Trans-abdominal fetal reduction in higher order multiple pregnancies: a pioneer cohort retrospective study in Nepal.

Objective: To share the initial experience of trans-abdominal multifetal pregnancy reduction (MFPR) in Nepal. Method: The procedure was performed in 108 patients in a private hospital over a period of 3 years. Under ultrasound guidance, intracardiac injection of 0.2-3.0 ml of 15% w/v (2 mEq/ml) potassium chloride (KCl) was administered via trans-abdominal route. Results: A total of 108 fetal reduction procedures were carried out at the seventh to fifteenth weeks of gestation, a maximum of 44 (40.7%) of which were done at the ninth to tenth weeks of gestation. A total of 123 fetuses were reduced. Out of total 108 multifetal pregnancies, 96 (88.8%) were due to in-vitro fertilization (IVF). Eighty-five pregnancies (78.7%) underwent reduction from triplet to twin. The second-time reduction was needed in five cases. Two attempts (in the same sitting) were required in three cases. The inadvertent demise of the second fetus was noted in three cases of dichorionic tri-amniotic triplet pregnancy. Conclusion: Ultrasound-guided trans-abdominal fetal reduction performed between the seventh and twelfth weeks of gestation is safe and effective.

Late selective termination in dichorionic twins: comparing late second and third trimester procedures.

RESEARCH QUESTION: Do perinatal outcomes of selective termination performed in the late second versus third trimester differ and what risk factors are associated with subsequent preterm birth? DESIGN: This is a retrospective cohort study of late selective terminations performed in dichorionic twins between 2009 and 2021. Perinatal outcomes were compared between two groups: group A, late second trimester (20.2 to 24.2 weeks, n = 26), and group B, third trimester (≥28.2 weeks, n = 55) selective terminations. Univariate and multivariate analyses were conducted to identify factors associated with post-procedure preterm birth. RESULTS: In total, 81 dichorionic twin pregnancies were included. There were no pregnancy losses but 16% (13/81) of cases experienced complications. Group A had a higher median birthweight centile (36.5th versus 15th centile, P = 0.002) and lower rates of intrauterine growth restriction (IUGR) and Caesarean delivery (11.5% versus 32.7%, P = 0.04; and 26.9% versus 61.8%, P = 0.003) than group B. Preterm birth rates were similar (46.2% versus 63.6%, P = 0.15). Multiple regression revealed that reduction of the presenting twin and cervical length ≤35 mm were independently associated with post-procedure preterm birth (odds ratio [OR] 8.7, P = 0.001, 95% confidence interval [CI] 2.5-29.8; OR 3.8, P = 0.015, 95% CI 1.3-11). CONCLUSIONS: Late second trimester selective termination is associated with a higher birthweight centile and lower rates of IUGR and Caesarean delivery, compared with third trimester selective termination. Cervical length 35 mm or less and reduction of the presenting twin are independent risk factors for post-procedural preterm birth. These findings may help determine the optimal time to perform a late selective termination.

Combined hysteroscopic Bigatti shaver (IBS) and resectoscope removal of a heterotopic cesarean scar pregnancy in the first trimester.

OBJECTIVE: To report a case of heterotopic cesarean scar pregnancy reduction using a combined hysteroscopic integrated Bigatti shaver (IBS) and resectoscope with the preservation of a normal gestational sac in the uterine cavity under simultaneous transabdominal ultrasound guidance. DESIGN: Video article. SETTING: University-affiliated hospital. PATIENT: A 30-year-old woman, G5P2A2L2, with two previous cesarean deliveries and a history of fertility problems, was admitted with a heterotopic cesarean scar pregnancy at 7+2 gestational weeks. Ultrasound examination showed a dichorionic diamniotic pregnancy. The first gestational sac (1.7 × 1.7 × 0.6 cm) was located in the previous hysterotomy scars, with a thin layer of myometrium measuring 0.2 cm in thickness and a rich blood supply. The second chorionic sac (2.8 × 2.4 × 1.8 cm) was observed at the uterine fundus. Normal cardiac activity and yolk sacs were observed in both gestational sacs. The couple strongly desired to preserve the intrauterine pregnancy. INTERVENTION(S): After Institutional Review Board approval was obtained, a hysteroscopic IBS combined with a bipolar resectoscope was used to remove the heterotopic cesarean scar pregnancy while preserving the intrauterine gestational sac under simultaneous transabdominal ultrasound guidance. MAIN OUTCOME MEASURE(S): The heterotopic cesarean scar pregnancy was completely resected using hysteroscopy, and the gestational sac in the uterine cavity was successfully preserved. RESULT(S): Trophoblastic tissue was confirmed using histopathological examination. The patient had an unremarkable postoperative recovery. Subsequent serial ultrasonography confirmed a single ongoing pregnancy with normal growth parameters and a normal placental site. CONCLUSION(S): The inability of an IBS to perform coagulation can be offset by its combination with the bipolar resectoscope. Hysteroscopic IBS combined with resectoscope to remove a heterotopic cesarean scar pregnancy offers a short operation time and minimum blood loss. It could be an optimized approach for the management of heterotopic cesarean scar pregnancy in the first trimester when an intrauterine pregnancy needs to be preserved.

Successful Fetal Reduction in Early Second Trimester: Series of Three Cases Conceived With Infertility Treatment.

This case series explores three instances of a successful fetal reduction in early second-trimester pregnancies conceived through infertility treatments. The patients, all admitted to a central Indian tertiary care hospital, underwent assisted reproductive technologies such as in vitro fertilization (IVF) or intrauterine insemination (IUI). Faced with triplet pregnancies, fetal reduction was made to mitigate risks and enhance maternal and fetal well-being. The reduction procedures, conducted either transvaginally or transabdominally under continuous ultrasound guidance, resulted in the cessation of targeted fetal heart activity and motility. Post-reduction, pregnancies progressed without major complications, culminating in successful deliveries via lower segment cesarean section (LSCS) in the third trimester. This case series underscores the importance of selective fetal reduction in managing pregnancies arising from infertility treatments, emphasizing its role in minimizing risks associated with multiple gestations. Using continuous ultrasound guidance during the reduction procedures proved effective in ensuring precision and safety. These cases contribute valuable insights to the evolving field of reproductive medicine, offering clinicians a nuanced understanding of successful interventions to optimize outcomes in complex pregnancies.

Fetal Reduction by Potassium Chloride Infusion in Unruptured Heterotopic Pregnancy: A Comprehensive Review.

This comprehensive review explores the practice of fetal reduction through potassium chloride infusion in unruptured heterotopic pregnancies. Heterotopic pregnancies, characterized by the simultaneous occurrence of intrauterine and extrauterine gestations, present unique challenges in reproductive medicine. The review defines fetal reduction and underscores its significance in mitigating risks associated with heterotopic pregnancies, including the threat of rupture, maternal morbidity, and adverse outcomes. The analysis encompasses the background, methods, efficacy, ethical considerations, and future directions related to the procedure. Findings highlight the efficacy and safety of potassium chloride infusion, emphasizing the importance of proper patient selection and counseling. Implications for clinical practice underscore the procedure's viability in specific cases where the benefits outweigh the associated risks. The review concludes with recommendations for future studies, encouraging further research on procedural techniques, alternative methods, and the psychosocial impact on patients. This work is a foundation for advancing the management of unruptured heterotopic pregnancies, providing insights for clinicians and researchers to improve clinical outcomes and patient care.

Clinical value of high-intensity focused ultrasound in fetal reduction.

Complex twin reduction surgery is a common but challenging procedure that aims to reduce the risks and complications of multiple pregnancies. The search for safer and more effective methods has led to the development of high-intensity focused ultrasound (HIFU) technology in the field of fetal reduction. This technology utilizes high-energy sound waves to focus precisely on specific areas, achieving non-invasive therapeutic effects. This paper discusses the principles and features of HIFU technology, as well as its application in complex twin reduction surgery. The paper aims to elucidate the important role of this technology in improving surgical outcomes and reducing risks, explore the current limitations of the modality, and propose directions for future development. Through these investigations, it is hoped to improve overall understanding of HIFU, and thereby promote the application of this technology in the field of fetal reduction.

Pregnancy outcomes of fetal reduction in patients with intrauterine haematoma following double embryo transfer.

RESEARCH QUESTION: Is there an association between intrauterine haematoma (IUH) and pregnancy outcomes in patients who undergo fetal reduction after double embryo transfer (DET), and if so, what is the relationship between IUH-related characteristics and pregnancy outcomes? DESIGN: Clinical information and pregnancy outcomes of women who underwent fetal reduction after DET were analysed. Patients with other systematic diseases, ectopic pregnancy or heterotopic pregnancy, monochorionic twin pregnancies and incomplete data were excluded. Stratification of IUH pregnancies was undertaken based on IUH-related characteristics. The main outcome was incidence of fetal demise (<24 weeks), with other adverse pregnancy outcomes considered as secondary outcomes. RESULTS: Thirty-four IUH patients and 136 non-IUH patients who underwent fetal reduction after DET were included based on a 1:4 match for age, cycle type and fertilization method. IUH patients had a higher incidence of early fetal demise (20.6% versus 7.4%, P = 0.048), threatened abortion (48.1% versus 10.3%, P<0.001) and postpartum haemorrhage (PPH; 14.8% versus 4.0%, P = 0.043) compared with non-IUH patients. IUH was an independent risk factor for early fetal demise [adjusted OR (aOR) 3.34, 95% CI 1.14-9.77] and threatened abortion (aOR 8.61, 95% CI 3.28-22.61) after adjusting for potential confounders. IUH pregnancies undergoing fetal reduction that resulted in miscarriage had larger IUH volumes and earlier diagnosis (both P < 0.03). However, IUH characteristics (i.e. volume, changing pattern, presence or absence of cardiac activity) were not associated with threatened abortion or PPH. CONCLUSIONS: Fetal reduction should be performed with caution in IUH pregnancies after DET as the risk of fetal demise is relatively high. Particular attention should be given to IUH patients with early signs of threatened abortion and inevitable fetal demise.

Quadruplet pregnancy outcome with and without fetal reduction: Danish national cohort study (2008-2018) and comparison with dichorionic twins.

OBJECTIVES: To perform a nationwide study of quadrichorionic quadriamniotic (QCQA) quadruplet pregnancies and to compare the pregnancy outcome in those undergoing fetal reduction with non-reduced quadruplets and dichorionic diamniotic (DCDA) twin pregnancies from the same time period. METHODS: This was a retrospective Danish national register-based study performed using data from the national Danish Fetal Medicine Database, which included all QCQA quadruplets and all non-reduced DCDA twin pregnancies with an estimated due date between 2008 and 2018. The primary outcome measure was a composite of adverse pregnancy outcomes, including pregnancy loss or intrauterine death of one or more fetuses. Secondary outcomes included gestational age at delivery, the number of liveborn children, preterm delivery before 28, 32 and 37 gestational weeks and birth weight. Data on pregnancy complications and baseline characteristics were also recorded. Outcomes were compared between reduced and non-reduced quadruplet pregnancies, and between DCDA pregnancies and quadruplet pregnancies reduced to twins. A systematic literature search was performed to describe and compare previous results with our findings. RESULTS: Included in the study were 33 QCQA quadruplet pregnancies, including three (9.1%) non-reduced pregnancies, 28 (84.8%) that were reduced to twin pregnancy and fewer than three (6.1%) that were reduced to singleton pregnancy, as well as 9563 DCDA twin pregnancies. Overall, the rate of adverse pregnancy outcome was highest in non-reduced quadruplets (66.7%); it was 50% in quadruplets reduced to singletons and 10.7% in quadruplets reduced to twins. The proportion of liveborn infants overall was 91.1% of the total number expected to be liveborn in quadruplet pregnancies reduced to twins. This was statistically significantly different from 97.6% in non-reduced dichorionic twins (P = 0.004), and considerably higher than 58.3% in non-reduced quadruplets. The rates of preterm delivery < 28, < 32 and < 37 weeks were decreased in quadruplets reduced to twins compared with those in non-reduced quadruplet pregnancies. Quadruplets reduced to twins did not achieve equivalent pregnancy outcomes to those of DCDA twins. CONCLUSION: This national study of QCQA quadruplets has shown that multifetal pregnancy reduction improves pregnancy outcome, including a decreased rate of preterm delivery and higher proportion of liveborn children. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

New radiofrequency ablation procedure for selective reduction in complicated monochorionic twin or triplet pregnancy using multistep, incremental expansion technique.

OBJECTIVE: Radiofrequency ablation (RFA) is the preferred approach for selective reduction in complex monochorionic (MC) multiple pregnancies owing to the ease of operation and minimal invasiveness. To optimize the RFA technique and reduce the risk of adverse pregnancy outcome resulting from the heat-sink effect of RFA therapy, we used an innovative RFA method, in which an electrode needle was expanded incrementally and stepwise. This study aimed to assess the efficacy and safety profile of this novel multistep incremental expansion RFA method for selective fetal reduction in MC twin and triplet pregnancies. METHODS: This was a single-center retrospective cohort study of all MC multiple pregnancies undergoing RFA between March 2016 and October 2022 at our center. The multistep RFA technique involved the use of an expandable needle, which was gradually expanded during the RFA procedure until cessation of umbilical cord blood flow was achieved. The needle used for the single-step RFA method was fully extended from the start of treatment. RESULTS: In total, 132 MC multiple pregnancies underwent selective reduction using RFA, including 50 cases undergoing multistep RFA and 82 cases undergoing single-step RFA. The overall survival rates were not significantly different between the multistep and single-step RFA groups (81.1% vs 72.3%; P = 0.234). Similarly, the rates of preterm prelabor rupture of the membranes within 2 weeks after RFA, procedure-related complications, spontaneous preterm delivery and pathological findings on cranial ultrasound, as well as gestational age at delivery and birth weight, did not differ between the two groups. However, there was a trend towards a prolonged procedure-to-delivery interval following multistep RFA compared with single-step RFA (median, 109 vs 99 days; P = 0.377). Moreover, the fetal loss rate within 2 weeks after RFA in the multistep RFA group was significantly lower than that in the single-step RFA group (10.0% vs 24.4%; P = 0.041). The median ablation time was shorter (5.3 vs 7.8 min; P < 0.001) and the median ablation energy was lower (10.2 vs 18.0 kJ; P < 0.001) in multistep compared with single-step RFA. There were no significant differences in neonatal outcomes following multistep vs single-step RFA. CONCLUSIONS: Overall survival rates were similar between the two RFA methods. However, the multistep RFA technique was associated with a lower risk of fetal loss within 2 weeks after RFA. The multistep RFA technique required significantly less ablation energy and a shorter ablation time compared with single-step RFA in selective fetal reduction of MC twin and triplet pregnancies. Additionally, there was a trend towards a prolonged procedure-to-delivery interval with the multistep RFA technique. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Corrigendum: Pregnancy loss: consequences for mental health.

[This corrects the article DOI: 10.3389/fgwh.2022.1032212.].

The initial number of fetuses in multiple pregnancy before reduction affects perinatal outcomes.

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.

Maternal, pregnancy and neonatal outcomes in triplet pregnancies in Sweden - a nationwide cohort study.

Background: Triplet pregnancies carry a high risk of pregnancy-related complications. The primary aim of this study was to describe maternal, pregnancy, and neonatal outcomes in expectantly managed triplet pregnancies in Sweden. The secondary aim was to compare outcomes in expectantly managed triplet pregnancies with triplet pregnancies where fetal reduction had been performed with the only indication to reduce the number of fetuses. Methods: Nationwide cohort study based on linkage of data from three national Swedish registers. Triplet pregnancies with delivery at gestational age ≥ 22+0 weeks between 2014 and 2019 were included. Results: In the main cohort of expectantly managed triplet pregnancies (n = 106), 98% (312/318) of infants were liveborn with a mean gestational age at birth of 32+3 weeks and a mean birthweight of 1,726 g. Nine percent (n = 29) suffered from severe neonatal morbidity, and 4% (n = 12) died during the neonatal period. In the reduced cohort (n = 13 pregnancies), all infants were liveborn (n = 22). Mean gestational age at birth (36+0 weeks) and mean birthweight (2,444 g) were higher than in the expectantly managed cohort (P < 0.01 for both comparisons). There were no cases of severe neonatal morbidity (P = 0.24) or mortality (P = 1.00). Conclusion: Overall neonatal survival from 22+0 weeks of gestation in expectantly managed triplet pregnancies in Sweden was high. Nine out of 10 infants did not suffer from severe neonatal morbidity. Fetal reduction was performed in only a very small number of cases and was associated with higher gestational age at birth and higher birth weight.

Clinical outcomes of vanishing twin syndrome and selective fetal reduction after double embryos transferred in IVF pregnancy: A propensity score matching study.

OBJECTIVE: The purpose of this study was to analyze the influence of early vanishing twin syndrome (VTS) and selective fetal reduction (SEFR) on surviving singleton births in in-vitro fertilization (IVF) pregnancy. METHODS: We collected patients who conceived through IVF and delivered singletons over the past six years. The VT group (n = 194) and SEFR group (n = 144) had underwent double embryos transferred (DET) and only one fetus was born, due to the subsequent one birth reduction. The SET group had one embryo transferred (SET) and gave birth to singleton. Using the propensity score matching (PSM) method to reduce confounding, the VT group and SEFR group were matched and compared with 570 and 576 singleton controls, respectively (SET-I/II group). Obstetric complications and neonatal outcomes were compared. In addition, quantity and quality of transferred embryos of VT (n = 194) and singleton groups (born with singleton after DET and matched with VT group by PSM, n = 554) were compared. RESULTS: Compared with the SET-I group, VT group had increased incidence of severe obstetric complications, including severe preeclampsia (p = 0.031), oligohydramnios (p = 0.038) and polyhydramnios (p = 0.015). VT group was more likely to show more frequent small for gestational age (SGA) (p = 0.046) and very small for gestational age (VSGA) (p = 0.031). Newborns in the SEFR group had a significantly lower birth weight (p = 0.005) and were more likely to manifest as low birthweight (LBW) (p = 0.009) and very low birthweight (VLBW, birth weight < 1500 g) (p = 0.012), and the incidence of very large for gestational age (VLGA) was lower (p = 0.030), compared with the control group. There were more developmental abnormalities in newborns of VTS, for decreased incidence of SGA (OR 0.156, 95% CI 0.036-0.669), VSGA (OR 0.057, 95% CI 0.006-0.553) and VLGA (OR 0.415, 95% CI 0.212-0.815) in SEFR group. The good quality embryo rate was higher in VT group (72.7% vs. 63.3%, p = 0.001) compared with the singleton group. CONCLUSIONS: DET with subsequent VTS/SEFR carried a higher rate of adverse clinical outcomes, and the VTS group had worse perinatal outcome compared with SEFR. Therefore, we recommend SET in ART.

[Analysis of Pregnancy Outcomes After Fetal Reduction in Monochorionic, Dichorionic, and Trichorionic Triplet Pregnancies].

Objective: To compare the pregnancy outcomes of pregnancy outcomes after selective fetal reduction treatment in monochorionic, dichorionic, and trichorionic triplet pregnancies. Methods: We conducted a retrospective analysis of the clinical data of 118 pregnant women carrying triplets. All subjects underwent regular prenatal check-ups and were admitted for delivery at West China Second University Hospital, Sichuan University between January 1, 2012 and January 31, 2021. According to the chorionicity, the subjects were divided into a monochorionic group ( n=13), a dichorionic group ( n=44), and a trichorionic group ( n=61). Within each group, the subjects were further divided into two subgroups, a reduction group and an expectant treatment group, according to whether they underwent fetal reduction or not. The clinical data and pregnancy outcomes were compared between the subgroups within each group. Results: In the monichorionic group, the reduction subgroup had a lower preterm birth rate and higher neonatal birth body mass than those of the expectant management subgroup, but the differences were not statistically significant. In the dichorionic and trichorionic groups, the rates of preterm delivery, neonatal hospitalization, and serious complications of the reduction subgroups were lower than those of the expectant subgroups ( P<0.05), while the neonatal birth body mass was higher in the reduction subgroups than that in the expectant subgroups ( P<0.05). In the dichorionic group, the incidence of intrahepatic cholestasis during pregnancy was lower in the reduction subgroup than that in the expectant treatment subgroup. In all 3 groups, there was no statistically significant difference between the subgroups in the incidence of gestational diabetes, hypertensive disorders of pregnancy, premature rupture of membranes, and postpartum hemorrhage. The survival curve analysis showed that women receiving fetal reduction during the first trimester had a lower risk of pregnancy loss and more significant prolonged of gestational age than those undergoing the procedure during the second trimester. Conclusion: Fetal reduction of triplets can significantly prolong the gestational age and improve the perinatal prognosis. In addition, selective reduction in the first trimester may lead to greater benefits than selective reduction in the second trimester does.

Outcomes of higher-order multiple pregnancies in an Australian setting.

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.

[Clinical effect of fetal reduction by intracranial and intrathoracic KCl injection].

OBJECTIVE: To evaluate the feasibility and effectiveness of fetal reduction by transabdominal intracranial KCl injection for multifetal pregnancies in the early second trimester. METHODS: The data of 363 patients who underwent transabdominal fetal reduction in the Reproductive Medical Center of Peking University Third Hospital from January 2006 to December 2019 were analyzed retrospectively. According to the location of fetal reduction, they were divided into two groups: Intracranial injection group (n=196) and intrathoracic injection group (n=167). The process of fetal reduction and pregnancy outcome of the two groups were compared. RESULTS: There was no significant difference between the two groups in the average age and the proportion of type of infertility before assisted reproductive technology, conception method, indication for fetal reduction, starting number of fetuses, reduced number of fetuses, and finishing number of fetuses (P>0.05). There was no significant difference between the two groups in the proportion of the number of puncture ≥ 2 times (12.1% vs. 8.6%, P=0.249) and the incidence of replacing puncture site (10.7% vs. 6.4%, P=0.161). The next day after fetal reduction, color Doppler ultrasound was rechecked. In the intracranial injection group and intrathoracic injection group, the incidence of fetal heartbeat recovery [3.6% (8/224) vs. 1.1% (2/187), P=0.188], the volumes of KCl used [(2.6±1.0) mL vs. (2.8±1.1) mL, P=0.079], and the abortion rate within 4 weeks after fetal reduction (1.0% vs. 0.6%, P=0.654) were of no significant difference. In addition, there was no significant difference in the total abortion rate after fetal reduction, premature delivery rate, cesarean section rate, delivery gestational week and neonatal birth weight between the two groups (P>0.05). CONCLUSION: Intracranial KCl injection can be an effective alternative to intrathoracic KCl injection for multifetal pregancy reduction.

Co-twin survival after selective fetal reduction in complicated multiple gestations: A systematic review and meta-analysis of survival rate according to indication for intervention.

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.

Fetal reduction for everyone?

Infertility treatments have benefited millions of couples to have their own children; however, the complication of multiple pregnancies with their increased morbidity and mortality has created significant problems. Fetal reduction (FR) was developed to ameliorate these issues. Over 30 years of publications show that FR has been highly successful in substantially reducing both mortality and morbidity. As with most radically new techniques, initial cases were in the "nothing to lose" category. With experience, indications liberalize, and quality of life issues increase as a proportion of cases. Overall risks for twins are not twice as those for singletons, but they are approximately 4- to 5-fold higher. In experienced hands, the combination of genetic testing by CVS followed by FR has made most multiples behave statistically as if they were originally the lower number. The use of microarray analysis to better determine fetal genetic health before deciding on which fetus(es) to keep or reduce further improves pediatric outcomes. With increasing experience and lower average starting numbers, the proportion of FRs to a singleton has increased considerably. Twins to a singleton FR now constitute an increasing proportion of cases performed. Data on such cases show improved outcomes, and we believe FR should be at least discussed and offered to all patients with a dichorionic twin pregnancy or higher. eSET is not a panacea because of the resultant monochorionic twins.

Fetoscopic Laser Ablation for the Selective Fetal Reduction in Twin-Twin Transfusion Syndrome Stage II-IV: The Experience of a New Fetal Medicine Center.

Objective: To evaluate the surgery outcomes of fetoscopic laser ablation (FLA) for selective umbilical cord in treating twin-twin transfusion syndrome (TTTS) with special conditions and neonatal outcomes post-operation. Methods: A prospective study, 21 monochorionic diamniotic (MCDA) twins diagnosed with TTTS stage II-IV according to Quintero classification from 16 to 26 weeks of gestation, among that, 12 cases of TTTS stage II with selective intrauterine growth restriction (sIUGR), 6 cases of TTTS stage II with proximate cord insertions, 3 cases of TTTS stage IV underwent fetoscopic laser ablation for the selective fetal reduction at Hanoi Obstetrics and Gynecology Hospital from September 2019 to July 2021. Complications and surgical outcomes were noted. Prenatal care was carried out every 2 weeks post operation until birth. Newborn neurologic complications were assessed at birth, three months, and six months after birth using Denver II test and magnetic resonance imaging (MRI). Results: The mean gestational age at operation was 20.30 weeks. The average operation duration was 39.52 minutes. No complications of operation, such as bleeding or infection, were recorded. The mean gestational age at birth was 34.70 ± 4.33 weeks, with a mean duration of 12.97 ± 6.87 weeks between intervention and delivery. The survival rate of newborns after the operation was 90.48%. There were two stillbirths (9.52%) within seven days after the operation. No short-term neurological complications have been reported with follow-up of the newborn to 6 months after birth. Conclusion: Our study showed that fetoscopic laser ablation of selected fetal reduction surgery for treatment of special conditions of TTTS had no complications of operation, high neonatal survival result (90.48%), no short-term neurological complications. This should be considered for TTTS in cases of indication.

The clinical outcomes of selective and spontaneous fetal reduction of twins to a singleton pregnancy in the first trimester: a retrospective study of 10 years.

BACKGROUND: Singleton pregnancy is encouraged to reduce pregnancy complications. In addition to single embryo transfer (SET), selective and spontaneous fetal reduction (SEFR and SPFR) can also achieve singleton pregnancies. After SEFR or SPFR, an inanimate fetus remains in the uterus. It is unclear whether the inanimate fetus would adversely affect another fetus or the mother. Previous studies have focused on the differences between pre- and post-reduction. However, studies focusing on the influence of SEFR and SPFR on the remaining fetal development and maintenance of pregnancy are rare. METHODS: Materials from 5922 patients whose embryo transfer dates ranged from March 2011 to January 2021 were collected. Both the SEFR group (n = 390) and SPFR group (n = 865) had double embryos transferred (DET) and got twin pregnancies, but subsequent selective or spontaneous fetal reduction occurred. The SET group (n = 4667) had only one embryo transferred. All were singleton pregnancies on the 65th day after embryo transfer. Clinical outcomes, including pregnancy outcomes, pregnancy complications, and newborn outcomes, were compared among the three groups. RESULTS: After adjusting for age, infertility duration, types of infertility, states of embryos, body mass index, and factors affecting SET or DET decisions, multivariate regression analysis revealed that SEFR increased the risk of miscarriage (OR 2.368, 95% CI 1.423-3.939) and preterm birth (OR 1.515, 95% CI 1.114-2.060), and reduced the gestational age (ßeta -0.342, 95% CI -0.544- -0.140). SPFR increased the risk of gestational diabetes mellitus (GDM) (OR 1.657, 95% CI 1.215-2.261), preterm premature rupture of membranes (PPROM) (OR 1.649, 95% CI 1.057-2.574), and abnormal amniotic fluid volume (OR 1.687, 95% CI 1.075-2.648). Both SEFR and SPFR were associated with reduced live birth rate (OR 0.522, 95% CI 0.330-0.825; OR 0.671, 95% CI 0.459-0.981), newborn birth weight (ßeta -177.412, 95% CI -235.115--119.709; ßeta -42.165, 95% CI -83.104--1.226) as well as an increased risk of low-birth-weight newborns (OR 2.222, 95% CI 1.490-3.313; OR 1.510, 95% CI 1.092-2.087). CONCLUSIONS: DET with subsequent fetal reduction was related to poor clinical outcomes. We recommend that DET with subsequent fetal reduction should only be considered as a rescue method for multiple pregnancy patients with potential complications, and SET is more advisable.