The outcome of the multifetal pregnancy reduction procedures in a single centre: A report of 202 completed cases

Multifetal pregnancy reductions and selective fetocide in a tertiary referral center - a retrospective cohort study

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.

Birth outcomes of twins after multifetal pregnancy reduction compared with primary twins

BACKGROUND

The introduction of assisted reproductive technology and the trend of increasing maternal age at conception have contributed to a significant rise in the incidence of multiple pregnancies. Multiple pregnancies bear several inherent risks for both mother and child. These risks increase with plurality and type of chorionicity. Multifetal pregnancy reduction is the selective abortion of ≥1 fetuses to improve the outcome of the remaining fetus(es) by decreasing the risk of premature birth and other complications.

OBJECTIVE

This study aimed to compare birth outcomes of trichorionic triplets reduced to twins with those of trichorionic triplets and primary dichorionic twins. The added value of this study is the comparison with an additional control group, namely primary dichorionic twins.

STUDY DESIGN

This was a retrospective cohort study. Data from January 1990 to November 2016 were collected from the East Flanders Prospective Twin Survey, one of the largest European multiple birth registries. A total of 85 trichorionic triplet pregnancies (170 neonates) undergoing multifetal pregnancy reduction to twins were compared with 5093 primary dichorionic twin pregnancies (10,186 neonates) and 104 expectantly managed trichorionic triplet pregnancies (309 neonates). The assessed outcomes were gestational age at delivery, birthweight, and small for gestational age.

RESULTS

Pregnancy reduction from triplets to twins was associated with higher birthweight (+365.44 g; 95% confidence interval, 222.75-508.14 g; P<.0001) and higher gestational age (1.7 weeks; 95% confidence interval, 0.93-2.46; P<.0001) compared with ongoing trichorionic triplets after adjustment for sex, parity, method of conception, birth year, and maternal age. A trend toward lower risk of small for gestational age was observed. Reduced triplets had, on average, lower birthweight (-263.12 g; 95% confidence interval, -371.80 to -154.44 g; P<.0001) and lower gestational age (-1.13 weeks; 95% confidence interval, -1.70 to -0.56; P=.0001) compared with primary twins. No statistically significant difference was observed between primary twins and reduced triplets that reached 32 weeks of gestation.

CONCLUSION

Multifetal pregnancy reduction from trichorionic triplets to twins significantly improved birth outcomes. This suggests that multifetal pregnancy reduction of trichorionic triplets to twins is medically justifiable. However, the birth outcomes of primary twins before 32 weeks of gestation are still better than those of reduced triplets. The process of multifetal pregnancy reduction includes at least 1 fetal death by definition, and thus prevention of higher-order pregnancies is preferable.

Triple trouble: uncovering the risks and benefits of early fetal reduction in trichorionic triplets in a large national Danish cohort study

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.

Sexing of Embryos at the Time of Twin Reduction: A Clinical Approach

This study provides new unique information on bovine twin pairs during the late embryonic period (28-34 days of pregnancy) in relation to (1) a predictive ultrasound measurement that was differential for sexing heterosexual twins; (2) intrauterine embryonic growth patterns in twin pairs; and (3) a higher vulnerability of female embryos compared to males following an induced embryo reduction in heterosexual twins. The study population comprised 92 dairy cows carrying bilateral twins. A length difference between co-twins equal to or greater than 25% in around 50% of pregnancies served to determine the sex of embryos with 100% accuracy in heterosexual twins, which was assessed four weeks later on the remaining fetus after twin reduction. The apparent rates of growth of twin pairs and of individual male and female embryos from day 28 to 34 of gestation were similar to established growth pattern standards for singletons. Mean embryo sizes in relation to gestational age were smaller by some 5 days' growth equivalent in twins compared to singletons. After the reduction in the female embryo in heterosexual twins, the risk of male embryo loss was null. This new information allowed for sex selection at the time of twin reduction.

Expectant management of triplets or multifetal reduction to twins; comparison of preterm delivery and live birth rates

OBJECTIVE

The management of multiple pregnancies is still a challenge. The aim of this study was to compare the outcome of triplet pregnancies managed expectantly or by multifetal pregnancy reduction to twins.

STUDY DESIGN

For this retrospective, comparative and monocentric study, the medical files of all women with triplets who admitted to our institution over a 13-year period were examined. Women requesting multifetal pregnancy reduction to have twins formed the study group, and women with triplets who wished to continue their pregnancies formed the control group. Main outcome measures were durations of pregnancies presented as number of weeks gestation, abortion rates, term and preterm birth rates, fetal loss and live birth rates.

RESULTS

During the study period, 171 women with triplets admitted to our institution. One hundred fifty one patients are included in this study. Forty-five women carrying triplets wished to continue their pregnancies and 106 women requested multifetal pregnancy reduction to have twins. Fetal reduction of triplets to twins was associated with a significantly lower incidence of birth before 34th gestational week and higher incidence of late preterm and term birth rates without changing live birth rates.

CONCLUSION

Multifetal pregnancy reduction of triplet pregnancies to twins resulted in a later gestational age at birth compared with the triplet gestations managed expectantly.

Twins in Dairy Herds. Is It Better to Maintain or Reduce a Pregnancy?

Simple Summary

In dairy herds, twin or other multiple pregnancies are not desirable as they compromise the health and productive lifespan of the cows. The mean productive lifespan of primiparous and secundiparous dairy cows delivering twins is about 300 and 200 days shorter, respectively, than that of cows delivering singletons. In addition, the long-term negative effects of twinning are not limited to the early lactation but continue for a period of up to 800 days after calving. Herd management options after diagnosing a twin pregnancy are discussed from an animal health and economic perspective.

Abstract

Multiple ovulations and so multiple pregnancies have increased recently in dairy cattle. The incidence of the double ovulation impact in high producers at insemination may be over 20%. Twin pregnancies are undesirable as they seriously compromise the welfare and productive lifespan of the cow and herd economy. Clinical problems extend from the time of pregnancy diagnosis to pregnancy loss, abortion or parturition. Early pregnancy loss or abortion of multiple pregnancies lead in most cases to culling. In cows reaching their term, mean productive lifespan is up to about 300 days shorter for cows delivering twins than for cows delivering singletons. While there is an urgent need to address multiple pregnancy prevention procedures in the foreseeable future, the incidence of twin pregnancies continues to rise in parallel with increased milk production. Herein, we review two contrasting measures proposed for the time of twin pregnancy diagnosis: (1) gonadotropin-releasing hormone treatment for pregnancy maintenance, or (2) embryo reduction. These options are discussed in terms of their implications for individual animal health and herd economy. Our main conclusions find that manual twin reduction has proven to be the best management option, whereas the use of prostaglandin F_2α for inducing abortion may be a better option than doing nothing.

Safety and Efficacy of Higher Order Multifetal Pregnancy Reduction: A Single-Center Retrospective Study

Objective  This research was aimed to study the safety and efficacy of higher order multifetal pregnancy reduction (MFPR). Study Design  This was a retrospective study of patients from an academic maternity center between 2005 and 2015. We evaluated outcomes of 131 consecutive patients who underwent higher order MFPR (quadruplets and greater). MFPR was performed at 11 to 18 weeks of gestation in all cases. In total, 122 of 131 cases of higher order multiple pregnancy were reduced to twins. We discuss the perinatal outcomes of patients who underwent higher order MFPR, followed by a comparative analysis between the 122 cases of MFPR that were reduced to twins and 101 cases of nonreduced twin pregnancies. Results  The study included 104 sets of quadruplets, 20 sets of quintuplets, 5 sets of sextuplets, 1 set of septuplets, and 1 set of octuplets. The perinatal outcomes of the 131 cases were as follows: pregnancy loss, preterm deliveries at 28 to 33 (+ 6/7 ) weeks, and preterm deliveries at 34 to 36 (+ 6/7 ) weeks occurred in 23.66, 9, and 37% of cases, respectively. The mean time of delivery was 36.56 ± 1.77 weeks, and mean birth weight was 2,409.90 ± 458.16 g, respectively. A total of 122 cases that were reduced to twins were compared with nonreduced twins. The pregnancy loss rate for reduced twins was significantly higher than that for nonreduced twins. The preterm labor rate, mean delivery week, mean birth weight, birth-weight discordance, incidence of gestational diabetes mellitus, and pregnancy-induced hypertension were not significantly different between the groups ( p  > 0.05). Conclusion  Perinatal outcomes were significantly improved by reducing the number of fetuses in higher order multifetal pregnancies. This study involved a large, diverse sample population, and the results can be used as a reference while conducting prenatal counseling.