Australian and New Zealand Journal of Obstetrics and Gynaecology 2014; 54: 424–427
DOI: 10.1111/ajo.12225
Original Article
Comparison of the outcomes between reduced and nonreduced triplet pregnancies achieved by Assisted Reproductive Technology Marzieh SHIVA,1 Ladan MOHAMMADI YEGANEH,1 Elaheh MIRZAAGHA,1 Mohammad CHEHRAZI2 and Narges BAGHERI LANKARANI2 1
Department of Endocrinology and Female Infertility at Reproductive Biomedicine Research Center and 2Department of Epidemiology and Reproductive Health at Reproductive Epidemiology Research Center, Royan Institute for Reproductive Biomedicine, ACECR, Tehran, Iran
Background: In recent years, the significant increase in multiple pregnancies as a result of assisted reproductive technology (ART) has introduced the concept of multifetal reduction techniques. However, it is still unclear whether there are significant advantages of using this technique. Aim: To compare the outcomes of triplet pregnancies achieved by ART managed expectantly with those receiving fetal reduction interventions. Materials and Methods: In this retrospective study of 115 triplet pregnancies, 57 pregnancies were reduced to twins while 58 were managed expectantly. Results: The fetal loss rate before 24 weeks did not differ between reduced and nonreduced pregnancies (12.3% vs 12.1%). However, the results of those using fetal reduction techniques showed a lower incidence of preterm labour (26.3% vs 50%, P = 0.009), higher mean gestational age at delivery (35.1 2.6 vs 32.4 3.6 weeks, P = 0.002) and higher mean birthweights compared with the control group (2188 547 vs 1674 546 g, P < 0.001). The perinatal mortality rate was significantly lower in reduced triplets compared with those expectantly managed (6% vs 17.6%, P = 0.007). The rate of live birth was 94% in reduced and 82.4% in nonreduced pregnancies (P = 0.007). The percentages of neonates admitted to the neonatal intensive care unit (NICU) were 27.7 and 62.7% in reduced and nonreduced pregnancies, respectively (P < 0.001). Conclusions: In this observational cohort study reduction of triplets to twins decreased prematurity and increased birthweight without an increase in fetal loss. Additionally, there was a lower perinatal mortality, higher live birth rate and lower NICU admission. Key words: assisted reproductive techniques, fetal loss, multifetal pregnancy reduction, prematurity, triplet pregnancies.
Introduction During recent decades, the worldwide use of assisted reproductive techniques has progressively increased. Multiple embryos have been transferred using in vitro fertilisation (IVF) to maximise the success of pregnancy but have resulted in a substantial increase in the incidence of multiple pregnancies.1,2 Multiple pregnancies are associated with an increase in the risk of maternal and fetal complications including pre-eclampsia, spontaneous abortion, preterm labour, intra-uterine growth restriction and perinatal mortality and morbidity.3–4 Moreover, multiple pregnancies may carry significant emotional, social and financial implications for couples.5,6
Correspondence: Dr Marzieh Shiva, No 12, East Hafez Avenue, Banihashem Street, Resalat highway, Tehran, Iran. E-mail:
[email protected] Received 18 July 2013; accepted 4 May 2014.
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The appropriate use of infertility therapies and limiting the number of embryos transferred may reduce the incidence of multiple pregnancies. However, despite recent reports in United States, Europe and Australia indicating the diminution of the number of embryos transferred during ART, multiple pregnancies may still occur.7–9 Since the 1980s, multifetal pregnancy reduction has been used as a secondary method to reduce fetal number and potentially improve the survival of the remaining fetuses.10 Preterm birth and pregnancy loss are the main complications of multifetal gestations, which may be decreased with fetal reduction procedures.11,12 However, as this invasive procedure is a distressing experience for couples,13 the potential benefits should be weighed with the disadvantages to assist women in their decision-making regarding using this technique. Although there is consensus regarding the benefits of fetal reduction in high-order multiple pregnancies (quadruplets and more),14–16 the major debate involves its role in triplet pregnancies. This study was conducted to compare the outcomes of triplet pregnancies managed expectantly with those who underwent fetal reduction to assess the potential risks and benefits of this procedure.
© 2014 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists The Australian and New Zealand Journal of Obstetrics and Gynaecology
Multifetal pregnancy reduction
Materials and Methods The study population consisted of 115 trichorionic triplet pregnancies conceived with ART between October 2006 and September 2012 in Reproductive Biomedicine Research Center, Royan Institute, Tehran, Iran. In the study period, the medical records of 57 triplet gestations who had been reduced to twins (reduced group) and 58 triplets who were managed expectantly (nonreduced group) were reviewed. Triplet pregnancies reduced to singletons were excluded from the study to prevent bias in calculating outcomes. Ethical and Institutional Review Board approval was obtained for the collection of retrospective data from the medical records.
Fetal reduction Before the fetal reduction procedure, all women were counselled about the potential risks of fetal reduction and written consent was obtained. All women underwent prenatal screening tests and an ultrasound scan was performed to determine the number, chorionicity and position of the fetuses. Fetal reduction procedures were performed between 11 and 14 weeks gestation by transabdominal injection of potassium chloride solution into the fetal heart under ultrasound guidance. After cleaning the abdominal skin with an antiseptic solution and using local anaesthesia, a 20-gauge needle was inserted into the fetal heart and 3–10 mL potassium chloride (KCl) 10% was injected. Prophylactic antibiotic therapy with Amoxicillin was used for seven days in all cases. The most accessible fetuses, based on easy access to transabdominal needle insertion, were selected for termination. All multifetal pregnancy reductions were performed by a single operator. After the procedure, all women referred to their primary obstetrician for the remaining period of prenatal care.
Pregnancy outcomes The main outcome measures were fetal loss before 24 weeks of gestation, preterm labour, gestational age at delivery, neonatal birthweight, perinatal mortality rate, live birth rate and admission to the NICU. Fetal loss was defined as spontaneous termination of pregnancy before completing 24 weeks of gestation. Perinatal mortality was defined as deaths occurring from the 24th week of gestation to the 7th day after delivery. All deliveries between 24–34 weeks of gestation were considered preterm and deliveries after 24 and before 28 completed weeks of pregnancy were defined as extreme preterm birth. Live birth referred to the birth of a live fetus regardless of gestation.
Statistical analysis All data analyses were performed using Statistical Package for Social Sciences (SPSS Inc., Chicago, IL, USA) version
18.0. For comparison of the mean values between groups, an independent t-test was used. The chi-square test was used to compare fetal loss, preterm labour, perinatal mortality, live birth and admission in NICU between two groups. Gestational age at delivery and birthweight as categorical variables were compared by chi-square test among two groups. A P-value of
