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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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Key Clinical Message 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. [ABSTRACT FROM AUTHOR]

Objective: To assess the diagnostic accuracy and show the prognostic influence of different ultrasonographic criteria in triplet pregnancies(TP). Design: Retrospective study. Setting: Tertiary care center in France. Population: Fifty-one consecutive TP in which at least one of the children, live- or stillborn, weighed 500 g or more, and with a gestation period of at least 22 weeks. Methods: Chorionicity, abnormal umbilical artery Doppler waveforms, intrauterine weight (IUW) <10th centile and prenatal diagnosis of fetal anomaly were studied simultaneously as prognostic criteria. Chorionicity was confirmed at birth by placental pathology. Main Outcome Measures: Diagnosis of chorionicity/amnionicity and IUW <10th centile. Neonatal intensive care unit admission, occurrence of respiratory distress syndrome and perinatal mortality. Results: Prenatal misclassification of chorionicity/amnionicity after postnatal perinatal pathology review was 12%. The positive predictive value of IUW <10th centile diagnosis was 44% for the prediction of birthweight <10th centile. Prenatal diagnosis of mono- or dichorionic placentation was associated with increased neonatal morbidity in comparison with that of trichorionic triplets. Perinatal mortality was significantly increased where mono- or dichorionic placentation was diagnosed prenatally (OR: 4.2; CI: 1.04-17), IUW <10th centile (OR: 10; CI: 2.4-41), with raised odds for abnormal umbilical Doppler measurements (OR: 9.7; CI: 2-47) and fetal anomaly (OR: 6.4; CI: 1.4-28.9). Conclusion: Early prenatal diagnosis of chorionicity is of major importance in triplet pregnancy. Experienced sonographers must quickly evaluate any uncertain diagnosis. In cases of unknown chorionicity, other ultrasonographic criteria can highlight high-risk triplet pregnancy, but at a later stage. [ABSTRACT FROM AUTHOR]

Hydatidiform mole with a coexistent fetus is rare, but this condition has recently shown an increased incidence because of assisted reproduction technology. Herein, we report on a case of triplet pregnancy with a partial hydatidiform mole coexisting with two fetuses. It was diagnosed by p57kip2 immunohistochemical staining which is helpful in determining histologically equivocal cases. After termination of pregnancy, the patient was diagnosed with persistent gestational trophoblastic disease. Six courses of methotrexate chemotherapy were performed. Her β-human chorionic gonadotrophin titers then fell to a normal level. [ABSTRACT FROM AUTHOR]

Objective To compare the placental volume at 11 + 0 to 13 + 6 weeks' gestation between singleton and multiple pregnancies and to examine the possible effect of chorionicity on placental volume. Methods The placental volume was measured by three-dimensional (3D) ultrasound using the Virtual Organ Computer-aided AnaLysis (VOCAL) technique in 290 consecutive twin and 3 7 triplet pregnancies at 11 + 0 to 13 + 6 weeks of gestation. For the comparison of twin, triplet and singleton placental volumes each measurement was expressed as a multiple of the median (MoM) for singletons, previously established from the study of 417 normal fetuses at 11 + 0 to 13 + 6 weeks of gestation. Results Median twin and triplet placental volumes were 1.66 and 2.28 MoM for singletons, respectively. In twins the placental volumes increased significantly with gestation from a median of 83.6 mL (5th and 95th centiles: 56.0mL and 124.9mL) at 11 + 0 weeks to 149.3 mL (5th and 95th centiles: 100.0 mL and 223.1 mL) at 13 + 6 weeks. The median MoM in monochorionic twins was not significantly different from that in dichorionic twins with fused placentas or dichorionic twins with separate placentas. In triplets the placental volumes increased significantly with gestation from a median of 114.9 mL (5th and 95th centiles: 77.6 mL and 170.1 mL) at 11 weeks to 217.9 mL (5th and 95th centiles: 147.2 mL and 322.5 mL) at 13 + 6 weeks. There were no significant differences in total placental volume between monochorionic and dichorionic triplets, monochorionic and trichorionic triplets, or dichorionic and trichorionic triplets. Conclusions Placental volume in multiple pregnancies does not depend on chorionicity, and the rate of placental growth between 11 and 13 + 6 weeks is not significantly different between singletons, twins and triplets. Moreover, for a given gestational age the placental volume corresponding to each fetus in twins and triplets is 83% and 76%, respectively, of the placental volume in singletons. [ABSTRACT FROM AUTHOR]

We report two cases of conjoined twins complicating a triplet pregnancy diagnosed by two-dimensional ultrasound in the first trimester and evaluated further by three-dimensional ultrasound. A review of the literature over the last 30 years revealed 11 other cases diagnosed prenatally by ultrasound. Overall, three (23%) of these 13 pregnancies were achieved by assisted reproductive techniques and 10 (77%) were diagnosed before 18 weeks. Four women opted for termination of the whole pregnancy and three were managed expectantly, with two delivering before 32 weeks. Two monochorionic pregnancies underwent selective feticide with intrauterine demise of the non-conjoined fetus in both cases. All four dichorionic pregnancies undergoing selective termination or spontaneous embryo reduction to singleton in the first trimester resulted in term delivery of the non-conjoined fetus. The rare condition of conjoined twins in a triplet pregnancy poses a significant obstetric challenge from both diagnostic and management points of view. Accurate determination of chorionicity in these cases plays a critical role in determining management and outcome. [ABSTRACT FROM AUTHOR]

The mechanism of monozygotic multifetal pregnancy and its association with assisted reproductive technology are uncertain. This report presents two cases of dizygotic triplet pregnancy after the transfer of three embryos in utero . The incidence of monozygotic twinning following assisted conception procedures is higher than in the general population. Zonal manipulation may be a major factor in the increased incidence of monozygotic twinning. As both cases followed the conventional in vitro fertilization (IVF), the reason for these monozygotic twinnings might be because of the changes in the zona pellucida in in vitro conditions. In one case, fetuses developed into severe twin-to-twin transfusion syndrome (TTTS), resulting in one intrauterine fetal death at 26 weeks gestation. (Reprod Med Biol 2003; 2: 41–44). [ABSTRACT FROM AUTHOR]

The article presents a case report on a triplet pregnancy with a complete mole and coexisting fetuses. A 34-year-old Japanese woman treated for infertility became pregnant following artificial insemination. Ultrasonographic examination at 9 weeks revealed a triplet pregnancy with a complete hydatidiform moles (CHM). The pregnancy was terminated at 10 weeks due to the risk of persistent trophoblastic disease (PTD).

A triplet pregnancy that resulted from the transfer of two blastocysts demonstrated a twin reversed arterial perfusion sequence and conjoined twins as a “pump” fetus. [ABSTRACT FROM AUTHOR]