The outcome of reduced and non-reduced triplet pregnancies managed in a tertiary hospital during a 15-year-period – a retrospective cohort study
-
Riina Maria Jernman
Abstract
Objectives
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.
Methods
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.
Results
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).
Conclusions
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.
Funding source: This study was funded by grants from the Päivikki and Sakari Sohlberg foundation and the Helsinki University State Research Funding
Acknowledgments
Research nurse Eija Kortelainen is acknowledged for her valuable work in data collection for this project.
-
Research ethics: This study has been approved by the authors’ Institutional Review Board (Helsinki University Hospital, Obstetrics and Gynecology). Regarding ethical approval, the local Institutional Review Board deemed the study exempt from review.
-
Informed consent: Not applicable.
-
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission. V. Stefanovic and R. Jernman have designed the study. R. Jernman and A-R Rissanen have designed the study collection form and written the manuscript. V. Stefanovic has commented and approved the final version.
-
Competing interests: The authors state no conflict of interest.
-
Research funding: This study was funded by grants from the Päivikki and Sakari Sohlberg foundation and the Helsinki University State Research Funding.
-
Data availability: The data of this study are available on reasonable request from the corresponding author. The data are not publicly available due to privacy and ethical restrictions.
References
1. Evans, MI, Andriole, S, Britt, DW. Fetal reduction: 25 years’ experience. Fetal Diagn Ther 2014;35:69–82. https://doi.org/10.1159/000357974.Search in Google Scholar PubMed
2. Heino, A, Gissler, M, Hindori-Mohangoo, AD, Blondel, B, Klungsoyr, K, Verdenik, I, et al.. Euro-Peristat Scientific Committee. Variations in multiple birth rates and impact on perinatal outcomes in Europe. PLoS One 2016;11:e0149252. https://doi.org/10.1371/journal.pone.0149252.Search in Google Scholar PubMed PubMed Central
3. Multifetal gestations, twin, triplet and higher-order multifetal pregnancies. ACOG practice bulletin, number 231. Obstet Gynecol 2021;137:e145–62. https://doi.org/10.1097/AOG.0000000000004397.Search in Google Scholar PubMed
4. National Institute for Health and Clinical Excellence (NICE). Twin and triplet pregnancy. NICE Clinical guideline. London; 2019. Available at: www.nice.org.uk/guidance/ng137 [Accessed 22 Apr 2023].Search in Google Scholar
5. Hydén-Granskog, C, Tiitinen, A. Single embryo transfer in clinical practice. Hum Fertil 2004;7:175–82. https://doi.org/10.1080/14647270400006929.Search in Google Scholar PubMed
6. Legendre, CM, Moutel, G, Drouin, R, Favre, R, Bouffard, C. Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review. Reprod Biomed Online 2013;26:542–54. https://doi.org/10.1016/j.rbmo.2013.02.004.Search in Google Scholar PubMed
7. ACOG Committee opinion no. 719: multifetal pregnancy reduction. Obstet Gynecol 2017;130:e158–63. https://doi.org/10.1097/AOG.0000000000002302.Search in Google Scholar PubMed
8. Yaron, Y, Bryant-Greenwood, PK, Dave, N, Moldenhauer, JS, Kramer, RL, Johnson, MP, et al.. Multifetal pregnancy reductions of triplets to twins: a comparison with nonreduced triplets and twins. Am J Obstet Gynecol 1999;180:1268–71. https://doi.org/10.1016/s0002-9378(99)70627-7.Search in Google Scholar PubMed
9. Boulot, P, Vignal, J, Vegnes, C, Dechaud, H, Faure, JM, Hedon, B. Multifetal reduction of triplets to twins: a prospective comparison of pregnancy outcome. Hum Reprod 2000;15:1619–23. https://doi.org/10.1093/humrep/15.7.1619.Search in Google Scholar PubMed
10. Geipel, A, Berg, C, Katalinic, A, Plath, H, Hansmann, M, Smrcek, J, et al.. Targeted first-trimester prenatal diagnosis before fetal reduction in triplet gestations and subsequent outcome. Ultrasound Obstet Gynecol 2004;24:724–9. https://doi.org/10.1002/uog.1783.Search in Google Scholar PubMed
11. Okyay, E, Altunyurt, S, Soysal, D, Kaymak, O, Soysal, S, Danisman, N, et al.. A comparative study of obstetric outcomes in electively or spontaneously reduced triplet pregnancies. Arch Gynecol Obstet 2014;290:177–84. https://doi.org/10.1007/s00404-014-3175-y.Search in Google Scholar PubMed
12. Shiva, M, Mohammadi Yeganeh, L, Mirzaaga, E, Chehrazi, M, Bagheri Lankarani, N. Comparison of the outcomes between reduced and nonreduced triplet pregnancies achieved by assisted reproductive technology. Aust N Z J Obstet Gynaecol 2014;54:424–7. https://doi.org/10.1111/ajo.12225.Search in Google Scholar PubMed
13. Obican, S, Brock, C, Berkowitz, R, Wapner, RJ. Multifetal pregnancy reduction. Clin Obstet Gynecol 2015;58:574–84. https://doi.org/10.1097/GRF.0000000000000119.Search in Google Scholar PubMed
14. Zipori, Y, Haas, J, Berger, H, Barzilay, E. Multifetal pregnancy reduction of triplets to twins compared with non-reduced triplets: a meta-analysis. Reprod Biomed Online 2017;35:296–304. https://doi.org/10.1016/j.rbmo.2017.05.012.Search in Google Scholar PubMed
15. Karamustafaoglu Balci, B, Yayla, M, Bulut, N, Goynumer, G. Expectant management of triplets or multifetal reduction to twins; comparison of preterm delivery and live birth rates. Eur J Obstet Gynecol Reprod Biol 2022;268:18–21. https://doi.org/10.1016/j.ejogrb.2021.11.001.Search in Google Scholar PubMed
16. Kristensen, SE, Kvist Ekelund, C, Sandager, P, Jørgensen, FS, Sperling, L, Zingenberg, HJ, et al.. Triple trouble: uncovering the risks and benefits of early fetal reduction in trichorionic triplets in a large national Danish cohort study. Am J Obstet Gynecol 2023;229:555.e1–555.e14. https://doi.org/10.1016/j.ajog.2023.05.029.Search in Google Scholar PubMed
17. Finnish Institute for Health and Welfare (THL). Perinataalitilasto; 2021. Available at: http://julkari [Accessed 9 June 2023].Search in Google Scholar
18. Luu, TM, Rehman Mian, MO, Nuyt, AM. Long-term impact of preterm birth: neurodevelopmental and physical health outcomes. Clin Perinatol 2017;44:305–14. https://doi.org/10.1016/j.clp.2017.01.003.Search in Google Scholar PubMed
19. Treyvaud, K, Lee, KJ, Doyle, LW, Anderson, PJ. Very preterm birth influences parental mental health and family outcomes seven years after birth. J Pediatr 2014;164:515–21. https://doi.org/10.1016/j.jpeds.2013.11.001.Search in Google Scholar PubMed PubMed Central
20. Wenze, SJ, Battle, CL, Tezanos, KM. Raising multiples: mental health of mothers and fathers in early parenthood. Arch Womens Ment Health 2015;18:163–76. https://doi.org/10.1007/s00737-014-0484-x.Search in Google Scholar PubMed PubMed Central
21. Jernman, R, Stefanovic, V. Multifetal pregnancy reductions and selective fetocide in a tertiary referral center – a retrospective cohort study. J Perinat Med 2024;52:255–61. https://doi.org/10.1515/jpm-2023-0414.Search in Google Scholar PubMed
22. Chaveeva, P, Kosinski, P, Puglia, D, Poon, LC, Nicolaides, KH. Trichorionic and dichorionic triplet pregnancies at 10-14 weeks: outcome after embryo reduction compared to expectant management. Fetal Diagn Ther 2013;34:199–205. https://doi.org/10.1159/000356170.Search in Google Scholar PubMed
23. Kuhn-Beck, F, Moutel, G, Weingertner, AS, Kohler, M, Hornecker, F, Hunsinger, MC, et al.. Fetal reduction of triplet pregnancy: one or two? Prenat Diagn 2012;32:122–6. https://doi.org/10.1002/pd.2906.Search in Google Scholar PubMed
24. Yimin, Z, Minyue, T, Yanling, F, Huanmiao, Y, Saijun, S, Qingfang, L, et al.. Fetal reduction could improve but not completely reverse the pregnancy outcomes of multiple pregnancies: experience from a single center. Front Endocrinol 2022;13:851167. https://doi.org/10.3389/fendo.2022.851167.Search in Google Scholar PubMed PubMed Central
25. Ende, HB, Lozada, MJ, Chestnut, DH, Osmundson, SS, Walden, RL, Shotwell, MS, et al.. Risk factors for atonic postpartum hemorrhage: a systematic review and meta-analysis. Obstet Gynecol 2021;137:305–23. https://doi.org/10.1097/AOG.0000000000004228.Search in Google Scholar PubMed PubMed Central
26. Rissanen, ARS, Gissler, M, Nupponen, I, Nuutila, M, Jernman, R. Perinatal outcome of dichorionic and monochorionic-diamniotic Finnish twins. A historical cohort study. Acta Obstet Gynecol Scand 2022;101:153–62. https://doi.org/10.1111/aogs.14285.Search in Google Scholar PubMed PubMed Central
27. Stone, J, Ferrara, L, Kamrath, J, Getrajdman, J, Berkowitz, R, Moshier, E, et al.. Contemporary outcomes with the latest 1000 cases of multifetal pregnancy reduction (MPR). Am J Obstet Gynecol 2008;199:406.e1–4. https://doi.org/10.1016/j.ajog.2008.06.017.Search in Google Scholar PubMed
28. Zemet, R, Haas, J, Bart, Y, Barzilay, E, Zloto, K, Argaman, N, et al.. Pregnancy outcome after multifetal pregnancy reduction of triplets to twins versus reduction to singletons. Reprod Biomed Online 2020;40:445–52. https://doi.org/10.1016/j.rbmo.2019.12.014.Search in Google Scholar PubMed
29. www.monikkoperheet.fi Tieto – Usein kysyttyä [Accessed 29 Apr 2023].Search in Google Scholar
30. Britt, DW, Evans, MI. Sometimes doing the right thing sucks: frame combinations and multi-fetal pregnancy reduction decision difficulty. Soc Sci Med 2007;65:2342–56. https://doi.org/10.1016/j.socscimed.2007.06.026.Search in Google Scholar PubMed
31. Tiitinen, A, Gissler, M. Effect of in vitro fertilization practices on multiple pregnancy rates in Finland. Fertil Steril 2004;82:1689–90. https://doi.org/10.1016/j.fertnstert.2004.05.090.Search in Google Scholar PubMed
© 2024 Walter de Gruyter GmbH, Berlin/Boston
Articles in the same Issue
- Frontmatter
- Corner of Academy
- The outcome of reduced and non-reduced triplet pregnancies managed in a tertiary hospital during a 15-year-period – a retrospective cohort study
- Original Articles – Obstetrics
- Parental refusal of prenatal screening for aneuploidies
- Analysis of maternal mortality in Berlin, Germany – discrepancy between reported maternal mortality and comprehensive death certificate exploration
- Second twin outcome at birth: retrospective analysis in a single tertiary centre in Malaysia
- Incidence and first trimester risk factors of stillbirth in Indonesia
- Correlation of fetal heart rate dynamics to inflammatory markers and brain-derived neurotrophic factor during pregnancy
- Preliminary assessment of the Healthy Early Life Moments (HELMS) webinars in empowering Developmental Origins of Health and Disease (DOHaD) concept among healthcare professionals – a pragmatic serial cross-sectional study
- Original Articles – Fetus
- The changing Doppler patterns and perinatal outcomes of monochorionic diamniotic twins with selective fetal growth restriction
- Effects of umbilical vein flow on midbrain growth and cortical development in late onset fetal growth restricted fetuses: a prospective cross-sectional study
- Original Articles – Neonates
- Prediction of bronchopulmonary dysplasia by the chest radiographic thoracic area on day one in infants with exomphalos
- Impact of birth weight to placental weight ratio and other perinatal risk factors on left ventricular dimensions in newborns: a prospective cohort analysis
- Changes in regional tissue oxygen saturation values during the first week of life in stable preterm infants
- Letters to the Editor
- Optimal closure of the uterus during cesarean section: beyond the two layers
- Reply to: “Optimal closure of the uterus during cesarean section: beyond the two layers” commenting on “The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries”
Articles in the same Issue
- Frontmatter
- Corner of Academy
- The outcome of reduced and non-reduced triplet pregnancies managed in a tertiary hospital during a 15-year-period – a retrospective cohort study
- Original Articles – Obstetrics
- Parental refusal of prenatal screening for aneuploidies
- Analysis of maternal mortality in Berlin, Germany – discrepancy between reported maternal mortality and comprehensive death certificate exploration
- Second twin outcome at birth: retrospective analysis in a single tertiary centre in Malaysia
- Incidence and first trimester risk factors of stillbirth in Indonesia
- Correlation of fetal heart rate dynamics to inflammatory markers and brain-derived neurotrophic factor during pregnancy
- Preliminary assessment of the Healthy Early Life Moments (HELMS) webinars in empowering Developmental Origins of Health and Disease (DOHaD) concept among healthcare professionals – a pragmatic serial cross-sectional study
- Original Articles – Fetus
- The changing Doppler patterns and perinatal outcomes of monochorionic diamniotic twins with selective fetal growth restriction
- Effects of umbilical vein flow on midbrain growth and cortical development in late onset fetal growth restricted fetuses: a prospective cross-sectional study
- Original Articles – Neonates
- Prediction of bronchopulmonary dysplasia by the chest radiographic thoracic area on day one in infants with exomphalos
- Impact of birth weight to placental weight ratio and other perinatal risk factors on left ventricular dimensions in newborns: a prospective cohort analysis
- Changes in regional tissue oxygen saturation values during the first week of life in stable preterm infants
- Letters to the Editor
- Optimal closure of the uterus during cesarean section: beyond the two layers
- Reply to: “Optimal closure of the uterus during cesarean section: beyond the two layers” commenting on “The effect of uterine closure technique on cesarean scar niche development after multiple cesarean deliveries”
