Monochorionic triplet pregnancy complicated by severe fetofetal transfusion

Abstract

We report two cases of fetofetal transfusion in monochorionic triamniotic triplet pregnancies. Case 1: At 23 weeks' gestation an amnioreduction was carried out. Three days later, the donor triplet died in utero. Immediately after that, a cardiotocogram of the triplet who had been thought to be unaffected by the fetofetal transfusion, showed a non-reassuring fetal status. Although cesarean section was carried out, none of the triplets survived. Case 2: At 24 weeks' gestation a woman was transferred to our center because of fetofetal transfusion in monochorionic triplets. Cesarean section was carried out. However, the recipient died on the 75th day after birth, and the others had neurological problems. Previous reports on fetofetal transfusion in triplets are very limited. The prognosis of this condition has been reported to be severe, irrespective of chorionicity, gestational age at delivery, maternal age, and parity. When managing a monochorionic or dichorionic triplet pregnancy, serial and careful ultrasound examination is mandatory to find early symptoms of this serious condition.

Monochorionic Triplets Complicated by Fetofetal Transfusion Syndrome: A Case Series and Review of the Literature

“…From 1990 to 2010, 22 articles met the inclusion criteria and we identified 25 MC and 97 DC triplet pregnancies with TTTS [2,3,6,7,8,9,10,11,12,13,14,15,16,17,18,19,21,22,23,24,25]. Quintero stage, in the reported cases including the cases in this study, was stage I in 7% (2/27) stage II in 15% (4/27), stage III in 45% (12/27) and stage IV in 33% (9/27) of the MC triplets.…”

“…Conversely, in MC triplet pregnancies the outcome was poor. In 6 cases of MC [3,6,9,11,15,22] and 5 cases of DC [6,23,24] triplets complicated by TTTS, only 12/33 (36%) survived with expectant management. Although based on small numbers, these results strongly suggest that laser coagulation is preferable to expectant management or amniodrainage [17].…”

“…Management options and survival of triplets with TTTS are frequently discussed in the literature [2,6,7,8,9]. Because an MC twin pair can also be part of any other high-order multiple pregnancy, survival rates of MC triplets are often confused with DC triplets, with one pair of MC twins affected by TTTS and one singleton.…”

Incidences of Feto-Fetal Transfusion Syndrome and Perinatal Outcomes in Triplet Gestations with Monochorionic Placentation

“…Furthermore, the optimal perinatal management of MC triplet gestations has not been established, despite the reported feasibility and efficacy of fetoscopic laser photocoagulation (FLP) for FFTS in triplet gestations [6,7,8,9,10]. …”

“…Triplet gestations with MC placentation, which include MC triamniotic (MCTA) and dichorionic triamniotic (DCTA) triplet gestations, are at risk of feto-fetal transfusion syndrome (FFTS), which is caused by a blood imbalance via placental vascular anastomoses. FFTS is considered a cause of perinatal death and severe neurological complications [6,7,8]. However, the natural history of triplet gestations with MC placentation, including the incidence of FFTS, remains unknown, particularly after the early second trimester.…”