Trichorionic triplet pregnancies at 10–14 weeks: outcome after embryo reduction compared to expectant management

Objective: To compare the outcome of trichorionic triplet pregnancies managed expectantly with those reduced to twins or singletons. Methods: This was a retrospective study of trichorionic triplet pregnancies with three live fetuses at 10-14 (median 12) weeks' gestation referred to our unit for consideration of embryo reduction. Women were counselled as to the available options of either expectant management or embryo reduction. In those choosing reduction, a needle was inserted into the uterus transabdominally and potassium chloride was injected into the fetal heart. Using data derived from this study and from a review of studies reporting on survival and handicap by gestational age in singletons, the effects of embryo reduction on survival and handicap rates were estimated. Main outcome measures were miscarriage before 24 weeks of gestation, preterm delivery before 32 weeks, perinatal death and handicap rates. Results: In total, there were 280 trichorionic triplet pregnancies and 125 of these were managed expectantly, 133 were reduced to two fetuses and 22 were reduced to one fetus. The rates of miscarriage were 3.2% for those managed expectantly, 8.3% for those reduced to twins and 13.6% for those reduced to singletons. The rates of early preterm delivery in those pregnancies that did not miscarry were 23.1%, 9.8% and 5.3%, respectively. The percentages for pregnancies with at least one survivor were 95.2%, 91.0% and 81.8%, respectively, and the median gestation at delivery was 34 weeks for the non-reduced, 36 weeks for those reduced to twins and 38 weeks for those reduced to singletons. From the published series on early preterm delivery, it was estimated that survival increases from about 27% at 24 weeks to about 98% at 32 weeks, and handicap decreases from 28% at 24 weeks to less than 5% at 32 weeks. From these estimates and the data on triplet pregnancies, it was calculated that, in triplets reduced to twins, compared to those managed expectantly, the chance of survival is similar (90.3% compared to 93.3%), but the risk of handicap may be lower (0.6% compared to 1.5% per fetus). Conclusions: In trichorionic triplet pregnancies, embryo reduction to twins does not improve the chance of survival but may reduce the rate of handicap. Reduction from triplets to singletons may reduce both the survival rate and the handicap rate among survivors.