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Jernman RM, Rissanen ARS, Stefanovic V. The outcome of reduced and non-reduced triplet pregnancies managed in a tertiary hospital during a 15-year-period - a retrospective cohort study. J Perinat Med 2024; 52:361-368. [PMID: 38421237 DOI: 10.1515/jpm-2023-0538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
OBJECTIVES Triplet pregnancies involve several complications, the most important being prematurity as virtually all triplets are born preterm. We conducted this study to compare the outcomes of reduced vs. non-reduced triplet pregnancies managed in the largest tertiary hospital in Finland. METHODS This was a retrospective cohort study in the Helsinki University Hospital during 2006-2020. Data on the pregnancies, parturients and newborns were collected from patient records. The fetal number, chorionicity and amnionicity were defined in first-trimester ultrasound screening. The main outcome measures were perinatal and neonatal mortality of non-reduced triplets, compared to twins and singletons selectively reduced of triplet pregnancies. RESULTS There were 57 initially triplet pregnancies and 35 of these continued as non-reduced triplets and resulted in the delivery of 104 liveborn children. The remaining 22 cases were spontaneously or medically reduced to twins (9) or singletons (13). Most (54.4 %) triplet pregnancies were spontaneous. There were no significant differences in gestational age at delivery between triplets (mean 33+0, median 34+0) and those reduced to twins (mean 32+5, median 36+0). The survival at one week of age was higher for triplets compared to twins (p<0.00001). CONCLUSIONS Most pregnancies continued as non-reduced triplets, which were born at a similar gestational age but with a significantly higher liveborn rate compared to those reduced to twins. There were no early neonatal deaths among cases reduced to singletons. Prematurity was the greatest concern for multiples in this cohort, whereas the small numbers may explain the lack of difference in gestational age between these groups.
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Affiliation(s)
- Riina Maria Jernman
- Obstetrics and Gynecology, Fetomaternal Medical Center, 159841 University of Helsinki and Helsinki University Hospital , Helsinki, Finland
| | | | - Vedran Stefanovic
- Obstetrics and Gynecology, Fetomaternal Medical Center, 159841 University of Helsinki and Helsinki University Hospital , Helsinki, Finland
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Jernman RM, Stefanovic V. Multifetal pregnancy reductions and selective fetocide in a tertiary referral center - a retrospective cohort study. J Perinat Med 2024; 52:255-261. [PMID: 38281159 DOI: 10.1515/jpm-2023-0414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 12/23/2023] [Indexed: 01/30/2024]
Abstract
OBJECTIVES Multiple pregnancies involve several complications, most often prematurity, but also higher anomaly rates. Reducing fetuses generally improves pregnancy outcomes. We conducted this study to evaluate the obstetrical and neonatal results after multifetal pregnancy reduction (MFPR) in the largest tertiary hospital in Finland. METHODS This retrospective cohort study included all MFPR managed in Helsinki University Hospital during a 13 year period (2007-2019). Data on pregnancies, parturients and newborns were collected from patient files. The number of fetuses, chorionicities and amnionicities were defined in first-trimester ultrasound screening. RESULTS There were 54 MFPR cases included in the final analyses. Most often the reduction was from twins to singletons (n=34, 63 %). Majority of these (25/34, 73.5 %) were due to co-twin anomaly. Triplets (n=16, 29.6 %) were reduced to twins (n=7, 13 %) or singletons (n=9, 16.7 %), quadruplets (n=2, 3.7 %) and quintuplets (n=2, 3.7 %) to twins. Most (33/54, 61.1 %) MFPR procedures were done by 15+0 weeks of gestation. There were six miscarriages after MFPR and one early co-twin miscarriage. In the remaining 47 pregnancies that continued as twins (n=7, 14.9 %) or singletons (n=40, 85.1 %) the liveborn rate was 90 % for one fetus and 71.4 % for two fetuses. CONCLUSIONS Most MFPR cases were pregnancies with an anomalous co-twin. The whole pregnancy loss risk was 11.1 % after MFPR. The majority (70.6 %) of twins were spontaneous, whereas all quadruplets, quintuplets, and 56.3 % of triplets were assisted reproductive technologies (ART) pregnancies. Careful counselling should be an essential part of obstetrical care in multiple pregnancies, which should be referred to fetomaternal units for MFPR option.
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Affiliation(s)
- Riina Maria Jernman
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Vedran Stefanovic
- Department of Obstetrics and Gynecology, Fetomaternal Medical Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Meireson E, De Rycke L, Bijnens EM, Dehaene I, De Bock S, Derom C, Roelens K. Birth outcomes of twins after multifetal pregnancy reduction compared with primary twins. Am J Obstet Gynecol MFM 2024; 6:101230. [PMID: 37984690 DOI: 10.1016/j.ajogmf.2023.101230] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 11/14/2023] [Indexed: 11/22/2023]
Abstract
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.
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Affiliation(s)
- Eline Meireson
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium (Ms Meireson and Dr Roelens); Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium (Ms Meireson and Drs De Rycke, Dehaene, Derom, and Roelens).
| | - Laura De Rycke
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium (Ms Meireson and Drs De Rycke, Dehaene, Derom, and Roelens)
| | - Esmée M Bijnens
- Centre for Environmental Sciences, Hasselt University, Diepenbeek, Belgium (Dr Bijnens); Department of Environmental Sciences, Open University of the Netherlands, Heerlen, The Netherlands (Dr Bijnens)
| | - Isabelle Dehaene
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium (Ms Meireson and Drs De Rycke, Dehaene, Derom, and Roelens)
| | - Sophie De Bock
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium (Dr De Bock)
| | - Catherine Derom
- Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium (Ms Meireson and Drs De Rycke, Dehaene, Derom, and Roelens)
| | - Kristien Roelens
- Department of Human Structure and Repair, Ghent University, Ghent, Belgium (Ms Meireson and Dr Roelens); Department of Obstetrics and Gynaecology, Ghent University Hospital, Ghent, Belgium (Ms Meireson and Drs De Rycke, Dehaene, Derom, and Roelens)
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Kristensen SE, Kvist Ekelund C, Sandager P, Stener Jørgensen F, Hoseth E, Sperling L, Zingenberg HJ, Duelund Hjortshøj T, Gadsbøll K, Wright A, Wright D, McLennan A, Sundberg K, Petersen OB. Triple trouble: uncovering the risks and benefits of early fetal reduction in trichorionic triplets in a large national Danish cohort study. Am J Obstet Gynecol 2023; 229:555.e1-555.e14. [PMID: 37263399 DOI: 10.1016/j.ajog.2023.05.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 05/05/2023] [Accepted: 05/18/2023] [Indexed: 06/03/2023]
Abstract
BACKGROUND Triplet pregnancies are high risk for both the mother and the infants. The risks for infants include premature birth, low birthweight, and neonatal complications. Therefore, the management of triplet pregnancies involves close monitoring and may include interventions, such as fetal reduction, to prolong the pregnancy and improve outcomes. However, the evidence of benefits and risks associated with fetal reduction is inconsistent. OBJECTIVE This study aimed to compare the outcomes of trichorionic triplet pregnancies with and without fetal reduction and with nonreduced dichorionic twin pregnancies and primary singleton pregnancies. STUDY DESIGN All trichorionic triplet pregnancies in Denmark, including those with fetal reduction, were identified between 2008 and 2018. In Denmark, all couples expecting triplets are informed about and offered fetal reduction. Pregnancies with viable fetuses at the first-trimester ultrasound scan and pregnancies not terminated were included. Adverse pregnancy outcome was defined as a composite of miscarriage before 24 weeks of gestation, stillbirth at 24 weeks of gestation, or intrauterine fetal death of 1 or 2 fetuses. RESULTS The study cohort was composed of 317 trichorionic triplet pregnancies, of which 70.0% of pregnancies underwent fetal reduction to a twin pregnancy, 2.2% of pregnancies were reduced to singleton pregnancies, and 27.8% of pregnancies were not reduced. Nonreduced triplet pregnancies had high risks of adverse pregnancy outcomes (28.4%), which was significantly lower in triplets reduced to twins (9.0%; difference, 19.4%, 95% confidence interval, 8.5%-30.3%). Severe preterm deliveries were significantly higher in nonreduced triplet pregnancies (27.9%) than triplet pregnancies reduced to twin pregnancies (13.1%; difference, 14.9%, 95% confidence interval, 7.9%-21.9%). However, triplet pregnancies reduced to twin pregnancies had an insignificantly higher risk of miscarriage (6.8%) than nonreduced twin pregnancies (1.1%; difference, 5.6%; 95% confidence interval, 0.9%-10.4%). CONCLUSION Triplet pregnancies reduced to twin pregnancies had significantly lower risks of adverse pregnancy outcomes, severe preterm deliveries, and low birthweight than nonreduced triplet pregnancies. However, triplet pregnancies reduced to twin pregnancies were potentially associated with a 5.6% increased risk of miscarriage.
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Affiliation(s)
- Steffen Ernesto Kristensen
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Charlotte Kvist Ekelund
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Puk Sandager
- Department of Obstetrics and Gynecology, Center for Fetal Medicine, Aarhus University Hospital, Aarhus, Denmark; Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Finn Stener Jørgensen
- Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark; Fetal Medicine Unit, Department of Obstetrics and Gynecology, Copenhagen University Hospital, Hvidovre and Amager, Hvidovre, Denmark
| | - Eva Hoseth
- Department of Obstetrics and Gynecology, Clinic of Ultrasound, Aalborg University Hospital, Aalborg, Denmark
| | - Lene Sperling
- Department of Obstetrics and Gynecology, Center for Ultrasound and Pregnancy, Odense University Hospital, Odense, Denmark
| | - Helle Jeanette Zingenberg
- Department of Obstetrics and Gynecology, Copenhagen University Hospital, Herlev and Gentofte, Herlev, Denmark
| | - Tina Duelund Hjortshøj
- Department of Clinical Genetics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kasper Gadsbøll
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Alan Wright
- Institute of Health Research, University of Exeter, Exeter, United Kingdom
| | - David Wright
- Institute of Health Research, University of Exeter, Exeter, United Kingdom
| | - Andrew McLennan
- Sydney Ultrasound for Women, Chatswood, New South Wales, Australia; Discipline of Obstetrics, Gynaecology, and Neonatology, The University of Sydney, Sydney, New South Wales, Australia
| | - Karin Sundberg
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Olav Bjørn Petersen
- Department of Obstetrics, Center for Fetal Medicine and Ultrasound, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark; Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Wang X. Fetal reduction, moral permissibility and the all or nothing problem. JOURNAL OF MEDICAL ETHICS 2023; 49:772-775. [PMID: 36813549 DOI: 10.1136/jme-2022-108446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 02/16/2023] [Indexed: 06/18/2023]
Abstract
There is an ongoing debate about whether multifetal pregnancy reduction from twins to singletons (2-to-1 MFPR) is morally permissible. By applying the all or nothing problem to the cases of reducing twin pregnancies to singletons, Räsänen argues that an implausible conclusion seems to follow from two plausible claims: (1) it is permissible to have an abortion and (2) it is wrong to abort only one fetus in a twin pregnancy. The implausible conclusion is that women considering 2-to-1 MFPR for social reasons ought to abort both fetuses rather than just one. To avoid the conclusion, Räsänen suggests that it is best to carry both fetuses to term and give one for adoption. In this article, I argue that Räsänen's argument fails for two reasons: the inference from (1) and (2) to the conclusion rests on a bridge principle that does not work in certain circumstances, and there is good reason to reject the claim that it is wrong to abort only one fetus.
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Affiliation(s)
- Xueshi Wang
- School of Humanities and Social Science, The Chinese University of Hong Kong, Shenzhen, China
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Abstract
Advances in medical technology do not follow a smooth process and are highly variable. Implementation can occasionally be rapid, but often faces varying degrees of resistance resulting at the very least in delayed implementation. Using qualitative comparative analysis, we have evaluated numerous technological advances from the perspective of how they were introduced, implemented, and opposed. Resistance varies from benign - often happening because of inertia or lack of resources to more active forms, including outright opposition using both appropriate and inappropriate methods to resist/delay changes in care. Today, even public health has become politicized, having nothing to do with the underlying science, but having catastrophic results. Two other corroding influences are marketing pressure from the private sector and vested interests in favor of one outcome or another. This also applies to governmental agencies. There are a number of ways in which papers have been buried including putting the thumb on the scale where reviewers can sabotage new ideas. Unless we learn to harness new technologies earlier in their life course and understand how to maneuver around the pillars of obstruction to their implementation, we will not be able to provide medical care at the forefront of technological capabilities.
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Affiliation(s)
- Mark I Evans
- Fetal Medicine Foundation of America, New York, USA.
- Comprehensive Genetics, PLLC, New York, USA.
- Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt. Sinai, New York, USA.
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张 红, 杨 蕊, 杨 硕, 潘 宁, 王 琳, 李 蓉. [Clinical effect of fetal reduction by intracranial and intrathoracic KCl injection]. BEIJING DA XUE XUE BAO. YI XUE BAN = JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2022; 54:943-947. [PMID: 36241237 PMCID: PMC9568394 DOI: 10.19723/j.issn.1671-167x.2022.05.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To evaluate the feasibility and effectiveness of fetal reduction by transabdominal intracranial KCl injection for multifetal pregnancies in the early second trimester. METHODS The data of 363 patients who underwent transabdominal fetal reduction in the Reproductive Medical Center of Peking University Third Hospital from January 2006 to December 2019 were analyzed retrospectively. According to the location of fetal reduction, they were divided into two groups: Intracranial injection group (n=196) and intrathoracic injection group (n=167). The process of fetal reduction and pregnancy outcome of the two groups were compared. RESULTS There was no significant difference between the two groups in the average age and the proportion of type of infertility before assisted reproductive technology, conception method, indication for fetal reduction, starting number of fetuses, reduced number of fetuses, and finishing number of fetuses (P>0.05). There was no significant difference between the two groups in the proportion of the number of puncture ≥ 2 times (12.1% vs. 8.6%, P=0.249) and the incidence of replacing puncture site (10.7% vs. 6.4%, P=0.161). The next day after fetal reduction, color Doppler ultrasound was rechecked. In the intracranial injection group and intrathoracic injection group, the incidence of fetal heartbeat recovery [3.6% (8/224) vs. 1.1% (2/187), P=0.188], the volumes of KCl used [(2.6±1.0) mL vs. (2.8±1.1) mL, P=0.079], and the abortion rate within 4 weeks after fetal reduction (1.0% vs. 0.6%, P=0.654) were of no significant difference. In addition, there was no significant difference in the total abortion rate after fetal reduction, premature delivery rate, cesarean section rate, delivery gestational week and neonatal birth weight between the two groups (P>0.05). CONCLUSION Intracranial KCl injection can be an effective alternative to intrathoracic KCl injection for multifetal pregancy reduction.
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Affiliation(s)
- 红霞 张
- />北京大学第三医院生殖医学中心, 北京 100191Reproductive Medical Center, Peking University Third Hospital, Beijing 100191, China
| | - 蕊 杨
- />北京大学第三医院生殖医学中心, 北京 100191Reproductive Medical Center, Peking University Third Hospital, Beijing 100191, China
| | - 硕 杨
- />北京大学第三医院生殖医学中心, 北京 100191Reproductive Medical Center, Peking University Third Hospital, Beijing 100191, China
| | - 宁宁 潘
- />北京大学第三医院生殖医学中心, 北京 100191Reproductive Medical Center, Peking University Third Hospital, Beijing 100191, China
| | - 琳琳 王
- />北京大学第三医院生殖医学中心, 北京 100191Reproductive Medical Center, Peking University Third Hospital, Beijing 100191, China
| | - 蓉 李
- />北京大学第三医院生殖医学中心, 北京 100191Reproductive Medical Center, Peking University Third Hospital, Beijing 100191, China
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Gao L, Xu QQ, Wang S, Xia YQ, Zhao XR, Wu Y, Hua RY, Sun JL, Wang YL. Correlation analysis of adverse outcomes for the selective reduction of twin pregnancies. BMC Pregnancy Childbirth 2022; 22:417. [PMID: 35585573 PMCID: PMC9118778 DOI: 10.1186/s12884-022-04754-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Due to the extensive development of assisted reproductive technology, the number of twin pregnancies has increased significantly over recent decades. Twin pregnancy is the most representative type of multiple pregnancies and is associated with high infant morbidity and mortality. Perinatal complications of twin pregnancy are also markedly increased compared with those of single pregnancy. Transabdominal selective reduction (SR) is a remedial intervention. This study aimed to research the adverse outcomes of transabdominal selective reduction of twin pregnancy and the correlation between the reduction week and pregnancy outcomes. OBJECTIVE The purpose of this study was to examine the adverse outcomes of the transabdominal selective reduction of twin pregnancy and the correlation between the reduction week and pregnancy outcomes. METHODS A retrospective cohort study of the transabdominal reduction of twin pregnancy was conducted in a single prenatal diagnosis medical centre from September 2012 to October 2020. According to chorionicity, women with twin pregnancies were divided into 2 groups: dichorionic (DC) twin pregnancies and monochorionic (MC) twin pregnancies. Women with DC twin pregnancies underwent potassium chloride reduction, and those with MC twin pregnancies underwent radiofrequency ablation (RFA). The reduction indications included pregnancy complications, foetal abnormalities, and maternal factors. The perinatal outcomes of different chorionic twins after reduction were analysed. Each foetus with an adverse outcome was included. The relative relationship between the reduction weeks and delivery weeks of twins was examined by correlation analysis. RESULTS A total of 161 women were included in this study. A total of 112 women had DC twin pregnancies, and 49 women had MC twin pregnancies. Preterm delivery rates were significantly higher in the MC twin reduction group than in the DC twin reduction group prior to 37 weeks (53.1% vs. 29.5%, P = 0.004). The mean gestational age at delivery of the foetuses in the DC twin group that underwent SR was significantly older than that of those in the MC twin group that underwent SR (36.9 ± 4.0 vs. 33.5 ± 6.6 weeks, P = 0.001). The number of DC twins that underwent SR and were delivered after 37 weeks was obviously greater than that of the MC twins that underwent SR (70.5% vs. 46.9%, P = 0.004). The foetal survival rate was 95.5% in the DC twin reduction group and 77.6% in the MC twin reduction group. If the indication of TTTS was not included, there was no significant difference in the foetal survival rate of the DC and MC twin reduction groups (95.5% vs. 86.2%, P = 0.160). Cotwin death 1 week after reduction was greater in the MC group (6.1% vs. 0%, P = 0.027). Compared to other indications, this finding indicated that a significantly lower proportion of women remained undelivered after selective reduction with the indication of TTTS. There was a significant negative correlation between the reduction weeks and delivery weeks of the two groups (P < 0.01), and the best opportunity for reduction was before 22 weeks of gestation. CONCLUSION These findings highlighted an obviously negative correlation between the reduction week and delivery week. The transabdominal selective reduction of twin pregnancy should be considered for a lower rate of miscarriage or premature delivery if the reduction week takes place earlier in pregnancy. The rate of preterm delivery was the lowest when transabdominal selective reduction was completed before 22 weeks of gestation. Compared with other RFA indications, a higher rate of premature delivery was shown for MC twins with a reduction indication of TTTS. TTTS with sIUGR might be one of the reasons for the adverse outcomes of reduction for MC twin pregnancy.
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Affiliation(s)
- Li Gao
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Qian-Qian Xu
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Shan Wang
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yuan-Qing Xia
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Xin-Rong Zhao
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yi Wu
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Ren-Yi Hua
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Jin-Ling Sun
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yan-Lin Wang
- Division of Maternal-Fetal Fetal Medicine, Prenatal Diagnosis Center, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China. .,Shanghai Key Laboratory of Embryo Original Diseases, Shanghai, China. .,Shanghai Municipal Key Clinical Specialty, Shanghai, China.
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Evans MI, Curtis J, Evans SM, Britt DW. Fetal reduction for everyone? Best Pract Res Clin Obstet Gynaecol 2022; 84:76-87. [PMID: 35643756 DOI: 10.1016/j.bpobgyn.2022.04.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 04/19/2022] [Indexed: 11/18/2022]
Abstract
Infertility treatments have benefited millions of couples to have their own children; however, the complication of multiple pregnancies with their increased morbidity and mortality has created significant problems. Fetal reduction (FR) was developed to ameliorate these issues. Over 30 years of publications show that FR has been highly successful in substantially reducing both mortality and morbidity. As with most radically new techniques, initial cases were in the "nothing to lose" category. With experience, indications liberalize, and quality of life issues increase as a proportion of cases. Overall risks for twins are not twice as those for singletons, but they are approximately 4- to 5-fold higher. In experienced hands, the combination of genetic testing by CVS followed by FR has made most multiples behave statistically as if they were originally the lower number. The use of microarray analysis to better determine fetal genetic health before deciding on which fetus(es) to keep or reduce further improves pediatric outcomes. With increasing experience and lower average starting numbers, the proportion of FRs to a singleton has increased considerably. Twins to a singleton FR now constitute an increasing proportion of cases performed. Data on such cases show improved outcomes, and we believe FR should be at least discussed and offered to all patients with a dichorionic twin pregnancy or higher. eSET is not a panacea because of the resultant monochorionic twins.
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Affiliation(s)
- Mark I Evans
- Fetal Medicine Foundation of America, USA; Comprehensive Genetics, PC, New York, USA; Department of Obstetrics & Gynecology, Icahn School of Medicine at Mt. Sinai New York, USA.
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Hessami K, Evans MI, Nassr AA, Espinoza J, Donepudi RV, Cortes MS, Krispin E, Mostafaei S, Belfort MA, Shamshirsaz AA. Fetal reduction of triplet pregnancies to twins vs singletons: a meta-analysis of survival and pregnancy outcome. Am J Obstet Gynecol 2022; 227:430-439.e5. [PMID: 35351408 DOI: 10.1016/j.ajog.2022.03.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 03/22/2022] [Accepted: 03/22/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This systematic review and meta-analysis aimed to compare the fetal survival rate and perinatal outcomes of triplet pregnancies after selective reduction to twin pregnancies vs singleton pregnancies. DATA SOURCES PubMed, Web of Science, Scopus, and Embase were systematically searched from the inception of the databases to January 16, 2022. STUDY ELIGIBILITY CRITERIA Studies comparing the survival and perinatal outcomes between reduction to twin pregnancies and reduction to singleton pregnancies were included. The primary outcomes were fetal survival, defined as a live birth at >24 weeks of gestation. The secondary outcomes were gestational age at birth, preterm birth at <32 and <34 weeks of gestation, early pregnancy loss (<24 weeks of gestation), low birthweight, and rate of neonatal demise (up to 28 days after birth). METHODS The random-effect model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. To provide a range of expected effects if a new study was conducted, 95% prediction intervals were calculated for outcomes presented in >3 studies. RESULTS Of note, 10 studies with 2543 triplet pregnancies undergoing fetal reduction, of which 2035 reduced to twin pregnancies and 508 reduced to singleton pregnancies, met the inclusion criteria. Reduction to twin pregnancies had a lower rate of fetal survival (odds ratio, 0.61; 95% confidence interval, 0.40-0.92; P=.02; 95% prediction interval, 0.36-1.03) and comparable rates of early pregnancy loss (odds ratio, 0.89; 95% confidence interval, 0.58-1.38; P=.61; 95% prediction interval, 0.54-1.48) and neonatal demise (odds ratio, 0.57; 95% confidence interval, 0.09-3.50; P=.55) than reduction to singleton pregnancies. Reduction to twin pregnancies had a significantly lower gestation age at birth (weeks) (mean difference, -2.20; 95% confidence interval, -2.80 to -1.61; P<.001; 95% prediction interval, -4.27 to -0.14) than reduction to singleton pregnancies. Furthermore, reduction to twin pregnancies was associated with lower birthweight and greater risk of preterm birth at <32 and <34 weeks of gestation. CONCLUSION Triplet pregnancies reduced to twin pregnancies had a lower fetal survival rate of all remaining fetuses, lower gestational age at birth, higher risk of preterm birth, and lower birthweight than triplet pregnancies reduced to singleton pregnancies; reduction to twin pregnancies vs reduction to singleton pregnancies showed no substantial difference for the rates of early pregnancy loss and neonatal death.
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Evans MI, Curtis J, Evans SM, Britt DW. Fetal reduction and twins. Am J Obstet Gynecol MFM 2022; 4:100521. [PMID: 34700026 DOI: 10.1016/j.ajogmf.2021.100521] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 09/24/2021] [Accepted: 10/19/2021] [Indexed: 10/20/2022]
Abstract
Infertility treatments have allowed millions of couples to have their own children, but resultant multiple pregnancies with their increased morbidity and mortality have been a significant complication. Fetal reduction was developed to ameliorate this issue. Over 30 years of publications show that fetal reduction has been highly successful in substantially reducing both mortality and morbidity related to multiple pregnancies. As with most radically new techniques, initial cases were in the "nothing to lose" category. With experience, indications liberalize, and quality of life issues gain relevance. The overall risks of twin pregnancy are not twice that of singleton pregnancy; they are about 4 to 5 times higher. In experienced hands, the combination of genetic testing by chorionic villus sampling followed by fetal reduction has made the outcomes of most multiple pregnancies statistically equivalent to those of pregnancies with lower fetal numbers. Use of microarray analysis to better determine fetal genetic health before deciding on which fetus(es) to keep or reduce further improves pediatric outcomes. With increasing experience and lower average starting numbers, the proportion of fetal reductions to a singleton has increased considerably. Twins to a singleton fetal reductions now constitute an increasing proportion of cases performed. Data on such cases show improved outcomes, and we believe fetal reduction should be at least discussed and offered to all patients with a dichorionic twin pregnancy or higher. With the increasing reliance on elective single-embryo transfers, monochorionic twins, which have much higher complication rates than dichorionic twins, have increased substantially. Furthermore, monochorionic twins cannot be readily and safely reduced, so the adverse perinatal statistics of elective single-embryo transfer are a major setback for good outcomes. Although elective single-embryo transfer is appropriate for some, we believe that for many couples, the transfer of 2 embryos is generally a more rational approach.
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Affiliation(s)
- Mark I Evans
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY (Dr Evans, Ms Curtis, Ms Evans, and Dr Britt); Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, NY (Dr Evans).
| | - Jenifer Curtis
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY (Dr Evans, Ms Curtis, Ms Evans, and Dr Britt)
| | - Shara M Evans
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY (Dr Evans, Ms Curtis, Ms Evans, and Dr Britt); Department of Maternal Child Health, Gillings School of Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, NC (Ms Evans)
| | - David W Britt
- Comprehensive Genetics, Fetal Medicine Foundation of America, New York, NY (Dr Evans, Ms Curtis, Ms Evans, and Dr Britt)
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Yimin Z, Minyue T, Yanling F, Huanmiao Y, Saijun S, Qingfang L, Xiaoling H, Lanfeng X. Fetal Reduction Could Improve but Not Completely Reverse the Pregnancy Outcomes of Multiple Pregnancies: Experience From a Single Center. Front Endocrinol (Lausanne) 2022; 13:851167. [PMID: 35813622 PMCID: PMC9263074 DOI: 10.3389/fendo.2022.851167] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2022] [Accepted: 05/13/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE To investigate the effectiveness and limitations of multifetal pregnancy reduction (MFPR) on the improvement of pregnancy outcomes of triplet or twin pregnancies conceived by in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). METHODS We performed a cohort study of women undergoing IVF or ICSI from 2002-2016 in reproductive center, women's hospital, Zhejiang University School of Medicine. The cohort included 502 women who underwent MFPR and 9641 non-reduced women. Pregnancy outcomes were gestational age (GA) at delivery, pregnancy loss, preterm delivery, low birth weight (LBW), very low birth weight (VLBW), and small for gestational age (SGA). Multiple linear regression and logistic regression models were used to compare pregnancy outcomes between groups. RESULTS Triplets reduced to singletons had a longer median GA (39.07 vs 37.00, P<0.001), and lower rates of LBW (8.9% vs 53.2%, P<0.001) and SGA (17.8% vs 44.7%, P=0.001) than triplets reduced to twins, with a similar pregnancy loss rate (6.7% vs 6.6%, P=0.701). Twins reduced to singletons had a comparable pregnancy loss rate (4.8% vs. 6.5%, P=0.40), a longer median GA (38.79 vs. 37.00, P<0.001), and lower rates of LBW (13.5% vs. 47.0%, P<0.001) and SGA (13.5% vs. 39.6%, P<0.001) than primary twins. Triplets reduced to twins had higher rates of LBW (53.2% vs. 47.0%, P=0.028) and SGA (44.7% vs. 39.6%, P=0.040) than primary twins, with a similar pregnancy loss rate (6.6% vs. 6.5%, P=0.877). Singletons reduced from triplets/twins had higher rates of preterm delivery (15.8% vs. 7.3%, P<0.001), LBW (12.3% vs. 4.32%, P<0.001), VLBW (2.3% vs. 0.4%, P=0.002), and SGA (14.6% vs.6.6%, P<0.001) than primary singletons, with a comparable pregnancy loss rate (5.3% vs. 5.4%, P=0.671). CONCLUSIONS This study suggests that the pregnancy loss rate is similar between reduction and non-reduction groups. MFPR improves pregnancy outcomes, including the risk of preterm delivery, LBW, and SGA, but still could not completely reverse the adverse pregnancy outcomes of multiple pregnancies.
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Sarac Sivrikoz T, DEMIR O, Halil Kalelioglu I, Has R, Karakas Paskal E, Kundakci Ozdemir P, Yuksel A. The effects of early or late multifetal reduction procedure on perinatal outcomes in multiple pregnancies reduced to twins or singletons: A single tertiary center experience. Eur J Obstet Gynecol Reprod Biol 2022; 270:195-200. [DOI: 10.1016/j.ejogrb.2022.01.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 01/11/2022] [Accepted: 01/17/2022] [Indexed: 02/09/2023]
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Sam S, Tai-MacArthur S, Shangaris P, Sankaran S. Trends of Selective Fetal Reduction and Selective Termination in Multiple Pregnancy, in England and Wales: a Cross-Sectional Study. Reprod Sci 2021; 29:1020-1027. [PMID: 34902100 PMCID: PMC8863756 DOI: 10.1007/s43032-021-00819-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/01/2021] [Indexed: 12/01/2022]
Abstract
Selective abortion was shown to be increasingly common in England and Wales over a 9-year period, occurring most frequently as twin to singleton reductions in the 1st trimester. We analysed the trends in selective abortion (SA) in multiple pregnancies in England and Wales between 2009 and 2018. This is a cross-sectional study looking at 1143 women with multiple pregnancies in England and Wales undergoing SA. There were a total of 1143 cases of SA between 2009 and 2018 in England and Wales, representing 0.07% of total abortions. There has been a steady increase in cases, from 90 in 2009 to 131 in 2018, with 82.3% justified under ground E of The Abortion Act 1967. The majority of SAs were carried out at 13–19 weeks gestation, and intracardiac injection of potassium chloride was the most prevalent method (75%). Twin to singleton reductions accounted for 59%, the most common form of SAs. Over half of all cases (59%) were performed in women aged 30–39 years, and 84% of all women were of White ethnicity. SA has been an option available for couples diagnosed with multiple pregnancy, especially when there are discordant anomalies. Although SA may decrease multiple pregnancy-related complications, preventative methods must be championed.
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Affiliation(s)
- Sreya Sam
- GKT School of Biomedical Sciences, Kings College London, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Sarah Tai-MacArthur
- School of Bioscience Education, Kings College London, Guy's Campus, Great Maze Pond, London, SE1 1UL, UK
| | - Panicos Shangaris
- Department of Women and Children's Health, School of Life Course & Population Sciences, Faculty of Life Sciences and Medicine, Kings College London, London, 10th Floor North Wing St Thomas' Hospital, London, SE1 7EH, UK. .,Department of Women and Children, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK.
| | - Srividhya Sankaran
- Department of Women and Children, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, UK
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15
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Lee JY, Lee SM, Jeong M, Oh S, Hong S, Choe SA, Jun JK. Short-term and long-term outcomes of trichorionic triplet pregnancies with expectant management. Acta Obstet Gynecol Scand 2021; 101:111-118. [PMID: 34747006 DOI: 10.1111/aogs.14281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 09/09/2021] [Accepted: 10/04/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Ji Yeon Lee
- Department of Obstetrics and Gynecology, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Republic of Korea
| | - Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Mina Jeong
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea
| | - Subeen Hong
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung-Ah Choe
- Department of Preventive Medicine, Korea University, Seoul, Republic of Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Republic of Korea.,Institute of Reproductive Medicine and Population, Seoul National University Medical Research Center, Seoul, Republic of Korea
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Abstract
Along with the rise of assisted reproductive technology, multifetal gestations increased dramatically. Twin pregnancies account for 97% of multifetal pregnancies and 3% of all births in the United States. Twins and higher-order multiples carry increased risks of obstetric, perinatal, and maternal complications; these risks increase with increasing fetal number. Neonatal morbidity and mortality in multifetal gestations is driven primarily by prematurity. Both spontaneous and indicated preterm births are increased in multifetal gestations, and only a limited number of strategies are available to mitigate this risk. No single intervention has been shown to decrease the rate of spontaneous preterm birth in most twin pregnancies. Low-dose aspirin prophylaxis is recommended in all multifetal pregnancies to reduce the risk of preeclampsia and its associated complications. Antenatal management of multifetal gestations depends on chorionicity, which should be established using ultrasonography in the first trimester. Unlike dichorionic twin gestations, monochorionic pregnancies experience unique complications because of their shared vascular connections, and therefore, need frequent ultrasound surveillance. Even uncomplicated twin gestations have higher rates of unanticipated stillbirth compared with singletons. Delivery of twin pregnancies is generally indicated in the late preterm to early term period depending on chorionicity and other clinical factors. For most diamniotic twin pregnancies with a cephalic presenting fetus, vaginal delivery after 32 weeks' gestation is a safe and reasonable option with high rates of success and no increased risk of perinatal morbidity.
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Affiliation(s)
- Cassandra R Duffy
- Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, MA
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Singh C, Thakur S, Shahnaz G, Dagar S, Shastri A, Khurana D. Clinical outcomes in higher-order multiples reduced to dichorionic diamniotic (DCDA) twins compared with primary twins and singletons: A prospective observational study. Int J Gynaecol Obstet 2021; 157:671-676. [PMID: 34460958 DOI: 10.1002/ijgo.13901] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/18/2021] [Accepted: 09/26/2021] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Chanchal Singh
- Department of Fetal Medicine, Madhukar Rainbow Children's Hospital, New Delhi, India
| | - Seema Thakur
- Department of Medical Genetics and Fetal Medicine, Madhukar Rainbow Children's Hospital, New Delhi, India
| | - Gazala Shahnaz
- Department of Fetal Medicine, Madhukar Rainbow Children's Hospital, New Delhi, India
| | - Savita Dagar
- Department of Fetal Medicine, Madhukar Rainbow Children's Hospital, New Delhi, India
| | - Aditi Shastri
- Department of Fetal Medicine, Madhukar Rainbow Children's Hospital, New Delhi, India
| | - Deeksha Khurana
- Indian Institute of Public Health, Public Health Foundation of India, Bengaluru, India
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Pregnancy and birth outcomes of multiple gestations with PPROM occurred within 24 h after fetal reduction: A case series. Taiwan J Obstet Gynecol 2021; 59:895-898. [PMID: 33218408 DOI: 10.1016/j.tjog.2020.09.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2020] [Indexed: 11/22/2022] Open
Abstract
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.
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Multifetal Pregnancy Reduction in Quadruplets: Perinatal Outcome—Analysis of 20 Consecutive Cases. JOURNAL OF FETAL MEDICINE 2021. [DOI: 10.1007/s40556-021-00305-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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20
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Rajesh H, Natarajan L, Panicker S, Mithraprabhu S. Hyperreactio luteinalis following frozen embryo transfer managed by fetal reduction. BMJ Case Rep 2021; 14:14/3/e236455. [PMID: 33653831 PMCID: PMC7929798 DOI: 10.1136/bcr-2020-236455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report a rare case of hyperreactio luteinalis (HL) which developed in association with triplet pregnancy in a 27-year-old woman who underwent assisted reproductive technology treatment for primary infertility. She had undergone frozen embryo transfer 2 months after ovarian retrieval. She presented in the first trimester with abdominal pain and distension associated with ovarian enlargement and did not respond to conservative management. Fetal reduction was done from triplets to twins which resulted in good symptomatic relief for the patient. Fetal reduction may be an effective approach in such situations when conservative strategies fail in HL.
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Affiliation(s)
- Hema Rajesh
- Reproductive Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Lalitha Natarajan
- Fetal Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Seetha Panicker
- Obstetrics and Gynaecology, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
| | - Srisaranya Mithraprabhu
- Reproductive Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India
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21
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Meng YL, Ren LJ, Yin SW. Bibliometric analysis of research hotspots and development trends in selective fetal reduction. J Obstet Gynaecol Res 2021; 47:1694-1703. [PMID: 33634542 DOI: 10.1111/jog.14721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 01/03/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
Abstract
AIM To evaluate the theme trends and knowledge structure of multifetal pregnancy reduction (MPR)-related literature by using bibliometric analysis. METHODS Published scientific papers regarding MPR were retrieved from the PubMed database. Data extraction and statistics were conducted using Bibliographic Item Co-Occurrence Matrix Builder (BICOMB). Furthermore, gCLUTO software was used in the study for bi-clustering analysis and strategic diagram analysis. RESULTS According to the search strategy, 906 total papers were included. Among all the extracted MeSH terms, 41 high frequency ones were identified and hotspots were clustered into four categories. In the strategic diagram, research on intrauterine treatment of MPR was most well developed. In contrast, statistical data on the sequelae of fetal reduction surgery and applications of MPR in assisted reproductive technologies were relatively immature. CONCLUSION The analysis of common terms among the high-frequency network terms in multiparous pregnancy reduction can help researchers and clinicians understand the hotspots, key topics, and issues to be discovered on MPR. Research on intrauterine treatment of MPR was most well developed.
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Affiliation(s)
- Yi L Meng
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, Liaoning Province, China
| | - Li J Ren
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, Liaoning Province, China
| | - Shao W Yin
- Department of Gynecology and Obstetrics, Shengjing Hospital of China Medical University, Key Laboratory of Maternal-Fetal Medicine of Liaoning Province, Shenyang, Liaoning Province, China
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22
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Zemet R, Haas J, Bart Y, Barzilay E, Shapira M, Zloto K, Hershenson R, Weisz B, Yinon Y, Mazaki-Tovi S, Lipitz S. Optimal timing of fetal reduction from twins to singleton: earlier the better or later the better? ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:134-140. [PMID: 32529669 DOI: 10.1002/uog.22119] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/11/2020] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
OBJECTIVES To determine the rate of pregnancy complications and adverse obstetric and neonatal outcomes of twin pregnancies that were reduced to singleton at an early compared with a later gestational age. METHODS This was a historical cohort study of dichorionic diamniotic twin pregnancies that underwent fetal reduction to singletons in a single tertiary referral center between January 2005 and February 2017. The study population was divided into two groups according to gestational age at fetal reduction: those performed at 11-14 weeks' gestation, mainly at the patient's request or as a result of a complicated medical or obstetric history; and selective reductions performed at 15-23 weeks for structural or genetic anomalies. The main outcome measures compared between pregnancies that underwent early reduction and those that underwent late reduction included rates of pregnancy complications, pregnancy loss, preterm delivery and adverse neonatal outcome. RESULTS In total, 248 dichorionic diamniotic twin pregnancies were included, of which 172 underwent early reduction and 76 underwent late reduction. Although gestational age at delivery was not significantly different between the late- and early-reduction groups (38 weeks, (interquartile range (IQR), 36-40 weeks) vs 39 weeks (IQR, 38-40 weeks); P = 0.2), the rates of preterm delivery < 37 weeks (28.0% vs 14.0%; P = 0.01), < 34 weeks (12.0% vs 1.8%; P = 0.002) and < 32 weeks (8.0% vs 1.8%; P = 0.026) were significantly higher in pregnancies that underwent late reduction. Regression analysis revealed that late reduction of twins was an independent risk factor for preterm delivery, after adjustment for maternal age, parity, body mass index and the location of the reduced sac. Rates of early complications linked to the reduction procedure itself, such as infection, vaginal bleeding and leakage of fluids, were comparable between the groups (7.0% for early reduction vs 9.2% for late reduction; P = 0.53). There was no significant difference in the rate of pregnancy loss before 24 weeks (0.6% for early reduction vs 1.3% for late reduction; P = 0.52), and no cases of intrauterine fetal death at or after 24 weeks were documented. There was no significant difference in the prevalence of gestational diabetes mellitus, hypertensive disorders of pregnancy, preterm prelabor rupture of membranes or small-for-gestational age. The rates of respiratory distress syndrome (6.7% vs 0%; P = 0.002), need for mechanical ventilation (6.7% vs 0.6%; P = 0.01) and composite neonatal morbidity (defined as one or more of respiratory distress syndrome, sepsis, necrotizing enterocolitis, intraventricular hemorrhage, need for respiratory support or neonatal death) (10.7% vs 2.9%; P = 0.025) were higher in the late- than in the early-reduction group. Other neonatal outcomes were comparable between the groups. CONCLUSIONS Compared with late first-trimester reduction of twins, second-trimester reduction is associated with an increased rate of prematurity and adverse neonatal outcome, without increasing the rate of procedure-related complications. Technological advances in sonographic diagnosis and more frequent use of chorionic villus sampling have enabled earlier detection of fetal anatomic and chromosomal abnormalities. Therefore, efforts should be made to complete early fetal assessment to allow reduction during the first trimester. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- R Zemet
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - J Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Bart
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - E Barzilay
- Department of Obstetrics and Gynecology, Samson Assuta Ashdod University Hospital, Ashdod, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - M Shapira
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - K Zloto
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Hershenson
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - B Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Mazaki-Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - S Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Tel-Hashomer, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Yan L, Wang X, Li H, Hou H, Wang H, Wang Y. Effects of the timing of selective reduction and finishing number of fetuses on the perinatal outcome in triplets: a single-center retrospective study. J Matern Fetal Neonatal Med 2020; 35:2025-2030. [PMID: 33190556 DOI: 10.1080/14767058.2020.1846702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aimed to evaluate the effect of the timing of selective reduction and finishing the number of fetuses on perinatal outcomes in triplets. METHOD The study assessed 417 cases of triplets. Perinatal outcomes were compared between selective reduction (SR) performed at 11-14+6 weeks of gestation and SR performed at 15-24+6 weeks of gestation for the same starting and finishing numbers of fetuses. Then, the perinatal outcomes of reduction to singletons and twins were compared for the same range of SR of gestational weeks. RESULTS The spontaneous abortion rate was 6.5% and 14.9%, respectively, when SR was performed at 11-14+6 weeks of gestation (214 cases) and at 15-24+6 weeks of gestation (94 cases) (p = .019). In total, 74 cases of triplets were reduced to singletons and 214 cases were reduced to twins when SR was performed at 11-14+6 weeks of gestation. Preterm labor rates, low birth weight rates, birth weights, and gestational ages at delivery also showed significant differences (p < .001). In total, 35 cases of triplets were reduced to singletons and 94 cases were reduced to twins when SR was performed at 15-24+6 weeks of gestation. The preterm labor rates, low birth weight rates, birth weights and gestational ages at delivery also significantly differed (p < .05). CONCLUSIONS When the starting and finishing numbers of fetuses were the same, the timing of SR could affect the spontaneous abortion rates. When the starting number of fetuses was the same, the timing of SR did not affect the neonatal outcome. However, the finishing number of fetuses was the influencing factor.
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Affiliation(s)
- Liu Yan
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China.,Department of Obstetrics and Gynecology, Shandong Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Xietong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hongyan Li
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Haiyan Hou
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yanyun Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
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Palomaki GE, Chiu RWK, Pertile MD, Sistermans EA, Yaron Y, Vermeesch JR, Vora NL, Best RG, Wilkins-Haug L. International Society for Prenatal Diagnosis Position Statement: cell free (cf)DNA screening for Down syndrome in multiple pregnancies. Prenat Diagn 2020; 41:1222-1232. [PMID: 33016373 DOI: 10.1002/pd.5832] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 09/27/2020] [Indexed: 12/14/2022]
Affiliation(s)
- Glenn E Palomaki
- Department of Pathology and Laboratory Medicine, Women & Infants Hospital and the Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Rossa W K Chiu
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Mark D Pertile
- Victorian Clinical Genetics Services (VCGS), Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Erik A Sistermans
- Department of Clinical Genetics, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Yuval Yaron
- Prenatal Genetic Diagnosis Unit, Genetic Institute, Tel Aviv Medical Center, Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | | | - Neeta L Vora
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert G Best
- University of South Carolina SOM Greenville, Greenville, South Carolina, USA
| | - Louise Wilkins-Haug
- Division of Maternal Fetal Medicine and Reproductive Genetics, Department of Obstetrics and Gynecology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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25
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Beriwal S, Impey L, Ioannou C. Multifetal pregnancy reduction and selective termination. ACTA ACUST UNITED AC 2020. [DOI: 10.1111/tog.12690] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Sridevi Beriwal
- Clinical Research Fellow Nuffield Department of Women’s and Reproductive Health University of Oxford OxfordOX3 9DUUK
| | - Lawrence Impey
- Consultant and Lead for Fetal Medicine Fetal Medicine Unit John Radcliffe Hospital OxfordOX3 9DUUK
| | - Christos Ioannou
- Consultant in Fetal Medicine Fetal Medicine Unit John Radcliffe Hospital OxfordOX3 9DUUK
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26
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Sebghati M, Khalil A. Reduction of multiple pregnancy: Counselling and techniques. Best Pract Res Clin Obstet Gynaecol 2020; 70:112-122. [PMID: 32859535 DOI: 10.1016/j.bpobgyn.2020.06.013] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 06/16/2020] [Indexed: 12/01/2022]
Abstract
The incidence of multiple births has risen in the last few decades. This rise is mainly due to the widespread use of assisted reproduction techniques mainly as a result of increasing maternal age at conception. Twin and higher-order multiple pregnancies are associated with increased risk of perinatal, as well as maternal, mortality and morbidity compared to singleton pregnancies. There can also be psychosocial and socioeconomic implications for women and their families. In this chapter, we aim to discuss the risks associated with multiple pregnancies, the pros and cons of fetal reduction, the current techniques used in clinical practice, and how to approach counselling parents, enabling them to make informed decisions.
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Affiliation(s)
- Mercede Sebghati
- Fetal Medicine Unit, St George's University Hospitals, Blackshaw Road, London, UK
| | - Asma Khalil
- Fetal Medicine Unit, St George's University Hospitals, Blackshaw Road, London, UK; Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, Cranmer Terrace, London, UK; Twins Trust Centre for Research and Clinical Excellence, UK.
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27
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Greenberg G, Bardin R, Danieli-Gruber S, Tenenbaum-Gavish K, Shmueli A, Krispin E, Oron G, Wiznitzer A, Hadar E. Pregnancy outcome following fetal reduction from dichorionic twins to singleton gestation. BMC Pregnancy Childbirth 2020; 20:389. [PMID: 32620088 PMCID: PMC7333296 DOI: 10.1186/s12884-020-03076-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 06/24/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND There are still some controversies regarding the risks and benefits of fetal reduction from twins to singletons. We aimed to evaluate if fetal reduction from twins to singleton improves pregnancy outcome. METHODS Retrospective analysis of all dichorionic-diamniotic twin pregnancies, who underwent fetal reduction. Pregnancy outcome was compared to ongoing, non-reduced, dichorionic-diamniotic gestations. Primary outcome was preterm birth prior to 37 gestational weeks. Secondary outcomes included: preterm birth prior to 34 gestational weeks, gestational age at delivery, birthweight, small for gestational age, hypertensive disorders, gestational diabetes and stillbirth. RESULTS Ninety-eight reduced pregnancies were compared with 222 ongoing twins. Preterm birth < 37 gestational weeks (39.6% vs. 57.6%, p < 0.001) was significantly lower in the reduced group compared to the ongoing twins' group. A multivariate analysis, controlling for parity and mode of conception, demonstrated that fetal reduction independently and significantly reduced the risk for prematurity (aOR 0.495, 95% CI -0.299-0.819). Subgroup analysis, similarly adjusted demonstrated lower rates of preterm delivery in those undergoing elective reduction (aOR = 0.206, 95% CI 0.065-0.651), reduction due to fetal anomalies (aOR = 0.522, 95% CI 0.295-0.926) and 1st trimester reduction (aOR = 0.297, 95% Cl 0.131-0.674) all compared to ongoing twins. A Kaplan-Meier survival curve showed a significant proportion of non-delivered women at each gestational week in the reduced group compared to non-reduced twins, after 29 gestational weeks. CONCLUSIONS Fetal reduction from twins to singleton reduces the risk of preterm birth < 37 gestational weeks, but not for more severe maternal and perinatal complications.
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Affiliation(s)
- Gal Greenberg
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Bardin
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shir Danieli-Gruber
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kinneret Tenenbaum-Gavish
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Shmueli
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Krispin
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Galia Oron
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arnon Wiznitzer
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eran Hadar
- Helen Schneider's Hospital for Women, Rabin Medical Center, 39 Jabotinsky Street, 4941492, Petach-Tikva, Israel. .,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Liu Y, Wang XT, Li HY, Hou HY, Wang H, Wang YT. Safety and Efficacy of Higher Order Multifetal Pregnancy Reduction: A Single-Center Retrospective Study. AJP Rep 2020; 10:e228-e233. [PMID: 33094010 PMCID: PMC7571566 DOI: 10.1055/s-0040-1715167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Accepted: 04/24/2020] [Indexed: 11/02/2022] Open
Abstract
Objective This research was aimed to study the safety and efficacy of higher order multifetal pregnancy reduction (MFPR). Study Design This was a retrospective study of patients from an academic maternity center between 2005 and 2015. We evaluated outcomes of 131 consecutive patients who underwent higher order MFPR (quadruplets and greater). MFPR was performed at 11 to 18 weeks of gestation in all cases. In total, 122 of 131 cases of higher order multiple pregnancy were reduced to twins. We discuss the perinatal outcomes of patients who underwent higher order MFPR, followed by a comparative analysis between the 122 cases of MFPR that were reduced to twins and 101 cases of nonreduced twin pregnancies. Results The study included 104 sets of quadruplets, 20 sets of quintuplets, 5 sets of sextuplets, 1 set of septuplets, and 1 set of octuplets. The perinatal outcomes of the 131 cases were as follows: pregnancy loss, preterm deliveries at 28 to 33 (+ 6/7 ) weeks, and preterm deliveries at 34 to 36 (+ 6/7 ) weeks occurred in 23.66, 9, and 37% of cases, respectively. The mean time of delivery was 36.56 ± 1.77 weeks, and mean birth weight was 2,409.90 ± 458.16 g, respectively. A total of 122 cases that were reduced to twins were compared with nonreduced twins. The pregnancy loss rate for reduced twins was significantly higher than that for nonreduced twins. The preterm labor rate, mean delivery week, mean birth weight, birth-weight discordance, incidence of gestational diabetes mellitus, and pregnancy-induced hypertension were not significantly different between the groups ( p > 0.05). Conclusion Perinatal outcomes were significantly improved by reducing the number of fetuses in higher order multifetal pregnancies. This study involved a large, diverse sample population, and the results can be used as a reference while conducting prenatal counseling.
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Affiliation(s)
- Yan Liu
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
- Department of Obstetrics and Gynecology, Shandong Qianfoshan Hospital, Cheeloo College of Medicine, Shandong University, Jinan, China
| | - Xie Tong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hong Yan Li
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hai Yan Hou
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Hong Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yan Tun Wang
- Department of Obstetrics and Gynecology, Shandong Provincial Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
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Ouyang Y, Cai P, Gong F, Lin G, Qin J, Li X. The risk of twin pregnancies should be minimized in patients with a unicornuate uterus undergoing IVF-ET. Sci Rep 2020; 10:5571. [PMID: 32221343 PMCID: PMC7101414 DOI: 10.1038/s41598-020-62311-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 02/24/2020] [Indexed: 11/23/2022] Open
Abstract
Unicornuate uteri are associated with infertility, miscarriage, preterm delivery and even uterine rupture. The aim of this research was to investigate the effects of unicornuate uterine anomaly on twin pregnancies after in vitro fertilization-embryo transfer (IVF-ET). A total of 206 women with unicornuate uteri (A singleton, B selective reduction (SR) of twins to a singleton, C twins) and 314 women with normal uteri (D SR of twins to a singleton, E twins) who delivered at ≥22 weeks were included. C was associated with a significantly lower live birth rate (adjusted odds ratio (aOR) 0.08, 95% confidence interval (CI), 0.01-0.69) and higher risks of preterm delivery (aOR 11.63, 95% CI, 4.85-27.92), perinatal mortality (aOR 11.43, 95% CI, 1.44-90.57) and low birth weight (aOR 5.92, 95% CI 1.94-18.06) than A, a 15-fold greater risk of preterm delivery (aOR 15.54, 95% CI 3.09-78.28) than B and a greater risk of preterm delivery (aOR 2.76, 95% CI 1.33-5.73) than E. After SR to a singleton, the perinatal outcomes were statistically similar between B and D. These results showed that the risk of twin pregnancies should be minimized in patients with unicornuate uterine anomaly undergoing IVF-ET.
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Affiliation(s)
- Yan Ouyang
- College of Life Science, Hunan Normal University, Changsha, China
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Pei Cai
- Institute of Reproductive and Stem Cell Engineering, Central South University, Changsha, China
| | - Fei Gong
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Ge Lin
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China
| | - Jiabi Qin
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
| | - Xihong Li
- Reproductive and Genetic Hospital of CITIC-Xiangya, Changsha, China.
- Clinical Research Center For Reproduction and Genetics in Hunan Province, Changsha, China.
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30
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Rusanova NE. Gender choice in assisted reproductive technologies: opportunities, dangers, prospects. POPULATION 2020. [DOI: 10.19181/population.2020.23.2.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Today, assisted reproductive technologies (ART) are a birth rate factor, which allows almost every person to give birth to a child, regardless of health. Fully reliable gender selection is only possible through pre-implantation diagnostics (PGD) as part of in vitro fertilization (IVF). Usually preference is given to boys, and the problem turns from individual family into a socio-gender problem, which can only be solved at the state level. While traditional methods of gender regulation involved selective abortions or killing of newborns («infanticide»), modern ART technically solves the issue at the pre-implantation stage, but entails ethical, psychological and financial problems that require special control. By prohibiting sex-selective abortions, the state limits the possibility of gender choice at the stage of conception to the risk of inherited diseases transmission due to fears of seriously disturbing natural gender balance, creating prerequisites for «genomocide». According to the National ART registries, Surveys of the International Federation of Fertility Societies for 2010–2019, Russian and foreign «hospital» statistics and the media, the article shows increase in the popularity of PGD that makes it possible to make a gender choice. In Russia, where the number of children in a family rarely exceeds two, and reproductive clinics perform all IVF programs, the choice of child’s gender is possible only with medically-justified PGD, and almost always performed at the expense of the patient. The only perspective in this situation is inclusion of such a PGD in the Compulsory Health Insurance system, when the gender of an unborn child becomes an additional, and its health — the main result.
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Affiliation(s)
- Nina E. Rusanova
- Institute of Socio-Economic Studies of Population, Federal Center of Theoretical and Applied Sociology, Russian Academy of Sciences, Moscow, Russian Federation
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31
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Luo L, Fan XZ, Jie HY, Gao Y, Chen M, Zhou C, Wang Q. Is it worth reducing twins to singletons after IVF-ET? A retrospective cohort study using propensity score matching. Acta Obstet Gynecol Scand 2019; 98:1274-1281. [PMID: 31081540 DOI: 10.1111/aogs.13640] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Revised: 05/07/2019] [Accepted: 05/09/2019] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Many studies have shown that multifetal reduction of high-order multiple pregnancies results in improved pregnancy outcomes. However, whether conducting elective fetal reduction from dichorionic twins after in vitro fertilization (IVF) is worthwhile remains controversial. This study aimed to determine whether elective fetal reduction of dichorionic twins after IVF and embryo transfer (IVF-ET) is associated with increased take-home baby rate. MATERIAL AND METHODS This was a retrospective cohort study of 3600 dichorionic twin pregnancies after IVF-ET. The reduced group included 71 women with transvaginal elective fetal reduction between 7 and 8 weeks of gestation. The control group (n = 3529) comprised women who were managed expectantly. Propensity score matching was conducted before pregnancy outcomes were compared. RESULTS The take-home baby rate was significantly lower in the reduced group (83.1% vs 92.8%, P = 0.004). The total miscarriage rate was significantly higher in the reduced group (12.7% vs 6.2%, P = 0.04). Although preterm delivery rate was lower in the reduced group (P < 0.001), over 90% were over 32 weeks, whereas the proportions were equal in the reduced group. CONCLUSIONS In dichorionic twin pregnancies after IVF-ET, elective fetal reduction to singleton significantly decreased the chance of taking home live babies.
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Affiliation(s)
- Lu Luo
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Xiong-Zhi Fan
- Department of Medical Statistics and Epidemiology, School of Public Health, Sun Yat-sen University, Guangzhou, China
| | - Hui-Ying Jie
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Yong Gao
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Minghui Chen
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Canquan Zhou
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
| | - Qiong Wang
- The Center of Reproductive Medicine, The First Affiliated Hospital, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Reproductive Medicine, Guangzhou, China
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Ethical Considerations in Multiple Pregnancy: Preterm Delivery in the Setting of Discordant Fetal Anomaly. Twin Res Hum Genet 2019; 22:120-123. [PMID: 31023394 DOI: 10.1017/thg.2019.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Planning for the preterm birth of a fetus with known anomalies can raise complex ethical issues. This is particularly true of multiple pregnancies, where the interests of each fetus and of the expectant parent(s) can conflict. In these complex situations, parental wishes and values can also conflict with the recommendations of treating clinicians. In this article, we consider the case of a dichorionic twin pregnancy complicated by the diagnosis of vein of Galen aneurysmal malformation (VGAM) in one of the twins at 28 weeks' gestation. Subsequent deterioration of the affected twin prompted the parents to request preterm delivery to prevent the imminent in-utero demise of the affected twin. However, given the associated risks of prematurity, complying with the parents' request may have disadvantaged the health and wellbeing of the unaffected twin. This article canvases the complex ethical issues raised when parents request preterm delivery of a multiple pregnancy complicated by a fetal anomaly in one twin, and the various ethical tools and frameworks that clinicians can draw on to guide their decision-making in such cases.
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The outcome of the multifetal pregnancy reduction procedures in a single centre: A report of 202 completed cases. Eur J Obstet Gynecol Reprod Biol 2018; 230:22-27. [PMID: 30237136 DOI: 10.1016/j.ejogrb.2018.09.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 09/10/2018] [Indexed: 11/24/2022]
Abstract
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.
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35
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Drugan A, Weissman A. Multi-fetal pregnancy reduction (MFPR) to twins or singleton - medical justification and ethical slippery slope. J Perinat Med 2017; 45:181-184. [PMID: 27219098 DOI: 10.1515/jpm-2016-0058] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 04/19/2016] [Indexed: 11/15/2022]
Abstract
Multi-fetal pregnancy reduction (MFPR) is an ethically acceptable procedure aimed to increase survival and well-being of the remaining fetuses from high-order multiple gestations. In most cases we offer the procedure to triplets or quadruplets and opt to preserve twins; lately, the option to maintain a single fetus was suggested. We examined the outcomes of 140 pregnancies that underwent MFPR in our center and were followed to delivery - 105 were reduced to twins and 35 to singletons. The rate of procedure-related pregnancy loss was identical (2.9%). Leaving only one fetus was associated with a higher gestational age at delivery (35.4±2.4 weeks vs. 37.7±2.1 weeks, P<0.0001), with heavier neonates (2222 g vs. 3017 g, P<0.0001) and with a reduction in the cesarean section (CS) rate (76% in twins vs. 51.4% in singletons, P=0.02). Six pregnancies reduced to twins (5.8%) ended before 32 weeks as compared to one pregnancy reduced to a singleton. We conclude that reduction of triplets to singletons is medically and ethically acceptable, after thorough counseling of patients. However, considering the pregnancy loss risk of MFPR and the relatively good outcome of twin gestations, reduction of twins to singletons is ethically acceptable only in extraordinary maternal or fetal conditions.
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Haas J, Barzilay E, Hourvitz A, Dor J, Lipitz S, Yinon Y, Shlomi M, Shulman A. Outcome of early versus late multifetal pregnancy reduction. Reprod Biomed Online 2016; 33:629-634. [DOI: 10.1016/j.rbmo.2016.08.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 08/14/2016] [Accepted: 08/16/2016] [Indexed: 11/17/2022]
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Quarello E, Jacquemard F, Ville Y. [Screening of aneuploidies in twin pregnancies in 2016: We may miss the boat if we fail to take action]. ACTA ACUST UNITED AC 2016; 44:457-60. [PMID: 27363614 DOI: 10.1016/j.gyobfe.2016.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Indexed: 10/21/2022]
Affiliation(s)
- E Quarello
- Unité d'échographie et de diagnostic prénatal, hôpital Saint-Joseph, 26, boulevard de Louvain, 13285 Marseille cedex 08, France; Institut de médecine de la reproduction, 6, rue Rocca, 13008 Marseille, France.
| | - F Jacquemard
- Centre de diagnostic prénatal, hôpital américain de Paris, 63, boulevard Victor-Hugo, 92200 Neuilly-sur-Seine, France
| | - Y Ville
- Service d'obstétrique et de médecine fœtale, université Paris Descartes, hôpital Necker-Enfants-Malades, AP-HP, 149, rue de Sèvres, 75015 Paris, France
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Cordoba M, Andriole S, Evans SM, Britt D, Chu Lam M, Evans MI. Integrating Microarrays into Routine Prenatal Diagnosis: Determinants of Decision Making. Fetal Diagn Ther 2016; 40:135-40. [PMID: 26744845 DOI: 10.1159/000442197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 10/30/2015] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The explosion in genetic technologies, including array comparative genomic hybridization (aCGH), has increased the complexity of genetic counseling. We now offer chorionic villus sampling (CVS) and aCGH to all first-trimester patients, as this allows the prenatal diagnosis of an additional 1% of anomalies not otherwise detectable and can detect genetic copy number variants at a much higher resolution than conventional cytogenetics. Here, we explored some of the determinants of how patients are deciding to use or not use this new technology and evaluate risk-benefit analyses for that decision. METHODS This is a retrospective case-control study of singleton and multiples pregnancies at our center. Those having aCGH testing along with CVS were defined as 'testers' and those who declined aCGH but had the CVS were 'nontesters'. RESULTS Demographic data of 181 educated women who chose CVS were compared. Among those carrying singletons (n = 144), older women, defined as over 35 years of age (or 'advanced maternal age'; AMA), were more likely to choose the aCGH than younger women. Further, women who had a prior history of genetic testing and who wanted to know the gender of the fetus were more likely to choose the aCGH test. In women carrying multiples (n = 37), AMA ceases to be a predictor of choice. Having had prior genetic counseling remains a strong predictor for choosing aCGH, as does wanting to know the gender of the fetus. Neither prior abortions nor having prior children were significant for women carrying singletons or multiples. CONCLUSION Offering pregnant couples an individualized choice regarding aCGH seems an appropriate approach. There are discrete patterns associated with the choice of taking the aCGH that varied depending on whether the patient was carrying a singleton or multiples.
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Affiliation(s)
- Marcos Cordoba
- Comprehensive Genetics, New York University Langone Medical Center, New York, N.Y.,USA
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Gupta S, Fox NS, Feinberg J, Klauser CK, Rebarber A. Outcomes in twin pregnancies reduced to singleton pregnancies compared with ongoing twin pregnancies. Am J Obstet Gynecol 2015; 213:580.e1-5. [PMID: 26071922 DOI: 10.1016/j.ajog.2015.06.018] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 05/06/2015] [Accepted: 06/03/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Multifetal pregnancy reduction has been shown to improve outcomes in triplet and higher-order multiple pregnancies. The data for fetal reduction of twin pregnancies are limited. The purpose of this study was to compare adverse pregnancy outcomes in ongoing twin pregnancies compared with twin pregnancies reduced to singletons. STUDY DESIGN This was a retrospective cohort study comparing dichorionic diamniotic twin pregnancies with dichorionic diamniotic twin pregnancies reduced to singleton gestations between 11 and 24 weeks' gestation in a single maternal-fetal medicine practice over a 9 year period. Adverse pregnancy outcomes after 24 weeks were compared, with a value of P < .05 used for significance. RESULTS Five hundred one ongoing twin pregnancies and 63 twin pregnancies reduced to singletons were included. Patients with reductions to singletons had a significantly lower risk of preterm delivery before 37 weeks' gestation (10% vs 43%; P < .001) but no difference in the risk of preterm delivery before 34 weeks' or 28 weeks' gestation. Patients with reductions to singletons also had a lower risk of infant birthweight less than the 10% (23% vs 49%; P < .001) but no difference in the risk of infant birthweight less than the 5%. There was no difference in the risk of fetal demise after 24 weeks' gestation. CONCLUSION Fetal reduction of twin pregnancies decreases the risk of late preterm birth and birthweight less than the 10% but not the risks of more severe complications such as early preterm birth or birthweight less than the 5%.
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Chmait RH, Kontopoulos EV, Jackson M, Horenstein J, Timor-Tritsch I, Quintero RA. Selective Reduction Using Intravascular Potassium Chloride Injection after Laser Surgery for Twin-Twin Transfusion Syndrome. Fetal Diagn Ther 2015; 39:306-10. [PMID: 26067899 DOI: 10.1159/000431255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 05/05/2015] [Indexed: 11/19/2022]
Abstract
Selective reduction (SR) via intravascular potassium chloride (KCl) injection is contraindicated in monochorionic twins due to the presence of placental vascular communications, which may serve as a conduit for inter-twin passage of KCl or allow exsanguination of the living twin into the demised twin. After successful selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS), the twins' circulatory systems are rendered independent. Theoretically, intravascular KCl injection into one twin after successful SLPCV should not result in passage of the feticidal agent nor cause hemodynamic alterations in the co-twin. We describe 3 cases of 1,069 patients (0.3%) that underwent SLPCV for TTTS between 2003 and 2013 and subsequent SR. SLPCV was successfully completed at 180, 226, and 230 weeks' gestational age for Quintero stages III, IV, and III TTTS, respectively. SR via intravascular KCl injection was later performed at maternal request due to the risk of neurological compromise in one twin at 226, 254, and 236 weeks' gestational age. All co-twins survived after SR, and no neurological sequelae were suspected after birth. Further study is necessary before SR can be routinely considered after laser surgery for TTTS.
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Affiliation(s)
- Ramen H Chmait
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, Keck School of Medicine, University of Southern California, Los Angeles, Calif., USA
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Haas J, Mohr Sasson A, Barzilay E, Mazaki Tovi S, Orvieto R, Weisz B, Lipitz S, Yinon Y. Perinatal outcome after fetal reduction from twin to singleton: to reduce or not to reduce? Fertil Steril 2014; 103:428-32. [PMID: 25455874 DOI: 10.1016/j.fertnstert.2014.10.027] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2014] [Revised: 10/14/2014] [Accepted: 10/17/2014] [Indexed: 10/24/2022]
Abstract
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.
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Affiliation(s)
- Jigal Haas
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel.
| | - Aya Mohr Sasson
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
| | - Eran Barzilay
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
| | - Shali Mazaki Tovi
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
| | - Raoul Orvieto
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
| | - Boaz Weisz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
| | - Shlomo Lipitz
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
| | - Yoav Yinon
- Department of Obstetrics and Gynecology, Sheba Medical Center, Sackler School of Medicine, Tel-Aviv University, Tel-Hashomer, Israel
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