Monochorionic Triamniotic Triplet 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.

МОНОХОРИАЛЬНАЯ ТРИАМНИОТИЧЕСКАЯ ТРОЙНЯ: КЛИНИЧЕСКИЙ СЛУЧАЙ

This article presents our own observation of a case of spontaneous pregnancy with monochorionic triamniotic triplets, describes the course of pregnancy, ultrasound results, and results.

Perinatal outcomes of fetoscopic laser surgery for twin-twin transfusion syndrome in triplet pregnancy: cohort study, systematic review and meta-analysis.

The aims of this study were to investigate the perinatal outcome of dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplet pregnancies complicated by twin-twin transfusion syndrome (TTTS) treated with fetoscopic laser photocoagulation (FLP) in two academic fetal centers, and to conduct a systematic review of previously published data to investigate perinatal survival in this targeted population. The first part of the study was a retrospective cohort study of prospectively collected data of consecutive triplet pregnancies with TTTS that underwent FLP at two fetal treatment centers between 2012 and 2020. Demographic, preoperative and operative variables and postoperative outcome were collected. Perinatal outcomes were investigated. The second part of the study was a systematic review and meta-analysis of studies evaluating the outcome of DCTA and/or MCTA triplet pregnancies, including our cohort study. PubMed, Web of Science and Scopus were searched from inception to September 2020. Primary outcomes were fetal survival (survival to birth), neonatal survival (survival to 28 days of age) and gestational age (GA) at birth. A total of 31 sets of triplets with TTTS managed with FLP were included in the cohort study. Of these, 24 were DCTA and seven were MCTA. There were no significant differences in preoperative and operative variables between the two groups. There were also no significant differences between groups in GA at delivery or perinatal survival rate, including fetal and neonatal survival of at least one triplet, at least two triplets and all three triplets. Nine studies, including our cohort study, were included in the systematic review (156 DCTA and 37 MCTA triplet pregnancies treated with FLP). The overall fetal and neonatal survival was 79% (95% CI, 75-83%) and 75% (95% CI, 71-79%), respectively, in DCTA cases and 74% (95% CI, 52-92%) and 71% (95% CI, 49-89%), respectively, in MCTA cases. The rate of preterm birth before 28 weeks and before 32 weeks' gestation was 14% (95% CI, 4-29%) and 61% (95% CI, 50-72%), respectively, in DCTA triplets and 21% (95% CI, 3-45%) and 82% (95% CI, 62-96%), respectively, in MCTA triplets. Triplet pregnancies with TTTS are at high risk of adverse perinatal outcome and preterm birth, regardless of chorionicity. The rate of survival after FLP in MCTA triplets was higher in our study than that reported in previous studies and is currently comparable with survival in DCTA triplets, which could be due to improved surgical skills. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

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.

Selective termination of the fetus in multiple pregnancies using ultrasound-guided radiofrequency ablation

BackgroundTo evaluate the perinatal outcomes in women with selective termination using ultrasound-guided radiofrequency ablation (RFA).MethodsComplicated monochorionic (MC) twin pregnancies and multiple pregnancies with an indication for selective termination by ultrasound-guided coagulation of the umbilical cord with RFA under local anesthesia between July 2013 and Jan 2020 were reviewed. We analyzed the indications, gestational age at the time of the procedure, cycles of RFA, duration of the procedure, and perinatal outcome.ResultsThree hundred and thirteen patients were treated during this period. Seven of whom were lost of follow-up. The remaining 306 cases, including 266 pairs of monochorionic diamniotic (MCDA) twins (86.93%), two pairs of monoamniotic twins (0.65%), 30 dichorionic triamniotic (DCTA) triplets (1%), and three monochorionic triamniotic (MCTA) triplets (0.98%), were analyzed. Indications included twin-to-twin transfusion syndrome (TTTS) (n = 91), selective fetal growth restriction (sFGR) (n = 83), severe discordant structural malformation (n = 78), multifetal pregnancy reduction (MFPR) (n = 78), twin reverse arterial perfusion sequence (TRAPS) (n = 19), and twin anemia-polycythemia sequence (TAPS) (n = 3). Upon comparison of RFA performed before and after 20 weeks, the co-twin loss rate (20.9% vs. 21.5%), the incidence of preterm premature rupture of membranes (PPROM) within 24 h (1.5% vs. 1.2%), and the median gestational age at delivery [35.93 (28–38) weeks vs. 36 (28.54–38.14) weeks] were similar (p > 0.05).ConclusionsRFA is a reasonable option when indicated in multiple pregnancies and complicated monochorionic pregnancies. In our experience, the overall survival rate was 78.76% with RFA in selective feticide, and early treatment increases the likelihood of survival for the remaining fetus because the fetal loss rate is similar before and after 20 weeks.

Effect of monochorionicity on perinatal outcome and growth discordance in triplet pregnancy: collaborative multicenter study in England, 2000-2013.

To compare perinatal outcome and growth discordance between trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) or monochorionic triamniotic (MCTA) triplet pregnancies. This was a multicenter cohort study using population-based data on triplet pregnancies from 11 Northern Survey of Twin and Multiple Pregnancy (NorSTAMP) maternity units and the Southwest Thames Region of London Obstetric Research Collaborative (STORK) multiple pregnancy cohort, for 2000-2013. Perinatal outcomes (from ≥ 24 weeks' gestation to 28 days of age), intertriplet fetal growth and birth-weight (BW) discordance and neonatal morbidity were analyzed in TCTA compared with DCTA/MCTA pregnancies. Monochorionic placentation of a pair or trio in triplet pregnancy (n = 72) was associated with a significantly increased risk of perinatal mortality (risk ratio, 2.7 (95%CI, 1.3-5.5)) compared with that in TCTA pregnancies (n = 68), due mainly to a much higher risk of stillbirth (risk ratio, 5.4 (95%CI, 1.6-18.2)), with 57% of all stillbirth cases resulting from fetofetal transfusion syndrome, while there was no significant difference in neonatal mortality (P = 0.60). The associations with perinatal mortality and stillbirth persisted when considering only pregnancies not affected by a major congenital anomaly. DCTA/MCTA triplets had lower BW and demonstrated greater BW discordance than did TCTA triplets (P = 0.049). Severe BW discordance of > 35% was 2.5-fold higher in DCTA/MCTA compared with TCTA pregnancies (26.1% vs 10.4%), but this difference did not reach statistical significance (P = 0.06), presumably due to low numbers. Triplets in both groups were delivered by Cesarean section in over 95% of cases, at a similar gestational age (median, 33 weeks' gestation). The rate of respiratory (P = 0.28) or infectious (P = 0.08) neonatal morbidity was similar between the groups. Despite close antenatal surveillance, monochorionic placentation of a pair or trio in triamniotic triplet pregnancy was associated with a significantly increased stillbirth risk, mainly due to fetofetal transfusion syndrome, and with greater size discordance. In liveborn triplets, there was no adverse effect of monochorionicity on neonatal outcome. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

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.

EP21.02: Expectant management of monochorionic triamniotic triplets complicated by selective in utero growth restriction: report of two cases

EP21.02: Expectant management of monochorionic triamniotic triplets complicated by selective <i>in utero</i> growth restriction: report of two cases

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

Fetofetal Transfusion Syndrome in Monochorionic-Triamniotic Triplets Treated with Fetoscopic Laser Ablation: Report of Two Cases and A Systematic Review

Objective This study aims to determine the clinical outcomes of monochorionic-triamniotic (MT) pregnancies complicated by severe fetofetal transfusion undergoing laser photocoagulation. Study Design We report two cases of MT triplets complicated by fetofetal transfusion syndrome (FFTS) and a systematic review classifying cases into different subtypes: MT with two donors and one recipient, MT with one donor and two recipients, MT with one donor, one recipient, and one unaffected triplet. The number of neonatal survivors was analyzed based on this classification as well as Quintero staging. Results A total of 26 cases of MT triples complicated by FFTS were analyzed. In 56% of the cases, the FFTS involved all three triplets, 50% of whom had an additional donor and 50% an additional recipient. Among the 24 cases that survived beyond 1 week after the procedure, the average gestational age of delivery was 29.6 weeks, and the average interval from procedure to delivery was 10.1 weeks. The overall neonatal survival rate was 71.7%, with demises occurring equally between donor and recipient triplets. Overall neonatal survival including survival of at least two fetuses occurred with equal frequency between the different groups. Conclusion Significant neonatal survival can be achieved in most cases of MT triplets with FFTS.

Completed monochorionic triplets after fresh-cycle single embryo transfer

Abstract Single embryo transfer (SET) is the standard of care for in vitro fertilization procedures and is aimed at decreasing the rates of multiple gestations. We highlight a case report of a patient with monochorionic-triamniotic triplet gestations despite SET and discuss the necessity of counseling patients adequately prior to using assisted reproductive technology.