title: Expectant management versus multifetal pregnancy reduction in higher order multiple pregnancies containing a monochorionic pair and a review of the literature.
abstract: To compare the perinatal outcome in multifetal pregnancies containing a monochorionic twin pair, managed either expectantly or by fetal reduction (MFPR).
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Obstetrics and Prenatal Medicine, University Medical School Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.|Division of Prenatal Medicine and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, University Medical School Cologne, Cologne, Germany.
authors.forename: Judith Sarah
authors.initials: JS
authors.lastname: Abel
authors.affiliation: Department of Obstetrics and Prenatal Medicine, University Medical School Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
authors.forename: Anne
authors.initials: A
authors.lastname: Flöck
authors.affiliation: Department of Obstetrics and Prenatal Medicine, University Medical School Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.|Division of Prenatal Medicine and Gynecologic Ultrasound, Department of Obstetrics and Gynecology, University Medical School Cologne, Cologne, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Berg
authors.affiliation: Department of Obstetrics and Prenatal Medicine, University Medical School Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Gembruch
authors.affiliation: Department of Obstetrics and Prenatal Medicine, University Medical School Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Germany. annegret.geipel@ukb.uni-bonn.de.
authors.forename: Annegret
authors.initials: A
authors.lastname: Geipel
mesh_terms: D000328:Adult; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008875:Middle Aged; D011247:Pregnancy; D011256:Pregnancy Outcome; D018607:Pregnancy Reduction, Multifetal / Q000379:methods*; D011272:Pregnancy, Multiple; D012189:Retrospective Studies
keywords: Dichorionic; Embryo reduction; Monochorionic; Multifetal pregnancy reduction; Perinatal outcome; Triplet pregnancy