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A rare spontaneous triplet heterotopic pregnancy occurred in a patient using emergency contraception. This highlights the need to consider heterotopic pregnancy in differential diagnoses for patients presenting with abdominal pain or vaginal bleeding, even with detected intrauterine pregnancies, especially after failed emergency contraception, necessitating thorough laboratory and ultrasonographic diagnostic work-up., Competing Interests: The authors declare no conflicts of interest., (© 2025 The Author(s). Clinical Case Reports published by John Wiley & Sons Ltd.)

Objective: To explore the personal experiences of women faced with the decision to continue a triplet pregnancy or undergo multifetal pregnancy reduction., Methods: A qualitative study with semi-structured interviews was conducted between October 2021 and April 2023. Participants included women who continued a triplet pregnancy, and those who underwent multifetal pregnancy reduction from triplet to twins or singletons, 1-6 years post-decision. Interviews focused on: (1) the decision-making process, and (2) the emotional aspects and psychological impact of the decision. Thematic analysis was used to identify patterns, involving familiarization, defining themes, and producing the final report., Results: Data saturation was achieved after 16 interviews, revealing two main themes: (1) maternal intuition as a guiding force, and (2) navigating the crossroads: coping and reflection on the decision. These themes illustrate an interplay between maternal intuition and intrinsic feelings in the decision whether to perform multifetal pregnancy reduction, seemingly less influenced by external factors. Mothers who adhere to their intuition (15/16) have a low likelihood of experiencing regret. Despite the inclination to share and seek support, a persistent taboo surrounds the topic of multifetal pregnancy reduction. The findings also emphasize a considerable gap in aftercare for women, regardless of their decision., Conclusion: There is a need for improved care and support for parents facing the decision of continuing a triplet pregnancy or deciding on multifetal pregnancy reduction. Efforts should focus on fostering open societal dialog about this taboo subject, and addressing the gap in aftercare to provide comprehensive support to women post-decision and post-birth, thereby establishing a more supportive and compassionate framework., (© 2024 The Author(s). Prenatal Diagnosis published by John Wiley & Sons Ltd.)

Objective: This study aims to evaluate the perinatal outcomes of triplet pregnancies reduced from triplets to twins with fetal reduction (FR), followed expectantly without FR, and reduced to triplets from higher-order multiple pregnancies (HOMP) with FR., Materials and Methods: Multifetal pregnancies followed at the university hospital in the last 8 years were evaluated retrospectively. The study group was composed of three groups. The first group was those who started as trichorionic-triamniotic (TCTA) triplets and were followed by triplets. The second group consisted of HOMPs reduced to TCTA triplets with FR. The third group consisted of pregnant women who started as TCTA triplets and were reduced to dichorionic-diamniotic (DCDA) twins with FR., Results: A total of 69 multifetal pregnancies were included in the study. No statistical difference was observed between miscarriage rates in all groups ( p  = 0.190). Birth rates below 32 weeks were similar between groups ( p  = 0.158). The birth rates below 34 weeks were statistically significantly lower in the group in which DCDA was reduced by TCTA compared to the other two groups ( p  = 0.001). The first and second fetus weights in the group reduced to DCDA twins from TCTA were higher than the group followed expectantly, they were similar to the triplets reduced from HOMP. Stillbirth rates were similar in all groups ( p  = 0.057)., Conclusion: In TCTA pregnancies, when the priority is three live-born babies, expectant management seems to be a reasonable choice, considering the low rate of miscarriage and high rate of survivor neonates in this group.

Introduction: The coexistence of a complete hydatidiform mole with twin live fetuses in a triplet pregnancy is an extremely rare condition with an unknown incidence., Case Report: This report presents a case of a dichorionic diamniotic triplet pregnancy complicated by the coexistence of a complete hydatidiform mole and twin live fetuses. The pregnancy resulted in a preterm delivery at 30 weeks and 5 days of gestation, with both live fetuses surviving to date. During the pregnancy, the patient was diagnosed with pre-eclampsia and intrahepatic cholestasis. Post-delivery, she was found to have an invasive mole with lung metastases, which was ultimately successfully treated., Conclusion: This report highlights critical considerations for managing a multiple pregnancy complicated by a complete hydatidiform mole, alongside the associated potential complications. In light of the limited literature on the clinical management of this condition, our findings offer valuable insights into navigating the risks and optimizing patient outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Li et al.)

Background: Townes-Brocks syndrome (TBS) is a rare genetic disorder characterized by imperforate anus, dysplastic ears, thumb malformations, and other abnormalities. Previous studies have revealed that mutations in the SALL1 gene can disrupt normal development, resulting in the characteristic features of Townes-Brocks syndrome. Spalt-like transcription factors (SALLs) are highly conserved proteins that play important roles in various cellular processes, including embryonic development, cell differentiation, and cell survival. Over 400 different variants or mutations have been reported in the SALL1 gene in individuals with TBS. Most of these variants lead to the formation of premature termination codons (PTCs), also known as nonsense mutations. The majority of these PTCs occur in a specific region of the SALL1 gene called the "hotspot region", which is particularly susceptible to mutation., Methods: In this study, we conducted whole-exome sequencing on a three-generation Chinese family with anorectal malformations., Results: We identified a novel heterozygous mutation (chr16:51175376:c.757 C > T p.Gln253*) in the SALL1 gene. Molecular analysis revealed a heterozygous C to T transition at nucleotide position 757 in exon 2 of the SALL1 (NM_002968) gene. This mutation is predicted to result in the substitution of the Gln253 codon with a premature stop codon (p.Gln253*). The glutamine-rich domain forms a long alpha helix, enabling the mutant protein to interact with the wild-type SALL1 protein. This interaction may result in steric hindrance effects on the wild-type SALL1 protein., Conclusions: Our findings have expanded the mutation database of the SALL1 gene, which is significant for genetic counseling and clinical surveillance in the affected family. Furthermore, our study enhances the understanding of Townes-Brocks syndrome and has the potential to improve its diagnosis and treatment., (© 2024. The Author(s).)

Background: The worldwide occurrence of triplet pregnancy is estimated to be 0.093%, with a natural incidence of approximately 1 in 8000. This study aims to analyze the neonatal health status and birth weight discordance (BWD) of triplets based on chorionicity from birth until discharge., Methods: This was a retrospective study. We reviewed a total of 136 triplet pregnancies at our tertiary hospital between January 1, 2001, and December 31, 2021. Maternal and neonatal outcomes, inter-triplet BWD, neonatal morbidity, and mortality were analyzed., Results: Among all cases, the rates of intrauterine death, neonatal death, and perinatal death were 10.29, 13.07, and 24.26%, respectively. Thirty-seven of the cases resulted in fetal loss, including 13 with fetal anomalies. The maternal complications and neonatal outcomes of the 99 triplet pregnancies without fetal loss were compared across different chorionicities, including a dichorionic (DC) group (41 cases), trichorionic (TC) group (37 cases), and monochorionic (MC) group (21 cases). Neonatal hypoproteinemia (P < 0.001), hyperbilirubinemia (P < 0.019), and anemia (P < 0.003) exhibited significant differences according to chorionicity, as did the distribution of BWD (P < 0.001). More than half of the cases in the DC and TC groups had a BWD < 15%, while those in the MC group had a BWD < 50% (47.6%). TC pregnancy decreased the risk of neonatal anemia (adjusted odds ratio [AOR] = 0.084) and need for blood transfusion therapy after birth (AOR = 0.119). In contrast, a BWD > 25% increased the risk of neonatal anemia (AOR = 10.135) and need for blood transfusion after birth (AOR = 7.127). TC pregnancy, MCDA or MCTA, and BWD > 25% increased neonatal hypoproteinemia, with AORs of 4.629, 5.123, and 5.343, respectively., Conclusions: The BWD differed significantly according to chorionicity. Additionally, TC pregnancies reduced the risk of neonatal anemia and need for blood transfusion, but increased the risk of neonatal hypoproteinemia. In contrast, the BWD between the largest and smallest triplets increased the risk of neonatal anemia and the need for blood transfusion. TC pregnancy, MCDA or MCTA, and BWD > 25% increased the risks of neonatal hypoproteinemia. However, due to the limited number of triplet pregnancies, further exploration of the underlying mechanism is warranted., (© 2024. The Author(s).)

Introduction : The goal of this study was to evaluate the effect of chorionicity on maternal, fetal and neonatal morbidity and mortality in triplet pregnancies in our environment. Methods : A retrospective observational study was carried out on triplet pregnancies that were delivered in a tertiary center between 2006 and 2020. A total of 76 pregnant women, 228 fetuses and 226 live newborns were analyzed. Of these triplet pregnancies, half were non-trichorionic. We analyzed maternal characteristics and obstetric, fetal, perinatal and neonatal complications based on their chorionicity, comparing trichorionic vs. non-trichorionic triplet pregnancies. Prematurity was defined as <34 weeks. We measured perinatal and neonatal mortality, composite neonatal morbidity and composite maternal morbidity. Results : Newborns with a monochorionic component had a lower gestational age at birth, presented greater prematurity under 34 weeks, lower birth weight, greater probability of birth weight under 2000 g and an APGAR score below 7 at 5 min after birth, more respiratory distress syndrome and, overall, higher composite neonatal morbidity. The monochorionic component of triple pregnancies may entail the development of complications intrinsic to shared circulation and require premature elective termination. This greater prematurity is also associated with a lower birth weight and to the main neonatal complications observed. These findings are in line with those that were previously published in the meta-analysis by our research group and previous literature. Discussion : Triplet gestations with a monochorionic component present a higher risk of obstetric, fetal and neonatal morbidity and mortality.

Background: It is generally beneficial and recommended that dichorionic triamniotic (DCTA) triplet pregnancies be reduced to monochorionic (MC) twin or singleton pregnancies after assisted reproductive technology (ART). However, some infertile couples still have a firm desire to retain twins. For this reason, the best foetal reduction strategies need to be available for infertile couples and clinicians. Given that data on the elective reduction of DCTA triplet pregnancies to twin pregnancies are scarce, we investigated the outcomes of elective reduction of DCTA triplet pregnancies through the retrospective analysis of previous data., Method: Patients with DCTA triplet pregnancies who underwent elective foetal reduction between January 2012 and June 2020 were recruited. A total of 67 eligible patients with DCTA triplet pregnancies were divided into two groups: a DCTA-to-dichorionic diamniotic (DCDA) twin group (n = 38) and a DCTA-to-monochorionic diamniotic (MCDA) twin group (n = 29); the basic clinical data of the two groups were collected for comparison., Results: Compared with the DCDA-to-MCDA twin group, the DCTA-to-DCDA twin group had lower rates of complete miscarriage (7.89% versus 31.03%, p = 0.014), early complete miscarriage (5.26% versus 24.14%, p = 0.034), late preterm birth (25.71% versus 65.00%, p = 0.009) and very low birth weight (0 versus 11.11%, p = 0.025). In addition, the DCTA-to-DCDA twin group had higher rates of full-term delivery (65.71% versus 25.00%, p = 0.005), survival (92.11% versus 68.97%, p = 0.023), and taking the babies home (92.11% versus 68.97%, p = 0.023) than did the DCTA-to-MCDA twin group. In terms of neonatal outcomes, a significantly greater gestational age (38.06 ± 2.39 versus 36.28 ± 2.30, p = 0.009), average birth weight (3020.77 ± 497.33 versus 2401.39 ± 570.48, p < 0.001), weight of twins (2746.47 ± 339.64 versus 2251.56 ± 391.26, p < 0.001), weight of the larger neonate (2832.94 ± 320.58 versus 2376.25 ± 349.95, p < 0.001) and weight of the smaller neonate (2660.00 ± 345.34 versus 2126.88 ± 400.93, p < 0.001) was observed in the DCTA-to-DCDA twin group compared to the DCTA-to-MCDA twin group., Conclusion: The DCTA-to-DCDA twin group had better pregnancy and neonatal outcomes than the DCTA-to-MCDA twin group. This reduction approach may be beneficial for patients with dichorionic triamniotic triplet pregnancies who have a strong desire to have DCDA twins., (© 2024. The Author(s).)

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., (© The Author(s) 2024. Published by Oxford University Press on behalf of European Society of Human Reproduction and Embryology.)

There are limited U.S. reports of spontaneous triplet heterotopic pregnancies discussing both maternal and fetal outcomes. A 34-year-old patient at 7 weeks of gestation presented to the emergency department with abdominal pain. She was diagnosed with a spontaneous heterotopic triplet pregnancy, consisting of a twin monochorionic-diamniotic intrauterine gestation and a ruptured left ectopic pregnancy. She underwent a laparoscopic unilateral salpingectomy. Her antepartum course was complicated by gestational diabetes mellitus and fetal growth restriction. Delivery of liveborn twins was via a cesarean delivery at 32 weeks. Timely intervention and management of a ruptured spontaneous triplet heterotopic pregnancy can result in a viable twin delivery with overall favorable maternal and newborn outcomes, although long-term implications due to prematurity and other twin sequelae exist., Competing Interests: Conflict of Interest None declared., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. ( https://creativecommons.org/licenses/by-nc-nd/4.0/ ).)

Background: Triplet pregnancies carry a high risk of pregnancy-related complications. The primary aim of this study was to describe maternal, pregnancy, and neonatal outcomes in expectantly managed triplet pregnancies in Sweden. The secondary aim was to compare outcomes in expectantly managed triplet pregnancies with triplet pregnancies where fetal reduction had been performed with the only indication to reduce the number of fetuses., Methods: Nationwide cohort study based on linkage of data from three national Swedish registers. Triplet pregnancies with delivery at gestational age ≥ 22 +0 weeks between 2014 and 2019 were included., Results: In the main cohort of expectantly managed triplet pregnancies ( n = 106), 98% (312/318) of infants were liveborn with a mean gestational age at birth of 32 +3 weeks and a mean birthweight of 1,726 g. Nine percent ( n = 29) suffered from severe neonatal morbidity, and 4% ( n = 12) died during the neonatal period. In the reduced cohort ( n = 13 pregnancies), all infants were liveborn ( n = 22). Mean gestational age at birth (36 +0 weeks) and mean birthweight (2,444 g) were higher than in the expectantly managed cohort ( P < 0.01 for both comparisons). There were no cases of severe neonatal morbidity ( P = 0.24) or mortality ( P = 1.00)., Conclusion: Overall neonatal survival from 22 +0 weeks of gestation in expectantly managed triplet pregnancies in Sweden was high. Nine out of 10 infants did not suffer from severe neonatal morbidity. Fetal reduction was performed in only a very small number of cases and was associated with higher gestational age at birth and higher birth weight., Competing Interests: The authors report no conflict of interest., (© 2023 The Author(s). Published by Upsala Medical Society.)

Background: Higher-order multiple (HOM) pregnancies are associated with significant maternal and neonatal morbidity, especially consequent to preterm birth. Multi-fetal pregnancy reduction (MFPR) may be provided, though its benefits in prolonging gestation and improving neonatal outcomes must be weighed against its risks., Aims: The aim was to compare outcomes of HOM pregnancies where expectant management was chosen (EM) with those where MFPR was provided., Methods: The method involved a retrospective study of HOM pregnancies referred to a single quaternary hospital between 2007 and 2016. The primary outcome was gestational age. Secondary outcomes included miscarriage, nursery admission, hospital stay, Apgar scores, early fetal loss, stillbirth, neonatal death and composite fetal loss., Results: Fifty-seven pregnancies were eligible for inclusion. Median gestation at birth (weeks) was significantly higher for MFPR (35.3 vs 33.1, P < 0.01). Pregnancies after MFPR were less likely to lead to preterm birth (63.2 vs 100.0%, P < 0.001), half as likely to birth before 34 weeks (31.6 vs 60.0%, P = 0.09) but similarly likely to extremely preterm birth (<28 weeks, 8.6 vs 10.5%, P = 0.58). Miscarriage was more likely after MFPR (13.6 vs 0%, P = 0.05). EM neonates were more likely to be admitted to the nursery (P < 0.01) and have longer hospital stay (29.6 vs 20.2 days, P = 0.05); however, they had similar Apgar scores., Conclusion: Our study demonstrates that MFPR is associated with an increase in gestational age, with a reduction by almost half of births before 34 weeks, but no difference in extremely preterm births; the latter represents the highest risk group. This should be used to guide management counselling for HOM pregnancies., (© 2022 Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Objective: To compare the pregnancy outcomes of pregnancy outcomes after selective fetal reduction treatment in monochorionic, dichorionic, and trichorionic triplet pregnancies., Methods: We conducted a retrospective analysis of the clinical data of 118 pregnant women carrying triplets. All subjects underwent regular prenatal check-ups and were admitted for delivery at West China Second University Hospital, Sichuan University between January 1, 2012 and January 31, 2021. According to the chorionicity, the subjects were divided into a monochorionic group ( n =13), a dichorionic group ( n =44), and a trichorionic group ( n =61). Within each group, the subjects were further divided into two subgroups, a reduction group and an expectant treatment group, according to whether they underwent fetal reduction or not. The clinical data and pregnancy outcomes were compared between the subgroups within each group., Results: In the monichorionic group, the reduction subgroup had a lower preterm birth rate and higher neonatal birth body mass than those of the expectant management subgroup, but the differences were not statistically significant. In the dichorionic and trichorionic groups, the rates of preterm delivery, neonatal hospitalization, and serious complications of the reduction subgroups were lower than those of the expectant subgroups ( P <0.05), while the neonatal birth body mass was higher in the reduction subgroups than that in the expectant subgroups ( P <0.05). In the dichorionic group, the incidence of intrahepatic cholestasis during pregnancy was lower in the reduction subgroup than that in the expectant treatment subgroup. In all 3 groups, there was no statistically significant difference between the subgroups in the incidence of gestational diabetes, hypertensive disorders of pregnancy, premature rupture of membranes, and postpartum hemorrhage. The survival curve analysis showed that women receiving fetal reduction during the first trimester had a lower risk of pregnancy loss and more significant prolonged of gestational age than those undergoing the procedure during the second trimester., Conclusion: Fetal reduction of triplets can significantly prolong the gestational age and improve the perinatal prognosis. In addition, selective reduction in the first trimester may lead to greater benefits than selective reduction in the second trimester does., (Copyright© by Editorial Board of Journal of Sichuan University (Medical Sciences).)

We report an extremely challenging case of fetal goitrous hypothyroidism involving all three fetuses of a triplet pregnancy in which successful fetal treatment led to a favorable pregnancy outcome. The patient had a trichorionic, triamniotic triplet pregnancy and was referred to us at 24 weeks gestation after goiters affecting all three fetuses and polyhydramnios involving two fetuses were noted. Immediately before the conception, she underwent hysterosalpingography with an oil-soluble iodinated contrast medium. After the diagnosis of fetal hypothyroidism was made, intra-amniotic injection of levothyroxine was performed for two fetuses with polyhydramnios 3 times between 28 and 31 weeks gestation. The goiters shrunk and the polyhydramnios improved in response to the in utero treatment. No complications occurred. Cesarean section was performed at 33 weeks gestation. None of the three neonates developed respiratory insufficiency. Our experience suggested that successful intrauterine treatment is possible for fetal goitrous hypothyroidism, even in a triplet pregnancy. The indication, treatment timing, and diagnostic and assessment strategies should be carefully discussed to minimize puncture-related complications., (© 2022 Japan Society of Obstetrics and Gynecology.)

Background: The number of triplet pregnancies in the United States has increased significantly. Perinatal morbidity and mortality are higher in these pregnancies mainly due to higher preterm birth rates. Interventions to decrease the risk of preterm delivery in this population are needed. Evidence regarding cerclage placement in triplets is limited. We performed a population-based, retrospective cohort study to study the risk of preterm birth and neonatal outcomes after cerclage placement in triplet pregnancies., Methods: All U.S. triplet deliveries from 2006 to 2013 with risk factors for cervical insufficiency were selected, excluding cases with indicated preterm delivery. Cases were categorized according to cerclage placement status. The risk of preterm birth and adverse neonatal outcomes were calculated using propensity score analysis, generalized linear, and logistic regression models., Results: From ∼33 million deliveries, 43,000 were triplets, and 7308 fulfilled eligibility criteria. There was no difference in the gestational age at delivery between the cerclage and noncerclage groups, aOR (95% CI) = 1.0(0.9-1.0). The difference between the risk of preterm delivery at <34 weeks and <32 weeks was not statistically significant. The risk of the composite outcome of neonatal complications was higher in the cerclage compared to the noncerclage group, aOR (95% CI) = 1.5 (1.1-2.2)., Conclusions: Cerclage placement in triplet pregnancies does not appear to decrease preterm birth rates and seems to increase the risk of neonatal complications.

Conjoined twins represent a rare type of monoamniotic twins. Ultrasound assessment during the first trimester can facilitate the diagnosis, however further assessment by colour Doppler studies, 3D imaging, fetal echocardiography and fetal magnetic resonance imaging (MRI) is usually required in order to determine the specific fetal abnormalities and to guide appropriate pregnancy management. This case report presents a rare case of conjoined twins complicating a dichorionic-diamniotic triplet pregnancy, achieved after intracytoplasmic sperm injection (ICSI) and blastocyst transfer. A 44-year-old woman was referred for chorionicity determination to our Fetal Medicine Centre due to suspicion of conjoined twins in a triplet pregnancy. Ultrasound assessment at 11 weeks demonstrated a dichorionic triplet pregnancy which was also complicated by a rare type of conjoined twins (thoracoomphalopagus) and after a successful embryo reduction a neonate of 2200 g was delivered by caesarean section at term. The accurate diagnosis and early detection of conjoined twins by a fetal medicine specialist is crucial, especially as far as multiple pregnancies with three or more fetuses are concerned.

Objective: This systematic review and meta-analysis aimed to compare the fetal survival rate and perinatal outcomes of triplet pregnancies after selective reduction to twin pregnancies vs singleton pregnancies., Data Sources: PubMed, Web of Science, Scopus, and Embase were systematically searched from the inception of the databases to January 16, 2022., Study Eligibility Criteria: Studies comparing the survival and perinatal outcomes between reduction to twin pregnancies and reduction to singleton pregnancies were included. The primary outcomes were fetal survival, defined as a live birth at >24 weeks of gestation. The secondary outcomes were gestational age at birth, preterm birth at <32 and <34 weeks of gestation, early pregnancy loss (<24 weeks of gestation), low birthweight, and rate of neonatal demise (up to 28 days after birth)., Methods: The random-effect model was used to pool the mean differences or odds ratios and the corresponding 95% confidence intervals. To provide a range of expected effects if a new study was conducted, 95% prediction intervals were calculated for outcomes presented in >3 studies., Results: Of note, 10 studies with 2543 triplet pregnancies undergoing fetal reduction, of which 2035 reduced to twin pregnancies and 508 reduced to singleton pregnancies, met the inclusion criteria. Reduction to twin pregnancies had a lower rate of fetal survival (odds ratio, 0.61; 95% confidence interval, 0.40-0.92; P=.02; 95% prediction interval, 0.36-1.03) and comparable rates of early pregnancy loss (odds ratio, 0.89; 95% confidence interval, 0.58-1.38; P=.61; 95% prediction interval, 0.54-1.48) and neonatal demise (odds ratio, 0.57; 95% confidence interval, 0.09-3.50; P=.55) than reduction to singleton pregnancies. Reduction to twin pregnancies had a significantly lower gestation age at birth (weeks) (mean difference, -2.20; 95% confidence interval, -2.80 to -1.61; P<.001; 95% prediction interval, -4.27 to -0.14) than reduction to singleton pregnancies. Furthermore, reduction to twin pregnancies was associated with lower birthweight and greater risk of preterm birth at <32 and <34 weeks of gestation., Conclusion: Triplet pregnancies reduced to twin pregnancies had a lower fetal survival rate of all remaining fetuses, lower gestational age at birth, higher risk of preterm birth, and lower birthweight than triplet pregnancies reduced to singleton pregnancies; reduction to twin pregnancies vs reduction to singleton pregnancies showed no substantial difference for the rates of early pregnancy loss and neonatal death., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objectives: To develop gestational age-based reference ranges for cervical length in triplet pregnancies. The secondary objective was to assess the performance of cervical length measured between 18 and 20 + 6 days for the prediction of preterm delivery before 28 and 32 weeks, respectively., Methods: Observational retrospective study of triplet pregnancies in three Spanish tertiary-care hospitals between 2001 and 2019. Cervical length measurements were consecutively obtained between 15 and 34 weeks of gestation. Pregnancies undergoing multifetal reduction or fetal surgery were excluded., Results: Two hundred and six triplet pregnancies were included in the final analysis. There was a quadratic decrease in cervical length with gestational age. The median and fifth centiles for cervical length at 20 weeks were 35 and 13 mm. In the prediction of preterm birth < 28 weeks, for a false positive rate of 5%, and 10%, the detection rates were 40.9%, and 40.9%, respectively, and the prediction of preterm birth < 32 weeks, 22.0% and 26.0%, respectively., Conclusions: In triplet pregnancies, cervical length decreases with gestational age. The performance of cervical length at 18-20 + 6 in screening for preterm birth before 28 and 32 weeks is poor., (© 2022. The Author(s).)

Aim: We present two cases of triplet pregnancy with complete hydatidiform mole (CHM) in contrasting outcomes and discuss the complications of mothers and outcomes of fetuses through a literature review, raising an important issue on the management of this special pregnancy., Methods: We share our manage experience for two cases of triplet pregnancy with CHM and retrospectively analyze 18 similar pregnancies reported previously with different pregnancy outcomes., Results: In our cases, one case receiving Clomiphene ovulation induction delivered two live fetuses by cesarean section at 30+ weeks without GTN (gestational trophoblastic neoplasia), unfortunately, the other case following ICSI-ET terminated the pregnancy in the setting of complications at 18+ weeks without GTN. No severe complications were detected during pregnancy and no pGTD was developed after delivery in neither of the pregnant., Conclusions: Co-existing complete hydatidiform mole in multiple pregnancies may become more common owing to the spreading use of ART. The decision for whether continue pregnancy depending on the personalized conditions including the complications of the pregnancy, the outcomes of the fetuses, the gestational age for delivery, and the potential progression of persistent gestational trophoblastic disease (pGTD). Furthermore, close monitor is necessary for the pregnant with triplet pregnancy with CHM who want to continue pregnancy., (© 2022 Japan Society of Obstetrics and Gynecology.)

Introduction: This report presents a rare case of spontaneous twin anemia-polycythemia sequence (TAPS) between two dichorionic fetuses in a spontaneous, homozygotic, dichorionic, triamniotic, triplet pregnancy treated with multiple intrauterine blood transfusions (IUTs) and partial exchange transfusions (PETs)., Case Presentation: The pregnancy was diagnosed with stage IV TAPS at gestational week 25+1. The patient was treated with laser surgery combined with multiple IUTs and PETs. The triplets were delivered at a planned caesarean section at gestational week 28+1 with postnatal hemoglobin values of 18.21, 26.43, and 11.92 g/dL in triplet 1, 2, and 3, respectively. At 4 years of age, triplet 1 is considered healthy, triplet 2 is diagnosed with mild mental retardation, and triplet 3 with profound mental retardation and dystonic cerebral palsy., Discussion: This is an extremely rare case of TAPS between dichorionic fetuses in a triplet pregnancy, and routine surveillance with measurement of middle cerebral artery peak systolic velocity in dichorionic pregnancies may contribute to the detection of similar cases in the future. Furthermore, this case contributes with rare long-term follow-up data of children treated for high-stage TAPS with multiple IUTs and PETs., (© 2022 S. Karger AG, Basel.)

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., (© 2021 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Monochorionic triamniotic (MCTA) pregnancies present a high number of complications, mainly due to the presence of unbalanced vascular anastomoses, such as twin anemia-polycythemia sequence (TAPS). Previous reported cases related to TAPS are in twin pregnancies or only affect the monochorionic component of dichorionic triamniotic (DCTA) pregnancies. We report an exceptional case, the only one reported as far as we know, of a MCTA pregnancy that developed a TAPS in which the three triplets are implicated, from two donors to one recipient. The pregnancy had been previously sonographically diagnosed as DCTA pregnancy and this could not explain the clinical results. The pathological study of the placenta showed the presence of three monochorionic dividing membranes, a congested area in the recipient parenchyma and two non-congested areas in the donor's parenchyma that confirmed the clinical findings. Pathological study of multiple placentas should always be done because it provides understanding of pregnancy complications., (© 2021 Japan Society of Obstetrics and Gynecology.)

A 40-year-old primigravida woman with a monochorionic-triamniotic (MT) triplet pregnancy was hospitalized due to threatened abortion at 16 gestational weeks. Polyhydramnios in two fetuses and oligohydramnios in the third supported a diagnosis of feto-fetal transfusion syndrome (FFTS) at 23 weeks and 3 days of gestation. Severe dyspnea and liver dysfunction required intensive care unit admission and mechanical ventilation support, and abdominal compartment syndrome (ACS) caused by polyhydramnios was clinically diagnosed. When her general condition was not improved regardless of intensive care, the patient delivered the three fetuses by cesarean section at 23 weeks and 5 days gestation. Abdominal decompression was achieved with delivery, and the patient was discharged 13 days after operation without morbidity. This is the first case report of ACS caused by FFTS in a MT triplet pregnancy resulting in extremely preterm birth., (© 2021 Japan Society of Obstetrics and Gynecology.)

Background: Coronavirus disease 2019 (COVID-19), the global pandemic that has spread throughout the world, is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Given the limited scientific evidence on the manifestations and potential impact of this virus on pregnancy, we decided to report this case., Case Presentation: The patient was a 38 year-old Iranian woman with a triplet pregnancy and a history of primary infertility, as well as hypothyroidism and gestational diabetes. She was hospitalized at 29 weeks and 2 days gestational age due to elevated liver enzymes, and finally, based on a probable diagnosis of gestational cholestasis, she was treated with ursodeoxycholic acid. On the first day of hospitalization, sonography was performed, which showed that biophysical scores and amniotic fluid were normal in all three fetuses, with normal Doppler findings in two fetuses and increased umbilical artery resistance (pulsatility index [PI] > 95%) in one fetus. On day 4 of hospitalization, she developed fever, cough and myalgia, and her COVID-19 test was positive. Despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses leading to the rapid development of absent umbilical artery end-diastolic flow. Finally, 6 days later, the patient underwent cesarean section due to rapid exacerbation of placental insufficiency and declining biophysical score in two of the fetuses. Nasopharyngeal swab COVID-19 tests were negative for the first and third babies and positive for the second baby. The first and third babies died 3 and 13 days after birth, respectively, due to collapsed white lung and sepsis. The second baby was discharged in good general condition. The mother was discharged 3 days after cesarean section. She had no fever at the time of discharge and was also in good general condition., Conclusions: This was a complicated triplet pregnancy, in which, after maternal infection with COVID-19, despite mild maternal symptoms, exacerbated placental insufficiency occurred in two of the fetuses, and the third fetus had a positive COVID-19 test after birth. Therefore, in cases of pregnancy with COVID-19 infection, in addition to managing the mother, it seems that physicians would be wise to also give special attention to the possibility of acute placental insufficiency and subsequent fetal hypoxia, and also the probability of vertical transmission.

We report the unique case of a patient who recovered cardiac function despite a history of doxorubicin-induced cardiomyopathy, chest radiation therapy, high dose chemotherapy post-allogeneic stem cell transplant, and triplet pregnancy. Data are sparse on doxorubicin-induced cardiomyopathy in pregnant patients, calling for further studies to help formulate management or surveillance recommendations. ( Level of Difficulty: Advanced. )., (© 2020 The Authors.)

Research Question: Does fetal reduction of triplet pregnancies to singleton result in superior obstetric and neonatal outcomes compared with triplets reduced to twins?, Design: A historical cohort study including 285 trichorionic and dichorionic triplet pregnancies that underwent abdominal fetal reduction at 11-14 weeks in a single tertiary referral centre. The study population comprised two groups: reduction to twins (n = 223) and singletons (n = 62). Main outcome measures were rates of pregnancy complications, preterm delivery and neonatal outcomes. Non-parametric statistical methods were employed., Results: Triplet pregnancies reduced to twins delivered earlier (36 versus 39 weeks, P < 0.001) with higher prevalence of Caesarean section (71.1% versus 32.2%, P < 0.001) compared with triplets reduced to singletons. Preterm delivery rates were significantly higher in twins compared with singletons prior to 37 weeks (56.9% versus 13.6%, P < 0.001), 34 weeks (20.2% versus 3.4%, P = 0.002) and 32 weeks (9.6% versus 0%, P = 0.01). No significant difference was found in the rate of pregnancy loss before 24 weeks (1.3% in twins versus 4.8% in singletons, P = 0.12) or in the rate of intrauterine fetal death after 24 weeks (0.4% versus 0%, P = 1.0). Both groups had comparable obstetrical complications and neonatal outcomes, except for higher rates of neonatal intensive care unit admission in twins (31.9% versus 6.8%, P < 0.001)., Conclusions: Reduction of triplets to singletons rather than twins resulted in superior obstetric outcomes without increasing the procedure-related complications. However, because the rate of extreme prematurity in pregnancies reduced to twins was low, the overall outcome of those pregnancies was favourable. Therefore, the option of reduction to singletons should be considered in cases where the risk of prematurity seems exceptionally high., (Copyright © 2019 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.)

In September 2019, NICE published updated guidance on the management of multiple pregnancy (NG 137). Many of the previous recommendations for care are upheld but there have been important changes: increased frequency of combined ultrasound/specialist antenatal care appointments for pregnancies containing a monochorionic placenta (twins and triplets), increased frequency of ultrasound monitoring in all triplet pregnancies, changes in the definition of selective growth restriction and its subsequent referral pathways, the introduction of some monitoring for twin (or triplet) anemia polycythemia sequence in monochorionic pregnancies (albeit in complex pregnancies or at an advanced stage), and a recommended timing of birth for any pregnancy with monoamniotic fetuses. New recommendations have been made for mode of delivery, fetal monitoring in labor, maternal analgesia, and the prevention of postpartum hemorrhage. The absence of any recommendation relating to the prevention of preterm birth is notable. The basis and implications of the updates that may improve perinatal outcomes are discussed., (© 2019 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: In women with a triplet pregnancy, there is debate on the preferred mode of delivery. We performed a nationwide cohort study to assess the impact of mode of delivery on perinatal outcome in women with a triplet pregnancy. Methods: Nationwide cohort study on women with a triplet pregnancy who delivered between 26 + 0 and 40 + 0 weeks of gestation in the years 1999-2008. We compared perinatal outcomes according to the intended mode of delivery and the actual mode of delivery. Outcome measures were perinatal mortality and neonatal morbidity. Perinatal outcomes were analyzed taking into account the dependency between the children of the same triplet pregnancy ("any mortality" and "any morbidity") and were also analyzed separately per child. Results: We identified 386 women with a triplet pregnancy in the study period. Mean gestational age at delivery was 33.1 weeks (SD 2.5 weeks; range 26.0-40.0 weeks). Perinatal mortality was 2.3% for women with a planned caesarean section and 2.4% in women with a planned vaginal delivery (aOR 0.37; 95% confidence interval (CI) 0.09-1.5) and neonatal morbidity was 26.0% versus 36.0%, (aOR 0.88; 95% CI 0.51-1.4) respectively. In the subgroup analyses according to gestational age and in the analysis of perinatal outcomes per child separately, there were also no large differences in perinatal outcomes. The same applied for perinatal outcomes according to the actual mode of delivery. Conclusion: In this large cohort study among women with a triplet pregnancy, caesarean delivery is not associated with reduced perinatal mortality and morbidity.

Background: Spontaneous multiple pregnancies are rare, and the incidence of spontaneous triplet pregnancy is about 1/4000. TRAP (Twin Reversed Arterial Perfusion) sequence has acardiac foetus with non-viable multiple anomalies, and there is a pump foetus which feeds this foetus with placental anastomoses. TRAP sequence phenomena is quite rare in triplet pregnancies., Case Presentation: The patient who applied to our clinic was 30 years old. Monochorionic diamniotic triplet pregnancy was detected by ultrasonographic examination. First amniotic sac had one foetus (Foetus A). Ultrasonographic evaluation of Foetus A revealed gestational age of 31 weeks, adequate amniotic fluid and no fetal structural anomalies. The second amniotic sac contained 2 foetuses and polyhydromnios. Ultrasonic measurements of Foetus B were consistent with 32 weeks gestational age. Color flow doppler indicated Foetus B was the pump foetus. Foetus C was an acardiac foetus with no sonographic visualization of cranium, thoracic organs or extremities, but abdominal circumference consistent with 28 weeks. Pregnancy was followed conservatively and evaluated regularly by ultrasonography twice a week. When prolonged bradycardia was detected in fetus B at 35 4/7 weeks, emergency cesarean section was performed. Two healthy fetuses weighing 2 kg were delivered each with an 8/10 APGAR score (Appearance, Pulse, Eye Insertion, Activity, Respiration)., Conclusion: This case was managed without any invasive procedures and demonstrates that treatment of TRAP sequence cases can be individualized considering clinical conditions, the size of the acardia twin and extent of placental venous anastomoses.

Purpose: To review our experience in ultrasound fetal weight estimation in our large population of triplet pregnancies., Methods: Ninety-seven triplet pregnancies were retrospectively included between January 2003 and January 2017. Sonographic fetal weight estimation using Hadlock's and Schild's formulas was compared to actual birth weight in a tertiary-care center in Vienna, Austria. Statistical analyses were performed using a stepwise linear regression model and crosstabs., Results: The median discrepancy between the sonographically estimated fetal weight by Hadlock's formula and the actual birth weight was 106 g (IQR 56-190). The percentage error and its standard deviation were - 2.5 ± 12.1%, and the median percentage error was - 3.6%. Concerning the use of Hadlock's formula, estimated fetal weight was the most important factor predictive of actual birth weight with an estimate of 0.920 (p < 0.001). Female neonates had been overestimated by a mean of 50.473 g per fetus. The sonographic prediction of small-for-gestational-age neonates was significantly reliable (p < 0.001), with positive and negative predictive values ranging from 81.3 to 100.0%. Similar results were obtained for Schild's formula., Conclusion: Even if sonographically estimated fetal weight in triplet pregnancies has a high overall accuracy of fetal weight estimation, there are some limitations in prediction of intrauterine growth restrictions, especially in female fetuses.

Objective: To report the outcome of dichorionic (DC) triplet pregnancies reduced to DC twins by laser ablation of the pelvic vessels of one of the monochorionic (MC) twins., Methods: Intrafetal laser embryo reduction (ER) from DC triplets to DC twins was carried out in 61 pregnancies at 11 + 0 to 14 + 3 weeks' gestation. Pregnancy outcome was examined., Results: Intrafetal laser was successfully carried out in all cases, but ultrasound examination within 2 weeks of the procedure demonstrated that the MC cotwin had died in 28 (45.9%) cases and was alive in the other 33 (54.1%). In the DC group, there was one miscarriage at 23 weeks, one neonatal death after delivery at 26 weeks and in the other 31 cases there were two live births at a median gestational age of 35.3 (range, 30.4-38.4) weeks. In the 28 cases in which both MC fetuses died, there was one miscarriage at 16 weeks and in the other 27 cases the separate triplet was liveborn at a median gestation of 38.2 (range, 32.2-42.1) weeks. The overall rate of miscarriage was 3.3% (2/61) and that of preterm birth (PTB) at < 33 weeks was 6.8% (4/59)., Conclusions: In the management of DC triplet pregnancies, ER to DC twins by intrafetal laser ablation is associated with lower rates of miscarriage or early PTB, compared with expectant management or ER by fetal intracardiac injection of potassium chloride. However, about half of the pregnancies result in the birth of one rather than two babies. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd., (Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.)

Objective: To identify appropriate weight gain in triplet gestations, which may aid in reducing the risk of perinatal morbidity within this high-risk cohort., Methods: This retrospective cohort study evaluated all non-anomalous triplet pregnancies between 23 and 40 weeks' gestation resulting in live births at five tertiary-care medical centers between 1991 and 2011. Subjects were divided by pre-pregnancy BMI into underweight, normal-weight, overweight, and obese groups, and then stratified by low (<0.5 lb/week), moderate (0.5-1.49 lbs/week), or excess weight gain (≥1.5 lbs/week). Primary outcomes included spontaneous preterm birth and preeclampsia., Results: We included 116 mothers and 348 corresponding neonates for final analysis. The incidence of preeclampsia and preterm delivery less than 32 weeks' gestation was 37% and 41%, respectively. The incidence of preeclampsia increased with weight gain per week, but was not statistically different from subjects who gained less weight. We found no statistical correlation between weight gain per week and preterm delivery., Conclusion: We found no association between preeclampsia or preterm delivery and increasing weight gain in triplet pregnancies. The association with increased risk for preeclampsia was predominantly due to BMI effect. Based on the current study, recommendations for optimal weight gain in mothers with triplet gestations could not be defined.

Purpose: To review our experience with a screening program that included sequential cervical length measurements in our large population of triplet pregnancies., Methods: Seventy-eight triplet pregnancies were retrospectively included. Cervical length measurements were performed by transvaginal ultrasound in 2-week intervals from week 16 + 0 onwards in a tertiary-care center in Vienna. The main outcome measurement was preterm delivery prior to 32 + 0 weeks of gestation. Statistical analyses were performed using paired and unpaired t tests and a stepwise linear regression model., Results: There were 26 cases of preterm delivery (33.3%). Women with preterm delivery revealed significant cervical length shortening from week 22 + 0 (median 33 mm, interquartile range, IQR 17-39) to 24 + 0 (median 21 mm, IQR 7-30; p = 0.005). This was not observed in women without preterm delivery. From week 22 + 0 onwards, both groups showed further significant 2-week differences in cervical length (p < 0.05). Univariate analysis of cervical length in weeks 20 + 0, 22 + 0, and 24 + 0 as well as cervical length dynamics from 22 + 0 to 24 + 0 predicted preterm delivery., Conclusions: In triplet pregnancies, a decrease in cervical length seems physiological from week 22 + 0 onwards. A sharp decrease in cervical length from the 22 + 0 to the 24 + 0 week as well as the smaller cervical length in weeks 20 + 0, 22 + 0, and 24 + 0 increase the risk of preterm delivery.

Background  Monochorionic-triamniotic pregnancies are rare and fraught with complications. Case  A case of monochorionic-triamniotic triplet pregnancy complicated by twin reversed arterial perfusion (TRAP) sequence is presented. The patient declined termination or selective fetal reduction. Triplet C was acardiac. At 24 weeks, triplet B developed polyhydramnios. At 30 weeks, polyhydramnios was seen in all three amniotic sacs, but without signs of fetal hydrops and with normal Doppler velocimetry measurements in the umbilical artery, middle cerebral artery, and ductus arteriosus of triplets A and B. At 32 2/7 weeks, the patient presented with preterm premature rupture of membranes and preterm labor. Two live male infants were delivered by cesarean delivery weighing 1,350 and 1,390 g, respectively; the acardiac fetus weighed 1,460 g. Pathology examination revealed a single placenta weighing1,250 g, with evidence of direct vascular connections between triplets A and C as well as between triplets A and B. Conclusion  Monochorionic-triamniotic triplet pregnancy with TRAP sequence is rare. Although the risk of complications is high, such pregnancies can be managed conservatively in select cases.

Purpose: To compare the perinatal outcome in multifetal pregnancies containing a monochorionic twin pair, managed either expectantly or by fetal reduction (MFPR)., Methods: This was a retrospective analysis of prospectively collected data on 47 triplet and 10 quadruplet pregnancies recruited between 10 and 14 weeks. Main outcome measures were miscarriage <24 weeks, preterm birth, fetal growth restriction, birth weight and survival rates., Results: For triplets the miscarriage rates <24 weeks were 6.3 % after reduction and 20.0 % for expectant management and MFPR, respectively. While we recorded no case of severe preterm delivery <30 weeks in the reduction group, it was 25 % in those with expectant management. Mean gestational age and birth weight were significantly higher after fetal reduction than for the conservative approach (37.7 ± 1.6 weeks vs. 30.9 ± 3.2 weeks, p < 0.01 and 2676 ± 705 g vs. 1429 ± 542 g, p < 0.01). Expectantly managed triplets were complicated by twin-twin transfusion syndrome in 18.8 % and intrauterine fetal death in 8.3 %. Survival rates were 85.4 % for those managed expectantly and 80.0 % after fetal reduction. Mean gestational age of ongoing quadruplets was 26.9 ± 2.0 weeks vs. 34.5 ± 4.3 weeks for those with reduction of the monochorionic pair (p < 0.05). Survival rates were 100 % in the reduction group and 58.3 % in the expectant management group (p < 0.05). There was an inverse correlation between the final number of fetuses and the birth weight., Conclusion: Fetal reduction in triplets and quadruplets including a monochorionic pair is associated with decreased early prematurity. While in quadruplets the overall survival is higher after reduction, there was no difference for dichorionic triplets with reduction or conservative management. Complications owing to monochorionicity are frequently observed.

Background: Preterm birth complicates almost all triplet pregnancies and no preventive strategy has proven effective., Objective: To determine, using individual patient data (IPD) meta-analysis, whether the outcome of triplet pregnancy is affected by prophylactic administration of 17-hydroxyprogesterone caproate (17OHPc)., Search Strategy: We searched literature databases, trial registries and references in published articles., Selection Criteria: Randomised controlled trials (RCTs) of progestogens versus control that included women with triplet pregnancies., Data Collection and Analysis: Investigators from identified RCTs collaborated on the protocol and contributed their IPD. The primary outcome was a composite measure of adverse perinatal outcome. The secondary outcome was the rate of birth before 32 weeks of gestation. Other pre-specified outcomes included randomisation-to-delivery interval and rates of birth at <24, <28 and <34 weeks of gestation., Main Results: Three RCTs of 17OHPc versus placebo included 232 mothers with triplet pregnancies and their 696 offspring. Risk-of-bias scores and between-study heterogeneity were low. Baseline characteristics were comparable between 17OHPc and placebo groups. The rate of the composite adverse perinatal outcome was similar among those treated with 17OHPc and those treated with placebo (34 and 35%, respectively; risk ratio [RR] 0.98, 95% confidence interval [95% CI] 0.79-1.2). The rate of birth at <32 weeks was also similar in the two groups (35 and 38%, respectively; RR 0.92, 95% CI 0.55-1.56). There were no significant between-group differences in perinatal mortality rate, randomisation-to-delivery interval, or other specified outcomes., Conclusion: Prophylactic 17OHPc given to mothers with triplet pregnancies had no significant impact on perinatal outcome or pregnancy duration., Tweetable Abstract: 17-Hydroxyprogesterone caproate had no significant impact on the outcome or duration of triplet pregnancy., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Objective: The objective of our study was to evaluate the prevalence of abnormal maternal echocardiographic findings in triplet pregnancies presenting with dyspnoea., Study Design: Between 2003 and 2013, patients' records of 96 triplet pregnancies at our department were analysed including maternal and fetal outcome, echocardiographic parameters and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels. After exclusion of triplet pregnancies with fetal demise before 23 + 0 weeks, selective feticide or missing outcome data, the study population consisted of 60 triplet pregnancies. All women with dyspnoea underwent echocardiography and measurement of NT-proBNP., Results: Dyspnoea towards the end of pregnancy was observed in 13.3% (8/60) of all women with triplet pregnancies, and all of these women underwent echocardiography. The prevalence of abnormal echocardiographic findings in women with dyspnoea was 37.5% (3/8) with peripartum cardiomyopathy in one woman. Median serum NT-proBNP was significantly higher in women with abnormal echocardiographic findings compared with those without (1779 ng/ml, range 1045-6076 ng/ml vs 172 ng/ml, range 50-311 ng/ml; p < 0.001 by Mann-Whitney-U Test)., Conclusion: We conclude that triplet pregnancies presenting with dyspnoea show a high prevalence of abnormal echocardiographic findings. Since dyspnoea is a common sign in triplet pregnancies and is associated with a high rate of cardiac involvement, echocardiography and evaluation of maternal NT-proBNP could be considered to improve early diagnosis and perinatal management.

This case is extraordinary because it was never before described in English literature. The case describes a long-standing debate about the safety of carrying this pregnancy to term. Some authors are for and some are against. The risks and benefits should be thoroughly reviewed before a decision is made.

The incidence of spontaneous triplet pregnancy is approximately 1 in 7000 deliveries. Due to the fact that every presentation of a triplet and higher order pregnancy is associated with high rate of morbidity and preterm delivery, chorionicity and amnionicity remain significant predictive factors which determine specific management throughout the pregnancy. Ultrasound chorionicity assessment in triplet pregnancies is more complex than in twins, and in many cases it remains unknown. We present a case report of a 24-year-old primipara in a spontaneous dichorionic triplet pregnancy, qualified for a cesarean section at 33 weeks of gestation, with subsequent placental examination with dye injections and post-delivery chorionicity assessment.

Background: Monozygotic monochorionic triplet pregnancy with conjoined twins is a very rare condition and is associated with many complications., Case: In this study, we describe a monochorionic-diamniotic triplet pregnancy after in vitro fertilization with an intracytoplasmic sperm injection. At a gestational age of 6 weeks and 4 days of pregnancy one gestational sac was observed, and at a gestational age of 12 weeks and 2 days, triplets with conjoined twins were diagnosed. After consulting with the parents, they chose fetal reduction of the conjoined twins. Selective feticide was successfully performed by radiofrequency ablation at 16 weeks of pregnancy. Unfortunately, the day after the procedure, the membrane ruptured, and 1 week later, all fetuses and placenta were spontaneously aborted., Conclusion: Monochorionic triplet pregnancy with conjoined twins is very rare. These pregnancies are associated with very serious complications. Intra cytoplasmic sperm injection increases the rate of monozygotic twinning and conjoined twins. Counseling with parents before IVF is very important.

Background: In trichorionic pregnancies, fetal reduction from three to two lowers the risk of severe preterm delivery, but provides no advantage in survival. Similar data for dichorionic triamniotic (DCTA) triplets is not readily available., Objectives: To document the natural history of DCTA triplets and the effect of reduction on the risk of miscarriage and severe preterm delivery, compared with expectant management., Search Strategy: Systematic search on MEDLINE, EMBASE, and the Cochrane Library., Selection Criteria: DCTA triplets with three live fetuses at 8-14 weeks of gestation, outcome data with expectant management and/or reduction, miscarriage before 24 weeks of gestation and/or severe preterm delivery before 32-33 weeks of gestation., Data Collection and Analysis: Five studies were included. Data from these were combined with data from three centres., Main Results: There were 331 DCTA triplets. The miscarriage rate was 8.9% (95% CI 5.8-13.3%) and the severe preterm delivery rate was 33.3% (95% CI 27.5-39.7%), with expectant management. The miscarriage rate was 14.5% (95% CI 7.6-26.2%) with a reduction of the monochorionic pair, 8.8% (95% CI 3.0-23.0%) with a reduction of one fetus of the monochorionic pair, and 23.5% (9.6-47.3%) with a reduction of the fetus with a separate placenta. Severe preterm delivery rates were 5.5% (95% CI 1.9-14-9%), 11.8% (95% CI 4.7-26.6%), and 17.6% (95% CI 6.2-41.0%), respectively., Conclusions: In DCTA triplets, expectant management is a reasonable choice when the top priority is a liveborn infant. Where the priority is to minimise severe preterm delivery, the most advisable option is fetal reduction. Further studies are needed to clarify which particular technique is advisable to optimise the outcome., (© 2015 Royal College of Obstetricians and Gynaecologists.)

Many triplets are conceived as a consequence of assisted reproductive technology (ART). Concerns have been raised that triplet pregnancies conceived by ART are more complicated than those conceived spontaneously. The purpose of this study was to evaluate all triplet pregnancies managed over a 12-year period to determine if there were any differences in outcome based on the mode of conception. All triplet pregnancies between 1999 and 2011 that reached at least 20 weeks' gestation and that were managed at the Royal Women's Hospital (RWH), Melbourne, Victoria were identified. Maternal and neonatal outcomes were compared between ART conceived and spontaneously conceived triplets. In the study period, 53 sets of triplets managed in our institution met the eligibility criteria. Twenty-five triplet sets were conceived by ART and 28 were conceived spontaneously. More ART conceptions resulted in trichorionic triamniotic (TCTA) triplets than did spontaneous conceptions (p = .015). There were no differences between ART and spontaneously conceived triplets for any of the maternal or neonatal complications studied. Trichorionic (TC) triplets delivered at a later gestation than other triplets: 32.1 (SD 2.9) versus 30.4 (SD 3.9) weeks (p = .08). TC triplets were significantly less likely to die than monochorionic (MC) or dichorionic (DC) triplets: 3/93 (3%) versus 13/66 (20%) (p = .025). In conclusion, triplets conceived by ART are more likely to have TCTA placentation and TCTA triplet sets had lower mortality rates than other triplet combinations. Outcomes for triplets conceived by ART were similar to those of triplets conceived spontaneously.

Introduction: In Brazil, as in all Latin America, access to infertility care, including assisted reproductive technology (ART) is on debate. This paper evaluates the availability and access of Brazilian couples to ART services., Methods: It is a qualitative study conducted about the Brazilian possibilities of ART in the public sector. A questionnaire was sent by e-mail to 14 public centers identified as providing ART (IVF/ICSI and/or IUI), with questions about their performance on 2013. The questionnaire was objective with seven questions. It was asked the number of patients seen for 1st time in 2013, and number IVF procedures and/or IUI in this interval, the source of funds to support the center, the input source of the patients, who pays for medications and how much (%), number of cycles or age limitations, whether or not oocyte donation is held., Results: There were 11 answers out of 14 and during 2013 in public centers were performed 1088 IUI cycles plus 4044 IVF/ICSI cycles. The waiting lists of patients can vary from 300 to 1500 and wait from 6 months to 4 years., Conclusions: As infertility goes, charges remain incompatible with the financial possibilities of the majority of Brazilian population. The Brazilian government should consider buying cycles in private accredited centers to offer ART procedures at no cost to low-income populations. Other possibility is to state as mandatory that Health Insurance Assistance Companies cover ART treatments, making it accessible for a large part of the population.

Dicephalic parapagus tribrachius conjoined twin is a very rare condition. We present a case of 5-days-old male dicephalic parapagus conjoined twins. The conjoined twins were diagnosed in 4(th) month of pregnancy by ultrasonography. The pregnancy terminates at 36 weeks by cesarean section and triplets were born. The babies were male conjoined twins and another healthy male baby. Many congenital defects of interest can now be detected before birth. Sever form of this malformation precludes postpartum life. It is supposed that with advances in screening methods for prenatal diagnosis these cases are terminated in first or second trimester of pregnancy.

Twin and triplet pregnancy is a high-risk situation, with increased risk of mortality and morbidity for both mother and babies. It is, therefore, essential that high-quality antenatal care is provided to optimise outcomes and identify and manage complications effectively. A number of additional elements of care are advised, which requires more monitoring and contact with healthcare professionals with appropriate expertise. In addition, women should be provided with accurate and relevant information and emotional support to mitigate against the anxiety and stress of these high-risk pregnancies. Early care focuses on determining chorionicity and screening for fetal complications, whereas later care concentrates on identifying and managing preterm birth, growth restriction, maternal complications, and planning for delivery. Unfortunately, the evidence base for managing these challenging pregnancies is often lacking, and a number of areas of further research is required., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Fetus papyracie in a triplet pregnancy is indeed rare and can pose serious management challenges. These challenges are more pronounced where facilities for monitoring are either inadequate or nonexistent. A 39-year-old, grand multipara multipara was referred to the University of Maiduguri Teaching Hospital at 27 weeks gestation with preterm contractions. Materno fetal monitoring did not reveal the cause of the preterm contractions. She was delivered via caesarean section, at 36 weeks of gestation, on account of decreased fetal movement and the products were a live female fetus weighing 2.3 kg and two male papyraceous fetuses weighing 150 g and 130 g, respectively.

Objectives: To evaluate the impact of advances in perinatal and neonatal care in the past three decades on the outcome of triplet pregnancies., Study Design: We compared the outcome of 29 sets of triplets born in our medical center during 1978-1987 with 34 sets of triplets born in the same medical center during 2001-2011. Data were extracted from maternal and neonatal medical records., Results: There were no significant differences in mortality or morbidity in any of the studied outcome measures between the two epochs. Of the 34 women with triplet pregnancies in the present cohort only 28 (82%) took all three born babies home, not different from the 86% found in the early cohort. The overall take-home baby rate was 93% (95/102) in the present cohort, not different than the 86% (74/86) in the early cohort., Conclusions: Despite technological advances in perinatal and neonatal care, there was no significant improvement in the outcome of triplet pregnancies during the past three decades., (Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.)

Objective: The purpose of this study was to evaluate the perinatal risk of death by chorionicity at >22 weeks of gestation of triplet pregnancies., Study Design: In a retrospective cohort study, the perinatal data were collected from triplet pregnancies in Japanese perinatal care centers between 1999 and 2009. We included maternal characteristics and examined the following factors: prenatal interventions, pregnancy outcome, and neonatal outcome. The association between fetal or neonatal death of triplets and chorionicity was evaluated by logistic regression analysis., Results: After the exclusion of 253 cases, the study group comprised 701 cases: 507 trichorionic triamniotic (TT) triplet pregnancies, 144 diamniotic triamniotic (DT) triplet pregnancies, and 50 monochorionic triamniotic (MT) triplet pregnancies. The mortality rate (fetal death at >22 weeks of gestation; neonatal death) in triplets was 2.6% and included 2.1% of TT triplet pregnancies, 3.2% of DT triplet pregnancies, and 5.3% of MT triplet pregnancies. No significant risk of death was identified in DT triplet pregnancies; however, MT triplet pregnancies had a 2.6-fold greater risk (adjusted odds ratio, 2.60; 95% confidence interval, 1.17-5.76; P = .019) compared with TT triplet pregnancies. Prophylactic cervical cerclage did not reduce the perinatal mortality rate at >22 weeks of gestation in triplets., Conclusion: The risk of death for MT triplet pregnancies is significantly higher than that of TT triplet pregnancies; however, the risk of death for DT triplet pregnancies is not., (Copyright © 2013 Mosby, Inc. All rights reserved.)

Objective: To evaluate changes in several triplet fetal growth parameters associated with gestational age by means of a longitudinal study designed to compare ethnic differences in fetal growth in Japanese and American populations., Subjects: Twenty-one Japanese triplet fetuses (7 triplet pregnancies) and 21 American triplet fetuses (7 triplet pregnancies). The Japanese pregnancies were in middle-class Japanese women living in the Kagawa area; the American pregnancies, in middle-class white women living in the Houston area., Methods: Head circumference, abdominal circumference, femur length, and estimated weight were measured every 2 to 3 weeks from 15 weeks of gestational age until delivery. Values for each parameter at each gestational age were measured in each fetal group, and the data of the groups were compared., Results: Head circumference, abdominal circumference, femur length, and estimated weight were significantly lower in the Japanese than in the American triplet fetuses after 20 weeks of gestation (p<0.01)., Conclusion: These results suggest that triplet fetal growth in Japanese populations and American populations differs significantly in the second half of pregnancy.