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Purpose: To characterize the differences between twomatched groups of patients treated by ICSI: those pregnantafter all embryos transferred implanted (100% implantationrate) compared with nonpregnant patients. Methods: Twenty-one patients in whom one transferredembryo achieved a singleton pregnancy (group A) and 21pregnant patients to whom two or three embryos were transferredand achieved 11 twin and 10 triplet pregnancies(group B) compared with matched nonpregnant patients(group C and D, respectively). Results: The singleton pregnant patients were significantlyolder than the twin and triplet pregnancy patients. Althougha similar number of human menopausal gonadotropinampules were used in the singleton compared with the twinsand triplets a significantly lower number of oocytes andembryos were achieved at lower levels of estradiol on thehuman chorionic gonadotropin day in the former than inthe latter respectively. No difference was found between thepregnant women and their nonpregnant controls in any ofthe mentioned parameters. Good embryo morphology wasfound in 86% of the embryos in group A compared with62% in group C (P = 0.08) and 92% in group B comparedwith 66% in group D (P < 0.002). Conclusions: The only parameter in which pregnant patientswith 100% implantation rate differ from their nonpregnantcontrols was embryo quality.

A 28-year-old Taiwanese woman who had received ovulation induction by clomiphene citrate (CC), follicular-stimulating hormone (FSH), and human chorionic gonadotrophin (hCG) treatment was diagnosed with a quadruplet pregnancy containing a hydatidiform mole and three fetuses at nine weeks' gestation. Expectant management failed to achieve any viable neonate due to massive antepartum haemorrhage and preterm delivery at 25 weeks' gestation. Five other cases previously reported involving quadruplets or triplets with a complete hydatidiform mole and two or three fetuses are reviewed. All cases ended as premature non-viable fetuses. Analysis of the clinical features, management, and outcome both in our patient and these reports suggest that more efficacious treatment planning, such as selective feticide, should be considered in order to improve the likelihood of attaining an advanced gestational age for a single fetus.

Ectopia cordis is a rare congenital anomaly. We present 4 cases of ectopia cordis, 1 of which is the first report of an affected fetus in a triplet pregnancy. The morphological relationship between the types of ectopia cordis and their outcomes were investigated in all 4 cases. In addition, the literature on ectopia cordis in Japan was reviewed and discussed.

OBJECTIVES: Cord entanglement is a severe complication in monoamniotic multiple pregnancies. Three cases were reviewed to determine how early ultrasound diagnosis might improve counselling and management. METHODS: In two monoamniotic twin and one dichorionic diamniotic triplet pregnancies, cord entanglement was detected between 10 and 18 gestational weeks by color Doppler and pulsed Doppler velocimetry. Pregnancies were followed up on a weekly basis with special observation of fetal behavior and use of color Doppler velocimetry. RESULTS: In Case 1, a monoamniotic twin pregnancy with cord entanglement close to the umbilical insertions was diagnosed at 10 weeks. Longitudinal follow-up showed intrauterine death of both twins at 15 weeks. In Case 2, entanglement of the umbilical cords of two monoamniotic triplets within a dichorionic diamniotic triplet pregnancy was diagnosed at 10 weeks. The pregnancy continued uneventfully until 35 weeks when cord entanglement was confirmed at Cesarean section. All triplets have since developed normally. In Case 3, monoamniotic twins were diagnosed at 18 weeks. Color Doppler detected side-by-side insertion of the umbilical cords and Doppler velocimetry suggested an entanglement at the chorionic plate. The pregnancy was complicated by polyhydramnios. Cesarean section at 36 weeks confirmed cord entanglement at the chorionic plate. Postnatal computer angiography and morphological examination of the placenta showed the presence of superficial artery-to-artery and vein-to-vein anastomoses and of deep arteriovenous shunts. The development of the twins was uneventful. CONCLUSIONS: Diagnosis of cord entanglement is feasible early in gestation. Future protocols are proposed to document the gestational age at detection, the location, and the Doppler flow patterns and to facilitate the assessment of short- and long-term development. (Less)

Objective: To establish the charges associated with triplet pregnancies managed at a single tertiary center, over a 5-year time period, and to evaluate the impact of prematurity on these charges.Methods: All triplet pregnancies that reached at least 20 weeks gestation and received prenatal and neonatal care at our center from 1992 to 1996 were included. Charges for these mothers and neonates were extracted from two separate hospital billing computer systems, encompassing all inpatient, outpatient, technical, and professional charges. Linear regression was used to evaluate the relationship between gestational age at delivery and total charges.Results: Fifty-five triplet pregnancies were included, resulting in the admission of 149 liveborn neonates. The median gestational age at delivery was 32.1 weeks. The mean charges per triplet mother were: $6,899 (professional), $3,959 (hospital outpatient), and $32,686 (hospital inpatient). The mean charges per neonatal sibling set were: $20,107 (professional) and $12...

In infertile men who carry a balanced reciprocal translocation, intracytoplasmic sperm injection (ICSI) may induce a pregnancy with an abnormal karyotype. This report describes a previously unreported paternal reciprocal translocation leading to a chromosomally unbalanced ICSI pregnancy. The triplet pregnancy resulted in 1 normal girl, 1 physically normal boy with the same balanced paternal translocation, and a severely malformed boy with trisomy 20p and monosomy 22q who died in the neonatal period.

We report a patient with a dichorionic triplet pregnancy complicated by Quintero stage IV twin-twin transfusion syndrome, presenting with hypertension and severe edema at 19 weeks of gestation. Sonography revealed one set of female twins with poly-/oligohydramnios sequence, the recipient twin showing hydropic changes, and another male fetus with normal amniotic fluid content. The maternal laboratory data revealed that, in addition to mild anemia (hemoglobin 10.2 g/dl, hematocrit 32%), there was a high lactate dehydrogenase level of up to 1,042 U/l. Due to the placenta of the uninvolved male fetus hampering the insertion of a fetoscope into the recipient sac and because the distance of the two cords of the 2 female fetuses was as short as 2.5 cm, laser coagulation of the communicating vessels on the placenta of the female twins with twin-twin transfusion syndrome would have posed great difficulty. After discussing other treatment options, including serial amniocentesis, selective termination of the hydropic fetus, or reducing the triplet pregnancy to a singleton pregnancy, the parents decided to perform selective fetocide. Hypertension and severe edema of the mother resolved after selective termination of the hydropic fetus, and so did the lactate dehydrogenase level that dropped from 1,042 to 90 U/l. Unfortunately the donor twin died in utero 2 days after selective termination, and the whole pregnancy was lost at the gestational age of 21 weeks. Nevertheless, we have demonstrated an example of reversal of maternal symptoms and signs after termination of the hydropic fetus in twin-twin transfusion syndrome complicated by mirror syndrome.

Fetus in fetu (FIF) is a rare form of twinning in which an immature twin develops parasitically inside the other twin. The most frequent location of a parasitic fetus is the retroperitoneal region. A FIF located on the abdominal wall is an unusual condition, and it should be kept in mind as one of the differential diagnoses of abdominal wall masses.

To evaluate the results of IVF in womenor = 40 years of age using their own oocytes.Retrospective study.Wolfson and Royal Masonic in vitro fertilization units, London, United Kingdom.A total of 1,087 IVF cycles were started in womenor = 40 years of age.Medical records of patient outcomes were reviewed.Clinical pregnancy, miscarriage, and delivery rates.Of the 1,087 cycles started in 471 womenor = 40 years of age, 842 reached oocyte retrieval (77.5%) and 702 had embryos transferred (64.6%). The pregnancy rate (PR) was significantly lower in womenor = 40 years of age than in a control group of women40 years of age (11.3% versus 28.2%). It decreased sharply in women42 years of age, and no women45 years of age had a child. Womenor = 40 years of age were more likely to miscarry (27% versus 12.7%). When only one embryo was available for transfer, the PR was 3.3%. When2 embryos were available for transfer, the PR was similar whether 2 or 3 embryos were replaced. No triplet pregnancy occurred. Womenor = 40 years of age achieved a cumulative PR of 30% after three cycles with a cumulative "take home baby" rate of 21%.In vitro fertilization is a reasonable treatment for women45 years of age using their own gametes. Those with a "good response" in their first attempt may be encouraged to complete three cycles with an acceptable chance of conception.

In spite of the widespread use of assisted reproductive technology, there have been, to our knowledge, only two reported cases of molar pregnancies after gamete intra-Fallopian transfer and five reported cases after in-vitro fertilization and embryo transfer. We report here a case of a complete hydatidiform mole in a twin pregnancy after gamete intra-Fallopian transfer, as well as a case of a complete hydatidiform mole in a triplet pregnancy after in-vitro fertilization and embryo transfer. The genetic constitution of each conceptus was determined by examination of the restriction fragment length polymorphism of the DNA with four different single-locus probes. This analysis revealed that both hydatidiform moles were of androgenetic origin and probably of monospermic origin. Moreover, the analysis confirmed that the pregnancies were dizygotic and trizygotic pregnancies respectively. The diagnostic utility of the analysis of DNA polymorphism is discussed in cases of a molar pregnancy with coexisting fetuses.

Ultrasound has been found to be extremely accurate in diagnosing the chorionicity of multiple gestations. Prenatal counselling and/or planning for selective termination is most often based on the sonographic prediction of chorionicity. We present a case of triplet pregnancy in which early sonographic prediction of chorionicity did not match the pathological diagnosis at delivery.

Our purpose was to describe interrelationships and contacts between twins in utero by use of three-dimensional ultrasonography with a specially developed abdominal three-dimensional transducer. Thirteen twin pregnancies (3 monochorionic and 10 dichorionic pairs) and one triplet pregnancy (trichorionic triplet) from 9 to 36 weeks of gestation were studied with a specially developed abdominal three-dimensional transducer (3.5 MHz). This imaging system can provide conventional two-dimensional ultrasonography images and can also generate within seconds high-quality three-dimensional images in the surface and transparent mode with no need for an external workstation. Interrelationships and contacts between twins or triplets are described. Various types of contacts (head/body/arm/leg) and interrelationships were clearly visualized. Crowding of in utero twin fetuses increased with advancing gestation. Sometimes two placentas and dividing membrane were beautifully depicted. In one triplet pregnancy, the interrelationships among 3 fetuses and dividing membranes were easily recognized. Three-dimensional ultrasonography provides a novel means of visualizing multiple pregnancies in utero. These results suggest that three-dimensional ultrasonography has the potential to be a supplement to two-dimensional ultrasonography and would be useful in evaluating the interhuman contacts and crowdings of twin and triplet fetuses in utero.

Conjoined twins, rare complications of monozygotic twinning, occur in approximately 1% of monozygotic twins or between 1 per 100,000 and 1 per 250,000 live births. 1,2 Thoracopagus is the most common type of conjoined twins, with approximately 75% of such cases having conjoined hearts. 3 Reported cases of first-trimester transvaginal sonographic diagnosis of conjoined twins have almost uniformly involved gestational ages ranging between 11 and 14 weeks. 4-11 Earlier diagnosis is uncommon, yet single cases have been reported at 9 and 10 weeks, respectively. 12-17 An additional case of conjoined twins in a triplet pregnancy at 10.5 weeks' gestation was reported by Sepulveda et al. 18 We report an unusual case in which transvaginal color Doppler imaging confirmed the presence of thoracopagus, suspected during real-time sonography at 7 weeks' gestation.

A heterotopic pregnancy is the coexistence of one or more ectopic and a single or multiple eutopic pregnancy. Heterotopic pregnancy currently occurs in approximately 1 of 7000 spontaneous pregnancies. However, artificial reproductive techniques increase the incidence to 1%. Coexisting bilateral tubal and an intrauterine pregnancy is a rare condition. We present a case of a combined bilateral ectopic and intrauterine pregnancy in a patient with a pituitary adenoma who was managed with bromocriptine. (J GYNECOL SURG 22:123)

A 24-year-old female was admitted in Apollo Hospitals, Ahmedabad with history of caesarian section 24 hrs ago for PET and triplet pregnancy. Her condition deteriorated after caesarian section. A clinical diagnosis of HELLP syndrome was made, supported by laboratory investigations. She stayed in hospital for 14 days with close monitoring in high dependency unit with supportive and symptomatic care and blood products. She also developed peripartum cardiomyopathy but a multidisciplinary team approach in the hospital saved the life of the patient which was a near miss mortality.

Due to a surge in the availability of assisted reproductive techniques (ART), the incidence of multiple pregnancies is increasing. Preterm labor is a major complication in such pregnancies. Preterm delivery of the first fetus is often followed by delivery of the remaining fetuses. However, conservative management and delayed interval delivery in the remaining fetuses might allow for fetal lung maturity and would reduce perinatal morbidities. A 32-year-old female had a quadruplet pregnancy after receiving ART. Fetal reduction to triplet pregnancy was performed at 11 weeks of gestation. The remaining triplet pregnancy was stable until 29 weeks of gestation, when the first triplet was delivered after spontaneous rupture of membranes. Under intensive monitoring, the remaining 2 fetuses were delivered by cesarean section at 31 weeks of gestation. Only the first fetus had retinopathy after discharge. In conclusion, delayed interval delivery of the remaining fetuses should be attempted after preterm delivery of the first fetus.

Objectives The purpose of this study was to review the management and outcomes of all patients with pregnancy of unknown location who had serum human chorionic gonadotropin (hCG) levels greater than 1000 mIU/mL in our institution and to determine the likelihood of a subsequent normal intrauterine pregnancy at different hCG discriminatory levels. Methods A retrospective review was performed on all women admitted with the diagnosis of pregnancy of unknown location and an hCG level greater than 1000 mIU/mL over a 5-year period (July 2007 to June 2012). Patients were identified from a computerized hCG result database. The medical records, including sonographic findings, hCG levels, and outcomes, were reviewed. Results A total of 113 patients were identified. There were 23 viable intrauterine pregnancies (20.4%) and 22 visualized ectopic pregnancies (19.5%). The highest hCG level associated with a subsequent normal intrauterine pregnancy was 9083 mIU/mL in a patient with triplet pregnancy. Possible factors associated with nonvisualization of a normal intrauterine pregnancy included uterine fibroids, adenomyosis, endometrial polyps, and obesity. The negative laparoscopy rate was 48.8%. Conclusions Viable intrauterine pregnancy is possible in patients with pregnancy of unknown location and hCG levels above the generally accepted discriminatory zone, strict adherence to which can potentially disrupt a normal pregnancy. We support the need for judicious use of the hCG discriminatory level in hemodynamically stable patients with pregnancy of unknown location, and the decision to intervene should not be based solely on a single hCG level.

In multiple pregnancy, the following may be considered to delay the delivery: bed rest, antibiotics, tocolytics, steroids, and, possibly, cervical cerclage. Analysis of uterine contraction intensity, reevaluation of the chorion and the amnion, as well as monitoring of the mother and the fetus are also very important. Clinical and laboratory parameters ought to be carefully monitored to prevent intra-amniotic infection. We present a case of a delayed delivery in a trichorionic, triamniotic, triplet pregnancy after IVF. The first and the second fetuses were delivered spontaneously at 23 and 26 weeks of gestation, respectively. The third fetus was delivered by a cesarean section at 26 weeks of gestation. The delay between the first and the second/third fetuses was 18 days. Only the second child survived. At present, the psychomotor development of the infant is considered as normal.

Heterotopic triplet pregnancy is an exceptionally rare medical condition. The broad use of assisted reproductive technologies has contributed to the increase of ectopic and subsequently heterotopic pregnancy rate, masking a life-threatening condition for the gravid and the intrauterine pregnancy. We describe a case of a woman with heterotopic triplets at 9+4gestational week following transfer of three embryos obtained by in vitro fertilization techniques. The ectopic tubal pregnancy was ruptured and salpingectomy was performed by laparotomy. The intrauterine pregnancy progressed to the delivery by cesarean section of two healthy twins at 36+2gestational age. Heterotopic triplets with tubal ectopic are a special diagnostic and therapeutic challenge for the obstetrician. High index of suspicion and timely treatment by laparotomy or laparoscopy can preserve the intrauterine gestation with a successful outcome of the pregnancy.

There has been growing concern about the number of multiple gestations resulting from assisted reproductive technologies. For in-vitro fertilization (IVF), there are guidelines concerning the number of embryos to be transferred. In oocyte donation, however, there is a paucity of studies addressing this issue and common practice is extrapolated from standard IVF procedures. This may not be correct since endometrial receptivity has been shown to be altered in oocyte donation. Thus the purpose of this study was to assess the optimal number of embryos to be transferred in oocyte donation. The study population included 254 patients with ovarian failure who underwent a total of 601 embryo transfers in a single shared oocyte donation programme. Pregnancy rates (PRs), multiple pregnancies, triplet pregnancy rates, and implantation rates were evaluated according to the number of embryos transferred. A significant linear increase in PRs was noted with the increasing number of embryos transferred up to five (11.1% for one embryo, 36.7% for five embryos). Multiple pregnancies increased significantly from 15.8% for two embryos transferred, to 44.4% for five embryos. The rate of triplet pregnancies also increased from 2.7% for three embryos transferred, to 8.3% for five embryos. Optimization of the number of embryos to be transferred is discussed.

Heterotopic pregnancy has been traditionally considered a rare event; however, with the use of assisted reproductive technology, the incidence of heterotopic pregnancies is increasing. Diagnosing a heterotopic pregnancy can be challenging. This report describes a 30-year-old female at 11 weeks' gestation with an intrauterine twin pregnancy after gonadotropin stimulation and intrauterine insemination who presented complaining of left lower quadrant abdominal pain with constipation and cramps. The patient was empirically treated for diverticulitis but failed to respond to therapy. A heterotopic triplet pregnancy was ultimately diagnosed at laparoscopy. Heterotopic pregnancy must be considered in the differential diagnosis of abdominal pain in the first trimester, especially in patients who conceived by means of assisted reproductive technology. Surgical treatment is the most frequently used method of treatment.

Objective: To describe a new technique for embryo reduction (ER) in dichorionic triplet (DCT) pregnancies. Methods: In 22 DCT pregnancies, ER to dichorionic twins was carried out at 11.3-13.9 weeks' gestation by ultrasound-guided laser ablation of the pelvic vessels of one of the monochorionic twins. Results: Intrafetal laser was successfully carried out in all cases, but ultrasound examination within 2 weeks of the procedure demonstrated that the co-twin had died in 11 cases and was alive in the other 11. In the dichorionic group there was one miscarriage at 23 weeks due to cervical incompetence and in the other 10 cases there were two live births at a median gestational age of 35.0 (range 32.2-37.1) weeks. In the 11 cases where both monochorionic fetuses died the separate triplet was live born at a median gestation of 38.0 (range 32.2-40.5) weeks. Conclusions: In the management of DCT pregnancies, ER to dichorionic twins by intrafetal laser is an additional option to the traditional ones of expectant management, ER by intrafetal injection of potassium chloride (KCl) to monochorionic twins or ER by KCl to singleton.

Objective: To compare the outcome of trichorionic triplet (TCT) and dichorionic triplet (DCT) pregnancies managed expectantly and those with embryo reduction (ER) at 10-14 weeks to twins or singletons. Methods: This was a retrospective study of triplet pregnancies with 3 live fetuses managed expectantly or by ER. Data were combined with the results of previous studies that used similar entry criteria and outcome measures. The management options were compared for rates of miscarriage and preterm birth Results: In TCTs managed expectantly (n = 358), the rates of miscarriage and preterm birth were 3.1 and 35.1%. Compared to the expectantly managed TCTs, the rate of miscarriage was higher and preterm birth lower in TCTs with ER to 2 fetuses (n = 833, 7.3 and 13.1%, respectively) and TCTs with ER to 1 fetus (n = 78, 11.5 and 8.7%). In DCTs managed expectantly (n = 136), the rates of miscarriage and preterm birth were 8.8 and 46.0%. In DCTs with ER to 2 fetuses (n = 15) or ER to 1 fetus (n = 42), there was a non-significant increase in miscarriage (13.3 and 16.7%, respectively) and decrease in preterm birth (23.1 and 8%, respectively). Conclusions: In TCT and DCT pregnancies, ER increases the rate of miscarriage but reduces the rate of preterm birth.

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.

Delayed deliveries in multiple gestations occur rarely, and there are no explicit guidelines covering procedures after the delivery of the first fetus or attempts to delay further deliveries. Our c...

Twin–twin transfusion syndrome (TTTS) is an antenatal complication of monochorionic multiple gestations. There have been few studies exploring the role of laser photocoagulation or outcomes following treatment in monochorionic triplet pregnancies with TTTS. We present a case where TTTS and twin anemia–polycythemia sequence (TAPS) complicated a monochorionic triplet pregnancy. Following the laser photocoagulation to treat the TTTS between the triplets, an intra-uterine death occurred in one triplet and TAPS developed in the remaining two triplets. Intervention in this case resulted in a 2-week prolongation of pregnancy and a positive outcome for the remaining fetuses. This case and other published data reviewed in this article suggest that laser photocoagulation has a potential role for TTTS in monochorionic triplet pregnancies.

Objective To determine chorionicity in triplet pregnancies by ultrasonographic assessment of the ipsilon zone, the junction of the three interfetal membranes. Methods The thickness of the component membranes in the ipsilon zone was studied to determine chorionicity in 28 triplet pregnancies, by retrospective examination of the ultrasonographic images taken at 9–24 weeks' gestation, and in 20 consecutive triplet pregnancies followed prospectively by targeted ultrasonography at 8–21 weeks' gestation. Prenatal ultrasonographic findings were compared with those obtained from the records of the infertility centers or referring hospitals (the number of gestational sacs and live embryos in each sac seen by transvaginal scanning at 6–7 weeks' gestation). Results Of the 28 triplet pregnancies with appropriate images demonstrating the ipsilon zone, 22 were classified as trichorionic, five dichorionic, and one monochorionic. This classification was correct in all but one trichorionic pregnancy, which was misclassified as dichorionic. In the prospective subset ( n = 20) there were 16 trichorionic and four dichorionic triplet pregnancies. The ipsilon zone was not present in one case in which the interfetal membrane did not intersect. In the remaining 19 pregnancies, there was a complete correlation between the findings at the ipsilon zone and transvaginal ultrasonography at 6–7 weeks. Conclusion Ultrasonographic assessment of the ipsilon zone is useful for predicting chorionicity in triplet pregnancies.

We report two unusually florid cases of polymorphic eruption of pregnancy (PEP) or pruritic urticarial papules and plaques of pregnancy, the first occurring in a triplet pregnancy, and the second with some clinical features more suggestive of pemphigoid gestationis (PG). The first case responded to treatment with moderately potent topical steroids while the second case required a short course of systemic steroids. Our first case is the only reported case of PEP occurring during a triplet pregnancy. We discuss the effect of multiple pregnancy on PEP and some distinguishing factors between PEP and PG.

Hyperreactio luteinalis is a non-neoplastic tumor-like ovarian lesion associated with pregnancy. Most patients are asymptomatic, with the ovarian enlargement being incidentally discovered at the time of cesarean section. It can simulate a neoplasm on clinical, gross and sometimes microscopic examination. We report a case of hyperrreactio luteinalis in a patient, who was diagnosed as having polycystic ovary disease before conceiving a triplet pregnancy after three treatment cycles of human menopausal gonadotropin-human chorionic gonadotropin therapy, and discuss its pathogenesis.

For the first time we report on an intact and ongoing triplet pregnancy after intracytoplasmatic sperm injection of cryopreserved testicular sperm. Indication was azoospermia due to hypergonadotropic hypogonadism. The patient conceived in the third treatment cycle after 25 treatment cycles with donor sperm that had been carried out without success in two other treatment centers.

One triplet and two twin pregnancies, with a delayed delivery of 70, 98 and 85 days, respectively, are presented. In all cases one neonate survived. Regarding both the literature and our own cases, we can make the following management suggestions: (a) the cord should be ligated as high as possible; (b) fetal growth, cervical length and dilatation should be observed by weekly ultrasound scans, and (c) it seems that both cervical cerclage and tocolysis prolong the delivery interval, while prophylactic antibiotics have no beneficial effect. Triplet pregnancy in a single uterus and with a 70-day interval between the delivery of the first and that of the remaining 2 fetuses is a rare occurrence. Moreover the delay of 98 days, in our second case, represents the fourth longest delivery interval reported in the literature.

Summary Objective Triplet pregnancies have a high risk of preterm delivery, and the incidence of chromosomal anomalies is higher than that of singletons. Abnormal fetuses should be diagnosed and properly reduced to prevent preterm delivery of the remaining fetuses. Case Report A 36-year-old female was unable to conceive due to male factor infertility. After treatment with a long protocol of buserelin therapy, in vitro fertilization, and tubal embryo transfer, she achieved a triplet pregnancy. She underwent amniocentesis because of her advanced age; it was determined that one of the triplets had translocation Down syndrome. Under ultrasound guidance, we performed selective termination of the affected fetus at 20 weeks' gestation. The patient developed preterm uterine contractions at 31+4 weeks' gestation and was hospitalized. She spontaneously delivered a fetus papyraceous at 33+1 weeks' gestation. Three days later, interval delivery was performed and the two remaining fetuses were delivered in good condition by cesarean section. Conclusion The risk of fetal chromosomal anomalies is increased in multiple pregnancies. Abnormal fetuses can be diagnosed using amniocentesis and selectively terminated safely. Delayed-interval delivery can be used to improve the outcome for the remaining fetuses.

Die Listeriose wird durch das grampositive kokkoide Stabchen Listeria monocytogenes ausgelost und ist in der Schwangerschaft mit einer hohen Abort- und Fruhgeburtenrate verbunden. Die Symptomatik bei den Schwangeren ist unspezifisch, wobei sowohl grippeahnliche Symptome wie Fieber, Entzundungen der oberen Atemwege als auch Zystitiden und Pyelonephritiden auftreten konnen. Der Erregernachweis erfolgt als Direktnachweis aus Blut und anderen Korperflussigkeiten. In unserem Fall wird ein ungewohnlicher Verlauf einer Drillingsschwangerschaft mit Listeriose beschrieben, wobei es zum protrahierten Abort des 1. und 2. Drillings und zur Lebendgeburt des 3. Drillings kam. Listeriosis is an infection caused by the bacterium Listeria monocytogenes. In pregnancy listeriosis may result in abortion, stillbirth, premature delivery or severe neonatal infection. Clinical manifestations of maternal listeriosis are often influenza-like symptoms. We present a case of listeriosis in a triplet pregnancy with abortion of the 1st and 2nd fetus and the birth of a healthy 3rd child in the 25th week of gestation.

We encountered a triplet pregnancy case with a mole and two normal fetuses, analyzed their karyotypes, and genotyped 15 STR markers and amelogenin after their termination in early pregnancy. The results of genotypes indicated that the triplets were trizygotic. The molar tissue lacked any of the maternal alleles at seven loci and, at one (D2S1338) of the seven loci, transmissions of the heterozygous paternal alleles to the mole were observed. These findings indicated that the mole resulted from dispermic androgenesis. The diagnosis with STR markers should prove very useful to better understand the zygosity of gestation and the genetic origin of hydatidiform moles.

Objective To examine whether mood state or infertility stress influences perceptions of risk, preferences for embryo transfer, or views on multiple pregnancy. Design Observational cohort study. Setting Hospital-based fertility clinic. Patient(s) One hundred seventy-six women participating in IVF treatment. Intervention(s) None. Main Outcome Measure(s) Mood scores, ratings of risk, preference for multiple embryo transfer, and attitudes toward multiple pregnancy. Result(s) Growing feelings of tension across the cycle corresponded with increases in the perceived riskiness of double-embryo transfer, but there was no change in strength of transfer preferences. Women experiencing negative moods, such as depression, viewed twin and triplet pregnancy as less likely, whereas increasing positive feelings across the cycle were associated with increasing desire for twin pregnancy. Overall, women perceived double- and triple-embryo transfer as less risky by cycle end than at cycle beginning and felt more certain about multiple-embryo transfer. Conclusion(s) The dyssynchrony observed among changes in mood, perceptions of risk, and transfer preferences challenges assumptions about the way medical risk information influences transfer preferences, and the findings suggest that mood states experienced during an IVF cycle might affect transfer preferences by influencing attitudes toward multiple pregnancy. Additional considerations beyond providing risk information are needed to facilitate effective patient decision making.

In the past decades, we have observed a large increase in the number of multifetal pregnancies, which is mainly associated with the introduction of assisted reproductive techniques. Even though neonatal intensive care of very premature infants has improved significantly, the risk of mortality and long-term morbidity is still much higher among these newborns. A longer interdelivery period may reduce perinatal mortality and morbidity. The authors report the case of a delayed interval delivery in trichorionic, triamniotic triplet pregnancy. After the labor of the first fetus in the 22nd week of gestation, a 75-day interval was achieved before the delayed delivery. To save the surviving fetuses, the umbilical cord was ligated at the cervical level immediately after the first delivery. The patient received antibiotics, tocolytics, and corticosteroids. A baby boy who weighed 1750 g and a girl who weighed 1700 g were successfully delivered by cesarean section in the 33rd week of pregnancy. The babies were discharged home at the age of 28 days. A follow-up examination 20 weeks later showed that their neurological development was normal and without any major problems. The maternal postpartum course was uneventful; the patient stayed in hospital taking care of the babies.

Morphology of the spermatozoa is one of the major criteria in severe male subfertility. We report on a case of severe Oligoasthenoteratozoospermia in which a triplet pregnancy could be achieved after intracytoplasmic sperm injection (ICSI). After treatment with GnRH-analogues/HMG/HCG seven oocytes of metaphase II could be retrieved and injected. Three of them fertilised and were transferred as four-cell stage embryos after two days. Seven weeks later an intact triplet pregnancy could be detected by ultrasonography. The severe sperm defects in this case were evaluated with the technique of electron microscopy. Ultramorphology of spermatozoa appears to have an important predictive value for fertilisation and pregnancy in classical IVF. Its value for the assisted procreation techniques such as ICSI remains to be investigated.

Objective To describe the reproductive and obstetric outcomes of women ≥ 50 years attempting pregnancy using donor oocytes. Setting The IVF program at the University of Southern California. Patients Thirty-six postmenopausal women aged 50 to 59 years, mean 52.3 ± 2.6 years (mean ± SD) were screened medically, reproductively, and psychologically and enrolled in a trial of oocyte donation. Interventions Recipients underwent hormone replacement therapy using oral micronized E 2 and IM administered P. Oocytes were provided by designated gamete donors (mean age 30.5 ± 4.4 years). Embryos (4.3 ± 1.2) were transferred transcervically. Main Outcome Measures Rates for embryo implantation, spontaneous abortion, ongoing and delivered pregnancies, as well as the gestational age at delivery, birthweights, complications, and postpartum outcomes. Results Forty-five aspirations resulted in 22 pregnancies (48.9%): 3 preclinical, 2 ending in spontaneous abortion, and 17 viable pregnancies (37.8%). The embryo implantation rate was 20.6%. Nine of 17 pregnancies (52.9%) were multiple gestations (6 twins; 1 triplet; and 2 quadruplets, selectively terminated to twins). All pregnancies delivered beyond 32 weeks: mean gestational age for singletons was 38.4 ± 1.9 weeks (range 35 to 41 weeks); mean gestational age for twins was 36.3 ± 1.4 weeks (range 34 to 38 weeks); the triplet pregnancy delivered at 32 weeks. Complications occurred in eight patients; gestational hypertension (n = 7), preterm labor (n = 3), gestational diabetes (n = 2), and pre-eclampsia (n = 1). One infant was trisomy-21. Conclusion Patients ≥ 50 years experience similar pregnancy rates after oocyte donation as younger women and are at equal risk for multiple gestation. Antenatal complications were experienced by the majority of patients, underscoring the importance of high risk obstetric surveillance and care.

Pre-eclampsia is a multisystem disorder with incidence rates ranging from 2% to 5%. Hyponatraemia is a rare complication of pre-eclampsia. A 41-year-old, para 0+1 in vitro fertilisation monochorionic diamniotic triplet pregnancy woman presented at 25 weeks with dyspnoea and general malaise. Her antenatal course was complicated by the diagnosis of intrauterine growth restriction in triplet one at 27 weeks of gestation. At 27+3 weeks gestation, she was diagnosed as having pre-eclampsia. Subsequent biochemical analysis demonstrated hyponatraemia with serum sodium falling steadily to 117 mmol/L over the next 19 days. She was admitted to intensive care unit for stabilisation of fulminant pre-eclampsia and severe hyponatraemia at 30+5 weeks of gestation. Hypertonic saline and intravenous labetolol were administered prior to delivery by caesarean section. She recovered well postdelivery with stabilisation of her blood pressure and normalisation of her sodium level to 135 mmol/L. Awareness and frequent monitoring of hyponatraemia should become an integral part of monitoring women with pre-eclampsia.

Our purpose was to describe the total costs involved in the delivery, prenatal, and neonatal care for triplet pregnancies.Twenty triplet pregnancies were born at our institution over the 1-year period between July 1, 1992, and June 30, 1993. Total charges for prenatal care, physician fees, antepartum admissions, delivery, postpartum inpatient and outpatient care, and neonatal inpatient and outpatient care were extracted from the hospital billing computers.Our 20 triplet pregnancies were delivered of 54 live born infants at an average gestation of 30.2 weeks. Mothers averaged 16.7 inpatient hospital days. Total cost of prenatal care, outpatient laboratories and ultrasonography, delivery, and maternal inpatient care averaged $27,491. Neonates averaged 13.7 hospital days. Total neonatal costs for the inpatient stay and short term-postpartum (6 week) outpatient period was $36,856 per family. Total average cost per family was $64,347.Combined maternal and neonatal costs per individual baby delivered was approximately $21,000. Although expensive, this cost is far from prohibitive, even in times of close attention to health care expenditures.

Delayed delivery in multifetal gestation can be successfully accomplished if labor arrests after delivery of the first fetus. We report a triplet pregnancy in which aggressive therapy was needed to delay delivery after the birth of the first triplet at 22 weeks gestation. Cervical cerclage, broad spectrum antibiotic therapy, and aggressive tocolysis allowed a delay of 6 weeks before the remaining 2 triplets were delivered. C-reactive protein values were useful in monitoring the effectiveness of antibiotic therapy.

This study was conducted to investigate the prevalence rates of handicaps in twins and triplets. The subjects were 252 twins and 287 triplets. The following results were obtained. 1) The prevalence rates of the handicapped were 8.7 per 100 triplets, and 4.4 per 100 twins. The risk of producing at least one handicapped child was approximately 22% in triplet pregnancy and 9% in twin pregnancy. This means that one in 4 or 5 sets of triplets had at least one handicapped child, as did one in 11 pairs of twins. 2) Cerebral palsy was the most frequent handicap in twins and triplets. The risks of producing a child with cerebral palsy were 2.0% and 3.1% in twins and triplets, respectively. 3) The prevalence rates of congenital anomalies (congenital heart disease, limb anomalies, and others) were 2.4% in twins and 4.5% in triplets. Approximately 45% of the handicaps in twins and triplets resulted from congenital anomalies. 4) The prevalence rate of the handicapped in twins and triplets was not associated with maternal age, but was associated with the years of delivery in triplets, and was higher in babies with shorter gestation periods.

Objective: to determine if there is a significant difference in immediate perinatal morbidity and mortality in triplets selected for delivery vaginally compared to delivery by Caesarean section. Study Design: over a ten-year period, 57 triplet pregnancies were delivered at the B.C.’s Women’s Hospital. In four cases, vaginal delivery of triplets was attempted. Criteria for attempted vaginal delivery included: (i) gestational age greater than 33 weeks, (ii) triplet A with a cephalic presentation, (iii) no evidence of fetal distress, A case controlled study was performed comparing the four vaginal deliveries to eight triplet pregnancies delivered by Caesarean section, matched for: (i) fetal presentation, (ii) multiparity, (iii) gestational age. Outcome variables compared included: (i) birthweight, (ii) Apgar scores at one and five minutes, (iii) length of stay in the Special Care Nursery (SCN) and evidence of trauma associated with delivery. Maternal outcome characteristics included: post-partum haemorrhage, infection, and maternal length of stay. Means were compared by student t-test and categorical variables were compared using chi-squared analysis. Results: our study revealed no significant difference in perinatal outcome between the triplets (A, B or C) delivered vaginally as compared to Caesarean section. However, a statistically significant increase in estimated maternal bleeding (875cc versus 600) and hospital stay (6 versus 4 days) for the Caesarean section group compared with the vaginal group were noted. Conclusion: in selected cases with gestational age greater than 33 weeks and triplet A cephalic, attempted vaginal delivery is not associated with any increase in adverse perinatal outcome and may be offered.

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.