Early prenatal diagnosis of multiple midline defects and limb anomalies in one fetus of triplets undergoing an in vitro fertilization program with laser-assisted hatching.

Multiple midline defects (MMD) combined with limb anomalies are severe structural abnormalities with poor prognosis (Khoury et al., 1989). Prenatal diagnosis is mandatory for early detection and management. To date, prenatal diagnosis of MMD in one fetus of a triplet in early pregnancy has never been reported. In this communication, we have reported prenatal diagnosis of a case of MMD (encephalocele, omphalocele, cleft lip and palate) combined with scoliosis and clubfeet in one fetus of a triplet pregnancy revealed by a routine ultrasound scan at 16 weeks of gestation. The triplet pregnancy had been conceived by in vitro fertilization (IVF) with laserassisted hatching (LAH). To the best of our knowledge, this may be the first such case. A 37-year-old woman with primary unexplained infertility for seven years had undergone three cycles of IVF unsuccessfully. She underwent a new IVF program combined with LAH owing to the thickened zona of the embryo. On the third day after the IVF (i.e. at the eightcell stage of the embryo), the reproductive specialists used a ‘noncontact’ infrared laser (1480 nm in wave length) with 5 ms/shot for 3 shots to assist hatching. Immediately after LAH, three embryos were transferred into the uterine cavity smoothly. A triplet pregnancy was then successfully implanted and developed. At 16 weeks of gestation, she was transferred to our department for prenatal ultrasound scanning. There were three fetuses with three chorions and three amnions in utero. Unexpectedly, we found one of the triplets to have MMD, including encephalocele (Figure 1a), omphalocele, cleft lip and cleft palate, scoliosis and clubfeet as well. Prenatal diagnosis of MMD with limb anomalies was made. In contrast, the other two fetuses were structurally normal. Genetic counseling was given, and the couple decided to continue the triplet pregnancy. At 34 weeks of gestation, a Cesarean section was undertaken to deliver the three fetuses owing to preterm labor. The abnormal female fetus died soon after delivery. The other two fetuses (one male and one female) were grossly normal