BACKGROUND: The increase in the rate of multiple pregnancies in clinical practice is associated with assisted reproductive technology (ART). Given the high risk of dichorionic triamniotic (DCTA) triplet pregnancies, reducing DCTA triplet pregnancies to twin or singleton pregnancies is often beneficial.
METHODS: This article reports on two cases of DCTA triplet pregnancies resulting from two blastocyst transfers. Given the high risk of complications such as twin-to-twin transfusion syndrome (TTTS) in monochorionic diamniotic (MCDA) twin pregnancies, patients have a strong desire to preserve the dichorionic diamniotic (DCDA) twins. Multifetal pregnancy reduction (MFPR) was performed in both cases to continue the pregnancy with DCDA twins by reducing one of the MCDA twins. Both of the pregnant women in this report eventually gave birth to healthy twins at 37 weeks.
CONCLUSIONS: For infertile couples with multiple pregnancies but with a strong desire to remain the DCDA twins, our report suggests that reducing DCTA triplets to DCDA twin pregnancies may be an option based on clinical operability and assessment of surgical difficulty.

BACKGROUND: Conjoined twins are a rare and serious complication of monochorionic twins. The total incidence is 1.5 per 100,000 births, and about 50% are liveborn. Prenatal screening and diagnosis of conjoined twins is usually performed by ultrasonography. Magnetic resonance imaging can be used to assist in the diagnosis if necessary. Conjoined twins in dichorionic diamniotic triplet pregnancy are extremely rare.
METHODS: We reported three cases of dichorionic diamniotic triplet pregnancy with conjoined twins. Due to the poor prognosis of conjoined twins evaluated by multidisciplinary teams, selective termination of conjoined twins was performed in three cases. In case 1, selective reduction of the conjoined twins was performed at 16 gestational weeks, and a healthy female baby weighing 3270 g was delivered at 37 weeks. In case 2, the conjoined twins were selectively terminated at 17 weeks of gestation, and a healthy female baby weighing 2760 g was delivered at 37 weeks and 4 days. In case 3, the conjoined twins were selectively terminated at 15 weeks and 2 days, and a healthy female baby weighing 2450 g was delivered at 33 weeks and 6 days. The babies of all three cases were followed up and are in good health.
CONCLUSIONS: Surgical separation is the only treatment for conjoined twins after birth. Early determination of chorionicity and antenatal diagnosis of conjoined twins in triplet gestations are critical for individualized management options and the prognosis of normal triplets. Expecting parents should be extensively counseled by multidisciplinary teams. If there are limitations in successful separation after birth, early selective termination of the conjoined twins by intrathoracic injection of potassium chloride may be a procedure in dichorionic diamniotic triplet pregnancy to improve perinatal outcomes of the normal triplet.

BACKGROUND: Conjoined twins are a rare complication of monochorionic pregnancies and an extremely rare condition in spontaneous triplet pregnancies. We report a case of conjoined twins in a spontaneous monochorionic triplet pregnancy. The conjoined twins might have suffered from twin anemia-polycythemia sequence, which was reported to be extremely rare.
METHODS: A 26-year-old woman conceived spontaneously with an obstetric history of invasive mole 4 years ago.
METHODS: We initially misdiagnosed her as having monochorionic triamniotic triplets at 10 weeks of gestation. However, we confirmed conjoint twins with the monochorionic diamniotic triplet pregnancy at 12 weeks of gestation and classified them as omphalopagus.
METHODS: As the woman decided to continue the pregnancy, regular and careful antenatal care was conducted.
RESULTS: Unexpectedly, she had a stillbirth 3 weeks later and had to terminate the pregnancy at 15 weeks of gestation. After abortion, the diagnosis of omphalopagus was confirmed in the induced fetuses. Moreover, the skin colors of the conjoined twins were different: one was plethoric, and the other was pale. Additionally, the parents agreed to examine the chromosome of the fetuses, and the results were normal.
CONCLUSIONS: Dichorionic triplet and monochorionic triplet pregnancies have a poorer prognosis than trichorionic triplet pregnancies. Surgery is the main therapy for conjoined twins; however, most conjoined twins in triplet pregnancies cannot survive, including omphalopagus twins. The conjoined twins may have suffered from twin anemia-polycythemia sequence, which could probably not be diagnosed intrauterine. Transvaginal probe and 3-dimensional ultrasound may be helpful for clarifying the diagnosis in early pregnancy.

Delayed delivery is designed to allow the remaining fetus(es) to develop after premature expulsion of the first twin in the second trimester of pregnancy. This decision is aimed to allow the remaining fetus(es) to reach full fetal growth. We here report a clinical case of delayed delivery in a patient with triple pregnancy in whom the time between the expulsion of the first twin and the birth of the third twin was 10 weeks. The purpose of this study was to highlight the benefit and indications for delayed delivery.

BACKGROUND: Monochorionic twinning involves numerous maternal and fetal complications, triplets complicated by a monochorionic pair are at further increased risk. Here, we report a case of repeated triplets complicated by monochorionic diamniotic twins with successful pregnancy outcomes in a woman using autologous oocytes.
METHODS: A 30-year-old female undergoing embryo transfer with fresh and frozen embryo cycles with autologous oocytes. The two cycles were confirmed by transvaginal ultrasound to result in successful clinical pregnancies of triplets complicated by a monochorionic twinning. The first pregnancy resulted in a singleton delivery after a selective reduction of the monochorionic pair. The subsequent pregnancy resulted in a dichorionic diamniotic twin pregnancy after the heartbeat of one of the monochorionic twin fetuses stopped at 43 days after embryo transfer. Both of the pregnancies ended with successful live births.
CONCLUSIONS: Our case report of repeated triplets with monochorionic twins suggests the potential causes and risk factors of monochorionic twinning in assisted reproduction and raises concern regarding the timing of multifetal pregnancy reduction.

OBJECTIVE: The incidence of perinatal mortality and morbidity in triplet pregnancies according to chorionicity is yet to be established. The aim of this systematic review was to quantify perinatal mortality and morbidity in trichorionic triamniotic (TCTA), dichorionic triamniotic (DCTA) and monochorionic triamniotic (MCTA) triplets.
METHODS: MEDLINE, EMBASE and CINAHL databases were searched in December 2017 for literature published in English describing outcomes of DCTA, TCTA and/or MCTA triplet pregnancies. Primary outcomes were intrauterine death (IUD), neonatal death, perinatal death (PND) and gestational age at birth. Secondary outcomes comprised respiratory, neurological and infectious morbidity, as well as a composite score of neonatal morbidity. Data regarding outcomes were extracted from the included studies. Random-effects meta-analysis was used to estimate the risk of mortality and morbidity and to compute the difference in gestational age at birth between TCTA and DCTA triplet pregnancies.
RESULTS: Nine studies (1373 triplet pregnancies, of which 1062 were TCTA, 261 DCTA and 50 MCTA) were included in the analysis. The risk of PND was higher in DCTA than in TCTA triplet pregnancies (odds ratio (OR), 3.3 (95% CI, 1.3-8.0)), mainly owing to the higher risk of IUD in DCTA triplet pregnancies (OR, 4.6 (95% CI, 1.8-11.7)). There was no difference in gestational age at birth between TCTA and DCTA triplets (mean difference, 1.1 weeks (95% CI, -0.3 to 2.5 weeks); I2  = 85%; P = 0.12). Neurological morbidity occurred in 2.0% (95% CI, 1.1-3.3%) of TCTA and in 11.6% (95% CI, 1.1-40.0%) of DCTA triplets. Respiratory and infectious morbidity affected 28.3% (95% CI, 20.7-36.8%) and 4.2% (95% CI, 2.8-5.9%) of TCTA and 34.0% (95% CI, 21.5-47.7%) and 7.1% (95% CI, 2.7-13.3%) of DCTA triplets, respectively. The incidence of composite morbidity in TCTA and DCTA triplets was 29.6% (95% CI, 21.1-38.9%) and 34.0% (95% CI, 21.5-47.7%), respectively. When translating these figures into a risk analysis, the risk of neurological morbidity (OR, 5.4 (95% CI, 1.6-18.3)) was significantly higher in DCTA than in TCTA triplets, while there was no significant difference in the other morbidities explored. Only one study reported on outcomes of MCTA pregnancies, hence, no formal comparison with the other groups was performed.
CONCLUSIONS: DCTA triplets are at higher risk of perinatal mortality and morbidity than are TCTA triplets. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

BACKGROUND: We describe two cases of dichorionic triplet pregnancy after a frozen-thawed poor-stage embryo transfer. A 39-year-old and a 41-year-old woman underwent ART treatment. The first patient underwent intracytoplasmic sperm injection (ICSI) at 34 years of age, and two frozen-thawed poor-stage embryos were transferred at 39 years of age with assisted hatching, resulting in a trichorionic triamniotic triplet pregnancy. The second patient underwent ICSI, and two poor-grade blastocysts were transferred followed by assisted hatching, resulting in a dichorionic triamniotic triplet pregnancy. In the first case, the heartbeat of one monozygotic twin fetus had stopped on day 48 post-transfer (9 weeks 2 days), resulting in a dichorionic diamniotic twin pregnancy. A healthy boy and girl were delivered by elective caesarean section at 36 weeks, 5-days gestation. In the second case, the patient underwent selective reduction of the monochorionic twins, resulting in a single pregnancy that was vaginally delivered without any problems at 38 weeks 0-days gestation.
UNASSIGNED: Numerous factors may be associated with the development of a monochorionic pregnancy; however, controversies still remain. The present morphological grading for embryos is insufficient for inhibiting the development of a monochorionic pregnancy.

OBJECTIVE: To investigate the clinical characteristics of twins with thyroxine binding globulin (TBG) deficiency and to find SERPINA7 gene mutations.
METHODS: Data(2015) related to clinical characteristics, serum biochemistry, gene mutations and pedigree of two children with TBG deficiency were collected in the First Affiliated Hospital of College of Medicine, Zhejiang University. The related literature was searched form China National Knowledge Infrastructure, Wanfang Data Knowledge Service Platform, National Center for Biotechnology Information and PubMed (up to December 2015) by using search terms \"Thyroxine binding globulin deficiency, gene, mutation\" .
RESULTS: Both patients were diagnosed as central hypothyroidism at the beginning and treated with L-thyroxine. Both of the identical twins of the triplet were observed for mutation in exon3, c. 631G﹥A(p.A211T), a new mutation had not been reported, but their parents and another non-identical triplet brother were normal. Literature review showed that 23 foreign cases with SERPINA7 gene mutation had been reported, however, no Chinese with SERPINA7 gene mutation had been reported. Among reported cases it was shown that SERPINA7 gene mutations located in exon, intron, promoter and enhancer. Up to now, 49 variants had been identified, 41 of them located in the mutated genes. Including these two cases, patients with thyroxine binding globulin deficiency were characterized by reduced serum TH levels, but normal free TH and TSH and absence of clinical manifestations.
CONCLUSIONS: The new mutation of SERPINA7 gene c. 631G﹥A(p.A211T)is not transmitted via the known X chromosome linked heredity, and as the cases were test tube triplet infants, it is a de novo mutation. The serum thyroid function tests of TBG deficiency showed decreased TT4, TT3 and normal TSH and TBG deficiency is often misdiagnosed as central hypothyroidism.

Objective This study aims to determine the clinical outcomes of monochorionic-triamniotic (MT) pregnancies complicated by severe fetofetal transfusion undergoing laser photocoagulation. Study Design We report two cases of MT triplets complicated by fetofetal transfusion syndrome (FFTS) and a systematic review classifying cases into different subtypes: MT with two donors and one recipient, MT with one donor and two recipients, MT with one donor, one recipient, and one unaffected triplet. The number of neonatal survivors was analyzed based on this classification as well as Quintero staging. Results A total of 26 cases of MT triples complicated by FFTS were analyzed. In 56% of the cases, the FFTS involved all three triplets, 50% of whom had an additional donor and 50% an additional recipient. Among the 24 cases that survived beyond 1 week after the procedure, the average gestational age of delivery was 29.6 weeks, and the average interval from procedure to delivery was 10.1 weeks. The overall neonatal survival rate was 71.7%, with demises occurring equally between donor and recipient triplets. Overall neonatal survival including survival of at least two fetuses occurred with equal frequency between the different groups. Conclusion Significant neonatal survival can be achieved in most cases of MT triplets with FFTS.

Monozygotic triplet pregnancies are very rare, even after in vitro fertilization (IVF). We present a case of a live birth of triplets from a monochorionic triamniotic pregnancy after blastocyst transfer. A 29-year-old woman underwent intracytoplasmic sperm injection (IVF-ICSI). Her medical history included a 4-year infertility treatment with ovarian stimulation, three cycles of intrauterine insemination, hysteroscopy and an unsuccessful attempt at IVF. During the second IVF attempt, the patient underwent ovulation simulation according to the long GnRH agonist protocol. Eleven metaphase II (MII) oocytes were injected with spermatozoa, resulting in four expanded blastocysts. In the end, two blastocysts (4AA) were transferred into the uterine cavity. Ultrasound examination performed at 7 weeks of gestation showed an ongoing triamniotic triplet pregnancy. Regular uterine contractions began at 33 weeks of gestation and a cesarean section was performed, resulting in a birth of three healthy girls, weighing 2060g (Apgar 7), 1860g (Apgar 6), 2000g (Apgar 6). After 13 days of hospitalization the infants and the mother were discharged home.
CONCLUSIONS: The causes of monozygotic multiple gestations in spontaneous and ART pregnancies are poorly understood. They seem to occur more often after IVF. Any definitive relationship between particular stages of the IVF procedure and monozygotic multiple pregnancies remains controversial.