Intrafetal alcohol chemosclerosis of acardiac twins: a multicenter experience

OBJECTIVE: To report a multicenter experience with intrafetal alcohol chemosclerosis in the treatment of pregnancies complicated with the twin reversed arterial perfusion sequence. METHODS: Percutaneous injection of 1- 2 ml of absolute alcohol into the intra-abdominal segment of the single umbilical artery was performed in 8 acardiac twins. Cases were collected from 5 centers following a standardized protocol. The procedure was performed under continuous ultrasound control, using color Doppler ultrasound to identify the main arterial vessel entering the abdomen of the acardiac twin and passing a 20-gauge spinal needle into the targeted vessel. Intraoperative and short-term complications were noted. Information on pregnancy outcome was obtained by reviewing the medical records or contacting the referring obstetrician. RESULT: At the time of the procedure, the acardiac twin was severely hydropic and the size exceeded 70% of the size of the pump twin in all cases. In addition, there were associated complications in all the pump twins including polyhydramnios in 8 cases (100%), cardiac insufficiency in 5 (63%), and fetal growth restriction in 1 (13%). The procedure was performed at a mean gestational age of 24.7 weeks (range 20-32), and it was technically successful in all cases. However, it was complicated with thrombosis of the umbilical vessels of the pump twin in 1 case, and transient bradycardia in 2 others. These 3 pump twins died in utero as a result of the procedure. The other 5 procedures were technically and clinically successful, resulting in an overall survival rate of 63%. In 4 pregnancies, the pump twin was delivered after 35 weeks and had no neonatal complications. CONCLUSIONS: Intrafetal alcohol chemosclerosis is a simple procedure that can be performed in any fetal medicine center around the world to stop the vascular supply to acardiac twins. However, the main concern with this technique is intravascular transfer of the ablative material to the circulation of the pump twin. The use of this technique should therefore be restricted to those pregnancies with poor prognostic factors and in countries where more sophisticated methods for the treatment of this condition are not available.     

The management of acardiac twins: a conservative approach

OBJECTIVE: Optimal management of acardiac twin pregnancies is controversial. Data suggest a 50% mortality rate in the "pump" twin when the pregnancy is managed expectantly. Because of increased antenatal diagnosis, outcomes in expectantly managed cases may be better than reported. Our objective was to determine the outcome of expectantly managed acardiac twin pregnancies. STUDY DESIGN: All cases of antenatally diagnosed acardiac twins delivered in our community between 1994 and 2001 were ascertained. All were managed expectantly. Perinatal outcome of pump twins was the primary outcome variable. RESULTS: Ten cases were identified. Nine women were delivered of healthy pump twins. There was one neonatal death. The mean gestational age at delivery was 34.2 weeks. The mean weights of the pump and acardiac twins were 2279 g and 1372 g, respectively. CONCLUSION: Neonatal mortality of pump twins in antenatally diagnosed acardiac twin pregnancies may be considerably less than reported. Expectant management with close antepartum surveillance deserves consideration.     

Percutaneous ultrasonographically guided ablation of an acardiac twin

Acardiac twinning is caused by twin reversed arterial perfusion (TRAP). Normal "pump" twins may face early delivery and cardiac decompensation and have a high perinatal mortality. A primagravid patient had serial evaluation of a TRAP pregnancy beginning early in the second trimester. Rapid growth of the acardiac sibling, high diastolic velocity Doppler waveforms in the perfusing vessel, and early hydramnios prompted ablation of blood flow by a percutaneous ultrasonographically guided infusion of absolute alcohol. A term birth of a normal pump twin was the outcome. Ablation of blood flow into an acardiac sibling of a TRAP pregnancy may be indicated in cases with a poor prognosis by use of an effective percutaneous ultrasonographically guided technique.     

Twin-Reversed Arterial Perfusion (TRAP) Sequence: Case Reports and Review of Literature

Summary: The twin reversed-arterial-perfusion (TRAP) sequence found in monozygotic twins is a consequence of primary or secondary cardiac development disruption and direct arterioarterial and venovenous placental anastomoses. Associated findings include the presence of a single umbilical artery (66%) and chromosomal abnormalities in the acardiac twin (33%). Morphological abnormalities in the acardiac twin are consistent with perfusion of tissues supplied by the common iliac and lower branches of the aorta with deoxygenated blood. The pump or donor twin may develop cardiac failure because of the anomalous perfusion circuit. Polyhydramnios is significantly associated with the presence of renal tissue in the acardiac twin. An acardiac pump twin weight ratio (>50%) is associated with the development of polyhydramnios and preterm labour. Identified high-risk factors for poor obstetrical outcome include: acardiac anceps, polyhydramnios, acardiac twin with ears, and pump twin cardiac failure. Management options include elective termination, observation (serial cardiotocography (CTG), ultrasonography and echocardiography) and selective nonsurgical interventions (indomethacin, digitalis, tocolysis). Additionally, surgical interventions (hysterotomy with selective delivery of the acardiac twin or ligation of the acardiac twin's umbilical cord), and ultrasound-guided embolization of the acardiac twin's umbilical artery with absolute alcohol, platinum coils, or thrombogenic coils have been reported. The most appropriate interventions for the varous clinical presentations of this disorder are as yet undetermined, and conservative nonintervention is often appropriate. Long-term follow-up data on surviving pump twins are lacking. It is anticipated that centres with active study protocols for these conditions will best serve patient care and clinical research needs.     

Twin reversed arterial perfusion sequence: two different heartbeats in one umbilical cord - rare finding in monochorionic twin pregnancy

The development of twin-twin transfusion syndrome complicates 5-35% of twin pregnancies with monochorionic placentation. Acardiac twinning is the most extreme manifestation of pathological vascular anastomoses between twins. An acardiac twin is a rare complication of multifetal pregnancy, reported in the literature with an incidence of 1% in monochorionic twin pregnancies, i.e. 1/35 000 pregnancies, and more than 400 cases have been described. We review the literature on this subject and report a special case of twin reversed arterial perfusion (TRAP) sequence in a twin pregnancy with the rare finding of a functional univentricular circulation pump in the acranius, its antenatal ultrasound diagnosis and postnatal findings. Remarkably, prenatally we could demonstrate two different arterial pulsations in the umbilical cord of the acranius. Etiological hypotheses of the TRAP sequence and new implications for risk-adapted therapeutic options are discussed.     

Feto acardio en gestación gemelar a término

Twin reversed arterial perfusion sequence (TRAP) is a serious complication of monochorionic twin pregnancies, in which one twin perfuses the other twin (an acardiac fetus) via large arterio-arterial and veno-venous anastomoses.We report a case of monochorionic twin pregnancy at term, in which the second twin was an acardiac fetus with only an undeveloped lower limb and rudimentary colonic tissue. The first twin was born healthy, a very rare outcome in this entity as the pump twin usually shows distinct degrees of cardiac overload, leading to intrauterine death from heart failure in more than 50% of cases.     

Monochorionic, diamniotic triplet pregnancy complicated by twin reversed arterial perfusion sequence. Postpartum autopsy of placenta and acardiac fetus

The twin reversed-arterial-perfusion sequence (TRAP) is a severe complication of monochorionic twin pregnancies characterized by the hemodynamic dependence of a "recipient" twin from a "pump" twin. The recipient twin exhibits lethal abnormalities including acardia and acephaly. The pump twin has a mortality rate of 50% as a result of high-output heart failure. We present a case of a 24-year-old female, gravida 2, para 2, with monochorionic diamniotic triplet pregnancy. The sonographic examination at 18 weeks' gestation revealed acardiac-acephalus fetus. Reversed arterial perfusion sequence was confirmed with Doppler sonography. Postpartum autopsy examination of placenta and acardiac fetus (acardius anceps) was detailed described.     

The normal fetus of an acardiac twin pregnancy: perinatal management based on echocardiographic and sonographic evaluation

Experience with three prenatally diagnosed pregnancies complicated by an acardiac twin reveals that ultrasonography and echocardiography are helpful in detecting early signs of in-utero congestive heart failure in the normal twin. The use of Doppler blood flow analysis to determine direction of blood flow, post-mortem placental and fetal angiography, and umbilical cord blood gas determination provided proof that retrograde arterial perfusion occurs in the acardiac fetus. In a fourth pregnancy, an experimental approach to occlude the acardiac twin's umbilical cord was attempted, but was unsuccessful.     

Acardiac twins: pronostics markers' study

ObjectivesTo determine ultrasonographic markers that can help to predict prognosis in twins acardiac pathology in order to manage it.Patients and methodsA retrospective multicentric study has been led between 1997 and 2006. The following data were collected: frequency of monitoring, ultrasonographic markers studied according to the outcome of each pregnancy, associated with a review of the literature.ResultsSix twin pregnancies with this condition were identified. The main studied criteria are: foetal growth of the pump twin, congestive heart failure, resistance index of the umbilical arteries, ductus venosus Doppler and middle cerebral artery peak velocity. There was no consensus concerning the method of ultrasonographic monitoring.Discussion and conclusionAccording to our study and the literature, our management must take into account the ratio of (or the difference in) resistance indices between the twins, the middle cerebral artery peak velocity, the tricuspid regurgitation and the ratio of abdominal circumferences of the two twins.     

Prognostic markers in twin pregnancies with an acardiac fetus.

OBJECTIVE: With twin reversed arterial perfusion sequence, the normal cotwin is at risk of heart failure. The purpose of this study was to identify ultrasonographic variables that can help predict prognosis. We hypothesized that variables reflecting the hyperdynamic circulatory condition of the normal fetus and the changes in circulatory impedance in the acardiac mass would correlate with final outcome. METHODS: Ten twin pregnancies with this condition were identified. Follow-up was available for nine. Adverse outcome was defined as death, cardiac failure, or delivery before 30 weeks' gestation for reasons related to the presence of the mass. The following data were collected on the normal fetus: cardiothoracic ratio and left ventricular shortening fraction; and on the mass: maximal length, presence and size of cysts, and presence of a rudimentary heart. The pulsatility index (PI) of the umbilical arteries (UA) of both twins was measured. RESULTS: Four fetuses died, two in utero (22 weeks) and two after cesarean (26 and 31 weeks) for advanced cardiac failure. In the five other cases, the outcome was favorable. The cardiothoracic ratio and presence of cysts or of a rudimentary heart did not correlate with outcome. A PI in the mass' UA significantly lower than that of the normal twin (ratio of 0.71 compared with 1.04 for good outcome, P<.05), an elevated shortening fraction in the second trimester, and a rapid growth rate of the mass were associated with a poor prognosis. CONCLUSION: In pregnancies with twin reversed arterial perfusion sequence, final outcome and treatment decisions can be determined based on hemodynamic criteria.     

15例双胎反向动脉灌注序列症的自然病程及围生儿预后探讨

目的:了解双胎反向动脉灌注序列症(TRAP序列症)的自然病程,分析其围生儿预后。方法:回顾性分析我院2008年7月至2011年12月收治的TRAP序列症15例患者的临床资料,对足月产、早产、流产及平均分娩孕周等资料进行统计,分析无心畸胎/供血儿的腹围比(AC比值)、脐动脉搏动指数(UA-PI)比、供血儿心脏情况等,并追踪供血儿出生后1年的健康状况。结果:15例TRAP序列症患者无心无头型11例,无心无脑型4例。10例孕早期超声检查误诊为双胎之一死亡(3例)、胎儿水肿(2例)和颈部淋巴水囊瘤(5例)。供血儿情况:羊水过多2例(1例引产,1例自然流产);心功能不全2例(1例因合并先天性心脏病引产,1例早产);羊水过多合并心功能不全1例(自然流产)。无心畸胎情况:无心畸胎血流自然阻断2例(13.3%),其中1例孕37周突发宫内死胎,1例继续妊娠(情况稳定);无心畸胎血流微弱(UA-PI比值<0.7)8例(53.3%),其中自然流产2例,引产1例,分娩活胎3例(追踪1年,3例新生儿均健康),继续妊娠2例(情况稳定);无心畸胎血流丰富5例(33.3%)(均引产)。另外无心畸胎出现迅速增长(AC比值>50%)共10例(66.7%),其中引产7例,自然流产1例,仅2例剖宫产分娩存活。结论:无心畸胎较小、血流不丰富者,自然病程良好。出现无心畸胎迅速生长、供血儿心力衰竭或水肿,提示胎儿死亡风险高或预后不良。     

Fetal therapy in twin reserve arterial perfusion sequence pregnancies with alcohol ablation or bipolar cord coagulation

Objective  We aimed to evaluate perinatal outcome of seven pregnancies with twin reserve arterial perfusion sequence. Materials and methods  Study group included seven cases of acardiac twins. Out of seven acardiac twins, two cases were followed without interventions. We performed four alcohol ablation and one bipolar caogulation. For alcohol ablation, a 20-gauge needle guided with color Doppler USG was directed to abdominal insertion site of the single umbilical artery of the acardiac twin, and 1.0–2.0 mL of absolute alcohol was injected. For bipolar coagulation of the umbilical cord, we used 3.5 mm laparoscopic trocar and 3.0 mm bipolar forceps. The procedures were performed under the guidance of transabdominal ultrasonography. Results  Gestational age of the cases at diagnosis and at delivery was 15–32 and 17–38 weeks, respectively. Two cases without intervention were lost at 17 and 32 weeks. The mean time of procedure for bipolar coagulation and alcohol ablation were 30 and 10 min, respectively. One of the four cases of alcohol ablation group was aborted although alcohol ablation was succesful. Another one case was aborted after alcohol ablation due to lost of fetal cardiac activity of the pump fetus. In two other cases, umbilical cord ablation with alcohol was successful, and they delivered live birth at 36 and 38 weeks. In one case, we performed bipolar cord coagulation successfully, and the case delivered live birth at 39 weeks. The overall survival rate for intrauterine surgery was 60% (N 3/5). Conclusion  In twin reserve arterial perfusion sequence pregnancies with findings of poor prognosis, alcohol ablation or bipolar cord coagulation as fetal therapy under the guidance of ultrasonography can be done successfully, and should be offered as a choice to families upon discussion of intervention or follow-up with own complications.     

Prenatal diagnosis and outcome of multiple pregnancies with reversed arterial perfusion (TRAP-sequence)

Objectives

We analyse the prenatal detection and pregnancy outcome of twin reversed arterial perfusion syndrome (TRAP-sequence) in monochorionic twin pregnancies.

Methods

We included all cases in which the prenatal diagnosis of a TRAP-sequence had been established and reviewed the prenatal, obstetrical, and pathological records of the acardiac twin as well as the neonatal/pediatric records of the donor twin. Minimal follow-up for the donor twin after birth was 6?months.

Results

We detected six cases of TRAP-sequence in 412 examined monochorionic multiple pregnancies (incidence 1.46%) Mean gestational age at diagnosis was 20.4 (13.1?C28.0) gestational weeks. All donor twins survived without detectable mid- or long-term sequelae. There was neither missed prenatal diagnosis nor a false-positive diagnosis of TRAP-sequence. Mean birthweight of the acardiac twins was 1,400?g (830?C2800?g). There was an uneventful medical history in the maternal records of all included women. Fetal karyotype was available for 5/6 twin-pairs, all revealing a normal distribution of the chromosomes. All acardiac twins had post-mortem examination with specification of the subtypes of acardiac twin displaying 3/6 acardius acephalus, 2/6 acardius amorphus, and 1/6 acardius anceps.

Conclusions

The antenatal diagnosis of TRAP-sequence is feasible and can be established during the first-trimester-screening. The discrimination of the adequate time to end the pregnancy, though a crucial concern, remains a challenging question. Future studies should address this topic.     

Treatment of twin reversed arterial perfusion sequence by septostomy and amniodrainage: a case report

Introduction An acardiac fetus is the most severe malformation seen in humans. It is an extremely rare complication, occurring in approximately 1% of all monozygotic twin gestations, with an incidence of about 1 in 35,000 births. This malformation happens as a result of the syndrome of reversed arterial perfusion of the acardiac twin from the other normal fetus (pump twin), due to the presence of arterio-arterial anastomoses in a monochorionic placenta. Several obstetric and perinatal complications have been associated to this anomaly and several treatments have been proposed to reduce the morbimortality of the pump twin. There’s no report in MEDLINE about the treatment of twin gestations with acardiac fetus through septostomy. Case report The present article reports a case of reversed arterial perfusion sequence complicated by polyhydramnios diagnosed at 19th week of pregnancy, treated with septostomy and serial amniodrainage. Discussion This case presented it demonstrate favorable development of the gestation, with labor happening at 35 weeks gestation and pump twin presenting good vitality conditions. In cases with no major factors of bad prognosis, septostomy combined with amniodrainage could be an interesting therapeutic option for a safe and efficacious management of selected cases of TRAP sequence.     

Perinatal outcome of forty-nine pregnancies complicated by acardiac twinning

Acardiac twinning affects 1 in 100 monozygotic twin pregnancies and 1 in 35,000 pregnancies overall. The presence of an acadiac twin requires the normal (or "pump") twin to provide circulation for itself, as well as the acardiac sibling. In many cases the acardiac twin is almost equal to the normal twin. The principal perinatal problems associated with acardiac twinning are pump-twin congestive heart failure, maternal hydramnios, and preterm delivery. We reviewed the perinatal courses of 49 acardiac twin pregnancies to identify factors prognostic of favorable outcome. The overall perinatal mortality was 55%, primarily associated with prematurity. Mean (+/- SD) gestational age at delivery was 29 +/- 7.3 weeks, with a mean (+/- SD) normal twin weight of 1378 +/- 1047 gm. The acardiac weight averaged 651 +/- 571 gm. However, the occurrence of hydramnios, the occurrence of preterm labor, and perinatal outcome were strongly related to the ratio of the acardiac and pump-twin's weight. The mean overall ratio of the twin weights was 52% +/- 42%. However, the mean weight ratio for patients delivered before 34 weeks was 60% versus 29% (p less than 0.04). Preterm delivery was strongly associated with the development of hydramnios and congestive heart failure in the pump twin (p less than 0.01). If the twin-weight ratio was above 70% (25% of cases), the incidence of preterm delivery was 90%; hydramnios, 40%; and pump-twin congestive heart failure, 30% compared with 75%, 30%, and 10%, respectively, when the ratio was less (p less than 0.05). Regression of the weight of the acardiac twin against its longest dimension (L) resulted in this equation for prediction of acardiac weight: Weight (grams) = 1.2 L2-1.7L; r = 0.79, p less than 0.01. These data suggest that estimation of the relative weights in acardiac twins provides prognostic information regarding outcome. Poor outcome occurs with congestive heart failure and hydramnios in the normal twin. Use of the above data may assist in counseling patients and determining optimal management.     

Fetal therapy in twin reversed arterial perfusion sequence pregnancies with alcohol ablation or bipolar cord coagulation

Objective  We aimed to evaluate perinatal outcome of seven pregnancies with twin reserve arterial perfusion sequence. Materials and methods  The study group included seven cases of acardiac twins. Out of seven acardiac twins, two cases were in follow-up without any interventions. We performed four alcohol ablation and one bipolar coagulation. For alcohol ablation, a 20-gauge needle guided with color Doppler USG was directed to abdominal insertion site of the single umbilical artery of the acardiac twin, and 1.0–2.0 mL of absolute alcohol was injected. For bipolar coagulation of the umbilical cord, we used 3.5 mm laparoscopic trocar and 3.0 mm bipolar forceps. The procedures were performed under the guidance of transabdominal ultrasonography. Results  Gestational age of the cases at diagnosis and at delivery was 15–32 and 17–38 weeks, respectively. Two cases without intervention were lost at 17 and 32 weeks. The mean time of procedure for bipolar coagulation and alcohol ablation were 30 and 10 min, respectively. One of the four cases of alcohol ablation group was aborted although alcohol ablation was successful. The other one case was aborted after alcohol ablation due to lost of fetal cardiac activity of the pump fetus. In two other cases, umbilical cord ablation with alcohol was successful, and they delivered live fetuses at 36 and 38 weeks. In one case we performed bipolar cord coagulation successfully, and the case delivered a live fetus at 39 weeks. The overall survival rate for intrauterine surgery was 60% (N = 3/5). Conclusion  In twin reversed arterial perfusion sequence pregnancies with findings of poor prognosis, alcohol ablation or bipolar cord coagulation as fetal therapy under the guidance of ultrasonography can be done successfully, and should be offered as a choice to families upon discussion of intervention or follow-up with own complications.     

Selective reduction of acardiac twin by radiofrequency ablation

OBJECTIVE: Acardiac/acephalic twinning is a rare anomaly in which a normal "pump" twin perfuses an acardiac twin, which results in twin reversed arterial perfusion sequence. A novel technique for selective reduction and obliteration of blood flow in the acardiac twin is described. STUDY DESIGN: Thirteen consecutive cases of monochorionic twin gestation with twin reversed arterial perfusion sequence underwent selective reduction of the abnormal twin with the use of radiofrequency ablation. Under direct real-time sonographic guidance, a 3-mm (14-gauge) radiofrequency ablation needle was percutaneously inserted through the maternal abdominal wall into the intrauterine fetal abdomen at the level of the cord insertion site of the acardiac twin. Energy was applied until termination of blood flow to the acardiac fetus was documented by Doppler ultrasound scanning. RESULTS: All 13 mothers tolerated the procedure without major complications. All 13 "pump" fetuses have been delivered. Twelve of 13 infants are alive and well. The first patient in this series was delivered at 24.4 weeks and the infant subsequently died from complications of prematurity. Average gestational age at intervention was 20.7 weeks, and the average gestational age at delivery was 36.2 weeks. CONCLUSION: Radiofrequency ablation is a minimally invasive, percutaneous technique that can effectively obliterate blood supply to an acardiac twin to preserve and protect the pump twin.     

Perinatal mortality in twin pregnancies: a 3-year analysis in Seine Saint-Denis (France).

OBJECTIVES: Our purpose was to evaluate perinatal mortality in twins and to investigate factors associated with this mortality. STUDY DESIGN: A prospective study on the perinatal mortality was performed in the department of Seine-Saint-Denis. Out of all the perinatal deaths, we have retrospectively isolated those arising from twin pregnancies. RESULTS: There were 54 twin pregnancies complicated with perinatal death. The perinatal mortality rate in twin pregnancy was 78.0 per 1000 twin babies delivered. Out of 86 twin deaths, 38 (44.2%) were born before 28 weeks gestation and out of 82 twin perinatal deaths, 37 (45.1%) weighed less than 1000 g. Chorionicity was recorded in 44 twin pairs: 21 (47.7%) were dichorionic and 23 (52.3%) monochorionic. Finally, out of 48 twin sets there were four (8.3%) monoamniotic pregnancies. CONCLUSIONS: The present data show that extreme prematurity represents nearly half of perinatal mortality in twins. This study indicates also a significant proportion of monochorionic placentation among twin pregnancies with poor outcome.     

The case of an acardiac headless twin, review of the literature

INTRODUCTION: Monochorial twin pregnancies are characterized by the presence of vascular connections between the twins. These connections can be at the origin of pathologies such as the transfused/transfuser syndrome or the TRAP syndrome which is defined as the association of a headless, acardiac twin with a healthy twin, which is the subject we will study and then review the literature. THE CLINICAL CASE: The case of an acardiac, headless twin which was not diagnosed during pregnancy and was discovered at birth. DISCUSSION AND CONCLUSION: The TRAP syndrome is a very rare phenomenon. Yet, it is crucial to diagnose it as early as possible during pregnancy so as to offer adequate supervision. It is associated to a high death rate in the healthy twin caused by anemia and heart failure. There are therapeutic means to stop vascular anostomoses between the twins so as to perform a selective feticide.     

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.