Risks of miscarriage and early preterm birth in trichorionic triplet pregnancies with embryo reduction versus expectant management: new data and systematic review

Pregnancy outcomes of foetal reduction from twin to singleton gestation compared to ongoing twin gestations: a systematic review and meta-analysis

BACKGROUND

Foetal reduction, which involves selectively terminating one or more foetuses in a multiple gestation pregnancy, has become more common. This systematic review and meta-analysis aims to assess and compare pregnancy outcomes of foetal reduction from twin to singleton gestation to ongoing twin gestations.

METHODS

A comprehensive search of electronic databases (MEDLINE, EMbase, Cochrane Library, CINAHL and PsycINFO) was done for studies published until 15 April 2023. The outcomes analysed included gestational diabetes mellitus (DM), hypertension, caesarean delivery, foetal loss, perinatal death, preterm birth (PTB), intrauterine growth restriction (IUGR), preterm prelabour rupture of membranes (PPROM) and birth weight.

RESULTS

A total of 13 studies comprising 1241 cases of twin to singleton foetal reduction gestation were compared to 20,693 ongoing twin gestations. Our findings indicate that foetal reduction was associated with a significantly lower risk of developing maternal gestational DM (odds ratio [OR] = 0.40, 95% confidence interval [CI] 0.27-0.59) and hypertension (OR = 0.36, 95% CI 0.23-0.57) compared to the control group. Incidence rate of caesarean delivery (OR = 0.65, 95% CI 0.53-0.81) after foetal reduction was significantly lower compared to ongoing twin gestations. There was a 63% lower chance of PTB before 37 weeks of pregnancy. However, there was no significant association between foetal reduction and outcomes such as foetal loss, perinatal death, IUGR and PPROM.

CONCLUSIONS

Our findings suggest that foetal twin to singleton reduction entails potential benefits as compared to ongoing twin gestations. Further well planned studies are needed to explore underlying mechanisms to understanding of the outcomes associated with foetal reduction procedures and inform clinical decision-making for pregnant individuals and healthcare providers alike.

Selective fetal reduction of uncomplicated dichorionic twins on parental request vs ongoing twins and pregnancy outcomes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to assess the effect of elective fetal reduction on maternal-fetal outcomes in uncomplicated twin pregnancies compared with ongoing twin pregnancies.

DATA SOURCES

The data sources included PubMed, Scopus (until December 2023), and references of retrieved articles.

STUDY ELIGIBILITY CRITERIA

We included clinical studies examining the association between selective fetal reduction of uncomplicated dichorionic twins on pregnancy outcomes.

METHODS

Quality assessment of observational studies was conducted using the ROBINS-I tool. The overall quality of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. A quantitative analysis was performed for electively reduced dichorionic twins. The primary outcome was preterm birth. The secondary outcomes were gestational age at delivery, stillbirth, neonatal intensive care unit admission, gestational diabetes mellitus, preeclampsia, and pregnancy loss at <24 weeks of gestation. Summary odds ratios with 95% confidence intervals were calculated, and random-effects models were used for data synthesis.

RESULTS

The initial electronic search yielded 745 studies; 175 studies were further identified from reference citations. Five articles included appropriate data and were finally included in the meta-analysis. All studies were evaluated as having "moderate risk of bias." These 5 studies reported on dichorionic twins. Elective reduction in dichorionic twins reduces the risk for preterm birth at <37 weeks (4 studies; n=1577; odds ratio, 0.14; 95% confidence interval, 0.09-0.22; moderate-quality evidence), <34 weeks (3 studies; n=1335; odds ratio, 0.22; 95% confidence interval, 0.07-0.69; low-quality evidence), and <32 weeks (3 studies; n=1335; odds ratio, 0.31; 95% confidence interval, 0.11-0.88; low-quality evidence), gestational diabetes (3 studies; n=1410; odds ratio, 0.57; 95% confidence interval, 0.33-0.97; low-quality evidence), pregnancy-associated hypertensive disorders (2 studies; n=581; odds ratio, 0.29; 95% confidence interval, 0.10-0.83; low-quality evidence), and birthweight <10th centile (2 studies; n=1163; odds ratio, 0.27; 95% confidence interval, 0.17-0.43; moderate-quality evidence) and <5th centile (2 studies; n=1163; odds ratio, 0.31; 95% confidence interval, 0.19-0.50; low-quality evidence), and increases gestational age at delivery (4 studies; n=1362; mean difference, 2.93 weeks; 95% confidence interval, 2.08-3.77; moderate-quality evidence). The risks for stillbirth (2 studies; n=1311; odds ratio, 1.63; 95% confidence interval, 0.43-6.21; very low-quality evidence) and pregnancy loss at <24 weeks (3 studies; n=1436; odds ratio, 1.20; 95% confidence interval, 0.55-2.58; very low-quality evidence) were not statistically significantly different.

CONCLUSION

Compared with ongoing dichorionic twin pregnancies, dichorionic pregnancies that undergo elective selective fetal reduction are associated with lower incidences of preterm birth at <37, <34, and <32 weeks, birthweight <10th and <5th centile, gestational diabetes, and hypertensive disorders of pregnancy, and later gestational age at delivery by almost 3 weeks. These associations were often based on very low-quality evidence. Thus, these results should be interpreted with caution, and further studies should be conducted.

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.

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.

A case series of higher-order multifetal pregnancies managed at a tertiary maternity unit

Delayed childbearing and increased use of assisted reproduction technology (ART) have resulted in a dramatic rise in the incidence of multifetal pregnancies. In 2022, the incidence of twin birth was 1 in 38.2 (932 live births) and triplet birth 1 in 1978 (18 live births) in Singapore.1 Preterm birth and its associated complications remain the most significant risks of multifetal pregnancies—60.5% of twins and 100% of triplets were born <37 weeks in Singapore in 2019. The relative risks of cerebral palsy in triplets and twins compared with singletons are 12.7 and 4.9, respectively.2

Perinatal outcomes of fetoscopic laser surgery for twin-twin transfusion syndrome in triplet pregnancy: cohort study, systematic review and meta-analysis

OBJECTIVES

The aims of this study were to investigate the perinatal outcome of dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplet pregnancies complicated by twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) in two academic fetal centers, and to conduct a systematic review of previously published data to investigate perinatal survival in this targeted population.

METHODS

The first part of the study was a retrospective cohort study of prospectively collected data of consecutive triplet pregnancies with TTTS that underwent FLP at two fetal treatment centers between 2012 and 2020. Demographic, preoperative and operative variables and postoperative outcome were collected. Perinatal outcomes were investigated. The second part of the study was a systematic review and meta-analysis of studies evaluating the outcome of DCTA and/or MCTA triplet pregnancies, including our cohort study. PubMed, Web of Science and Scopus were searched from inception to September 2020. Primary outcomes were fetal survival (survival to birth), neonatal survival (survival to 28 days of age) and gestational age (GA) at birth.

RESULTS

A total of 31 sets of triplets with TTTS managed with FLP were included in the cohort study. Of these, 24 were DCTA and seven were MCTA. There were no significant differences in preoperative and operative variables between the two groups. There were also no significant differences between groups in GA at delivery or perinatal survival rate, including fetal and neonatal survival of at least one triplet, at least two triplets and all three triplets. Nine studies, including our cohort study, were included in the systematic review (156 DCTA and 37 MCTA triplet pregnancies treated with FLP). The overall fetal and neonatal survival was 79% (95% CI, 75-83%) and 75% (95% CI, 71-79%), respectively, in DCTA cases and 74% (95% CI, 52-92%) and 71% (95% CI, 49-89%), respectively, in MCTA cases. The rate of preterm birth before 28 weeks and before 32 weeks' gestation was 14% (95% CI, 4-29%) and 61% (95% CI, 50-72%), respectively, in DCTA triplets and 21% (95% CI, 3-45%) and 82% (95% CI, 62-96%), respectively, in MCTA triplets.

CONCLUSIONS

Triplet pregnancies with TTTS are at high risk of adverse perinatal outcome and preterm birth, regardless of chorionicity. The rate of survival after FLP in MCTA triplets was higher in our study than that reported in previous studies and is currently comparable with survival in DCTA triplets, which could be due to improved surgical skills. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

Pregnancy and obstetric outcomes of dichorionic and trichorionic triamniotic triplet pregnancy with multifetal pregnancy reduction: a retrospective analysis study

Background

It is generally beneficial for triplet gestation or high-order multiple pregnancies to operate multifetal pregnancy reduction (MFPR) after assisted reproductive techniques. However, data on pregnancy outcomes is lacking regarding dichorionic triamniotic (DCTA) and trichorionic triplets (TCTA) pregnancy.

Method

This research analyzes the difference between 128 DCTA and 179 TCTA pregnancies with or without MFPR after in vitro fertilization/intracytoplasmic sperm injection cycles between January 2015 and June 2020. The subdivided subgroups of the two groups are reduction to singleton, reduction to dichorionic twins, and expectant management groups. We also compare the pregnancy and obstetric outcomes between 2104 dichorionic twins and 122 monochorionic twins.

Result

The research subgroups were DCTA to monochorionic singleton pregnancies (n = 76), DCTA to dichorionic twin pregnancies (n = 18), DCTA-expectant management (n = 34), TCTA to monochorionic singleton pregnancies (n = 31), TCTA to dichorionic twin pregnancies (n = 130), and TCTA-expectant management (n = 18). In DCTA-expectant management group, the complete miscarriage rate is dramatically higher, and the survival rate and the rate of take-home babies are lower. However, there was no difference between the rates of complete miscarriages, survival rates, and take-home babies in TCTA-expectant management group. But the complete miscarriage rate of DCTA-expectant management was obviously higher than that of TCTA-expectant management group (29.41 vs. 5.56%, p = 0.044). For obstetric outcomes, MFPR to singleton group had higher gestational week and average birth weight, but lower premature delivery, gestational hypertension rates and low birth weight in both DCTA and TCTA pregnancy groups (all p < 0.05). DCTA to monochorionic singleton had the lowest incidence of gestational diabetes, whereas The subdivided subgroups of TCTA had no significant difference in the incidence of gestational diabetes. Monochorionic twins have higher rates of complete, early, and late miscarriage, premature delivery, and late premature delivery, and lower survival rate (p < 0.05).

Conclusion

MFPR could improve gestational week and average birth weight, reducing premature delivery, LBW, and gestational hypertension rates in DCTA and TCTA pregnancies. Monochorionic twins have worse pregnancy and obstetric outcomes. MFPR to singleton is preferable recommended in the pregnancy and obstetric management of complex triplets with monochorionic pair.

Maternal, Perinatal and Neonatal Outcomes of Triplet Pregnancies According to Chorionicity: A Systematic Review of the Literature and Meta-Analysis

Triplet pregnancies are rare events that affect approximately 93 in 100,000 deliveries in the world, especially due to the increased use of assisted reproductive techniques and older maternal age. Triplet pregnancies are associated with a higher risk of fetal and maternal morbidity and mortality compared to twins and singletons. Chorionicity has been proposed as a major determinant of perinatal and maternal outcomes in triplet pregnancies, although further evidence is needed to clarify the extent and real influence of this factor. Thus, the aim of this study was to conduct a systematic review of the literature and a meta-analysis of the maternal and perinatal outcomes of triplet pregnancies, evaluating how chorionicity may influence these results. A total of 46 studies with 43,653 triplet pregnancies and 128,145 live births were included. Among the main results of our study, we found a broad spectrum of fetal and maternal complications, especially in the group of monochorionic and dichorionic pregnancies. Risk of admission to NICU, respiratory distress, sepsis, necrotizing enterocolitis, perinatal and intrauterine mortality were all found to be higher in non-TCTA pregnancies than in TCTA pregnancies. To date, our meta-analysis includes the largest population sample and number of studies conducted in this field, evaluating a wide variety of outcome measures. The heterogeneity and retrospective design of the studies included in our research represent the main limitations of this review. More evidence is needed to fully assess outcome measures that could not be studied in this review due to scarcity of publications or insufficient sample size.

Multiple gestation associated with infertility therapy: a committee opinion

This Committee Opinion provides practitioners with suggestions to reduce the likelihood of iatrogenic multiple gestation resulting from infertility treatment. This document replaces the document of the same name previously published in 2012 (Fertil Steril 2012;97:825-34 by the American Society for Reproductive Medicine).

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.

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.

Clinical outcomes in higher-order multiples reduced to dichorionic diamniotic (DCDA) twins compared with primary twins and singletons: A prospective observational study

OBJECTIVE

To compare outcomes in higher-order multiple pregnancies reduced to dichorionic diamniotic (DCDA) twins with primary DCDA twins and singleton pregnancies.

METHODS

This prospective observational study included all higher-order multiple pregnancies that underwent ultrasound-guided transabdominal fetal reduction at 11-13 weeks of gestation from January 2018 to June 2020. Outcomes were compared with 100 primary DCDA twins and 1078 singletons.

RESULTS

Sixty-four higher-order multiples underwent reduction at mean gestational age of 11.46 weeks. Of the reduced pregnancies, 3.12% resulted in miscarriage before 24 weeks compared with 2% (2/100) of primary twins and 0.74% of singletons (P = 0.09). The mean gestational age at delivery was 33.48 weeks for reduced twins, 34.52 weeks for primary twins (P = 0.10) and 38.14 weeks for singletons (P < 0.001). Compared with primary twins, the adjusted odds of preterm delivery before 34 weeks and before 36 weeks for reduced twins were 0.56 (95% confidence interval [CI] 0.48-3.54, P = 0.62) and 0.84 (95% CI 0.78-8.85, P = 0.08), respectively. There was no significant difference in rates of pre-eclampsia, Cesarean delivery, birth weight below the 10th and 3rd centiles, and perinatal mortality among primary and reduced twins. All risks were significantly lower in singleton pregnancies.

CONCLUSION

Reduced twins have similar obstetric and perinatal outcomes as primary twins, but adverse outcomes are significantly higher in both groups when compared with singleton pregnancies.

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.

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.

The reproductive stress hypothesis

In this paper, we propose the reproductive stress hypothesis that describes the pregnant females response to reproductive events based upon the activation of the hypothalamic–pituitary–adrenal axis and sympathetic adrenomedullary system. The main components of the reproductive stress hypothesis can be summarized as follows: (1) events unique to reproduction including empathema, pregnancy, parturition and lactation cause non-specific responses in females, called active reproductive stress; (2) the fetus is a special stressor for pregnant females where endocrine hormones, including corticotropin-releasing hormones and fetal glucocorticoids secreted by the fetus and placenta, enter the maternal circulatory system, leading to another stress response referred to as passive reproductive stress and (3) response to uterine tension and intrauterine infection is the third type of stress, called fetal intrauterine stress. Appropriate reproductive stress is a crucial prerequisite in normal reproductive processes. By contrast, excessive or inappropriate reproductive stress may result in dysfunctions of the reproductive system, such as compromised immune function, leading to susceptibility to disease. The novel insights of the reproductive stress hypothesis have important implications for deciphering the pathogenesis of certain diseases in pregnant animals, including humans, which in turn may be applied to preventing and treating their occurrence.

Ovarian hyperstimulation syndrome in a frozen-thawed embryo transfer pregnancy: a rare case report

Background

Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of ovarian stimulation. Prevention and early recognition of OHSS are important to ensure patient safety.

Case presentation

In this case, we reported a patient who underwent controlled ovarian hyperstimulation (COH) and in vitro fertilization (IVF). All embryos were cryopreserved to reduce possible OHSS. However, OHSS still occurred after the patient had a frozen-thawed embryo transfer (FET) with hormone replacement therapy (HRT) and obtained a dichorionic diamniotic triplet pregnancy. After multifetal pregnancy reduction (MFPR) and supportive treatment, all the symptoms regressed.

Conclusions

Prompt recognition of OHSS, especially in patients who have no history of ovulation induction and fresh embryo transfer, is very important. Multiple pregnancies may lead to severe OHSS because of the high level of human chorionic gonadotropin (hCG) in the early stages. We suggest that a single embryo transfer may be necessary and beneficial for patients.

Pregnancy outcomes of dichorionic triamniotic triplet pregnancies after in vitro fertilization-embryo transfer: multifoetal pregnancy reduction versus expectant management

Background

Trichorionic triplet pregnancy reduction to twin pregnancy is associated with a lower risk of preterm delivery but not with a lower risk of miscarriage. However, data on dichorionic triamniotic (DCTA) triplet pregnancy outcomes are lacking. This study aimed to compare the pregnancy outcomes of DCTA triplets conceived via in vitro fertilization-embryo transfer (IVF-ET) managed expectantly or reduced to a monochorionic (MC) singleton or monochorionic diamniotic (MCDA) twins at 11–13^+ 6 gestational weeks.

Methods

Two hundred ninety-eight patients with DCTA triplets conceived via IVF-ET between 2012 and 2016 were retrospectively analysed. DCTA triplets with three live foetuses were reduced to a MC singleton (group A) or MCDA twins (group B) or underwent expectant management (group C). Each multifoetal pregnancy reduction (MFPR) was performed at 11–13^+ 6 gestational weeks. Pregnancy outcomes in the 3 groups were compared.

Results

Eighty-four DCTA pregnancies were reduced to MC singleton pregnancies, 149 were reduced to MCDA pregnancies, and 65 were managed expectantly.

There were no significant differences among groups A, B, and C in miscarriage rate (8.3 vs. 7.4 vs. 10.8%, respectively) and live birth rate (90.5 vs. 85.2 vs. 83.1%, respectively) (P > 0.05).

Group A had significantly lower rates of preterm birth (8.3 vs. 84.6%; odds ratio (OR) 0.017, 95% confidence interval (CI) 0.006–0.046) and low birth weight (LBW; 9.2 vs. 93.2%; OR 0.007, 95% CI 0.003–0.020) than group C (P < 0.001).

Group B had significantly lower preterm birth (47.0 vs. 84.6%; OR 0.161, 95% CI 0.076–0.340) and LBW rates (58.7 vs. 93.2%; OR 0.103, 95% CI 0.053–0.200) than group C (P < 0.001).

Group A had significantly lower preterm birth (8.3 vs. 47.0%; OR 0.103, 95% CI 0.044–0.237; P < 0.001), LBW (9.2 vs. 58.7%; OR 0.071, 95% CI 0.032–0.162; P < 0.001) and perinatal death rates (1.3 vs. 9.1%; OR 0.132, 95% CI 0.018–0.991; P = 0.021) than group B.

Conclusion

The MFPR of DCTA triplets to singleton or MCDA pregnancies was associated with better pregnancy outcomes compared to expectant management. DCTA triplets reduced to singleton pregnancies had better perinatal outcomes than DCTA triplets reduced to MCDA pregnancies.

Pregnancy outcome after multifetal pregnancy reduction of triplets to twins versus reduction to singletons

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.

Perinatal mortality and morbidity in triplet pregnancy according to chorionicity: systematic review and meta-analysis

OBJECTIVE

The incidence of perinatal mortality and morbidity in triplet pregnancies according to chorionicity is yet to be established. The aim of this systematic review was to quantify perinatal mortality and morbidity in trichorionic triamniotic (TCTA), dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplets.

METHODS

MEDLINE, EMBASE and CINAHL databases were searched in December 2017 for literature published in English describing outcomes of DCTA, TCTA and/or MCTA triplet pregnancies. Primary outcomes were intrauterine death (IUD), neonatal death, perinatal death (PND) and gestational age at birth. Secondary outcomes comprised respiratory, neurological and infectious morbidity, as well as a composite score of neonatal morbidity. Data regarding outcomes were extracted from the included studies. Random-effects meta-analysis was used to estimate the risk of mortality and morbidity and to compute the difference in gestational age at birth between TCTA and DCTA triplet pregnancies.

RESULTS

Nine studies (1373 triplet pregnancies, of which 1062 were TCTA, 261 DCTA and 50 MCTA) were included in the analysis. The risk of PND was higher in DCTA than in TCTA triplet pregnancies (odds ratio (OR), 3.3 (95% CI, 1.3-8.0)), mainly owing to the higher risk of IUD in DCTA triplet pregnancies (OR, 4.6 (95% CI, 1.8-11.7)). There was no difference in gestational age at birth between TCTA and DCTA triplets (mean difference, 1.1 weeks (95% CI, -0.3 to 2.5 weeks); I²  = 85%; P = 0.12). Neurological morbidity occurred in 2.0% (95% CI, 1.1-3.3%) of TCTA and in 11.6% (95% CI, 1.1-40.0%) of DCTA triplets. Respiratory and infectious morbidity affected 28.3% (95% CI, 20.7-36.8%) and 4.2% (95% CI, 2.8-5.9%) of TCTA and 34.0% (95% CI, 21.5-47.7%) and 7.1% (95% CI, 2.7-13.3%) of DCTA triplets, respectively. The incidence of composite morbidity in TCTA and DCTA triplets was 29.6% (95% CI, 21.1-38.9%) and 34.0% (95% CI, 21.5-47.7%), respectively. When translating these figures into a risk analysis, the risk of neurological morbidity (OR, 5.4 (95% CI, 1.6-18.3)) was significantly higher in DCTA than in TCTA triplets, while there was no significant difference in the other morbidities explored. Only one study reported on outcomes of MCTA pregnancies, hence, no formal comparison with the other groups was performed.

CONCLUSION

DCTA triplets are at higher risk of perinatal mortality and morbidity than are TCTA triplets. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

How far is too far? A nationwide cross-sectional study for establishing optimal hospital access time for Korean pregnant women

OBJECTIVES

Access to a delivery unit is a major factor in determining maternal morbidity and mortality. However, there is little information about the optimal access time to a delivery unit. This study aimed to establish the optimal hospital access time (OHAT) for pregnant women in South Korea.

DESIGN

Nationwide cross-sectional study.

SETTING

We used the National Health Insurance System database of South Korea.

PARTICIPANTS

We analysed the data of 371 341 women who had experienced pregnancy in 2013.

PRIMARY AND SECONDARY OUTCOME MEASURES

Access time to hospital was defined as the time required to travel from the patient's home to the delivery unit. The incidence of obstetric complications was plotted against the access time to hospital. Change-point analysis was performed to identify the OHAT by determining a point wherein the incidence of obstetric complications changed significantly. As a final step, the risk of obstetric complications was compared by type among pregnant women who lived within the OHAT against those who lived outside the OHAT.

RESULTS

The OHAT associated with each adverse pregnancy outcomes were as follows: inadequate prenatal care, 41-50 min; preeclampsia, 51-60 min; placental abruption, 51-60 min; preterm delivery, 31-40 min; postpartum transfusion, 31-40 min; uterine artery embolisation, 31-40 min; admission to intensive care unit, 31-40 min; and caesarean hysterectomy, 31-40 min. Pregnant women who lived outside the OHAT had significantly higher risk for obstetric complications than those who lived within the OHAT.

CONCLUSIONS

Our results showed that the OHAT for each obstetric complication ranged between 31 and 60 min. The Korean government should take the OHAT under consideration when establishing interventions for pregnant women who live outside OHAT to reduce maternal morbidity and mortality.

How much have the perinatal outcomes of triplet pregnancies improved over the last two decades?

Objective

This study was conducted to demonstrate the temporal trends in perinatal outcomes of triplet pregnancies over the last two decades.

Methods

The medical records of patients with triplet pregnancies at two Korean tertiary-care hospitals from 1992 to 2012 were retrospectively reviewed in regard to maternal and neonatal outcomes. The study was divided into two periods for analysis: period I (1992-2001) and period II (2003-2012).

Results

Over a 21-year period, 65 women with triplet pregnancies and 185 neonates were analyzed. Period II, when compared with period I, was associated with improved maternal outcomes, characterized by a decreased incidence of preeclampsia (31.8% vs. 2.3%, P=0.002) and anemia (68.2% vs. 30.2%, P=0.003) during pregnancy. Regarding neonatal aspects, the composite morbidity of period II was significantly decreased compared with that of period I, as assessed with a generalized estimating equation for logistic regression (26.2% vs. 8.1%, P=0.03). Multivariable analysis revealed that the gestational age at delivery and the period were significantly associated with the composite neonatal morbidity (P<0.001 and 0.007, respectively).

Conclusion

Improved neonatal morbidity was associated with a higher gestational age at delivery and with the more recent decade.

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

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.

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.

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 outcomes in multifetal pregnancy following fetal reduction

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.

Comparative analysis of perinatal outcome of spontaneous pregnancy reduction and multifetal pregnancy reduction in triplet pregnancies conceived after assisted reproductive technique

INTRODUCTION

With the advent of assisted reproductive treatment options, the incidence of multiple pregnancies has increased. Although the need for elective single embryo transfer is emphasized time and again, its uniform applicability in practice is yet a distant goal. In view of the fact that triplet and higher order pregnancies are associated with significant fetomaternal complications, the fetal reduction is a commonly used option in such cases. This retrospective study aims to compare the perinatal outcome in patients with triplet gestation who have undergone spontaneous fetal reduction (SFR) as against those in whom multifetal pregnancy reduction (MFPR) was done.

MATERIALS AND METHODS

In the present study, eighty patients with triplet gestation at 6 weeks were considered. The patients underwent SFR or MFPR at or before 12-13 weeks and were divided into two groups (34 and 46), respectively.

RESULTS

Our study found no statistical difference in perinatal outcome between the SFR and MFPR groups in terms of average gestational age at delivery, abortion rate, preterm delivery rate, and birth weight. The study shows that the risk of aborting all fetuses after SFR is three times (odds ratio [OR] = 3.600, 95% confidence interval [CI] = 0.2794-46.388) that of MFPR in subsequent 2 weeks. There were more chances of loss of extra fetus in SFR (23.5%) group than MFPR group (8.7%) (OR = 3.889, 95% CI = 1.030-14.680). As neither group offers any significant benefit from preterm delivery, multiple pregnancies continue to be responsible for preterm delivery despite fetal reduction.

CONCLUSION

There appears to be some advantages of MFPR in perinatal outcome when compared to SFR, especially if the latter happens at advanced gestation. Therefore, although it is advisable to wait for SFR to occur, in patients with triplet gestation at 11-12 weeks, MFPR is a viable option to be considered.

Outcomes of Triplets reduced to Twins versus non-reduced Triplet Pregnancies

INTRODUCTION

This study examined the outcomes of triplet pregnancies selectively reduced to twin pregnancies, compared with non-reduced triplet pregnancies using a standardized approach.

MATERIAL AND METHODS

This study is an observational retrospective study of all women who presented to the Fetal Diagnostic Center between 1999-2009, had triplet pregnancies in the first trimester, received prenatal care and delivered at Abington Memorial Hospital. Data analysis was performed with SPPS version 15 for Windows using analysis of variance and Fisher's Exact test.

RESULTS

132 triplet pregnancies were identified. In the reduced group (n = 30) compared to the non-reduced triplet group (n = 102) average gestational age of delivery was longer 34.6 weeks versus 31.2 weeks gestation (P = <0.0005) and days in hospital were less 9.0 versus 26.7 days (P = .001). There was a significantly lower incidence of gestational diabetes and preterm labor in reduced pregnancies. Rate of loss, defined as delivery less than 24 weeks, were similar [3.3% versus 4.9%].

DISCUSSION

Women electing to reduce a triplet pregnancy to twins have higher gestational ages at delivery, lower rates of gestational diabetes and preterm labor, and spent fewer days in hospital than non-reduced triplet pregnancies.

A Triplet Pregnancy With Spontaneous Delivery of a Fetus at Gestational Age of 20 Weeks and Pregnancy Continuation of Two Other Fetuses Until Week 33

INTRODUCTION

The prevalence of pregnancies with triplet or more has been increased due to using assisted reproductive treatments. Meanwhile, multiple pregnancies have higher risks and long-term maternal-fetal complications compared to twin and singleton pregnancies. Delayed interval delivery (DID) is a new approach in the management of multiple pregnancies following delivery or abortion. The purpose of this paper is to evaluate the benefits of DID and present a case that used this method.

METHODS

This paper covers a report on a case of triplet pregnancy resulting from assisted reproductive techniques with spontaneous delivery of a fetus at gestational age of 20 weeks and the use of conservative DID for two other fetuses until the 33rd week.

RESULTS

In our case, the delivery of two other fetuses occurred spontaneously at gestational age of 33 weeks after the delivery of the first fetus at week 20.

CONCLUSIONS

Using DID is a useful and reliable method, but requires careful monitoring, especially in patients with a history of infertility.

Selective Fetal Reduction in Triplet Pregnancy: Indian Experience — A Retrospective Review of 32 Cases

Aim

To review the effects of selective fetal reduction in trichorionic triplet pregnancy with focus on risk of miscarriage and preterm delivery in Indian women and thus provide local data for counseling the prospective parents in similar situation.

Materials and methods

This retrospective study reviewed the pregnancy outcome of 32 sets of triplet pregnancies following fetal reduction. All mothers had trichorionic triplet pregnancy with three live fetuses at 10 to 11 weeks of gestation. One to two milliliter ml of 10% potassium chloride (KCl) was injected into the heart of the target fetus to achieve asystole.

Results

The miscarriage (pregnancy loss before 24 completed weeks) rate in our study was 3.12%. The delivery in our study at. 32 and. 35 weeks were 6.45 and 51.61% respectively. The mean gestational age (mean ± SD) of the mothers was 242.58 ± 12.93 days. Regarding the birthweight of neonates, 5.08% babies were <1500 gm, 89.83% were between 1500 and. 2500 gm and 5.08% were > 2500 gm. The mean birth weight (mean ± SD) of the babies was 1921.18 ± 339.78 gm. There was no neonatal death in this cohort.

Conclusion

Our study results, when compared with ‘expectant management’ group of two European studies as there was no control in our study, appeared significantly better in terms of gestational age at delivery and neonatal birth weight. Selective fetal reduction remains an effective option to Indian women with trichorionic triplet pregnancy.

How to cite this article

Chaudhury K, Mukherjee K. Selective Fetal Reduction in Triplet Pregnancy: Indian Experience — A Retrospective Review of 32 Cases. J South Asian Feder Obst Gynae 2014;6(3):144-150.

The effectiveness of multifetal pregnancy reduction in trichorionic triplet gestation

OBJECTIVE

The objective of the study was to assess in trichorionic triplet pregnancies the effectiveness of elective reduction to twins.

STUDY DESIGN

This was a nationwide retrospective cohort study. We compared the time to delivery and perinatal mortality in trichorionic triplet pregnancies electively reduced to twins with ongoing trichorionic triplets and primary dichorionic twins.

RESULTS

We identified 86 women with reduced trichorionic triplet pregnancies, 44 with ongoing trichorionic triplets, and 824 with primary twins. Reduced triplets had a median gestational age at delivery of 36.1 weeks (interquartile range [IQR], 33.3-37.5 weeks) vs 33.3 (IQR, 28.1-35.2) weeks for ongoing triplets and 37.1 (IQR, 35.3-38.1) weeks for primary twins (P < .001). The total number of surviving children in the reduced group was 155 (90%) vs 114 (86%) in the ongoing triplet group. After reduction, 75 of women (87%) had all their fetuses surviving, compared with 36 (82%) (relative risk [RR], 1.3; 95% confidence interval [CI], 0.72-2.3) for ongoing triplets and 770 (93%) (RR, 0.91; 95% CI, 0.82-1) for primary twins. There were 6 women without any surviving children (7%) after reduction vs 5 (11.4%) (RR, 0.81; 95% CI, 0.47-1.4) among women with ongoing triplets and 32 (3.9%) (RR, 1.7; 95% CI, 0.8-3.7) in women with primary twins.

CONCLUSION

In women with a triplet pregnancy, fetal reduction increases gestational age at birth with 3 weeks as compared with ongoing triplets. However, there the impact on neonatal survival is limited.

The cumulative probability of liveborn multiples after in vitro fertilization: a cohort study of more than 10,000 women

OBJECTIVE

To estimate the cumulative probability of liveborn multiples after IVF to improve patient counseling regarding this significant morbidity.

DESIGN

Retrospective cohort study.

SETTING

Large academic-affiliated infertility practice.

PATIENT(S)

A total of 10,169 women were followed from their first fresh, nondonor IVF cycle through up to six fresh and frozen IVF cycles from 2000-2010.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Delivery of a liveborn infant(s).

RESULT(S)

After three IVF cycles the cumulative live birth rate (CLBR) was 53.2%. The singleton, twin, and triplet CLBRs were 38.0%, 14.5%, and 0.7%. After six IVF cycles the CLBR was 73.8%, with 52.8%, 19.8%, 1.3% for singletons, twins, and triplets. Of the 5,433 live births, 71.4% were singletons, 27.1% were twins, and 1.5% were triplets. Women more than 39 years had the lowest incidence of liveborn multiples with CLBRs of 5.2% after three cycles and 9.5% after six cycles. The twin CLBR doubled from cycles 1 through 3 with the rate of increase slowing from cycles 3 through 6. Although very low in absolute terms, the triplet CLBR also doubled from cycles 1 through 3 and doubled again from cycles 3 through 6. Of the 1,970 pregnancies that began as multifetal on ultrasound, 77.4% resulted in liveborn multiples.

CONCLUSION(S)

Providers should be aware of the cumulative probability of liveborn multiples to effectively counsel patients on this important issue. With nearly three-quarters of all women having live birth after up to six IVF cycles, it is encouraging to report a low incidence of liveborn multiples.

Fetal reduction of triplet pregnancy: one or two?

OBJECTIVE

To review outcomes following reductions in trichorionic triplet pregnancies at our institution.

METHOD

Retrospective analysis of the outcome of trichorionic triamniotic triplets reduced to singletons (group I, n = 44) or twins (group II, n = 136) at 10 and 12 weeks of gestation.

RESULTS

Reduction to one or two was based on parent's preference, hence unrelated to any specific obstetrical or maternal issue. Early fetal loss rate (e.g. <24 weeks) was 9.1% in group I versus 5.1% in group II (p = 0.83). In group I, the take-home baby rate was 86.4% versus 91.9% in group II (p = 0.8). In group I, 17.5% of the women gave birth between 33 and 36(+6) weeks of gestation versus 40.6% in group II (p = 0.026). Delivery beyond 37 weeks was 72.5% in group I and 46.9% in group II (p = 0.01). Intrauterine growth restriction rate was 27.0% in group I versus 45.0% in group II (p = 0.049).

CONCLUSION

Reduction to one rather than two fetuses led to significantly higher term delivery rate without significant differences in fetal loss rate or take-home baby rate.

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.

Prediction of outcome in dichorionic twin pregnancies at 6-10 weeks' gestation

OBJECTIVE

The objective of the study was to predict the outcome of dichorionic (DC) twin pregnancies at 6-10 weeks' gestation from intertwin discordance in crown-rump length (CRL), heart rate (HR), and gestational sac diameter (GSD).

STUDY DESIGN

Intertwin discordance in CRL, HR, and GSD, was compared in 3 groups of DC twin pregnancies with 2 live embryos at 6-10 weeks. In one group, there were 2 live births (n = 174), in another 1 live birth (n = 24), and in a third group there were no live births (n = 33). Regression analysis was used to determine the predictors of outcome.

RESULTS

Significant contributors to the prediction of 1 intrauterine death were discordance in CRL and GSD. The only predictor of 2 deaths was discordance in CRL. Detection rates of screening for single or double death, at 10% false-positive rate, were 79.2% and 27.3%, respectively.

CONCLUSION

In DC twins, intertwin discordance in CRL and GSD at 6-10 weeks can predict outcome.

Clinical and biochemical predictors of very preterm birth in twin-to-twin transfusion syndrome treated by fetoscopy

OBJECTIVE

To evaluate pre- and postoperative predictors of preterm birth in twin-to-twin transfusion syndrome treated with fetoscopic placental laser coagulation.

STUDY DESIGN

Prospective cohort study (n = 166) assessing cervical length (pre and postoperatively), amniotic fluid interleukin-6, serum C-reactive protein and duration of surgery. Logistic regression was used to investigate associations with preterm delivery.

RESULTS

Preterm delivery within 7 days, before 28.0 and 32.0 weeks occurred in 4.8%, 16.8%, and 28.9%, respectively. The only significant predictor of delivery within 7 days was postoperative cervical length (odds ratio [OR], 0.5; 95% confidence interval [CI], 0.3-0.9). Concerning delivery before 32.0 weeks, preoperative cervical length (OR, 0.9; 95% CI, 0.8-1.0), and gestational age (OR, 0.8; 95% CI, 0.4-0.9) were independent risk factors but the association was weak. The presence of a single survivor after surgery was associated with a clear reduction of risk (OR, 0.3; 95% CI, 0.1-0.6). Inflammatory biomarkers and duration of surgery did not discriminate risk of prematurity.

CONCLUSION

No strong preoperative predictive factor of preterm birth could be identified. A single survivor was a strong protective factor of very preterm birth.