Comparisons between two methods of multifetal pregnancy reduction in women with a dichorionic triamniotic triplet pregnancy

Dichorionic triamniotic triplets after two blastocysts transfer underwent multifetal pregnancy reduction: two case reports and literature review

BACKGROUND

The increase in the rate of multiple pregnancies in clinical practice is associated with assisted reproductive technology (ART). Given the high risk of dichorionic triamniotic (DCTA) triplet pregnancies, reducing DCTA triplet pregnancies to twin or singleton pregnancies is often beneficial.

CASE PRESENTATION

This article reports on two cases of DCTA triplet pregnancies resulting from two blastocyst transfers. Given the high risk of complications such as twin-to-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twin pregnancies, patients have a strong desire to preserve the dichorionic diamniotic (DCDA) twins. Multifetal pregnancy reduction (MFPR) was performed in both cases to continue the pregnancy with DCDA twins by reducing one of the MCDA twins. Both of the pregnant women in this report eventually gave birth to healthy twins at 37 weeks.

CONCLUSIONS

For infertile couples with multiple pregnancies but with a strong desire to remain the DCDA twins, our report suggests that reducing DCTA triplets to DCDA twin pregnancies may be an option based on clinical operability and assessment of surgical difficulty.

Fetal Reduction by Potassium Chloride Infusion in Unruptured Heterotopic Pregnancy: A Comprehensive Review

This comprehensive review explores the practice of fetal reduction through potassium chloride infusion in unruptured heterotopic pregnancies. Heterotopic pregnancies, characterized by the simultaneous occurrence of intrauterine and extrauterine gestations, present unique challenges in reproductive medicine. The review defines fetal reduction and underscores its significance in mitigating risks associated with heterotopic pregnancies, including the threat of rupture, maternal morbidity, and adverse outcomes. The analysis encompasses the background, methods, efficacy, ethical considerations, and future directions related to the procedure. Findings highlight the efficacy and safety of potassium chloride infusion, emphasizing the importance of proper patient selection and counseling. Implications for clinical practice underscore the procedure's viability in specific cases where the benefits outweigh the associated risks. The review concludes with recommendations for future studies, encouraging further research on procedural techniques, alternative methods, and the psychosocial impact on patients. This work is a foundation for advancing the management of unruptured heterotopic pregnancies, providing insights for clinicians and researchers to improve clinical outcomes and patient care.

Intertwin nuchal translucency difference predicts the chance of co-twin death after fetal reduction in dichorionic triplet pregnancies: a retrospective analysis study

OBJECTIVES

To compare the clinical outcomes of different multifetal pregnancy reduction (MFPR) programs in dichorionic (DC) triplets, and explore the association between early ultrasound characteristics and co-twin death after potassium chloride (KCl) injection into one monochorionic (MC) twin.

METHODS

We retrospectively reviewed the data of DC triplets who underwent MFPR at our center during 2012-2021. Patients were grouped as follows: intracardiac KCl injection into one MC twin (group A), intracardiac KCl injection into both MC twins simultaneously (group B), and reduction of the singleton fetus (group C) and pregnancy outcomes were compared. Logistic regression was used to determine whether ultrasound measurements at 11-13+6 weeks predicted co-twin death and the receiver operator characteristic (ROC) analysis was conducted to assess the predictive performance.

RESULTS

Finally, we enrolled 184 patients. 153 cases were in group A, and 18, 13 cases were in group B and C respectively. Gestational age at the time of MFPR did not differ among the 3 groups (median: [Formula: see text] weeks). The survival rate was 89.6%, 88.9%, and 92.3% in group A, B, and C respectively, which was comparable among groups. Preterm birth was more common in group C (10/12, 83.3%). After KCl injection into one MC twin, co-twin death occurred in 86.3% cases (132/153) within 1 day; however, 3 patients had 2 live births each, with normal postnatal development. Intertwin nuchal translucency (NT) difference/discordance significantly predicted co-twin death within 1 day after MFPR, and the areas under the ROC curve were 0.694 and 0.689, respectively.

CONCLUSIONS

For MFPR in DC triplet pregnancies, reduction of the MC twins results in less preterm birth, and women with KCl injection into either one or both MC twins had similar outcomes. Large intertwin NT difference/discordance was associated with co-twin death within 1 day after KCl injection into one of the MC twins.

Pregnancy and birth outcomes of multiple gestations with PPROM occurred within 24 h after fetal reduction: A case series

OBJECTIVE

The study aims to analyze the pregnancy outcomes of multiple gestations with preterm premature rupture of membranes (PPROM) that occurred within 24 h after fetal reduction with potassium chloride (KCL).

MATERIALS AND METHODS

We identified and evaluated the outcomes of 16 retrospectively recorded multigestational pregnancies that met the inclusion criteria between 2006 and 2016, from the Obstetrics Department of Shandong Provincial Hospital. A total of 16 patients carrying twins or higher order multiple gestations experienced PPROM within 24 h after fetal reduction, and all of them received expectant management after understanding the relevant risks. The maternal and neonatal records were retrospectively collected and reviewed. Every surviving child was followed up to at least 2 years old.

RESULT

Of the 16 cases, 12 cases (75%) ended in successful pregnancy, resulting in the delivery of at least 1 child surviving from a multiple gestational pregnancy. All cases of successful pregnancies were either term (≥37 weeks) or near-term (36⁺⁵ weeks) at delivery. And of those 20 infants delivered, only 3 were low birth weight infants (<2500g) (15%), None of the 16 women had fever, or other clinical symptoms and signs of chorioamnionitis during hospital stay. Postnatal follow-up of the surviving babies showed no obvious sequelae thus far. No newborn baby had neonatal complications, or needed to be transferred to neonatal intensive care unit.

CONCLUSION

Overall, our data demonstrate that dichorionic diamniotic (DCDA) twins or higher-order gestations who experienced PPROM of the reduced fetus within 24 h after selective reduction with KCL had relatively good outcomes with expectant management alone.

Conjoined twins in a spontaneous monochorionic triplet pregnancy: A case report and literature review

RATIONALE

Conjoined twins are a rare complication of monochorionic pregnancies and an extremely rare condition in spontaneous triplet pregnancies. We report a case of conjoined twins in a spontaneous monochorionic triplet pregnancy. The conjoined twins might have suffered from twin anemia-polycythemia sequence, which was reported to be extremely rare.

PATIENT CONCERNS

A 26-year-old woman conceived spontaneously with an obstetric history of invasive mole 4 years ago.

DIAGNOSES

We initially misdiagnosed her as having monochorionic triamniotic triplets at 10 weeks of gestation. However, we confirmed conjoint twins with the monochorionic diamniotic triplet pregnancy at 12 weeks of gestation and classified them as omphalopagus.

INTERVENTIONS

As the woman decided to continue the pregnancy, regular and careful antenatal care was conducted.

OUTCOMES

Unexpectedly, she had a stillbirth 3 weeks later and had to terminate the pregnancy at 15 weeks of gestation. After abortion, the diagnosis of omphalopagus was confirmed in the induced fetuses. Moreover, the skin colors of the conjoined twins were different: one was plethoric, and the other was pale. Additionally, the parents agreed to examine the chromosome of the fetuses, and the results were normal.

CONCLUSION

Dichorionic triplet and monochorionic triplet pregnancies have a poorer prognosis than trichorionic triplet pregnancies. Surgery is the main therapy for conjoined twins; however, most conjoined twins in triplet pregnancies cannot survive, including omphalopagus twins. The conjoined twins may have suffered from twin anemia-polycythemia sequence, which could probably not be diagnosed intrauterine. Transvaginal probe and 3-dimensional ultrasound may be helpful for clarifying the diagnosis in early pregnancy.