Monochorionic Triplet Research Articles

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.

Fetal Reduction of Triplet Pregnancies to Twins vs Singletons: A Meta-analysis of Survival and Pregnancy Outcome

ABSTRACT Fetal reduction (FR) for higher-order multiples accounted for 103.6 per 100,00 births across the United States in 2015, and the need for this service has expanded over the last 30 years. Despite improvements in neonatal care, triplet pregnancies are more likely to experience adverse outcomes, including infant mortality and morbidity, than twin or singleton pregnancies. In triplet pregnancies, prematurity is associated with an 11-fold increase and low birth weight with a 2.2-fold increase in infant deaths compared with singleton and twin prematurity pregnancies. This contributes to higher all-cause healthcare expenses for triplet pregnancies (US $407,000) versus singleton pregnancies (US $21,500). Fetal reduction has been shown to improve outcomes, including a lower risk of premature birth, in triplet pregnancies reduced to twins compared with triplet pregnancies with no FR. Another study found improved outcomes when triplet pregnancies were reduced to singleton or twin pregnancies versus expectant management. However, it remains unclear whether FR in triplet pregnancies to singleton pregnancy (RTS) improved outcomes compared with a reduction to twin pregnancies (RTT). The aim of this study was to compare perinatal outcomes and survival rates of RTS pregnancies versus RTT pregnancies, and FR in any triplet pregnancies versus expectant management. This was a systematic review and meta-analysis based on a literature search for studies with data comparing selective RTT and RTS pregnancies. Excluded were studies with multiple pregnancies >3 fetuses, monochorionic triplets, and missing data. The primary outcome was the rate of fetal survival of RTT and RTS pregnancies, defined as a live birth >24 weeks of gestation. Secondary outcomes included gestational age (GA) at birth, birth weight, incidence of preterm birth, early pregnancy loss at <24 weeks, and neonatal death, up to 28 days after birth. A total of 10 studies directly comparing RTT pregnancies with RTS pregnancies and another 10 studies comparing FR with no FR were included in the analysis. The studies represented 1903 RTT pregnancies and 489 RTS pregnancies. There was a significantly lower survival rate among RTT pregnancies versus RTS pregnancies (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.40–0.92; 95% prediction interval [PI], 0.36–1.03; P = 0.02; I 2 = 0%). There was a comparable risk of early pregnancy loss (OR, 0.89; 95% CI, 0.58–1.38; 95% PI, 0.54–1.48; P = 0.61; I 2 = 0%) and neonatal death (OR, 0.56; 95% CI, 0.10–3.21; P = 0.55; I 2 = 28%). RTT pregnancies had significantly lower GA (mean difference, −2.20; 95% CI, −2.80 to −1.61; 95% PI, −4.27 to −0.14; P < 0.001; I 2 = 79%) and lower birth rates (OR, 8.76; 95% CI, 5.56–13.80; 95% PI, 4.60–16.67; P < 0.001; I 2 = 0%) than RTS pregnancies. RTT pregnancies also had a greater risk of preterm birth at <34 weeks (OR, 3.04; 95% CI, 1.45–6.36; 95% PI, 0.54–17.18; P = 0.003; I 2 = 22%) and at <32 weeks (OR, 2.14; 95% CI, 1.02–4.49; 95% PI, 0.64–7.13; P = 0.04; I 2 = 0%). No difference in live birth rate was observed between RTT pregnancies and expectant management. In conclusion, triplet pregnancies RTS pregnancies had better outcomes than RTT pregnancies, including higher fetal survival rate, higher GA at birth, lower risk of preterm birth, and higher birth weight. Understanding the potential risks and benefits of FR in triplet pregnancies is essential for obstetricians providing parental counseling.

Highlights from the International Twins Congress 2021

Highlights from the International Twins Congress 2021

Intrafetal laser therapy in a monochorionic diamniotic triplet pregnancy with two acardiac fetuses: a case report and literature review

BackgroundMonochorionic diamniotic triplet pregnancies are rare. Twin reversed arterial perfusion sequence in monochorionic triplet pregnancies is extremely rare, and it is associated with high perinatal morbidity and mortality rates in the “pump fetus.”Case presentationWe reported a case of monochorionic diamniotic triplet pregnancy with twin reversed arterial perfusion sequence, including two acardiac fetuses sharing a single amniotic sac and a normal fetus in another amniotic sac. Due to rapid growth of the acardiac fetuses, intrafetal laser therapy was performed in both of them under ultrasound guidance at 15 weeks +5 days. Subsequently, regular and careful antenatal care including fetal ultrasonography and doppler and fetal echocardiography was conducted. At 37 weeks +4 days, a healthy female baby weighing 2510 g was delivered. The baby was followed up and now at 11 months old is in good health.ConclusionsTwin reversed arterial perfusion sequence in monochorionic triplet pregnancy should be diagnosed early by ultrasound imaging during pregnancy. Individualized management should be based on clinical conditions to improve the perinatal outcome of the pump twin. Intrafetal laser therapy could be an alternative procedure when intrauterine intervention is required.

DNA Methylation Pattern of CALCA and CALCB in Extremely Premature Infants with Monochorionic Triplets after Single-Embryo Transfer.

Compared with full-term peers, premature infants are more likely to suffer from neonatal diseases and death. Variations in DNA methylation may affect these pathological processes. Calcitonin gene-related peptide (CGRP) plays a complex and diversified role in reproduction and chronic inflammation, and participates in the functional maintenance of vascular adaptation and trophoblast cells during pregnancy. Here, premature live births with single-chorionic triple embryos after single-embryo transfer were used as research objects, while full-term infants with double embryos and double-chorionic twins were used as controls. DNA was extracted from umbilical cord tissues for pyrosequencing to detect the methylation level of CpG island in CGRP promoter region. The average values of CGRP methylation in the umbilical cord tissues of very premature fetuses were higher than that of normal controls obtained from the databases. Immunofluorescence results showed that the expression of αCGRP was decreased in the blood vessel wall of the umbilical cord of monozygotic triplets, especially in death cases, while the βCGRP had a compensatory expression. In conclusion, our findings suggest that hypermethylation of CGRP might be considered as an important cause of serious neonatal morbidities.

Perinatal outcomes of monochorionic diamniotic triplet pregnancies: a case series

BackgroundTriplet pregnancies are associated with higher fetal morbidity and mortality rates as well as life-threatening maternal complications. Monochorionic diamniotic (MCDA) triplet pregnancies are very rare compared to other types of triplet pregnancies.Case presentationWe report three cases of MCDA triplet pregnancies between January 2012 and December 2017. Two of these MCDA triplet pregnancies received regular and intensive prenatal care, were diagnosed by ultrasonography during the first trimester or early second trimester, and had good perinatal outcomes. The case with irregular perinatal care had poor outcomes, and the MCDA triplet pregnancy was diagnosed intrapartum.ConclusionsThe possibility of continuing an MCDA triplet pregnancy should be recognized. Early diagnosis, regular antenatal care, close prenatal monitoring, and sufficient communication are recommended to obtain better perinatal outcomes in MCDA triplet pregnancies.

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.

OP23.04: Selective reduction in complex triplet pregnancy by radio frequency ablation: single centre experience

The risk of miscarriage and preterm delivery are significantly higher in multiple pregnancies with a monochorionic pair. Intra fetal anastomosis in monochorionic (MC) pair preclude the use of intracardiac potassium chloride and fetal reduction must be performed using cord occlusion techniques such as bipolar cord coagulation, interstitial laser or by radiofrequency ablation. We present our series of selective reduction in complex triplet pregnancy with an MC pair using radiofrequency ablation (RFA). This was a retrospective study of the procedures in our unit for the period between 2010 and 2016. We had 25 cases of complex triplets (19 Dichorionic and 6 Monochorionic triplets). The indications for fetal reduction include 14 of multifetal pregnancy reduction, 9 cases of TTTs in the Monochorionic pair, 1 of fetal anomaly in co twin and 1 of discordant growth in the MC pair. Outcome data was available in 24 cases. Median GA at procedure was 15.4 weeks (range 12.1-21.7) and at delivery was 32.9 weeks (range 17.4-41). We had 3 miscarriages; 2 cases occurred within 2 weeks of procedure. IUD of the co-twin occurred in 3 cases (2 in DCTA and 1 in MCTA). The median GA at delivery following MFPR in complex triplets was 34.6 weeks and in the TTTS group was 32.3 weeks. Complications included complex thermal injury to the co twin in 1 case resulting in the subsequent termination of the co twin. There were no cases of neurological impairment in the survivors post procedure. This is the largest case series of fetal reduction in complex triplets by RFA. Selective reduction by RFA in complex triplet pregnancies resulted in a total pregnancy loss in 12.5% of the cases with an 87.5% favourable outcome, in other words two live babies at discharge from hospital. The gestational age was higher at delivery in the MFPR group compared to other indications for selective fetal reduction. This data is useful in appropriate counselling of complex triplex pregnancies.

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 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.

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

Single fetal demise in monochorionic pregnancies: incidence and patterns of cerebral injury.

To evaluate the incidence, type and severity of cerebral injury in the surviving monochorionic (MC) cotwin after single fetal demise in twin pregnancies. All MC pregnancies with single fetal demise that were evaluated at the Leiden University Medical Center between 2002 and 2013 were included. Perinatal characteristics, neonatal outcome and the presence of cerebral injury, observed on neuroimaging, were recorded for all cotwin survivors. A total of 49 MC pregnancies with single fetal demise, including one MC triplet, were included in the study (n = 50 cotwins). Median gestational age at occurrence of single fetal demise was 25 weeks and median interval between single fetal demise and live birth was 61 days, with a median gestational age at birth of 36 weeks. Severe cerebral injury was diagnosed in 13 (26%) of the 50 cotwins and was detected antenatally in 4/50 (8%) and postnatally in 9/50 (18%) cases. Cerebral injury was mostly due to hypoxic-ischemic injury resulting in cystic periventricular leukomalacia, middle cerebral artery infarction or injury to basal ganglia, thalamus and/or cortex. Risk factors associated with severe cerebral injury were advanced gestational age at the occurrence of single fetal demise (odds ratio (OR), 1.14 (95% CI, 1.01-1.29) for each week of gestation; P = 0.03), twin-twin transfusion syndrome developing prior to single fetal demise (OR, 5.0 (95% CI, 1.30-19.13); P = 0.02) and a lower gestational age at birth (OR, 0.83 (95% CI, 0.69-0.99) for each week of gestation; P = 0.04). Single fetal demise in MC pregnancies is associated with severe cerebral injury occurring in 1 in 4 surviving cotwins. Routine antenatal and postnatal neuroimaging, followed by standardized long-term follow-up, is mandatory.

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.

Embarazo triple monocorial triamniótico: Experiencia de dos casos y revisión de la literatura

SUMMARY Multiple pregnancies are considered a high-risk obstetric entity. Their incidence has been increasing due to the use of assisted reproductive techniques and increased maternal age. Here, we describe two cases of triamniotic monochorionic triplet pregnancies, female and male respectively. Both pregnancies demonstrated complications, mainly fetal and neonatal, attributed to multiple pregnancies reported in the literature.

Indirect pump: unique presentation of a monochorionic–triamniotic triplet gestation complicated by TRAP sequence and successfully managed with radiofrequency ablation of the acardiac fetus

Twin reversed arterial perfusion (TRAP) sequence is a rare complication of multiple gestations. Only a few cases of TRAP sequence in monochorionic triplets have been reported. Here we report a case of TRAP sequence in a monochorionic-triamniotic triplet gestation treated with radiofrequency ablation of the acardiac fetus. The response to the radiofrequency ablation procedure and subsequent examination of the placenta support the hypothesis of an 'indirect' pump triplet.

Twin–Twin Transfusion Syndrome and Twin Anemia–Polycythemia Sequence in a Monochorionic Triamniotic Pregnancy

Twin-twin transfusion syndrome (TTTS) is an antenatal complication of monochorionic multiple gestations. There have been few studies exploring the role of laser photocoagulation or outcomes following treatment in monochorionic triplet pregnancies with TTTS. We present a case where TTTS and twin anemia-polycythemia sequence (TAPS) complicated a monochorionic triplet pregnancy. Following the laser photocoagulation to treat the TTTS between the triplets, an intra-uterine death occurred in one triplet and TAPS developed in the remaining two triplets. Intervention in this case resulted in a 2-week prolongation of pregnancy and a positive outcome for the remaining fetuses. This case and other published data reviewed in this article suggest that laser photocoagulation has a potential role for TTTS in monochorionic triplet pregnancies.

Monochorionic triplet with concordant congenital cardiac defects

The chances of congenital cardiac defects are often increased in multiple birth orders. However, there is a paucity of data on its incidence amongst triplets in Nigeria. Here is a report of a set of triplet with concordant atrial septal defects and the third triplet found to have a concomitant ventricular septal defect.

Monochorionic Triplets Complicated by Fetofetal Transfusion Syndrome: A Case Series and Review of the Literature

Objective: To compare perinatal outcome in monochorionic (MC) triplets with twin-to-twin transfusion syndrome (TTTS) versus dichorionic (DC) triplets with TTTS. Study Design: Retrospective analysis of all triplets with TTTS treated at our center and all cases reported in the literature between 1990 and 2010. Survival and gestational age at birth of MC and DC triplets were compared and stratified by type of intervention. We excluded triplets with one or more fetal deaths <16 weeks’ gestation and those with one or more fetuses with congenital anomalies. Results: MC triplets were affected by TTTS in a total of 27 cases, and overall survival was 51% (38/75 fetuses) compared to 105 DC triplets with a survival of 76% (220/291 fetuses) (p < 0.05). Mean gestational age at birth in MC triplets was 28 weeks, compared to 31 weeks in DC triplets (p < 0.05). Perinatal survival of at least one fetus in MC triplet and DC triplet pregnancies was 70% (19/27) and 91% (96/105) (p < 0.05). In DC triplets, survival after laser therapy was significantly improved compared to expectant management, amniodrainage or selective feticide (p < 0.05). Conclusion: MC triplets with TTTS are at a considerably higher risk for perinatal mortality and preterm birth than DC triplets. The optimal strategy to manage MC triplets with TTTS, including the role of selective feticide and laser therapy of all anastomoses, is still to be established.

Effects of Chorionicity and Zygosity on Triplet Birth Weight

Birth weight in triplets is, on average, lower than in singletons and twins, and more children are classified as having very low or extremely low birth weight. Still, there is limited research on factors that affect triplet birth weight, and samples under study are often small. Chorionicity and zygosity influence triplet birth weight, but it is unknown whether the effect of zygosity can be entirely ascribed to the effect of chorionicity or whether zygosity has an additional effect on triplet birth weight. This question was investigated in 346 triplets (from 116 trios) registered with the Netherlands Twin Register for whom data on chorionicity were available. 'Triplet' refers to one child and the set of three triplets is referred to as 'trio'. Trios and triplets were classified based on zygosity and chorionicity. With regression analysis, the effects of zygosity and chorionicity on triplet birth weight were examined, while controlling for gestational age, sex, and maternal smoking during pregnancy. In addition, within the dizygotic trios a within-family comparison was made between the birth weight of the triplets that were part of a monozygotic pair (with some pairs sharing a chorion), and the birth weight of the dizygotic triplet. Based on the classification on individual level, monozygotic, monochorionic triplets had a lower mean birth weight than dizygotic, dichorionic triplets. Most remarkably, in dizygotic trios, monozygotic pairs only had a lower mean birth weight than their dizygotic sibling triplet when the pair shared a chorion. We conclude that having shared a chorion, rather than being monozygotic, increases the risk of a low birth weight.