Monochorionic Triamniotic Triplet Pregnancy Research Articles

Intrauterine Treatment of Monochorionic Triamniotic Triplet Pregnancy with Twin Reverse Arterial Perfusion Sequence

Intrauterine Treatment of Monochorionic Triamniotic Triplet Pregnancy with Twin Reverse Arterial Perfusion Sequence

Aplasia cutis congenita as a complication of early interstitial laser embryo reduction in a case of monochorionic triamniotic triplet pregnancy ‒ a case report

Abstract Objectives Monochorionic multiple pregnancies are being increasingly encountered. Early embryo reduction by interstitial laser is an option of therapeutic intervention. The patient counseling is mainly focused on miscarriage and fetal demise but this case report highlights that the counseling also needs to mention the possibility of developing Aplasia cutis congenita post intervention and that interstitial laser though technically feasible can have rare complications. Case presentation This was a uncommon form of twinning diagnosed as monochorionic triamniotic triplet pregnancy where the parents wanted to continue with a single fetus. Interstitial laser was performed in two of the embryos, which became papyraceous. The newborn on delivery was seen to have extensive skin scarring on the trunk which was diagnosed as Aplasia cutis congenita. Conclusions Awareness on complications on early interstitial laser procedures beyond miscarriage and fetal demise and the psychological impact on the parents of seeing the scarred neonate for the first time, if they have not been made aware of this complication.

Perinatal outcomes of monochorionic triplet pregnancies: multicenter cohort study.

Monochorionic triplet pregnancies are extremely rare and information on these pregnancies and their complications are limited. We aimed to investigate the risk of early and late pregnancy complications, perinatal outcomes, and the timing and methods of fetal intervention in monochorionic triplet pregnancies. This was a multicenter retrospective cohort study including monochorionic triamniotic (MCTA) triplet pregnancies. The exclusion criteria were twins, or multiple pregnancies with higher order than triplets (e.g. quadruplets, quintuplets), and dichorionic or trichorionic triplet pregnancies. Data on maternal age, mode of conception, diagnosis of major fetal structural anomalies or aneuploidy, gestational age (GA) at diagnosis of anomalies, twin to twin transfusion syndrome (TTTS), twin anemia polycythemia syndrome (TAPS), twin reversed arterial perfusion sequence (TRAP), or selective fetal growth restriction (sFGR) were ascertained from the patient records. Data on antenatal interventions were collected, including selective (fetal) reduction (3 to 2 or 3 to 1), laser surgery, or any active fetal intervention (including amniodrainage). Finally, perinatal outcomes included livebirth, intrauterine demise (IUD), neonatal death (NND), perinatal death (PND) and termination of pregnancy (TOP). Neonatal data such as GA at birth, birthweight, neonatal intensive care unit (NICU) admission, and neonatal morbidity were also collected. In our cohort of MCTA triplet pregnancies (n=153 after excluding early miscarriages, TOP and loss to follow-up), the majority (90%) were managed expectantly. The incidence of fetal abnormalities and TRAP was 13.7% and 5.2%, respectively. The most common antenatal complication related to chorionicity was TTTS, which complicated just over a quarter (27.6%) of the pregnancies, followed by sFGR (16.4%), while TAPS (both spontaneous and post-laser) occurred in only 3.3%; no antenatal complication was recorded in 49.3% of pregnancies. Survival was largely associated with the development of these complications: 85.1%, 100% and 47.6% of pregnancies had at least one surviving newborn in those without antenatal complications, complicated by sFGR, or complicated by TTTS, respectively. The overall rates of preterm birth prior to 28 weeks and prior to 32 weeks' gestation were 14.5% and 49.2%, respectively. MCTA triplet pregnancies represent a challenge in counseling, surveillance and management as monochorionicity-related complications occur in almost half of these pregnancies, which negatively impact their perinatal outcomes. This article is protected by copyright. All rights reserved.

Outcome of monochorionic triamniotic triplet pregnancies: Expectant management versus fetal reduction.

To compare the outcomes of monochorionic triamniotic (MCTA) triplets managed expectantly with those reduced to twins. This was a retrospective cohort study comparing expectant management (EM) with fetal reduction (FR) to twins in 43 consecutive MCTA triplets with 3 live fetuses at 11-14weeks between 2012 and 2021. Nineteen patients managed expectantly and 24 triplets reduced to twins were included. The rate of pregnancy with at least one survivor was 84.2% in the EM group and 66.7% in the FR group (P=0.190). Compared to the EM cases, triplets reduced to twins had a higher median gestational age at delivery (36.0 vs. 33.3weeks; P<0.001), a higher mean birth weight (2244.3±488.6g vs. 1751.1±383.2g; P<0.001) and a lower risk of preterm birth before 34weeks (11.8% vs. 64.7%; P=0.001). There were no significant differences in the risk of miscarriage, pregnancy complications and composite adverse neonatal outcomes. In MCTA triplets, FR to twins could reduce the risk of preterm birth, whereas EM seems to be a reasonable choice when the priority is at least one survivor. However, due to the small sample size of this study, these findings must be interpreted with great caution.

256 Monochorionic-triamniotic triplet pregnancy, complicated by trap sequence: A case report

Background: Twin reversed arterial perfusion (TRAP) sequence ia a rare complications of multiple pregnancy. It is characterized by lethal anomalies (e.g acardia) exhibiting recipient fetus and a generally structurally normal pump fetus. Objective: We present a rare case of monochorionic-triamniotic triplet pregnancy complicated by twin reversed arterial perfusion sequence. Methods: A 39 -year-old patient gravida 1, para 1 with underwent in vitro fertilization treatment with transfer of two embryos resulting in a monochorionic-triamniotic triplet pregnancy diagnosed at 10 weeks of gestation.

Amnioprotective cesarean section in monochorionic-triamniotic triplet pregnancy, spontaneously conceived, complicated by intrahepatic cholestasis

Amnioprotective cesarean section in monochorionic-triamniotic triplet pregnancy, spontaneously conceived, complicated by intrahepatic cholestasis

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.

Multicystic encephalomalacia and gastrointestinal injury following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy: a case report

BackgroundMonochorionic multifetal pregnancies are at increased risk of adverse perinatal outcome because of placental vascular anastomoses. We present a case of multicystic encephalomalacia and gastrointestinal injury in two surviving fetuses following single fetal death in first trimester and subsequent fetofetal transfusion syndrome in a monochorionic triplet pregnancy.Case presentationA 31-year-old nulliparous woman had a spontaneous monochorionic triamniotic triplet pregnancy. Three live fetuses with single placenta were seen at 8-week ultrasound scan. One fetus demised at 11 weeks and 3 days of gestation. Dilated echogenic bowel and ascites were found in one surviving fetus at 23 weeks of gestation. At 28 weeks of gestation, the pregnancy was complicated by fetofetal transfusion syndrome in which discordant amniotic fluid volumes were found. Two days later, emergency Caesarean section was performed because of worsening of fetal Doppler and biophysical profile. One baby was found to have jejunal atresia requiring surgery at 4 days old. He had periventricular leukomalacia and intracranial haemorrhage, but subsequent normal neurological development. Another baby had gastric perforation requiring surgery at 2 days old. He was confirmed to have multicystic encephalomalacia by cranial ultrasound and magnetic resonance imaging. He suffered from developmental delay, epilepsy and cerebral palsy.ConclusionThis case alerts the obstetricians the possible hypoxic-ischemic injury to the survivors of monochorionic triplet pregnancy after the co-triplet death in the first trimester and fetofetal transfusion syndrome. Antenatal assessment and postnatal follow-up are important for these high-risk multiple pregnancies.

Monochorionic Triamniotic Triplet Pregnancy Following Assisted Reproductive Technology and Radiofrequency Ablation for Selective Reduction

Monochorionic Triamniotic Triplet Pregnancy Following Assisted Reproductive Technology and Radiofrequency Ablation for Selective Reduction

EP20.14: Natural history of a monochorionic triamniotic triplet pregnancy complicated with TRAP sequence: prenatal ultrasonographic and postnatal placental findings – “a pump, an indirect pump and an acardiac triplets' destiny”

EP20.14: Natural history of a monochorionic triamniotic triplet pregnancy complicated with TRAP sequence: prenatal ultrasonographic and postnatal placental findings – “a pump, an indirect pump and an acardiac triplets' destiny”

EP20.12: The heartless triplet: acardius anceps complicating monochorionic pregnancy

Twin Reversed Arterial Perfusion (TRAP) sequence affects 1% of monochorionic twins and 3% of monochorionic triplets. Acardius acephalus, acardius amorphous, acardius acormus and acardius anceps have been described. In the acardius anceps (9% of cases) the fetal head and body are differentiated. A 28 y.o. woman, G1P0 was referred at 14 weeks gestation with a monochorionic triamniotic triplet pregnancy complicated by demise of triplet 3; the fetus appeared fully formed with a marked cystic hygroma and no heartbeat. At 18 weeks there was a significant increase in size, hydrops and Doppler perfusion into triplet 3; TRAP sequence was diagnosed. End-diastolic flow (EDF) in the umbilical artery and a-wave in the ductus venosus of triplet 2 were absent, therefore interstitial laser coagulation of pelvic vessels was performed in triplet 3. Subsequent positive EDF in umbilical artery of triplet 2 deteriorated at 33+2 weeks, the babies were therefore delivered by emergency Caesarean section. Triplet 1 weight was 2030g with Apgars 10,10 and Triplet 2: 1650g with Apgars 7,9,10. Acardius anceps variant of TRAP was diagnosed on autopsy of triplet 3. Unlike other cases described, the upper body was better developed with normal occipital, parietal and frontal bones. Aortic type vessel was extending rostrally with two apparent brachial arteries and two apparent common carotid-like arteries. The upper limbs had 5 digits on each hand and were held in partially reducible flexion at shoulders and elbows; there was a bilateral cleft palate. In the lower body, the vasculature was difficult to assess, fracture dislocations were seen at knees and ankles, with fusion of the fourth and fifth digits of the feet. QFPCR confirmed a monozygotic pregnancy. The above case highlights the difficulties posed by well differentiated variants of TRAP at early gestations and the importance of a thorough examination, including Doppler studies to aid the diagnosis of these rare and challenging cases.

Монохориальная триамниотическая тройня в программе ВРТ: клиническое наблюдение

Монохориальная триамниотическая тройня в программе ВРТ: клиническое наблюдение

Endoscopic laser coagulation of the communicating placental vessels for twin-twin transfusion syndrome of monochorionic triamniotic triplet pregnancy conceived by IVF and ICSI

Endoscopic laser coagulation of the communicating placental vessels for twin-twin transfusion syndrome of monochorionic triamniotic triplet pregnancy conceived by IVF and ICSI

Perinatal death of triplet pregnancies by chorionicity

The purpose of this study was to evaluate the perinatal risk of death by chorionicity at >22 weeks of gestation of triplet pregnancies. In a retrospective cohort study, the perinatal data were collected from triplet pregnancies in Japanese perinatal care centers between 1999 and 2009. We included maternal characteristics and examined the following factors: prenatal interventions, pregnancy outcome, and neonatal outcome. The association between fetal or neonatal death of triplets and chorionicity was evaluated by logistic regression analysis. After the exclusion of 253 cases, the study group comprised 701 cases: 507 trichorionic triamniotic (TT) triplet pregnancies, 144 diamniotic triamniotic (DT) triplet pregnancies, and 50 monochorionic triamniotic (MT) triplet pregnancies. The mortality rate (fetal death at>22 weeks of gestation; neonatal death) in triplets was 2.6% andincluded 2.1% of TT triplet pregnancies, 3.2% of DT triplet pregnancies, and 5.3% of MT triplet pregnancies. No significant riskofdeath was identified in DT triplet pregnancies; however, MT triplet pregnancies had a 2.6-fold greater risk (adjusted odds ratio,2.60; 95% confidence interval, 1.17-5.76; P= .019) compared with TT triplet pregnancies. Prophylactic cervical cerclage did not reduce the perinatal mortality rate at >22 weeks of gestation in triplets. The risk of death for MT triplet pregnancies is significantly higher than that of TT triplet pregnancies; however, the risk of death for DT triplet pregnancies is not.

P23.15: Monochorionic triamniotic triplet pregnancy complicated by twin reversed arterial perfusion (TRAP) sequence

M. Murata1, K. Ishii1, M. Kamitomo2, T. Murakoshi3, Y. Takahashi4, M. Sekino5, K. Kiyoshi6, H. Sago7, R. Yamamoto1, H. Kawaguchi1, N. Mitsuda1 1Department of Maternal Fetal Medicine, Osaka Prefectural Hospital Organization, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan; 2Department of Obstetrics and Gynecology, Kagoshima City Hospital, Kagoshima, Japan; 3Maternal and Perinatal Care Center, Seirei Hamamatsu General Hospital, Hamamatsu, Japan; 4Department of Fetal-Maternal Medicine, Nagara Medical Center, Gifu, Japan; 5Department of Obstetrics and Gynecology, Hiroshima City Hospital, Hiroshima, Japan; 6Division of Perinatology, Feto-Maternal Center, Hyogo Prefectural Kobe Children’s Hospital, Kobe, Japan; 7Department of Maternal-Fetal and Neonatal Medicine, National Center for Child Health and Development, Tokyo, Japan

Triplet pregnancy complicated by two acardiac fetuses

Triplet pregnancy complicated by two acardiac fetuses

Monochorionic triamniotic triplet pregnancies with assisted reproductive technology: Two case reports

Developments in assisted reproductive technology have allowed us to decrease the numbers of transferred embryos and thereby reduce the risk of multifetal pregnancies. However, even when the numbers of transferred embryos are restricted, the incidence of monozygotic multiple pregnancies is not reduced, and can be significantly higher than normal. We report two cases of monochorionic triamniotic triplet pregnancies after applying assisted reproductive technology. Three male babies were born in one pregnancy and the other pregnancy aborted at 10 weeks of gestation. Several factors, such as manipulation of the zona pellucida or extended blastocyst culture, might increase the risk of such monozygotic multiple gestations in this setting, but the actual causes remain unknown. Besides detecting predictive factors for monozygotic pregnancies, any manipulation of the zona pellucida in combination with blastocyst culture must be done cautiously to minimize the likelihood of monochorionic multiple pregnancies.

Monozygotic multiple gestation after intracytoplasmic sperm injection and preimplantation genetic diagnosis

To report a possible association between intracytoplasmic sperm injection (ICSI)-preimplantation genetic diagnosis (PGD) and monozygotic multiple gestation. Small case series. In vitro fertilization unit in an academic medical center. Three patients were treated with ICSI-PGD for sexing as well as selection against a known translocation. Transfer of day 4 embryos to the uterus. Clinical pregnancy. Two pairs of monozygotic twins and a triplet pregnancy. Repeated manipulation of the zona pellucida as well as extended embryo culture during ICSI-PGD treatments may result in monozygotic twin and triplet pregnancies.

P37.10: Growth discordance and abnormal Doppler flow in a monochorionic triamniotic triplet pregnancy: A case report

Prevalence of spontaneous monochorionic triplet pregnancy is 1 in 7000 pregnancies with a 50–60% incidence of growth restriction. We report a case of 25 year old G1 P0 hospitalized at 24 6/7 weeks for one fetus with selective intrauterine growth restriction (IUGR) with absent or reversed end diastolic flow in the free loop of umbilical artery (FLUA). The estimated growths of the three fetuses were < 10%, 28% and 38%. There was no evidence of structural or functional cardiac abnormalities in any of the fetuses. There was no evidence of twin-twin transfusion syndrome. The patient was managed with bed rest, oxygen by nasal cannula, steroids and followed with daily biophysical profile and non-stress test, weekly Doppler and amniotic fluid evaluations. After eleven days, the IUGR fetus showed improvement in the ductus venosus and middle cerebral artery pulsatility index (PI) while FLUA showed mildly elevated PI. The plan was to prolong delivery of the triplets until after 32 weeks gestation, if possible. The antenatal course remained uneventful while on maternal oxygen therapy. At 32 weeks, the smaller fetus had grown to 37% percentile with all Doppler values within normal limits while on maternal oxygen and the delivery was conducted by scheduled cesarean section. The placental pathology showed a monochorionic placenta with one eccentric and two central insertions of the three vessel umbilical cords. The newborns weighed 1015 grams (g), 1350 g and 1530 g with normal Apgar score at 5 minutes. All of the triplets received continuous positive airway pressure and parenteral support in the newborn period. We conclude that oxygen therapy improved the Doppler flow pattern in the IUGR fetus of this triplet pregnancy and allowed for substantial growth in that fetus, thereby successfully prolonging the delivery date.

EPC-002 Successful delivery of spontaneous monochorionic triamniotic triplet pregnancy following conservative management: first reported case in Singapore

EPC-002 Successful delivery of spontaneous monochorionic triamniotic triplet pregnancy following conservative management: first reported case in Singapore