Inflammatory bowel disease and preterm delivery

Objective: The present study investigates pregnancy outcome in women with IBD and examines the effect of pregnancy on the severity of IBD. Method: A case-control study comparing deliveries by mothers with IBD between January 1988 and January 2005 was performed. For every birth by a mother with IBD, four births by non-IBD mothers were randomly selected and adjusted for ethnicity and year of delivery. Result: During the study period there were 48 deliveries to patients with Crohn's disease and 79 deliveries to patients with ulcerative colitis. Higher rates of preterm delivery (< 37 weeks) were found among patients with IBD as compared to the controls (odds ratios (OR) = 2.2; 95% confidence interval (CI) = 1.3–3.8). This association remained significant after adjustment for labor induction and multiple gestations, using the Mantel–Haenszel technique (weighted OR = 2.1; 95% CI 1.3–3.5 and weighted OR = 2.0; 95% CI 1.2–3.5; P = 0.012; respectively). In addition, these patients had higher rates of fertility treatments (OR = 2.2; 95% CI = 1.1–4.4). Using a multivariate analysis, controlling for maternal age and fertility treatments, preterm delivery was seen to be significantly associated with IBD (adjusted OR = 2.0; 95% CI = 1.2–3.5). Perinatal outcomes, such as perinatal mortality, low Apgar scores, and congenital malformations, were comparable to the outcomes in the control group. Conclusion: Maternal IBD is an independent risk factor for preterm delivery. IBD is not associated with adverse perinatal outcome.     

Anal incontinence among women with one versus two complete third-degree perineal lacerations

Objective: To compare the rate of anal incontinence and severe incontinence among women who had 0, 1, and ≥ 2 additional vaginal deliveries after sustaining a third-degree perineal laceration and between subjects with one versus two third-degree tears. Method: A telephone survey was done to assess the anal function of all subjects who sustained a complete third-degree tear as a nullipara. Result: The rate of anal incontinence and severe incontinence was similar among women who had 0, 1, and ≥ 2 additional deliveries (11/65, 11/67, and 12/40, p = 0.179; 2/65, 1/67, and 2/40, p = 0.811) and between women who had one sphincter tear and no additional delivery versus those with two tears and ≥ 2 subsequent deliveries (11/65 and 10/37, p = 0.225. 2/65 and 2/37, p = 0.460). Conclusion: Additional vaginal deliveries and a repeat sphincter tear after the initial third-degree laceration were not associated with a higher rate or severity of anal incontinence.     

Intravaginal misoprostol 600 μg and 800 μg for the treatment of early pregnancy failure

Objective: To compare the respective effectiveness and safety of 600 μg and 800 μg of intravaginal misoprostol for complete abortion in cases of early pregnancy failure (occurring in the first 12 weeks). Method: A total of 114 women with a diagnosis of early pregnancy failure made by transvaginal ultrasonography at Rajavithi Hospital between November 25, 2002 and July 31, 2003, were assigned randomly to 2 groups of equal size. In one group the women received 600 μg of misoprostol and in the other 800 μg of misoprostol intravaginally. Results: The rate of complete abortion within 24 h was significantly higher in the group that received 800 μg of misoprostol (68.4%) than in the other group (45.6%) (P < 0.05). There were no significant differences between the 2 groups regarding time interval between misoprostol insertion and complete abortion or side effects. Conclusion: Intravaginal misoprostol 800 μg is significantly more effective than vaginal misoprostol 600 μg for the termination of an early pregnancy failure, with no significant differences in side effects.     

Pregnancy outcome in renal transplant recipients

Objective: To correlate pregnancy outcome with complications in pregnancy and transplantation-to-pregnancy interval in renal transplant recipients in Croatia. Method: Data on 23 pregnancies after prepregnancy stabilization of blood pressure and normalization of graft function were retrospectively analyzed. Result: The mean interval between transplantation and conception was 3.1 years. Primary renal disease was chronic glomerulonephritis in 7, chronic pyelonephritis in 7 and agenesis of right kidney and stenosis of left renal artery in 1 patient. There were 10 term and 5 preterm deliveries, 6 induced and 2 spontaneous abortions. The mean gestational age was 38.1 weeks and the mean newborn birthweight was 3015 g. The prematurity rate was 21.7%. Patients with arterial hypertension in pregnancy, elevated serum creatinine level and bacteriuria, as well as those with conception occurring less than 2 years after transplantation, had a higher rate of therapeutic and spontaneous abortions, preterm deliveries and low birth weight infants. Conclusion: The interval between transplantation and conception, as well as allograft function during pregnancy, seem to be of great importance for successful obstetric outcome in renal transplant patients.     

Calcium to creatinine ratio in a spot sample of urine for early prediction of pre-eclampsia

Objectives: Based on the fact that urinary calcium excretion decreases in pre-eclampsia, this study was designed to determine the predictive value of calcium to creatinine ratio in a spot urine sample. Methods: The calcium to creatinine ratio was measured in a spot urine sample of 102 normotensive women at 20–24 weeks’ gestation who attended the prenatal care clinic of the Shiraz University of Medical Sciences. The women were followed-up until delivery and grouped according to pre-eclampsia occurrence. The prevalence of pre-eclampsia was measured and compared with the calcium to creatinine ratio. Results: Ninety-four women remained normotensive during pregnancy and eight developed pre-eclampsia. Mean age, gestational age at the beginning of the study, and gestational age at delivery did not differ significantly between the two groups. Mean urinary calcium concentration (15.9±8.5 mg/dl in normotensive vs. 10.2±7.5 mg/dl in pre-eclamptic women), and mean birth weight (3192±336.3 g vs. 2712±468.9 g) were significantly lower in pre-eclamptic patients (P=0.03 and 0.005, respectively). Mean calcium to creatinine ratio was also significantly lower in the pre-eclamptic group (P<0.03). Conclusions: Single urine calcium to creatinine ratio may be an effective method for screening women at greatest risk for pre-eclampsia.     

Anal sphincter disruption at vaginal delivery: is recurrence predictable?

Objectives: To evaluate the efficacy of clindamycin vaginal cream 2% once daily for 7 days in prolonging pregnancy. Study design: Randomised clinical trial of 112 women between 14 and 25 weeks of gestation with diagnosis of asymptomatic bacterial vaginosis were enrolled in a multicenter randomised trial and assigned to active or no treatment. A total of 55 women were assigned to clindamycin and 57 to no treatment. Main outcome measure: frequency of pre-term delivery. Results: The rates of pre-term delivery was 12.2% in the clindamycin group and 15.7% in the no treatment group (P=0.78). Birth weight was <2500 g in three and seven babies, respectively, in the two groups (P=0.32). Mean gestational ages at birth were 38.9 and 39.2 (P=0.52), respectively, in the clindamycin and no treatment groups. Conclusions: The results of this study suggest that treating asymptomatic bacterial vaginosis does neither markedly prolong pregnancy nor increase birthweight.     

Poor antenatal care and pregnancy outcome

Objectives: To characterize women receiving poor antenatal care and assess their perinatal risk. Design: Computerized data. Setting: Public hospital setting Paris (1987–1990). Comparison with representative sample in Ile-de-France region (n = 6423). Methods: Poor attenders with less than 3 visits (n = 210) were compared with good attenders with 3 visits or more (n = 5631). Results: Poor attenders were younger and had higher rates of perinatal mortality (4.7%), preterm delivery (Odds ratio 5.2:4.3–6.3) and low birth weight (Odds ratio 4.6:3.7–5.6). Conclusion: Women with poor antenatal care have a greater risk for adverse pregnancy outcome. This risk cannot be attributed to unfavourable living conditions only.     

Abdominal wall endometriomas

Objective: To investigate the clinical characteristics, treatment, and factors of recurrence of abdominal wall endometriomas (AWE). Method: Sixty-four cases of AWE diagnosed at Peking Union Medical College Hospital (PUMCH) from 1983 to 2003 were reviewed retrospectively. Result: There was an AWE incidence of 0.044% among the parturients undergoing cesarean section at PUMCH, of whom 87.5% had the typical complaint of an enlarging mass and pain during menstruation. Among these women, 62 underwent low abdominal surgery for endometrioma (2 for primary umbilicus endometrioma); 2 women with small endometriomas opted for a temporary medical solution and had relief after menopause. The latent period of AWE positively correlated to the women's age at onset of symptoms (P < 0.001). Of the 62 women who underwent local excision, 19 had an unsatisfactory experience with medical management. There were 5 recurrences and 1 evolution to malignancy during a mean follow-up of 83.7 months. Recurrence was closely related to the size and depth of lesions. Conclusion: Because of its typical clinical manifestations, abdominal wall endometriomas could be diagnosed before pregnancy. Surgical excision is the only effective treatment and wide local excision with clear margins is the key point to prevent recurrence.     

Recrudescent herpes labialis during and prior to early pregnancy

Objectives: To assess the experience of recrudescent herpes labialis (RHL) before and during early pregnancy. Methods: History of RHL prior to and during the first trimester of pregnancy was obtained from 3738 women attending at 10–15 weeks’ gestation. The influence of age, ethnicity, socioeconomic group, smoking behavior, and alcohol intake on RHL was assessed. Results: 1066 women (28.5%) reported a history of RHL lesions, with reduced incidence of RHL during pregnancy (0.111 lesions/subject per month) compared with outside pregnancy (0.19 lesions/subject per month) (P<0.0001). Those who did report lesions during pregnancy (n=296) experienced them at a higher monthly rate (0.41 lesions/subject per month) than before pregnancy (0.25 lesions/subject per month) (P<0.0001). RHL rate in early pregnancy was related solely to the previous rate of lesion recrudescence (P<0.001). Conclusion: Pregnant women with a history of RHL report reduced incidence of RHL during pregnancy.     

Outcome of pregnancy in renal allograft recipients

Objective  To evaluate risk factors affecting pregnancy, perinatal outcomes and graft condition in women who underwent renal transplantation. Methods  Retrospective study of 34 pregnancies in 28 renal recipients followed in a single tertiary center from January 1989 to January 2007. Main outcome measures  Pregnancy outcome, kidney allograft function, maternal complications and perinatal outcomes were evaluated in these patients. Results  Mean maternal age at time of pregnancy was 27 ± 5.1 years (18–37) and the interval between transplant and pregnancy varied between 1 and 134 months (mean 51.3 ± 34.2). Most pregnant women (25/28) were submitted to triple immunosuppression during the entire pregnancy. The fetal outcome included 27 live births (79.4%), 2 stillbirths (5.9%), 3 spontaneous abortions (8.8%) and 2 therapeutic abortions (5.9%). The most frequent maternal complications were hypertension in 18 pregnancies, 2 of which ended in pre-eclampsia; urinary tract infections in 10 pregnancies; gestational diabetes mellitus in 3, anemia in 3 and 2 acute graft rejections. The major fetal complications observed consisted of four (13. 8%) intrauterine growth restrictions and two (6.9%) stillbirths. Vaginal delivery occurred in 10 women (34.5%); in the other 19 (65.5%), a cesarean section was performed. Of the 27 successful pregnancies, 11 (40.7%) resulted in term deliveries and 16 (59.3%) in preterm deliveries (range 31–39 weeks). The mean birth weight of the offspring was 2,465 g (range 1,300–3,530). There were no major perinatal complications, but two allograft rejections occurred after pregnancy. Conclusions  This series results are in agreement with those in other studies. Even though pregnancy does not seem to adversely affect short-term renal allograft function, risks of obstetric and perinatal complications seem to be increased. Further studies of long term graft function and pediatric follow-up are needed.     

A comparison of two methods of labor induction with vaginal misoprostol

Objectives: To evaluate if labor induction with 50 μg of vaginal misoprostol twice per day is as effective as and safer than 100 μg used once per day. Methods: Misoprostol was used to induce labor in 204 consecutive pregnant women assessed as needing labor induction, 104 at the University Hospital of the West Indies in Kingston, Jamaica, and 100 at the Victoria Jubilee Hospital, also in Kingston. At the former institution the women were administered 100 μg of misoprostol once per 24 h and at the latter 50 μg every 12 h. The doses were repeated if there was no cervical change or if the woman was not in labor. Bishop scores were determined before initiation of induction and again 12 h later. Women's records were reviewed after 24 h to determine delivery outcome. Results: The indications for labor induction were similar in each group. There was no significant difference in the group demographics. In the group given 50 μg of misoprostol twice per day the mean time±S.D. from insertion of misoprostol to delivery was significantly shorter than in the other group (560.14±269.20 min vs. 729.90±471.65 min; P<0.01), and the percentage of women who were delivered within 12 h was higher (75% vs. 56.8%; P<0.002). There was no significant difference between the two groups in the rate of cesarean births, the need for oxytocin, or blood loss. Only two patients experienced uterine hyperstimulation, both in the group that had received 100 μg of misoprostol per day. There was no significant difference between the two groups in the birthweight of the neonates and in the number of neonates with Apgar scores less than 7 at 1 min and 5 min. There were, however, significantly fewer neonates who needed resuscitation (6% vs. 14.7%; P=0.04) and admission to the special care nursery (7% vs. 17%; P=0.03) in the group that had received 50 μg of misoprostol twice per day. Conclusions: A dose of 50 μg of misoprostol twice per day appears to be more efficient and safer than a dose of 100 μg once per day, but this may partially be due to weaknesses in the study design.     

Meconium stained amniotic fluid in very low risk pregnancies at term gestation

Objective: To determine the prevalence and clinical significance of meconium stained amniotic fluid (MSAF) in a low risk population at term gestation and to investigate whether MSAF is a predictor for intrapartum and neonatal morbidity. Methods: A very low risk population including 37 085 consecutive deliveries at term composed the study population. A cross-sectional study was conducted and two groups of patients were identified according to the presence (n=6164) or absence (n=30 921) of meconium in the amniotic fluid at delivery and the outcomes of the two groups compared. Results: The prevalence of MSAF was 16.6%. The incidence of cesarean section (5.6% vs 2.3% P<0.01), instrumental deliveries (3.2% vs 1.8% P<0.01), fetal distress (6.5% vs. 2.1% P<0.01), clinical chorioamnionitis (0.2% vs. 0.1% P<0.01), post-partum infection (0.5% vs. 0.2% P<0.01), 1-minute Apgar score <3 (1.9% vs. 1.1% P<0.01), small for gestational age (7.4% vs. 6.4% P<0.01). was significantly higher in the MSAF compared with the clear amniotic fluid group. Intrapartum and neonatal mortality in this low risk population was significantly higher in the MSAF group ( ) compared with women with clear AF ( ). Conclusions: MSAF in a low risk population at term gestation is a predictor for adverse perinatal outcome and peripartum complications.     

The effects of clomiphene citrate on normally ovulatory women

Objective: To investigate the efficacy of clomiphene citrate (CC) on normally ovulatory women who complained of infertility.

Design: A randomized study.

Setting: University Hospital.

Patient(s): Thirty-three normally ovulatory women with unexplained infertility.

Intervention(s): Eighteen women received CC at a 50-mg dosage. Fifteen women received no ovulation-induction drugs.

Main Outcome Measures: The pregnancy rate (PR) per patient, the PR per cycle, and the cumulative pregnancy rate.

Result(s): Seven patients in the CC group stopped taking CC, and observations were terminated because of antiestrogenic effects. The pregnancy rate (PR) per patient and the PR per cycle were significantly decreased (P < 0.005) in the CC group (4 of 18 [22.2%] and 4 of 66 [6.1%], respectively) than in the spontaneous group (11 of 15 [73.3%] and 11 of 52 [21.2%], respectively). Kaplan-Meier tests showed that the cumulative pregnancy rate in the CC group was significantly lower than in the spontaneous group (P <0.05). Five of seven patients who had stopped taking CC became pregnant in spontaneous cycles.

Conclusion(s): Administration of CC to normally ovulatory women is not efficacious in terms of increasing the pregnancy rate.     

Association of a maternal CD14 -159 gene polymorphism with preterm premature rupture of membranes and spontaneous preterm birth in multi-fetal pregnancies

CD14, the major receptor for bacterial lipopolysaccharide (LPS) as well as other microbial antigens, is a component of the innate immune system. We hypothesized that a single nucleotide C > T polymorphism at position −159 in the CD14 gene that results in elevated CD14 production would influence susceptibility to preterm premature rupture of membranes (PPROM) and spontaneous preterm birth (SPTB) in multi-fetal pregnancies. DNA from 107 mother–twin and three mother–triplet pairs was analyzed. Pregnancy outcomes were obtained after completion of testing. CD14*T homozygosity was present in 39.3% of 28 women whose pregnancies ended with PPROM, as opposed to 18.1% of 72 pregnancies without a SPTB (P = 0.03). There was no relation between the fetal CD14 genotype and PPROM. The likelihood ratio (LR) for PPROM was 2.2 for women homozygous for CD14*T. The LR increased to 3.3 and 3.6 if the CD14 polymorphism was present in combination with previously determined maternal polymorphisms in the genes coding for the inducible 70 kDa heat shock protein (hsp70-2) and the interleukin-1 receptor antagonist (IL1RN), respectively. Thus, an enhanced maternal pro-inflammatory immune response to LPS may increase susceptibility to PPROM in multi-fetal pregnancies.     

Expression of apoptosis-related proteins in peritoneal, ovarian and colorectal endometriosis

Endometriosis is defined as the presence of endometrial glands and stroma outside the uterus. Apoptosis, a physiological process by which multicellular organisms eliminate superfluous cells, is altered in tumor tissue. Here we studied the expression of the apoptosis-related proteins p53, bcl-2, bax, p21 and fas in proliferative (n = 9) and secretory (n = 9) endometrium, and in peritoneal (n = 11), ovarian (n = 20) and colorectal (n = 20) endometriosis, by qualitative and semi-quantitative immunohistochemical methods using the percentage of positive cells and HSCORE analysis.

In endometrium, p53, p21 and fas expression was low, whereas bax and bcl-2 expression was elevated. Using HSCORE analysis, only bcl-2 expression varied during the menstrual cycle (48.9 ± 34.2% in the proliferative phase, 11.5 ± 24.7% in the secretory phase, p = 0.01).

Using HSCORE analysis, p53 expression was higher in ovarian endometriosis than in peritoneal (p < 0.0001) and colorectal endometriosis (p = 0.03). P21 expression was higher in ovarian endometriosis than in peritoneal (p = 0.01) and colorectal endometriosis (p = 0.01). Bcl-2 expression was lower in ovarian endometriosis than in peritoneal (p = 0.0002) and colorectal endometriosis (p < 0.0001). Fas expression was higher in peritoneal endometriosis than in ovarian (p = 0.02) and colorectal endometriosis (p = 0.008).

In conclusion, these results confirm the involvement of apoptosis in the pathogenesis of endometriosis. Moreover, expression of apoptosis-related proteins varies according to the location of endometriosis suggesting the involvement of different apoptotic pathways.     

Prediction of adverse outcome associated with vaginal misoprostol for labor induction

Objective: To identify predictors of adverse outcome in pregnant women at term receiving 50 μg of intravaginal misoprostol for labor induction. Study design: A prospective observational study was conducted of 720 pregnant women at term with an unfavorable cervix and a medical or obstetric indication for labor induction. All patients received 50 μg of intravaginal misoprostol every 4 h up to three doses. The primary outcome measure was “adverse outcome” defined as: neonatal death, fetal acidemia and emergent cesarean delivery performed for non-reassuring fetal heart rate tracings. A stepwise logistic regression analysis was used to identify predictors of adverse outcome. Results: Tachysystole (frequent uterine contractions) (odds ratio (OR), 3.7; 95% confidence interval (CI), 1.2–10.8) and fetal tachycardia (OR, 4.8; 95% CI, 1.4–16.2) were determined as significant predictors of adverse outcome. The specificity of the model was 94.2%, whereas the sensitivity was 20.4%. Conclusion: In the absence of tachysystole and fetal tachycardia, an uneventful delivery might be expected for women receiving 50 μg of intravaginal misoprostol.     

Risk factors at caesarean section and failure of subsequent trial of labour

Objective: To identify risk factors at caesarean section (CS), related to failure of a trial of labour (TOL) in subsequent pregnancy. Study design: Hospital records (1988–1999) of the index pregnancy were reviewed at caesarean delivery for oxytocine use, indication for caesarean, dilatation of cervix, speed of dilatation, duration of contractions and birth weight. The records of the subsequent pregnancy were reviewed for successful vaginal birth after caesarean (VBAC), maternal and neonatal outcome. Data were tested for statistical significance with a Mantel–Haenszel equation for odds ratios (OR, with 95% confidence interval (CI)), a Fisher exact test or a Student’s ‘t’-test. Results: From 214 women with a previous caesarean section, 68.7% underwent a TOL, which was successful in 71.4%. A labour pattern during the index pregnancy characterised by oxytocine use (OR=3.1; 95% CI=1.4–7.1), contractions for more than 12 h (OR=3.0; 95% CI=1.3–7.0) and cervical dilatation less than 1 cm/h (OR=5.6; 95% CI=1.1–39.4) increased the risk of a failed TOL at subsequent labour significantly. Conclusion: Women who attempt VBAC may be informed that a labour pattern of their index pregnancy characterised by oxytocine use, contractions for more than 12 h and slow dilatation is associated with a reduced chance of success. A partograph obtained during first labour can be a managerial tool for subsequent labour.     

Timed intercourse after intrauterine insemination for treatment of infertility

Objective: To compare the pregnancy rates, between intrauterine insemination (IUI) followed by timed intercourse and IUI only for treatment of the infertile couples. Study design: A prospective study of two different protocols of intrauterine insemination in two hundred and one infertile couples with a normal spermiogram was carried out. Of these, 101 couples were treated with IUI alone and 100 couples had both IUI and timed intercourse within a 12-18 h period. The pregnancy rates were compared between groups. Results: The characteristics of the two groups were similar in terms of the mean age, as well as the duration and causes of infertility. The cycle characteristics following follicular stimulation were also similar between two groups. The pregnancy rate per cycle increased with increasing numbers of total motile sperm per insemination in the IUI alone group (P=0.045). Timed intercourse increased pregnancy rate in patients with lower motile sperm number (<40×10⁶) (27.7% versus 10.5%, P=0.023), but not in patients with higher sperm number (≥40×10⁶) (25.7% versus 22.7%, P=0.671). Conclusions: In IUI with low number of motile sperm inseminated, timed intercourse significantly increases the pregnancy rates over IUI alone in infertile couples with a normal sperminogram. This alternative treatment appears to be a practical, simple, and inexpensive addition that improves the pregnancy rate in patients receiving ovulation induction and intrauterine insemination program.     

Tuberculosis and pregnancy

Objectives: There are many myths surrounding pregnancy and tuberculosis (TB), and outcome of treatment. This prospective study was conducted at the Department of Obstetrics and Gynecology, SCB Medical College, Cuttack, India, and at the authors’ private clinics from 1986 to 2001 to determine the outcome of pregnancy if TB is treated properly. Methods: A total of 111 pregnant women diagnosed as having pulmonary and glandular TB were included in the study. They were matched for age, parity, and socioeconomic status with 51 pregnant women without TB (first control group), and 51 women with pulmonary TB but without pregnancy (second control group). The usual pregnancy management was given to the women in the study group, along with a short course of chemotherapy: either ethambutol, INH, or rifampicin and pyrazinamide for 2 months followed by INH and rifampicin for 4 months; or ethambutol, INH, and rifampicin for 2 months followed by INH and rifampicin for 7 months. Statistical analysis was done using a χ²-test. Results: There were no statistical differences in duration of gestation, preterm labor, and other complications of pregnancy, labor, and puerperium between the pregnancy groups. There were no congenital anomalies in the babies born to the groups. Pregnancy had no effect on the course of TB as regards sputum conversion, stabilization of the disease, and non-relapse even after 2–5 years of follow-up and a further delivery in a few cases. Conclusions: If proper and adequate chemotherapy is given to pregnant women with TB, they are not a higher risk than non-pregnant women with TB. Neither the disease nor chemotherapy is threatening to mother or newborn. However, today the ominous combination of human immunodeficiency virus, TB, and pregnancy poses a new challenge.     

Maternal and perinatal complications in triplet compared with twin pregnancy

Objective: To compare maternal and perinatal complications in triplet and twin pregnancies. Study design: Case-controlled study in the setting of a University Hospital. Each pregnancy of a consecutive series of 40 triplet pregnancies of 20 weeks or more was matched for parity and maternal age with two sets of twins delivered in the same year. Primary end points of the analysis were maternal complications and perinatal outcome. Results: Of the triplets 82% and of the twins 36% were a result of assisted reproduction. Pre-term labor occurred significantly more often in triplet than in twin gestation. Triplets had a significantly lower median birth-weight (1478 vs. 2030 g) and gestational age at delivery (32 vs. 35.5 weeks). The mean neonatal hospital stay was significantly longer in triplets, mainly related to the lower birth-weight, but there was no significant difference between triplets and twins in the incidence of major neonatal complications. Conclusion: This data of the anticipated perinatal outcome in triplet and twin pregnancies may be used to counsel women with a triplet pregnancy considering selective reduction to twins. All methods of assisted reproduction should aim at prevention of multifetal gestation.