| BACKGROUNDIn the last few decades,clinical evaluation of global variation in the incidence of multi-fetal pregnancy is largely a result of assisted reproduction technologies.With an increasing number of fetuses,the rates of fetal and maternal complications become significantly higher.Multi-fetal pregnancy reduction(MFPR)has been widely used to manage multi-fetal pregnancy to decrease fetal and maternal risk during birth.As a therapeutic option,MFPR has been widely used in the clinic.In recent years,studies on multifetal pregnancy reduction were focused on the effects of this operation.Factors that have previously been identified as being related to MFPR outcomes include operator experience,MFPR timing,the initial number of fetuses,and the final number of fetuses.1.There are some studies on initial number of fetuses.In these studies,perinatal outcome data were reported as percentages of these respective studies.There have been very few case-control studied exploring the relationship between the starting number of fetuses and perinatal outcomes following MFPR to date.2.The fetal ultrasound examination is still a common examination method during pregnancy.However,fetal malformations are often found in the later gestational weeks through fetal ultrasound examination,especially in twin pregnancies.Will fetal reduction at a later period of pregnancy increase the risk of perinatal outcomes?Compared with simply reducing the number of fetuses,does the fetal reduction due to fetal malformations and maternal reasons affect the outcome of pregnancy in dichorionic twin pregnancy?These issues need to be analyzed and evaluated.3.The starting number of fetuses was not modifiable and did not offer avenues to improve therapeutic outcomes.However,the timing of MFPR and the finishing number of fetuses could be selected.It is important to evaluate the effects of timing and the finishing number of fetuses on perinatal outcomes when the other factors were same.4.Studies of higher-order multi-fetal pregnancy(quadruplets and greater)are limited because of their relative rarity compared with twins and triplets.With an increasing number of fetuses,the rates of fetal and maternal complications become significantly higher.It is of great significance to provide more high-order multiple pregnancy data for clinical consultation,discuss the experience and evaluate the effectiveness and safety of high-order multiple pregnancy reduction surgery.5.This is by large attributed to the presence of placental vascular anastomoses in monochorionic twins.This kind of complicated monochorionic has significantly poor pregnancy outcomes.However,selective fetal reduction can reduced perinatal mortality and improve pregnancy outcome.To prevent cerebral injury and intrauterine fetal death,umbilical cord occlusion for selective fetal reduction is recommended.And radio frequency ablation is relatively simple and effective techniques and used in clinical practice.The study is a large sample of size in a single center.Firstly,we were established the relationship between the initial number of fetuses and perinatal outcomes following multifetal pregnancy reduction(MFPR)when MFPR timing and final fetus numbers were consistent.Secondly,we were evaluated the effective factors of dichorionic twins,triplets,quadruplets,respectively.Thirdly,we were shared the surgical experience of high-order multifetal pregnancy reduction,and evaluated the safety and efficacy of high-order multifetal pregnancy reduction.At the end,we were assessed the effect on timing and indication on perinatal outcome after radio frequency ablation for complicated monochorionic twin pregnancy,evaluated the difference of perinatal outcome according to difference type of TTTS and SIUGR and the occurrence of related pregnancy complications after RFA for selective reduction.Part ?:The Relationship between the Initial Number of Fetuses and Perinatal Outcomes following multifetal pregnancy reductionBackground and ObjectiveA few studies have explored the relationship between the number of fetuses prior to MFPR and perinatal outcomes.In these studies,perinatal outcome data were reported as percentages of these respective studies.There have been very few case-control studied exploring the relationship between the starting number of fetuses and perinatal outcomes following MFPR to date.In the present report,we conducted a single-center analysis in which the timing of MFPR and the final number of fetuses were matched in order to control for these potential confounding variables.Under these conditions,we compared the perinatal outcomes of triplets reduced to singletons and twins reduced to singletons,as well as those of quadruplets reduced to twins and triplets reduced to twins.Through this case-control approach,we can more directly understand the relationship between the initial number of fetuses and perinatal outcomes following MFPR in a statistically robust manner.Methods:?:The study included 682 sets of multifetal pregnancy1.104 quadruplet cases,6 cases of trichorionic quadruplets,the twins that share the same chorionic membrane are reduced to a dichorionic twin pregnancy.98 cases of quachorionic quadruplets,to reduce two fetuses to a dichorionic twin pregnancy.81 and 23 underwent MFPR at 11-14+6 and 15-24+6 weeks of gestation,respectively.2.Among the 417 triplet cases,85cases of dichorionic triplets,the twins that share the same chorionic membrane are reduced to a singleton pregnancy.24 cases of trichorionic triplets were required to reduce two fetuses to singleton pregnancy.109 cases of triplets were reduced to singletons(74 at 11-14+6 weeks of gestation and 35 at 15-24+6 weeks of gestation),308 cases of trichorionic triplets were reduced to twins(214 at 11-14+6 weeks of gestation and 94 at 15-24+6 weeks of gestation).3,161 dichorionic twin cases,47 and 114 underwent MPFR at 11-14+6 and 15-24+6 weeks of gestation,respectively.?:Standard techniques were used to perform MFPR,The same surgeon provided all procedures,administering a trans-abdominal intracardiac injection of KCl using a 20-or 22-gauge spinal needle under ultrasonic guidance.?:The timing of fetal reduction is divided into two periods:11-14+6 weeks of pregnancy and 15-24+6 weeks of pregnancy1?In these two timing of fetal reduction,the perinatal outcomes of triplets to singleton and twins to singleton were compared.That is,under the same final number of fetuses during the same fetal reduction surgery period,the difference between the initial number of fetuses and the difference in pregnancy outcome when the initial number of fetuses is three and two.2.In these two timing of fetal reduction,the perinatal outcomes of quadruplets to twins and triplets to twins were compared.That is,under the same final number of fetuses during the same fetal reduction surgery period,the difference between the initial number of fetuses and the difference in pregnancy outcome when the initial number of fetuses is four and three.Results?:The comparison with triplets to singleton and twins to singletonThe timing of MFPR was 11-14+6 weeks of gestation:comparison with 74 cases of triplets to singleton and 47 cases of twins to singleton,spontaneous abortion rates,preterm birth rate,low birth weight rate,birth weight,the gestational ages at delivery,P>0.05,no statistical differenceThe timing of MFPR was 15-24+6 weeks of gestation:comparison with 35 cases of triplets to singleton and 114 cases of twins to singleton,spontaneous abortion rates,preterm birth rate,low birth weight rate,birth weight,the gestational ages at delivery,P>0.05,no statistical difference?:The comparison with quadruplets to twins and triplets to twinsThe timing of MFPR was 11-14+6 weeks of gestation:81 cases of quadruplets reduced to twins were compared with 214 cases of triplets reduced to twins.There were significant differences in spontaneous abortion rates between these two groups(18.5%vs.6.5%,respectively;P=0.002).Similarly,low birth weight rates(50%vs.38.2%,respectively;P=0.017)and birth weights(2417.31g±491.83 vs.2561.31g±447.73 respectively;P=0.017)differed significantly between these groups.The timing of MFPR was 15-24+6 weeks of gestation:comparison with 23 cases of quadruplets to twins and 94 cases of triplets to twins,spontaneous abortion rates,preterm birth rate,low birth weight rate,birth weight,the gestational ages at delivery,P>0.05,no statistical difference.?:Analysis of resultThe timing of MFPR was 11-14+6 weeks of gestation,comparing with quadruplets to twins and triplets to twins,there were significant differences in spontaneous abortion rates,low birth weight rate,birth weight.The sample size of this comparison is much larger than the other three groups,and the test power is greater.ConclusionsWhen timing and final fetal numbers of MFPR were identical,the initial number of fetuses was found to be associated with spontaneous abortion rates and birth weights.Specifically,the starting number of fetuses was positively correlated with spontaneous abortion rates and low birth weight rates,while this number was negatively correlated with birth weights.Part ?:Effects of the Timing and indication of Multifetal Pregnancy Reduction on the Perinatal Outcome in Dichorionic twinsBackground and ObjectiveNon-invasive prenatal gene sequencing have not been widely used due to differences in regions and economic levels in our country.The chorionic villus sampling method is only recommended for medical indications.The fetal ultrasound examination is still a common examination method during pregnancy.However,fetal malformations are often found in the later gestational weeks through fetal ultrasound examination,especially in twin pregnancies.Will fetal reduction at a later period of pregnancy increase the risk after reduction?Compared with simply reducing the number of fetuses,does the fetal reduction due to fetal malformations and maternal reasons affect the outcome of pregnancy in dichorionic twin pregnancy?These issues need to be analyzed and evaluated.The aim of this study is to assess the effect on timing and indication on perinatal outcome after multifetal pregnancy reduction for dichorionic twin pregnancy.Methods?:The study included 180 dichorionic twin cases,47 cases underwent MPFR at 11-14+6 weeks of gestation,114 cases underwent MPFR at 15-24+6 weeks of gestation,19 cases underwent MPFR at 25 and after weeks of gestation.?:Among the 180 dichorionic twin cases,141 cases of fetal anomaly(one of twins is fetal anomaly),20 cases just reduced the number of fetuses,and 19 cases of maternal reason(the mother has a kind of disease that is not conducive to pregnancy)?:Standard techniques were used to perform MFPR,The same surgeon provided all procedures,administering a trans-abdominal intracardiac injection of KC1 using a 20-or 22-gauge spinal needle under ultrasonic guidance.ResultI:The effect of timing of MFPR on perinatal outcome Preterm labor rates were 17.0%?15.8%?42.1%respectively.Cases at 25 and after weeks compared with at 15-24+6,P=0.013.Low birth weight rates:cases at 25 and after weeks compared with at 11-14+6,P=0.007;cases at 25 and after weeks compared with at 15-24+6,P=0.011.Birth weights:at 25 and after weeks compared with at 11-14+6,P=0.018;at 25 and after weeks compared with at 15-24+6,P=0.040.Gestational ages at delivery:at 25 and after weeks compared with at 15-24+6P=0.025.?:The effect of indication of MFPR on perinatal outcome The comparison of birth weight among three teams was statistical difference.F=5.951,P=0.003.Indication of maternal reason compared with indication of fetal anomaly P=0.001.Gestational ages at delivery were 7.91±2.33weeks,36.08±2.91 weeks,37.93±1.96weeks,respectively.at 25 and after weeks compared with at 15-24+6,P=0.040.Indication of maternal reason compared with indication of fetal anomaly,P=0.045.ConclusionMFPR after 25 weeks of gestation can increase the premature birth rate and decrease the fetal birth weight in dichorionic twin.Compared with indication of reduced number and fetal abnormalities,the indication of maternal reasons has their own reasons that are not conducive to pregnancy,pregnancy outcome after MFPR is poor.Part ?:Effects of the Timing of Multifetal Pregnancy Reduction and Finishing Number of Fetuses on the Perinatal Outcome in TripletsBackground and ObjectiveSeveral studies reported the effects of MFPR on the perinatal outcome.A loss during pregnancy was dependent on not only the operator's experience but the timing of MFPR and the starting and finishing numbers of fetuses.The starting number of fetuses was not modifiable and did not offer avenues to improve therapeutic outcomes.However,the timing of MFPR and the finishing number of fetuses could be selected.Excluding other influencing factors,it is of great significance to study the best timing of fetal reduction and the most suitable final number of fetuses to improve the pregnancy outcome after fetal reduction.For twin pregnancy,fetal reduction surgery is usually performed when medically indicated.Studies of higher-order multi-fetal pregnancy(quadruplets and greater)are limited because of their relative rarity compared with twins and triplets.The case of fetal reduction of triple pregnancy is more common.Analysing studies of Lipitz?Chaveeva and Haas,they did not compare the outcome of triplets reduced to singletons.The starting and finishing numbers of fetuses,which were two influencing factors,were also considered to analyze the differences between the aforementioned studies and the present study.Data on the outcomes of multifetal pregnancy reduction in triplets late in pregnancy are limited.This study aimed to evaluate the effect of timing of MFPR and finishing number of fetuses on perinatal outcome in triplets.Methods:?:The study included 417 sets of triplets1.Among the 417 triplet cases,85cases of dichorionic triplets,the twins that share the same chorionic membrane are reduced to a singleton pregnancy.24 cases of trichorionic triplets were required to reduce two fetuses to singleton pregnancy.2.109 cases of triplets were reduced to singletons(74 cases at 11-14+6 weeks of gestation and 3 5cases at 15-24+6 weeks of gestation),3.308 cases of trichorionic triplets were reduced to twins(214 cases at 11-14+6 weeks of gestation and 94 cases at 15-24+6 weeks of gestation).?:Standard techniques were used to perform MFPR,The same surgeon provided all procedures,administering a trans-abdominal intracardiac injection of KCl using a 20-or 22-gauge spinal needle under ultrasonic guidance.?:The effect of timing of MFPR and finishing number of fetuses on perinatal outcome1.The effect of timing of MFPR on perinatal outcome:In triplets to singleton,comparing the pregnancy outcome of fetal reduction in 11-14+6 weeks of gestation and 15-24+6 weeks of gestation;In triplets to twin,comparing the pregnancy outcomes of fetal reduction in 14+6 weeks of gestation and 15-24+6 weeks of gestation2.The effect of finishing number of fetuses on perinatal outcome:The timing of fetal reduction is 11-14+6 weeks of pregnancy,the perinatal outcome of triplets to twins and triplets to singleton were compared.The timing of fetal reduction is 15-24+6 weeks of pregnancy,the perinatal outcome of triplets to twins and triplets to singleton were compared.Result:?:The effect of timing of MFPR on perinatal outcome1.The perinatal outcomes were compared when SR was performed at 11-14+6 weeks of gestation(74 cases)and at 15-24+6 weeks of gestation(35 cases).The spontaneous abortion rate,preterm labour rates,low birth weight rates,birth weight,and gestational ages at delivery showed no statistically significant difference P>0.052.In total,308 cases of triplets were reduced to twins.The perinatal outcomes were compared when SR was performed at 11-14+6 weeks of gestation(214 cases)and at 15-24+6 weeks of gestation(94 cases).The spontaneous abortion rate was 6.5%and 14.9%,respectively.These differences were statistically significant(P=0.019).Preterm labor rates,low birth weight rates,birth weights,and gestational ages at delivery showed no significant differences?:The effect of finishing number of fetuses on perinatal outcome1.In total,74 cases of triplets were reduced to singletons and 214 cases of triplets were reduced to twins when SR was performed at 11-14+6 weeks of gestation.Compared with the perinatal outcome,the preterm labor rate was 8.1%and 36.0%,respectively.The rate of low birth weight was 8.5%and 38.2%,respectively.The birth weight was 3093.24g ± 516.67 and 2561.31g±447.73,respectively.The gestational age at delivery was 38.50±2.08 weeks and 36.71± 2.05 weeks,respectively.These differences were statistically significant(P<0.001)2.A total of 35 cases of triplets were reduced to singletons and 94 cases of triplets were reduced to twins when SR was performed at 15-24+6 weeks of gestation.Compared with the perinatal outcome,the preterm labor rate was 17.1%and 33.0%,respectively.These differences were no statistically significant.The rate of low birth weight was 12.5%and 41.7%,respectively.These differences were statistically significant(P=0.002).The birth weight was 3028.13g ± 566.96 g and 2529.71g ±445.87,respectively.These differences were significantly different.ConclusionThe study showed that when the starting and finishing numbers of fetuses were the same,the timing of SR had an effect on the spontaneous abortion rates,therefore,MFPR performed later in pregnancy was associated with increased rates of spontaneous abortion.When the starting number of fetuses was the same,the timing of MFPR had no effect on the neonatal outcome and the finishing number of fetuses was the influencing factor.Part ?:Safety and Efficacy of Higher-order Multi-fetal Pregnancy ReductionBackground and ObjectiveStudies of higher-order multi-fetal pregnancy(quadruplets and greater)are limited because of their relative rarity compared with twins and triplets.With an increasing number of fetuses,the rates of fetal and maternal complications become significantly higher.It is of great significance to provide more high-order multiple pregnancy data for clinical consultation,discuss the experience of high-order multiple pregnancy reduction,and evaluate the effectiveness and safety of high-order multiple pregnancy reduction surgery.This study involved a large,diverse sample population of higher-order multifetal pregnancy.The aim of this study is to share the surgical experience of higher-order multifetal pregnancy,and evaluate the safety and efficacy of higher-order multifetal pregnancyMethods:?:The study included 131 consecutive patients with higher-order multi-fetal pregnancy(including 104 sets of quadruplets,20 quintuplets,5 sets of sextuplets,1set of septuplets,and lset octuplets)122/131 cases of higher-order multiple pregnancy were reduced to twins.We discuss the perinatal outcomes of patients who underwent higher-order MFPR,followed by a comparative analysis between the 122 cases of MFPR that were reduced to twins and 101 cases of non-reduced twin pregnancies?:Standard techniques were used to perform MFPR,The same surgeon provided all procedures,administering a trans-abdominal intracardiac injection of KCl using a 20-or 22-gauge spinal needle under ultrasonic guidance?:The study included 131 consecutive patients with higher-order multi-fetal.122 cases of higher-order multiple pregnancies were reduced to twins,(93 cases at 11-14+6 weeks of gestation and 29 cases at 15-24+6 weeks of gestation)1.To analyze the pregnancy outcomes of 131 cases of higher-order multifetal pregnancy reduction and share the surgical experience2.Comparing the pregnancy outcomes of 122 cases of reduced to twins with non-reduced twins.Result:?:The pregnancy outcomes of 131 cases of higher-order multifetal pregnancy reduction and share the surgical experience.1.104 quadruplet cases,6 cases of trichorionic quadruplets,the twins that share the same chorionic membrane are reduced to a dichorionic twin pregnancy.98 cases of quachorionic quadruplets,to reduce two fetuses to a dichorionic twin pregnancy.One hundred cases of quadruplets were reduced to twins.The rate of pregnancy loss,preterm deliveries at 28-33+6 weeks and preterm deliveries at 34-36+6 weeks was 20.2%,7.2%and 38.6%,respectively.The mean delivery time was 36.71±1.64 weeks,and the mean birth weight was 2450.42g±438.88.2.20 case of quinchorionic quintuplets,8 cases underwent two sessions of MFPR,12cases underwent one sessions of MFPR.The subsequent session should be planned after 5-7 days of postoperative observation.In regards to the quintuplets,one case was reduced to a single fetus,fourteen cases were reduced to twins and five cases were reduced to triplets.The rate of pregnancy loss,preterm deliveries at 28-33+6 weeks and preterm deliveries at 34-36+6 weeks was 40%,25%and 25%,respectively.The mean delivery time was 36.09 ±2.60 weeks,and mean birth weight was 2144.62 g± 544.31.3.Among five sets of sextuplets,one case was reduced to a single fetus,and three cases were reduced to twins.Only one case resulted in miscarriage after the first session,and one Set of sextuplets was delivered at 34-36+6 weeks.4.One patient pregnant with septuplets underwent three sessions of MFPR which resulted in preterm loss after the third session.5.One set of octuplets was reduced to twins after three sessions of reduction.Delivery was performed at 35 weeks and both babies survived?:122 cases of higher-order multiple pregnancies were reduced to twins,(93 cases at 11-14+6 weeks of gestation and 29 cases at 15-24+6 weeks of gestation.Comparing with 101cases of non-reduced twinsComparison between reduced to twins when MFPR were performed at 11-14+6 weeks and non-reduced twins,there were significant differences in spontaneous abortion rates between these two groups.P=0.014Comparison between reduced to twins when MFPR were performed after 15weeks and non-reduced twins,there were significant differences in spontaneous abortion rates between these two groups.P=0.049.ConclusionThere is rare of monochorionic in higher-order multi-fetal pregnancy.It is best to perform multiple procedures where one or two fetuses are targeted in one session.To compare with non-reduced twins,the spontaneous abortion rates of reduced to twins from higher-order multi-fetal pregnancy is higher.However,perinatal outcomes were significantly improved by reducing the number of fetuses in higher-order multi-fetal pregnancies.Part ?:Effect of Timing and Indication on Perinatal Outcome after Radio Frequency Ablation for Complicated Monochorionic Twin PregnancyBackground and objectiveThis is by large attributed to the presence of placental vascular anastomoses and associated complications such as twin-twin transfusion syndrome(TTTS),selective intrauterine growth restriction(SIUGR),twin reversed arterial perfusion(TRAP)and fetal anomaly.This kind of complicated monochorionic has significantly poor pregnancy outcomes.However,selective fetal reduction can reduced perinatal mortality and improve pregnancy outcome.To prevent cerebral injury and intrauterine fetal death,umbilical cord occlusion for selective reduction(SR)is recommended.And radio frequency ablation is relatively simple and effective techniques and used in clinical practice.The aim of this study is to assess the effect on timing and indication on perinatal outcome after radio frequency ablation for complicated monochorionic twin pregnancy,to evaluate the difference of perinatal outcome according to difference type of TTTS and SIUGR and the occurrence of related pregnancy complications after RFA for selective reduction.Methods?:The study included 66 sets of complicated monochorionic twins.26 cases of fetal anomaly,22 cases of TTTS:5 cases of TTTS-? type,14 cases of TTTS-? type,3 cases of TTTS-? type;14 cases SIUGR,10 cases of SIUGR-? type,4 cases of SIUGR-? type;4 cases TRAP.28 and 38 underwent SR at 16-20+6 and 20 and after weeks of gestation,respectively.?:Under ultrasound guidance,a 17G sarburst radiofrequency needle was inserted to get near to the abdominal segment of the umbilical vessel.Radiofrequency energy was applied 3 min to generate the target temperature of 100-110?.Blood flow was demonstrated in the umbilical card by pulsed-wave and color-flow Doppler.2-3 cycles were required before complete cessation.A cool-down period of 1 minute followed each cycle of heating.Result?:The effect of timing of MFPR on perinatal outcomeAmong 66 cases of Uonochorlolic twins,28 cases underwent SR at 16-20+6 weeks of gestation,38 cases case underwent SR at 21 and after weeks of gestation The comparison of timing of MFPR was statistically significant difference.However,the spontaneous abortion rate,preterm labour rates,live birth rates,low birth weight rates,birth weight,and gestational ages at delivery showed no statistically significant difference.?:The effect of indication of MFPR on perinatal outcome26 cases of fetal anomaly,22 cases of TTTS,14 cases SIUGR,4 cases TRAP.The spontaneous abortion rate and live birth rates were no significant differences Preterm labor rates were 35.0%?66.7%?12.6%?33.3%respectively.The TTTS team compared with SIUGR team,P=0.030.Low birth weight rates were 15.0%,61.1%,0,33.3%,respectively.The TTTS team compared with SIUGR team,P=0.007;Birth weights were 2835.10g±603.25,2296.44g±808.23,3315.00g±319.61 and 2516.67g±1086.66,respectively.The TTTS team compared with SIUGR team,P=0.001;The TTTS team compared with fetal anomaly team,P=0.02;gestational ages at delivery were 37.61±2.67weeks,34.34±3.83weeks,3 8.00±1.21 weeks and 35.67±4.42weeks,respectively.The TTTS team compared with SIUGR team,P=0.008;The TTTS team compared with fetal anomaly team,P=0.002.?:Perinatal outcome according to difference type of TTTS and SIUGRlive birth rates were 80%?64.3%?100%according to TTTS ?,?,? type.live birth rates were 50%?75%according to SIUGR ?,? type.?:Related pregnancy complications after RFA reduction.There were 3 cases of PPROM,3 cases of the co-twin demise among the 66 cases of monochorionic twins.There was no neurodevelopmental retardation in this study.ConclusionThe timing of SR did not affect the perinatal outcome in complicated monochorionic twin after RFA.The perinatal outcomes after FRA were correlated to the indication.The perinatal outcomes in TTTS were the worst. |
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