Intrafetal laser ablation for embryo reduction from dichorionic triplets to dichorionic twins

Perinatal outcome of monochorionic triamniotic triplet pregnancy: multicenter cohort study

OBJECTIVE

Monochorionic (MC) triplet pregnancies are extremely rare and information on these pregnancies and their complications is limited. We aimed to investigate the risk of early and late pregnancy complications, perinatal outcome and the timing and methods of fetal intervention in these pregnancies.

METHODS

This was a multicenter retrospective cohort study of MC triamniotic (TA) triplet pregnancies managed in 21 participating centers around the world from 2007 onwards. 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 sequence (TAPS), twin reversed arterial perfusion (TRAP) sequence and or selective fetal growth restriction (sFGR) were retrieved from patient records. Data on antenatal interventions were collected, including data on selective fetal reduction (three to two or three to one), laser surgery and any other active fetal intervention (including amniodrainage). Data on perinatal outcome were collected, including numbers of live birth, intrauterine demise, neonatal death, perinatal death and termination of fetus or pregnancy (TOP). Neonatal data such as GA at birth, birth weight, admission to neonatal intensive care unit and neonatal morbidity were also collected. Perinatal outcomes were assessed according to whether the pregnancy was managed expectantly or underwent fetal intervention.

RESULTS

Of an initial cohort of 174 MCTA triplet pregnancies, 11 underwent early TOP, three had an early miscarriage, six were lost to follow-up and one was ongoing at the time of writing. Thus, the study cohort included 153 pregnancies, of which the majority (92.8%) were managed expectantly. The incidence of pregnancy affected by one or more fetal structural abnormality was 13.7% (21/153) and that of TRAP sequence was 5.2% (8/153). The most common antenatal complication related to chorionicity was TTTS, which affected just over one quarter (27.6%; 42/152, after removing a pregnancy with TOP < 24 weeks for fetal anomalies) of the pregnancies, followed by sFGR (16.4%; 25/152), while TAPS (spontaneous or post TTTS with or without laser treatment) occurred in only 4.6% (7/152) of pregnancies. No monochorionicity-related antenatal complication was recorded in 49.3% (75/152) of pregnancies. Survival was apparently associated largely with the development of these complications: there was at least one survivor beyond the neonatal period in 85.1% (57/67) of pregnancies without antenatal complications, in 100% (25/25) of those complicated by sFGR and in 47.6% (20/42) of those complicated by TTTS. The overall rate of preterm birth prior to 28 weeks was 14.5% (18/124) and that prior to 32 weeks' gestation was 49.2% (61/124).

CONCLUSION

Monochorionicity-related complications, which can impact adversely perinatal outcome, occur in almost half of MCTA triplet pregnancies, creating a challenge with regard to counseling, surveillance and management. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Outcome of TRAP Sequence Treated in the First Trimester - A Ten-Year Single-Center Experience

PURPOSE

 To evaluate the outcome of first trimester intervention by intrafetal laser (IFL) in pregnancies complicated by twin reversed arterial perfusion (TRAP).

MATERIALS AND METHODS

 For a 10-year study period, all patients with TRAP diagnosed < 14.0 weeks of gestation were retrospectively analyzed for intrauterine course and outcome. Monoamniotic pregnancies were excluded. Patients were offered either intervention by IFL in the first trimester, expectant management, or termination of pregnancy (TOP). Adverse outcome was defined as either intrauterine death (IUD), neonatal death, or preterm birth.

RESULTS

 In 45 cases TRAP was diagnosed. 17 monoamniotics were excluded. The cohort was divided into two groups according to management. Group A: 24 cases underwent IFL and group B: 4 cases were managed expectantly. No patient opted for TOP. In group A, 70.8 % of pump twins were born alive, including one preterm delivery, and 29.2 % died within four days after the intervention. All 4 expectantly managed cases in group B had an adverse outcome (1 preterm delivery, 3 IUDs < 15.0 weeks). There were no neonatal deaths. In cases treated by IFL, a comparison of survivors and non-survivors identified no significant differences in gestational age at IFL or any of the assessed biometrical and functional parameters. There was a trend towards better outcome in the second half of the study period.

CONCLUSION

 IFL in first trimester TRAP sequence is technically feasible but is associated with significant mortality, albeit less than previously reported. No risk stratification is possible using the investigated parameters. However, there seems to be a learning curve.

Fetal reduction for everyone?

Infertility treatments have benefited millions of couples to have their own children; however, the complication of multiple pregnancies with their increased morbidity and mortality has created significant problems. Fetal reduction (FR) was developed to ameliorate these issues. Over 30 years of publications show that FR has been highly successful in substantially reducing both mortality and morbidity. As with most radically new techniques, initial cases were in the "nothing to lose" category. With experience, indications liberalize, and quality of life issues increase as a proportion of cases. Overall risks for twins are not twice as those for singletons, but they are approximately 4- to 5-fold higher. In experienced hands, the combination of genetic testing by CVS followed by FR has made most multiples behave statistically as if they were originally the lower number. The use of microarray analysis to better determine fetal genetic health before deciding on which fetus(es) to keep or reduce further improves pediatric outcomes. With increasing experience and lower average starting numbers, the proportion of FRs to a singleton has increased considerably. Twins to a singleton FR now constitute an increasing proportion of cases performed. Data on such cases show improved outcomes, and we believe FR should be at least discussed and offered to all patients with a dichorionic twin pregnancy or higher. eSET is not a panacea because of the resultant monochorionic twins.

Pregnancy and obstetric outcomes of dichorionic and trichorionic triamniotic triplet pregnancy with multifetal pregnancy reduction: a retrospective analysis study

Background

It is generally beneficial for triplet gestation or high-order multiple pregnancies to operate multifetal pregnancy reduction (MFPR) after assisted reproductive techniques. However, data on pregnancy outcomes is lacking regarding dichorionic triamniotic (DCTA) and trichorionic triplets (TCTA) pregnancy.

Method

This research analyzes the difference between 128 DCTA and 179 TCTA pregnancies with or without MFPR after in vitro fertilization/intracytoplasmic sperm injection cycles between January 2015 and June 2020. The subdivided subgroups of the two groups are reduction to singleton, reduction to dichorionic twins, and expectant management groups. We also compare the pregnancy and obstetric outcomes between 2104 dichorionic twins and 122 monochorionic twins.

Result

The research subgroups were DCTA to monochorionic singleton pregnancies (n = 76), DCTA to dichorionic twin pregnancies (n = 18), DCTA-expectant management (n = 34), TCTA to monochorionic singleton pregnancies (n = 31), TCTA to dichorionic twin pregnancies (n = 130), and TCTA-expectant management (n = 18). In DCTA-expectant management group, the complete miscarriage rate is dramatically higher, and the survival rate and the rate of take-home babies are lower. However, there was no difference between the rates of complete miscarriages, survival rates, and take-home babies in TCTA-expectant management group. But the complete miscarriage rate of DCTA-expectant management was obviously higher than that of TCTA-expectant management group (29.41 vs. 5.56%, p = 0.044). For obstetric outcomes, MFPR to singleton group had higher gestational week and average birth weight, but lower premature delivery, gestational hypertension rates and low birth weight in both DCTA and TCTA pregnancy groups (all p < 0.05). DCTA to monochorionic singleton had the lowest incidence of gestational diabetes, whereas The subdivided subgroups of TCTA had no significant difference in the incidence of gestational diabetes. Monochorionic twins have higher rates of complete, early, and late miscarriage, premature delivery, and late premature delivery, and lower survival rate (p < 0.05).

Conclusion

MFPR could improve gestational week and average birth weight, reducing premature delivery, LBW, and gestational hypertension rates in DCTA and TCTA pregnancies. Monochorionic twins have worse pregnancy and obstetric outcomes. MFPR to singleton is preferable recommended in the pregnancy and obstetric management of complex triplets with monochorionic pair.

Fetal reduction and twins

Infertility treatments have allowed millions of couples to have their own children, but resultant multiple pregnancies with their increased morbidity and mortality have been a significant complication. Fetal reduction was developed to ameliorate this issue. Over 30 years of publications show that fetal reduction has been highly successful in substantially reducing both mortality and morbidity related to multiple pregnancies. As with most radically new techniques, initial cases were in the "nothing to lose" category. With experience, indications liberalize, and quality of life issues gain relevance. The overall risks of twin pregnancy are not twice that of singleton pregnancy; they are about 4 to 5 times higher. In experienced hands, the combination of genetic testing by chorionic villus sampling followed by fetal reduction has made the outcomes of most multiple pregnancies statistically equivalent to those of pregnancies with lower fetal numbers. Use of microarray analysis to better determine fetal genetic health before deciding on which fetus(es) to keep or reduce further improves pediatric outcomes. With increasing experience and lower average starting numbers, the proportion of fetal reductions to a singleton has increased considerably. Twins to a singleton fetal reductions now constitute an increasing proportion of cases performed. Data on such cases show improved outcomes, and we believe fetal reduction should be at least discussed and offered to all patients with a dichorionic twin pregnancy or higher. With the increasing reliance on elective single-embryo transfers, monochorionic twins, which have much higher complication rates than dichorionic twins, have increased substantially. Furthermore, monochorionic twins cannot be readily and safely reduced, so the adverse perinatal statistics of elective single-embryo transfer are a major setback for good outcomes. Although elective single-embryo transfer is appropriate for some, we believe that for many couples, the transfer of 2 embryos is generally a more rational approach.

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

Background

To evaluate the perinatal outcomes in women with selective termination using ultrasound-guided radiofrequency ablation (RFA).

Methods

Complicated 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.

Results

Three 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).

Conclusions

RFA 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.

Outcome of radiofrequency ablation for selective fetal reduction before vs at or after 16 gestational weeks in complicated monochorionic pregnancy

OBJECTIVE

To investigate whether gestational age at intervention (< or ≥ 16 weeks) and other factors affect the risk of loss of the cotwin after selective fetal reduction using radiofrequency ablation (RFA) in monochorionic (MC) pregnancy.

METHODS

This was a single-center retrospective analysis of 63 consecutive RFA procedures performed at our institution from January 2011 to October 2019 for selective fetal reduction in complicated MC pregnancies. Indications for RFA were twin reversed arterial perfusion sequence (13 cases), twin-to-twin transfusion syndrome (12 cases), twin anemia-polycythemia sequence (two cases), selective fetal growth restriction (10 cases), discordant anomalies (17 cases) and multifetal pregnancy reduction in triplets or quadruplets with a MC pair (nine cases). Twenty-six (41.3%) of these procedures were performed before and 37 (58.7%) after 16 weeks. Potential factors that could affect the risk of loss of the cotwin, including gestational age at RFA, order of multiple pregnancy, amnionicity, indication for RFA and number of ablation cycles, were assessed first by univariate analysis and then by multivariate analysis.

RESULTS

There were 17 (27.0%) cotwin losses. Ablation cycles numbering four or more was the only factor among those investigated to be associated with loss of the cotwin after RFA (P = 0.035; odds ratio, 5.21), while the indication for RFA, order of multiple pregnancy, amnionicity and gestational age at RFA had no effect. Comparing RFA performed at < 16 vs ≥ 16 weeks, there was no difference in the rate of cotwin loss (23.1% vs 29.7%; P = 0.558) or preterm prelabor rupture of the membranes before 34 weeks (7.7% vs 5.4%; P = 0.853), or in the median gestational age at delivery (36.2 vs 37.3 weeks; P = 0.706).

CONCLUSIONS

RFA is a promising tool for early selective fetal reduction in MC pregnancy before 16 weeks. Four or more ablation cycles is a major risk factor for cotwin loss. Careful assessment pre- and post-RFA, together with proficient operative skills to minimize the number of ablation cycles, are the mainstay to ensure that this procedure is effective and safe. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Expectant management versus multifetal pregnancy reduction in dichorionic triamniotic (DCTA) triplets: Single centre experience

OBJECTIVES

In trichorionic triplet pregnancies, multifetal pregnancy reduction (MFPR) reduces the risk of preterm birth, neonatal morbidity and mortality without increasing miscarriage. A similar benefit has been suggested in dichorionic triamniotic (DCTA) pregnancy, but multiple methods are currently used. This study investigates if the method of reduction used in DCTA triplet pregnancy influences the evidence of benefit from MFPR.

METHODS

This is a retrospective cohort study of DCTA pregnancies between 2010 and 2019 who attended a single UK fetal medicine tertiary referral center. Cohorts were defined based on MFPR decision and method. The primary outcome was offspring survival until neonatal discharge. The secondary outcomes included miscarriage, preterm birth, livebirth, rates of small for gestational age (SGA) neonates, ans maternal morbidity. To evaluate the differences in neonatal survival until discharge we used Cox proportional regression to calculate hazard rates (HR) and 95% confidence intervals (CI). Differences in secondary outcomes were compared using univariate analysis.

RESULTS

The study reports the outcomes for 83 DCTA pregnancies. MFPR to DCDA twins was chosen in 19 pregnancies (14 radiofrequency ablation, RFA; 5 intrafetal laser, IFL); in 9 pregnancies selective reduction to a singleton was performed by KCl injection. The rate of pregnancies in with ≥ 1 fetus born alive was not different between groups (p = 0.90). However, the number of expected neonates alive at discharge from hospital was highest in the RFA group (89%, HR 0.28, 95% CI 0.21-0.87, p = 0.02). Rates of premature delivery before 32 weeks (p = 0.02), low birth weight (p < 0.001) and birthweight < 10th percentile (p = 0.01) were all elevated in the expectant management group, compared to women who opted for reduction. There was no difference in miscarriage between groups.

CONCLUSIONS

Our study suggests that MFPR by RFA, an established and widely available procedure, is of benefit in promoting neonatal survival until discharge in DCTA triplets.

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

Background

Trichorionic 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.

Methods

Two 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.

Results

Eighty-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.

Conclusion

The 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.