Monochorionic high-order multiple pregnancies and multifetal pregnancy reduction

OBJECTIVE: To study the frequency and obstetric outcome of monochorionic multiple pregnancies in a population referred for fetal reduction. METHODS: Data charts of all patients with multifetal (> or =3) pregnancies referred for fetal reduction over the last 10 years were reviewed for the presence of monochorionic twin pairs or triplets. RESULTS: Twenty-nine of 239 high-order multiple pregnancies contained a monochorionic component (12.1%), eight of which were monochorionic triplets. Half of all naturally conceived pregnancies contained a monochorionic component. High-order multiple pregnancies with a monochorionic component resulted significantly more frequently from natural conceptions (7 of 29) than multichorionic pregnancies (7 of 210) (P =.001). Fetal reduction of the monochorionic twin pair in 21 pregnancies resulted in eight twin and 13 singleton pregnancies; mean gestational age at delivery was, respectively, 34.3 +/- 2.9 and 39.2 +/- 1.4 weeks. Pregnancy loss rate was one of 21 (4.8%). In the remaining eight multiple pregnancies with a monochorionic triplet present, three were complicated by a twin reversed arterial perfusion sequence, and two couples requested a first trimester termination of pregnancy. Fetal reduction of the monochorionic triplet in a dichorionic quadruplet pregnancy resulted in a normal pregnancy outcome. In two monochorionic triplet pregnancies, fetal reduction to monochorionic twin pregnancies with bipolar coagulation of the umbilical cord resulted in a favorable pregnancy outcome. CONCLUSION: Monochorionic twins or triplets are frequently part of naturally conceived high-order multiple pregnancies. Reduction of the monochorionic twin pairs improves pregnancy outcome. Monochorionic triplet pregnancies show a high complication rate, but may benefit from fetal reduction by cord coagulation.     

体外受精-胚胎移植中含单绒毛膜双胎的三胎减胎术后妊娠结局分析

目的:探讨体外受精-胚胎移植(IVF-ET)中移植2枚胚胎后发生三胎妊娠行单绒毛膜双胎中一胎减灭术后的妊娠结局。方法:回顾性分析27例行单绒毛膜双胎中一胎减灭术的三胎妊娠患者的临床资料,了解术后一般情况,并对比术后仍保留双胎妊娠的与同期非减胎双胎妊娠的妊娠结局及新生儿情况。结果:减胎术后有12例(44.44%)发生自然减灭仅留一胎;保留双胎组与非减胎双胎组患者平均年龄、平均孕周及平均胎儿出生体质量无统计学差异(P0.05);早期均无流产发生,晚期流产率分别为6.67%和10.00%,抱婴回家率分别为93.33%、90.00%,早产率分别为21.43%和37.04%,低体质量儿出生比例分别为21.43%和33.33%,围产儿死亡率分别为0.0%和3.7%,组间均无统计学差异(P0.05),减胎后双胎组和非减胎双胎组均无畸形儿出生。结论:行减灭单绒毛膜双胎中一胎的减胎术有近一半的患者另一胎会发生自然减灭,余保留双胎的妊娠结局和新生儿一般情况与非减胎双胎妊娠组无统计学差异。     

Multifetal pregnancy reduction in pregnancies with a monochorionic component

We conducted a retrospective, cross-sectional study to evaluate the efficacy, safety, and effect of first-trimester multifetal pregnancy reduction on procedure-related complications and obstetrical outcome in multiple pregnancies with a monochorionic component. Although procedure-related complications were relatively common, the obstetrical outcome was favorable in most cases when the monochorionic twin component was reduced.     

Triplets: outcomes of expectant management versus multifetal reduction for 127 pregnancies

OBJECTIVE: Our purpose was to compare outcomes of women with triplet gestations conceived via assisted reproductive technology who chose expectant management or multifetal pregnancy reduction. STUDY DESIGN: We performed a retrospective review of all women who initiated assisted reproductive technology cycles from August 1995 through July 1997 with ultrasonographic documentation of triplets exhibiting fetal heart tones at 9 weeks of gestation (N = 127). Patients were then uniformly referred to a maternal-fetal medicine specialist and to 3 centers offering multifetal pregnancy reduction. RESULTS: Thirty-six percent of patients (46/127) chose multifetal pregnancy reduction with 95% undergoing reduction to twins. In the expectant management group, 13.6% of pregnancies were reduced spontaneously after 9 weeks of gestation. The "take home" infant per delivery rates for the multifetal pregnancy reduction and expectant management groups were 87% and 90.1%, respectively (P =.66). The mean gestational ages at delivery (+/-SE) for the multifetal pregnancy reduction and expectant management groups were 33.25 +/- 1. 03 weeks and 32.04 +/- 0.58 weeks (P =.23), and the mean birth weights of infants delivered at >24 weeks of gestation were 2226 +/- 79 and 1796 +/- 44, respectively (P <.0001). There were no significant differences in perinatal mortality, gestational age at delivery, or "take home" infant per delivery rates between these groups. CONCLUSIONS: These data suggest that multifetal pregnancy reduction does not have a significant impact on the probability of live birth or on gestational age at delivery for women with triplets conceived with assisted reproductive technology.     

Vascular occlusion in the management of complicated multifetal pregnancies

The decision to undergo ST is a personal one for the involved couple, and it can have many psychosocial implications. Appropriate counseling including offering all possible management options with related risks is imperative. Choosing the technique that best serves the clinical situation with minimization of maternal risks should be done taking under consideration the operator's experience. Ultimately, vascular occlusion techniques can help improve multifetal pregnancy outcomes in otherwise challenged gestations.     

Prevalence and outcome of higher order multiple pregnancies in Lagos,Nigeria

Abstract

Objective: To determine the prevalence and outcome of higher order multiple (HOM) pregnancies in Lagos, Nigeria.

Methods: The mode of delivery, gestational age, pregnancy and neonatal outcome of babies delivered from HOM pregnancies were reviewed retrospectively from the labor ward and theater registers, neonatal unit admission records and medical notes in a tertiary referral centre from April 2009 to March 2012.

Results: Twenty-two (15, 6 and 1 set of triplets, quadruplets and quintuplet, respectively) of 6521 pregnancies delivered during the period were HOM pregnancies giving a prevalence of 3.37/1000. All the 74 babies except 12 were delivered by cesarean section. There were 18 perinatal deaths giving a perinatal mortality rate of 243 per 1000. Overall mortality was significantly associated with no antenatal booking (21 versus 5, OR: 21.0, 95% CI: 2.1–72.3, p?=?0.000), gestational age ≤30 weeks (21 versus 5, OR: 46.2, 95% CI: 11.2–189.9, p?=?0.000) and birth weight <1000?g for live births (p?=?0.000). Mode of delivery and number of fetuses >3 were however not significantly associated with mortality.

Conclusion: Reduction of early preterm births by proper antenatal care and close feto-maternal monitoring of HOM pregnancies will significantly reduce the resultant immediate poor outcomes for these pregnancies and their newborns.     

Clinical outcomes of multifetal pregnancy reduction in trichorionic and dichorionic triplet pregnancies: A retrospective observational study

Objective

To observe the pregnancy and perinatal outcomes of trichorionic triplet (TCT) and dichorionic triplet (DCT) pregnancies with or without multifetal pregnancy reduction (MFPR).

Multifetal pregnancy reduction of triplet and higher-order multiple pregnancies to twins

This systematic review was performed to assess the effects of multifetal pregnancy reduction for women with triplet and higher-order multiple pregnancies on fetal loss, preterm birth, and perinatal and infant mortality and morbidity. From nonrandomized studies, multifetal pregnancy reduction seems to be an effective treatment option, with outcomes comparable to those obtained from twin pregnancies conceived spontaneously or after assisted reproductive techniques.     

多胎妊娠晚期1胎死亡后的期待疗法

目的 探讨多胎妊娠晚期l胎死亡后期待疗法的价值。方法 回顾性分析1997年1月至2002年12月住院分娩多胎孕妇344例，分析19例多胎妊娠晚期l胎死亡的临床处理。结果 19例多胎妊娠晚期l胎死亡后的存活胎儿在临床观察、超声、胎心监护及实验室检查监测下，期待1～8周均成活并分娩，母体凝血功能未发现异常。结论 在严密监测下，无产科并发症的多胎妊娠晚期l胎死亡后的活胎可以期待，从而降低成活胎儿的病死率。     

Relative contribution of ovarian stimulation versus in vitro fertilization and intracytoplasmic sperm injection to multifetal pregnancies requiring reduction to twins

The proportion of twins resulting from multifetal pregnancy reduction of higher-order multiples is increased in pregnancies resulting from hormone stimulation when compared with twins following in vitro fertilization/intracytoplasmic sperm injection treatment. These reduced twin pregnancies may carry a higher perinatal risk compared with other twin pregnancies, which should be taken into account when assessing the perinatal outcome of twin pregnancies after assisted reproduction.     

Twin pregnancies discordant for anencephaly-management, pregnancy outcome and review of literature

AIMS and METHODS: To examine the prognosis of conservative management in twin pregnancies discordant for anencephaly, we review the literature and report on four of our own cases, which were analyzed retrospectively. RESULTS: In the University Hospital of Erlangen, six twin pregnancies discrepant for anencephaly were observed during an 8-year period (1992-2000). Four of these pregnancies were managed conservatively. Preterm delivery occurred in all of the cases, but the unaffected fetuses all had favorable long-term outcome. Delayed interval delivery was performed in two cases due to extreme immaturity in the healthy fetus. CONCLUSIONS: Our data show that in twin pregnancies with early diagnosis of anencephaly in one fetus, the risk of premature delivery of the healthy fetus may be more increased than is already known in the literature. Therefore, selective fetocide of the anencephalic fetus is a management option, at least in dichorionic pregnancies, to prevent polyhydramnios and to reduce the risk of preterm delivery.     

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

ObjectiveTo compare the different pregnancy outcomes of women with a reduced dichorionic triamniotic (DCTA) triplet managed with radiofrequency ablation (RFA) or potassium chloride (KCL).Materials and methodsThis was a retrospective cohort study. We studied 30 women of DCTA triplets managed with RFA as well as 85 managed with KCL. We compared the mean neonatal birthweight, median gestational age and perinatal mortality of two groups.ResultsThe mean neonatal birthweight of children in RFA group was 2572.4 g (SD, 407.0), vs 2899.3 g (SD, 554.9) in KCL group (P < 0.001). The rate of low birth weight infants was 23 (42.6%) vs. 16 (18.0%), respectively, (p < 0.005). However, there was no statistically significant difference in the median gestational age of delivery, premature birth before 32&37 weeks' gestation, neonatal brain injury or successful pregnancy between two groups. (We define the successful pregnancy as the condition that at least one child survives for a specific woman, while the failed one as no child survives.)ConclusionWhat we took it for granted was that pregnancy outcomes in women with a reduced DCTA triplet managed with RFA was riskier than with KCL, however, we proved that it is not accurate. For women with a reduced DCTA triplet, managed with RFA is not much riskier than with KCL. What's more, most women have two children survived in RFA group, while in KCL group, only one child survives for most women. This result may change the management alternative for those women with DCTA triplet pregnancies who choose reduction, especially for women who desire to have two surviving and healthy fetuses.     

Two hundred ninety consecutive cases of multifetal pregnancy reduction: comparison of the transabdominal versus the transvaginal approach

OBJECTIVE: The purpose of this study was to compare the performance of the transabdominal versus the transvaginal route for the multifetal pregnancy reductions. STUDY DESIGN: Two hundred ninety consecutive cases of multifetal pregnancy reduction were reviewed. Two hundred three reductions (70.0%) were done transabdominally; 75 cases (25.9%) were done transvaginally, and 12 cases (4.1%) used both routes. The indications for the transvaginal route were extreme obesity, abdominal scars, or if the lower fetus could not be reached transabdominally. Two hundred seventy-one women were delivered of live born babies after 24 weeks (group 1). Nineteen cases had pregnancy losses /=6 fetuses. For finishing numbers, total pregnancy losses were 5.1% for ending with a singleton infant, 6.6% for ending with twins, and 0% for ending with triplets. Significant differences in complete pregnancy loss were observed between transabdominal and transvaginal routes for starting with triplets (2.7% for transabdominal versus 16.7% for transvaginal; P = .006) and for finishing with a single fetus (0% for transabdominal versus 20% for transvaginal; P < .004). CONCLUSION: The multifetal pregnancy reduction success rate was higher with the transabdominal route compared with the transvaginal route. Significant differences in favor of the transabdominal route were observed for starting with triplets or finishing with a single fetus. The transvaginal route should be reserved only for cases in which the transabdominal approach is hard or impossible to perform. The performance of the procedure at 12 to 13 weeks of gestation enables structural evaluation of the fetuses before reduction.     

多胎妊娠选择性减胎术的时机对妊娠结局的影响

目的 比较不同孕周实施减胎术后的妊娠结局,分析选择性减胎术(简称减胎术)的手术时机对妊娠结局的影响. 方法 选择2002年1月至2012年2月期间,在山东大学附属省立医院产科就诊的辅助生殖技术(assisted reproductive technology,ART)后妊娠的双(多)胎妊娠孕妇302例,其中减胎组为三胎和四胎妊娠孕妇152例,分别于妊娠12～13+6(91例)、14～15+6(32例)、16～24+6周(29例)接受了减胎术,对照组为ART后妊娠的双胎妊娠孕妇150例.手术方法采用超声引导下经腹胎儿心脏注射氯化钾.采用回顾性分析方法,记录分娩孕周和新生儿出生体重,观察妊娠期糖尿病和妊娠期高血压疾病的发病情况.采用t检验、单因素方差分析或x2检验进行统计学分析. 结果 减胎组流产率(14.5％,22/152)高于对照组(6.7％,10/150),差异有统计学意义(x2=4.857,P＜0.05);妊娠16～24+6周减胎组流产率(31.0％,9/29)分别高于妊娠12～13+6周减胎组(8.8％,8/91)和对照组,差异均有统计学意义(x2分别为7.212、12.749,P＜0.05);妊娠12～13+6和14～15+6周减胎组流产率(15.6％,5/32)分别与对照组比较,差异均无统计学意义(x2分别为0.370、1.739,P＞0.05).减胎组和对照组的平均分娩孕周分别为(36.9±1.8)周和(37.0±1.8)周,重体重儿出生体重分别为(2720.4±455.0)g和(2729.1±413.8)g、轻体重儿出生体重分别为(2409.2±412.6)g和(2416.2±436.8)g,差异均无统计学意义(t分别为 0.346、-0.163、-0.136,P＞0.05).减胎组和对照组妊娠28～34周分娩率分别为6.2％(8/130)和6.4％(9/140)、胎儿生长不均称发生率分别为12.3％(16/130)和11.4％(16/140)、妊娠期糖尿病发病率分别为3.1％(4/130)和2.1％(3/140),妊娠期高血压疾病发病率分别为11.5％(15/130)和8.6％(12/140),差异均无统计学意义(x2分别为0.009、0.050、0.659、0.010,P＞0.05). 结论 实施选择性减胎术将多胎妊娠减至双胎,术后存在流产风险.掌握适宜的手术时机,在妊娠16周前手术,能够存一定程度上降低流产率.     

Expectant management of early pregnancies of unknown location: a prospective evaluation of methods to predict spontaneous resolution of pregnancy

Objective To assess prospectively the ability of two multiparameter diagnostic models and their individual components to predict the outcome of early pregnancies which could not be identified on transvaginal ultrasound scan.
Design Prospective observational study.
Setting Dedicated early pregnancy unit in an inner city teaching hospital.
Population Women with a positive urine pregnancy test and clinical suspicion of early pregnancy complications.
Methods A full medical history, clinical examination and transvaginal ultrasound scan were carried out at the initial visit. When the location of the pregnancy could not be ascertained by ultrasound, serum beta-human chorionic gonadotrophin ( β -hCG) and progesterone levels were measured. All women were managed expectantly until either a normal pregnancy was visualised on scan; the pregnancy resolved spontaneously or intervention was required due to a worsening of clinical symptoms or non-declining β -hCG levels.
Main outcome measures Spontaneous resolution of pregnancy (i.e. cessation of symptoms and decline in serum β -hCG level to < 20 iu/L) without need for any active intervention.
Results Of the 104 women recruited, 72 (69%) pregnancies resolved spontaneously. Both multiparameter diagnostic models identified resolving pregnancies with positive predictive values  ≥ 95%  . Their performances were not significantly better compared with individual progesterone levels which achieved a positive predictive value of 97% using a cutoff level of 20 nmol/L.
Conclusion Serum progesterone measurement alone is as accurate as more complex diagnostic models for the prediction of successful expectant management in pregnancies of unknown location.     

Doppler waveforms patterns of vascular anastomoses in monochorionic twin pregnancies. A report of three cases and review of the literature

Three cases of intermittent absent end-diastolic and reversed end-diastolic flow velocity (A/REDV) are reported in the proximal umbilical artery of the growth-retarded twin in monochorionic twin pregnancies. This typical doppler velocimetric pattern has been related to arterio-arterial anastomoses in two cases of intra-uterine growth retardation and in one case of twin-twin transfusion syndrome. According to the literature, superficial arterio-arterial anastomoses may be detected by doppler colour velocimetry in 75 to 85% of cases, while identification of arteriovenous connections is more difficult to be documented in vivo (50% of cases in experienced hands). The role of superficial vascular anastomoses, either arterio-arterial or venovenous, and that of deep arteriovenous communications is now well documented in the main complications of monochorionic pregnancies, particularly for twin-twin transfusion syndrome, intrauterine growth retardation, intrauterine fetal death and acardiac twins.