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Purpose: The association between birth order and adverse perinatal outcomes has been well studied in twin pregnancies. However, little is known about the differences in immediate perinatal outcomes as well as long‐term hospitalization of the offspring in triplet pregnancies according to their birth order. As such, we aimed to assess the differences in immediate perinatal outcomes and long‐term hospitalizations among triplets by their birth order. Methods: In a retrospective hospital‐based cohort study, immediate perinatal outcomes and long‐term hospitalizations were compared among triplet siblings according to their birth order. Deliveries occurred between the years 1991 and 2021 in a tertiary medical center. The study groups were followed until 18 years of age for cardiovascular, respiratory, neurological, and infection‐related hospitalizations. Generalized estimation equation (GEE) models were used to control for confounders. Kaplan–Meier survival curves were used to compare cumulative long‐term hospitalization incidences and Cox proportional hazards models were performed to control for confounders. Results: The study included 117 triplet deliveries. Rates of small for gestational age (SGA) infants increased linearly by birth order (6.0%, 7.7%, and 15.4% for the first, second, and third siblings, respectively; p‐value for trends = 0.035). Using a GEE model controlling for maternal age, being born third in a triplet pregnancy was independently associated with SGA (third vs. first sibling, adjusted OR 3.0, 95% CI 1.38–6.59, p = 0.005). No significant differences in cardiovascular, respiratory, neurological, and infection‐related hospitalizations were noted among the first, second, and third siblings. Likewise, using Kaplan–Meier survival analyses, no significant differences in the cumulative incidence of long‐term pediatric hospitalizations were noted between the siblings. In Cox proportional hazards models, controlling for weight and gender, birth order in a triplet pregnancy did not exhibit an association with long‐term hospitalizations of the offspring. Conclusion: Despite the association between birth order and SGA, birth order in triplets does not seem to have an impact on the risk for long‐term offspring hospitalization. [ABSTRACT FROM AUTHOR]

Triplet pregnancies involve several complications, the most important being prematurity as virtually all triplets are born preterm. We conducted this study to compare the outcomes of reduced vs. non-reduced triplet pregnancies managed in the largest tertiary hospital in Finland. This was a retrospective cohort study in the Helsinki University Hospital during 2006–2020. Data on the pregnancies, parturients and newborns were collected from patient records. The fetal number, chorionicity and amnionicity were defined in first-trimester ultrasound screening. The main outcome measures were perinatal and neonatal mortality of non-reduced triplets, compared to twins and singletons selectively reduced of triplet pregnancies. There were 57 initially triplet pregnancies and 35 of these continued as non-reduced triplets and resulted in the delivery of 104 liveborn children. The remaining 22 cases were spontaneously or medically reduced to twins (9) or singletons (13). Most (54.4 %) triplet pregnancies were spontaneous. There were no significant differences in gestational age at delivery between triplets (mean 33+0, median 34+0) and those reduced to twins (mean 32+5, median 36+0). The survival at one week of age was higher for triplets compared to twins (p<0.00001). Most pregnancies continued as non-reduced triplets, which were born at a similar gestational age but with a significantly higher liveborn rate compared to those reduced to twins. There were no early neonatal deaths among cases reduced to singletons. Prematurity was the greatest concern for multiples in this cohort, whereas the small numbers may explain the lack of difference in gestational age between these groups. [ABSTRACT FROM AUTHOR]

Multiple pregnancies involve several complications, most often prematurity, but also higher anomaly rates. Reducing fetuses generally improves pregnancy outcomes. We conducted this study to evaluate the obstetrical and neonatal results after multifetal pregnancy reduction (MFPR) in the largest tertiary hospital in Finland. This retrospective cohort study included all MFPR managed in Helsinki University Hospital during a 13 year period (2007–2019). Data on pregnancies, parturients and newborns were collected from patient files. The number of fetuses, chorionicities and amnionicities were defined in first-trimester ultrasound screening. There were 54 MFPR cases included in the final analyses. Most often the reduction was from twins to singletons (n=34, 63 %). Majority of these (25/34, 73.5 %) were due to co-twin anomaly. Triplets (n=16, 29.6 %) were reduced to twins (n=7, 13 %) or singletons (n=9, 16.7 %), quadruplets (n=2, 3.7 %) and quintuplets (n=2, 3.7 %) to twins. Most (33/54, 61.1 %) MFPR procedures were done by 15+0 weeks of gestation. There were six miscarriages after MFPR and one early co-twin miscarriage. In the remaining 47 pregnancies that continued as twins (n=7, 14.9 %) or singletons (n=40, 85.1 %) the liveborn rate was 90 % for one fetus and 71.4 % for two fetuses. Most MFPR cases were pregnancies with an anomalous co-twin. The whole pregnancy loss risk was 11.1 % after MFPR. The majority (70.6 %) of twins were spontaneous, whereas all quadruplets, quintuplets, and 56.3 % of triplets were assisted reproductive technologies (ART) pregnancies. Careful counselling should be an essential part of obstetrical care in multiple pregnancies, which should be referred to fetomaternal units for MFPR option. [ABSTRACT FROM AUTHOR]

Multifetal gestations are at increased risk for structural anomalies relative to singletons. Determination of chorionicity is critical, as the risk is highest for monochorionic pregnancies. In a singleton gestation, counseling is structured around optimization of fetal outcomes and careful consideration of the patient's choices in management decisions. However, in multifetal gestations affected by a fetal anomaly, complex counseling with consideration for the pregnancy as a whole is necessary. We review the incidence of structural anomalies in twins and highlight unique considerations including selective termination for discordant anomalies. We emphasize the role of shared decision making between provider and patient. [ABSTRACT FROM AUTHOR]

Compared with singleton pregnancies, triplet pregnancies are associated with a significantly increased risk of adverse pregnancy outcomes. Early ultrasound examination is the best way to diagnose triplets, establish dating, and determine the number of placentas to provide appropriate counseling and monitoring. Dichorionic placentation adds risks specifically associated with a shared placenta, and limits options for intervention. Multifetal reduction is an option that can significantly improve pregnancy outcomes compared with non-reduced triplet pregnancies. Integration of a Maternal-Fetal Medicine specialist in the prenatal care for a triplet pregnancy reduces the risk of preeclampsia, preterm birth, low birthweight infants, perinatal mortality, and major neonatal morbidity. [ABSTRACT FROM AUTHOR]

Objective: In this study, we aimed to evaluate the perinatal outcomes of dichorionic diamniotic (DCDA) twin pregnancies reduced by the fetal reduction (FR) procedure and cases with continuing DCDA twin pregnancies without FR. Materials and Methods: FR performed in a university hospital in the last 10 years was evaluated. Pregnancies reduced to DCDA twin pregnancies by reduction from three or more pregnancies and pregnancies that started with DCDA twins and continued with DCDA twins were compared in terms of perinatal outcomes. In the subgroup analysis, those who were reduced from three‐chorionic three‐amniotic (TCTA) triplets to DCDA twins and those who were reduced to DCDA twin pregnancies from four or more were compared in terms of perinatal outcomes. Results: A total of 119 pregnant women were included in the study, 36 patients underwent FR, while 83 patients were DCDA twins who did not undergo FR. The groups were similar in terms of preterm delivery (p = 0.370). There was a higher rate of miscarriage (21.4% vs. 0.0%, p = 0.019) in the group that was reduced to DCDA twins from quadruplet and above pregnancies compared to the group that was reduced from TCTA triplets to DCDA twins. The gestational week at birth was lower in the group reduced to DCDA twins from quadruplets and above pregnancies (31.00 ± 4.31 vs. 34.64 ± 2.88, p = 0.019). Conclusion: The study's results show that the perinatal outcomes of multiple pregnancies with and without FR are the same As the number of reduced fetuses increases, the rates of preterm birth and miscarriage also increase. [ABSTRACT FROM AUTHOR]

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

Objective: The rate of multiple pregnancies increases the number of pregnancies conceived using assisted reproductive techniques. Although the studies indicate a positive effect of multi-fetal pregnancy reduction on pregnancy outcomes, procedure-associated miscarriages should be considered. Therefore, our study aimed to evaluate the outcomes of pregnancies that have undergone multi-fetal reduction and compare the pregnancies' outcomes without any intervention. Material and Methods: Patients from the Perinatology Clinic of Şanlıurfa Training and Research Hospital were selected between July 2017 and May 2021. The patients in the study group were divided into two groups: those with or without multi-fetal reduction. Obstetric outcomes of pregnancies were compared between the groups. Results: During this period, 95 gestations with three or more fetuses were applied to our clinic. Eighteen multi-fetal reduction procedures were performed because of multiple pregnancies. Reductions were performed from five to twins in one case, triplets to twins in ten, and quadruplets to twins in seven cases. Patients preferred to continue pregnancies without intervention in 6 quadruplets, one sextile, and 66 triplet pregnancies. Mean gestational age at birth in the intervention group was 34.43±0.40 (32-38) weeks, while in the non-intervened group, that was 30.46±0.48 (24-37) gestational weeks. Gestational age at birth was significantly lower in the non-intervention group. (p: 0.000029). Conclusion: Multi-fetal reduction is beneficial in preventing preterm delivery. [ABSTRACT FROM AUTHOR]

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

Abortion continues to be a hotly debated topic in the United States, despite the majority of the populace endorsing it as a legal right. The June 2022 ruling from the Supreme Court turned the legal question about abortion back to the states, which will drastically reduce abortion services in the country and confine abortion access mainly to the coasts. The intersection between abortion and a pregnancy achieved using assisted reproductive technology is one that lacks understanding. While presumed to be rare, as data is not collected in the US about abortions, this intersection exists but is understudied. This paper illuminates the little that we know to date about this intersection as well as where our knowledge is profoundly lacking. Creating a better sense of understanding will enable clinics to counsel patients appropriately when the intersection arises. [ABSTRACT FROM AUTHOR]

Objective: Determine the impact of indication for selective reduction (SR) on co-twin survival in monochorionic gestations undergoing radiofrequency ablation (RFA) or bipolar cord coagulation (BCC).Methods: PubMed and Web of Science were systematically searched from inception of databases to April 2021. Frequency of indications was compared between post-intervention co-twin survival and demise groups undergoing SR. Random-effect model was used to pool mean differences or odds ratios (OR) and corresponding 95% confidence intervals (CIs). Heterogeneity was assessed using the I2 value.Results: Of 1060 studies assessed for eligibility, nine studies met criteria. A total of 666 pregnancies underwent RFA (n = 483 co-twin survival) and 235 pregnancies underwent BCC (n = 188 co-twin survival). Twin twin transfusion syndrome (TTTS), as an indication for RFA, was associated with decreased co-twin survival (OR 0.61, 95% CI 0.41, 0.90, P 0.01, I2 0.0%). Other indications for RFA were not associated with significant difference in co-twin survival. With BCC, none of the indications were found to significantly influence the co-twin survival following intervention.Conclusion: RFA was found to have lower co-twin survival when performed for TTTS. No other indications was associated with differences in co-twin survival. BCC was not associated with any differences in co-twin survival based on indication. [ABSTRACT FROM AUTHOR]

Objective: To study the obstetric and neonatal outcomes of reduction to singleton and twin pregnancies by multifetal pregnancy reduction (MPR) in patients with triplet pregnancies. Methods: The multifetal reduction was performed in 27 patients with triplet pregnancies. Fourteen patients were reduced to singleton pregnancies and 13 patients to twin pregnancies. Obstetric and neonatal outcomes were compared between the two groups. Results: The mean gestational age at the time of the procedure was 12.43±0.76 weeks in patients reduced to singleton pregnancies and 12.08±0.64 weeks in those reduced to twin pregnancies. The most common complications of the procedure were abdominal pain (21.4%) in women with singleton pregnancies and both the presence of abdominal pain and vaginal bleeding (30.8%) in women with twin pregnancies. Gestational age at birth (33.07±5.73 versus 35.78±6.14 weeks, p=0.009) and neonatal birth weight (1998.46±808.07 versus 2765±803.03 gram, p=0.003) was significantly higher in the group reduced to singleton pregnancies than in twin pregnancies. Conclusion: The MPR procedure is a good and acceptable option for patients with multiple pregnancies of three or more children. Multifetal pregnancy reduction of triplets to singletons is associated with better pregnancy outcomes such as birth at higher weeks of gestation and higher neonatal birth weight than MPR of triplets to twins. [ABSTRACT FROM AUTHOR]

The selective termination of one or more fetuses in higher order multiple pregnancies began in the 1980s in response to the increased rate of multiples arising from assisted reproductive technology (ART). Multifetal Pregnancy Reduction (MFPR) was justified by improving outcomes for the remaining offspring and their mother, and while the evidence suggests prematurity and the morbidity associated with it are reduced, there is a cost in increased miscarriage and mortality. As perinatal care has advanced, the margins of improvement have narrowed and hence the cost/benefit ratio. At the same time, MFPR has morphed from a rare procedure undertaken for quadruplets and higher, to one in which triplets and twins are increasingly reduced to a singleton, and more so for social reasons. This review considers the evidence for MFPR's efficacy and risks, along with those changes over time. Notably absent is research on the surviving children or the ongoing physical and mental health of mothers. The ethical reasoning used by practitioners and others is also explored, as is the culture of ART and abortion that drive the practice. [ABSTRACT FROM AUTHOR]

Objective: The aim of the study was to compare the effect of early or late fetal reduction (FR) procedures on perinatal outcomes in multiple pregnancies reduced to twins or singletons.Study Design: This retrospective cohort study consisted of data from a single tertiary center between January 2013 and December 2020 and included 103 women with multiple pregnancies between 8 and 14 gestational weeks and who underwent FR by transabdominal approach. Late FR was defined as 11-13 6/7 gestational weeks (Group L) and early FR was defined as 8-10 6/7 gestational weeks (Group E) in the study. All pregnancies with FR were named Group S (Single) if reduced to singletons and Group T (Twin) if reduced to twin pregnancies.Results: Thirty four percent (n = 35) were reduced to single pregnancy, the remaining 66% of these cases (n = 68) were reduced to twin pregnancy. The overall survival rate was 90%.When the cases were examined in terms of pregnancy complications, it was observed that the PPROM rate and preterm labor rate in the Group T were statistically significantly higher than the Group S (p = 0.015 and p < 0.001, respectively). When comparing the overall survival results between Group S and Group T, it was found that the overall survival of Group S was statistically significantly better (p < 0.001). When Group E and Group L were compared in terms of their pregnancy course and neonatal outcomes, no statistically significant difference was found between them. No statistically significant difference was found between the complication rates in the first week after the procedure (p < 0.05). Neonatal intensive care need was found at a rate of 31% in those with Group E, while this rate was found as 39% in Group L, and this difference was also not statistically significant (p = 0.480). When the preterm labor rate was compared between these two groups, there was no statistically significant difference in all three subgroups (<32nd, <34th, and <37th gestational weeks).Conclusion: When FR to singleton is required for fetal or maternal reasons, it should be discussed with the parents that the risk of fetal loss is similar to FR to twins, but the effect on perinatal survival is more favorable than expected. [ABSTRACT FROM AUTHOR]

Objective: The management of multiple pregnancies is still a challenge. The aim of this study was to compare the outcome of triplet pregnancies managed expectantly or by multifetal pregnancy reduction to twins.Study Design: For this retrospective, comparative and monocentric study, the medical files of all women with triplets who admitted to our institution over a 13-year period were examined. Women requesting multifetal pregnancy reduction to have twins formed the study group, and women with triplets who wished to continue their pregnancies formed the control group. Main outcome measures were durations of pregnancies presented as number of weeks gestation, abortion rates, term and preterm birth rates, fetal loss and live birth rates.Results: During the study period, 171 women with triplets admitted to our institution. One hundred fifty one patients are included in this study. Forty-five women carrying triplets wished to continue their pregnancies and 106 women requested multifetal pregnancy reduction to have twins. Fetal reduction of triplets to twins was associated with a significantly lower incidence of birth before 34th gestational week and higher incidence of late preterm and term birth rates without changing live birth rates.Conclusion: Multifetal pregnancy reduction of triplet pregnancies to twins resulted in a later gestational age at birth compared with the triplet gestations managed expectantly. [ABSTRACT FROM AUTHOR]

Objectives: The aim of the study was to investigate decision making for or against multifetal pregnancy reduction (MFPR) and psychological outcome in women with a triplet pregnancy.Methods: We investigated medical and sociodemographic variables and characteristics of the decision process for or against MFPR in forty women with triplet pregnancies who had either undergone MFPR (MFPR-group: N = 10) or had delivered triplets (triplet-group: N = 30). Moreover, emotional experiences of the reduction procedure were assessed. Psychological outcome was measured using the Beck Depression inventory (BDI) and the 36-Item Short Form Health Survey (SF-36).Results: Women of the MFPR-group had a higher gestational age at delivery (p = 0.001), shorter NICU stay (p = 0.001), higher educational level (p = 0.010), more frequently utilized psychological counseling during the decision process (p = 0.016), rated their gynecologist as more helpful for the decision (p = 0.045), required more time for their decision (p = 0.016), and were more likely to be in paid employment at follow-up (p = 0.041) than women of the triplet-group. MFPR was experienced as stressful (90%) or terrifying (10%). At 3.2 (±2.2) years after delivery, the vast majority of women in both groups were free from clinically relevant depression.Conclusions: MFPR, though associated with emotional distress related to the procedure, results in a satisfactory psychological outcome in the majority of women. The decision for or against MFPR may be related to sociodemographic (such as educational) variables, which further supports the concept of framing in medical decision making. Having triplets most probably is associated with multiple (e.g. social or economic) consequences that may remain poorly investigated. [ABSTRACT FROM AUTHOR]

Objectives: In trichorionic triplet pregnancies, multifetal pregnancy reduction (MFPR) reduces the risk of preterm birth, neonatal morbidity and mortality without increasing miscarriage. A similar benefit has been suggested in dichorionic triamniotic (DCTA) pregnancy, but multiple methods are currently used. This study investigates if the method of reduction used in DCTA triplet pregnancy influences the evidence of benefit from MFPR.Methods: This is a retrospective cohort study of DCTA pregnancies between 2010 and 2019 who attended a single UK fetal medicine tertiary referral center. Cohorts were defined based on MFPR decision and method. The primary outcome was offspring survival until neonatal discharge. The secondary outcomes included miscarriage, preterm birth, livebirth, rates of small for gestational age (SGA) neonates, ans maternal morbidity. To evaluate the differences in neonatal survival until discharge we used Cox proportional regression to calculate hazard rates (HR) and 95% confidence intervals (CI). Differences in secondary outcomes were compared using univariate analysis.Results: The study reports the outcomes for 83 DCTA pregnancies. MFPR to DCDA twins was chosen in 19 pregnancies (14 radiofrequency ablation, RFA; 5 intrafetal laser, IFL); in 9 pregnancies selective reduction to a singleton was performed by KCl injection. The rate of pregnancies in with ≥ 1 fetus born alive was not different between groups (p = 0.90). However, the number of expected neonates alive at discharge from hospital was highest in the RFA group (89%, HR 0.28, 95% CI 0.21-0.87, p = 0.02). Rates of premature delivery before 32 weeks (p = 0.02), low birth weight (p < 0.001) and birthweight < 10th percentile (p = 0.01) were all elevated in the expectant management group, compared to women who opted for reduction. There was no difference in miscarriage between groups.Conclusions: Our study suggests that MFPR by RFA, an established and widely available procedure, is of benefit in promoting neonatal survival until discharge in DCTA triplets. [ABSTRACT FROM AUTHOR]

Selective termination is the term used for the elimination of an abnormal fetus. In contrast, multifetal pregnancy reduction refers to the termination of one or more members of a twin or higher-order multiple birth set, respectively, to reduce the high risks associated with these pregnancies. The procedure can also be used when a serious physical condition is detected prenatally in a member of a multiple birth set. In a minority of cases, selective termination has reduced two healthy fetuses to one when parents wanted just one additional child in the family. In the present article, the perspectives of a surviving twin whose family wished to terminate both healthy fetuses are examined. Next, past and present twin studies of primordial dwarfism, public service motivation, an analytical model, the global twinning rate and germline differences are summarized. The article concludes with a synopsis of twin-related news that covers twins and Dyngus Day, triplets born in an Austrian displaced persons' camp, the film Superior - about estranged identical twin sisters, a couple adopting their own twins after surrogacy and a new case of twins and primordial dwarfism, a condition introduced in the research reviews. [ABSTRACT FROM AUTHOR]

Aim: To evaluate the theme trends and knowledge structure of multifetal pregnancy reduction (MPR)‐related literature by using bibliometric analysis. Methods: Published scientific papers regarding MPR were retrieved from the PubMed database. Data extraction and statistics were conducted using Bibliographic Item Co‐Occurrence Matrix Builder (BICOMB). Furthermore, gCLUTO software was used in the study for bi‐clustering analysis and strategic diagram analysis. Results: According to the search strategy, 906 total papers were included. Among all the extracted MeSH terms, 41 high frequency ones were identified and hotspots were clustered into four categories. In the strategic diagram, research on intrauterine treatment of MPR was most well developed. In contrast, statistical data on the sequelae of fetal reduction surgery and applications of MPR in assisted reproductive technologies were relatively immature. Conclusion: The analysis of common terms among the high‐frequency network terms in multiparous pregnancy reduction can help researchers and clinicians understand the hotspots, key topics, and issues to be discovered on MPR. Research on intrauterine treatment of MPR was most well developed. [ABSTRACT FROM AUTHOR]

Objective: We examined the potential value of combining ultrasound and non-invasive prenatal screening (NIPS) of maternal blood to screen for major aneuploidies as an early approach before selective fetal reduction from twin pregnancy to singleton.Study Design: The sample was composed of pregnant women with di-chorionic di-amniotic twins who chose to undergo fetal reduction to singleton at 12-24 weeks of gestation. These women were asked to provide a blood sample for cell-free fetal DNA (cffDNA) testing prior to fetal reduction.Results: A total of 24 pregnant women with a twin pregnancy prior to fetal reduction to singleton were enrolled. There were 8 cases with structural anomalies (33.3%) in one twin that dictated fetal reduction. The proportion of patients who underwent selective fetal reduction for fetal abnormalities was larger than in several other studies. The NIPS identified 1 case of Trisomy 13 (4.2%). The other 15 cases (62.5%) had no structural or chromosomal anomalies. The decision to undergo elective reduction of twin pregnancy to singleton was made for social reasons or upon the parents' request. Given the 33% of structural anomalies in the cohort, a cost analysis indicated that this procedure was 6.6-fold less expensive (vs. 4.6-fold with 4% structural anomalies in other publications) than conducting invasive procedures for the entire cohort.Conclusion: The findings suggest that an early anatomical scan and cffDNA can increase the overall safety margin and reduce interventional procedures before elective reduction of twin pregnancy to singleton. However, a larger cohort is needed to confirm these results. [ABSTRACT FROM AUTHOR]

Objective: Twin-twin transfusion syndrome (TTTS) is a condition that complicates 10-15% of monochorionic twin pregnancies. Fetoscopic laser photocoagulation (FLP) is an established treatment. Selective fetal reduction (SFR) is one of the treatment options for TTTS. SFR can be performed by various methods. Intrafetal laser is a medical procedure that uses lasers to treat certain conditions in fetuses while they are still in the womb. TTTS is used to treat conditions such as selective intrauterine growth restriction (sFGR), twins with reverse arterial perfusion (TRAP) and fetal tumours. Here we report a rare case of intrafetal laser for SFR in a late-gestation MCDA twin pregnancy complicated by TTTS. Case: A 26-year-old woman was referred to our clinic with a G2P1Y1, MCDA twin pregnancy at 20 weeks and 5 days. The first-trimester ultrasound was unremarkable. We diagnosed Quintero stage 4 by ultrasound. The following day, the patient underwent fetoscopic laser photocoagulation under general anaesthesia. The procedure was surgically successful and no intra- or post-operative complications were observed. Worsening hydrops in the recipient fetus and Doppler flow abnormalities in the ductus venosus were noted at 3 weeks after the procedure. The selective fetal reduction was offered to the recipient fetus. SFR was performed by intrafetal laser at 24 weeks gestation. Pregnancy is currently ongoing. At 34 weeks, the fetus currently has FGR. However, pregnancy followup will continue as Doppler flow is good. Discussion: TTTS is a serious complication of monochorionic twin pregnancies. SFR is a treatment option for TTTS, especially in late stages or with a poor prognosis. SFR can be performed using several techniques, including umbilical cord occlusion, radiofrequency ablation, bipolar coagulation and intrafetal laser therapy. Intrafetal laser therapy is an innovative approach that uses ultrasound guidance to deliver laser energy to the body or organs of a specific twin fetus. This treatment modality has been shown to treat a variety of conditions including TTTS, Selective Fetal Growth Restriction (sFGR), Twin Reverse Arterial Perfusion Sequence (TRAP) and fetal tumours. It is well known that intrafetal laser is usually performed between 12-18 weeks of gestation. In this case, we have shown that intrafetal laser can be performed at 24 weeks of gestation. Conclusion: We performed selective fetal reduction with intrafetal laser at 24 weeks gestational age. We did not observe any complications. This case may be encouraging for the use of intrafetal laser in later weeks. However, as it is a single case, more cases are needed to see the real effect and to evaluate possible adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: To evaluate the perinatal outcomes in women with complicated monochorionic diamniotic twins who underwent selective reduction using radiofrequency ablation (RFA).Methods: This retrospective study included patients with complicated monochorionic diamniotic twins between 16 to 28 weeks who underwent selective reduction using RFA.Results: During the study period, 143 women with complicated monochorionic twins underwent RFA including 52 with selective fetal growth restriction (sFGR), 48 with twin to twin transfusion syndrome (TTTS), 33 with major fetal anomalies in one of the twins, and 10 with reversed arterial perfusion sequence (TRAP). The overall survival was 71.3% (102/143). The procedures were technically successful in achieving selective termination in all cases. The mean ± SD of gestational age at the time of the procedure was 21.0 ± 2.3 weeks. The mean ± SD of gestational age at delivery was 34.6 ± 3.3 weeks. The mean ± SD of overall procedure-to-delivery time was 12 ± 1.7 weeks. The pregnancy success rates among sFGR, TRAP, TTTS and anomaly groups were 82.7, 80, 73 and 60.7% respectively. There were no maternal complications.Conclusion: Radiofrequency ablation for fetal reduction in complicated monochorionic twin pregnancies appears to be a reasonable option. The pregnancy success rate following RFA selective reduction was highest among sFGR and TRAP groups and lowest in the anomaly group. [ABSTRACT FROM AUTHOR]

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a new coronavirus, was first identified in December 2019 in Wuhan, China and spread rapidly, affecting many other countries. The disease is now referred to as coronavirus disease 2019 (COVID-19).The Italian government declared a state of emergency on 31st January 2020 and on 11th March World Health Organization (WHO) officially declared the COVID-19 outbreak a global pandemic. Although the COVID-19 incidence remained considerably lower in Sardinia than in the North Italy regions, which were the most affected, the field of prenatal screening and diagnosis was modified because of the emerging pandemic. Data on COVID-19 during pregnancy are so far limited. Since the beginning of the emergency, our Ob/Gyn Department at Microcitemico Hospital, Cagliari offered to pregnant patients all procedures considered essential by the Italian Ministry of Health. To evaluate the influence of the COVID-19 pandemic on the activities of our center, we compared the number of procedures performed from 10th March to 18th May 2020 with those of 2019. Despite the continuous local birth rate decline, during the 10-week pandemic period, we registered a 20% increment of 1st trimester combined screening and a slight rise of the number of invasive prenatal procedures with a further increase in chorionic villi sampling compared to amniocentesis. Noninvasive prenatal testing remained unvariated. The request for multifetal pregnancy reduction as a part of the growing tendency of voluntary termination of pregnancy in Sardinia increased. The COVID-19 pandemic provides many scientific opportunities for clinical research and study of psychological and ethical issues in pregnant women. [ABSTRACT FROM AUTHOR]

Key content: Multifetal pregnancy reduction (MFPR) and selective termination (ST) are conceptually different procedures.Essential prerequisites for delivering these interventions are detailed counselling, multidisciplinary input within a tertiary fetal medicine service, careful choice of operative technique and appropriate gestational age, depending on the type of pregnancy and indication.Operative techniques that may be used are chemical, thermal, radiofrequency and laser, depending on chorionicity as well as other factors.Intracardiac potassium chloride is appropriate to employ when there is independent chorionicity and carries a lower risk of pregnancy loss; vascular occlusion using radiofrequency ablation, bipolar coagulation or intrafetal laser can be employed in monochorionic fetuses and twin reversed arterial perfusion pregnancies, but carry a higher risk of pregnancy loss.Women struggle with decision‐making, particularly with fetal reduction, and should be supported with frank discussion of the risks, but also emotionally: the need for emotional and psychological support may long outlast the pregnancy. Learning objectives: To know the differences between first trimester MFPR, second trimester cord occlusion and third trimester ST.To understand that MFPR is an intervention to reduce preterm birth‐related disability in high‐order multifetal pregnancies.To understand procedural outcomes and complications of MFPR and ST to enable adequate planning for subsequent obstetric care. Ethical issues: The decision to undergo ST to improve the chances of survival of one fetus over another may have consequences on the parental project and the grieving process.Ethical questions are raised when MFPR occurs following in vitro fertilisation in which more than two embryos were intentionally transferred.In uncomplicated twin pregnancies, MFPR to singleton may reduce the risk of late preterm birth, but the benefit in long‐term outcomes is less clear. [ABSTRACT FROM AUTHOR]

Objective: To report our experience and evaluate outcomes in monochorionic pregnancies with Twin Reversed Arterial Perfusion sequence with intrafetal laser therapy.Methods: Retrospective review of records of all pregnancies with TRAP sequence treated by intrafetal laser therapy between 2011 January and 2015 December that were retrieved and analysed.Results: Electronic search of the scan database retrieved 57 cases of TRAP sequence during the study period, 7 triplets and 50 monochorionic twins. Intrafetal laser was done in 27 cases, 22 cases of twins and 5 cases of triplets. In the twins group, median gestational age at intervention was 22.5 weeks, the earliest done at 16.3 weeks. The median gestational age at delivery and birth weight was 37 weeks and 2.5 Kgs. The median procedure and delivery interval was 14 weeks. Live birth rate was 17/22 (77%) the pump survival rate was 16/22 (73%). Pregnancies with non-surviving pump were 5 in numbers (5/22). A repeat procedure was warranted in one case. In the triplet group, median gestational age at intervention, delivery and procedure delivery interval was 18, 35 and 17 weeks.Conclusion: Intrafetal laser is simple, effective and the treatment of choice to interrupt the vascular supply to acardiac twin. [ABSTRACT FROM AUTHOR]

Objective: To determine hemodynamic changes by Doppler ultrasound of the living fetus during 24 h after umbilical cord occlusion (UCO) in monochorionic diamniotic (MCDA) twin pregnancies.Method: We conducted a prospective observational study on fetuses undergoing UCO from 2015 to 2017. Doppler parameters peak systolic velocity (PSV) and umbilical pulsatility index (PI) were obtained in the middle cerebral artery (MCA), umbilical artery (UA) and ductus venosus (DV) before and right after UCO, and at 1, 3, 6, 12, and 24 h after. We used multiple of the median (MoM) to adjust for gestational age. Spaghetti plots visualized flow changes over time. Mixed model adjusting for paired longitudinal data compared the values at different time points.Results: A total of 16 women were included. MCA-PSV dropped within the first hour after surgery from 0.91 to 0.82 MoM (p = 0.08). MCA-PI and UA-PI increased in the first hour from 0.75 to 0.91 MoM (p = 0.02) and 0.94 to 0.98 MoM (p = 0.22), respectively. The DV-PIV increased to 1.14 MoM 3 h after surgery (p = 0.07). The spaghetti plots illustrated the small changes within the first hours and showed a stabilization of flow measurements near initial values 24 h after UCO.Conclusion: Within the first hours after UCO the circulation of the survivor twin undergoes small hemodynamic changes. [ABSTRACT FROM AUTHOR]

Objective: We aimed to present a special case underwent the selective termination because of multiple structural anomaly and trisomy 13 in dichorionic and diamniotic pregnancy after stimulated intrauterine insemination. It achieved at 28 weeks of gestation by cervical cerclage with retained placenta after expulsion of nonviable fetus at 21 weeks of gestation which underwent selective termination at 20 weeks of gestation. Case(s): Twenty-two-year-old patient (G1P0) underwent intrauterine insemination (IUI) for unexplained infertility. A dichorionic diamniotic twin pregnancy has been confirmed by the ultrasonographic examination at 12 weeks of gestation. The selective termination for twin A was performed at 20 weeks of gestation because of trisomy 13 and at 21 weeks of gestation dead twin A with ventriculomegaly, vermian agenesis, micrognathia, microphthalmia, hypertelorism, polydactyly on both hands, atrioventricular channel defect in the heart, hyperechogenic and polycystic imaging on both kidneys was delivered normally. On the absence of infection parameters, McDonald-Shirodkar cerclage were carried out after the delivery of the dead twin A under antibiotherapy and tocolysis. Conclusion: Vaginal delivery was performed and 1150 g male baby with 8/9 Apgar score was born at 28 weeks of gestation. Cervical cerclage may take into consideration an alternative to prolong the pregnancy, although the retention of nonviable fetal placenta following expulsion of nonviable fetus after the selective reduction may increase maternal and fetal risk. [ABSTRACT FROM AUTHOR]

Objective: In complicated mono-chorionic twin pregnancies, vaso-occlusive techniques like bipolar cord coagulation (BPCC), radiofrequency ablation (RFA), interstitial laser ablation (ILA) of cord and fetoscopy guided cord coagulation with lasers are the methods proposed for selective fetal reduction. This study brings forth preliminary data of selective fetal reduction procedures at a tertiary care center in India. Material and Methods: This was a prospective observational study of 31 patients with complicated mono-chorionic twin pregnancies. Methods used were ILA, RFA and BPCC. Outcome measures included overall co-twin survival after selective feticide, survival rates with each method, miscarriage (defined as all fetal loss before 24 weeks), early fetal death (<24 hours after procedure) and late fetal death (>24 hours after the procedure) of co-twin. Results: Technical success was achieved in 30/31 (96.8%) of pregnancies. Over all take home baby rate was 63.3%. Live birth rates were 50%, 71.4% and 75% with ILA, RFA and BPCC respectively. Conclusion: Data from initial cases of selective fetal reduction in complicated mono-chorionic twins suggests that these procedures are feasible but are associated with high adverse perinatal outcome. [ABSTRACT FROM AUTHOR]

Purpose: To prevent perinatal morbidity and mortality of high-order multiple pregnancy (HOMP), multifetal pregnancy reduction (MPR) is offered to some patients. In this study, we investigated whether twin pregnancies derived from MPRs carry a higher adverse obstetrical outcome compared to non-reduced control group of twins.Methods: We retrospectively analyzed the data from HOMPs on which transvaginal ER (n = 153) at a mean gestational age of 7.6 weeks or transabdominal FR (n = 59) at a mean gestational age of 12.4 weeks was performed between December 2006 and January 2018. The risk of each procedure was evaluated by comparing obstetrical outcome with that of a control population of 157 non-reduced twins conceived by infertility treatment.Results: The mean gestational ages at delivery were 35.2 weeks in the ER group, 35.7 weeks in the FR group, and 34.1 weeks in the control group (P = NS). Compared with those in the control group, the ER group had higher miscarriage (1.3% vs. 6.5%; P = 0.047; OR 0.21; 95% CI 0.45-0.898) and higher overall fetal loss (3.8% vs. 14.4%; P = 0.003; OR 0.24; 95% CI 0.09-0.60) rates. Differently compared with those in the control group, the FR group had no statistical difference in miscarriage (2.5% vs. 1.7%; P=NS) and overall fetal loss (3.8% vs. 6.8%; P=NS) rates.Conclusions: Compared with the control group, ER in twins had a higher miscarriage and fetal loss rate, whereas FR in twins was similar to the control group. So, the FR procedure is overall a better and safer approach of MPR in reducing morbidity and mortality in HOMPs. [ABSTRACT FROM AUTHOR]

Objective: To compare the obstetric outcome and incidence of procedure-related adverse events after embryo reduction (ER) vs fetal reduction (FR), in multifetal pregnancies undergoing reduction to twins or singletons.Methods: We analyzed retrospectively data from multifetal pregnancies that underwent transvaginal ER (n = 181) at a mean gestational age of 7.6 weeks or transabdominal FR (n = 115) at a mean gestational age of 12.9 weeks between December 2006 and January 2017. FR was performed after a detailed fetal anomaly scan. The two groups were compared with respect to obstetric outcomes, such as incidence of miscarriage, early or late preterm delivery, maternal complications and fetal loss, and procedure-related adverse events, including incidence of subchorionic hematoma and procedure-related fetal loss.Results: Compared with pregnancies that underwent ER, the incidence of procedure-related fetal loss was lower in the FR group (7.2% vs 0.9%; P = 0.039; odds ratio (OR), 0.12; 95% CI, 0.02-0.89). Mean gestational age at delivery for twins was 34.2 weeks in the ER group and 35.7 weeks in the FR group (P = 0.014). Compared with the ER group, the FR group had lower miscarriage (8.8% vs 2.6%; P = 0.045; OR, 0.28; 95% CI, 0.08-0.97) and overall fetal loss (13.3% vs 5.2%; P = 0.031; OR, 0.36; 95% CI, 0.14-0.91) rates.Conclusions: The FR procedure is, overall, a better and safer approach to reducing morbidity and mortality in multifetal pregnancies. Spontaneous demise of one fetus may occur after ER, and FR has the advantage that chorionic villus sampling and ultrasound screening for increased nuchal translucency and anatomical defects can be conducted before the procedure. The ER approach is still reasonable when a patient's religious or other ethical concerns are of primary importance. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd. [ABSTRACT FROM AUTHOR]

Aim: The present study investigates the procedure‐related fetal loss rate and obstetrical outcomes of selective feticide in dichorionic twins. Methods: We retrospectively analyzed the data of 44 cases of dichorionic twins. Two different indications for selective feticide were set: (i) the presence of genetic or congenital anomaly; and (ii) an obstetrical indication specified as a past maternal history of preterm delivery that caused fetal death or cerebral palsy of the child. Primarily, data on procedure‐related fetal loss and obstetrical outcomes were retrieved. Additionally, data on obstetrical outcomes by reduction time and by indication of SF were obtained. Results: Selective feticide was performed in 44 cases – specifically, in 23 cases with genetic or congenital anomaly and in 21 cases with obstetrical indications. The median gestational age at delivery was 38 + 4 weeks. One pregnancy loss (2.3%, 1/44) occurred within 4 weeks after the procedure. The overall pregnancy loss rate throughout the pregnancy term was 2.3% (1/44). When selective feticide was performed at 15 weeks and beyond, the birth weight was significantly decreased compared with when selective feticide was performed earlier than 15 weeks. Conclusion: Transabdominal ultrasound‐guided selective feticide in dichorionic twins is an effective and safe procedure. If a patient desires to maximize her chances of having a healthy child and decrease the risk of prematurity, the option of selective feticide should be considered in certain cases of twin pregnancies. Selective feticide may be a reasonable alternative to expectant management or termination of the whole twin pregnancy. [ABSTRACT FROM AUTHOR]

Objective: To review the results of fetal reduction procedures in our institution, evaluate its effects on the pregnancy outcome in terms of miscarriage, preterm delivery, taking home healthy babies and discuss the factors that may have contributed to the outcome.Study Design: This is a retrospective study performed at the Fetal Medicine Unit of the Sisli Memorial Hospital in Istanbul after ART therapies in our unit from 2000 to 2011.Results: The sample comprised 151 triplets, 35 quadruplets, 11 quintuplets, 3 twins, 1 sextuplet and 1 septuplet. The average maternal age was 30 ± 4.4 and the average week of interventions was 11.7 ± 1.3 weeks. In 40 cases two or more needle insertions were necessary. The two-week post-procedure loss rate, defined as 'the procedure related loss rate', was 0.7%; however, for the whole sample, the losses were 6.9% when they occured before 24 completed weeks and was defined as 'the total loss rate'. 184 of the remaining 188 cases had at least one baby to take home (91.1% of 202 patients). The average birth week for those healthy babies discharged home was 35.5 ± 2.4. The rate of early preterm birth before gestational weeks of 32 was 9%. The mean birthweight of this "take-home" group was 2302 ± 525 g.Conclusion: Fetal reduction in multifetal pregnancy is associated with low miscarriage rate and preterm delivery rates. Fetal reduction in multifetal pregnancy should be considered for better pregnancy outcomes and the results of this study can be used in prenatal counseling. [ABSTRACT FROM AUTHOR]

Photocatalytic selective organic transformations (SOTs) with sunlight offer a “green” route for synthesis of fine chemicals. In this work, a bare ternary chalcogenide CdLa 2 S 4 photocatalyst was fabricated to couple the selective oxidation (SO) of aromatic alcohols to aldehydes and selective reduction (SR) of nitroarenes to anilines in one reaction system. The photocatalyst showed a high stability and a good generality for the conversions due to the well–matched band structure and the high separation efficiency of photoinduced electrons (e–) and holes (h + ). For p–substituted aromatic alcohols, the selectivities to the corresponding aldehydes are as high as ca. 90%. The electro–donating substituent in the para position benefits the SO reactions, which are triggered by h + via a successive deprotonation; while for p–substituted nitroarenes, the SR to the corresponding anilines is vulnerable to the electro–withdrawing groups and the steric hindrance of the substituent and the selectivities to anilines are substantially lower than that of the SO conversions. H + deprotonated in the SO of aromatic alcohols is indispensable for the SR of nitroarenes as they are achieved by a H + –coupled six e– reduction process, which leads to the low conversion efficiencies. The half conversions not only be coupled by the photoinduced e– and h + , but also collaborate with each other through H + . Our results clearly demonstrate the emerging concept of a coupled reaction system for sunlight–driven synthesis of fine chemicals and reveal the underlying mechanism. [ABSTRACT FROM AUTHOR]

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Aim: Autopsy is a beneficial procedure to determine the cause of death and the frequency of anomalies in perinatal losses. Even in the event of an autopsy not providing any additional information, completion of the procedure confirming the clinical diagnoses gives reassurance to both clinicians and parents. Here we present a 15-year archival study based on findings of perinatal autopsies. Design and methods: Four hundred and eighty-six cases from our archive were reviewed and according to the findings they were divided into three subcategories; (1) miscarriages (MCF); (2) fetuses terminated (FTA) for vital anomalies detected by prenatal ultrasonography; (3) premature or term newborns died within first month of life (neonates: NN). Autopsies were documented and classified according to week/age of cases, anomalies and causes of abortion or death. Results: Two hundred and twenty-six of 486 cases (46.5%) were in MCF group while 227 (46.7%) and 33 (6.8%) were of them in FTA and NN groups, respectively. In FTA group, the most frequent anomaly detected was neural tube defects. In NN group, prematurity related complications were the most common cause of death. The autopsy process was found valuable in 39.7% of all cases. Conclusions: We suggest that autopsy procedure is diagnostically valuable even in situations when there is USG findings that are confirming FTAs or there is no important major fetal or placental anomaly detected in MCFs. [ABSTRACT FROM AUTHOR]

Introduction: The aim of this study is to evaluate the incidence and causes of intentional fetal and neonatal demise in twin-twin transfusion syndrome (TTTS).Material and Methods: All TTTS pregnancies managed at our centre between 2000 and 2014 were included. We evaluated incidence and causes of intentional fetal/neonatal demise, defined as termination of pregnancy, selective fetal reduction, or withdrawal of neonatal intensive care.Results: Intentional fetal/neonatal demise occurred in 9.8% (110/1,122) of fetuses and was due to termination of pregnancy (2.2%), selective fetal reduction (4.2%), or withdrawal of neonatal intensive care (3.4%). Reasons for termination of pregnancy included complications of laser treatment (72.0%), severe fetal anomaly (20.0%), and unwanted pregnancy (8.0%). Reasons for selective fetal reduction were technical difficulties to perform laser surgery (51.1%), fetal complications (38.3%), and parental preference for fetal reduction rather than laser treatment (10.6%). Reasons for withdrawal of neonatal intensive care treatment were severe cerebral injury (47.4%), severe pulmonary complications (15.8%), birth asphyxia (5.3%), multiple complications of TTTS and/or prematurity combined (21.1%), or other (10.5%).Conclusions: Intentional fetal or neonatal demise in TTTS occurs frequently and is often due to complications after laser surgery and/or severe (cerebral) injury in affected fetuses or neonates. [ABSTRACT FROM AUTHOR]

The article focuses on surrogacy contracts and recovery for non-performance by implicating both constitutional issues and contractual issues with enforcement of selective reduction and termination clauses. Topics discussed include constitutional protection of a woman's right to abortion is immensely important, contract remedies for breach and the standard of care to which surrogates and clinics should be held and intended parents should receive damages for breach of contract.

Objective This study aims to determine the efficacy of multifetal pregnancy reduction (MFPR) in improving obstetrical outcomes for trichorionic triplet gestations. Study Design Retrospective cohort study of patients with multiple gestations delivered by a single maternal-fetal medicine practice from 2005 to 2016. We compared patients with trichorionic triamniotic triplet gestations who underwent MFPR to those with an ongoing triplet pregnancy (TT), as well as primary dichorionic diamniotic twin gestations (DD). Logistic regression analysis was used to control for any differences at baseline. Results There were 42 patients in the MFPR group, 43 women in the TT group, and 693 women in the DD group. Comparing MFPR to TT, the likelihood of preterm birth < 34 weeks was similar (31.0 vs. 39.5%, adjusted odds ratio [aOR]: 0.63, 95% confidence interval [CI]: 0.21, 1.87). There were no differences in gestational age at delivery, pregnancy loss < 24 weeks, or the likelihood of all, none, or at least two babies surviving to discharge. Mean birth weights were significantly higher and cesarean delivery rates lower for MFPR (2,128 vs. 1,836 g, p = 0.028 and 69 vs. 86%, aOR: 0.25, 95% CI: 0.06, 0.94) as compared with the TT group. MFPR had significantly worse outcomes than DD. Conclusion In trichorionic triamniotic triplet pregnancies, our study suggests that obstetrical outcomes may not be as dramatically improved with MFPR as seen in older studies. [ABSTRACT FROM AUTHOR]

The current systematic review and meta-analysis evaluate the perinatal outcomes in twin pregnancies following multifetal pregnancy reduction (MPR) compared with non-reduced triplet pregnancies. All studies comparing perinatal outcome of twin pregnancies following MPR to non-reduced triplet pregnancies were considered. MEDLINE, non-indexed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials and Web of Science were searched for relevant published articles up to August 2016. The search yielded 653 publications of which 92 were assessed for eligibility. A total of 24 studies met the inclusion criteria. Overall, the outcomes of pregnancies following MPR were better compared with expectantly managed triplets. The MPR group delivered at a later gestational age and was less likely to be delivered before 32 or 28 weeks' gestation. Newborns in the MPR group had significantly higher birthweight at delivery (mean difference 500 g [95% CI 439.95, 560.04]). Rates of pregnancy loss before 24 weeks' gestation and overall infant survival were comparable between the groups. This meta-analysis suggests that MPR of triplet pregnancies to twins is associated with improved perinatal outcome compared with non-reduced triplets. Should primary prevention of high order multiple pregnancy fail, MPR is an appropriate alternative to minimize the perinatal morbidity and mortality of triplet pregnancies. [ABSTRACT FROM AUTHOR]

The current systematic review and meta-analysis evaluates the perinatal outcomes in twin pregnancies following multifetal pregnancy reduction (MPR) compared with non-reduced twins. We considered all studies comparing perinatal outcomes of twin pregnancies following MPR to non-reduced twin pregnancies. Our search yielded 639 publications, of which 91 were assessed for eligibility. A total of 22 studies met our inclusion criteria. Overall, fetal reduction of triplets to twins resulted in comparable perinatal outcomes to non-reduced twins with regards to gestational age and birthweight at delivery, pregnancy loss prior to 24 weeks, as well as the development of gestational diabetes and hypertensive disorders of pregnancy. Of all outcomes, only the Caesarean section rate was significantly higher in the MPR group compared with the non-reduced twins group with an odds ratio of 1.95 (95% confidence interval 1.33–2.87). This meta-analysis suggests that MPR of triplet pregnancies to twins is associated with comparable perinatal outcomes to that of non-reduced twins. This information can further help in guiding, and probably reassuring, clinician and patient decision-making when faced with high-order multifetal pregnancies. [ABSTRACT FROM AUTHOR]

We argue that politically and religiously conservative areas tend to lead to distortion of the flow of risk information in ways that appear to reduce the apparent need for reductions from a medical-risk point of view. They also minimize the credibility of non-medical risks experienced by patients. Understanding that this type of investigation is fraught with difficulties of definition and analysis, we bring to bear two different sources of data to engage this dialog. First, we examine in some detail medico-legal testimony in settled cases, to flesh out the ways in which processes of distortion may take place with respect to risk and options for dealing with it. Second, we use qualitative comparative analysis to examine a set of selective reduction cases from diversely conservative environments around the world in the period from December, 2014 through April, 2015 for which the main issue has been the advisability of reducing from two or three fetuses to one. We conclude that external conservative cultural forces may undermine the treatment of patients seeking a selective reduction in several ways. From these analyses, we make recommendations for intervention. [ABSTRACT FROM AUTHOR]

Study Question: Is pregnancy outcome in triplet pregnancies improved with embryo reduction (ER) to twins compared to expectant management?Summary Answer: In trichorionic triplet pregnancies, ER to twins reduces the risk of preterm birth (<34 weeks) without significantly increasing the risk of miscarriage (<24 weeks), whereas in dichorionic triplet pregnancies, the results are inconclusive.What Is Known Already: Triplet pregnancies are associated with a high risk of miscarriage and preterm birth. ER can ameliorate these conditions in higher order multiple gestations but is still controversial in triplets.Study Design, Size, Duration: This study aimed to conduct a systematic review, following the PRISMA guidelines, and critically appraise ER at 8-14 weeks of gestation in both trichorionic triamniotic (TCTA) and dichorionic triamniotic (DCTA) pregnancies. Selective ER to twins was compared with expectant management, focusing on the risks of miscarriage and preterm birth. The computerized database search was performed on 8 January 2017. Overall, from 25 citations of relevance, eight studies with a total of 249 DCTA and 1167 TCTA pregnancies fulfilled the inclusion criteria.Participants/materials, Setting, Methods: A comprehensive computerized systematic literature search of all English language studies between 2000 and 2016 was performed in PubMed, EMBASE, Scopus, Evidence Based Medicine Reviews (Cochrane Database and Cochrane Central Register of Controlled Trials) and Google Scholar. Relevant article reference lists were hand searched. The management options were compared for rates of miscarriage <24 weeks and preterm birth <34 weeks. Only studies with both expectant management and ER to twins were included in the analysis. The quality of each individual article was critically appraised and appropriate statistical methods were used to extract results.Main Results and the Role Of Chance: In TCTA pregnancies managed expectantly (n = 501), the rates of miscarriage and preterm birth were 7.4 and 50.2%, respectively. Meta-analysis demonstrated that ER to twins in TCTA pregnancies (n = 666) was associated with a lower risk (17.3 versus 50.2%) of preterm birth (RR = 0.36, 95% CI: 0.28-0.48), whereas the risk of miscarriage (8.1% versus 7.4%) did not significantly increase (RR = 1.08, 95% CI: 0.58-1.98). In DCTA triplets managed expectantly (n = 200), the rates of miscarriage and preterm birth were 8.5 and 51.9%, respectively. Although the meta-analysis was inconclusive, it suggested that ER to twins in DCTA triplets, either of the foetus with a separate placenta (n = 15) or one of the monochorionic pair (n = 34), was neither significantly associated with an increased risk of miscarriage (8.5 versus 13.3%, P = 0.628 and RR = 1.22, 95% CI: 0.38-3.95, respectively) nor with a lower risk of preterm birth (51.9 versus 46.2%, P = 0.778 and RR = 0.5, 95% CI: 0.04-5.7, respectively).Limitations, Reasons For Caution: No randomized controlled trials of ER versus expectant management in TCTA or DCTA pregnancies were identified from our literature search. We were able to include only a handful of papers with small sample sizes and suffering from bias, and non-English publications were missed. Irrespective of the strict inclusion and exclusion criteria, publication bias was evident.Wider Implications Of the Findings: The greatest strength of our systematic review is that, contrary to the existing literature, it only included studies with both the intervention and expectant arm. Our results are in agreement with current literature. In TCTA pregnancies, ER to twins is associated with a lower risk of preterm birth but is not associated with a higher risk of miscarriage. In the absence of a randomized trial, the data from systematic reviews appear to be the best existing evidence for counselling in the first trimester on the different options available. Finally, in DCTA pregnancies, indications exist that ER (of one of the MC pair) to twins could possibly reduce the risk of preterm birth without increasing the risk of miscarriage.Study Funding/competing Interest(s): None to declare.Registration Number: N/A. [ABSTRACT FROM AUTHOR]

Background: There is currently insufficient evidence regarding the prognosis of multifetal pregnancy following elective fetal reduction to twin or singleton pregnancy. We compared perinatal outcomes in pregnancies with and without fetal reduction.Methods: We used data on all stillbirths and live births in British Columbia, Canada, from 2009 to 2013. We compared outcomes of multifetal pregnancies with fetal reduction (to twin or singleton pregnancy) with outcomes of pregnancies without fetal reduction. The primary outcome was a composite of serious neonatal morbidity or perinatal death. Other outcomes studied included preterm birth, low birth weight and small-for-gestational-age live birth.Results: The rate of serious neonatal morbidity or perinatal death did not differ significantly between pregnancies reduced to twins and unreduced triplet pregnancies (adjusted rate ratio 0.50, 95% confidence interval [CI] 0.24-1.07) or between pregnancies reduced to singletons and unreduced twin pregnancies (adjusted rate ratio 1.57, 95% CI 0.74-3.33). The rate was significantly lower in the fetal reduction group reduced to twins versus unreduced triplet pregnancies when we restricted the analysis to pregnancies conceived following the use of assisted reproduction technologies (adjusted rate ratio 0.35, 95% CI 0.18-0.67). The rates of preterm birth, very preterm birth, low birth weight and very low birth weight were significantly lower among pregnancies reduced to twins than among unreduced triplet pregnancies. Compared with unreduced twin pregnancies, pregnancies reduced to singletons had lower rates of preterm birth and low birth weight.Interpretation: Fetal reduction to twins and singletons was not associated with a decreased risk of serious neonatal morbidity or perinatal death. However, such fetal reduction was associated with substantial improvements in several other perinatal outcomes, such as preterm birth and low birth weight. Clinicians discussing the risks associated with multifetal pregnancy should counsel parents on the potential risks and benefits of fetal reduction. [ABSTRACT FROM AUTHOR]

Carrying twins has been extensively described as an emerging principal non-infectious factor jeopardizing pregnancy maintenance and reducing the lifespan of dairy cows. The risk of pregnancy loss during the first trimester of gestation for cows carrying twins may be from three to seven times higher than for cows carrying singletons. Longer calving to conception intervals, higher culling rates and a shorter mean production lifespan of 200 days have been reported for cows delivering twins compared to cows delivering singletons. There is therefore a need accurately to detect twin embryos at the time of pregnancy diagnosis to follow twin pregnancies carefully or, alternatively, to remove one of the embryos. Therapeutic approaches for the problem of twin pregnancies include GnRH treatment or induced embryo reduction. With similar results, manual rupture of the amniotic vesicle or transvaginal ultrasound-guided aspiration of allanto-amniotic fluid have been proposed as methods of choice to perform twin reduction in cows on Day 28–41 of gestation. However, benefits and risks of induced twin reduction should be quantified. This report reviews various aspects concerning control of twin pregnancies and the practical implications at herd level. Special attention is paid to timing of spontaneous twin reduction. Prospects for induced embryo reduction are also discussed. [ABSTRACT FROM AUTHOR]

Background: On rare occasions, elective iatrogenic reduction of a dichorionic twin is performed due to maternal request and in order to improve the perinatal outcome. Materials and methods: Nine twin-to-singleton reductions were identified retrospectively at the Feto-maternal Unit, University of Szeged, Hungary, between December 1997 and June 2015. A post-procedure, routine weekly sonographic scan revealed severe oligohydramnios in two out of the nine cases (22.2%) and amnioinfusion was performed in the mid-trimester to prolong gestation. The fetus survived in one case (11.1%) and the pregnancy continued until preterm birth. Conclusion: A repeated sonographic follow-up for an early diagnosis of oligohydramnios is feasible to avoid miscarriage after artificial embryo reduction. [ABSTRACT FROM AUTHOR]

Multi-fetal pregnancy reduction (MFPR) is an ethically acceptable procedure aimed to increase survival and well-being of the remaining fetuses from high-order multiple gestations. In most cases we offer the procedure to triplets or quadruplets and opt to preserve twins; lately, the option to maintain a single fetus was suggested. We examined the outcomes of 140 pregnancies that underwent MFPR in our center and were followed to delivery - 105 were reduced to twins and 35 to singletons. The rate of procedure-related pregnancy loss was identical (2.9%). Leaving only one fetus was associated with a higher gestational age at delivery (35.4±2.4 weeks vs. 37.7±2.1 weeks, P<0.0001), with heavier neonates (2222 g vs. 3017 g, P<0.0001) and with a reduction in the cesarean section (CS) rate (76% in twins vs. 51.4% in singletons, P=0.02). Six pregnancies reduced to twins (5.8%) ended before 32 weeks as compared to one pregnancy reduced to a singleton. We conclude that reduction of triplets to singletons is medically and ethically acceptable, after thorough counseling of patients. However, considering the pregnancy loss risk of MFPR and the relatively good outcome of twin gestations, reduction of twins to singletons is ethically acceptable only in extraordinary maternal or fetal conditions. [ABSTRACT FROM AUTHOR]

Background: Heterotopic cesarean scar pregnancy is a cesarean scar pregnancy combined with an intrauterine pregnancy that predisposes a woman to life-threatening complications such as uterine rupture and massive bleeding. Preservation of the intrauterine pregnancy in heterotopic cesarean scar pregnancy is a great challenge. Case presentation: We report a case of a 33-year-old woman with heterotopic cesarean scar pregnancy after IVF-embryo transfer (ET). Expectant management was carried out with early diagnosis of heterotopic cesarean scar pregnancy (HCSP), and selective fetal reduction of cesarean scar pregnancy (CSP) was performed by ultrasound-guided intrathoracic injection of potassium chloride (KCl) at 16 + 4 weeks of gestation due to aggravation of CSP. Preservation of the intrauterine pregnancy was successful and a healthy baby was delivered by cesarean section at 37 + 6 weeks of gestation. Conclusions: Heterotopic cesarean scar pregnancy is an extremely rare form of heterotopic pregnancy. Patients should be appropriately counseled regarding the different treatment options available. An ultrasound-guided injection of potassium chloride may constitute a safe, minimally invasive and reliable way to terminate the heterotopic gestation and preserve the intrauterine pregnancy. Intensive management should be performed during the ongoing pregnancy and cesarean section. [ABSTRACT FROM AUTHOR]

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

Aims: To review pregnancy outcomes, complication rates and neonatal neural development of selective termination procedures for complicated monochorionic (MC) twins.Methods: This was a retrospective review of the pregnancies that underwent selective reduction with radiofrequency ablation (RFA) and bipolar cord coagulation (BCC) in our institution.Results: Forty-eight cases underwent selective reduction with BCC and the remaining 45 with RFA. Overall survival was not statistically different between the RFA and BCC groups (71.1 and 62.5%, p = 0.379). With regard to the indications, the survival rates were not significantly different for twin to twin transfusion syndrome, twin reversed arterial perfusion, discordant anomalies and selective intrauterine growth restriction. Preterm premature rupture of membrane was not statistically different between the BCC and RFA groups (47.9 and 33.3%, p = 0.153). Five foetuses presented with abnormal middle cerebral artery-peak systolic velocity in the BCC group and 4 in the RFA group (p = 0.829). In the BCC group, neurological injury was detected in 2 neonates, presenting with cerebral dysplasia on MR scanning. In the RFA group, intracranial haemorrhage Grade III was detected in one neonate with cranial ultrasound (p = 0.607).Conclusions: Overall survival and complication rates following selective reduction in complicated MC twin pregnancies is similar irrespective of whether the reduction was performed using RFA or BCC. Key Message: It seems that selective reduction in MC pregnancies with RFA does not carry a significant decrease in the overall survival and complication rates than the cases with BCC. According to our data, neurodevelopmental impairment of the co-twins is relatively seldom after selective reduction. [ABSTRACT FROM AUTHOR]