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Rasmussen MK, Kristensen SE, Ekelund CK, Sandager P, Jørgensen FS, Hoseth E, Sperling L, Zingenberg HJ, Hjortshøj TD, Gadsbøll K, Wright A, Wright D, McLennan A, Sundberg K, Petersen OB. Quadruplet pregnancy outcome with and without fetal reduction: Danish national cohort study (2008-2018) and comparison with dichorionic twins. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 63:514-521. [PMID: 37743648 DOI: 10.1002/uog.27497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 09/04/2023] [Accepted: 09/18/2023] [Indexed: 09/26/2023]
Abstract
OBJECTIVES To perform a nationwide study of quadrichorionic quadriamniotic (QCQA) quadruplet pregnancies and to compare the pregnancy outcome in those undergoing fetal reduction with non-reduced quadruplets and dichorionic diamniotic (DCDA) twin pregnancies from the same time period. METHODS This was a retrospective Danish national register-based study performed using data from the national Danish Fetal Medicine Database, which included all QCQA quadruplets and all non-reduced DCDA twin pregnancies with an estimated due date between 2008 and 2018. The primary outcome measure was a composite of adverse pregnancy outcomes, including pregnancy loss or intrauterine death of one or more fetuses. Secondary outcomes included gestational age at delivery, the number of liveborn children, preterm delivery before 28, 32 and 37 gestational weeks and birth weight. Data on pregnancy complications and baseline characteristics were also recorded. Outcomes were compared between reduced and non-reduced quadruplet pregnancies, and between DCDA pregnancies and quadruplet pregnancies reduced to twins. A systematic literature search was performed to describe and compare previous results with our findings. RESULTS Included in the study were 33 QCQA quadruplet pregnancies, including three (9.1%) non-reduced pregnancies, 28 (84.8%) that were reduced to twin pregnancy and fewer than three (6.1%) that were reduced to singleton pregnancy, as well as 9563 DCDA twin pregnancies. Overall, the rate of adverse pregnancy outcome was highest in non-reduced quadruplets (66.7%); it was 50% in quadruplets reduced to singletons and 10.7% in quadruplets reduced to twins. The proportion of liveborn infants overall was 91.1% of the total number expected to be liveborn in quadruplet pregnancies reduced to twins. This was statistically significantly different from 97.6% in non-reduced dichorionic twins (P = 0.004), and considerably higher than 58.3% in non-reduced quadruplets. The rates of preterm delivery < 28, < 32 and < 37 weeks were decreased in quadruplets reduced to twins compared with those in non-reduced quadruplet pregnancies. Quadruplets reduced to twins did not achieve equivalent pregnancy outcomes to those of DCDA twins. CONCLUSION This national study of QCQA quadruplets has shown that multifetal pregnancy reduction improves pregnancy outcome, including a decreased rate of preterm delivery and higher proportion of liveborn children. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M K Rasmussen
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S E Kristensen
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - C K Ekelund
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - P 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
| | - F S Jørgensen
- Department of Obstetrics and Gynecology, Fetal Medicine Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - E Hoseth
- Department of Obstetrics and Gynecology, Clinic of Ultrasound, Aalborg University Hospital, Aalborg, Denmark
| | - L Sperling
- Department of Obstetrics and Gynecology, Center for Ultrasound and Pregnancy, Odense University Hospital, Odense, Denmark
| | - H J Zingenberg
- Department of Gynecology and Obstetrics, Copenhagen University Hospital Herlev, Herlev, Denmark
| | - T D Hjortshøj
- Department of Clinical Genetics, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - K Gadsbøll
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - A Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - D Wright
- Institute of Health Research, University of Exeter, Exeter, UK
| | - A McLennan
- Sydney Ultrasound for Women, Chatswood, NSW, Australia
- Discipline of Obstetrics, Gynecology and Neonatology, The University of Sydney, Sydney, NSW, Australia
| | - K Sundberg
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - O B Petersen
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Luo L, Fan XZ, Jie HY, Gao Y, Chen M, Zhou C, Wang Q. Is it worth reducing twins to singletons after IVF-ET? A retrospective cohort study using propensity score matching. Acta Obstet Gynecol Scand 2019; 98:1274-1281. [PMID: 31081540 DOI: 10.1111/aogs.13640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 05/07/2019] [Accepted: 05/09/2019] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Many studies have shown that multifetal reduction of high-order multiple pregnancies results in improved pregnancy outcomes. However, whether conducting elective fetal reduction from dichorionic twins after in vitro fertilization (IVF) is worthwhile remains controversial. This study aimed to determine whether elective fetal reduction of dichorionic twins after IVF and embryo transfer (IVF-ET) is associated with increased take-home baby rate. MATERIAL AND METHODS This was a retrospective cohort study of 3600 dichorionic twin pregnancies after IVF-ET. The reduced group included 71 women with transvaginal elective fetal reduction between 7 and 8 weeks of gestation. The control group (n = 3529) comprised women who were managed expectantly. Propensity score matching was conducted before pregnancy outcomes were compared. RESULTS The take-home baby rate was significantly lower in the reduced group (83.1% vs 92.8%, P = 0.004). The total miscarriage rate was significantly higher in the reduced group (12.7% vs 6.2%, P = 0.04). Although preterm delivery rate was lower in the reduced group (P < 0.001), over 90% were over 32 weeks, whereas the proportions were equal in the reduced group. CONCLUSIONS In dichorionic twin pregnancies after IVF-ET, elective fetal reduction to singleton significantly decreased the chance of taking home live babies.
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Affiliation(s)
- Lu Luo
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Xiong-Zhi Fan
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Hui-Ying Jie
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Yong Gao
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Minghui Chen
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Canquan Zhou
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Qiong Wang
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
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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.
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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
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Hershko-Klement A, Lipitz S, Wiser A, Berkovitz A. Reduced versus nonreduced twin pregnancies: obstetric performance in a cohort of interventional conceptions. Fertil Steril 2013; 99:163-167. [DOI: 10.1016/j.fertnstert.2012.09.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2012] [Revised: 09/01/2012] [Accepted: 09/04/2012] [Indexed: 11/17/2022]
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Abstract
RATIONALE, AIMS AND OBJECTIVES Patient-centred care has been a central part of US and UK health policy for over a decade, but, despite its importance, the policy literature often fails to provide an adequate theoretical justification for why and how we should value it. This omission is problematic because it renders the status, content and appropriate evaluation of patient-centredness unclear. In this paper we aim to examine two different accounts of patient-centred care. METHOD We draw upon methods of conceptual and ethical analysis. RESULTS We argue that neither of the two accounts of patient-centred care identified appropriately grounds patient-centredness because neither of them takes into account the inherently moral nature of terms such as 'respect' and 'dignity', terms that are central to discussions of patient-centred care. CONCLUSIONS We suggest that clinical ethics can help to provide a theoretical justification for patient-centred care, and that clinical ethical practices can further patient-centred initiatives through ethics consultation, education and policy development and review.
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Affiliation(s)
- Leah M McClimans
- Warwick Medical School, The University of Warwick, Coventry, UK.
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Sarhan A, Beydoun H, Jones HW, Bocca S, Oehninger S, Stadtmauer L. Gonadotrophin ovulation induction and enhancement outcomes: analysis of more than 1400 cycles. Reprod Biomed Online 2011; 23:220-6. [PMID: 21665547 DOI: 10.1016/j.rbmo.2011.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 05/09/2011] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
Abstract
Ovulation induction (OI) or ovulation enhancement (OE) with gonadotrophins can be a reasonable treatment option for patients with a variety of infertility diagnoses. It must be used with extensive monitoring and management given the risk of multiple pregnancy,especially high-order multiples. This retrospective study evaluated per cycle outcomes of a large cohort of 1452 gonadotrophin OI/OE cycles at an academic infertility centre, and the efficacy of specific guidelines in limiting multiple pregnancy. The lowest possible gonadotrophin doses were used and cycle cancellation was recommended if more than three dominant follicles were present, and/or ifserum oestradiol was above 1500 pg/ml. Overall, pregnancy rate (PR) was 12% and live birth rate was 7.7%, with an increasing trend in younger patients (P = 0.0002 and <0.0001, respectively). Multiple clinical PR was 2.6% with 1.9% twins and 0.7% triplets and above.The birthweight of a singleton from a vanishing twin pregnancy (n = 8)was significantly lower than other singletons (2882 g versus 3250 g,P = 0.013). Reducing multiple pregnancies from OI/OE cycles remains an important and challenging goal. In this large cohort, high-order multiple clinical PR was limited to 0.7% per cycle by using specific management strategies while maintaining a reasonable PR.
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Affiliation(s)
- Abbaa Sarhan
- The Jones Institute for Reproductive Medicine, Department of Obstetrics and Gynecology, Eastern Virginia Medical School, 601 Colley Avenue, Norfolk, VA 23507, USA.
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Abstract
In this article, the authors review the standard management of several maternal and fetal complications of pregnancy and examine the effect these practices may have on the late preterm birth rate. Given the increasing rate of late preterm birth and the increased recognition of the morbidity and mortality associated with delivery between 34 and 37 weeks, standard obstetric practices and practice patterns leading to late preterm birth should be critically evaluated. The possibility of expectant management of some pregnancy complications in the late preterm period should be investigated. Furthermore, prospective research is warranted to investigate the role of antenatal corticosteroids beyond 34 weeks.
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Affiliation(s)
- Karin Fuchs
- Division of Maternal and Fetal Medicine, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA.
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Sentilhes L, Audibert F, Dommergues M, Descamps P, Frydman R, Mahieu-Caputo D. Réduction embryonnaire: indications, techniques, impact psychologique. Presse Med 2008; 37:295-306. [PMID: 17572051 DOI: 10.1016/j.lpm.2007.05.016] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Ombelet W, Camus M, de Catte L. Relative contribution of ovarian stimulation versus in vitro fertilization and intracytoplasmic sperm injection to multifetal pregnancies requiring reduction to twins. Fertil Steril 2007; 88:997-9. [PMID: 17681333 DOI: 10.1016/j.fertnstert.2006.12.036] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2006] [Revised: 12/20/2006] [Accepted: 12/20/2006] [Indexed: 11/25/2022]
Abstract
The proportion of twins resulting from multifetal pregnancy reduction of higher-order multiples is increased in pregnancies resulting from hormone stimulation when compared with twins following in vitro fertilization/intracytoplasmic sperm injection treatment. These reduced twin pregnancies may carry a higher perinatal risk compared with other twin pregnancies, which should be taken into account when assessing the perinatal outcome of twin pregnancies after assisted reproduction.
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Affiliation(s)
- Willem Ombelet
- Genk Institute for Fertility Technology, Department of Obstetrics and Gynaecology, Genk, Belgium.
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Cheang CU, Huang LS, Lee TH, Liu CH, Shih YT, Lee MS. A comparison of the outcomes between twin and reduced twin pregnancies produced through assisted reproduction. Fertil Steril 2007; 88:47-52. [PMID: 17270181 DOI: 10.1016/j.fertnstert.2006.11.084] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2006] [Revised: 11/01/2006] [Accepted: 11/16/2006] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To compare the outcome of twin pregnancies, derived from IVF cycles, with and without fetal reduction. DESIGN A retrospective cohort study. SETTING The IVF Division of the Lee Women's Hospital, Taiwan. PATIENT(S) Seven hundred forty-two twin pregnancies, including 389 nonreduced pregnancies, 353 of which resulted from fetal reduction. INTERVENTION(S) Selective fetal reduction for high-order multiple pregnancies. MAIN OUTCOME MEASURE(S) The rates of extreme prematurity and prematurity (i.e., less than 28 and 36 weeks gestational age, respectively), frequency of birth weight discordance, mean birth weight of twins, neonatal mortality, and morbidity. RESULT(S) The fetal reduction group was associated with a higher incidence of extreme prematurity, prematurity, and lower birth weight than the nonreduced group, although the impact was relatively small. These findings were more pronounced among patients with a higher initial number of fetuses. The rates of discordant birth weights between the two groups were not significantly different. CONCLUSION(S) High-order multiple pregnancies after fetal reduction is still associated with a mild increased risk of premature delivery and low birth weight when compared to nonreduced twin pregnancies. These results provide an additional reason to limit the number of embryos transferred during IVF.
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Affiliation(s)
- Chong-U Cheang
- Department of Obstetrics and Gynecology, Kiang Wu Hospital, Macau
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Shebl O, Ebner T, Sommergruber M, Sir A, Urdl W, Tews G. [Multiple pregnancies after ART: problems and possible solutions]. GYNAKOLOGISCH-GEBURTSHILFLICHE RUNDSCHAU 2007; 47:3-8. [PMID: 17272931 DOI: 10.1159/000098119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Multiple pregnancies following an assisted reproduction technique (ART) should be seen as a complication, and for that reason they should be avoided. In contrast to singleton pregnancies following ART, the multiple pregnancies are associated with a higher prenatal, neonatal and maternal risk; furthermore this results in a financial burden for the health care system. This paper gives an overview of the latest literature and different attempts of European countries, trying to reduce the multiple pregnancy rate. An efficient reduction is only possible by single-embryo transfers. There should be strict and cross-national regulation for the choice of women who should have a transfer of more than one embryo.
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Affiliation(s)
- O Shebl
- IVF-Unit Linz, Landesfrauen- und Kinderklinik Linz, Linz, Osterreich.
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Verberg MFG, Macklon NS, Heijnen EMEW, Fauser BCJM. ART: iatrogenic multiple pregnancy? Best Pract Res Clin Obstet Gynaecol 2007; 21:129-43. [PMID: 17074535 DOI: 10.1016/j.bpobgyn.2006.09.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Assisted reproductive technologies (ART) are now widely accepted as effective treatment for most causes of infertility. With improving success rates, attention has turned to the problem of multiple pregnancies, which are associated with a poor perinatal outcome, maternal complications and significant financial consequences. The challenge is to reduce multigestational pregnancies while maintaining good treatment outcomes. Methods to prevent multiple pregnancy include restrictive use of ART in couples with a good chance of spontaneous pregnancy, cautious use of gonadotrophins, and increased use of natural-cycle intra-uterine insemination and elective single embryo transfer in in-vitro fertilization and intracytoplasmic sperm injection. The aim of this article is to review the contribution of fertility treatment to multiple pregnancies and strategies for reducing multiples in ART.
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Affiliation(s)
- M F G Verberg
- Department of Reproductive Medicine and Gynaecology, University Medical Centre Utrecht, PO Box 85500, 3508 GA Utrecht, The Netherlands.
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Papageorghiou AT, Avgidou K, Bakoulas V, Sebire NJ, Nicolaides KH. Risks of miscarriage and early preterm birth in trichorionic triplet pregnancies with embryo reduction versus expectant management: new data and systematic review. Hum Reprod 2006; 21:1912-7. [PMID: 16613889 DOI: 10.1093/humrep/del048] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Triplet pregnancies are associated with a high risk of miscarriage and early preterm birth. It is uncertain if the outcome is improved by embryo reduction (ER). METHODS We examined trichorionic triplet pregnancies with three live fetuses at 10-14 weeks of gestation that were managed expectantly or by ER. The two groups were compared for the rates of miscarriage, defined as pregnancy loss before 24 weeks, and preterm delivery prior to 32 weeks. In addition, systematic searches were performed to identify studies comparing outcomes in expectant management versus ER in triplet pregnancies. RESULTS We combined data from 365 pregnancies managed in our centre with those of five previous studies. In total there were 893 pregnancies. In the ER group (n=482) compared to the expectantly managed group (n=411), the rate of miscarriage was higher [8.1 versus 4.4%; relative risk (RR)=1.83, 95% confidence interval (CI)=1.08-3.16, P=0.036] and the rate of early preterm delivery was lower (10.4 versus 26.7%, RR=0.37, 95% CI=0.27-0.51, P<0.0001). It was calculated that seven (95% CI=5-9) reductions needed to be performed to prevent one early preterm delivery, while the number of reductions that would cause one miscarriage was 26 (95% CI=14-193). CONCLUSIONS In trichorionic triplets, ER to twins is associated with an increase in the risk of subsequent miscarriage and decrease in risk of early preterm birth.
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Affiliation(s)
- A T Papageorghiou
- Harris Birthright Research Centre for Fetal Medicine, King's College Hospital Medical School, London, UK
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Blickstein I, Keith LG. The decreased rates of triplet births: temporal trends and biologic speculations. Am J Obstet Gynecol 2005; 193:327-31. [PMID: 16098851 DOI: 10.1016/j.ajog.2005.01.007] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2004] [Revised: 10/22/2004] [Accepted: 01/06/2005] [Indexed: 11/22/2022]
Abstract
Recent data from the US and from England and Wales demonstrate decreasing rates of higher-order multiple births and represent, for the first time, a striking change in trend when compared with the previous steep 4-fold increase since the early 1980s. However, the incidence of other multiples--twins--continued to escalate. The most probable reasons for this change are new embryo transfer guidelines and availability of multi-fetal pregnancy reduction procedures. Because actual numbers of higher-order multiples are by far lower than the number of twins, and because twins are predictably associated with significant perinatal morbidity and mortality, the implications of the ever-increasing multiple birth rates are no less alarming. As long as the incidence of twins is not reduced, the decreasing incidence of higher-order multiples, per se, does not herald the end of the epidemic of multiple births.
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Affiliation(s)
- Isaac Blickstein
- Department of Obstetrics and Gynecology, Kaplan Medical Center, Rehovot, Israel
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Current awareness in prenatal diagnosis. Prenat Diagn 2005. [DOI: 10.1002/pd.1016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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