Pregnancy outcome after fetal reduction in women with a dichorionic twin pregnancy

Perinatal outcomes of selective termination in dichorionic twin pregnancies: a retrospective study from a single center

OBJECTIVE

Selective termination (ST) is an appropriate procedure for managing discordant fetal anomalies in dichorionic diamniotic (DCDA) twin pregnancies. The aim of this study was to investigate the perinatal outcomes of ST at different gestational ages in DCDA twin pregnancies.

METHODS

This retrospective study was conducted on DCDA twin pregnancies with STs at West China Second University Hospital between January 2012 and December 2022. According to the gestational age at which ST was performed, the patients were assigned to four groups: Group 1 (13 to 17 + 6 weeks), Group 2 (18 to 23 + 6 weeks), Group 3 (24 to 27 + 6 weeks), and Group 4 (≥ 28 weeks).

RESULTS

We identified 230 patients for this study. The overall rates of miscarriage, preterm delivery at < 32 weeks, and term delivery were 1.3%, 10.5%, and 50%, respectively, while the rates of live birth and neonatal survival were 98.7% and 98.2%, respectively. The rate of term birth was highest (70.6%) and the birth weight was heaviest (2931 ± 535 g) in Group 1 (p = 0.000). In the presence of a fetus subjected to feticide, the mean delivery age was earlier than that in the non-presenting group (p = 0.017); accordingly, the mean birth weight in the feticide group was lower (2366 ± 628 g) than that in the non-presenting group (2590 ± 634 g) (p = 0.011). When we examined the relative relationship between reduction weeks and delivery weeks of twins by correlation analysis, we observed that with regard to maternal prognosis, two pregnancies involved preterm premature rupture of membranes (PPROM) at 7 days and 3 days after the procedure. Intrauterine infection occurred in two patients in Group 4, but there were no maternal deaths or maternal coagulatory abnormalities.

CONCLUSIONS

Optimal perinatal outcomes were obtained by ST of DCDA pregnancies before 18 weeks, regardless of whether or not the reduced fetus was the presenting twin. However, if legally possible, late (i.e., after 28 weeks) procedures can be a safe alternative for patients diagnosed after the 18th week of gestation. Overall, we herein noted a negative correlation between the procedure week and the delivery week in this study. Moreover, ST of the non-presenting twin was associated with a heavier birth weight and later gestational age at delivery.

Pregnancy outcomes of foetal reduction from twin to singleton gestation compared to ongoing twin gestations: a systematic review and meta-analysis

BACKGROUND

Foetal reduction, which involves selectively terminating one or more foetuses in a multiple gestation pregnancy, has become more common. This systematic review and meta-analysis aims to assess and compare pregnancy outcomes of foetal reduction from twin to singleton gestation to ongoing twin gestations.

METHODS

A comprehensive search of electronic databases (MEDLINE, EMbase, Cochrane Library, CINAHL and PsycINFO) was done for studies published until 15 April 2023. The outcomes analysed included gestational diabetes mellitus (DM), hypertension, caesarean delivery, foetal loss, perinatal death, preterm birth (PTB), intrauterine growth restriction (IUGR), preterm prelabour rupture of membranes (PPROM) and birth weight.

RESULTS

A total of 13 studies comprising 1241 cases of twin to singleton foetal reduction gestation were compared to 20,693 ongoing twin gestations. Our findings indicate that foetal reduction was associated with a significantly lower risk of developing maternal gestational DM (odds ratio [OR] = 0.40, 95% confidence interval [CI] 0.27-0.59) and hypertension (OR = 0.36, 95% CI 0.23-0.57) compared to the control group. Incidence rate of caesarean delivery (OR = 0.65, 95% CI 0.53-0.81) after foetal reduction was significantly lower compared to ongoing twin gestations. There was a 63% lower chance of PTB before 37 weeks of pregnancy. However, there was no significant association between foetal reduction and outcomes such as foetal loss, perinatal death, IUGR and PPROM.

CONCLUSIONS

Our findings suggest that foetal twin to singleton reduction entails potential benefits as compared to ongoing twin gestations. Further well planned studies are needed to explore underlying mechanisms to understanding of the outcomes associated with foetal reduction procedures and inform clinical decision-making for pregnant individuals and healthcare providers alike.

Optimal management strategies for promoting gestational extension in dichorionic diamniotic twin pregnancies

Background

Preterm birth is a significant concern in multiple pregnancies, warranting effective strategies to improve outcomes. Delaying delivery of the second fetus is crucial for reducing perinatal mortality rates.

Case Presentation

In a dichorionic diamniotic twin pregnancy, one fetus experienced premature rupture of membranes (PROM) at 16+6 weeks gestation. Proactive fetal reduction through potassium chloride injection and emergency cervical cerclage at 19+1 week successfully extended the pregnancy to 39+5 weeks, resulting in a notable 160-day prolongation. Postoperative management encompassed comprehensive tocolytic therapy.

Conclusion

The combined approach of proactive fetal reduction and emergency cervical cerclage proved successful in managing PROM in dichorionic diamniotic twin pregnancies. This innovative strategy offers a promising clinical solution for optimizing outcomes and prolonging gestation in high-risk multiple pregnancies, underscoring the importance of tailored interventions in complex obstetric scenarios.

Selective fetal reduction of uncomplicated dichorionic twins on parental request vs ongoing twins and pregnancy outcomes: a systematic review and meta-analysis

OBJECTIVE

This study aimed to assess the effect of elective fetal reduction on maternal-fetal outcomes in uncomplicated twin pregnancies compared with ongoing twin pregnancies.

DATA SOURCES

The data sources included PubMed, Scopus (until December 2023), and references of retrieved articles.

STUDY ELIGIBILITY CRITERIA

We included clinical studies examining the association between selective fetal reduction of uncomplicated dichorionic twins on pregnancy outcomes.

METHODS

Quality assessment of observational studies was conducted using the ROBINS-I tool. The overall quality of evidence was evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework. A quantitative analysis was performed for electively reduced dichorionic twins. The primary outcome was preterm birth. The secondary outcomes were gestational age at delivery, stillbirth, neonatal intensive care unit admission, gestational diabetes mellitus, preeclampsia, and pregnancy loss at <24 weeks of gestation. Summary odds ratios with 95% confidence intervals were calculated, and random-effects models were used for data synthesis.

RESULTS

The initial electronic search yielded 745 studies; 175 studies were further identified from reference citations. Five articles included appropriate data and were finally included in the meta-analysis. All studies were evaluated as having "moderate risk of bias." These 5 studies reported on dichorionic twins. Elective reduction in dichorionic twins reduces the risk for preterm birth at <37 weeks (4 studies; n=1577; odds ratio, 0.14; 95% confidence interval, 0.09-0.22; moderate-quality evidence), <34 weeks (3 studies; n=1335; odds ratio, 0.22; 95% confidence interval, 0.07-0.69; low-quality evidence), and <32 weeks (3 studies; n=1335; odds ratio, 0.31; 95% confidence interval, 0.11-0.88; low-quality evidence), gestational diabetes (3 studies; n=1410; odds ratio, 0.57; 95% confidence interval, 0.33-0.97; low-quality evidence), pregnancy-associated hypertensive disorders (2 studies; n=581; odds ratio, 0.29; 95% confidence interval, 0.10-0.83; low-quality evidence), and birthweight <10th centile (2 studies; n=1163; odds ratio, 0.27; 95% confidence interval, 0.17-0.43; moderate-quality evidence) and <5th centile (2 studies; n=1163; odds ratio, 0.31; 95% confidence interval, 0.19-0.50; low-quality evidence), and increases gestational age at delivery (4 studies; n=1362; mean difference, 2.93 weeks; 95% confidence interval, 2.08-3.77; moderate-quality evidence). The risks for stillbirth (2 studies; n=1311; odds ratio, 1.63; 95% confidence interval, 0.43-6.21; very low-quality evidence) and pregnancy loss at <24 weeks (3 studies; n=1436; odds ratio, 1.20; 95% confidence interval, 0.55-2.58; very low-quality evidence) were not statistically significantly different.

CONCLUSION

Compared with ongoing dichorionic twin pregnancies, dichorionic pregnancies that undergo elective selective fetal reduction are associated with lower incidences of preterm birth at <37, <34, and <32 weeks, birthweight <10th and <5th centile, gestational diabetes, and hypertensive disorders of pregnancy, and later gestational age at delivery by almost 3 weeks. These associations were often based on very low-quality evidence. Thus, these results should be interpreted with caution, and further studies should be conducted. El resumen está disponible en Español al final del artículo.

Late selective termination in dichorionic twins: comparing late second and third trimester procedures

RESEARCH QUESTION

Do perinatal outcomes of selective termination performed in the late second versus third trimester differ and what risk factors are associated with subsequent preterm birth?

DESIGN

This is a retrospective cohort study of late selective terminations performed in dichorionic twins between 2009 and 2021. Perinatal outcomes were compared between two groups: group A, late second trimester (20.2 to 24.2 weeks, n = 26), and group B, third trimester (≥28.2 weeks, n = 55) selective terminations. Univariate and multivariate analyses were conducted to identify factors associated with post-procedure preterm birth.

RESULTS

In total, 81 dichorionic twin pregnancies were included. There were no pregnancy losses but 16% (13/81) of cases experienced complications. Group A had a higher median birthweight centile (36.5th versus 15th centile, P = 0.002) and lower rates of intrauterine growth restriction (IUGR) and Caesarean delivery (11.5% versus 32.7%, P = 0.04; and 26.9% versus 61.8%, P = 0.003) than group B. Preterm birth rates were similar (46.2% versus 63.6%, P = 0.15). Multiple regression revealed that reduction of the presenting twin and cervical length ≤35 mm were independently associated with post-procedure preterm birth (odds ratio [OR] 8.7, P = 0.001, 95% confidence interval [CI] 2.5-29.8; OR 3.8, P = 0.015, 95% CI 1.3-11).

CONCLUSIONS

Late second trimester selective termination is associated with a higher birthweight centile and lower rates of IUGR and Caesarean delivery, compared with third trimester selective termination. Cervical length 35 mm or less and reduction of the presenting twin are independent risk factors for post-procedural preterm birth. These findings may help determine the optimal time to perform a late selective termination.

ESHRE Guideline Group on the Number of Embryos to Transfer, Alteri A, Arroyo G, Baccino G, Craciunas L, De Geyter C, Ebner T, Koleva M, Kordic K, Mcheik S, Mertes H, Pavicic Baldani D, Rodriguez-Wallberg KA, Rugescu I, Santos-Ribeiro S, Tilleman K, Woodward B, Vermeulen N, Veleva Z. ESHRE guideline: number of embryos to transfer during IVF/ICSI†

STUDY QUESTION

Which clinical and embryological factors should be considered to apply double embryo transfer (DET) instead of elective single embryo transfer (eSET)?

SUMMARY ANSWER

No clinical or embryological factor per se justifies a recommendation of DET instead of eSET in IVF/ICSI.

WHAT IS KNOWN ALREADY

DET is correlated with a higher rate of multiple pregnancy, leading to a subsequent increase in complications for both mother and babies. These complications include preterm birth, low birthweight, and other perinatal adverse outcomes. To mitigate the risks associated with multiple pregnancy, eSET is recommended by international and national professional organizations as the preferred approach in ART.

STUDY DESIGN, SIZE, DURATION

The guideline was developed according to the structured methodology for development and update of ESHRE guidelines. Literature searches were performed in PUBMED/MEDLINE and Cochrane databases, and relevant papers published up to May 2023, written in English, were included. Live birth rate, cumulative live birth rate, and multiple pregnancy rate were considered as critical outcomes.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Based on the collected evidence, recommendations were discussed until a consensus was reached within the Guideline Development Group (GDG). A stakeholder review was organized after the guideline draft was finalized. The final version was approved by the GDG and the ESHRE Executive Committee.

MAIN RESULTS AND THE ROLE OF CHANCE

The guideline provides 35 recommendations on the medical and non-medical risks associated with multiple pregnancies and on the clinical and embryological factors to be considered when deciding on the number of embryos to transfer. These recommendations include 25 evidence-based recommendations, of which 24 were formulated as strong recommendations and one as conditional, and 10 good practice points. Of the evidence-based recommendations, seven (28%) were supported by moderate-quality evidence. The remaining recommendations were supported by low (three recommendations; 12%), or very low-quality evidence (15 recommendations; 60%). Owing to the lack of evidence-based research, the guideline also clearly mentions recommendations for future studies.

LIMITATIONS, REASONS FOR CAUTION

The guideline assessed different factors one by one based on existing evidence. However, in real life, clinicians' decisions are based on several prognostic factors related to each patient's case. Furthermore, the evidence from randomized controlled trials is too scarce to formulate high-quality evidence-based recommendations.

WIDER IMPLICATIONS OF THE FINDINGS

The guideline provides health professionals with clear advice on best practice in the decision-making process during IVF/ICSI, based on the best evidence currently available, and recommendations on relevant information that should be communicated to patients. In addition, a list of research recommendations is provided to stimulate further studies in the field.

STUDY FUNDING/COMPETING INTEREST(S)

The guideline was developed and funded by ESHRE, covering expenses associated with the guideline meetings, the literature searches, and the dissemination of the guideline. The guideline group members did not receive payment. DPB declared receiving honoraria for lectures from Merck, Ferring, and Gedeon Richter. She is a member of ESHRE EXCO, and the Mediterranean Society for reproductive medicine and the president of the Croatian Society for Gynaecological Endocrinology and Reproductive Medicine. CDG is the past Chair of the ESHRE EIM Consortium and a paid deputy member of the Editorial board of Human Reproduction. IR declared receiving reimbursement from ESHRE and EDCD for attending meetings. She holds an unpaid leadership role in OBBCSSR, ECDC Sohonet, and AER. KAR-W declared receiving grants for clinical researchers and funding provision to the institution from the Swedish Cancer Society (200170F), the Senior Clinical Investigator Award, Radiumhemmets Forskningsfonder (Dnr: 201313), Stockholm County Council FoU (FoUI-953912) and Karolinska Institutet (Dnr 2020-01963), NovoNordisk, Merck and Ferring Pharmaceuticals. She received consulting fees from the Swedish Ministry of Health and Welfare. She received honoraria from Roche, Pfizer, and Organon for chairmanship and lectures. She received support from Organon for attending meetings. She participated in advisory boards for Merck, Nordic countries, and Ferring. She declared receiving time-lapse equipment and grants with payment to institution for pre-clinical research from Merck pharmaceuticals and from Ferring. SS-R received research funding from Roche Diagnostics, Organon/MSD, Theramex, and Gedeo-Richter. He received consulting fees from Organon/MSD, Ferring Pharmaceuticals, and Merck Serono. He declared receiving honoraria for lectures from Ferring Pharmaceuticals, Besins, Organon/MSD, Theramex, and Gedeon Richter. He received support for attending Gedeon Richter meetings and participated in the Data Safety Monitoring Board of the T-TRANSPORT trial. He is the Deputy of ESHRE SQART special interest group. He holds stock options in IVI Lisboa and received equipment and other services from Roche Diagnostics and Ferring Pharmaceuticals. KT declared receiving payment for honoraria for giving lectures from Merck Serono and Organon. She is member of the safety advisory board of EDQM. She holds a leadership role in the ICCBBA board of directors. ZV received reimbursement from ESHRE for attending meetings. She also received research grants from ESHRE and Juhani Aaltonen Foundation. She is the coordinator of EHSRE SQART special interest group. The other authors have no conflicts of interest to declare.

DISCLAIMER

This guideline represents the views of ESHRE, which were achieved after careful consideration of the scientific evidence available at the time of preparation. In the absence of scientific evidence on certain aspects, a consensus between the relevant ESHRE stakeholders has been obtained. Adherence to these clinical practice guidelines does not guarantee a successful or specific outcome, nor does it establish a standard of care. Clinical practice guidelines do not replace the need for application of clinical judgement to each individual presentation, nor variations based on locality and facility type. ESHRE makes no warranty, express or implied, regarding the clinical practice guidelines and specifically excludes any warranties of merchantability and fitness for a particular use or purpose (full disclaimer available at https://www.eshre.eu/Guidelines-and-Legal).

Multifetal pregnancy reductions and selective fetocide in a tertiary referral center - a retrospective cohort study

OBJECTIVES

Multiple pregnancies involve several complications, most often prematurity, but also higher anomaly rates. Reducing fetuses generally improves pregnancy outcomes. We conducted this study to evaluate the obstetrical and neonatal results after multifetal pregnancy reduction (MFPR) in the largest tertiary hospital in Finland.

METHODS

This retrospective cohort study included all MFPR managed in Helsinki University Hospital during a 13 year period (2007-2019). Data on pregnancies, parturients and newborns were collected from patient files. The number of fetuses, chorionicities and amnionicities were defined in first-trimester ultrasound screening.

RESULTS

There were 54 MFPR cases included in the final analyses. Most often the reduction was from twins to singletons (n=34, 63 %). Majority of these (25/34, 73.5 %) were due to co-twin anomaly. Triplets (n=16, 29.6 %) were reduced to twins (n=7, 13 %) or singletons (n=9, 16.7 %), quadruplets (n=2, 3.7 %) and quintuplets (n=2, 3.7 %) to twins. Most (33/54, 61.1 %) MFPR procedures were done by 15+0 weeks of gestation. There were six miscarriages after MFPR and one early co-twin miscarriage. In the remaining 47 pregnancies that continued as twins (n=7, 14.9 %) or singletons (n=40, 85.1 %) the liveborn rate was 90 % for one fetus and 71.4 % for two fetuses.

CONCLUSIONS

Most MFPR cases were pregnancies with an anomalous co-twin. The whole pregnancy loss risk was 11.1 % after MFPR. The majority (70.6 %) of twins were spontaneous, whereas all quadruplets, quintuplets, and 56.3 % of triplets were assisted reproductive technologies (ART) pregnancies. Careful counselling should be an essential part of obstetrical care in multiple pregnancies, which should be referred to fetomaternal units for MFPR option.

Considering multifetal pregnancy reduction in triplet pregnancies: do we forget the emotional impact on fathers? A qualitative study from The Netherlands

STUDY QUESTION

What factors influence the decision-making process of fathers regarding multifetal pregnancy reduction or maintaining a triplet pregnancy, and how do these decisions impact their psychological well-being?

SUMMARY ANSWER

For fathers, the emotional impact of multifetal pregnancy reduction or caring for triplets is extensive and requires careful consideration.

WHAT IS KNOWN ALREADY

Multifetal pregnancy reduction is a medical procedure with the purpose to reduce the number of fetuses to improve chances of a healthy outcome for both the remaining fetus(es) and the mother, either for medical reasons or social considerations. Aspects of the decision whether to perform multifetal pregnancy reduction have been rarely investigated, and the impact on fathers is unknown.

STUDY DESIGN, SIZE, DURATION

Qualitative study with semi-structured interviews between October 2021 and February 2023.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Fathers either after multifetal pregnancy reduction from triplet to twin or singleton pregnancy or ongoing triplet pregnancies 1-6 years after the decision were included. The interview schedule was designed to explore key aspects related to (i) the decision-making process whether to perform multifetal pregnancy reduction and (ii) the emotional aspects and psychological impact of the decision. Thematic analysis was used to identify patterns and trends in the father's data. The process involved familiarization with the data, defining and naming themes, and producing a final report. This study was a collaboration between a regional secondary hospital (OLVG) and a tertiary care hospital (Amsterdam University Medical Center, Amsterdam UMC), both situated in Amsterdam, The Netherlands.

MAIN RESULTS AND THE ROLE OF CHANCE

Data saturation was achieved after 12 interviews. Five main themes were identified: (i) initial responses and emotional complexity, (ii) experiencing disparities in counselling quality and post-decision care, (iii) personal influences on the decision journey, (iv) navigating parenthood: choices, challenges, and emotional adaptation, and (v) shared wisdom and lessons. For fathers, the decision whether to maintain or reduce a triplet pregnancy is complex, in which medical, psychological but mainly social factors play an important role. In terms of psychological consequences after the decision, this study found that fathers after multifetal pregnancy reduction often struggled with difficult emotions towards the decision; some expressed feelings of doubt or regret and were still processing these emotions. Several fathers after an ongoing triplet had experienced a period of severe stress in the first years after the pregnancy, with major consequences for their mental health. Help in emotional processing was not offered to any of the fathers after the decision or birth.

LIMITATION, REASONS FOR CAUTION

While our study focuses on the multifetal pregnancy reduction process in the Amsterdam region, we recognize the importance of further investigation into how this process may vary across different regions in The Netherlands and internationally. We acknowledge the potential of selection bias, as fathers with more positive experiences might have been more willing to participate. Caution is needed in interpreting the role of the mother in the recruitment process. Additionally, the time span of 1-6 years between the decision and the interviews may have influenced emotional processing and introduced potential reporting bias.

WIDER IMPLICATIONS OF THE FINDINGS

The emotional impact of multifetal pregnancy reduction or caring for triplets is significant, emphasizing the need for awareness among caregivers regarding the emotional challenges faced by fathers. A guided trajectory might optimize the decision-making and primarily facilitate the provision of appropriate care thereafter to optimize outcomes around decisions with potential traumatic implications.

STUDY FUNDING/COMPETING INTEREST(S)

This study received no funding. The authors have no conflicts of interest to declare.

TRIAL REGISTRATION NUMBER

N/A.

Pregnancy outcomes of fetal reduction in patients with intrauterine haematoma following double embryo transfer

RESEARCH QUESTION

Is there an association between intrauterine haematoma (IUH) and pregnancy outcomes in patients who undergo fetal reduction after double embryo transfer (DET), and if so, what is the relationship between IUH-related characteristics and pregnancy outcomes?

DESIGN

Clinical information and pregnancy outcomes of women who underwent fetal reduction after DET were analysed. Patients with other systematic diseases, ectopic pregnancy or heterotopic pregnancy, monochorionic twin pregnancies and incomplete data were excluded. Stratification of IUH pregnancies was undertaken based on IUH-related characteristics. The main outcome was incidence of fetal demise (<24 weeks), with other adverse pregnancy outcomes considered as secondary outcomes.

RESULTS

Thirty-four IUH patients and 136 non-IUH patients who underwent fetal reduction after DET were included based on a 1:4 match for age, cycle type and fertilization method. IUH patients had a higher incidence of early fetal demise (20.6% versus 7.4%, P = 0.048), threatened abortion (48.1% versus 10.3%, P<0.001) and postpartum haemorrhage (PPH; 14.8% versus 4.0%, P = 0.043) compared with non-IUH patients. IUH was an independent risk factor for early fetal demise [adjusted OR (aOR) 3.34, 95% CI 1.14-9.77] and threatened abortion (aOR 8.61, 95% CI 3.28-22.61) after adjusting for potential confounders. IUH pregnancies undergoing fetal reduction that resulted in miscarriage had larger IUH volumes and earlier diagnosis (both P < 0.03). However, IUH characteristics (i.e. volume, changing pattern, presence or absence of cardiac activity) were not associated with threatened abortion or PPH.

CONCLUSIONS

Fetal reduction should be performed with caution in IUH pregnancies after DET as the risk of fetal demise is relatively high. Particular attention should be given to IUH patients with early signs of threatened abortion and inevitable fetal demise.

Twin pregnancy, fetal reduction and the 'all or nothing problem'

Fetal reduction is the practice of reducing the number of fetuses in a multiple pregnancy, such as quadruplets, to a twin or singleton pregnancy. Use of assisted reproductive technologies increases the likelihood of multiple pregnancies, and many fetal reductions are done after in vitro fertilisation and embryo transfer, either because of social or health-related reasons. In this paper, I apply Joe Horton's all or nothing problem to the ethics of fetal reduction in the case of a twin pregnancy. I argue that in the case of a twin pregnancy, there are two intuitively plausible claims: (1) abortion is morally permissible, and (2) it is morally wrong to abort just one of the fetuses. But since we should choose morally permissible acts rather than impermissible ones, the two claims lead to another highly implausible claim: the woman ought to abort both fetuses rather than only one. Yet, this does not seem right. A plausible moral theory cannot advocate such a pro-death view. Or can it? I suggest ways to solve this problem and draw implications for each solution.

Fetal Reduction Could Improve but Not Completely Reverse the Pregnancy Outcomes of Multiple Pregnancies: Experience From a Single Center

OBJECTIVE

To investigate the effectiveness and limitations of multifetal pregnancy reduction (MFPR) on the improvement of pregnancy outcomes of triplet or twin pregnancies conceived by in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI).

METHODS

We performed a cohort study of women undergoing IVF or ICSI from 2002-2016 in reproductive center, women's hospital, Zhejiang University School of Medicine. The cohort included 502 women who underwent MFPR and 9641 non-reduced women. Pregnancy outcomes were gestational age (GA) at delivery, pregnancy loss, preterm delivery, low birth weight (LBW), very low birth weight (VLBW), and small for gestational age (SGA). Multiple linear regression and logistic regression models were used to compare pregnancy outcomes between groups.

RESULTS

Triplets reduced to singletons had a longer median GA (39.07 vs 37.00, P<0.001), and lower rates of LBW (8.9% vs 53.2%, P<0.001) and SGA (17.8% vs 44.7%, P=0.001) than triplets reduced to twins, with a similar pregnancy loss rate (6.7% vs 6.6%, P=0.701). Twins reduced to singletons had a comparable pregnancy loss rate (4.8% vs. 6.5%, P=0.40), a longer median GA (38.79 vs. 37.00, P<0.001), and lower rates of LBW (13.5% vs. 47.0%, P<0.001) and SGA (13.5% vs. 39.6%, P<0.001) than primary twins. Triplets reduced to twins had higher rates of LBW (53.2% vs. 47.0%, P=0.028) and SGA (44.7% vs. 39.6%, P=0.040) than primary twins, with a similar pregnancy loss rate (6.6% vs. 6.5%, P=0.877). Singletons reduced from triplets/twins had higher rates of preterm delivery (15.8% vs. 7.3%, P<0.001), LBW (12.3% vs. 4.32%, P<0.001), VLBW (2.3% vs. 0.4%, P=0.002), and SGA (14.6% vs.6.6%, P<0.001) than primary singletons, with a comparable pregnancy loss rate (5.3% vs. 5.4%, P=0.671).

CONCLUSIONS

This study suggests that the pregnancy loss rate is similar between reduction and non-reduction groups. MFPR improves pregnancy outcomes, including the risk of preterm delivery, LBW, and SGA, but still could not completely reverse the adverse pregnancy outcomes of multiple pregnancies.

Fetal reduction from twin to singleton gestation: A meta-analysis

OBJECTIVE

To evaluate outcomes of fetal reduction in twin pregnancy.

SEARCH STRATEGY

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar were searched from 1980 through December 2020.

SELECTION CRITERIA

Prospective or retrospective studies of pregnant women with twin gestations who had a transabdominal reduction of twin to singleton pregnancy with a comparison group of ongoing twin gestations.

DATA COLLECTION AND ANALYSIS

Outcomes were meta-analyzed only if reported in at least three studies.

MAIN RESULTS

Six studies with a pooled sample of 2867 women with a twin pregnancy of whom 624 underwent 2-to-1 reduction and 2243 did not. In the fetal reduction group, the odds of preterm birth before 34 and 37 weeks of pregnancy were lower by 36% (odds ratio [OR] 0.64, 95% confidence interval [CI] 0.48-0.86, P < 0.003) and 77% (OR 0.23, 95% CI 0.12-0.44, P < 0.001), respectively, than in the control group, and the odds of hypertensive disorders and cesarean delivery were lower by 75% (OR 0.25, 95% CI 0.15-0.43, P < 0.001) and 65% (OR 0.35, 95% CI 0.20-0.62, P < 0.001), respectively.

CONCLUSION

Twin reduction to singleton pregnancy decreased the possibility of preterm birth, hypertensive disorders in pregnancy and cesarean delivery. Sufficiently powered prospective studies are needed to support these findings.

Short-term and long-term outcomes of trichorionic triplet pregnancies with expectant management

INTRODUCTION

Reproductive endocrinologists recommend selective multifetal pregnancy reduction (MFPR) to save at least one or two babies, because triplet pregnancy is known to increase the risk of miscarriage and preterm delivery. However, recently improved obstetric and neonatal care may affect pregnancy outcomes differently in triplet pregnancies, which could alter practice. We compared the maternal, perinatal, and long-term outcomes of triplet pregnancies managed expectantly with those of pregnancies reduced to twins.

MATERIAL AND METHODS

In this retrospective cohort study, we reviewed the clinical records of 552 trichorionic triplet pregnancies for obstetric, perinatal, and neurodevelopmental outcomes, which consisted of the expectant management (EM) group (n = 225) and MFPR group (n = 327), in Seoul National University Hospital and CHA Bundang Medical Center from January 2006 to December 2018. Neuromotor development was evaluated using the Korean-Ages and Stages Questionnaire, Bayley-III tests, and/or Gross Motor Function Measure. The two groups were compared for the following outcomes: (1) nonviable pregnancy loss before 23 weeks, (2) preterm birth before 32 weeks of gestation, (3) fetal and neonatal survival and (4) long-term neurodevelopmental outcomes.

RESULTS

There were no differences in maternal age, body mass index, nulliparity or previous preterm birth between the two groups. The risk of nonviable pregnancy loss was lower in the EM group than that in the MFPR group (2 [0.9%] vs 21 [6.4%], p = 0.001). The risk of preterm delivery before 34 weeks of gestation was lower in the MFPR group (adjusted odds ratios [aOR] = 0.47, 95% confidence interval [CI] 0.30-0.73, p = 0.001). The survival rate of neonates until discharge (644 [95.4%] vs 572 [87.5], p < 0.001) and the rate of pregnancies with at least one survivor (220 [97.8%] vs 301 [92.0], p = 0.002) were higher in the EM group than those in the MFPR group. In the MFPR group, the risk of developmental delay (aOR = 2.89, 95% CI 1.38-6.02, p = 0.005) was higher.

CONCLUSIONS

In trichorionic triplet pregnancies, the possibility of EM to improve survival and reduce the risk of developmental delay has been shown.

High Maternal Serum Estradiol in First Trimester of Multiple Pregnancy Contributes to Small for Gestational Age via DNMT1-Mediated CDKN1C Upregulation

High maternal serum estradiol (E₂) levels in the first trimester of pregnancy are associated with a high incidence of low birth weight (LBW) and small for gestational age (SGA). This study aimed to investigate the effect of first-trimester high maternal serum E₂ levels on fetal growth and the underlying mechanisms in multiple pregnancies. Maternal serum E₂ levels of women at 8 weeks of gestation were measured. The expression levels of imprinted genes and DNMT1 were determined by RT-qPCR, and KvDMR1 methylation in embryo tissue, placenta, and newborn cord blood samples was examined by bisulfite sequencing PCR. The effect of E₂ on CDKN1C expression was investigated in HTR8 cells. The incidence of SGA was significantly higher in multiple pregnancies reduced to singleton than that in primary singleton pregnancies (11.4% vs. 2.9%) (P < 0.01) and multiple pregnancies reduced to twins than primary twins (38.5% vs. 27.3%) (P < 0.01). The maternal serum E₂ level at 8 weeks of gestation increased with the number of fetuses and was negatively correlated with offspring birth weight. CDKN1C and DNMT1 expression was significantly upregulated in embryo tissue, placenta, and cord blood from multiple pregnancies. Furthermore, there was a positive correlation between CDKN1C mRNA expression and KvDMR1 methylation levels. In HTR8 cells, DNMT1 mediated the estrogen-induced upregulation of CDKN1C, which might contribute to SGA. To minimize the risks of LBW and SGA, our findings suggest that abnormally high maternal serum E₂ levels should be avoided during the first trimester of multiple pregnancies from assisted reproductive technology (ART).

Perinatal outcome after selective termination in dichorionic twins discordant for congenital anomalies

INTRODUCTION

Our objective was to evaluate the perinatal outcome of selective termination of dichorionic twin pregnancies with discordant anomalies, according to gestational age at time of procedure.

MATERIAL AND METHODS

Retrospective review of 147 dichorionic twin pregnancies referred to our Fetal Medicine Unit between 2003 and 2018 for selective termination. Gestational age at delivery, fetal loss, and overall and 28-day post-delivery survival rates, were evaluated according to gestational age at time of procedure. Selective termination procedure was defined as early, intermediate, and late when performed before 18 weeks, between 18 and 23 weeks, and after 23 weeks, respectively. Kruskal-Wallis and chi-squared test were used to compare groups.

RESULTS

Overall survival at 28 days post-delivery, pregnancy loss, and preterm delivery before 32 weeks of gestation rates were 93.4%, 6.9%, and 15.5%, respectively. When stratified by gestational age at procedure, intermediate selective termination was associated with a lower survival rate than early and late procedures (86% vs. 96.9% and 100%, respectively; p = 0.035), and a nonsignificant trend for higher pregnancy loss (12% vs. 3.1%). Preterm delivery before 32 weeks of gestation occurred in 27% of late procedures, which was significantly higher than in early (9.5%) and intermediate (18.2%) procedures.

CONCLUSIONS

Selective termination in dichorionic twin pregnancies with discordant fetal anomaly is associated with low pregnancy loss and preterm delivery rate, primarily when performed before 18 weeks. When legally possible, late procedures can be a good alternative, particularly in those cases diagnosed beyond the 18th week of gestation.

Elective Fetal Reduction in Dichorionic Diamniotic Twin Pregnancies on Parental Request: A Single-Centre Experience

OBJECTIVES

Our study aimed to examine a subset of electively reduced twins and compare their outcomes with those of expectantly managed twins, along with a cohort of singleton pregnancies. The secondary aim was to ascertain the procedure-related miscarriage risks.

METHODS

A retrospective cohort analysis was performed at Apollo Centre for Fetal Medicine, New Delhi, comparing pregnancy outcomes in dichorionic diamniotic twin pregnancies which were reduced to singletons (group 1) with that of women with dichorionic twins managed expectantly (group 0) and women with a singleton pregnancy (group 2). Comparison of continuous and categorical variables was conducted using standard statistical tests.

RESULTS

We analysed 35 twins which were reduced to singletons, 421 expectantly managed dichorionic twins and 1915 women with a singleton pregnancy. In the reduction group, the rate of procedure related pregnancy loss<24 weeks was lower, compared to the expectantly managed twins, although the difference was not statistically significant (5.71% [2/35] vs. 7.13% [30/421]; p = 1.000). The median gestational age at delivery was significantly higher in reduced twins compared to expectantly managed twin pregnancies (38.0 vs. 35.4 weeks respectively, p < 0.001) with a higher mean birth weight at delivery, both of which were comparable to that among the singleton pregnancies (38.3 weeks). The rates of preterm birth <32 weeks and <34 weeks in the expectantly managed twins were significantly higher at 19.8% (66/334) and 25.7% (86/334) compared to the reduced twins, all of whom delivered beyond 34 weeks. The rates of preterm births <32 weeks, <34 weeks, and the late preterm births in the reduced twins were comparable to those in the singleton cohort.

CONCLUSIONS

The obstetric and perinatal outcomes after reduction of a dichorionic twin are better than an expectantly managed twin without an associated increase in pregnancy loss rates. Fetal reduction of dichorionic twin to a singleton appears to be a safe procedure in expert hands.

Bibliometric analysis of research hotspots and development trends in selective fetal reduction

AIM

To evaluate the theme trends and knowledge structure of multifetal pregnancy reduction (MPR)-related literature by using bibliometric analysis.

METHODS

Published scientific papers regarding MPR were retrieved from the PubMed database. Data extraction and statistics were conducted using Bibliographic Item Co-Occurrence Matrix Builder (BICOMB). Furthermore, gCLUTO software was used in the study for bi-clustering analysis and strategic diagram analysis.

RESULTS

According to the search strategy, 906 total papers were included. Among all the extracted MeSH terms, 41 high frequency ones were identified and hotspots were clustered into four categories. In the strategic diagram, research on intrauterine treatment of MPR was most well developed. In contrast, statistical data on the sequelae of fetal reduction surgery and applications of MPR in assisted reproductive technologies were relatively immature.

CONCLUSION

The analysis of common terms among the high-frequency network terms in multiparous pregnancy reduction can help researchers and clinicians understand the hotspots, key topics, and issues to be discovered on MPR. Research on intrauterine treatment of MPR was most well developed.

Is vanishing twin syndrome associated with adverse obstetric outcomes of ART singletons? A systematic review and meta-analysis

PURPOSE

The objective of our meta-analysis was to estimate the effect of VTS on obstetric outcomes of ART singletons.

METHODS

PubMed, Embase, MEDLINE, and ClinicalTrials.gov were searched up to January 2019 to find studies reporting the obstetric outcomes of ART singletons with VTS. Dichotomous data were expressed as odds ratios (OR) with 95% confidence intervals (CI). Continuous data were expressed as weighted mean difference (WMD) with 95% CI.

RESULTS

A total of 17 observational studies encompassing more than 60,000 ART singletons were included in this meta-analysis. The impact of VTS on singletons was highly dependent on the definition of VTS, precisely, the vanishing timing and intrauterine growth stage. When VTS happened at or before 14 weeks, regardless of intrauterine growth stage, there were no differences in terms of gestational age (GA) [WMD = - 0.08, 95% CI = - 0.27, 0.10], preterm birth (< 37 weeks) (PTB) [OR = 1.23, 95% CI = 0.89, 1.70], and low birth weight (< 2.5 kg) (LBW) [OR = 1.56, 95% CI = 1.00, 2.43] in original singletons versus singleton with VTS. On the contrary, VTS occurred after 14 weeks was associated with significantly shorter GW and lower BW, as well as higher risks of PTB and LBW. When the sac reduced in VTS was an empty gestational sac, there would be no differences in GW, PTB, and LBW between singletons versus singletons with VTS, whereas the loss of a fetus with cardiac-activity was associated with adverse obstetric outcomes.

CONCLUSIONS

This meta-analysis suggests whether or not VTS is harmful to obstetric outcomes is highly dependent on the vanishing timing and intrauterine growth stage.

Transabdominal fetal reduction: a report of 124 cases

To prevent fetal loss, preterm delivery, and perinatal morbidity of multifetal pregnancies (MPs), fetal reduction (FR) is offered to some patients. We retrospectively analysed the data of 124 MPs that underwent transabdominal FR to twin (n = 63) and singleton (n = 61) pregnancies at a mean gestational age of 12 + 6 weeks between December 2006 and January 2018. FR was performed transabdominally with the injection of potassium chloride into the intracardiac or intrathoracic space of the fetus or fetuses after ultrasound screening for nuchal translucency and anatomical defects. The initial number of embryos were 48 twins, 63 triplets, 11 quadruplets, and 2 quintuplets. The procedure-related pregnancy loss rate was 0.8% (1/124), the overall pregnancy loss rate was 2.4% (3/124), the fetal loss rate was 1.6% (2/124), and the neonatal death rate was 0.8% (1/124). The baby take-home rates were 96% for twin pregnancies and 96.7% for singletons. This study shows that transabdominal FR is an effective and safe procedure with a pregnancy loss rate of 2.4%.Impact statementWhat is already known on this subject? The incidence of multifetal pregnancies has increased over the years. Because multifetal pregnancies increase perinatal morbidity and mortality due to prematurity, fetal reduction is offed to some patients.What the results of this study add? The results of this study add to the growing body of research on fetal reduction. The study showed that transabdominal fetal reduction is a safe procedure with a pregnancy loss rate of 2.4%.What the implications are of these findings for clinical practice and/or further research? The results of this study can be used in counselling couples with multifetal pregnancies who are considering fetal reduction. Further research is needed to confirm the current findings.

Pregnancy outcome following fetal reduction from dichorionic twins to singleton gestation

BACKGROUND

There are still some controversies regarding the risks and benefits of fetal reduction from twins to singletons. We aimed to evaluate if fetal reduction from twins to singleton improves pregnancy outcome.

METHODS

Retrospective analysis of all dichorionic-diamniotic twin pregnancies, who underwent fetal reduction. Pregnancy outcome was compared to ongoing, non-reduced, dichorionic-diamniotic gestations. Primary outcome was preterm birth prior to 37 gestational weeks. Secondary outcomes included: preterm birth prior to 34 gestational weeks, gestational age at delivery, birthweight, small for gestational age, hypertensive disorders, gestational diabetes and stillbirth.

RESULTS

Ninety-eight reduced pregnancies were compared with 222 ongoing twins. Preterm birth < 37 gestational weeks (39.6% vs. 57.6%, p < 0.001) was significantly lower in the reduced group compared to the ongoing twins' group. A multivariate analysis, controlling for parity and mode of conception, demonstrated that fetal reduction independently and significantly reduced the risk for prematurity (aOR 0.495, 95% CI -0.299-0.819). Subgroup analysis, similarly adjusted demonstrated lower rates of preterm delivery in those undergoing elective reduction (aOR = 0.206, 95% CI 0.065-0.651), reduction due to fetal anomalies (aOR = 0.522, 95% CI 0.295-0.926) and 1st trimester reduction (aOR = 0.297, 95% Cl 0.131-0.674) all compared to ongoing twins. A Kaplan-Meier survival curve showed a significant proportion of non-delivered women at each gestational week in the reduced group compared to non-reduced twins, after 29 gestational weeks.

CONCLUSIONS

Fetal reduction from twins to singleton reduces the risk of preterm birth < 37 gestational weeks, but not for more severe maternal and perinatal complications.

Perinatal outcomes in dichorionic diamniotic twins with multifetal pregnancy reduction versus expectant management: A systematic review and meta-analysis

BACKGROUND

Published findings on perinatal outcomes of multifetal pregnancy reduction (MPR) of dichorionic diamniotic (DCDA) twin pregnancy to singleton are controversial. We performed a meta-analysis to appraise the effects of MPR of DCDA twin pregnancy versus expectant management on perinatal outcomes.

METHODS

Four electronic databases were searched from their inception to June 15, 2019, to identify publications that appraised MPR before 15 weeks of gestation. Studies reporting perinatal outcomes of both MPR of DCDA twin pregnancy to singleton and expectant management were considered. The relative risks (RRs) and mean differences with 95% confidence intervals (CIs) were pooled using a random-effects model.

RESULTS

Six studies involving 7398 participants showed that MPR of DCDA twin pregnancy to singleton was associated with a lower risk of preterm birth (5 studies with 7297 participants; RR: 0.30, 95% CI: 0.22-0.40; P < .001) and higher birth weight (4 studies with 5763 participants; mean differences: 548.10 g, 95% CI: 424.04-672.15; P < .001) than expectant management; there was no difference in the occurrence of miscarriages (5 studies with 7355 participants; RR: 1.57, 95% CI: 0.90-2.75; P = .11). Sensitivity analysis showed that all the results were stable and reliable, with the omission of 2 studies with serious risk of bias.

CONCLUSION

Compared to expectant management, MPR of DCDA twin pregnancy to singleton prevents preterm birth and low birth weight, without increasing the risk of miscarriages. Regarding perinatal morbidity related to preterm birth, MPR can be reserved as a remediation measure to improve the perinatal outcomes of DCDA twin pregnancies.

Discordance for Potter's Syndrome in a Dichorionic Diamniotic Twin Pregnancy-An Unusual Case Report

INTRODUCTION

Potter's syndrome, also known as Potter's sequence, is an uncommon and fatal disorder. Potter's sequence in a multiple pregnancy is uncommon, and its frequency remains unknown. Worldwide in a diamniotic twin pregnancy, there are only a few cases described.

CASE REPORT

We present an unusual case discordance for Potter's syndrome in a dichorionic diamniotic twin pregnancy. Twin A had the typical physical and histological Potter's findings. Twin B had normal respiratory function and normal physical examination findings. There are many controversies about this condition in diamniotic twin pregnancy. One case report concluded that that the presence of a normal co-twin in diamniotic pregnancy prevented the cutaneous features seen in Potter's syndrome and ameliorated the pulmonary complications, whereas two other case studies reported that the affected twin had extrarenal features typical of the syndrome.

CONCLUSION

We performed an autopsy and calculated lung weight/body weight ratio to diagnose pulmonary hypoplasia. Histopathologic examination of lungs and kidneys was performed. We concluded that the appearance of extrarenal features in the affected twin depends on the amniocity.

Comparing pregnancy outcomes and loss rates in elective twin pregnancy reduction with ongoing twin gestations in a large contemporary cohort

BACKGROUND

As compared with singleton gestations, twin pregnancies are associated with a significantly higher risk of preterm birth and maternal complications as well as fetal and neonatal morbidity and mortality. Multifetal pregnancy reduction is a technique developed in the 1980s to reduce the fetal number in higher-order multiple pregnancies to reduce the risk of adverse pregnancy outcomes, most importantly preterm birth.

OBJECTIVE

The objective of the study was to compare pregnancy outcomes and loss rates in elective twin pregnancy reduction to ongoing twin gestations in a large contemporary cohort.

STUDY DESIGN

This was a retrospective review of dichorionic diamniotic twin gestations that underwent first-trimester ultrasound at our institution from January 2008 to September 2016. Planned elective 2-to-1 multifetal pregnancy reductions at less than 15 weeks' gestation were compared with ongoing dichorionic diamniotic twin gestations. Data were collected via chart review. Demographics between 2-to-1 reduced singletons and ongoing twins were assessed using a Student t test or a Wilcoxon rank-sum test, as appropriate, for continuous variables and χ² or Fisher exact tests, as appropriate, for categorical variables. Univariable and multivariable logistic regressions were used to compare pregnancy outcomes between ongoing twins and reduced singletons adjusting for maternal age, body mass index, race, in vitro fertilization, use of chorionic villus sampling, prior term birth, and prior preterm birth.

RESULTS

Of 1070 dichorionic diamniotic twin pregnancies identified, completed follow-up data were available and analyzed for 855 patients (79.9%). Among those, 250 (29.2%) were 2-to-1 singletons and 605 (70.8%) were ongoing twins. Reduced singleton patients were slightly older, more likely white, and had lower body mass index. They were also more likely to have undergone in vitro fertilization (63.6% vs 48.8%), had chorionic villus sampling (92% vs 37.5%), and had prior term births (54% vs 35.7%). Compared with 2-to-1 singletons, the adjusted odds of having preterm delivery at 37 weeks for ongoing twins were 5.62 times (95% confidence interval, 3.67-8.61; P < .001) and 2.22 times (95% confidence interval, 1.20-4.11; P < .001) at 34 weeks. While intrauterine growth restriction, placental abruption, and gestational diabetes were not significant, ongoing twins were more likely to have a cesarean delivery (odds ratio, 5.53, 95% confidence interval, 3.60-8.49; P < .001) and preeclampsia (odds ratio, 3.33, 95% confidence interval, 1.60-6.96; P < .001) after adjusting for maternal characteristics. There were also significant differences between groups for preterm premature rupture of membranes and low birthweight at less than the fifth and 10th percentiles. Total pregnancy loss (at 24 and 20 weeks) was similar between singleton and ongoing twins (4% vs 2.5%, P = .23, and 3.6% vs 1.7%, P = .09 for respective weeks). There were no significant differences in the rate of unintended pregnancy loss (2.4% vs 2.3%; P = .94) and the rate of intrauterine fetal death greater than 24 weeks (1.2% vs 0.7%; P = .43) in reduced singleton versus ongoing twin group, respectively.

CONCLUSION

In our study, patients who elected to reduce to a singleton pregnancy had a higher gestational age of delivery and lower rates of preterm birth and pregnancy complications without an increased risk of pregnancy loss.

Is it worth reducing twins to singletons after IVF-ET? A retrospective cohort study using propensity score matching

INTRODUCTION

Many studies have shown that multifetal reduction of high-order multiple pregnancies results in improved pregnancy outcomes. However, whether conducting elective fetal reduction from dichorionic twins after in vitro fertilization (IVF) is worthwhile remains controversial. This study aimed to determine whether elective fetal reduction of dichorionic twins after IVF and embryo transfer (IVF-ET) is associated with increased take-home baby rate.

MATERIAL AND METHODS

This was a retrospective cohort study of 3600 dichorionic twin pregnancies after IVF-ET. The reduced group included 71 women with transvaginal elective fetal reduction between 7 and 8 weeks of gestation. The control group (n = 3529) comprised women who were managed expectantly. Propensity score matching was conducted before pregnancy outcomes were compared.

RESULTS

The take-home baby rate was significantly lower in the reduced group (83.1% vs 92.8%, P = 0.004). The total miscarriage rate was significantly higher in the reduced group (12.7% vs 6.2%, P = 0.04). Although preterm delivery rate was lower in the reduced group (P < 0.001), over 90% were over 32 weeks, whereas the proportions were equal in the reduced group.

CONCLUSIONS

In dichorionic twin pregnancies after IVF-ET, elective fetal reduction to singleton significantly decreased the chance of taking home live babies.

Obstetrical Outcomes of Amniocentesis or Chorionic Villus Sampling in Dichorionic Twin Pregnancies

BACKGROUND

Under certain situations, women with twin pregnancies may be counseled to undergo invasive prenatal diagnostic testing. Chorionic villus sampling and amniocentesis are the two generally performed invasive prenatal diagnostic tests. Studies comparing procedure-related fetal loss between first-trimester chorionic villus sampling and second-trimester amniocentesis in twin pregnancies are limited. This study aimed to evaluate the procedure-related fetal loss and the obstetrical outcomes of these two procedures, chorionic villus sampling and amniocentesis in twin pregnancies.

METHODS

The data from dichorionic-diamniotic twin pregnancies on which first-trimester chorionic villus sampling (n = 54) or second-trimester amniocentesis (n = 170) was performed between December 2006 and January 2017 in a single center were retrospectively analyzed. The procedure-related fetal loss was classified as loss of one or all fetuses within 4 weeks of procedure, and overall fetal loss was classified as loss of one or all fetuses during the gestation. The groups were compared with respect to the procedure-related and obstetrical outcomes.

RESULTS

The difference in proportion of procedure-related fetal loss rate (1.9% for chorionic villus sampling vs. 1.8% for amniocentesis; P = 1.000) and the overall fetal loss rate (7.4% for chorionic villus sampling vs. 4.7% for amniocentesis; P = 0.489) between the two groups was not significant. The mean gestational ages at delivery were not statistically significant.

CONCLUSION

Both the overall fetal loss rate and the procedure-related fetal loss rate of chorionic villus sampling and amniocentesis in dichorionic twin pregnancies had no statistical significance. Both procedures can be safely used individually.

Procedural and obstetric outcomes after embryo reduction vs fetal reduction in multifetal pregnancy

OBJECTIVE

To compare the obstetric outcome and incidence of procedure-related adverse events after embryo reduction (ER) vs fetal reduction (FR), in multifetal pregnancies undergoing reduction to twins or singletons.

METHODS

We analyzed retrospectively data from multifetal pregnancies that underwent transvaginal ER (n = 181) at a mean gestational age of 7.6 weeks or transabdominal FR (n = 115) at a mean gestational age of 12.9 weeks between December 2006 and January 2017. FR was performed after a detailed fetal anomaly scan. The two groups were compared with respect to obstetric outcomes, such as incidence of miscarriage, early or late preterm delivery, maternal complications and fetal loss, and procedure-related adverse events, including incidence of subchorionic hematoma and procedure-related fetal loss.

RESULTS

Compared with pregnancies that underwent ER, the incidence of procedure-related fetal loss was lower in the FR group (7.2% vs 0.9%; P = 0.039; odds ratio (OR), 0.12; 95% CI, 0.02-0.89). Mean gestational age at delivery for twins was 34.2 weeks in the ER group and 35.7 weeks in the FR group (P = 0.014). Compared with the ER group, the FR group had lower miscarriage (8.8% vs 2.6%; P = 0.045; OR, 0.28; 95% CI, 0.08-0.97) and overall fetal loss (13.3% vs 5.2%; P = 0.031; OR, 0.36; 95% CI, 0.14-0.91) rates.

CONCLUSIONS

The FR procedure is, overall, a better and safer approach to reducing morbidity and mortality in multifetal pregnancies. Spontaneous demise of one fetus may occur after ER, and FR has the advantage that chorionic villus sampling and ultrasound screening for increased nuchal translucency and anatomical defects can be conducted before the procedure. The ER approach is still reasonable when a patient's religious or other ethical concerns are of primary importance. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Transabdominal selective feticide in dichorionic twins: Ten years' experience at a single center

AIM

The present study investigates the procedure-related fetal loss rate and obstetrical outcomes of selective feticide in dichorionic twins.

METHODS

We retrospectively analyzed the data of 44 cases of dichorionic twins. Two different indications for selective feticide were set: (i) the presence of genetic or congenital anomaly; and (ii) an obstetrical indication specified as a past maternal history of preterm delivery that caused fetal death or cerebral palsy of the child. Primarily, data on procedure-related fetal loss and obstetrical outcomes were retrieved. Additionally, data on obstetrical outcomes by reduction time and by indication of SF were obtained.

RESULTS

Selective feticide was performed in 44 cases - specifically, in 23 cases with genetic or congenital anomaly and in 21 cases with obstetrical indications. The median gestational age at delivery was 38 + 4 weeks. One pregnancy loss (2.3%, 1/44) occurred within 4 weeks after the procedure. The overall pregnancy loss rate throughout the pregnancy term was 2.3% (1/44). When selective feticide was performed at 15 weeks and beyond, the birth weight was significantly decreased compared with when selective feticide was performed earlier than 15 weeks.

CONCLUSION

Transabdominal ultrasound-guided selective feticide in dichorionic twins is an effective and safe procedure. If a patient desires to maximize her chances of having a healthy child and decrease the risk of prematurity, the option of selective feticide should be considered in certain cases of twin pregnancies. Selective feticide may be a reasonable alternative to expectant management or termination of the whole twin pregnancy.

Transabdominal amnioinfusion in the correction of oligohydramnios following twin-to-singleton reduction – A report of two cases

Background:

On rare occasions, elective iatrogenic reduction of a dichorionic twin is performed due to maternal request and in order to improve the perinatal outcome.

Materials and methods:

Nine twin-to-singleton reductions were identified retrospectively at the Feto-maternal Unit, University of Szeged, Hungary, between December 1997 and June 2015. A post-procedure, routine weekly sonographic scan revealed severe oligohydramnios in two out of the nine cases (22.2%) and amnioinfusion was performed in the mid-trimester to prolong gestation. The fetus survived in one case (11.1%) and the pregnancy continued until preterm birth.

Conclusion:

A repeated sonographic follow-up for an early diagnosis of oligohydramnios is feasible to avoid miscarriage after artificial embryo reduction.

In-vitro fertilization and spontaneous pregnancies: matching outcomes in Douala, Cameroon

BACKGROUND

Couples are considered infertile if they do not conceive over a 12-month period of unprotected intercourse. Studies have shown that female causes accounted for between 25 to 37 percent of infertility worldwide (with larger proportions in sub-Saharan Africa and Southeast Asia) and male causes accounted for between 8 to 22 percent. Both male and female causes accounted for between 21 to 38 percent. Although the majority of ART children are normal, there are concerns about the increased risk for adverse pregnancy outcomes. More than 30 % of ART pregnancies are twins or higher-order multiple gestations (triplets or greater) and more than one half of all ART neonates are the products of multifetal gestations, with an attendant increase in prematurity complications. The aim of this study was to evaiuate the outcome of pregnancies conceived by In-vitro fertilisation compared to those conceived naturally in two hospitals in Douala, Cameroon.

METHODS

This was a prospective study carried out from October 1, 2011 to September 30, 2012. Participants were recruited from two hospitals: the Douala General Hospital (DGH) and the Clinique de l' Aéroport (CDA), also in Douala. A total of 102 women were recruited for study: 51 who conceived by IVF (cases) and 51 who conceived naturally (controls). Of the 102 women, 52.9 % were between 31 - 39 years of age, while 21.6 % were above 40.

RESULTS

Participants who conceived through IVF-ET were 4.1 times more likely to undergo cesarean delivery than those who conceived naturally [OR 4.10, 95 % CI 1.78-9.42]. Similarly, a higher percentage of patients in the IVF group than those in the control group have never given birth (33.3 % vs 2.0 %) (P < 0.0001). The percentage of multiple pregnancies was 7.5 times higher in the IVF group than in the control group (14.7 % vs.1.96 %) (P = 0.000). The leading indication for cesarean delivery was advanced maternal age (27.3 %) followed by IVF or precious pregnancy (18.2 %).

CONCLUSIONS

Cesarean delivery was more frequent amongst the IVF group than in the control group. The leading indications for cesarean delivery were advanced maternal age and IVF or precious pregnancy. The long-term neonatal outcomes of IVF babies beyond 5-min Apgar scores should be studied in Cameroon and follow-up beyond 1 year encouraged.