Expectant management versus multifetal pregnancy reduction in higher order multiple pregnancies containing a monochorionic pair and a review of the literature.

Abstract

To compare the perinatal outcome in multifetal pregnancies containing a monochorionic twin pair, managed either expectantly or by fetal reduction (MFPR). This was a retrospective analysis of prospectively collected data on 47 triplet and 10 quadruplet pregnancies recruited between 10 and 14weeks. Main outcome measures were miscarriage <24weeks, preterm birth, fetal growth restriction, birth weight and survival rates. For triplets the miscarriage rates <24weeks were 6.3% after reduction and 20.0% for expectant management and MFPR, respectively. While we recorded no case of severe preterm delivery <30weeks in the reduction group, it was 25% in those with expectant management. Mean gestational age and birth weight were significantly higher after fetal reduction than for the conservative approach (37.7±1.6weeks vs. 30.9±3.2weeks, p<0.01 and 2676±705g vs. 1429±542g, p<0.01). Expectantly managed triplets were complicated by twin-twin transfusion syndrome in 18.8% and intrauterine fetal death in 8.3%. Survival rates were 85.4% for those managed expectantly and 80.0% after fetal reduction. Mean gestational age of ongoing quadruplets was 26.9±2.0weeks vs. 34.5±4.3weeks for those with reduction of the monochorionic pair (p<0.05). Survival rates were 100% in the reduction group and 58.3% in the expectant management group (p<0.05). There was an inverse correlation between the final number of fetuses and the birth weight. Fetal reduction in triplets and quadruplets including a monochorionic pair is associated with decreased early prematurity. While in quadruplets the overall survival is higher after reduction, there was no difference for dichorionic triplets with reduction or conservative management. Complications owing to monochorionicity are frequently observed.