Two- and three-dimensional sonography of a monochorionic triplet gestation

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.

Three-dimensional sonograph of a monochorionic diamniotic triplet pregnancy

A monochorionic diamniotic triplet pregnancy was diagnosed by sonographic scan at 9 weeks of gestation. The three embryos appeared to share the same trophoblast, with two of them sharing the same amniotic sac. The two amniotic sacs were divided by a thin membrane, with no chorionic projection within it, and each amniotic sac presented a single yolk sac. Only few cases of nontrichorionic-triamniotic triplets have been reported in the literature. Although the diagnosis was reached using the two-dimensional ultrasound, the complementary use of three-dimensional ultrasound helped in confirming the diagnosis, and in offering the couple an adequate counseling.

An Experience of Laser Surgery for Feto-Fetal Transfusion Syndrome Complicated with Unexpected Feto-Fetal Hemorrhage in a Case of Monochorionic Triamniotic Triplets

Feto-fetal transfusion syndrome (FFTS) in monochorionic triplets is a rare clinical entity which may share the principal adverse perinatal outcomes of twin-twin transfusion syndrome. Recently, favorable prognoses regarding morbidity and mortality in twins after selective laser photocoagulation of placental communicating vessels (SLPCV) have been described. But descriptions of this procedure in monochorionic triplet cases are limited. This is the case report of an experience of SLPCV applied to monochorionic triamniotic triplets with FFTS. Triplet A had polyhydramnios, while absent end-diastolic flow in the umbilical artery of triplet B, the triplet with anhydramnios, was persistent. Triplet C looked normal, vertical amniotic pocket and Doppler studies yielding normal results. At the beginning of the SLPCV procedure, feto-fetal hemorrhage, subsequent to the fetal death of the donor triplet, occurred. Both surviving cofetuses showed persistent bradycardia; and 1 fetus died while the other recovered from the fetal bradycardia. All vascular anastomoses between the 3 triplets could be identified and obliterated, requiring two trocars. Our fetoscopic observation revealed feto-fetal hemorrhage after demise of monochorionic triplet, which led to injury of other fetuses due to hypovolemia in an instant. In conclusion, SLPCV might be a valid option for FFTS in triplet cases, while further experience is required in order to evaluate the risks and benefits of this procedure in triplet cases.

Feto-feto-fetal transfusion syndrome in monozygotic monochorionic triamniotic triplets: vascular evaluation by a cast model

A unique cast model of the placenta in a rare case of feto-feto-fetal triplet transfusion syndrome (FFFTTS) allowed the demonstration of why the transfusion syndrome developed in one fetus and not in the other two in that single placenta. The vasculature anatomy of a monochorionic triamniotic triplet placenta with FFFTTS of three healthy infants (one donor, two recipients) born in the 35th week of gestation was cast by means of dental casting materials. After the cast hardened, the tissue was corroded, revealing the cast blood vessels. The diameters and lengths of the chorionic blood and intraplacental vessels of the cast placenta were measured with a digital caliper. The cast revealed two artery-artery (A-A) anastomoses on the chorionic plate between the two recipients and the donor. Seven artery-vein (A-V) deep anastomoses connected only the arteries of the donor and the veins of the two recipients. The blood vessel connections among the fetuses allowed the evaluation of a pathologic case with its own control in a single placenta. From the vascular appearance, we speculate that the A-A anastomoses between the two fetuses protected them from developing blood transfusions, but that the A-V anastomoses contributed to their development.

Monochorionic Triplets following Intracytoplasmic Sperm Injection: A Report of Two Consecutive Cases

Monochorionic triplet pregnancies are very rare. Here we report 2 cases of multiple pregnancies with monochorionic triplets following intracytoplasmic sperm injection (ICSI) and day 3 embryo transfer. The 2 women concomitantly underwent controlled ovarian hyperstimulation due to male factor infertility. Following oocyte retrieval, ICSI and assisted hatching (AH) were performed, and the 2 women conceived consecutively. One patient had a quadruplet pregnancy, which included monochorionic triplets, while the other had monochorionic triplets. Selective embryo reduction by intracardiac KCl injection targeted at 2 of the triplets was performed on the patient with the quadruplet pregnancy, but the third triplet also died. The gestation continued as a singleton pregnancy, and the patient gave birth to a healthy female baby at 38 weeks. The other patient gave birth to 3 healthy female babies at 34 weeks. Possible etiologic factors for the formation of monozygotic splitting among women undergoing assisted reproduction treatment are discussed.