Dichorionic Triamniotic Triplet Research Articles

585: Pregnancy complications for di-chorionic tri-amniotic triplets: markedly increased over tri-chorionic and reduced cases

585: Pregnancy complications for di-chorionic tri-amniotic triplets: markedly increased over tri-chorionic and reduced cases

444: Outcomes of laser photocoagulation for feto-fetal transfusion syndrome in dichorionic-triamniotic triplet gestations as compared to monochorionic-diamniotic twins

To compare the outcomes of dichorionic-triamniotic (DC,TA) triplet gestations with the outcomes of a paired cohort of monochorionic-diamniotic twin (MC,DA) gestations undergoing laser photocoagulation of placental anastomosis for treatment of feto-fetal transfusion syndrome.

Early diagnosis, follow-up, and prenatal treatment of a case of TRAP sequence occurring in a dichorionic triamniotic triplet pregnancy

We are reporting a case of twin reversed arterial perfusion (TRAP) sequence occurring in a dichorionic triamniotic triplet pregnancy with successful percutaneous prenatal treatment and excellent neonatal outcome. TRAP sequence was diagnosed at 11 weeks in a spontaneous dichorionic-triamniotic triplet. Sonographic assessment showed persistent arterial flow and development of hydrops in the acardiac twin. Percutaneous cord interstitial laser coagulation was performed, and the co-twin subsequently developed growth restriction. The 9-month-old twins have a normal developmental course. This report confirms that fetal intervention is indicated in cases of TRAP sequence in which the acardiac twin presents a significant enlargement on follow-up sonographic examinations.

Perinatal and Neonatal Outcomes of Triplet Gestations Based on Placental Chorionicity

The purpose of our study was to evaluate perinatal and neonatal outcomes in triplet gestations in relation to placental chorionicity. We hypothesized that triplets containing a monochorionic pair (dichorionic triamniotic) would have increased morbidity compared with triplets without a monochorionic pair (trichorionic triamniotic). We retrospectively analyzed all triplet sets > or =20 weeks delivering at our institutions from January 1995 through April 2007. Data were collected via perinatal and neonatal databases, chart review, and placental pathology. Individuals in dichorionic triamniotic triplet sets (N = 75), when compared with trichorionic triamniotic triplets (N = 309), were more likely to have a lower mean birth weight (P < 0.001) and lower gestational age at delivery (P < 0.001), spend more days in the neonatal intensive care unit (P = 0.045), have culture-proven sepsis (P = 0.02), and require intubation (P = 0.05). Multivariate analysis demonstrated that dichorionicity is not an independent cause of morbidity, but results in earlier delivery and lower birth weight. Dichorionic triamniotic triplets are at increased risk for earlier deliveries and lower birth weight at delivery compared with trichorionic triamniotic triplets.

Delivery of a Live Newborn in a Triplet Pregnancy Complicated by Preeclampsia after Intrauterine Demise of Two and Expulsion of One Triplet: A Case Report

Delayed interval delivery in twin pregnancies is an unusual occurrence, even more so in triplet pregnancies. We report on a delayed interval delivery in a dichorionic triamniotic triplet pregnancy after in vitro fertilization (IVF). Because of severe twin to twin transfusion syndrome (TTTS), two fetuses demised at 22 weeks of gestation. One of the two fetuses spontaneously aborted at 25 weeks of gestation. The remaining live fetus and the second demised fetus were delivered by cesarean section 9 weeks later because of the occurrence of preeclampsia. This case indicates that delayed interval delivery in triplets is possible and that preeclampsia can occur after intrauterine demise of two fetuses.

Dichorionic triamniotic triplet pregnancy with monozygotic twins discordant for trisomy 13 after preimplantation genetic screening: case report

To report the first dichorionic triamniotic triplet pregnancy discordant for trisomy 13 after in vitro fertilization (IVF) treatment with preimplantation genetic screening (PGS). Case report. Private IVF center. A 40-year-old para 1+6 woman. IVF combined with PGS for chromosomes 13, 16, 18, 21, and 22, resulting in the transfer of two embryos. Prenatal fetal ultrasonography revealed a dichorionic triamniotic triplet pregnancy. An amniocentesis, performed at 15-weeks' gestation, confirmed that the singleton and one monozygotic twin were normal but the other monozygotic twin was trisomy 13. After diagnosis and counseling, selective termination of the trisomy 13 monozygotic twin was performed at 16 weeks and 4 days. At 18 weeks and 4 days the co-twin died. A healthy boy was delivered by elective caesarean section at 36-weeks' gestation. Assisted reproductive techniques that breach the embryo's zona pellucida such as assisted hatching and PGS embryo biopsy increase the incidence of monozygotic twins. Due to high levels of mosaicism in human preimplantation embryos, PGS cannot ensure that embryos diagnosed as normal and selected for transfer do not contain abnormal cells. Hence, further reports of discordant monozygotic twins following PGS are expected, emphasizing the need for appropriate counseling of patients wishing to embark on an IVF/PGS treatment cycle.

Comparative study of perinatal outcome of dichorionic and trichorionic iatrogenic triplets

The purpose of this study was to compare the perinatal outcome of dichorionic and trichorionic triplets who were conceived by assisted reproductive techniques. In this retrospective study, the maternal, neonatal, and chorionicity data were collected from 106 sets of trichorionic triamniotic and 34 sets of dichorionic triamniotic triplet pregnancies who were conceived by assisted reproductive techniques between January 1986 and December 2000. Perinatal and neonatal data were evaluated in relation to chorionicity and intertriplet birth weight discordance. The dichorionic triamniotic triplets have an 8-fold higher risk of perinatal death than trichorionic triamniotic gestations (odds ratio, 7.9; 95% CI, 4.4-14.0; P < .001). This is attributed to a higher risk of very low birth weight (P < .01), delivery at < 30 weeks of gestation (P < .001), and premature rupture of membrane (P < .001) in dichorionic triamniotic triplets compared with trichorionic triamniotic pregnancies. Twin-twin transfusion syndrome (odds ratio, 11.5; 95% CI, 4.8-27.7; P < .001), delivery at < 30 weeks of gestation (odds ratio, 40.5; 95% CI, 16.9-97; P < .01), premature rupture of membrane (odds ratio, 6.7; 95% CI, 3.8-11.9; P < .01), and nulliparity (odds ratio, 3.1; 95% CI, 1.6-6.1; P < .05) had independent effects on perinatal loss rate. The dichorionic triplets have an 8 times higher perinatal mortality rate than trichorionic triamniotic pregnancies.

Spontaneous dichorionic triamniotic triplet pregnancy affected by TTTS: follow-up from diagnosis to three months of extrauterine life

Article Spontaneous dichorionic triamniotic triplet pregnancy affected by TTTS: follow-up from diagnosis to three months of extrauterine life was published on December 1, 2006 in the journal Journal of Perinatal Medicine (volume 34, issue 6).

Antenatal Detection of Arterio-Arterial Anastomoses by Doppler Placental Assessment in Monochorionic Twin Pregnancies

Objectives: To evaluate the reproducibility of Doppler antenatal detection of arterio-arterial anastomoses (AAA) in monochorionic (MC) twin pregnancies. Methods: Between October 2002 and February 2004, 21 MC diamniotic twin pregnancies and one dichorionic triamniotic triplet seen at the Twin Clinic at the University of Brescia were recruited. After routine ultrasonographic assessment, AAA were searched using Color or Power and spectral Doppler. The presence of AAA was confirmed postnatally by placental injection studies. Results: Data of 19 patients were available for the analysis. AAA were detected in 12 cases (63%) antenatally and in 16 (84.2%) at injection study. Sensitivity and specificity of Doppler for detecting AAA were 75 and 100%, respectively. Detection rates increased at advanced gestations and with anterior/fundal placentae. The incidence of twin-twin transfusion syndrome was higher in the group with no AAA detected in vivo compared to the group with AAA found with Doppler (28.5 vs. 16.6%), but the difference was not statistically significant (p = 0.5). Conclusion: This study confirmed the feasibility of AAA Doppler detection in vivo in MC pregnancies.

Perinatal outcome of spontaneously conceived triplet pregnancies in relation to chorionicity

The purpose of this study was to determine the perinatal outcome of spontaneously conceived triplet pregnancies in relation to chorionicity. In this retrospective study, maternal, neonatal, and chorionicity data were collected from 88 sets of triplet pregnancies that were delivered at >20 weeks of gestation from 3 tertiary referral centers in the United Kingdom. The data were collected between January 1986 and December 2000. There were 49 sets of trichorionic triamniotic triplet pregnancies and 39 sets of triplet pregnancies with a monochorionic pair (ie, dichorionic triamniotic triplets). The outcome of each pregnancy was assessed in relation to chorionicity. The overall perinatal mortality rate was 151.5 per 1000 total births, with dichorionic triamniotic triplets having a 5.5-fold higher risk than trichorionic triamniotic gestations (odds ratio, 5.5; 95% CI, 2.5-12.2). The dichorionic triamniotic triplets have a higher risk of delivery at < 30 weeks of gestation (odds ratio, 4.6; 95% CI, 1.6-11.8; P < .05) and birth weight of < 1000 g (odds ratio, 53.6; 95% CI, 17.5-164; P < .05) than those of trichorionic triamniotic pregnancies. The neonatal morbidity in terms of respiratory distress syndrome (P < .001), anemia (P < .01), and intraventricular hemorrhage (P < .001) were higher in dichorionic triamniotic compared with trichorionic triamniotic triplets. The premature rupture of membrane (odds ratio, 7.5; 95% CI, 3.5-15.7) and twin-twin transfusion syndrome (odds ratio, 14.9; 95% CI, 6.6-4) were independent risk factors for perinatal death. In spontaneously conceived triplets, the incidence of dichorionicity was 44%. The dichorionic triamniotic triplets have a 5.5-fold higher risk of adverse perinatal outcome predominantly because of twin-twin transfusion syndrome and premature rupture of membranes.

Fetoscopic surgery in triplet pregnancies: A multicenter case series

The purpose of this study was to evaluate the feasibility of fetoscopic surgery in complicated monochorionic and dichorionic triplet pregnancies. This was a case series of fetoscopic surgery in 12 cases of monochorionic (n = 5) or dichorionic (n = 7) triamniotic triplets complicated by severe feto-fetal transfusion (n = 8), twin reversed arterial perfusion sequence (n = 3), or discordant for an anomaly (n = 1). Six underwent cord occlusion, and 6 had laser coagulation of the vascular anastomoses. All procedures were successfully completed, and the outcome was comparable to that reported for similar procedures in twins. Eighty-three percent of fetuses survived, and 13% had long-term problems. Fetoscopic surgery may be considered as a therapeutic option in complicated triplet pregnancies, with results similar to those found in twins.

P12.23: Outcome of 21 twin gestations after selective feticide of one malformed fetus in the second trimester of pregnancy

Objective: To report our initial experience with selective laser photocoagulation of the placental communicating vessels (SLPCV) in the treatment of severe mid trimester twin-to-twin transfusion syndrome (TTTS). Methodology: Eight cases of severe TTTS (6 monochorionic diamniotic twins and 2 dichorionic triamniotic triplets) diagnosed before the 26th week of gestation were managed by SLPCV, as Quintero reported in 1998, from November 2003 to February 2004. A 2 mm fetoscope and 600 ?m diode laser fibers were used through a 3 mm sheath inserted by ultrasound guidance. All procedures were performed under local anaesthesia. Main outcome items were perinatal survival and neurological morbidity up to the 28th day of postnatal life. Results: The median gestational age at laser was 20.3 weeks (range 18.2–24.5). 4 placentas were posterior and 4 were anterior, with a median number of 5 placental anastomoses (range 4–7). A median of 2175 ml (range 1500–4500) of amniotic fluid was drained, and the median time for performing the whole procedure, skin to skin, was 45 minutes (range 30–60). The overall survival rate was 66.7% (12/18), 2 (or 3) fetuses survived in 50% (4/8), and at least 1 fetus survived in 87.5% (7/8) of the cases. Excluding the case that miscarried at 24 hours after the procedure, the median gestational age at delivery was 30.5 weeks (range 27.1–35.5), with a median (range) weight of 1236 (675–2170) and 1359 (814–2280) grams for the donor and the recipient respectively. No single case of major brain damage was detected among the survivors up to the first month of life, as assessed either by clinical examination or by imaging techniques. Conclusion: Our initial results doing SLPCV in TTTS are comparable with those reported by others. Strict follow-up of children’s neurodevelopmental function is warranted, as we are aware that some neurologic deficiencies may not be evident at first month of life yet.)

P343a: Fetoscopic laser treatment in monochorionic and dichorionic triplets

To report on feasibility and outcome of 7 consecutive fetoscopic laser procedures in monochorionic (MC) or dichorionic (DC) triamniotic (TA) triplets. Consecutive case series. Variables were principal indication, gestational age (GA) at diagnosis, preoperative decision making in terms of technical limitations and clinical presentation, performed procedure, success rate, delivery, survival rate, birth weight, duration of follow-up and long-term outcome. Indications were TRAP in 3 MCTA triplets and severe TTTS in 3 DCTA triplets and 1 MCTA triplet. Median GA at diagnosis in TRAP was 16.2 wks (range 16–18) and 17 wks (range: 15–22) in TTTS. Cord coagulation was done in all cases of TRAP. In cases with TTTS cord coagulation was performed in 3 cases, in 1 case because of ventriculomegaly in the donor, in the 2 remaining because of an anterior placenta, limiting the chances for successful inspection of the vascular equator, and poor Doppler examination (“stage III”). In one case of TTTS (“stage III”) with posterior placenta and involvement of all 3 fetuses (1 recipient, 2 donors), laser coagulation of the vascular anastomoses was performed. Each procedure was done percutaneously by a single port and successful in arresting flow in the target cord or TTTS. All patients delivered beyond 30 weeks (range: 30.3–38 weeks), except for one. This patient underwent cord coagulation for TTTS at 22 wks, and developed PPROM within 3 weeks postoperatively. She delivered at 25 wks leading to 2 early neonatal deaths. There was 1 unexplained IUFD within 24 hours in a case of TRAP. One pregnancy is still ongoing without problems so far. Overall survival rate and survival of at least 1 fetus were respectively 77% (10/13) and 83% (5/6). Median birth weight of liveborn children was 1688 g (range: 700–2804). All surviving children had an uneventful neonatal course and of the children more than 1 yr of age (range: 1–6) (n = 5), all are developing normally. In this small case series of fetoscopic laser procedures in complicated MC or DC triplets, overall survival rate was 77% with favourable outcome. For cord occlusion, this is comparable with the outcome in twins. Fetoscopic surgery seems feasible. Technical restrictions and clinical presentation may influence the choice of procedure.