be necessary to open the debate on this problem and the ethical questions it raises.
Collapse
Affiliation(s)
- Cécile Pasteau
- Service de gynécologie obstétrique, hôpitaux universitaires de Strasbourg, hôpital de Hautepierre, 1, avenue Molière, 67200 Strasbourg, France.
| | - Karima Bettahar
- Service d'orthogénie, hôpitaux universitaires de Strasbourg, CMCO, 19, rue Louis-Pasteur, 67300 Schiltigheim, France.
| | - Anne-Sophie Weingertner
- Service de diagnostic anténatal, hôpitaux universitaires de Strasbourg, CMCO, 19, rue Louis-Pasteur, 67300 Schiltigheim, France.
| | - Philippe Bouhanna
- Service de diagnostic anténatal, hôpital américain de Paris, 55, boulevard du Château, 92200 Neuilly-sur-Seine, France.
| | - Nicolas Sananès
- Service de gynécologie obstétrique, hôpital américain de Paris, 5, boulevard du Château, 92200 Neuilly-sur-Seine, France.
| |
Collapse
|
2
|
Jernman RM, Rissanen ARS, Stefanovic V. The outcome of reduced and non-reduced triplet pregnancies managed in a tertiary hospital during a 15-year-period - a retrospective cohort study. J Perinat Med 2024; 52:361-368. [PMID: 38421237 DOI: 10.1515/jpm-2023-0538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Triplet pregnancies involve several complications, the most important being prematurity as virtually all triplets are born preterm. We conducted this study to compare the outcomes of reduced vs. non-reduced triplet pregnancies managed in the largest tertiary hospital in Finland. METHODS This was a retrospective cohort study in the Helsinki University Hospital during 2006-2020. Data on the pregnancies, parturients and newborns were collected from patient records. The fetal number, chorionicity and amnionicity were defined in first-trimester ultrasound screening. The main outcome measures were perinatal and neonatal mortality of non-reduced triplets, compared to twins and singletons selectively reduced of triplet pregnancies. RESULTS There were 57 initially triplet pregnancies and 35 of these continued as non-reduced triplets and resulted in the delivery of 104 liveborn children. The remaining 22 cases were spontaneously or medically reduced to twins (9) or singletons (13). Most (54.4 %) triplet pregnancies were spontaneous. There were no significant differences in gestational age at delivery between triplets (mean 33+0, median 34+0) and those reduced to twins (mean 32+5, median 36+0). The survival at one week of age was higher for triplets compared to twins (p<0.00001). CONCLUSIONS Most pregnancies continued as non-reduced triplets, which were born at a similar gestational age but with a significantly higher liveborn rate compared to those reduced to twins. There were no early neonatal deaths among cases reduced to singletons. Prematurity was the greatest concern for multiples in this cohort, whereas the small numbers may explain the lack of difference in gestational age between these groups.
Collapse
Affiliation(s)
- Riina Maria Jernman
- Obstetrics and Gynecology, Fetomaternal Medical Center, 159841 University of Helsinki and Helsinki University Hospital , Helsinki, Finland
| | | | - Vedran Stefanovic
- Obstetrics and Gynecology, Fetomaternal Medical Center, 159841 University of Helsinki and Helsinki University Hospital , Helsinki, Finland
| |
Collapse
|
3
|
Jernman RM, Stefanovic V. Multifetal pregnancy reductions and selective fetocide in a tertiary referral center - a retrospective cohort study. J Perinat Med 2024; 52:255-261. [PMID: 38281159 DOI: 10.1515/jpm-2023-0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/23/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Multiple pregnancies involve several complications, most often prematurity, but also higher anomaly rates. Reducing fetuses generally improves pregnancy outcomes. We conducted this study to evaluate the obstetrical and neonatal results after multifetal pregnancy reduction (MFPR) in the largest tertiary hospital in Finland. METHODS This retrospective cohort study included all MFPR managed in Helsinki University Hospital during a 13 year period (2007-2019). Data on pregnancies, parturients and newborns were collected from patient files. The number of fetuses, chorionicities and amnionicities were defined in first-trimester ultrasound screening. RESULTS There were 54 MFPR cases included in the final analyses. Most often the reduction was from twins to singletons (n=34, 63 %). Majority of these (25/34, 73.5 %) were due to co-twin anomaly. Triplets (n=16, 29.6 %) were reduced to twins (n=7, 13 %) or singletons (n=9, 16.7 %), quadruplets (n=2, 3.7 %) and quintuplets (n=2, 3.7 %) to twins. Most (33/54, 61.1 %) MFPR procedures were done by 15+0 weeks of gestation. There were six miscarriages after MFPR and one early co-twin miscarriage. In the remaining 47 pregnancies that continued as twins (n=7, 14.9 %) or singletons (n=40, 85.1 %) the liveborn rate was 90 % for one fetus and 71.4 % for two fetuses. CONCLUSIONS Most MFPR cases were pregnancies with an anomalous co-twin. The whole pregnancy loss risk was 11.1 % after MFPR. The majority (70.6 %) of twins were spontaneous, whereas all quadruplets, quintuplets, and 56.3 % of triplets were assisted reproductive technologies (ART) pregnancies. Careful counselling should be an essential part of obstetrical care in multiple pregnancies, which should be referred to fetomaternal units for MFPR option.
Collapse
Affiliation(s)
- Riina Maria Jernman
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
4
|
Liu S, Xu Q, Liu D, Li Q, Qian J, Zhang B, Chen X. Pregnancy and obstetric outcomes of dichorionic triamniotic triplet pregnancies with selective foetal reduction after assisted reproductive technology. Reprod Biol Endocrinol 2024; 22:30. [PMID: 38491531 PMCID: PMC10941449 DOI: 10.1186/s12958-024-01199-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 02/27/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND It is generally beneficial and recommended that dichorionic triamniotic (DCTA) triplet pregnancies be reduced to monochorionic (MC) twin or singleton pregnancies after assisted reproductive technology (ART). However, some infertile couples still have a firm desire to retain twins. For this reason, the best foetal reduction strategies need to be available for infertile couples and clinicians. Given that data on the elective reduction of DCTA triplet pregnancies to twin pregnancies are scarce, we investigated the outcomes of elective reduction of DCTA triplet pregnancies through the retrospective analysis of previous data. METHOD Patients with DCTA triplet pregnancies who underwent elective foetal reduction between January 2012 and June 2020 were recruited. A total of 67 eligible patients with DCTA triplet pregnancies were divided into two groups: a DCTA-to-dichorionic diamniotic (DCDA) twin group (n = 38) and a DCTA-to-monochorionic diamniotic (MCDA) twin group (n = 29); the basic clinical data of the two groups were collected for comparison. RESULTS Compared with the DCDA-to-MCDA twin group, the DCTA-to-DCDA twin group had lower rates of complete miscarriage (7.89% versus 31.03%, p = 0.014), early complete miscarriage (5.26% versus 24.14%, p = 0.034), late preterm birth (25.71% versus 65.00%, p = 0.009) and very low birth weight (0 versus 11.11%, p = 0.025). In addition, the DCTA-to-DCDA twin group had higher rates of full-term delivery (65.71% versus 25.00%, p = 0.005), survival (92.11% versus 68.97%, p = 0.023), and taking the babies home (92.11% versus 68.97%, p = 0.023) than did the DCTA-to-MCDA twin group. In terms of neonatal outcomes, a significantly greater gestational age (38.06 ± 2.39 versus 36.28 ± 2.30, p = 0.009), average birth weight (3020.77 ± 497.33 versus 2401.39 ± 570.48, p < 0.001), weight of twins (2746.47 ± 339.64 versus 2251.56 ± 391.26, p < 0.001), weight of the larger neonate (2832.94 ± 320.58 versus 2376.25 ± 349.95, p < 0.001) and weight of the smaller neonate (2660.00 ± 345.34 versus 2126.88 ± 400.93, p < 0.001) was observed in the DCTA-to-DCDA twin group compared to the DCTA-to-MCDA twin group. CONCLUSION The DCTA-to-DCDA twin group had better pregnancy and neonatal outcomes than the DCTA-to-MCDA twin group. This reduction approach may be beneficial for patients with dichorionic triamniotic triplet pregnancies who have a strong desire to have DCDA twins.
Collapse
Affiliation(s)
- Shuhua Liu
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China.
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China.
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China.
| | - Qianhua Xu
- Reproductive Medicine Center, Department of Obstetrics and Gynecology, The First Affiliated Hospital of Anhui Medical University, Hefei, 230032, China
| | - Dehong Liu
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China
| | - Qiuru Li
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China
| | - Jingyu Qian
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China
| | - Bin Zhang
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China.
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China.
| | - Xianxia Chen
- Department of Obstetrics and Gynecology, Hefei Maternity Child Health Hospital, Hefei, 230000, China.
- Department of Obstetrics and Gynecology, Anhui Women and Children's Medical Center, Hefei, 230000, China.
| |
Collapse
|
5
|
Kristensen SE, Kvist Ekelund C, Sandager P, Stener Jørgensen F, Hoseth E, Sperling L, Zingenberg HJ, Duelund Hjortshøj T, Gadsbøll K, Wright A, Wright D, McLennan A, Sundberg K, Petersen OB. Triple trouble: uncovering the risks and benefits of early fetal reduction in trichorionic triplets in a large national Danish cohort study. Am J Obstet Gynecol 2023; 229:555.e1-555.e14. [PMID: 37263399 DOI: 10.1016/j.ajog.2023.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/05/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Triplet pregnancies are high risk for both the mother and the infants. The risks for infants include premature birth, low birthweight, and neonatal complications. Therefore, the management of triplet pregnancies involves close monitoring and may include interventions, such as fetal reduction, to prolong the pregnancy and improve outcomes. However, the evidence of benefits and risks associated with fetal reduction is inconsistent. OBJECTIVE This study aimed to compare the outcomes of trichorionic triplet pregnancies with and without fetal reduction and with nonreduced dichorionic twin pregnancies and primary singleton pregnancies. STUDY DESIGN All trichorionic triplet pregnancies in Denmark, including those with fetal reduction, were identified between 2008 and 2018. In Denmark, all couples expecting triplets are informed about and offered fetal reduction. Pregnancies with viable fetuses at the first-trimester ultrasound scan and pregnancies not terminated were included. Adverse pregnancy outcome was defined as a composite of miscarriage before 24 weeks of gestation, stillbirth at 24 weeks of gestation, or intrauterine fetal death of 1 or 2 fetuses. RESULTS The study cohort was composed of 317 trichorionic triplet pregnancies, of which 70.0% of pregnancies underwent fetal reduction to a twin pregnancy, 2.2% of pregnancies were reduced to singleton pregnancies, and 27.8% of pregnancies were not reduced. Nonreduced triplet pregnancies had high risks of adverse pregnancy outcomes (28.4%), which was significantly lower in triplets reduced to twins (9.0%; difference, 19.4%, 95% confidence interval, 8.5%-30.3%). Severe preterm deliveries were significantly higher in nonreduced triplet pregnancies (27.9%) than triplet pregnancies reduced to twin pregnancies (13.1%; difference, 14.9%, 95% confidence interval, 7.9%-21.9%). However, triplet pregnancies reduced to twin pregnancies had an insignificantly higher risk of miscarriage (6.8%) than nonreduced twin pregnancies (1.1%; difference, 5.6%; 95% confidence interval, 0.9%-10.4%). CONCLUSION Triplet pregnancies reduced to twin pregnancies had significantly lower risks of adverse pregnancy outcomes, severe preterm deliveries, and low birthweight than nonreduced triplet pregnancies. However, triplet pregnancies reduced to twin pregnancies were potentially associated with a 5.6% increased risk of miscarriage.
Collapse
Affiliation(s)
- Steffen Ernesto Kristensen
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Charlotte Kvist Ekelund
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Puk Sandager
- Department of Obstetrics and Gynecology, Center for Fetal Medicine, Aarhus University Hospital, Aarhus, Denmark; Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Finn Stener Jørgensen
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Fetal Medicine Unit, Department of Obstetrics and Gynecology, Copenhagen University Hospital, Hvidovre and Amager, Hvidovre, Denmark
| | - Eva Hoseth
- Department of Obstetrics and Gynecology, Clinic of Ultrasound, Aalborg University Hospital, Aalborg, Denmark
| | - Lene Sperling
- Department of Obstetrics and Gynecology, Center for Ultrasound and Pregnancy, Odense University Hospital, Odense, Denmark
| | - Helle Jeanette Zingenberg
- Department of Obstetrics and Gynecology, Copenhagen University Hospital, Herlev and Gentofte, Herlev, Denmark
| | - Tina Duelund Hjortshøj
- Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kasper Gadsbøll
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Alan Wright
- Institute of Health Research, University of Exeter, Exeter, United Kingdom
| | - David Wright
- Institute of Health Research, University of Exeter, Exeter, United Kingdom
| | - Andrew McLennan
- Sydney Ultrasound for Women, Chatswood, New South Wales, Australia; Discipline of Obstetrics, Gynaecology, and Neonatology, The University of Sydney, Sydney, New South Wales, Australia
| | - Karin Sundberg
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Olav Bjørn Petersen
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
6
|
Hessami K, Evans MI, Nassr AA, Espinoza J, Donepudi RV, Cortes MS, Krispin E, Mostafaei S, Belfort MA, Shamshirsaz AA. Fetal reduction of triplet pregnancies to twins vs singletons: a meta-analysis of survival and pregnancy outcome. Am J Obstet Gynecol 2022; 227:430-439.e5. [PMID: 35351408 DOI: 10.1016/j.ajog.2022.03.050] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/22/2022] [Accepted: 03/22/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to compare the fetal survival rate and perinatal outcomes of triplet pregnancies after selective reduction to twin pregnancies vs singleton pregnancies. DATA SOURCES PubMed, Web of Science, Scopus, and Embase were systematically searched from the inception of the databases to January 16, 2022. STUDY ELIGIBILITY CRITERIA Studies comparing the survival and perinatal outcomes between reduction to twin pregnancies and reduction to singleton pregnancies were included. The primary outcomes were fetal survival, defined as a live birth at >24 weeks of gestation. The secondary outcomes were gestational age at birth, preterm birth at <32 and <34 weeks of gestation, early pregnancy loss (<24 weeks of gestation), low birthweight, and rate of neonatal demise (up to 28 days after birth). METHODS The random-effect model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. To provide a range of expected effects if a new study was conducted, 95% prediction intervals were calculated for outcomes presented in >3 studies. RESULTS Of note, 10 studies with 2543 triplet pregnancies undergoing fetal reduction, of which 2035 reduced to twin pregnancies and 508 reduced to singleton pregnancies, met the inclusion criteria. Reduction to twin pregnancies had a lower rate of fetal survival (odds ratio, 0.61; 95% confidence interval, 0.40-0.92; P=.02; 95% prediction interval, 0.36-1.03) and comparable rates of early pregnancy loss (odds ratio, 0.89; 95% confidence interval, 0.58-1.38; P=.61; 95% prediction interval, 0.54-1.48) and neonatal demise (odds ratio, 0.57; 95% confidence interval, 0.09-3.50; P=.55) than reduction to singleton pregnancies. Reduction to twin pregnancies had a significantly lower gestation age at birth (weeks) (mean difference, -2.20; 95% confidence interval, -2.80 to -1.61; P<.001; 95% prediction interval, -4.27 to -0.14) than reduction to singleton pregnancies. Furthermore, reduction to twin pregnancies was associated with lower birthweight and greater risk of preterm birth at <32 and <34 weeks of gestation. CONCLUSION Triplet pregnancies reduced to twin pregnancies had a lower fetal survival rate of all remaining fetuses, lower gestational age at birth, higher risk of preterm birth, and lower birthweight than triplet pregnancies reduced to singleton pregnancies; reduction to twin pregnancies vs reduction to singleton pregnancies showed no substantial difference for the rates of early pregnancy loss and neonatal death.
Collapse
|
7
|
Sarac Sivrikoz T, DEMIR O, Halil Kalelioglu I, Has R, Karakas Paskal E, Kundakci Ozdemir P, Yuksel A. The effects of early or late multifetal reduction procedure on perinatal outcomes in multiple pregnancies reduced to twins or singletons: A single tertiary center experience. Eur J Obstet Gynecol Reprod Biol 2022; 270:195-200. [DOI: 10.1016/j.ejogrb.2022.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 02/09/2023]
|
8
|
Maternal, Fetal, and Neonatal Outcomes of Elective Fetal Reduction Among Multiple Gestation Pregnancies: A Systematic Review. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2021; 44:60-70.e12. [PMID: 34411728 DOI: 10.1016/j.jogc.2021.07.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 07/25/2021] [Accepted: 07/27/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review the existing literature on fetal and maternal health outcomes following elective pregnancy reduction. DATA SOURCES MEDLINE, EMBASE, CINAHL, the Cochrane Database of Systematic Reviews, and the Cochrane Controlled Trials Register. STUDY SELECTION Studies involving women pregnant with dichorionic twins, trichorionic triplets, or quadra-chorionic quadruplets who underwent elective fetal reduction of 1 or more fetuses to reduce the risks associated with multiple gestation pregnancies. DATA EXTRACTION The main fetal health outcomes measured were gestational age at delivery, preterm birth, miscarriage, birthweight, and small for gestational age at delivery. The main maternal health outcomes measured were gestational diabetes, hypertensive disorders of pregnancy, and cesarean delivery. DATA SYNTHESIS Of 7678 studies identified, 24 were included (n = 425 dichorionic twin pregnancies, n = 2753 trichorionic triplet pregnancies, and n = 111 quadra-chorionic quadruplet pregnancies). Fifteen studies (62.5%) did not report maternal health outcomes, while every study reported at least 1 fetal health outcome. Fetal reduction was associated with higher gestational age at birth, lower preterm birth, higher birthweight, and lower rates of small for gestational age infants and intrauterine growth restriction. No consistent pattern was observed for miscarriage and neonatal mortality rates. Following fetal reduction, cesarean delivery rates were lower in most studies. There were no appreciable trends with respect to gestational diabetes or hypertensive disorders of pregnancy. CONCLUSION Fetal reduction reliably optimizes gestational age at birth and neonatal birthweight. Miscarriage rates and other adverse procedural outcomes did not increase following transabdominal reduction. Further research on maternal outcomes is needed given a paucity of information in the literature.
Collapse
|
9
|
Zemet R, Haas J, Bart Y, Barzilay E, Zloto K, Argaman N, Schwartz N, Weisz B, Yinon Y, Mazaki-Tovi S, Lipitz S. Pregnancy outcome after multifetal pregnancy reduction of triplets to twins versus reduction to singletons. Reprod Biomed Online 2019; 40:445-452. [PMID: 32067870 DOI: 10.1016/j.rbmo.2019.12.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 11/12/2019] [Accepted: 12/18/2019] [Indexed: 11/28/2022]
Abstract
RESEARCH QUESTION Does fetal reduction of triplet pregnancies to singleton result in superior obstetric and neonatal outcomes compared with triplets reduced to twins? DESIGN A historical cohort study including 285 trichorionic and dichorionic triplet pregnancies that underwent abdominal fetal reduction at 11-14 weeks in a single tertiary referral centre. The study population comprised two groups: reduction to twins (n = 223) and singletons (n = 62). Main outcome measures were rates of pregnancy complications, preterm delivery and neonatal outcomes. Non-parametric statistical methods were employed. RESULTS Triplet pregnancies reduced to twins delivered earlier (36 versus 39 weeks, P < 0.001) with higher prevalence of Caesarean section (71.1% versus 32.2%, P < 0.001) compared with triplets reduced to singletons. Preterm delivery rates were significantly higher in twins compared with singletons prior to 37 weeks (56.9% versus 13.6%, P < 0.001), 34 weeks (20.2% versus 3.4%, P = 0.002) and 32 weeks (9.6% versus 0%, P = 0.01). No significant difference was found in the rate of pregnancy loss before 24 weeks (1.3% in twins versus 4.8% in singletons, P = 0.12) or in the rate of intrauterine fetal death after 24 weeks (0.4% versus 0%, P = 1.0). Both groups had comparable obstetrical complications and neonatal outcomes, except for higher rates of neonatal intensive care unit admission in twins (31.9% versus 6.8%, P < 0.001). CONCLUSIONS Reduction of triplets to singletons rather than twins resulted in superior obstetric outcomes without increasing the procedure-related complications. However, because the rate of extreme prematurity in pregnancies reduced to twins was low, the overall outcome of those pregnancies was favourable. Therefore, the option of reduction to singletons should be considered in cases where the risk of prematurity seems exceptionally high.
Collapse
Affiliation(s)
- Roni Zemet
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yossi Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Barzilay
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod, Israel; Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Keren Zloto
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Natan Argaman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Noa Schwartz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Boaz Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shali Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shlomo Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
10
|
Liu Y, Shen Y, Zhang H, Tang Y, Lu G, Lin G, Gong F. Clinical outcomes of multifetal pregnancy reduction in trichorionic and dichorionic triplet pregnancies: A retrospective observational study. Taiwan J Obstet Gynecol 2019; 58:133-138. [PMID: 30638467 DOI: 10.1016/j.tjog.2018.11.025] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/31/2018] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVE To observe the pregnancy and perinatal outcomes of trichorionic triplet (TCT) and dichorionic triplet (DCT) pregnancies with or without multifetal pregnancy reduction (MFPR). MATERIALS AND METHODS This was a retrospective study of 732 TCT and 118 DCT pregnancies after IVF/ICSI cycles between October 1999 and May 2014 at the Reproductive & Genetic Hospital of CITIC-Xiangya. The TCT and DCT groups were subdivided into three subgroups: MFPR to single fetus group, MFPR to twins group and expectant group. Pregnancy and perinatal outcomes were compared between different subgroups. RESULTS The resulting subgroups were TCT-Expectant (n = 40), TCT to twin (n = 610), TCT to single (n = 22), DCT-Expectant (n = 17), DCT to twin (n = 50), and DCT to single (n = 22). The groups with MFPR had the better pregnancy and perinatal outcomes. Meanwhile, the significantly higher abortion rates but lower live birth and take home baby rates were found in TCT-Expectant group and DCT-Expectant group (all P < 0.05). Besides, the abortion rate of DCT-Expectant group was much higher than TCT-Expectant group (41% verse 15%, P = 0.032). As for the perinatal outcomes, retaining single fetus group showed the advantage of higher birth weight, and elder gestational age in both DCT and TCT pregnancies (all P < 0.05). CONCLUSION For DCT and TCT pregnancies, MFPR application could reduce the miscarriage rate, while improving live birth and take home baby rates compared to the expectant groups. Especially, when reduced to a single fetus, MFPR could provide the better perinatal outcomes.
Collapse
Affiliation(s)
- Yaqiong Liu
- Institute of Reproductive and Stem Cell Engineering, School of Basic Medicine, Central South University, China; Key Laboratory of Reproductive and Stem Cell Engineering, Ministry of Health, China
| | - Yan Shen
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
| | - Hong Zhang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
| | - Yi Tang
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
| | - Guangxiu Lu
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China; Key Laboratory of Reproductive and Stem Cell Engineering, Ministry of Health, China
| | - Ge Lin
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China; Institute of Reproductive and Stem Cell Engineering, School of Basic Medicine, Central South University, China; Key Laboratory of Reproductive and Stem Cell Engineering, Ministry of Health, China
| | - Fei Gong
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China; Institute of Reproductive and Stem Cell Engineering, School of Basic Medicine, Central South University, China; Key Laboratory of Reproductive and Stem Cell Engineering, Ministry of Health, China.
| |
Collapse
|
11
|
The outcome of the multifetal pregnancy reduction procedures in a single centre: A report of 202 completed cases. Eur J Obstet Gynecol Reprod Biol 2018; 230:22-27. [PMID: 30237136 DOI: 10.1016/j.ejogrb.2018.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/10/2018] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To review the results of fetal reduction procedures in our institution, evaluate its effects on the pregnancy outcome in terms of miscarriage, preterm delivery, taking home healthy babies and discuss the factors that may have contributed to the outcome. STUDY DESIGN This is a retrospective study performed at the Fetal Medicine Unit of the Sisli Memorial Hospital in Istanbul after ART therapies in our unit from 2000 to 2011. RESULTS The sample comprised 151 triplets, 35 quadruplets, 11 quintuplets, 3 twins, 1 sextuplet and 1 septuplet. The average maternal age was 30 ± 4.4 and the average week of interventions was 11.7 ± 1.3 weeks. In 40 cases two or more needle insertions were necessary. The two-week post-procedure loss rate, defined as 'the procedure related loss rate', was 0.7%; however, for the whole sample, the losses were 6.9% when they occured before 24 completed weeks and was defined as 'the total loss rate'. 184 of the remaining 188 cases had at least one baby to take home (91.1% of 202 patients). The average birth week for those healthy babies discharged home was 35.5 ± 2.4. The rate of early preterm birth before gestational weeks of 32 was 9%. The mean birthweight of this "take-home" group was 2302 ± 525 g. CONCLUSION Fetal reduction in multifetal pregnancy is associated with low miscarriage rate and preterm delivery rates. Fetal reduction in multifetal pregnancy should be considered for better pregnancy outcomes and the results of this study can be used in prenatal counseling.
Collapse
|
12
|
Dadhwal V, Khoiwal K. Multifetal Pregnancy Reduction. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0137-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
|
13
|
Razaz N, Avitan T, Ting J, Pressey T, Joseph KS. Perinatal outcomes in multifetal pregnancy following fetal reduction. CMAJ 2017; 189:E652-E658. [PMID: 28483844 DOI: 10.1503/cmaj.160722] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND There is currently insufficient evidence regarding the prognosis of multifetal pregnancy following elective fetal reduction to twin or singleton pregnancy. We compared perinatal outcomes in pregnancies with and without fetal reduction. METHODS We used data on all stillbirths and live births in British Columbia, Canada, from 2009 to 2013. We compared outcomes of multifetal pregnancies with fetal reduction (to twin or singleton pregnancy) with outcomes of pregnancies without fetal reduction. The primary outcome was a composite of serious neonatal morbidity or perinatal death. Other outcomes studied included preterm birth, low birth weight and small-for-gestational-age live birth. RESULTS The rate of serious neonatal morbidity or perinatal death did not differ significantly between pregnancies reduced to twins and unreduced triplet pregnancies (adjusted rate ratio 0.50, 95% confidence interval [CI] 0.24-1.07) or between pregnancies reduced to singletons and unreduced twin pregnancies (adjusted rate ratio 1.57, 95% CI 0.74-3.33). The rate was significantly lower in the fetal reduction group reduced to twins versus unreduced triplet pregnancies when we restricted the analysis to pregnancies conceived following the use of assisted reproduction technologies (adjusted rate ratio 0.35, 95% CI 0.18-0.67). The rates of preterm birth, very preterm birth, low birth weight and very low birth weight were significantly lower among pregnancies reduced to twins than among unreduced triplet pregnancies. Compared with unreduced twin pregnancies, pregnancies reduced to singletons had lower rates of preterm birth and low birth weight. INTERPRETATION Fetal reduction to twins and singletons was not associated with a decreased risk of serious neonatal morbidity or perinatal death. However, such fetal reduction was associated with substantial improvements in several other perinatal outcomes, such as preterm birth and low birth weight. Clinicians discussing the risks associated with multifetal pregnancy should counsel parents on the potential risks and benefits of fetal reduction.
Collapse
Affiliation(s)
- Neda Razaz
- Department of Obstetrics and Gynaecology (Razaz, Pressey, Joseph), University of British Columbia, and BC Women's Hospital and Health Centre, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Razaz), Karolinska University Hospital in Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Avitan), Hadassah Medical Centre, Jerusalem, Israel; Department of Pediatrics (Ting) and School of Population and Public Health (Joseph), University of British Columbia, Vancouver, BC
| | - Tehila Avitan
- Department of Obstetrics and Gynaecology (Razaz, Pressey, Joseph), University of British Columbia, and BC Women's Hospital and Health Centre, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Razaz), Karolinska University Hospital in Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Avitan), Hadassah Medical Centre, Jerusalem, Israel; Department of Pediatrics (Ting) and School of Population and Public Health (Joseph), University of British Columbia, Vancouver, BC
| | - Joseph Ting
- Department of Obstetrics and Gynaecology (Razaz, Pressey, Joseph), University of British Columbia, and BC Women's Hospital and Health Centre, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Razaz), Karolinska University Hospital in Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Avitan), Hadassah Medical Centre, Jerusalem, Israel; Department of Pediatrics (Ting) and School of Population and Public Health (Joseph), University of British Columbia, Vancouver, BC
| | - Tracy Pressey
- Department of Obstetrics and Gynaecology (Razaz, Pressey, Joseph), University of British Columbia, and BC Women's Hospital and Health Centre, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Razaz), Karolinska University Hospital in Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Avitan), Hadassah Medical Centre, Jerusalem, Israel; Department of Pediatrics (Ting) and School of Population and Public Health (Joseph), University of British Columbia, Vancouver, BC
| | - K S Joseph
- Department of Obstetrics and Gynaecology (Razaz, Pressey, Joseph), University of British Columbia, and BC Women's Hospital and Health Centre, Vancouver, BC; Clinical Epidemiology Unit, Department of Medicine (Razaz), Karolinska University Hospital in Solna, Karolinska Institutet, Stockholm, Sweden; Department of Obstetrics and Gynecology (Avitan), Hadassah Medical Centre, Jerusalem, Israel; Department of Pediatrics (Ting) and School of Population and Public Health (Joseph), University of British Columbia, Vancouver, BC
| |
Collapse
|
14
|
Pregnancy outcome of early multifetal pregnancy reduction: triplets to twins versus triplets to singletons. Reprod Biomed Online 2014; 29:717-21. [DOI: 10.1016/j.rbmo.2014.09.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2014] [Revised: 08/13/2014] [Accepted: 09/03/2014] [Indexed: 11/19/2022]
|
15
|
Murray SR, Norman JE. Multiple pregnancies following assisted reproductive technologies--a happy consequence or double trouble? Semin Fetal Neonatal Med 2014; 19:222-7. [PMID: 24685368 DOI: 10.1016/j.siny.2014.03.001] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The association between assisted reproduction technologies (ART) and multiple pregnancy is well-established, with a multiple birth rate of 24% in ART pregnancies. Multiple pregnancy is associated with significantly increased maternal and perinatal morbidity and mortality, as well as increased costs to the National Health Service. Evidence relating to the obstetric outcomes of ART twins versus naturally conceived twins is discussed in this review. Methods to reduce the risk of multiple births including elective single embryo transfer and multifetal pregnancy reduction are also discussed.
Collapse
Affiliation(s)
- S R Murray
- Simpson Centre for Reproductive Health, Royal Infirmary Edinburgh, 47 Little France Crescent, UK.
| | - J E Norman
- MRC Centre for Reproductive Health, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, UK
| |
Collapse
|
16
|
Legendre CM, Moutel G, Drouin R, Favre R, Bouffard C. Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review. Reprod Biomed Online 2013; 26:542-54. [PMID: 23518032 DOI: 10.1016/j.rbmo.2013.02.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2012] [Revised: 01/31/2013] [Accepted: 02/05/2013] [Indexed: 10/27/2022]
Abstract
Although selective termination of pregnancy and fetal reduction in multiple pregnancy both involve the termination in utero of the development of live fetuses, these two procedures are different in several aspects. Nevertheless, several authors tend to amalgamate and confuse their psychosocial consequences and the ethical issues they raise. Therefore, this narrative review, derived from a comparative analysis of 91 articles, shines a light on these amalgamations and confusions, as well as on the medical, contextual, experiential and ethical differences specific to selective termination and fetal reduction.
Collapse
Affiliation(s)
- Claire-Marie Legendre
- Division of Genetics, Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, 3001 12e Avenue Nord, Sherbrooke, Québec, Canada
| | | | | | | | | |
Collapse
|
17
|
Chaveeva P, Kosinski P, Puglia D, Poon L, Nicolaides K. Trichorionic and Dichorionic Triplet Pregnancies at 10-14 Weeks: Outcome after Embryo Reduction Compared to Expectant Management. Fetal Diagn Ther 2013; 34:199-205. [DOI: 10.1159/000356170] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2013] [Accepted: 10/01/2013] [Indexed: 11/19/2022]
|