Amnioprotective cesarean section in monochorionic-triamniotic triplet pregnancy, spontaneously conceived, complicated by intrahepatic cholestasis

Triplet pregnancies from spontaneous conception are very rare. According to Hellin’s rule: triplets = (a²) = 1 : 80² = 1 : 6400 are 0.015% of all pregnancies (monochorionic-triamniotic triplet pregnancy occurs in 1 : 100 000). They are at a high risk of pregnancy complications and have higher rates of perinatal morbidity and mortality, such as structural defects and neurodevelopmental anomalies.
A 30-year-old woman, gravida 2, para 2, was admitted to the 3rd level perinatal center at 29 weeks in a monochorionic-triamniotic triplet pregnancy to observe fetal well-being. In past medical history removal of adrenal adenoma is worth mentioning. Previous pregnancy resulted in natural term birth of healthy male fetus weighing 3600 g in 2016.
Doppler ultrasound examination was performed and did not reveal any abnormalities in values either for middle cerebral or umbilical artery pulsatility index. This is shown in the graphs below (Figures 1 A, B).
Cardiotocographic (CTG) records were performed every day. They did not reveal any abnormalities either.
At 30 weeks the patient reported itching of both hands that corresponded with the laboratory test results revealing cholestasis (AST 52,7 U/l, ALT 80,7 U/l). Bile acid level was 20 µmol/l. Due to the onset of labor (4 cm cervical dilatation) at 33 weeks of gestation and elevated liver enzyme levels, a caesarean delivery was indicated, resulting in live birth of triplets weighing 2050 g (AS 10), 1910 g (AS 9), 2050 g (AS 10). An APCS procedure (amnion protective caesarean section) was performed. The aim of this procedure is to remove the fetus in the entire amniotic sac, limiting the injury.
On the day after the surgery, the patient reported abdominal pain. Inflammatory parameters proved to be increased. An ultrasound examination revealed an inhomogeneous echogenic structure that might have corresponded to a hematoma (131 × 80 × 117 mm) in the lower part of the uterine muscle. Indeed, the hematoma was detected and removed during the next surgery. The inflammatory parameters decreased to normal values within the three following days (Figure 2).
The patient and newborns left the clinic on the 10th day after the surgery in good health.
This is the third reported case of spontaneous monochorionic triamniotic triplets without fetal abnormalities or feto-fetal transfusion that was managed conservatively with an excellent health outcome for the mother and her three babies. This normal...


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