Multifetal Pregnancy

Reduction

Prof Aboubakr elnashar

Benha University Hospital, Egypt

Multiple pregnancy

(MP)

1. Incidence

2.Maternal Hazards

3.Fetal Hazards

4.Prevention

Incidence

Over the last 20 years:

MP: increased

ART

Fertility drugs

Higher-order multiple pregnancies(HOMP)

(triplets or greater):

increased >100-folds.

As a result of recent efforts of prevention

HOMP: declined

Still a significant proportion of twin pregnancies.

Maternal risks Hyperemesis gravidarum

Iron- and folate-deficiency anemias

Diabetes,

PIH or PET

PTL

The average length of pregnancy

39 w for singletons,

35-38 w for twins,

30-33 w for triplets, and

28-29 w for quadruplets.

Placenta abruption

CS

Pulmonary embolism

Vaginal/uterine hemorrhage.

Foetal risk

Miscarriage

Acute polyhydramnios

Low birth weight:

wt <2500 gm is considered low,

wt < 1500 gm is considered very low.

2/3: significant short-term and long-term health

problems

Quadruplet Triplet Twin

70% 85% 98% Survival

50% 10% 5% Impairment

28-29 30-33 35-38 Average gestation (W)

Birth defects

Monozygotic twins are twice as likely as dizygotic

twins to be born with congenital malformations .

Cerebral palsy:

and other types of permanent neurological damage

Infant mortality

{premature delivery}.

Most occur in gestations ≤32 w and birth

weight≤1500 gm.

RSD: 50% of neonatal deaths resulting from

premature birth .

Financial

Emotional

Medical costs: extremely high.

Multiple pregnancy in Egypt

Medical oversight: lax

Fertility drugs: cheap

Efficient NICU: rare

Overpopulation

Effective method for prevention of PTL in

multiple pregnancy:

No

Prevention

ART success rate should be measured as a

singleton live birth rate& not as PR

1- Individualize protocols of COS: based on

Risk of MP.

Age

good response to stimulation

2- COS:

with multifollicular development:

canceled or converted to IVF.

3-Elective double ET :

Most European countries:

reduced HOMP

no impact on twin pregnancies

4-Elective single ET:

Age

1st or 2nd nd IVF cycles

Number of good-quality embryos.

5-Convince reproductive medicine physicians

-Hazards of MP&HOMP: Obstetrical, neonatal,

developmental& financial

-Singleton pregnancy is desired:

uterine anomaly, pregnancy following uterine

surgery, or for socioeconomic reasons.

-Measure of performance of ART:

cumulative live birth/patient not PR/cycle

6- Health education

Couples: hazards of MP&HOMP

7- Convince policymakers

Hazards of MP&HOMP particularly cost

8-Multifetal pregnancy reduction (MFPR)

Disadvantages

Ethical dilemma

Psychological trauma

It should never be considered as a standard line

for prevention of MP and HOMP.

It is only a rescue if other methods fail in the

prevention

Multifetal Pregnancy Reduction

(MFPR) 1. Types of f reduction

2. Why?

3. Ethical concern

4. Indications

5. Preoperative

6. Operative

7. Postoperative

8. Success rate

9. Risks

10.Conclusion

Types of Fetal Reduction

1. Multifetal Pregnancy Reduction (MFPR)

Termination of one or more of high order fetuses,

hopefully leaving the rest to develop to full term.

2. Selective Fetal reduction

Reduction of fetus with:

severe malformations or

chromosomal defects or

expected to die later in the pregnancy, which would

threaten the life of the surviving fetus or fetuses.

3. Spontaneous fetal reduction (reabsorption)

After US visualization of FH:

6% (Kol et al, 1993)

90% occur up to 7 w and never after13 w: (Manzur et al, 1995)

F Reduction is done once FH is visualized

Why?

1. Reduce perinatal morbidity and mortality

• severe prematurity and its consequences

• prevent neuro-developmental handicaps

2. Reduce the risk of maternal complications

• PET

• Abruptio placentae

For all starting numbers, including twins,

reduction to a lower number of fetuses:

Reduces:

fetal losses

prematurity

infant mortality and morbidity.

(Prenat Diagn. 2005)

Ethical concern Ethically justified

Meets the criterion of least harm and

most potential good Tantawi S: Islamic Sharia and selective fetal reduction. AlAhram Daily Newsletter, Cairo: Egypt, 1991. Serour GI. (ed.). Ethical guidelines for human reproduction research in the Muslim Worlds. The International Islamic Center for Population studies and Research. Cairo: Al Azhar University, 1992.

MP particularly HOMP should be

prevented in the first place.

Should HOMP occur inspite of all

preventive measures then MFPR may be

performed applying the jurisprudence

principles of necessity permits the

prohibited and the choice of the lesser

harm.

تخفيض عدد أألجنه

جائز شرعا

اقل الضرر

يجب منع الحمل المتعدد

في المقا م أألول

الضرورات تبيح

المحظورات

اذا حدث حمل

متعددعلي الرغم من كل

التدابير الوقائية قد يتم

تخفيض عدد أألجنه

تطبيقا لمبادئ فقه

الضرورة الذي يسمح

بالمحظور واختيار

.الضرر أألقل

MFPR is only allowed if

the prospect of carrying

the pregnancy to viability

is small.

Also it is allowed if the

life or the health of the

mother is in jeopardy.

It is performed with the

intention not to induce

abortion but to preserve

the life of remaining

fetuses and minimize

complications to the

mother.

مسموح

اذا كان احتمال قابليه 1.

الجنين للحياه صغيره

إذا ما كانت حياة أو صحة 2.

. األم في خطر

يتم تنفيذ ذلك ليس بنية 3.

الحث على اإلجهاض ولكن

للحفاظ على حياة األجنة

المتبقية وتقليل المضاعفات

. لألم

(. عضو هيئة التدريس جبامعة الإمام)سلامين بن فهد العيىس / الش يخ

:اجلـواب

ماكنية التسمم امحليل، كام ورد -ما دام أأن امحلل بأأربعة أأجنة يشلك خطرًا عىل الأم، واإ

: أأي)، وأأن ختفيض امحلل رضورة كام قرره الطبيب، وأأن هذا التخفيض -يف السؤال

قبل نفخ الروح يف اجلنني أأو : يومًا أأي( 120)سيمت قبل متام ( الإسقاط لبعض امحلل

ذا اكن الأمر كذكل الأجنة؛ لأن اجلنني تنفخ فيه الروح بعد أأربعة أأشهر من امحلل، اإ

ابلتفصيل اذلي ذكرته واذلي جاء يف السؤال فاإسقاط بعض امحلل جائز رشعًا رضورة،

. فالرضورات تبيح احملظورات، وهللا أأعمل

Indications 1. Quadruplets and higher order multiple:

widely accepted

2. Twins

generally not acceptable

3. Triplets

Controversial

Recent advances in neonatal

intensive care and in obstetric

care have greatly improved the

outcome for younger and lighter

neonates: benefits of performing

MFPR in order to improve

neonatal outcome in triplets may

no longer exist [Barr et al, 2003; Papageorghiou et al, 2006].

MFPR of triplets: (Drugan et al, 2013)

Reduces

risk of severe prematurity

neonatal morbidity

cost of care per survivor.

MFPR should be offered in triplet gestations.

FIGO Recommendation, 2006

MP of an order of magnitude higher than twins involves

great danger for the woman's health and also for her

fetuses, which are likely to be delivered prematurely

with a high risk of either dying or suffering damage" and

"where such pregnancies arise, it may be considered

ethically preferable to reduce the number of fetuses

rather than to do nothing

Preoperative 1. Counsel lining

1. Risk of miscarriage and PTL in MP and

offered the option of MFPR.

2. If the patients chose the option, possible

risks of the procedure

3. Informed consents

2. Rh

3. US: Number

Locations

sizes of fetuses and gestational sacs.

Fetal heart beats: confirmed in each fetus

Any sign of fetal abnormality

5. Determine • Number of fetuses to be reduced

• Which sac can be reached easier with less

trauma

• Approach and timing

between the 7 and 12 w. TA approach: between 10 and 12 w. TV approach: between 7 and 9 w 8-9: optimal {Later more difficult time and less probability of spontanous F reabsorption}

Operative Transvaginal

Antibiotic prophylaxis

with intravenous injection of cefazolin 2.0 g, one

hour prior to procedure.

Lithotomy position

Vaginal preparation

10% povidone iodine and then thoroughly rinsed

with sterile saline solution.

If uterus is mobile, an assistant push with 2 hands

on hypogastrium supporting the uterus region

during needle puncture

Under US guidance with on-screen

guideline, the selected fetus is

approached transvaginally with a 19-

gauge needle.

Exact alignment between the needle

and US screen guide is important

Most easily accessible fetuses are

selected for embryo reduction.

Alternatively:

1. embryos with a smaller fetal or sac

size are selected.

2. Smallest and/or that is located close

to the fundus {decrease infection and

bleeding if E close to cervix is

selected) (Iberico et al, 2000)

Killing Foetus

1. Cardiac puncture, aspiration of fetus if possible,

aspiration of amniotic fluid

Suction is applied using a 50 mL syringe: complete or

partial aspiration of the embryo and amniotic fluid.

2. Only puncture of the heart till asystolia is confirmed (Iberico et al, 2000).

No injection of any substance

No aspiration of embryo substance or amniotic fluid:

visualise the embryo through out the entire procedure

3. Intracardiac (or intrathoracic) injection of 2 mEq/mL

of KCl (1-2 ml) .

MC twins: when vascular anastomosis is present

between the fetuses: immediate demise of the

noninjected twin

After ensuring that the fetus concerned had been

completely aspirated, or if not, that no fetal heart

beat occurred over one minute, the needle is

withdrawn.

The above procedure is repeated for other

gestational sacs in cases of quadruplet

or higher-order pregnancies.

Post operative 1. Antibiotic

2. Analgesics

3. Anti D if indicated

4. Follow-up ultrasound examination after one

week.

video

Technique and timing of first choice

Non-KCl Vs KCl:

higher take-home-baby rate

lower risk of extreme prematurity and PPROM. (Lee et al, 2008)

Early’ (before 8 w) Vs ‘Late’ (at 8 w or later) lower immediate loss rate.

Early, transvaginal, non-KCl’:

superior in terms of immediate loss

pregnancy loss

take-home-baby

PPROM rates.

Better option for MFPR.

Transabdominal MFPR

more associated with a poor outcome than

transvaginal MFPR

video

Success rates

Over 80%

Improved

1. Increasing experience

2. Better ultrasound

3. Lower starting numbers.

4. Genetic diagnosis prior to reduction can

improve the overall outcomes.

Risks Depend on

1.Operator:

less experienced operators have worse outcomes

2. Starting number

An increasing rate of poor outcomes correlated

with the starting number.

3. Finishing numbers

with twins having the best viable pregnancy

outcomes for cases starting with three or more.

1. Pregnancy loss

4-5%: miscarry as a result of the procedure

Lower than that for HOMP.

Pregnancy loss rate (%)

4.5 Triplets

8 quadruplets

11 quintuplets

15 sextuplets

2. PTL .

lower than it is for HOMP

3. Infection

of the abdomen or uterus (rare).

4. Psychological impact

(Za Zhi. 2006)

(a) Pre-fetal reduction:

feeling threatened by the confirmed diagnosis of MP,

facing guilt and conflict of undergoing fetal reduction

(b) Undergoing fetal reduction:

Confused due to family's concern about fetal reduction

losing a sense of body boundary intactness

Worrying about the safety of the remaining fetuses

(c) Post-fetal reduction:

Grieving for losing fetus

Returning to the course of normal pregnancy.

Conclusion

HOMP has increased >100 folds due to IVF & COS.

HOMP has many fetal and maternal complications.

Fetal reduction could be justified in these conditions.

Fetal reduction is now safe and effective in most of

the cases.

Early transvaginal non-KCl method is the first

choice

Women receiving fetal reduction usually encounter

difficult decision and tremendous emotional stress.

We continue to hope, MFPR will become obsolete

as better control of ovulation agents and ART make

multifetal pregnancies uncommon

video

Thank you