Journal Health of Woman. 2025. 5(180): 89-94. doi: 10.15574/HW.2025.5(180).8994
Sklyarovа V. О.^1,2,  Prokopchuk N. M.¹, Maksymyuk V. V.³, Chajkivskyj R. A.¹, Nepyjvoda O. M.^1,2, Chajkivska V. R.^1
1Danylo Halytskyi National Medical University, Lviv, Ukraine
²Lviv Regional Hospital of War Veterans and Repressed People named after Yu. Lypa, Ukraine
³Bukovinian State Medical University, Chernivtsi, Ukraine

citation: Sklyarovа VО, Prokopchuk NM, Maksymyuk VV, Chajkivskyj RA, Nepyjvoda OM, Chajkivska VR. (2025). Dichoirial triamniotic triplets after in vitro fertilization, complicated by twins to twins transfusion syndrome and the death of two fetuses at 19 weeks of gestation: a clinical case of successful pregnancy and full-term delivery. Ukrainian Journal Health of Woman. 5(180): 89-94. doi: 10.15574/HW.2025.5(180).8994
Article received: Aug 27, 2025. Accepted for publication: Oct 30, 2025.

Triplet pregnancy after assisted reproductive technologies (ART) carries risks of complications for both the woman and the fetuses. Multiple pregnancies are becoming more common due to the widespread use of ART, particularly in vitro fertilization. Although single blastocyst transfer has become the standard, cases of monozygotic twin pregnancies and complicated multiple pregnancies remain relevant.
Aim – to present a rare clinical case of dichorionic triamniotic triplets after the use of ART, complicated by twin-to-twin transfusion syndrome (TTTS) and intrauterine death of two fetuses, as well as to analyze management tactics and perinatal outcome.
Clinical case. A 29-year-old patient underwent in vitro fertilization. After the transfer of two blastocysts, dichorial triamniotic triplets were diagnosed. At 19 weeks of pregnancy, TTTS developed in a pair of monochorionic fetuses. They died in utero, but one fetus continued to develop in its amniotic sac. The pregnancy was successfully carried to 37 weeks, delivery was by cesarean section, and the newborn was healthy. This case highlights the clinical complexity of managing dichorionic triamniotic triplets with TTTS complications and the death of two fetuses at 19 weeks. The main dilemma was whether to continue the pregnancy after the intrauterine death of two fetuses. Given the stable condition of the mother and positive dynamics of ultrasound, D-dimer, and blood counts, the pregnancy was continued. The perinatal outcome indicates the use of a personalized approach.
Conclusions. Despite the risks, the strategy of maintaining pregnancy with intrauterine monitoring showed positive results. This case may be useful for obstetricians and gynecologists who encounter similar cases.
The study was conducted in accordance with the principles of the Declaration of Helsinki. The informed consent was obtained from all participants.
The authors declare no conflict of interest.
Keywords: dichorionic triamniotic triplets, monochorial twins, fetal demise at 19 weeks, treatment, progesterone, management.

REFERENCES

1. Bebbington M, Danzer E, Moldenhauer JS, Khalek N, Johnson MP. (2005). Expectant management of monochorionic diamniotic and triamniotic triplet gestations complicated by fetal demise. Prenat Diagn. 25(8): 704-709. https://doi.org/10.1002/pd.1093; PMid:15712378

2. Blickstein I, Keith LG. (Eds.). (2005). Multiple Pregnancy: Epidemiology, Gestation, and Perinatal Outcome (2nd ed.). CRC Press. https://doi.org/10.1201/b14615; PMCid:PMC3455504

3. Blumenfeld YJ, Shamshirsaz AA, Belfort MA, Hintz SR, Moaddab A, Ness A et al. (2015). Fetofetal transfusion syndrome in monochorionic-triamniotic triplets treated with fetoscopic laser ablation: report of two cases and a systematic review. AJP Rep. 5(2): e153-e160. https://doi.org/10.1055/s-0035-1552931; PMid:26495175 PMCid:PMC4603872

4. Buca D, Rizzo G, Khalil A, Familiari A, Liberati M, Scambia G et al. (2021). Outcome of triplet pregnancies: systematic review and meta‐analysis. Prenat Diagn. 41(4): 406-417. https://doi.org/10.1002/pd.5988; PMid:34132402

5. Cara S, Bafaro MG, Cattoli M, Coticchio G, Di Paola R, Borini A. (2024, Feb). First case of dichorionic diamniotic triplet pregnancy after single blastocyst transfer. J Assist Reprod Genet. 41(2): 437-440. https://doi.org/10.1007/s10815-023-02989-4; PMid:38079075 PMCid:PMC10894801

6. Chang HJ, Lee JR, Jee BC, Suh CS, Kim SH. (2009). Impact of blastocyst transfer on offspring sex ratio and the monozygotic twinning rate: a systematic review and meta-analysis. Fertil Steril. 91(6): 2381-2390. Epub 2008 Aug 20. https://doi.org/10.1016/j.fertnstert.2008.03.066; PMid:18718582

7. Downing M, Sulo S, Parilla BV. (2017, Jan). Perinatal and Neonatal Outcomes of Triplet Gestations Based on Chorionicity. AJP Rep. 7(1): e59-e63. https://doi.org/10.1055/s-0037-1599124; PMid:28367358 PMCid:PMC5373902

8. Guzman ER, Walters C, O'Reilly-Green C, Kappy K, Vintzileos AM. (1994). Retention of the dead fetus: a cause of maternal coagulopathy. Am J Obstet Gynecol. 171(3): 913-917. doi: 10.1016/0002-9378(94)90206-2.

9. Hack KE, Derks JB, Elias SG, Franx A, Roos EJ, Voerman SK et al. (2008). Perinatal mortality and morbidity in monochorionic versus dichorionic triplet pregnancies. BJOG. 115(6): 710-718. https://doi.org/10.1111/j.1471-0528.2008.01824.x

10. Hall JG. (2003). Twinning. The Lancet. 362: 735-743. https://doi.org/10.1016/S0140-6736(03)14237-7; PMid:12957099

11. Herranz G. (2015). The timing of monozygotic twinning: a criticism of the common model. Zygote (Cambridge, England). 23(1): 27-40. https://doi.org/10.1017/S0967199413000257; PMid:23735171

12. Lewi L, Gratacós E, Ortibus E, Van Schoubroeck D, Carreras E, Higueras T et al. (2010). Pregnancy and perinatal outcome of monochorionic triplet pregnancies. Am J Obstet Gynecol. 202(6): 543.e1-543.e7. https://doi.org/10.1016/j.ajog.2009.11.019; PMid:20035918

13. Liu S, Xu Q, Liu D, Li Q, Qian J, Zhang B, Chen X. (2024, Mar 15). Pregnancy and obstetric outcomes of dichorionic triamniotic triplet pregnancies with selective fetal reduction after assisted reproductive technology. Reprod Biol Endocrinol. 22(1): 30. https://doi.org/10.1186/s12958-024-01199-6; PMid:38491531 PMCid:PMC10941449

14. Li Y, Chang Q, Mai Q. (2023). Pregnancy and neonatal outcomes of monozygotic twins resulting from assisted reproductive technology: a 10-year retrospective study. Reproductive biology and endocrinology : RB&E. 21(1): 51. https://doi.org/10.1186/s12958-023-01104-7; PMid:37268975 PMCid:PMC10236834

15. Perry H, Duffy JMN, Umadia O, Khalil A et al. (2018, Nov). Outcome reporting across randomized trials and observational studies evaluating treatments for twin-twin transfusion syndrome: systematic review. Ultrasound Obstet Gynecol. 52(5): 577-585. Epub 2018 Sep 24. https://doi.org/10.1002/uog.19068; PMid:29607558

16. Practice Committee of the Society for Reproductive Endocrinology and Infertility, Quality Assurance Committee of the Society for Assisted Reproductive Technology, and the Practice Committee of the American Society for Reproductive Medicine. (2022). Multiple gestation associated with infertility therapy: a committee opinion. Fertility and sterility. 117(3): 498-511. https://doi.org/10.1016/j.fertnstert.2021.12.016; PMid:35115166

17. Quintero RA, Morales WJ, Allen MH, Bornick PW, Johnson PK, Kruger M. (1999). Staging of twin-twin transfusion syndrome. Am J Obstet Gynecol. 180(4): 846-851. doi: 10.1016/S0002-9378(99)70541-3.

18. Sato Y, Ishii K, Yokouchi T, Murakoshi T, Kiyoshi K, Nakayama S et al. (2016). Incidences of Feto-Fetal Transfusion Syndrome and Perinatal Outcomes in Triplet Gestations with Monochorionic Placentation. Fetal Diagn Ther. 40(3): 181-186. Epub 2016 Jan 14. https://doi.org/10.1159/000443610; PMid:26760043

19. Song B, Wang Z, Chen Y, Wang C, Wei Z et al. (2020, Jun 23). Repeated triplets complicated by monochorionic diamniotic twins following assisted reproduction: a case report and literature review. BMC Pregnancy Childbirth. 20(1): 373. https://doi.org/10.1186/s12884-020-03055-y; PMid:32576252 PMCid:PMC7313207

20. Ville Y, Hyett J, Hecher K, Nicolaides K. (2003). Preliminary experience with endoscopic laser surgery for severe twin-twin transfusion syndrome. Ultrasound Obstet Gynecol. 22(5): 420-426. doi: 10.1046/j.1469-0705.2003.01002.x.

21. Yanaihara A, Ohgi S, Motomura K et al. (2017). Dichorionic triplets following frozen-thawed poor-stage embryo transfer: a report of two cases and a review. Reprod Biol Endocrinol. 15: 80. https://doi.org/10.1186/s12958-017-0302-1; PMid:28974228 PMCid:PMC5627466

22. Yang Y, Ye X, Sun X. (2024, Jan 1). Clinical outcomes of fetal selective reduction in dichorionic triplet pregnancies. J Chin Med Assoc. 87(1): 103-108. Epub 2023 Nov 10. https://doi.org/10.1097/JCMA.0000000000001017; PMid:37962135 PMCid:PMC12718878