Spontaneous reduction before 12 weeks' gestation and selective reduction similarly extend time to delivery in in vitro fertilization of trichorionic-triamniotic triplets

Trans-abdominal fetal reduction in higher order multiple pregnancies: a pioneer cohort retrospective study in Nepal

Objective

To share the initial experience of trans-abdominal multifetal pregnancy reduction (MFPR) in Nepal.

Method

The procedure was performed in 108 patients in a private hospital over a period of 3 years. Under ultrasound guidance, intracardiac injection of 0.2-3.0 ml of 15% w/v (2 mEq/ml) potassium chloride (KCl) was administered via trans-abdominal route.

Results

A total of 108 fetal reduction procedures were carried out at the seventh to fifteenth weeks of gestation, a maximum of 44 (40.7%) of which were done at the ninth to tenth weeks of gestation. A total of 123 fetuses were reduced. Out of total 108 multifetal pregnancies, 96 (88.8%) were due to in-vitro fertilization (IVF). Eighty-five pregnancies (78.7%) underwent reduction from triplet to twin. The second-time reduction was needed in five cases. Two attempts (in the same sitting) were required in three cases. The inadvertent demise of the second fetus was noted in three cases of dichorionic tri-amniotic triplet pregnancy.

Conclusion

Ultrasound-guided trans-abdominal fetal reduction performed between the seventh and twelfth weeks of gestation is safe and effective.

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.

Short-term and long-term outcomes of trichorionic triplet pregnancies with expectant management

INTRODUCTION

Reproductive endocrinologists recommend selective multifetal pregnancy reduction (MFPR) to save at least one or two babies, because triplet pregnancy is known to increase the risk of miscarriage and preterm delivery. However, recently improved obstetric and neonatal care may affect pregnancy outcomes differently in triplet pregnancies, which could alter practice. We compared the maternal, perinatal, and long-term outcomes of triplet pregnancies managed expectantly with those of pregnancies reduced to twins.

MATERIAL AND METHODS

In this retrospective cohort study, we reviewed the clinical records of 552 trichorionic triplet pregnancies for obstetric, perinatal, and neurodevelopmental outcomes, which consisted of the expectant management (EM) group (n = 225) and MFPR group (n = 327), in Seoul National University Hospital and CHA Bundang Medical Center from January 2006 to December 2018. Neuromotor development was evaluated using the Korean-Ages and Stages Questionnaire, Bayley-III tests, and/or Gross Motor Function Measure. The two groups were compared for the following outcomes: (1) nonviable pregnancy loss before 23 weeks, (2) preterm birth before 32 weeks of gestation, (3) fetal and neonatal survival and (4) long-term neurodevelopmental outcomes.

RESULTS

There were no differences in maternal age, body mass index, nulliparity or previous preterm birth between the two groups. The risk of nonviable pregnancy loss was lower in the EM group than that in the MFPR group (2 [0.9%] vs 21 [6.4%], p = 0.001). The risk of preterm delivery before 34 weeks of gestation was lower in the MFPR group (adjusted odds ratios [aOR] = 0.47, 95% confidence interval [CI] 0.30-0.73, p = 0.001). The survival rate of neonates until discharge (644 [95.4%] vs 572 [87.5], p < 0.001) and the rate of pregnancies with at least one survivor (220 [97.8%] vs 301 [92.0], p = 0.002) were higher in the EM group than those in the MFPR group. In the MFPR group, the risk of developmental delay (aOR = 2.89, 95% CI 1.38-6.02, p = 0.005) was higher.

CONCLUSIONS

In trichorionic triplet pregnancies, the possibility of EM to improve survival and reduce the risk of developmental delay has been shown.

Maternal, Fetal, and Neonatal Outcomes of Elective Fetal Reduction Among Multiple Gestation Pregnancies: A Systematic Review

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.

Report of the first live birth after uterus transplantation in People's Republic of China

OBJECTIVE

To present the first live birth after uterine transplantation (UTx) in the People's Republic of China.

DESIGN

Case study.

SETTING

University hospital.

PATIENT(S)

A 22-year-old woman with Mayer-Rokitansky-Kuster-Hauser syndrome and previous surgery for vaginal reconstruction and UTx.

INTERVENTION(S)

Endometrial preparation, frozen embryo transfer, pregnancy follow-up, and cesarean section.

MAIN OUTCOME MEASURE(S)

Results of in vitro fertilization, frozen embryo transfer, ultrasound measurements during pregnancy, rejection diagnosis and treatment, delivery, live birth, and histology of uterus.

RESULTS(S)

Frozen embryo (cleavage stage) transfer started 1.5 years after UTx. The first embryo transfer (n = 2) resulted in a biochemical pregnancy. The second, third, and fourth embryo transfer (n = 2, 2, 3) did not result in pregnancy. The fifth embryo transfer (n = 3) resulted in pregnancy with two gestational sacs, but with spontaneous disappearance of one in early pregnancy. During early pregnancy three episodes of vaginal bleedings occurred (gestational weeks 6 + 2, 13 + 1, and 16 + 3), with a spontaneously resorbing subchorionic hematoma diagnosed at the last bleeding episode. Bleeding episodes were treated with corticosteroids and tacrolimus. During pregnancy, blood flow velocity waveforms and fetal growth parameters were normal. A subacute cesarean section was performed at gestational week 33 + 6 due to uterine contraction pattern suggesting imminent labor. A healthy boy (2,000 g) with Apgar scores of 10, 10, 10 was delivered. The uterus was kept for a possible second pregnancy.

CONCLUSION(S)

The first live birth after UTx in the People's Republic of China is reported and this occurred after a robotic-assisted laparoscopic uterus retrieval from the mother.

Risks of miscarriage or preterm delivery in trichorionic and dichorionic triplet pregnancies with embryo reduction versus expectant management: a systematic review and meta-analysis

STUDY QUESTION

Is pregnancy outcome in triplet pregnancies improved with embryo reduction (ER) to twins compared to expectant management?

SUMMARY ANSWER

In trichorionic triplet pregnancies, ER to twins reduces the risk of preterm birth (<34 weeks) without significantly increasing the risk of miscarriage (<24 weeks), whereas in dichorionic triplet pregnancies, the results are inconclusive.

WHAT IS KNOWN ALREADY

Triplet pregnancies are associated with a high risk of miscarriage and preterm birth. ER can ameliorate these conditions in higher order multiple gestations but is still controversial in triplets.

STUDY DESIGN, SIZE, DURATION

This study aimed to conduct a systematic review, following the PRISMA guidelines, and critically appraise ER at 8-14 weeks of gestation in both trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) pregnancies. Selective ER to twins was compared with expectant management, focusing on the risks of miscarriage and preterm birth. The computerized database search was performed on 8 January 2017. Overall, from 25 citations of relevance, eight studies with a total of 249 DCTA and 1167 TCTA pregnancies fulfilled the inclusion criteria.

PARTICIPANTS/MATERIALS, SETTING, METHODS

A comprehensive computerized systematic literature search of all English language studies between 2000 and 2016 was performed in PubMed, EMBASE, Scopus, Evidence Based Medicine Reviews (Cochrane Database and Cochrane Central Register of Controlled Trials) and Google Scholar. Relevant article reference lists were hand searched. The management options were compared for rates of miscarriage <24 weeks and preterm birth <34 weeks. Only studies with both expectant management and ER to twins were included in the analysis. The quality of each individual article was critically appraised and appropriate statistical methods were used to extract results.

MAIN RESULTS AND THE ROLE OF CHANCE

In TCTA pregnancies managed expectantly (n = 501), the rates of miscarriage and preterm birth were 7.4 and 50.2%, respectively. Meta-analysis demonstrated that ER to twins in TCTA pregnancies (n = 666) was associated with a lower risk (17.3 versus 50.2%) of preterm birth (RR = 0.36, 95% CI: 0.28-0.48), whereas the risk of miscarriage (8.1% versus 7.4%) did not significantly increase (RR = 1.08, 95% CI: 0.58-1.98). In DCTA triplets managed expectantly (n = 200), the rates of miscarriage and preterm birth were 8.5 and 51.9%, respectively. Although the meta-analysis was inconclusive, it suggested that ER to twins in DCTA triplets, either of the foetus with a separate placenta (n = 15) or one of the monochorionic pair (n = 34), was neither significantly associated with an increased risk of miscarriage (8.5 versus 13.3%, P = 0.628 and RR = 1.22, 95% CI: 0.38-3.95, respectively) nor with a lower risk of preterm birth (51.9 versus 46.2%, P = 0.778 and RR = 0.5, 95% CI: 0.04-5.7, respectively).

LIMITATIONS, REASONS FOR CAUTION

No randomized controlled trials of ER versus expectant management in TCTA or DCTA pregnancies were identified from our literature search. We were able to include only a handful of papers with small sample sizes and suffering from bias, and non-English publications were missed. Irrespective of the strict inclusion and exclusion criteria, publication bias was evident.

WIDER IMPLICATIONS OF THE FINDINGS

The greatest strength of our systematic review is that, contrary to the existing literature, it only included studies with both the intervention and expectant arm. Our results are in agreement with current literature. In TCTA pregnancies, ER to twins is associated with a lower risk of preterm birth but is not associated with a higher risk of miscarriage. In the absence of a randomized trial, the data from systematic reviews appear to be the best existing evidence for counselling in the first trimester on the different options available. Finally, in DCTA pregnancies, indications exist that ER (of one of the MC pair) to twins could possibly reduce the risk of preterm birth without increasing the risk of miscarriage.

STUDY FUNDING/COMPETING INTEREST(S)

None to declare.

REGISTRATION NUMBER

N/A.

Outcomes of Multifetal Reduction: A Hospital-Based Study

Background

Higher-order multiple (HOM) pregnancies are associated with increased incidences of pregnancy complications mainly abortions, pre-eclampsia, preterm delivery and fetal death. Multifetal reduction (MFR) during first trimester and subsequent delivery of twins can reduce pregnancy associated morbidities. This study was conducted to evaluate the maternal and fetal outcomes of MFR procedure in patients with HOMs those managed in a tertiary care hospital.

Methods and Material

It was a prospective observational study carried out in a tertiary care military hospital, India, and all women with higher-order multiples (triplets or more) conceived spontaneously or after infertility treatment (ovulation induction, intra-uterine insemination, or in vitro fertilization) during the 3-year period from Jan 2014 to Dec 2016 were included for MFR. Demographic and clinical data, and obstetric and neonatal outcomes were tabulated.

Results

The study included 32 HOM pregnancies which underwent MFR. 16% patients had pre-eclampsia and 12% patients had gestational diabetes. The study had 2 pregnancy losses before 24 weeks period of gestation (POG). 70% patients underwent cesarean delivery with mean gestational age of 35.5 weeks. Average birth weight of newborn was 1820 gm and 80% of them required NICU admission.

Conclusion

Favorable pregnancy outcomes can be achieved after multifetal reductions during first trimester in higher-order multiples, but the procedure is not totally safe.

Multifetal pregnancy reduction of triplets to twins compared with non-reduced triplets: a meta-analysis

The current systematic review and meta-analysis evaluate the perinatal outcomes in twin pregnancies following multifetal pregnancy reduction (MPR) compared with non-reduced triplet pregnancies. All studies comparing perinatal outcome of twin pregnancies following MPR to non-reduced triplet pregnancies were considered. MEDLINE, non-indexed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science were searched for relevant published articles up to August 2016. The search yielded 653 publications of which 92 were assessed for eligibility. A total of 24 studies met the inclusion criteria. Overall, the outcomes of pregnancies following MPR were better compared with expectantly managed triplets. The MPR group delivered at a later gestational age and was less likely to be delivered before 32 or 28 weeks' gestation. Newborns in the MPR group had significantly higher birthweight at delivery (mean difference 500 g [95% CI 439.95, 560.04]). Rates of pregnancy loss before 24 weeks' gestation and overall infant survival were comparable between the groups. This meta-analysis suggests that MPR of triplet pregnancies to twins is associated with improved perinatal outcome compared with non-reduced triplets. Should primary prevention of high order multiple pregnancy fail, MPR is an appropriate alternative to minimize the perinatal morbidity and mortality of triplet pregnancies.

Perinatal outcome after fetal reduction from twin to singleton: to reduce or not to reduce?

OBJECTIVE

To determine whether reduction of twin gestation to singleton pregnancy is associated with improved perinatal outcome.

DESIGN

A retrospective cohort study.

SETTING

Single tertiary care medical center.

PATIENT(S)

A cohort of 63 singleton pregnancies after reduction from dichorionic-diamniotic twins gestation and 62 dichorionic-diamniotic nonreduced twins.

INTERVENTION(S)

Fetal reduction between 11 and 14 weeks of gestation.

MAIN OUTCOME MEASURE(S)

Obstetric outcome.

RESULT(S)

The rates of preterm delivery at <34 weeks (1.6% in pregnancies after reduction vs. 11.7% in nonreduced twins) and at <37 weeks of gestation (9.5% vs. 56.7%) were significantly lower in patients whose pregnancies were reduced to singletons. The rates of miscarriage of one twin (0% vs. 4.8%) and early pregnancy loss before 24 weeks of gestation as well as the rates of gestational diabetes (11.1% vs. 10%), hypertensive diseases of pregnancy (6.3% vs. 15%), and intrauterine growth restriction (0% vs. 3.3%) were similar in both groups.

CONCLUSION(S)

Fetal reduction of twins to singleton is associated with a lower risk of prematurity and superior perinatal outcome compared with nonreduced twins. Therefore, the option of fetal reduction should be considered in certain cases of twin pregnancies, where the risk for adverse outcome seems exceptionally high.

Paternity balancing

BACKGROUND

Gestational carriers and egg donors have been used by 'traditional' and now increasingly, gay couples. Three gay male couples, all using egg donors and gestational carriers with semen from both partners, had triplets. All desired reductions to twins for the standard medical indications, but requested, if reasonably possible, to have twins with one fathered by each partner.

METHODS

Following our usual clinical protocol, we performed chorionic villus sampling at 12 weeks on all fetuses obtaining FISH and karyotype. For paternity analysis, 14 polymorphic molecular markers on villi were compared to DNA samples from the two men to include or exclude each.

RESULTS

Standard assessments were all normal. Paternity testing showed that one partner fathered two of the triplets, and the other one. In all cases, one of the 'twins' was reduced with good clinical outcomes ensuing.

CONCLUSIONS

Paternity balancing increases options for satisfying family planning desires of gay male couples. We believe it comparable to gender preferences in reductions, i.e. it can be considered but only completely subservient to any clinical criteria. Paternity balancing raises similar ethical issues as reduction with gender preferences, but may increase patient autonomy and mainstream acceptance of stable, gay families.

Obstetric outcomes of IVF trichorionic triamniotic triplets which are spontaneously or electively reduced to twins

PURPOSE

To assess the obstetric outcome of IVF triplets which are spontaneously or electively reduced to twins.

METHODS

Retrospective study of trichorionic triplets (TT) and dichorionic twins (DT) conceived with IVF.

RESULTS

Compared to TT without reduction, TT with spontaneous reduction (SR) (OR: 5.6, 95% CI: 1.6-19.9) or elective reduction (ER) (OR: 14.0, 95% CI: 3.92-50.02) to twins were significantly more likely to be delivered at ≥34 weeks. Compared to DT likelihood of delivery ≥34 weeks was similar for SR and ER. Compared to TT without reduction, the risk of pregnancy loss before 24 weeks was not increased with SR or ER. Compared to DT the risk of pregnancy loss before 24 weeks was not significantly increased for SR or ER.

CONCLUSION

Obstetric outcome of IVF triplets with SR is better than ongoing triplets and is similar to that of ER of TT and DT.