Risks and challenges in multiple pregnancy

Because of breakthroughs in reproductive medicine, multiple pregnancies have become more common in the industrialized world. As a result, obstetric care for women with multiple pregnancies and neonatal care for the same has become more demanding. Multifetal pregnancies are linked to an elevated risk for both the mother and child. There is increased incidence of obstetric complications such as spontaneous abortion, hypertensive disorders, placenta previa, and fetal malformations. Perinatal outcome is also affected which is attributable to increased incidence of fetal complications like prematurity, congenital malformations, growth discordance and cord accidents. We are presenting 2 cases, one of MCMA twin pregnancy with fetal congenital anomaly and another of a triplet pregnancy and their perinatal outcomes.

Conjoined twins in dichorionic diamniotic triplet pregnancy: a report of three cases and literature review

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. Case presentation 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. Conclusion(s) 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.

Infection of Cronobacter sakazakii ST1 Producing SHV-12 in a Premature Infant Born from Triplet Pregnancy

Cronobacter sakazakii can cause severe life-threatening invasive infections in neonates, with a high mortality rate mostly associated with powdered infant formula consumption. The study describes a fatal C. sakazakii infection in premature infant fed only with expressed human milk. Despite the identification of etiological factor from patient’s blood, the epidemiological investigation, including mother’s skin, hospital surfaces, milk expressing devices, and milk samples, did not show bacterial contamination. The infection was caused by C. sakazakii ST1, being one of the leading genotypes reported in invasive infections. The phylogenetic analysis of the international collection of the ST1 organisms allowed us to identify the isolate as a member of the main cluster. The pathogenic potential of the isolate was augmented by the presence of IncFIB-like molecule representing virulence plasmids of pESA-3 family. Isolate presented ESBL phenotype associated with blaSHV-12 gene harboured by IncX3 plasmid. The described case gave valuable information to genetics of Cronobacter, and also urges the need of wider whole-genome sequencing implementation as a part of diagnostic procedure.

A rare presentation of endogenous human chorionic gonadotrophin associated severe ovarian hyperstimulation in the second trimester: a case report

Background Ovarian hyperstimulation syndrome is usually an iatrogenic and potentially life-threatening disease. It develops following ovulation induction and use of in vitro fertilization techniques. Case summary A 32-year-old primigravida Ethiopian woman presented at 15 weeks gestation with a history of progressive bilateral leg swelling and abdominal pain of 2 weeks duration. She had triplet pregnancy and conceived through in vitro fertilization. She was managed in intensive care unit. Conclusion Patients with multiple pregnancy following in vitro fertilization conception can have ovarian hyperstimulation syndrome as late as 15 weeks gestation. Hence, frequent follow-up should be continued to detect early signs of OHSS to avoid further complications and need of intensive care unit care.

Who Are Your Patients, and What Happens When They Disagree?

Third-party reproduction carries significant legal and ethical challenges. Although well-intentioned mutual desire typically guides parties entering a gestational surrogacy or egg donation arrangement, the potential for conflict cannot be avoided. Because the physician’s role includes treating both their patient (the intended parent/s) and the “third-party patient” (the egg donor or surrogate), the physician should be aware of potential conflicting desires about medical treatment (i.e., an intended parent may desire a triplet pregnancy, while the surrogate may prefer to reduce). Systematic bias should also be considered, as it may result in favoring one patient’s medical needs over the other. The laws in this area are unsettled and in many situations no definitive legal answers are available. Prior to engaging in third-party reproduction each patient should be fully informed of potential medical risks and consult with mental health professionals and independent lawyers to confirm agreement with respect to the arrangement.

Spontaneous fetal reduction in triplets and prolongation of twin pregnancy for 111 days as an outpatient: a case report

Background Multiple gestation has been on the rise because of advancement in assisted reproductive technology. Triplet pregnancy is associated with fetal loss and preterm birth as its major complications. Spontaneous triplet pregnancy is rare. In the case of fetal loss, delayed interval delivery has been used to achieve delivery of the retained fetuses. There is no common approach to delayed interval delivery. Case A 31-year-old East African lady with spontaneous triplet pregnancy presented to our institution at gestation age of 19 weeks with features of threatened miscarriage. One fetus was miscarried, and delayed interval delivery was done as an outpatient. At gestation age of 35 weeks, she delivered healthy twins by cesarean section. Conclusion Delayed interval delivery improves neonatal outcomes of high-order pregnancy after fetal loss even in a resource-limited setting.