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Ovarian hyperstimulation syndrome (OHSS) is a potentially life-threatening complication, usually iatrogenic after ovulation induction. OHSS is a very rare event in spontaneously conceived pregnancies. Only few cases have been reported in literature to the best of our knowledge. We report a very rare case of spontaneous critical OHSS (according to classification of severity of OHSS as mentioned in Greentop guidelines no. 5, 2006) associated with triplet pregnancy in a 26-year-old woman suffering from severe abdominal pain, distension, and dyspnea. Our case highlights the importance of a strong suspicion for OHSS when a clinical presentation could not be explained by common medical conditions.

ObjectiveTo report a triplet pregnancy complicated by clear cell cervical carcinoma that was managed using neoadjuvant chemotherapy followed by caesarean radical hysterectomy.Patient HistoryA 26-year-old woman had a diagnosis of cervical clear cell carcinoma, which was International Federation of Gynecology and Obstetrics stage IB1, at 18 weeks of gestation during a triplet pregnancy. Owing to the patient’s strong desire for full-term pregnancy, 3 cycles of neoadjuvant chemotherapy was administered after magnetic resonance imaging evaluation of the tumor. The patient underwent cesarean delivery and radical hysterectomy at gestational week 32. The hysterectomy specimen revealed stage IB1 clear cell adenocarcinoma of the cervix. The neonates and the mother did not have any complications related to the treatment during 36 months of follow-up.ConclusionTo the best of our knowledge, this is the first report of a triplet pregnancy complicated by cervical clear cell carcinoma that was successfully treated with neoadjuvant chemotherapy and cesarean radical hysterectomy. Our experience and literature review suggest that neoadjuvant chemotherapy for cervical carcinoma diagnosed during pregnancy is associated with excellent oncologic and fetal outcome; therefore, it may be considered as a temporary fertility-sparing approach in selected patients with a strong desire for full-term pregnancy. Nonetheless, additional research and long-term follow-up are needed to reach a more definitive conclusion.

Following in vitro fertilisation treatment, a 40-year-old woman was expecting trichorionic, triamniotic triplets. Her cervix shortened from 34 mm at 16(+5) weeks to 16 mm at 20(+5) weeks, a risk reported with 100% delivery before 28 weeks gestation. She was admitted to hospital and at 24(+1) weeks was given corticosteroids. From 21(+5) weeks her cervical length remained below 16 mm. However, weekly fetal fibronectin (fFN) tests were negative from 22(+5) weeks to delivery at 35(+5) weeks. This, along with an absence of symptoms, gave her doctors confidence to manage her as an outpatient from 28 weeks. At 33(+5) weeks she was diagnosed as having pre-eclampsia and three live births were delivered by prelabour caesarean section. Prior to delivery her cervical length was 10 mm and fFN test remained negative. There are no reports of outcome following a negative fFN with a short cervix in triplet pregnancies but fFN could be a useful tool, in conjunction with cervical length measurement, in the management of triplets.

Three cases of extreme male factor infertility, not acceptable for conventional IVF, are presented. In the first case, only 30 sluggishly motile spermatozoa were obtained in two ejaculates but treatment with SUZI resulted in a viable singleton pregnancy. In the second case, a combination of microepididymal sperm aspiration, for vasal obstruction after failure of reversal, with intracytoplasmic sperm injection resulted in a viable singleton pregnancy. In the third case, the husband had a vasal reservoir for distal vasal blockage. Sperm from the reservoir with extremely low motility and high antisperm antibody were microinjected by intracytoplasmic sperm injection and this resulted in a triplet pregnancy.

The aim of this study was to compare transplacental with non-transplacental amniocentesis in terms of related complications. Between January 1991 and December 1992, 4564 genetic amniocenteses were performed in 4527 patients (4491 singleton, 35 twin, and one triplet pregnancy) at 15-16 weeks of gestation. All the procedures were ultrasound-guided and performed by the same operator. In 1487 cases, an anterior placenta was traversed with the needle, whereas in 3077 cases, the needle was inserted directly into the amniotic cavity without traversing the placenta. After the exclusion of patients in whom amniotic cell culture failed or in whom an abnormal karyotype was obtained, and of patients lost to follow-up, a total of 4454 patients (98 per cent) were followed for 30 days after amniocentesis. Two spontaneous abortions occurred after a transplacental procedure, and five after a nontransplacental procedure (P = not significant). There were no episodes of amniotic fluid leakage in the first group, whereas 16 ruptures of the membranes that resolved spontaneously occurred in the second group (P < 0.01). Our data suggest that transplacental amniocentesis carries a similar abortive risk to and a lower risk of transient rupture of the membranes than non-transplacental amniocentesis and may therefore be preferred at the gestational period examined (15-16 weeks). However, the risk of feto-maternal haemorrhage, which is reported to be higher for a transplacental procedure, must be considered in the case of an anterior placenta.

Background. Conjoined twins are a rare complication of monozygotic twinning and are associated with high perinatal mortality.Case. Here we present a case of conjoined twins in a triplet pregnancy diagnosed at 13 of weeks gestation. With the aid of 3D ultrasound and MRI images, the parents were counseled regarding the management options, including continuation of pregnancy, termination of pregnancy, or selective fetocide. They chose selective fetocide of the conjoined twins and went on to deliver the remaining triplet at term.Conclusion. This case represents to our knowledge the only MRI images of conjoined twins in a triplet pregnancy and demonstrates how 3D imaging can be used to better counsel patients about management options.

A case of heterotopic triplet pregnancy after frozen-thawed embryo transfer is presented. The patient conceived after transfer of three frozen-thawed embryos at a fertility clinic where she had previously undergone laparoscopic left salpingectomy due to pyosalpinx. Approximately 4 weeks after the embryo transfer, she presented with a complaint of abnormal genital bleeding and was diagnosed by ultrasound as having a dichorionic twin pregnancy. One week later, she was referred to our hospital because of lower abdominal pain. Hematoperitoneum was suspected based on findings of low blood pressure and tachycardia. Diagnostic emergent laparoscopy demonstrated an ectopic pregnancy in the remnant isthmic portion of the left tube. Laparoscopic excision of the remnant fallopian tube was performed, but the procedure resulted in early-pregnancy loss of one of the twins. The risk of heterotopic pregnancy is not small under assisted reproductive technology. Attention should be paid to the risk of tubal pregnancy after transferring more than two embryos or controlled ovarian hyperstimulation, even after salpingectomy has been performed.

Introduction The United Kingdom Abortion Act was passed in 1967 and amended in 1990 when the Human Fertilisation and Embryology Act was passed. The main changes were that an upper time limit of 24 weeks was introduced for the termination of pregnancy where fetal abnormality was not the indication for the procedure. There was also the removal of any time limit if a termination was being carried out for fetal abnormality, such that no offence was committed under either the law relating to abortion or the Infant Life Preservation Act 1929 if a medical practitioner was involved within the clauses of the Abortion Act in this work. The main clause concerning termination for fetal abnormality is found in Section I(d) of the Act and this states that termination is permitted when two registered medical practitioners are of an opinion formed in good faith that ‘there is substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped’. This, therefore, forms the basis of legal termination of pregnancy for fetal abnormality in the UK. The stage of pregnancy at which the diagnosis is made and the time of pregnancy when the decision to perform a termination is made are crucial in terms of how the procedure may be performed. The decision to terminate a pregnancy because of fetal abnormality is often extremely difficult and it is vital that a comprehensive counselling service is available to the couple concerned before undertaking the procedure. This should involve multidisciplinary teamwork from obstetricians, midwives, geneticists and paediatricians, where appropriate. This complex area is dealt with in detail by Fisher and Staham.

The single fetal death in multiple pregnancy is not rare. Death of one fetus in multiple pregnancy increases the risk of mortality and morbidity of the surviving fetus. Proper diagnosis and intervention in appropriate time can improve the maternal and neonatal outcome. Adequate counselling psychological support and close follow up are mandatory. DOI: http://dx.doi.org/10.3329/medtoday.v26i1.21320 Medicine Today 2014 Vol.26(1): 69-70

Heterotopic pregnancy (HP) is a rare condition defined as the simultaneous presence of intrauterine pregnancy (IUP) and ectopic pregnancy (EP). It occurs in around 1/30000 of spontaneous pregnancie...

The prenatal diagnosis of an 11q;22q translocation in a triplet pregnancy detected at the time of chorionic villus sampling (CVS) because of advanced maternal age is reported. Karyo-types obtained from two apparently different CV samples showed the balanced form of translocation, while the one obtained from a third empty sac showed the unbalanced form: 46, XX, −22, + der(22)t(11;22). Second-trimester amniocentesis confirmed the balanced translocation in one of the two viable fetuses and a normal karyotype in the other. The detected karyotypes derived from two different types of meiotic segregation, alternate and adjacent 1. To our knowledge, this is the first reported case of an unbalanced karyotype not due to a 3:1 meiotic segregation of this specific translocation.

Evidence-based medicine (EBM) relies on judgement and applica-bility to the individual case as much as research hierarchy (Rawlins 2008). Th e complexity and clinical integration of EBM education into practice is underdeveloped (Malick et al. 2010). As the stated aim is to improve practice, the discipline of assessing and applying evidence can be illustrated using a complicated case with management path-ways broken into components. Maternal age (Engmann et al. 2001) and assisted reproduction account for rising incidence of higher-order pregnancies (Blondel and Kaminski 2002) paralleled by prematurity and its sequelae (Kiely et al. 1992; Millar et al. 1992; Luke 1994; Kiely and Kiely 2001). Th ere are no randomised trials regarding optimal gestation or mode of delivery, although most clinical series describe elective delivery by 37 weeks ’ gestation (Chang 2004). We describe the rationale for intervention in triplet pregnancy complicated by intrauterine growth ion t cstreri (IUGR).

Case reportA 27 year old woman booked at 12 weeks of gestationin her first pregnancy which was conceived sponta-neously. A booking scan diagnosed a monochorionicmonoamniotic triplet pregnancy, and serial weekly ultra-sound scans were arranged to monitor this potentiallyhigh risk pregnancy. An ultrasound scan at 16 weeksshowed marked entanglement of all three umbilicalcords. At 17 weeks a repeat scan suggested twin totwin transfusion, one of the fetuses being larger thanthe others. The risk of polyhydramnios was discussedwith the parents, and they were offered either serialamniodrainage or sulindac (Clinoril, APS, Generics) asa preventative measure. They opted for sulindac; this wasstarted at a dose of 400 mg orally daily.Subsequent scans demonstrated good growth of allthree fetuses, mild polyhydramnios and mild twin totwin transfusion involving two of the fetuses. No struc-tural abnormalities were identified and the Dopplerindices remained normal. The sulindac was stopped at25 weeks of gestation as the amniotic fluid volume wasreduced. At the same time, dexamethasone injectionswere started (two injections of 12 mg intramuscularlyonce a week). During the following weeks the fetusesgrew along the 5th to 10th centiles with normal growthvelocities and the amniotic fluid volume remained withinnormal limits. Delivery by elective caesarean section wasplanned for 34 weeks of gestation. AT 33 weeks of gesta-tion, however, the mother was admitted to the labourward with a history of spontaneous rupture of themembranes and onset of regular contractions. The cervixwas 4cm dilated, and an emergency caesarean sectionwas carried out without delay.The first triplet was delivered cephalic, the other two asbreech. There was difficulty in delivering the second andthird babies due to marked cord and limb entanglement.The babies’ weights were 1430, 1490 and 1410 g, respec-tively, and all were structurally normal. They requiredadmission to the neonatal intensive care unit for 11days, but all three were well on discharge. Their renalfunction remained normal throughout their admission.Histological examination confirmed a single placentaand a single amniotic sac Fig. 1 .DiscussionSuccessful delivery of live monoamniotic triplets hasnever previously been reported. Indeed, there is no recordin the literature of monoamniotic triplets even with a lessfavourable outcome. Consequently, the incidence of thiscondition, even in early gestation, is unknown, but it islikely to be very rare. Although the sonographic diagno-sis of amnionicity can be difficult

A monochorionic diamniotic triplet pregnancy was diagnosed by sonographic scan at 9 weeks of gestation. The three embryos appeared to share the same trophoblast, with two of them sharing the same amniotic sac. The two amniotic sacs were divided by a thin membrane, with no chorionic projection within it, and each amniotic sac presented a single yolk sac. Only few cases of nontrichorionic-triamniotic triplets have been reported in the literature. Although the diagnosis was reached using the two-dimensional ultrasound, the complementary use of three-dimensional ultrasound helped in confirming the diagnosis, and in offering the couple an adequate counseling. © 2011 Wiley Periodicals, Inc. J Clin Ultrasound, 2011

BACKGROUND Bed rest used to be widely advised for women with a multiple pregnancy. OBJECTIVES The objective was to assess the effect of bed rest in hospital for women with a multiple pregnancy for prevention of preterm birth and other fetal, neonatal and maternal outcomes. SEARCH STRATEGY The Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and reference lists of relevant articles were searched. Date of last search: August 2000. SELECTION CRITERIA Randomised trials which compare outcomes in women with a multiple pregnancy and their babies who were offered bed rest in hospital with women only admitted to hospital if complications occurred. DATA COLLECTION AND ANALYSIS Assessment for inclusion and methodological quality of the trials was done by the reviewer. Data were extracted by the reviewer and double entered. All eligible trials were included in the initial analysis. Prespecified sensitivity analyses have been carried out to evaluate the effect of trial quality, the effects of hospitalisation for bed rest in women with an uncomplicated twin pregnancy, in women with a triplet pregnancy and in women with a twin pregnancy complicated by cervical effacement and dilatation prior to labour. MAIN RESULTS Six trials were included which involved over 600 women and 1400 babies. (1) Analyses of all trials. Routine bed rest in hospital for multiple pregnancy did not reduce the risk of preterm birth, or perinatal mortality. There was a trend to a decreased number of low birth weight infants born to women in the routinely hospitalised group, which became significant when the trial using alternate allocation was excluded (odds ratio (OR) 0.79; 95% confidence interval (CI) 0.63-0.99). No differences were seen in the number of very low birth weight infants. No support for the policy was found in other neonatal outcomes. No information is available on developmental outcomes for infants in any of the trials. Women's views about the care they received were reported rarely. (2) Analyses of hospitalisation for bed rest in women with an uncomplicated twin pregnancy. The risk of preterm birth was not reduced. Indeed significantly more women gave birth very preterm (< 34 weeks gestation) (OR 1.84; 95% CI 1.01-3.34). No differences were seen in perinatal mortality, or in other neonatal outcomes. Women receiving hospitalisation for bed rest had a decreased risk of developing hypertension (OR 0.55; 95% CI 0.32-0.97), although this effect was no longer apparent when the trial using alternate allocation was excluded. (3) Analyses of hospitalisation for bed rest in women with a triplet pregnancy. Most of the comparisons made between the hospitalised and control groups suggest beneficial treatment effects from routine hospitalisation for bed rest. However all the differences observed between the experimental and control groups were compatible with chance variation. (4) Analyses of hospitalisation for bed rest in women with a twin pregnancy complicated by cervical effacement and dilatation prior to labour. No differences were seen in the risk of preterm birth, perinatal mortality, fetal growth or in other neonatal outcomes. REVIEWER'S CONCLUSIONS There is currently not enough evidence to support a policy of routine hospitalisation for bed rest in multiple pregnancy. No reduction in the risk of preterm birth or perinatal death is evident, although there is a suggestion that fetal growth is improved. For women with an uncomplicated twin pregnancy the results of this review suggest that it may be harmful in that the risk of very preterm birth is increased. Until further evidence is available to the contrary, the policy cannot be recommended for routine clinical practice.

Objective To test whether 17 alpha-hydroxyprogesterone caproate (17P) will reduce neonatal morbidity by increasing gestational age at delivery in triplet pregnancies. Study Design Double-blind, randomized clinical trial. Mothers carrying trichorionic-triamniotic triplets were randomly assigned (in a 2:1 ratio) to weekly injections of 250 mg of 17P or placebo, starting at 16-22 weeks and continued until 34 weeks. Primary outcome was composite neonatal morbidity. Results Fifty-six women were randomized to 17P and 25 to placebo. Composite neonatal morbidity occurred with similar frequency in the 17P and placebo groups (38% vs 41%, respectively; P = .71). Mean gestational age at delivery was not affected by 17P (31.9 vs 31.8 weeks; P = .36). There were 13 midtrimester fetal losses with 17P vs none with placebo ( P Conclusion In triplet pregnancy, prophylactic treatment with 17P did not reduce neonatal morbidity or prolong gestation but was associated with increased midtrimester fetal loss.

Objective To describe a case of successful triplet pregnancy after testicular sperm extraction (TESE) from a man with AZFc deletion and intracytoplasmic sperm injection (ICSI). Design Case report. Setting University hospital. Patient(s) A 38-year-old man affected by complete AZFc deletion and azoospermia. Intervention(s) Spermiogram, Y-chromosome microdeletion screening, TESE for sperm recovery from testicular tissue on the same day as ICSI, transfer of frozen-thawed embryos, vaginal ultrasound examination. Main Outcome Measure(s) The Y chromosome genetic status of an azoospermic patient who underwent TESE and ICSI, the fertilization and pregnancy outcome. Result(s) The patient was found to be azoospermic, and the deletion screening showed complete AZFc deletion. After TESE, the recovered testicular sperm were selected for ICSI. Three good quality embryos were obtained and were frozen due to ovarian hyperstimulation syndrome in the female partner. After transfer of the thawed embryos, a triplet pregnancy was diagnosed by vaginal ultrasonography at the seventh week of gestation. Two male and one female healthy babies were born. Conclusion(s) This is the first report of a successful triplet pregnancy after the transfer of frozen-thawed embryos in a couple in whom the male partner was azoospermic and a carrier of complete AZFc deletion. This deletion should not adversely affect a man's TESE retrieval prognosis or the fertilization, cleavage, and implantation of embryos. The offspring were healthy, although the two sons inherited the AZFc deletion.

The spontaneous occurrence of triplets is rare. With increased utilization of "assisted reproductive technologies," multifetal gestations have become more common. The empiric fetal risk for major malformation is approximately 3%. In a triplet pregnancy each fetus independently carries this risk so that the probability of having at least one malformed fetus is approximately 9%. It is much less likely to have 2 or 3 simultaneously but discordantly malformed fetuses in a multizygotic triplet gestation (.09% and .0027% risk, respectively). We report on the first case, to our knowledge, of an ovulation-stimulated triplet pregnancy complicated by 3-way discordance for major malformations diagnosed in the late second trimester by ultrasound. Fetus A was affected by congenital diaphragmatic hernia and trisomy 21; fetus B had encephalocele, a midline facial defect, and a cleft palate; and fetus C had evidence of unilateral claw hand but an otherwise normal fetal survey. At 19 weeks of gestation, fetus A was found to have spontaneously died, and a selective termination of triplet B was performed. We conclude: (1) the finding of a single major malformation in one fetus should lead to extensive search for malformations in all members of the pregnancy, and (2) the simultaneous occurrence of major malformations in more than one member of a multifetal gestation is a circumstance under which multiple selective termination deserves consideration. In this article we discuss important issues and caveats in the performance of selective termination for abnormal members of multifetal gestations.

In four cases of one twin pregnancy and three triplet pregnancies, efforts were made to prolong the pregnancy after the death of one foetus between 15th and 26th weeks of gestation. Two patients had a history of spontaneous abortion, three patients had undergone infertility treatment. In a further three cases the membranes ruptured prematurely in association with severe disturbance of the vaginal flora. Treatment consisted of rest in bed, sedation, and administration of magnesium and antibiotics. Neither cervical cerclage nor general IV tocolysis were performed. Although the pregnancies could be prolonged for 4, 22, 28, and 76 days, they all terminated before the 27th week, mainly due to ascending infection. Of the 11 children, two survived with no morbidity, two children (B and C of the third triplet pregnancy), died 2 and 19 days after delivery, respectively, and seven were stillborn. A comparison with prolongations of twelve twin and four triplet pregnancies reported in the literature, reveals the various concepts for treatment. After infection has been ruled out and the parents have been fully informed, efforts could be made to prolong the multiple pregnancy after the death of one foetus until the surviving child is viable. This requires intensive supervision.

It has been suggested that a minimum number (six) of cumulus-oocyte complexes (COCs) should be retrieved for fertilization to offer enough chances to ensure a pregnancy after a preimplantation genetic diagnosis (PGD) procedure. Therefore a decision to cancel a PGD cycle should be adequately weighted to offer the patients the highest chances to obtain a pregnancy. We describe a case where, after retrieving only three COCs suitable for fertilization, a triplet pregnancy was obtained. This case suggests that, although low numbers of COCs can reduce the effectiveness of the PGD procedure, other factors are involved in its final result. Thus, the opportunity of routinely cancelling such cycles should be reconsidered. In addition, this is, to our knowledge, the first case where sex selection was carried out to prevent the birth of carriers of the abnormal gene, and not of affected offspring.

Multiple pregnancies account for 3 % of all births. The incidence of triplet pregnancy is 1 in 8,100 pregnancies. However, use of in vitro fertilization and ovulation induction has increased the incidence of multiple pregnancies. The incidence of Mullerian defects in women with recurrent miscarriage is 5–10 % [1] and the incidence in late miscarriage and preterm births is more than 25 % [1]. The occurrence of triplet pregnancy in patients with a septate uterus and previous recurrent pregnancy losses is rare. The occurrence of intrauterine fetus death (IUFD) of two fetuses of the triplets with development of chronic disseminated intravascular coagulation (DIC) in the mother with survival of one fetus is all the more rare. Heparin has an important but controversial role in treatment of such cases.

Background: To estimate the normal level of adrenomedullin (AM) during multiple pregnancy. Methods: The study population consisted of 5 women with normal cycles, 130 women with normal pregnancy between 6 and 40 weeks of gestation, 93 women with twin pregnancy and 42 women with triplet pregnancy. Results: Total AM concentration in the first trimester (13.7 ± 0.58 fmol/ml), second trimester (26.8 ± 1.13 fmol/ml) and third trimester (37.8 ± 1.32 fmol/ml) in pregnant women was significantly higher than that in nonpregnant women (8.0 ± 0.71 fmol/ml). In each trimester, the maternal plasma concentrations of triplet-pregnant women were significantly higher than in twin and singleton-pregnant women. Umbilical venous AM levels (29.9 ± 2.63 fmol/ml) were higher than umbilical arterial AM (20.2 ± 2.04 fmol/ml). Conclusion: Since alterations in the AM concentration in maternal plasma may mediate compensatory vascular responses in the uterine circulation, it might be useful to know the normal level of AM during multiple pregnancy in order to detect abnormalities during multiple pregnancy.

The incidence of multiple pregnancies is increasing with the availability of assisted reproductive techniques. Preterm labor and preterm rupture of membranes are major complications in such pregnancies. Preterm delivery of the first fetus is often followed by delivery of the remaining fetuses. However, conservative management in such circumstances might allow for fetal lung maturity in the remaining fetuses.We present a case of conservative management of an in vitro-fertilized triplet pregnancy with early loss of the leading triplet. A 33-year-old woman in the 21st week of a triplet pregnancy delivered her one of the fetuses, 4 days after the preterm rupture of membranes. To save the surviving fetuses, ligation of the umbilical cord at the cervical level was performed. Patient received antibiotics, tocolytics and corticosteroids after then. The second and the third fetuses were successfully delivered by cesarean section in the 28th week of pregnancy, 43 days after the first fetus was born.We can improve the life expectancy of the retained fetuses by conservative management using tocolytics, antenatal steroids to stimulate lung maturation and antibiotics following the delivery of the first fetus.

Delayed interval delivery in twin pregnancies is an unusual occurrence, even moreso in triplet pregnancies. We report on a delayed interval delivery in a dichorionic triamniotic triplet pregnancy after in vitro fertilization (IVF). Because of severe twin to twin transfusion syndrome (TTTS), two fetuses demised at 22 weeks of gestation. One of the two fetuses spontaneously aborted at 25 weeks of gestation. The remaining live fetus and the second demised fetus were delivered by cesarean section 9 weeks later because of the occurrence of preeclampsia. This case indicates that delayed interval delivery in triplets is possible and that preeclampsia can occur after intrauterine demise of two fetuses.

Pregnancy in patients suffering from undifferentiated connective tissue disease (UCTD) represents a risk situation for both the mother and the child. SSA/SSB autoantibodies can determine neonatal lupus (NL) in the foetus, regardless of the maternal disease. Furthermore, pregnancy increases the risk of flares and evolution to differentiated connective tissue disease (CTD). We report an uncommon case in which these complications occurred in a mother and in her foetuses. A 37-year-old woman affected by UCTD developed systemic lupus erythematosus (SLE) after her triplet pregnancy. The only manifestation of neonatal lupus we observed in the three newborns was SSA positivity associated with asymptomatic transient neutropenia.

We report on an exceptional therapy with epidural anesthesia and tunnelling of the peridural catheter over a time period of 2-14 days in patients with threatening early preterm labor, intact membranes and vaginal engagement of the infants (4 singleton, 8 twin and 2 triplet pregnancies). A combination of bupivacaine (0.125%) and fentanyl (2 microg/mL) was used up to a maximum of 20 mL/h during the treatment period. Long-term follow-up of the infants was normal in 19/20 infants. The advantages, such as prolongation of pregnancy without maternal pain and disadvantages such as the risk of fetal and maternal infection and of sudden delivery are discussed. The online version of the Journal (see http://dx.doi.org/10.1515/jpm.2008.081_supp-1) allows video illustrations of a triplet pregnancy, in which the first triplet was born after one week of epidural anesthesia and the pregnancy continued under epidural anesthesia for the remaining two triplets staying with intact membranes in the vagina (delayed interval delivery) for six more days. The results of this pilot series suggest that prolongation of these pregnancies under epidural anesthesia might be an option in exceptional cases when viability is questionable or when corticosteroid therapy is desired before final delivery. Further evaluation of this strategy is needed but only in tertiary centers with 24-h presence of qualified obstetric and neonatal care and intensive surveillance.

In the early days of IVF, replacement of several embryos in order to compensate for low implantation rates in the human was considered good clinical practice. Lack of funding, suboptimal embryo culture and selection techniques and pressure from patients led to a staggering 50% of all children born after IVF/ICSI belonging to a set of multiples. The first step towards a more reasonable approach came when it was shown that transferring two or three embryos did not influence the pregnancy rate but only the triplet rate. Unfortunately, this step in the right direction did n ot result in a decrease of twins. Although the challenge of a triplet pregnancy is much greater than that of a twin, the epidemic size of iatrogenic twinning results in a more widespread negative effect on neonatal, perinatal and maternal outcome. The challenge is to combine excellent pregnancy rates with a reduction in twinning rate from 25–30% to 5–10%. The second step has received much attention but little following: elective single-embryo transfer (eSET). Published data indicate the feasibility to perform judicious eSET. This is definitely the case in good prognosis patients (less than 36 years of age, first or second IVF/ICSI trial) and if there is a choice from several embryos. Embryo selection, still on the basis of an optimized morphology assessment using strict criteria and time intervals, is essential. Apart from the preventive effect on the complications associated with many (but not all) twin pregnancies, both health-economic considerations and neonatal outcome considerations also underpin the value of SET. Cryopreservation is a useful tool in an optimal strategy and management of all oocyte harvests.

Nineteen women attending a special multiple pregnancy antenatal clinic with a triplet pregnancy were randomly allocated to either bed rest in hospital from 24 weeks gestation onwards until delivery, or to continue conventional outpatient management. Conclusions are limited by the trial size, but the study suggests that routine hospitalization for bed rest decreases the incidence of preterm delivery and light-for-gestational age infants and reduces the need for intensive neonatal care. Although still compatible with change variation, the observations, if confirmed in a larger randomized study, would have considerable implications for clinical practice. The policy needs further evaluation in a large multicentred collaborative study.

A case report is presented in which a triplet pregnancy ended in an immature delivery of triplet A at 20 weeks gestation, followed by a successful delay in delivery of 49 days of triplets B and C by means of a cervical cerclage and tocolysis. This is the first reported case in which two living infants could be vaginally delivered after a preceding vaginal delivery of the third infant in a triplet pregnancy.

SummaryWe report the obstetric outcome of 33 pregnancies in 32 women treated with pulsatile luteinising hormone releasing hormone (LHRH) for various causes of anovulatory infertility. Of the 35 births, one twin, one triplet and 30 singleton births occurred. Preterm intervention was necessary during two pregnancies (one singleton and the triplet pregnancy) as a result of deteriorating hypertensive disease of pregnancy. The twin pregnancy delivered spontaneously at 36 weeks while all the other singleton pregnancies proceeded to term. Patients with a low pre-treatment body mass index [maternal weight in kg/ (height in metres)2] had lighter babies than those who embarked on treatment with a normal body mass index. The instrumental and operative delivery rates were 22 and 16 per cent, respectively. The male-female sex ratio (singleton pregnancies) was 0.55. There were no congenital abnormalities detected at birth.

A case is reported of twin reversed arterial perfusion (TRAP) sequence in a triamniotic dichorionic triplet pregnancy conceived by in-vitro fertilization which was diagnosed at 25 weeks of gestation by colour Doppler sonography. It highlights the risk of monochorionicity-associated morbidity in multiple pregnancies obtained by assisted conception and stresses the importance of chorionicity determination by early ultrasound examination. Cytogenetic analysis of skin from the acardius showed trisomy 2 in all cells, whereas the karyotype in the monochorionic triplet was normal. This is an example of heterokaryotypic monozygotism where the chromosomal abnormality must have occurred during the early cleavage divisions. Aneuploidy as a possible aetiological factor of TRAP sequence is discussed.

Twenty-six triplet pregnancies were delivered over 6 years. Over 80% of pregnancies resulted after infertility treatment (21/26). Mean maternal age was 32. On average, the infants were delivered after 32 + 0 weeks; in 4 cases delivery was at

Objective To report an unusual case of congenital cervical atresia and tubal factor infertility, achieving triplet pregnancy through transmyometrial embryo transfer (ET) resulting in the delivery of healthy twins after multifetal pregnancy reduction (MFPR). Design Case report and literature review. Setting University hospital. Intervention(s) Controlled ovarian hyperstimulation, oocyte retrieval, in vitro fertilization, transmyometrial ET, MFPR procedure for triplet pregnancy. Patient(s) A 33-year-old patient with endometriosis-associated and tubal factor infertility who underwent uterovaginal canalization surgery for congenital cervical atresia 9 years ago. Main Outcome Measure(s) Successful delivery after transmyometrial ET followed by MFPR. Result(s) A total of three IVF cycles and four procedures of transmyometrial ET were performed. In the third cycle a triplet pregnancy was achieved. MFPR was performed 35 days after embryos transfer, two healthy babies delivered at 31 weeks gestation. Conclusion(s) With aggressive therapy, successful pregnancy is possible in similar patients.

The incidence of heterotopic/ectopic pregnancy has risen in recent years, largely due to more frequent use of ovulatory medicine and increased incidence of pelvic inflammatory disease. In a natural cycle, it is a very rare event. Most heterotopic/ectopic pregnancies are localized in the uterine tube and, usually, it is diagnosed when symptoms develop. We report the case of a 37 year-old, gravida 2, para 0, abortion 1 woman with no known risk factors for heterotopic pregnancy. The patient attended the emergency department because of acute abdominal pain. She was evaluated in our department and a heterotopic twin pregnancy in the tube was diagnosed by transvaginal sonography. Intrauterine pregnancy with positive fetal cardiac activity at 9 weeks of gestation according to crown-rump length measurement was detected. Laparotomy was carried out because of acute abdominal syndrome. Right ruptured tubal ectopic/heterotopic pregnancy and hemoperitoneum were diagnosed. Right salpingectomy was carried out. Pathology revealed monochorionic twin tubal pregnancy. In a review of the literature, this is first case of twin tubal pregnancy in one uterine tube. In conclusion, heterotopic pregnancy in twin form in the uterine tube is possible in natural cycles. Intrauterine pregnancy does not exclude extrauterine pregnancy in natural cycles.

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 p57(kip2) 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 beta-human chorionic gonadotrophin titers then fell to a normal level.

We present a unique, successful, triplet pregnancy in a septate uterus. At a dating scan, a triplet pregnancy was found – with monochorionic diamniotic (MCDA) twins in the left cavity and a singlet...

A case is reported of a transfusion syndrome in a triplet pregnancy with intrauterine death of two of the fetuses. This is an exceptional occurrence in a triplet pregnancy and raises the problem of the management of multiple pregnancies associated with the death of one or more of the fetuses. The problem of the method of delivery and the complications arising in triplet dizygotic pregnancies is discussed.

43 consecutive sets of triplet pregnancies progressing beyond 16 weeks and conceived following in vitro fertilisation at the Bourn Hallam Centre between 1984-1987 were included in the study. Follow-up information was available in the 31 sets born to United Kingdom residents. 91 live births resulted at an average gestation of 33 weeks and 2 days (range 26-38 weeks). All but one of the deliveries was by Caesarean section. The average birth weight was 1.85 kg and was significantly higher in the first-born triplet than in the third (1.93 kg versus 1.74 kg, respectively). The perinatal mortality rate amongst the triplets was 32.26 per thousand births, and the neonatal death rate was 21.98 per thousand live births. This compares favourably with the latest published data on perinatal mortality rates in triplets.

A triplet pregnancy in a 23-year-old woman was terminated at 15 weeks of gestation because of her severe hypertension, lung edema, and secondary hyperthyroidism. The pregnancy consisted of a hydatidiform mole with a 46,XY karyotype and two fetuses each with 46,XX and a 46,XY karyotype. To determine the zygosity and genetic origin of the mole and fetuses, PCR- and computer-assisted genotyping were performed at 27 CA-repeat marker loci that were distributed evenly over the genome. As a result, genotypes of the three pregnancy products were distinct from each other, indicating that the triplets were trizygotic. The mole lacked any maternal alleles but inherited both of the paternal alleles and/or one paternal allele in duplicate. This, along with the XY sex chromosome constitution, indicated that the mole resulted from dispermic androgenesis. The mother developed a persistent trophoblastic tumor thereafter.

The management of delayed delivery in a triplet pregnancy is described. A 25-year-old woman with an in vitro fertilization pregnancy aborted the presenting fetus at 19th gestational week. As she decided to carry on, cervical cerclage, tocolysis and antimicrobial prophylaxis were performed. The remaining fetuses survived until 29th gestational week. Prolongation of multiple pregnancies after the abortion of presenting fetuses is a possible approach, which is especially justified in women with a history of infertility.

Objective To present a case report of a unilateral triplet ectopic pregnancy (EP) conceived by IVF–embryo transfer. Design Case report. Setting University Hospital, Budapest, Hungary. Patient(s) A 26-year-old infertile woman with a history of right salpingectomy, hyperprolactinemia, and male factor infertility underwent IVF–embryo transfer of three embryos. Early transvaginal sonography revealed a triplet pregnancy in the left fallopian tube (two at interstitial and one at ampullary location). Intervention(s) Multiple dose methotrexate (MTX) therapy was applied. Main Outcome Measure(s) Follow-up pelvic ultrasounds and laboratory testing confirmed fetal cardiac activity cessation and decreasing β-hCG levels. Result(s) In spite of the decreasing β-hCG levels the tube's diameter increased, the patient's symptoms escalated, and finally, the level of hemoglobin and hematocrit decreased. Laparotomy was performed with the removal of the left tube and cornual part of the uterus. Conclusion(s) Our case represents a very rare condition, a unilateral triplet EP after IVF–embryo transfer—the first one ever reported in the literature. After IVF–embryo transfer early ultrasound examinations are important to identify EPs at an early stage when medical management can still be taken into consideration. Strict monitoring is necessary to identify the success of medical intervention or the need for surgery.

Objective: To report on a patient with a quintuplet pregnancy consisting of a monochorionic triamnionic triplet pregnancy and one case of monoamniotic twins after intracytoplasmic sperm injection (ICSI), laser-assisted hatching, and day 4 embryo transfer. Case Report: A 34-year-old woman who underwent ICSI due to male infertility. She underwent standard controlled ovarian hyperstimulation. Retrieved oocytes were fertilized in vitro, and 3 embryos were transferred on day 4 after laser-assisted hatching. Transvaginal ultrasound revealed a monoamniotic twin pregnancy and a monochorionic-triamniotic triplet pregnancy. A second ultrasound, 1 week later, showed three distinct foci of cardiac motion in one sac, while the sac of the monoamniotic twins had one embryo with heart beat. After extensive counseling with perinatologists about pregnancy complications, the patient elected to performed fetal reduction on the third sac. A healthy male infant was delivered by Caesarean section at 38 weeks of gestation. Conclusions: The exact mechanism of monozygotic multiple gestation is still poorly characterized. Procedures that modify the zona pellucida (e.g. ICSI and assisted embryo hatching) have been suggested as important in the monozygotic multiple gestation hypothesis, yet a definitive relationship between any clinical intervention during in vitro fertilization and the subsequent development of multiple monozygotic gestation remains speculative.

A hármasiker-fogamzás felismerését követően a várandósok számára részletes felvilágosítást kell nyújtani a hármasiker-terhesség kihordásának kockázatairól, a trigemini terhességből származó újszülöttek esélyeiről, amely alapján valóban körültekintő döntést tudnak hozni a terhesség továbbviseléséről, illetve a redukció lehetőségének igénybevételéről. Célkitűzés: A magyar hármasiker-populáció reprezentatívnak tekinthető, nagy esetszámú mintáján az anyai életkor mint kockázati tényező vizsgálata az anyai szövődmények és a perinatalis eredmények elemzésével. Módszer: Retrospektív kohorsz tanulmányunkban az I. sz. Szülészeti és Nőgyógyászati Klinikán az 1990. július 1. és 2006. június 30. közötti időszakban szüléssel végződött 114 hármasiker-terhességet vizsgáltuk. Eredmények: A vizsgált hármasiker-terhes populációban 15 beteg volt 35 éves vagy annál idősebb (35–39 éves) a szüléskor (13,2%), 99 várandós pedig 35 évnél fiatalabb (20–34 éves) (86,8%). A terhesség alatt jelentkező anyai szövődmények hasonló arányban voltak megfigyelhetők a két vizsgált csoportban, és nem volt szignifikáns különbség a szüléskor betöltött átlagos terhességi kort tekintve (33,0 ± 2,9 és 32,2 ± 3,3 hét), valamint az igen éretlen (6,7% és 9,1%) és éretlen koraszülések (32,9% és 43,4%) arányában, bár mindhárom jellemző a 35 év felettieknél mutatott kedvezőbb értéket. Az élve született újszülöttek átlagos születési súlya magasabb volt a 35 év feletti betegek csoportjában (1796 ± 492 és 1664 ± 506 g, p = 0,064), és az igen-igen kis súlyú (6,8% és 10,7%), valamint az igen kis súlyú újszülöttek aránya (34,1% és 38,6%) is alacsonyabb volt ebben a csoportban. A 35 év feletti várandósok újszülöttjeinek egyperces és ötperces Apgar-értéke szignifikánsan magasabb volt (8,4 ± 0,5 és 8,0 ± 1,0, p = 0,016, valamint 9,5 ± 0,7 és 9,2 ± 0,8, p = 0,006). A perinatalis halálozási mutatók nem jeleztek szignifikáns különbséget a két csoport között, és a puerperalis szövődmények tekintetében sem volt különbség. Sepsis/pneumonia ritkábban fordult elő a 35 év feletti betegek újszülöttjeinek körében (6,9% és 28,6%, p = 0,011), és ebben a csoportban lélegeztetésre is ritkábban volt szükség (31,0% és 58,2%, p = 0,011). A többi újszülöttkori szövődmény közel azonos arányban fordult elő a két csoportban. Következtetések: Bár a terhesség alatt és a gyermekágyas időszakban bizonyos anyai szövődmények kockázata magasabb idősebb életkorban, a kedvezőbb perinatalis eredmények és neonatalis morbiditási adatok alapján az idős anyai életkor hármasiker-terhességben kockázatot csökkentő (protektív) tényező.

Objectives: Mirror syndrome is the association of triple edema, i.e. fetal, placental and maternal edema, with maternal preeclampsia. We here report the first case of mirror syndrome resulting from hydropic acardius in triplet pregnancy. Methods/Results: A 26-year-old nulliparous woman spontaneously conceived two living fetuses and one acardius, and suffered preterm rupture of the membranes at 23 2/7 weeks of gestation. We observed triple edema, hydropic acardius, placental edema, and maternal edema, together with maternal high blood pressure, proteinuria and low hematocrit, and therefore suspected the presence of mirror syndrome. Due to the prematurity of the fetuses, we closely observed her, awaiting fetal maturity. Three days later (23 5/7 weeks), cord prolapse occurred, leading to emergent cesarean section. Female infants, weighing 492 and 554 g, respectively, were born alive; the former died on the 13th postnatal day and the latter was healthy with no sequelae. An acardius weighing 860 g had vascular communication with the 492-gram fetus. Histological examination confirmed a monochorionic, triamniotic single placenta. The mother suffered from pulmonary edema and was treated in the intensive care unit under respiratory support, but soon improved. Conclusions: When dealing with multifetal pregnancy, especially when complicated by an acardius, obstetricians must have the highest level of concern for the occurrence of mirror syndrome, a life-threatening condition both to the mother and the fetus.