J Perinat Med [Internet]. Arabin B, van Eyck J. Delayed-interval delivery in twin and triplet pregnancies: 17 years of experience in 1 perinatal center. Am J Obstet Gynecol [Internet]. Perinatal outcome of spontaneously conceived triplet pregnancies in relation to chorionicity.
Perinatal and neonatal outcomes of triplet gestations based on chorionicity. Am J Perinatol Rep. Temur I. A twin pregnancy provided with ICSI, an abortion of the first fetus at the 18th week and live birth of the second fetus at the end of the 36th week: a case report and literature review. Download references. You can also search for this author in PubMed Google Scholar. All authors participated in caring for this patient.
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Search all BMC articles Search. Download PDF. Abstract Background Multiple gestation has been on the rise because of advancement in assisted reproductive technology.
Case A year-old East African lady with spontaneous triplet pregnancy presented to our institution at gestation age of 19 weeks with features of threatened miscarriage. Conclusion Delayed interval delivery improves neonatal outcomes of high-order pregnancy after fetal loss even in a resource-limited setting. Background Multiple gestation means conceiving more than one fetus. Case We report a case of successful spontaneous reduction of triplets to twins.
Discussion This case involved multifetal gestation that happened spontaneously. Conclusion Delayed interval delivery is recommended in carefully selected cases and can be done even in limited-resource setting, and it is recommended for better neonatal outcome especially in these areas since caring for extreme preterm babies carries higher neonatal mortality rate. Availability of data and materials Available from the corresponding author upon request.
References 1. Google Scholar 6. Article Google Scholar Acknowledgements Not applicable. Funding None to declare.
View author publications. Ethics declarations Ethics approval and consent to participate Patient consented for this case report. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Competing interests The authors declare that they have no competing interests. Historically, controversy has surrounded decisions regarding reduction of twin or higher-order multifetal pregnancies to a singleton.
For some women, a multifetal pregnancy reduction to a singleton may be an appropriate or desired option for medical reasons or nonmedical reasons, such as financial, social, or emotional concerns Certain medical or obstetric considerations can significantly increase the risks of carrying even a twin pregnancy compared with a singleton pregnancy.
During patient counseling, physicians should consider discussing reduction to a singleton pregnancy based on their understanding of the particular patient, her unique medical situation, and her values. When a woman with a twin gestation requests such information, whether for medical or nonmedical reasons, it should be provided in a timely manner and without bias.
Multifetal pregnancies should be prevented whenever possible. In almost all cases, it is preferable to avoid the risk of higher-order multifetal pregnancy by limiting the number of embryos to be transferred or by cancelling a gonadotropin cycle when the ovarian response suggests a high risk of a multifetal pregnancy 4. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, posted on the Internet, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.
Multifetal pregnancy reduction. Committee Opinion No. American College of Obstetricians and Gynecologists. Obstet Gynecol ;e— This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary.
This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology.
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Recommendations On the basis of the principles outlined in this Committee Opinion, the American College of Obstetricians and Gynecologists ACOG makes the following recommendations: Fertility treatments have contributed significantly to the increase in multifetal pregnancies.
Introduction Multifetal pregnancy reduction is defined as a first-trimester or early second-trimester procedure for reducing the total number of fetuses in a multifetal pregnancy by one or more 1. Background Incidence Spontaneous multifetal pregnancies have always posed increased medical risks to pregnant women and their fetuses. Risks Obstetrician—gynecologists should be aware that multi-fetal pregnancies increase maternal and perinatal morbidity and mortality.
Economic and Quality of Life Challenges Medical costs to parents and society are quadrupled for twins and fold higher for triplets Parenting Parents of multiples are at an increased risk of severe stress and a compromised quality of life 22 Ethical Considerations Ethical principles serve to illustrate the moral complexities inherent in decisions pertaining to multi-fetal pregnancy reduction, and they offer guidance to obstetrician—gynecologists as they counsel patients regarding the management of these pregnancies.
Justice When assisted reproduction in the United States is viewed through the lens of justice, inequities become apparent. Nondirective Counseling and Informed Consent Nondirective patient counseling should be offered to all women with higher-order multifetal pregnancies and should include a discussion of the risks unique to multi-fetal pregnancy as well as the option to continue or reduce the pregnancy.
The Decision-Making Process Once the physician provides medical recommendations, the patient should then be given space to assess her personal value system and determine a course of action. Reduction When Fetal Sex Is Known Before multifetal pregnancy reduction, some patients will undergo chorionic villus sampling or amniocentesis. Reduction to a Singleton Historically, controversy has surrounded decisions regarding reduction of twin or higher-order multifetal pregnancies to a singleton.
Conclusion Obstetrician—gynecologists should be knowledgeable about the medical risks of multifetal pregnancy, the potential medical benefits of multifetal pregnancy reduction, and the complex ethical issues inherent in decisions regarding multifetal pregnancy reduction. Selective reduction: an unfortunate misnomer. Obstet Gynecol ;—4. Article Locations: Article Location. Article Location. Article Location Article Location. Delivery was performed by Caesarean section under spinal anaesthesia or vaginally, at the discretion of the senior obstetrician who was present at the time of the delivery.
For each delivery, three experienced neonate paediatricians were present in the delivery room. Management of the reduced group was as follows: as of , all reductions were performed as previously described Boulot et al. Before , two techniques were used, both performed by the same practitioner. The technique used in the initial 16 cases of our experience with MFPR was the transcervical mini-suction at 8—11 weeks using an echo-guided Karmann cannula no. Transabdominal echo-guided embryo puncture was then used in the 49 following cases.
Under local anaesthesia, a Then, potassium chloride solution amount ranging from 0. Antibioprophylaxy was used in all cases. The choice of technique was based on the period at which the patients entered the study. The transcervical approach was used until and then was replaced by the other technique because of a lower miscarriage rate.
The procedures were performed between 8. All pregnancies obtained were twins with typical ultrasonographic features of a dichorionic placentation. Scans were then performed monthly until the end of pregnancy. After the procedure, nearly half of the patients in the reduced group were referred to their primary care providers for the remainder of the pregnancy. Length of gestation was established according to the date of IVF or ovulation induction or, for cases of spontaneous gestation, on the first day of the last menstrual period, which was then verified by ultrasound examination.
Durations of pregnancies are presented as number of weeks gestation. Delivery at term was after 37 completed weeks gestation. Fetal weights were reported on growth curves for singletons. The perinatal mortality rate PMR included deaths occurring from the beginning of the 22nd week of gestation to the seventh day after birth.
The neonatal mortality rate included deaths occurring from birth to the 28th day after birth. Therefore deaths occurring during the first 7 days after birth were included in both perinatal and neonatal categories.
For uniformity, infant follow-up refers to follow-up until 6 months of age for both populations. Fetal loss before 24 weeks did not significantly differ between the two groups Table II.
Fifteen embryos were lost due to five complete miscarriages that occurred in the triplet cohort 6. In the reduced group, seven embryos were lost due to two complete miscarriages and three partial miscarriages resulting in singleton pregnancies 5.
Rates of prematurity were different in the two groups as deliveries ocurred earlier in the triplet group compared with the reduced group In this group, fetuses were delivered, alive and 11 dead Table IV. Among these 11 deaths, eight were spontaneous deaths in utero and three were related to second-trimester selective terminations performed on malformed fetuses neural tube defects or hydrocephaly.
There were four neonatal deaths , 1. The perinatal mortality rate was 6. Among the reduced pregnancies, 28 patients In all, fetuses were delivered including alive and seven dead all were deaths in utero.
The comparison of birthweights based on gestational age and the distribution of birthweights according to the tenth or third percentile are reported in Table IV. One death occurred in the immediate neonatal period due to a cerebral haemorrhage related to extreme prematurity. The neonatal mortality rate was 0.
The results from this expanded series confirm the results of our initial study Boulot et al. MFPR reduces extreme prematurity before 32 weeks and improves fetal growth without excessive fetal loss.
This last rate is in agreement with those reported in large series in which MFPR was performed by a limited number of experienced operators Evans et al. Furthermore, because the fetal loss rate is strongly associated with the starting and the finishing number of embryos, reducing triplets to twins is expected to lead to a lower rate of miscarriage than that observed when reducing triplets to singletons Berkowitz et al.
The ultrasonic prospective observation of expectantly managed triplet pregnancies reveals that fetal death is common before 24 weeks. Lipitz et al. Kol et al. These data suggest that the spontaneous loss rate in women carrying three fetuses may be similar to, or even higher than, the fetal loss rate observed following MFPR.
Late MFPR at the mean term of 20 weeks could lead to a more favourable perinatal outcome. For Hartoov Hartoov et al. However, studies are requested on larger series that should include only triplets with normal embryos in an effort to achieve homogeneity.
In our study, only one out of 13 couples with spontaneously obtained triplets decided to reduce whereas half of the ovulation induction and IVF groups decided to reduce. Couples requesting infertility treatments are well informed of the risks of multiple pregnancies before starting treatments. As information of MFPR is given at this time, it probably makes couples more inclined towards reduction in case of high order multiple pregnancy. Conversely, couples with spontaneous triplets do not always have an earlier diagnosis of the multiple gestation, and are not aware of the possibility of reducing the pregnancy.
The main challenge in triplet pregnancies is the high rate of premature delivery, ranging from The mean gestational age at delivery in the expectantly managed group was Extreme premature births occurred more frequently in the non-reduced group than in the reduced group. The rate of preterm births was 2-fold higher between 24 and 28 weeks and 2. In another study, the rate of prematurity among twins from reduced triplets did not significantly differ from that of dichorionic twins naturally obtained or by means of assisted reproduction procedures Macones et al.
Similar results were observed in the two other series that compare the outcome of triplets reduced to twins versus non-reduced triplets Macones et al. For Lipitz et al. For Macones et al. In a collaborative study Evans et al. These rates are consistent with our data.
Similar data were reported by Berkowitz et al. As for fetal growth, there was significant weight gain in the reduced group since the birthweights of the infants from that group were g higher than in the triplet cohort. Two other similar studies found differences of nearly to g Macones et al.
In the study of Lipitz et al. Macones et al. This weight gain may indicate that MFPR has no detrimental effects on the growth of the remaining twins, in agreement with the findings of Torok et al. In this latter study, no significant difference was found in the frequency of birthweight discordance or the incidence of IUGR when twins from reduced triplets were compared with a control group of dichorionic twins. Our study fails to demonstrate a significant decrease in perinatal or neonatal mortality rates among the reduced triplets despite a larger cohort of patients although the perinatal mortality rate of the non-reduced triplets was already very low 6.
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