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Chapter 39 - Fetal Reduction and Selective Termination

from Complications of Monochorionic Multiple Pregnancy: Multifetal Reduction in Multiple Pregnancy

Published online by Cambridge University Press:  21 October 2019

By
Mark I. Evans ,
Shara M. Evans ,
Jenifer Curtis  and
David W. Britt
Edited by
Mark D. Kilby ,
Anthony Johnson  and
Dick Oepkes
Mark D. Kilby
Affiliation:
University of Birmingham
Anthony Johnson
Affiliation:
University of Texas Medical School at Houston
Dick Oepkes
Affiliation:
Leids Universitair Medisch Centrum
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Summary

We first published on the subject of pregnancy management via fetal reduction (FR) 30 years ago [1]. Dramatic changes have occurred in medical technology, outcomes, and patient choices – large demographic and cultural shifts that have driven the pace and direction of progress and research [2, 3].

Type
Chapter
Information
Fetal Therapy
Scientific Basis and Critical Appraisal of Clinical Benefits
 , pp. 404 - 417
Publisher: Cambridge University Press
Print publication year: 2020

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References

Evans, MI, Fletcher, JC, Zador, IE, Newton, BW, Struyk, CK, Quigg, MH. Selective first trimester termination in octuplet and quadruplet pregnancies: clinical and ethical issues. Obstet Gynecol. 1988; 71: 289–96.Google Scholar
Cohen, AB, Hanft, RS. Technology in American Health Care: Policy Direction for Effective Evaluation and Management. Ann Arbor: University of Michigan Press, 2004.Google Scholar
Evans, MI, Hanft, RS. The introduction of new technologies. ACOG Clinical Seminars. 1997; 2: 1–3.Google Scholar
Society for Assisted Reproductive Technology (2019). SART National Summary Report 2017. www.sartcorsonline.com/rptCSR_PublicMultYear.aspx?reportingYear=2017.Google Scholar
Martin, JA, Hamilton, BE, Osterman, MJK: Births in the United States, 2018. NCHS Data Brief #346, July 2019. https://www.cdc.gov/nchs/products/databriefs/db346.htm.Google Scholar
Centers for Disease Control and Prevention (2015). Assisted Reproductive Technology (ART). www.cdc.gov/art/reports/Google Scholar
Evans, MI, Britt, DW. Medical, ethical, and legal aspects of fetal reduction. In Schenker, JL, ed., Ethical and Legal Aspects of ART. Berlin & New York: Walter De Gruyter GmbH & Co, 2011, pp. 121–130.Google Scholar
Martin, JA, Hamilton, BE, Osterman, MJK, Driscoll, AK, Drake, P. Births: Final Data for 2016. National Vital Statistics Report 67#1. Washington, DC: US Department Health and Human Services, CDC, NCHS, 2018.Google Scholar
Evans, MI, Andriole, SA, Britt, DW. Fetal Reduction – 25 years’ experience. Fetal Diagn Ther. 2014; 35: 69–82.Google Scholar
Lawlor, DA, Nelson, SM. Effect of age on decisions about the number of embryos to transfer in assisted conception: a prospective study. Lancet. 2012; 379: 521–7.Google Scholar
Task Force of American College of Obstetricians and Gynecologists. Neonatal Encephalopathy and Cerebral Palsy: Defining the Pathogenesis and Pathophysiology. Washington, DC: ACOG, 2003.Google Scholar
Task Force of American College of Obstetricians and Gynecologists. Neonatal Encephalopathy and Neurologic Outcome. Washington, DC: ACOG, 2014.Google Scholar
Petterson, B, Nelson, K, Watson, L, Stanley, F. Twins, triplets, and cerebral palsy in births in Western Australia in the 1980s. BMJ. 1993; 307: 1239–43.Google Scholar
Pharoah, PO, Cooke, T. Cerebral Palsy and Multiple Births. Arch Dis Child Fetal Neonatal Ed. 1996; 75: F174–7.Google Scholar
Dimitiiou, G, Pharoah, PO, Nicolaides, KH, Greenough, A. Cerebral palsy in triplet pregnancies with and without iatrogenic reduction. Eur J Pediatr. 2004; 163: 449–51.Google Scholar
Van Naarden Braun, K, Doernberg, N, Schieve, L, Christensen, D, Goodman, A, Yeargin-Allsopp, M. Birth prevalence of cerebral palsy: a population-based study. Pediatrics. 2016; 137: e2015872.Google Scholar
Christensen, D, Van Naarden Braun, K, Doernberg, NS, Maenner, MJ, Arneson, CL, Durkin, MS, et al. Prevalence of cerebral palsy, co-occurring autism spectrum disorders, and motor functioning – Autism and Developmental Disabilities Monitoring Network, USA, 2008. Devel Med Child Neurol. 2014; 56: 59–65.Google Scholar
Dahsling, MO, Anderson, GL, Irgens, L, Skranes, J, Vik, T. Risk of cerebral palsy in term-born singletons according to growth status at birth. Devel Med Child Neurol. 2014; 56: 53–58.Google Scholar
Boyle, CA, Boulet, S, Schieve, LA, Cohen, RA, Blumberg, SJ, Yeargin-Allsopp, M, Visser, S, Kogan, MD. Trends in the prevalence of developmental disabilities in US children, 1997–2008. Pediatrics. 2011; 127: 1034–42.Google Scholar
St. John, EB, Nelson, KG, Oliver, SP, Bishno, RR, Goldenberg, RL. Cost of neonatal care according to gestational age at birth and survival status. Am J Obstet Gynecol. 2000; 182: 170–5.Google Scholar
Kirby, RS. Contribution of cost of preterm infants to the total cost of infant health care in the United States. Pediatrics. 2017; 140: e20172240.Google Scholar
March of Dimes (2013). Long-term health effects of premature birth. www.marchofdimes.org/complications/long-term-health-effects-of-premature-birth.aspxGoogle Scholar
Grosse, SD, Waitzman, NJ, Yang, N, Abe, K, Barfield, WD. Employer sponsored plan expenditures for infants born preterm. Pediatrics. 2017; 140: e20171078.Google Scholar
Cuevas, KD, Silver, DR, Brooten, D, Youngblut, JM, Bobo, CM. The cost of prematurity: Hospital charges at birth and frequency of rehospitalizations and acute care visits over the first year of life: a comparison by gestational age and birth weight. Am J Nurs. 2005; 105: 56–64.CrossRefGoogle ScholarPubMed
Marlow, N, Wolke, D, Bracewell, MA, Samara, M, EPICure Study Group. Neurologic and developmental disability at six years of age after extremely preterm birth. N Engl J Med. 2005; 352: 9–19.Google Scholar
Rosenbaum, P, Paneth, N, Leviton, A, Goldstein, M, Bax, M, Damiano, D, Dan, B, Jacobsson, B. A report: The definition and classification of cerebral palsy April 2006. Dev Med Child Neurol. 2007; 49: 8–14. [Corrected in Rosenbaum et al. Dev Med Child Neurol. 2007; Suppl. 109: 8–14]Google Scholar
Hack, M, Taylor, HG, Drotar, D, Schluchter, M, Cartar, L, Andreias, L, Wilson-Costello, D, Klein, N. Chronic conditions, functional limitations, and special health care needs of school-aged children born with extremely low birth weights in the 1990s. JAMA. 2008; 94: 318–25.Google Scholar
Stoll, BJ, Hansen, NI, Bell, EF, Shankaran, S, Laptook, AR, Walsh, MC, et al. Neonatal outcomes of extremely preterm infants from the NICHD Neonatal Research Network. Pediatrics. 2010; 126: 443–56.Google Scholar
Yogev, Y, Melamed, N, Bardin, R, Tenenbaum-Gavish, K, Ben-Shitrit, G, Ben-Haroush, AB. Pregnancy outcome at extremely advanced maternal age. Am J Obstet Gynecol. 2010; 203: 558. e1–7.Google Scholar
Dumez, Y, Oury, JF. Method for first trimester selective abortion in multiple pregnancy. Contrib Gynecol Obstet. 1986; 15: 50.Google Scholar
Berkowitz, RL, Lynch, L, Chitkara, U, Wilkins, IA, Mehalek, KE, Alvarez, E. Selective reduction of multiple pregnancies in the first trimester. N Engl J Med. 1988; 318: 1043–7.Google Scholar
Wapner, RJ, Davis, GH, Johnson, A. Selective reduction of multifetal pregnancies. Lancet 1990; 335: 90–3.CrossRefGoogle ScholarPubMed
Timor-Tritsch, IE, Peisner, DB, Monteagudo, A, Lerner, JP, Sharma, S. Multifetal pregnancy reduction by transvaginal puncture: evaluation of the technique used in 134 cases. Am J Obstet Gynecol. 1993; 168: 799–804.Google Scholar
Li, R, Yang, R, Chen, X, Yang, S, Ma, C, Liu, P, Qiao, J. Intracranial KCl injection – an alternative method for multifetal pregnancy reduction in the early second trimester. Fetal Diag Ther. 2013; 34: 26–30.Google Scholar
Evans, MI, Dommergues, M, Wapner, RJ, Lynch, L, Dumez, Y, Goldberg, JD, et al. Efficacy of transabdominal multifetal pregnancy reduction: collaborative experience among the world’s largest centers. Obstet Gynecol. 1993; 82: 61–7.Google Scholar
Evans, MI, Drugan, A, Fletcher, JC, Platt, LD, Rodeck, CA, Hansmann, M, Bottoms, SF. Attitudes on the ethics of abortion, sex selection & selective termination among health care professionals, ethicists & clergy likely to encounter such situations. Am J Obstet Gynecol. 1991; 164: 1092–9.CrossRefGoogle ScholarPubMed
Yaron, Y, Bryant-Greenwood, PK, Dave, N, Moldenhauer, JS, Kramer, RL, Johnson, MP, Evans, MI. Multifetal pregnancy reduction (MFPR) of triplets to twins: Comparison with non-reduced triplets and twins. Am J Obstet Gynecol. 1999; 180: 1268–71.Google Scholar
Antsaklis, A, Souka, AP, Daskalakis, G, Papantoniou, N, Koutra, P, Kavalakis, Y, Mesogitis, S. Embryo reduction versus expectant management in triplet pregnancies. J Matern Fetal Neonatal Med. 2004; 16: 219–22.Google Scholar
Luke, B, Brown, MD, Nugent, C, Gonzalez-Quintero, VH, Witter, FR, Newman, RB. Risk factors for adverse outcomes in spontaneous versus assisted conception in twin pregnancies. Fertil Steril. 2004; 81: 315–19.Google Scholar
Kozinsky, Z, Zadori, J, Orvos, H, Katona, M, Pál, A, Kovács, L. Obstetric and neonatal risk of pregnancies after assisted reproductive technology: a matched control study. Acta Obstet Gynecol Scand. 2003; 82: 850–6.Google Scholar
McDonald, S, Murphy, K, Beyene, J, Ohlsson, A. Perinatal outcomes of in vitro fertilization twins: a systematic review and meta-analysis. Am J Obstet Gynecol. 2005; 193: 141–52.Google Scholar
Lipitz, S, Shulman, A, Achiron, R, Zalel, Y, Seidman, DS. A comparative study of multifetal pregnancy reduction from triplets to twins in the first versus early second trimesters after detailed fetal screening. Ultrasound Obstet Gynecol. 2001; 18: 35–8.Google Scholar
Sepulveda, W, Munoz, H, Alcalde, JL. Conjoined twins in a triplet pregnancy: early prenatal diagnosis with three-dimensional ultrasound and review of the literature. Ultrasound Obstet Gynecol. 2003; 22: 199–204.Google Scholar
Evans, MI, Berkowitz, R, Wapner, R, Carpenter, R, Goldberg, J, Ayoub, MA, et al. Multifetal pregnancy reduction (MFPR): improved outcomes with increased experience. Am J Obstet Gynecol. 2001; 184: 97–103.Google Scholar
Blickstein, I. How and why are triplets disadvantaged compared to twins. Best Pract Res Clin Obstet Gynecol. 2004; 18: 631–44.Google Scholar
Rosner, M, Pergament, E, Andriole, S, Gebb, J, Dar, P, Evans, MI. Detection of genetic abnormalities using CVS and FISH prior to fetal reduction in sonographically normal appearing fetuses. Prenat Diagn. 2013; 33: 940–4.Google Scholar
Chaveeva, P, Kosinski, P, Puglia, D, Poon, LC, Nicolaides, KH. Trichorionic and dichorionic triplet pregnancies at 10–14 weeks: outcome after embryo reduction compared to expectant management. Fetal Diag Ther. 2013; 34: 199–205.Google Scholar
Evans, MI, Kaufman, MI, Urban, AJ, Krivchenia, EL, Britt, DW, Wapner, RJ. Fetal reduction from twins to a singleton: a reasonable consideration. Obstet Gynecol. 2004; 104: 102–9.Google Scholar
Templeton, A. The multiple gestation epidemic: the role of the assisted reproductive technologies. Am J Obstet Gynecol. 2004; 190: 894–8.Google Scholar
Kalra, SK, Milad, MP, Klock, SC, Grobman, WA. Infertility patients and their partners: differences in the desire for twin gestations. Obstet Gynecol. 2003; 102: 152–5.Google Scholar
Evans, MI, Britt, DW. Selective Reduction in Multifetal Pregnancies. In Paul, M, Grimes, D, Stubblefield, P, Borgatta, L, Lichfield, S, Creinin, M, eds., Management of Unintended and Abnormal Pregnancy. London: Blackwell-Wiley Publishing Co, 2009, pp. 312–18.Google Scholar
Evans, MI, Britt, DW. Fetal reduction: ethical and societal issues. Sem Reprod Med. 2010; 28: 295–302.Google Scholar
Britt, DW, Von-Voris Schoenborn, S, Jamil, S, Gebb, J, Rosner, M, Evans, MI. The impact of area conservatism on deviations from best practice: women choosing to undergo selective reduction. Intl J Health Well Soc. 2017; 7: 115–40.Google Scholar
Balasch, J, Gratacós, E. Delayed childbearing: effects on fertility and the outcome of pregnancy. Curr Opin Obstet Gynecol. 2012; 24: 187–93.Google Scholar
Balasch, J, Gratacós, E. Delayed childbearing: effects on fertility and the outcome of pregnancy. Fetal Diagn Ther. 2011; 29: 263–73.Google Scholar
McLean, LK, Evans, MI, Carpenter, RJ, Johnson, MP, Goldberg, JD. Genetic amniocentesis (AMN) following multifetal pregnancy reduction (MFPR) does not increase the risk of pregnancy loss. Prenat Diagn. 1998; 18: 186–8.Google Scholar
Wapner, RJ, Johnson, A, Davis, G, Urban, A, Morgan, P, Jackson, L. Prenatal diagnosis in twin gestations: a comparison between second-trimester amniocentesis and first-trimester chorionic villus sampling. Obstet Gynecol. 1993; 82: 49–56.Google Scholar
Brambati, B, Tului, L, Baldi, M, Guercilena, S. Genetic analysis prior to selective fetal reduction in multiple pregnancy: technical aspects and clinical outcome. Hum Reprod. 1995; 10: 818–25.Google Scholar
Tabor, A, Alfirevic, Z. Update on procedure-related risks for prenatal diagnosis techniques. Fetal Diagn Ther. 2010; 27: 1–7.Google Scholar
Hern, WM. Selective termination for fetal anomaly/genetic disorder in twin pregnancy at 32+ menstrual weeks. Report of four cases. Fetal Diagn Ther. 2004; 19: 292–5.Google Scholar
Evans, MI, Goldberg, J, Horenstein, J, Wapner, R, Ayoub, MA, Stone, J, et al. Selective termination (ST) for structural (STR), chromosomal (CHR), and Mendelian (MEN) anomalies: International experience. Am J Obstet Gynecol. 1999; 181: 893–7.Google Scholar
Eddleman, KA, Stone, JL, Lynch, L, Berkowitz, RL. Selective termination of anomalous fetuses in multiple pregnancies: two hundred cases at a single center. Am J Obstet Gynecol. 2002; 187: 1168–72.Google Scholar
Lu, J, Ting, YH, Law, KM, Lau, TK, Leung, TY. Radiofrequency ablation for selective reduction in complicated monochorionic multiple pregnancies. Fetal Diagn Ther. 2013; 34: 211–16.Google Scholar
Pergament, E, Schulman, JD, Copeland, K, Fine, B, Black, SH, Ginsberg, NA, Frederiksen, MC, Carpenter, RJ. The risk and efficacy of chorionic villus sampling in multiple gestations. Prenat Diagn. 1992; 12: 377–84.Google Scholar
Nicolini, U, Lalatta, F, Natacci, F, Curcio, C, Bui, TH. The introduction of QF-PCR in prenatal diagnosis of fetal aneuploidies: time for reconsideration. Hum Reprod Update. 2004; 10: 541–8.CrossRefGoogle ScholarPubMed
Wapner, RJ, Martin, CL, Levy, B, Ballif, BC, Eng, CM, Zachary, JM, et al. Chromosomal microarray versus karyotyping for prenatal diagnosis. N Engl J Med. 2012; 367: 2175–84.Google Scholar
Evans, MI, Wapner, RJ, Berkowitz, RL. Noninvasive prenatal testing or advanced diagnostic testing: caveat emptor. Am J Obstet Gynecol. 2016; 215: 298–305.CrossRefGoogle ScholarPubMed
Evans, MI, Evans, SM, Bennett, TA, Wapner, RJ. The price of abandoning testing for cell-free fetal DNA screening. Prenat Diagn. 2018; 38: 243–5.Google Scholar
Evans, MI, Andriole, S, Curtis, J, Evans, SM, Kessler, AA, Rubenstein, AF. The epidemic of abnormal copy number variants missed because of reliance upon noninvasive prenatal screening. Prenat Diagn. 2018; 38: 730–4.CrossRefGoogle ScholarPubMed
Wapner, RJ, Babiarz, JE, Levy, B, Stosic, M, Zimmermann, B, Sigurjonsoon, S, et al. Expanding the scope of noninvasive prenatal testing: detection of fetal microdeletion syndromes. Am J Obstet Gynecol. 2015: 212: 322. e1–9.Google Scholar
Dreesen, J, Destouni, A, Kourlaba, G, Degn, B, Mette, WC, Carvalho, F, et al. Evaluation of PCR-based preimplantation genetic diagnosis applied to monogenic disease: a collaborative ESHRE PGD consortium study. Eur J Hum Genet. 2013; 22: 1012–18.Google Scholar
Yang, Z, Liu, J, Collins, GS, Salem, SA, Liu, X, Lyle, SS, et al. Selection of single blactocysts for fresh transfer via standard morphology assessment alone and with array CGH for good prognosis IVF patients: results from a randomized pilot study. Mol Cytogenet. 2012; 5: 24–32.Google Scholar
Dondorp, W, de Wert, G, Bombard, Y, Bianchi, DW, Bergmann, C, Borry, P, et al. Non-invasive prenatal testing for aneuploidy and beyond: challenges of responsible innovation in prenatal screening. Eur J Hum Genet. 2015; 57: 1–8.Google Scholar
Pantos, K, Kokkali, G, Petroutsou, K, Lekka, K, Malligiannis, P, Koratzis, A. Monochorionic triplet and monoamniotic twins gestation after intracytoplasmic sperm injection andlaser-assisted hatching. Fetal Diagn Ther. 2009; 25: 144–7.Google Scholar
Peeters, SH, Evans, MI, Slaghekke, F, Klumper, FJ, Middeldorp, JM, Lopriore, E, Oepkes, D. Pregnancy complications for di-chorionic, tri-amniotic triplets: markedly increased over trichorionic and reduced cases. Am J Obstet Gynecol. 2014; 210: S288.Google Scholar
Chaveeva, P, Peeva, G, Pugliese, SG, Shterev, A, Nicolaides, KH. Intrafetal laser ablation for embryo reduction from dichorionic triplets to dichorionic twins. Ultrasound Obstet Gynecol. 2017; 50; 632–4.Google Scholar
Evans, MI, Rosner, M, Andriole, S, Alkalay, A, Gebb, J, Britt, DW. Evolution of gender preferences in multiple pregnancies. Prenat Diagn. 2013; 33: 935–9.Google Scholar
Evans, MI, Andriole, S, Pergament, E, Curtis, J, Britt, DW. Paternity balancing. Fetal Diagn Ther. 2013; 33: 935–9.Google Scholar
Evans, MI, Goldberg, JD, Horenstein, J, Wapner, RJ, Ayoub, MA, Stone, J, et al. Selective termination (ST) for structural (STR), chromosomal (CHR), and Mendelian (MEN) anomalies: International experience. Am J Obstet Gynecol. 1999; 181: 893–7.Google Scholar
Hack, KE, Derks, JB, Elias, SG, Franx, A, Roos, EJ, Voerman, SK, et al. Increased perinatal mortality and morbidity in monochorionic versus dichorionic twin pregnancies: clinical implications of a large Dutch cohort study. BJOG. 2008; 115: 58–67.Google Scholar
Evans, MI, Lau, TK. Making decisions when no good options exist: Delivery of the survivor after intrauterine death of the co-twin in monochorionic twin pregnancies. Fetal Diagn Ther. 2010; 28: 191–5.Google Scholar
Quintero, RA, Reich, H, Puder, KS, Bardicef, M, Evans, MI, Cotton, DB, Romero, R. Brief report: umbilical cord ligation of an acardiac twin by fetoscopy at 19 weeks of gestation. N Engl J Med. 1994; 330: 469–71.Google Scholar
Gebb, J, Rosner, M, Dar, P, Evans, MI. Long term neurologic outcomes after fetal interventions: meta-analysis Am J Obstet Gynecol. 2014; 210: S115.Google Scholar
Beauchamp, TL, Childress, JC. Principles of Biomedical Ethics, 5th edn. New York: Oxford University Press, 2001, pp. 358–9.Google Scholar
Dziadosz, M, Evans, MI. Re-thinking single embryo transfer: increased risks of monozygotic twinning, a systematic review. Fetal Diagn Ther. 2017; 42: 81–91.Google Scholar
Benjamin, M. Splitting the Difference: Compromise and Integrity in Ethics and Politics. Lawrence: University Press of Kansas, 1990, pp. 72–4.Google Scholar
Britt, DW, Evans, MI. Sometimes doing the right thing sucks: Frame combinations and multifetal pregnancy reduction decision difficulty. Soc Sci Med. 2007; 65: 2342–56.Google Scholar
Britt, DW, Evans, MI: Information sharing among couples considering multifetal pregnancy reduction. Fertil Steril. 2007; 87: 490–5.Google Scholar
Tavrow, P. Promote or discourage: how providers can influence service use. In Malarcher, S, ed., Social Determinants of Sexual and Reproductive Health: Informing Future Research and Programme Implementation. Geneva: World Health Organization, 2010, pp. 17–36.Google Scholar
Britt, DW, Norton, J, Hubanks, A, Arias-Navidad, SG, Perkins, RJ, Lowery, C. A two period assessment of changes in specialist contact in a high risk pregnancy telemedical program. Telemed J E Health. 2006; 12: 1–7.Google Scholar
Britt, DW, Bronstein, J, Norton, JA. Absorbing and transferring risk: a logistic regression analysis of a statewide high-risk-pregnancy telemedical program on VLBW maternal transports. BMC Pregnancy Childbirth. 2006; 6: 11.Google Scholar
Yeung, D. Social media as a catalyst for policy action and social change for health and well-being – a viewpoint. J Med Internet Res. 2018; 20: 3 e94.Google Scholar
Britt, DW, Eden, RD, Evans, MI. Matching risk and resources in high-risk pregnancies. J Matern Fetal Neonatal Med. 2006; 19: 645–50.Google Scholar

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