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

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.