Dichorionic Triamniotic Triplet Research Articles

Pregnancy outcomes of dichorionic triamniotic triplet pregnancies after in vitro fertilization-embryo transfer: multifoetal pregnancy reduction versus expectant management

BackgroundTrichorionic triplet pregnancy reduction to twin pregnancy is associated with a lower risk of preterm delivery but not with a lower risk of miscarriage. However, data on dichorionic triamniotic (DCTA) triplet pregnancy outcomes are lacking. This study aimed to compare the pregnancy outcomes of DCTA triplets conceived via in vitro fertilization-embryo transfer (IVF-ET) managed expectantly or reduced to a monochorionic (MC) singleton or monochorionic diamniotic (MCDA) twins at 11–13+ 6 gestational weeks.MethodsTwo hundred ninety-eight patients with DCTA triplets conceived via IVF-ET between 2012 and 2016 were retrospectively analysed. DCTA triplets with three live foetuses were reduced to a MC singleton (group A) or MCDA twins (group B) or underwent expectant management (group C). Each multifoetal pregnancy reduction (MFPR) was performed at 11–13+ 6 gestational weeks. Pregnancy outcomes in the 3 groups were compared.ResultsEighty-four DCTA pregnancies were reduced to MC singleton pregnancies, 149 were reduced to MCDA pregnancies, and 65 were managed expectantly.There were no significant differences among groups A, B, and C in miscarriage rate (8.3 vs. 7.4 vs. 10.8%, respectively) and live birth rate (90.5 vs. 85.2 vs. 83.1%, respectively) (P > 0.05).Group A had significantly lower rates of preterm birth (8.3 vs. 84.6%; odds ratio (OR) 0.017, 95% confidence interval (CI) 0.006–0.046) and low birth weight (LBW; 9.2 vs. 93.2%; OR 0.007, 95% CI 0.003–0.020) than group C (P < 0.001).Group B had significantly lower preterm birth (47.0 vs. 84.6%; OR 0.161, 95% CI 0.076–0.340) and LBW rates (58.7 vs. 93.2%; OR 0.103, 95% CI 0.053–0.200) than group C (P < 0.001).Group A had significantly lower preterm birth (8.3 vs. 47.0%; OR 0.103, 95% CI 0.044–0.237; P < 0.001), LBW (9.2 vs. 58.7%; OR 0.071, 95% CI 0.032–0.162; P < 0.001) and perinatal death rates (1.3 vs. 9.1%; OR 0.132, 95% CI 0.018–0.991; P = 0.021) than group B.ConclusionThe MFPR of DCTA triplets to singleton or MCDA pregnancies was associated with better pregnancy outcomes compared to expectant management. DCTA triplets reduced to singleton pregnancies had better perinatal outcomes than DCTA triplets reduced to MCDA pregnancies.

Successful monozygotic triplet pregnancy after a single blastocyst transfer following in vitro maturation of oocytes from a woman with polycystic ovary syndrome: a case report

BackgroundAlthough women with polycystic ovarian syndrome (PCOS)-related sub-fertility are high responders to controlled ovarian stimulation, it is difficult to obtain mature oocytes in these women. Therefore, in vitro maturation (IVM), which is the technique of letting the contents of the ovarian follicles and the oocytes inside mature in vitro, has often been proposed in such women. We describe the first successful delivery of monozygotic triplets resulting from transfer of a single blastocyst following IVM of oocytes.Case presentationA 32-year-old nulligravida female with PCOS underwent IVM. She underwent vitrified-warmed single blastocyst transfer following IVM, and a dichorionic triamniotic triplet pregnancy was confirmed at 8 weeks. Healthy triplets were delivered by cesarean section at 33 weeks’ gestation. This is the first case of monozygotic triplets derived from IVM oocytes that were successfully delivered. The determination of chorionicity and amnionicity is generally supposed until 3 days after fertilization, and no division or splitting of her embryo was observed on transfer. Interestingly, her embryo might have split after the transfer, resulting in a dichorionic triamniotic triplet pregnancy.ConclusionsPatients should be informed of a possible increased risk of monozygotic multiple pregnancies after single embryo transfer following IVM.

Perinatal mortality and morbidity in triplet pregnancy according to chorionicity: systematic review and meta-analysis.

The incidence of perinatal mortality and morbidity in triplet pregnancies according to chorionicity is yet to be established. The aim of this systematic review was to quantify perinatal mortality and morbidity in trichorionic triamniotic (TCTA), dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplets. MEDLINE, EMBASE and CINAHL databases were searched in December 2017 for literature published in English describing outcomes of DCTA, TCTA and/or MCTA triplet pregnancies. Primary outcomes were intrauterine death (IUD), neonatal death, perinatal death (PND) and gestational age at birth. Secondary outcomes comprised respiratory, neurological and infectious morbidity, as well as a composite score of neonatal morbidity. Data regarding outcomes were extracted from the included studies. Random-effects meta-analysis was used to estimate the risk of mortality and morbidity and to compute the difference in gestational age at birth between TCTA and DCTA triplet pregnancies. Nine studies (1373 triplet pregnancies, of which 1062 were TCTA, 261 DCTA and 50 MCTA) were included in the analysis. The risk of PND was higher in DCTA than in TCTA triplet pregnancies (odds ratio (OR), 3.3 (95% CI, 1.3-8.0)), mainly owing to the higher risk of IUD in DCTA triplet pregnancies (OR, 4.6 (95% CI, 1.8-11.7)). There was no difference in gestational age at birth between TCTA and DCTA triplets (mean difference, 1.1 weeks (95% CI, -0.3 to 2.5 weeks); I2 = 85%; P = 0.12). Neurological morbidity occurred in 2.0% (95% CI, 1.1-3.3%) of TCTA and in 11.6% (95% CI, 1.1-40.0%) of DCTA triplets. Respiratory and infectious morbidity affected 28.3% (95% CI, 20.7-36.8%) and 4.2% (95% CI, 2.8-5.9%) of TCTA and 34.0% (95% CI, 21.5-47.7%) and 7.1% (95% CI, 2.7-13.3%) of DCTA triplets, respectively. The incidence of composite morbidity in TCTA and DCTA triplets was 29.6% (95% CI, 21.1-38.9%) and 34.0% (95% CI, 21.5-47.7%), respectively. When translating these figures into a risk analysis, the risk of neurological morbidity (OR, 5.4 (95% CI, 1.6-18.3)) was significantly higher in DCTA than in TCTA triplets, while there was no significant difference in the other morbidities explored. Only one study reported on outcomes of MCTA pregnancies, hence, no formal comparison with the other groups was performed. DCTA triplets are at higher risk of perinatal mortality and morbidity than are TCTA triplets. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

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.

2393 A Unique Case of Liver Disease in Pregnancy

INTRODUCTION: Pregnancy-related liver disease is seen in up to 3% of all pregnancies. Pregnancy-related etiologies include hyperemesis gravidarum, pre-eclampsia, HELLP, intrahepatic cholestasis of pregnancy, and acute fatty liver of pregnancy (AFLP). Given the significant morbidity and mortality associated with these conditions, there is a need for early recognition. Here we present a unique case of pregnancy-related liver disease in an asymptomatic patient. Despite a thorough evaluation for liver and non-liver related causes, her lack of symptomatology and associated laboratory findings made establishing a definitive diagnosis difficult. CASE DESCRIPTION/METHODS: 30 year-old woman G1P0 at 29 weeks gestation with dichorionic triamniotic triplets presented with generalized weakness. Her past medical and surgical histories were otherwise non-contributory and her only medication included prenatal vitamins. The physical exam was unremarkable except for a gravid uterus. Throughout her hospital course, she remained normotensive. Admission labs were significant for an abnormal liver profile: AST 200 U/L, ALT 349 U/L, ALP 121 U/L, and total bilirubin 0.5 mg/dL, compared to a previous normal baseline. Complete blood count and renal function were normal. Abdominal ultrasound (US) showed increased liver echogenicity consistent with fatty liver disease. Additional work-up revealed a normal coagulation profile, fibrinogen, lactate dehydrogenase, and haptoglobin. Urinalysis was negative for proteinuria. Serologies for viral and autoimmune hepatitis were negative. Total bile acids were mildly elevated at 9.3 umol/L (normal &lt; 6.8umol/L) and 24-hour urinary copper was normal. Though she remained asymptomatic, liver enzymes continued to uptrend. On day 16 she underwent urgent C-section due to rising liver enzymes and evidence of fetal distress. Liver enzymes continued to rise until POD1 before rapidly declining. DISCUSSION: This was a unique case of pregnancy-related liver disease of unknown etiology, but most consistent with an early manifestation of AFLP. We suspected AFLP based on the steatosis noted on US, however, since we could not check her children for LCHAD deficiency a definitive diagnosis could not be made. Surveillance US showing resolution of steatosis would have helped confirm the diagnosis however the patient was lost to follow up. This was an interesting presentation of AFLP as most cases are discovered in women presenting with acute liver failure; this case was unique in that it was discovered unexpectedly.

OC07.07: Pregnancy outcomes of multifetal pregnancy reduction in women with dichorionic triamniotic triplets after in vitro fertilisation‐embryo transfer

OC07.07: Pregnancy outcomes of multifetal pregnancy reduction in women with dichorionic triamniotic triplets after in vitro fertilisation‐embryo transfer

143. Recovery of second trimester preeclampsia in triplet after foetal reduction; a case history and review of the literature

Introduction Women with a multiple pregnancy are at increased risk of developing hypertensive disorders of pregnancy. Electively reduction in a triplet pregnancy have lower prevalence of preeclampsia compared to ongoing triplets or spontaneously reduced triplets. Objective/hypothesis Selective feticide might suggested as an option in early onset preeclampsia in dichorionic multiple pregnancies as alternative for termination the whole pregnancy. Methods We described a case of a dichorionic triamniotic triplet complicated by severe preeclampsia at 16 weeks gestational age. Additionally, we performed a review of the literature on selective feticide in multiple pregnancies on maternal indication in PubMed, MEDINE and EMBASE. Results In our case, after reduction of the monochorionic twin, symptoms of preeclampsia clinically resolved, and delivery was postponed for more than 17 weeks at 32 weeks of gestation. In an additional review of the literature, we described 6 papers including 8 cases on multifetal pregnancy reduction on maternal indication. Reduction of multifetal pregnancy resulted in 2 to 21 week extension of time to delivery in women with preeclampsia. Discussion Selective feticide might be suggested as an (exceptional) alternative in early onset preeclampsia in dichorionic multiple pregnancies. Unequivocal counselling is essential because of the increased risk of adverse pregnancy outcome by extension of complicated pregnancy.

Outcome reporting across randomized trials and observational studies evaluating treatments for twin-twin transfusion syndrome: systematic review.

Twin-twin transfusion syndrome (TTTS) is associated with significant mortality and morbidity. Potential treatments for the condition require robust evaluation. The aim of this study was to evaluate outcome reporting across observational studies and randomized controlled trials assessing treatments for TTTS. Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE were searched from inception to August 2016. Observational studies and randomized controlled trials reporting outcome following treatment for TTTS in monochorionic-diamniotic twin pregnancy and monochorionic-triamniotic or dichorionic-triamniotic triplet pregnancy were included. Outcome reporting was systematically extracted and categorized. Six randomized trials and 94 observational studies were included, reporting data from 20 071 maternal participants and 3199 children. Six different treatments were evaluated. Included studies reported 62 different outcomes, including six fetal, seven offspring mortality, 25 neonatal, six early childhood and 18 maternal/operative outcomes. Outcomes were reported inconsistently across trials. For example, when considering offspring mortality, 31 (31%) studies reported live birth, 31 (31%) reported intrauterine death, 49 (49%) reported neonatal mortality and 17 (17%) reported perinatal mortality. Four (4%) studies reported respiratory distress syndrome. Only 19 (19%) studies were designed for long-term follow-up and 11 (11%) of these reported cerebral palsy. Studies evaluating treatments for TTTS have often neglected to report clinically important outcomes, especially neonatal morbidity outcomes, and most are not designed for long-term follow-up. The development of a core outcome set could help standardize outcome collection and reporting in TTTS studies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Risk factors for fetal death after radiofrequency ablation for complicated monochorionic twin pregnancies.

Radiofrequency ablation (RFA) is a management alternative for complicated monochorionic twin pregnancies. The purpose of this study is to evaluate risk factors for fetal death after RFA. An observational study was performed to document the perinatal outcomes of all cases undergoing fetal reduction using RFA from 2010 to 2016 at the Shanghai First Maternity and Infant Hospital. A multiple regression model was built to identify predictors of the death of the remaining fetus after RFA. A total of 183 patients treated with RFA for fetal reduction were analyzed, including 53 selective intrauterine growth restriction, 35 twin-twin transfusion syndrome, 36 dichorionic triamniotic triplets, 24 monochorionic twins discordant for fetal anomaly, and 35 twin reversed arterial perfusion. The prevalence of fetal death after RFA was 23% (43:183). The occurrence of fetal death after RFA was independently associated with more than 2 cycles of RFA coagulation (OR 3.46; 95% CI, 1.34-8.94; P=.01). More than 2 cycles of RFA coagulation is the only independent risk factors of fetal death after RFA.

Our results of spontaneously conceived triplet pregnancies

The natural incidence of spontaneous triplet pregnancy is approximately 1 in 8000 births. Premature delivery of one fetus, compromise of one fetus, and death of one fetus of a multiple gestation with healthy co-fetuses are complications unique to multiple gestations. Our purpose was to evaluate the outcome of spontaneous triplet gestations. In this retrospective study, maternal, neonatal data were collected from 25 sets of triplet pregnancies that were diagnosed between 2011 March and December 2013 in Zekai Tahir Burak WomenÂ’s Health Education and Research Hospital - Obstetric Department. There were 15 sets of trichorionic triamniotic triplet pregnancies and 10 sets of triplet pregnancies with a monochorionic pair (ie, dichorionic triamniotic triplets). The mean maternal age was 28 (20-33). 75% of patients were primigravida. 50% of patients (12 patient) had abortus (gave birth before 20 weeks). 3 patients gave birth about 33 weeks, birth weights were about 2100-2150 grams.4 patients gave birth about 30 weeks ,with birth weigths of 1800-1850 grams. 2 patients had spontaneous abortion of all fetuses after fetal reduction. Two patients (8%) had complication of postoperative endometritis. 3 patients had preeclampsia (12%). The incidence of dichorionicity in our study of spontaneous triplet pregnancy is 40%. Perinatal mortality was increased in dichorionic pregnancies. The abortus rate was 80%. Although abortus rate was high in spontaneous triplet pregnancy,gestational age at delivery was about 33 weeks. This is because of our hospitalÂ’s condition to be a tertiary hospital in obstetrics and neonatology.

Intrafetal Laser Coagulation for Trap Sequence in a Complicated Dichorionic Triamniotic Triplet Pregnancy Case Report and Review of the Literature

Summary A rare case is reported of twin-reversed arterial perfusion (TRAP) sequence in a triplet pregnancy, fetal intervention in the first trimester and pregnancy outcome. We report a case of TRAP sequence complication in dichorionic triamniotic triplet pregnancy, with a normally developing fetus and an acardiac fetus connected via arterio-arterial anastomoses in a monochorionic diamniotic twin pair and a separate fetus. TRAP sequence was diagnosed at 13 weeks in triplet pregnancy after in vitro fertilization (IVF) and embryo transfer of two blastocysts. Color Doppler assessment showed persistent arterial flow in the acardiac twin. Intrafetal laser coagulation was carried out at the time of the diagnosis, and the pregnancy outcome was two survivals at 36.4 weeks of gestation.

Outcome of dichorionic triamniotic triplet: the experience from an emerging fetal therapy center

Objectives: To report a cohort of dichorionic triamniotic (DCTA) triplets with access to contemporary fetal interventions.Design: Prospective study.Setting: A regional referral center for the diagnosis and management of complicated multiple pregnancies.Population: All DCTA triplets receiving consultation and prenatal care at our center from 2010 to 2015.Methods: The following management alternatives for DCTA were offered: 1) expectant management; 2) reduction of one or two fetus of the monochorionic (MC) component using radiofrequency ablation (RFA) after 16 weeks or potassium chloride (KCL) before 16 weeks, respectively; 3) reduction of the isolated fetus using KCL before 16 weeks.Main outcome measure: Survival rate of different management alternatives.Results: A total of 47 DCTA triplets were included in this study. After consultations on possible prognosis and management options, 19 patients chose expectant management, 14 patients opted RFA to reduce one fetus of the MC component, 14 patients required KCL to reduce the MC component. Fetal demise per pregnancy occurred more frequently in the subgroup managed expectantly (53%) compared to subgroups managed with RFA (7%, p = .02) or KCL (0%, p = .02). Overall survival was significantly lower in DCTA triplets managed expectantly (58%) compared to subgroup managed with RFA (93%, p < .01) or KCL (100%, p = .04).Conclusion: Fetal reduction seems to improve perinatal survival in DCTA triplets.

Задержка рождения второго и третьего плодов при многоплодной беременности тройней (Клинический случай)

This article describes a clinical case of vaginal delivery in nulliparous women 24 years old delayed interval delivery of the second and third fetuses in spontaneous multiple pregnancy dichorionic triamniotic triplet in a tertiary perinatal center. After preterm delivery in 27+5 weeks of gestation the first fetus to reduce perinatal morbidity and mortality of two fetuses that are left in the uterus, with informed consent of the woman preterm delivery the second and third fetuses occurred at intervals of 38 days, in 33+1 weeks of gestation. Careful monitoring of the state of the mother and fetuses was conducted. To increase the interval between the birth of the first fetus and the second and the third fetuses, prevention of obstetric and perinatal complications used tocolysis, antibiotics, progesterone, the prevention of respiratory distress syndrome of the newborn by corticosteroids and bed rest. Three girls were born alive with a weight of 980, 1800 and 1950 grams correspondingly. Childbirth complicated second degree perineal laceration and retained portions of placenta and membranes, puerperal period was uneventful. After 1.5 months, all infants discharged with her mother in a satisfactory condition with a weight of more than 3000 grams. Key words: multiple pregnancy, triplet pregnancy, delayed interval delivery in triplet pregnancy, preterm delivery.

Endoscopic Placental Laser Coagulation in Dichorionic and Monochorionic Triplet Pregnancies

Objective: To report the outcome of monochorionic (MC) and dichorionic (DC) triamniotic (TA) triplet pregnancies treated with endoscopic laser coagulation of the communicating placental vessels for severe feto-fetal transfusion syndrome (FFTS) and selective fetal growth restriction (sFGR). Methods: Laser surgery was performed at 18 (15-24) weeks' gestation in 11 MCTA and 33 DCTA pregnancies complicated by FFTS and 14 DCTA pregnancies complicated by sFGR. Data from our study and previous reports were pooled using meta-analytic techniques. Results: Survival of at least one baby and survival among all fetuses was 97.0 and 72.7% in DCTA pregnancies with FFTS, 78.6 and 52.4% in DCTA pregnancies with sFGR and 81.8 and 39.4% in MCTA pregnancies with FFTS. In the combined data from our study and previous reports, the pooled survival rates in 132 DCTA pregnancies with FFTS were 94.4 and 76.1%, and in 29 MCTA pregnancies with FFTS, they were 80.6 and 57.5%. Conclusions: Survival after laser surgery is higher in DC triplets with FFTS than in those with sFGR and in DC than in MC triplets with FFTS.

Outcome of Multifetal Pregnancy Reduction in Women with a Dichorionic Triamniotic Triplet Pregnancy to a Singleton Pregnancy: A Retrospective Nationwide Cohort Study

Objective: To study the pregnancy outcomes of women with a dichorionic triamniotic triplet pregnancy that was reduced to a singleton pregnancy and to review the literature. Methods: We performed a nationwide retrospective cohort study. We compared time to delivery and perinatal mortality in dichorionic triplet pregnancies reduced to singletons with ongoing dichorionic triplet pregnancies and primary singleton pregnancies. Additionally, we reviewed the literature on the subject. Results: We studied 46 women with a reduced dichorionic triplet pregnancy and 42 women with an ongoing dichorionic triplet pregnancy. Median gestational age at delivery was 38.7 vs. 32.8 weeks, respectively (p < 0.001). Delivery <24 weeks occurred in 9 (19.6%) women with a reduced triplet pregnancy and 4 (9.5%) with an ongoing triplet pregnancy (p = 0.19). Perinatal survival rates between the reduced group and the ongoing triplet group were not significantly different. Conclusion: Multifetal pregnancy reduction in women with a dichorionic triplet pregnancy to a singleton pregnancy prolongs median gestational age at birth. No statistically significant association was found with miscarriage and perinatal survival rates.

Dichorionic triplet pregnancies: risk of miscarriage and severe preterm delivery with fetal reduction versus expectant management. Outcomes of a cohort study and systematic review.

In trichorionic pregnancies, fetal reduction from three to two lowers the risk of severe preterm delivery, but provides no advantage in survival. Similar data for dichorionic triamniotic (DCTA) triplets is not readily available. To document the natural history of DCTA triplets and the effect of reduction on the risk of miscarriage and severe preterm delivery, compared with expectant management. Systematic search on MEDLINE, EMBASE, and the Cochrane Library. DCTA triplets with three live fetuses at 8-14 weeks of gestation, outcome data with expectant management and/or reduction, miscarriage before 24 weeks of gestation and/or severe preterm delivery before 32-33 weeks of gestation. Five studies were included. Data from these were combined with data from three centres. There were 331 DCTA triplets. The miscarriage rate was 8.9% (95% CI 5.8-13.3%) and the severe preterm delivery rate was 33.3% (95% CI 27.5-39.7%), with expectant management. The miscarriage rate was 14.5% (95% CI 7.6-26.2%) with a reduction of the monochorionic pair, 8.8% (95% CI 3.0-23.0%) with a reduction of one fetus of the monochorionic pair, and 23.5% (9.6-47.3%) with a reduction of the fetus with a separate placenta. Severe preterm delivery rates were 5.5% (95% CI 1.9-14-9%), 11.8% (95% CI 4.7-26.6%), and 17.6% (95% CI 6.2-41.0%), respectively. In DCTA triplets, expectant management is a reasonable choice when the top priority is a liveborn infant. Where the priority is to minimise severe preterm delivery, the most advisable option is fetal reduction. Further studies are needed to clarify which particular technique is advisable to optimise the outcome.

Clinical analysis of pregnancy outcomes and fetal loss after fetal reduction of triplets to twins or singleton pregnancy

To investigate and evaluate the pregnancy outcomes and fetal loss after fetal reduction of triplets to twins or singleton pregnancy. 282 cases of triplets who received multi-fetal pregnancy reduction (MFPR) at Shandong Provincial Hospital affiliated to Shandong University were recruited from Sep 2001 to Mar 2014. According to the remaining fetal number after MFPR, 231 cases were opted to reduce to twins (twins group) while 51 cases were opted to singleton pregnancy (singleton group). The indication of the former group was fetal abnormalities under ultrasound or on patients' demand; while the indication for the later group included dichorionic triamniotic (DCTA) triplets or patients' aspiration. Potassium chloride was injected into the targeted fetal heart until cardiac standstill was obtained. The pregnancy outcomes, gestational age at delivery, birth weight of newborns of the two groups were recorded. Successful pregnancy was defined as take-home at least one baby. (1) The overall rate of successful pregnancy was 91.5% (258/282). There were 413 neonates in the twins group, including 4 neonatal deaths and 409 live babies, with the successful rate of 90.5% (209/231). There were 49 neonates in the singleton group, including 2 cases of fetal loss. Thus the successful rate was 96.1% (49/51). There was no difference of successful pregnancy rate between the two groups (P>0.05). (2) The mean gestational age at operation for the twins group and singleton group were (16.5±3.5) weeks and (14.2±2.0) weeks, respectively. Each group was divided into three periods, 11-13(+6) weeks, 14-16(+6) weeks and ≥17 weeks. In the twins group, the cases in each time period were 129 (55.8%, 129/231), 50 (21.6%, 50/231) and 52 (22.5%, 52/231), respectively. While in the singleton group, the cases in each time period were 27 (53%, 27/51), 16 (31%, 16/51) and 8 (16%, 8/51). There was no difference between the two groups at each time period (P>0.05). (3) The fetal loss rate in the twins group were 7% (9/129), 12% (6/50), 10% (5/52) at each time period, respectively. While for the singleton group they were 4% (1/27), 0 (0/16) and 1/8, respectively. There was no significant difference between the two groups at each time period (P>0.05). (4) The mean birth weight of the twins group was lower than the singleton group [(2,555±447) g vs (3,084±550) g, respectively, P<0.05]. The rates of low birth weight infants (<2,499 g) in the twins group and the singleton group were 45.5% (188/413) and 8% (4/49), respectively (P<0.05). The rate of very low birth weight infants (≤1,499 g) was 3.9% (16/413) in the twins group compared with 0 (0/49) in the singleton group (P>0.05). (5) The gestational age at delivery of the twins group was earlier than the singleton group [(36.2±2.4) weeks vs (38.3±2.2) weeks, respectively, P<0.05]. The labor rate of the two groups was significantly different for both 34-36(+6) weeks and ≥ 37 weeks (P<0.05). The full-term delivery rate in the twins group was 47.6% (110/231), and was 88.2% (45/51) in the singleton group (P < 0.05). The fetal loss rate before 28 weeks did not differ between the two groups [8.7% (20/231) vs 3.9% (2/51), P>0.05]. Reduction to one fetus led to significantly better outcome than two fetuses, with no significant difference in fetal loss rate. It is better to advise patients with triplets reduce to singleton pregnancy.

Demographic and Assisted Reproduction Related Factors Associated with Dichorionic Triplet Gestations

Our objective was to evaluate which demographic factors or assisted reproductive technologies were associated with IVF triplet gestations where one of the embryos split, resulting in a dichorionic triplet gestation. This was a case-control study of dichorionic versus trichorionic triplet gestations that underwent assisted reproductive technology over the last 5 years at our fertility center. There were 53 cases of dichorionic triamniotic triplet gestations compared to 119 trichorionic triplet controls. There were no significant demographic differences between the cases and controls. 51/53 dichorionic triplets and 86/119 trichorionic triplets were conceived through IVF, the remaining utilized intrauterine insemination. ICSI was performed in virtually all patients that underwent IVF. Of the potential risk factors studied, hatching was used in 70.6% of dichorionic compared to 89.5% of trichorionic IVF triplets (p = 0.005); embryo transfer was performed on Day 5 or 6 compared to Day 3 in 88.0% dichorionic vs 71.8% trichorionic (p = 0.028). Frozen sperm was utilized more frequently with dichorionic than with trichorionic triplets, 26.0% vs 10.9% (p < 0.011). Only 4 (7.5%) of the IVF cases underwent pre-implantation genetics. Certain assisted reproductive technologies appear to be associated with embryo splitting and a dichorionic triplet gestation. More research is needed in this area to further elucidate these findings.

Outcome of fetoscopic laser ablation for twin‐to‐twin transfusion syndrome in dichorionic–triamniotic triplets compared with monochorionic–diamniotic twins

To compare outcome of dichorionic-triamniotic (DCTA) triplet gestations with that of a paired cohort of monochorionic-diamniotic (MCDA) twin gestations undergoing laser therapy for treatment of twin-to-twin transfusion syndrome (TTTS). All DCTA triplets treated at four referral centers between specified dates were included. A matched cohort group of MCDA twin gestations affected by TTTS was used for comparison. Sixteen sets of DCTA triplets treated with laser photocoagulation of placental anastomoses were compared with 32 matched sets of MCDA twins. All of the 'singleton' fetuses in the triplet gestations survived to birth and to the end of the neonatal period. There were no differences in single or double survival or the rate of non-survivors to birth and at age 28 days. A mean 3-week difference was found in the procedure-to-delivery interval in DCTA triplets vs MCDA twins (60 ± 35.8 days vs 83.6 ± 33.2 days; P = 0.029). A mean difference of 3 weeks was also found in the gestational age at delivery in DCTA triplets vs MCDA twins (28.5 ± 3.5 weeks vs 31.9 ± 5 weeks; P = 0.024). A similar post-laser fetal growth pattern in donors and recipients of both groups was noted. DCTA triplet gestations with TTTS have a similar rate of post-laser survival but deliver earlier than can be expected for twins treated with laser. These findings have potential implications for the risk of prematurity and long-term outcomes.

Perinatal outcome after laser surgery for triplet gestations with feto-fetal transfusion syndrome

The objective of this study is to evaluate the outcomes of fetoscopic laser photocoagulation (FLP) for a triplet gestation with feto-fetal transfusion syndrome (FFTS). On the basis of chorionicity, perinatal outcome at 28 days in triplets with FFTS after FLP were evaluated. Fetoscopic laser photocoagulation was completed for all 16 cases including nine dichorionic triamniotic (DT) cases and seven monochorionic triamniotic (MT) cases. The placenta was located anteriorly in six cases. The median gestational age at surgery was 21 (16-25) weeks, and the median operation time was 51 (25-125) minutes. Several technical maneuvers to complete the procedure in MT, such as trocar assistance in two cases, intentional septostomy of the dividing membrane in one, and double uterine entry in one, were used. The median gestational age at delivery was 31 (23-34) weeks. Overall perinatal survival in DT was 74% and that of MT was 95%. All 16 cases resulted in at least one survival, whereas three neonates survived in 44% of DT cases and in 86% of MT cases. Two MT neonates suffered severe intraventricular hemorrhages. Fetoscopic laser photocoagulation for FFTS in MT as well as DT triplets seems a valuable treatment.