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

Abstract

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.

Keywords: dichorionic diamniotic; expectant management; meta-analysis; midtrimester; rupture of membranes; selective fetal reduction; twins.