Expectant management versus selective fetal reduction in dichorionic-diamniotic twins following mid-trimester, preterm premature rupture of membranes in 1 twin: Review of literature and meta-analysis.

OBJECTIVE

To compare maternal and neonatal outcomes following selective fetal reduction versus expectant management in dichorionic-diamniotic twin pregnancies complicated by mid-trimester preterm premature rupture of membranes in 1 sac.

DATA SOURCES: A systematic literature search of PubMed, Embase, and Scopus was conducted through March 2025.

STUDY ELIGIBILITY CRITERIA: Included studies were observational (case series or cohort studies) comparing selective fetal reduction versus expectant management in twin pregnancies with mid-trimester preterm premature rupture of membranes (prior to 24+0 weeks). Only studies reporting relevant maternal or neonatal outcomes were included.

STUDY APPRAISAL AND SYNTHESIS

METHODS

Studies were assessed using the Newcastle-Ottawa Scale. Meta-analyses were performed using random- or fixed-effects models based on heterogeneity. Outcomes included perinatal survival, neonatal survival, latency period, gestational age at delivery, delivery ≥32 weeks, and other maternal and neonatal complications.

RESULTS

Five retrospective studies met eligibility criteria, and 4 were included in the meta-analysis. Neonatal survival was higher with selective fetal reduction (74% vs 69%), though not statistically significant (OR=1.72, 95% CI=0.96-4.25). Perinatal survival was significantly lower with selective fetal reduction (33% vs 69%), when the reduced fetuses were included (OR=0.40, 95% CI=0.19-0.8). Selective fetal reduction significantly increased odds of delivery ≥32 weeks (67.4% vs 11.3%; OR=15.34, 95% CI=3.86-61.03). Latency and mean gestational age at delivery trended higher in the reduction group but did not reach statistical significance. Maternal and neonatal complications - including chorioamnionitis, cesarean delivery and respiratory morbidity - were less frequent following selective reduction, except for pulmonary hypoplasia, which was higher.

CONCLUSIONS

Selective fetal reduction after mid-trimester rupture in 1 sac of dichorionic-diamniotic twins increases the likelihood of delivery ≥32 weeks. Although most other outcome differences were not significant, these findings suggest that fetal reduction may be an alternative to expectant management when termination of the entire pregnancy is not optional.