Successful Conservative Management After Expulsion Following Fetal Demise in a Triplet Pregnancy: A Case Report

TL;DR

A woman carrying triplets successfully continued her pregnancy after one fetus died, with careful management leading to the birth of two preterm infants.

Contribution

This case report demonstrates the feasibility of conservative management after fetal demise in a triplet pregnancy.

Findings

Conservative management with progesterone, antibiotics, and tocolysis prolonged the pregnancy after fetal loss.

The remaining two fetuses showed reassuring development despite complications like IUGR and hypertension.

The infants were delivered at 33 weeks via cesarean due to non-reassuring fetal heart rates.

Abstract

Triplet pregnancies are associated with high rates of complications, including miscarriage, preterm birth, and selective fetal loss. We present a case of a 42-year-old Caucasian woman with a history of infertility, multiple failed in vitro fertilization (IVF) attempts, and one prior pregnancy loss at 26 weeks of gestation due to placenta previa. She conceived trichorionic triamniotic (TCTA) triplets following intracytoplasmic sperm injection (ICSI) with donor oocytes. At 18 weeks and five days, she developed preterm premature rupture of membranes (PPROM) with umbilical cord prolapse of one fetus, which already had no detectable fetal heart activity. Intrauterine cord ligation (IUCL) was performed, and the demised fetus was retained until expulsion the following day. Conservative management with progesterone support, antibiotics, anticoagulation, tocolysis with atosiban (OXTR/V1A oxytocin and vasopressin V1A receptor antagonist), and antihypertensive therapy allowed prolongation of the pregnancy. Despite challenges including intrauterine growth restriction (IUGR), hypertension, hypothyroidism, and anemia, the remaining two fetuses continued to develop with reassuring Doppler ultrasonography (DUS) findings. At 33 weeks and two days, she underwent urgent cesarean delivery of two viable preterm infants for non-reassuring fetal heart rates (FHRs).

This case highlights that with individualized management and intensive monitoring, continuation of pregnancy after selective fetal loss in a triplet gestation is possible, improving neonatal outcomes.

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