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Outcomes of Multifetal Reduction: a Hospital-Based Study

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Outcomes of Multifetal Reduction: a Hospital-Based Study The Journal of Obstetrics and Gynecology of India (July–August 2018) 68(4):264–269 https://doi.org/10.1007/s13224-017-1024-1 ORIGINAL ARTICLE Outcomes of Multifetal Reduction: A Hospital-Based Study 1 1 Madhusudan Dey • Monica Saraswat Received: 20 April 2017 / Accepted: 2 June 2017 / Published online: 14 June 2017 Ó Federation of Obstetric & Gynecological Societies of India 2017 About the Author Madhusudan Dey is a Associate professor in Obstetrics and Gynecology at Armed Forces Medical College, Pune. He is a trained Maternal and Fetal medicine specialist with keen interest in intra-uterine intervention and fetoscopic procedures, and he is also the member of Genetics and Fetal medicine committee, FOGSI. He had completed five research projects and published research papers in various journals. He is regularly delivers lectures in various conferences and he was resource person for various workshops and symposia. He is presently working on risk factors associated with umbilical artery Doppler abnormalities and first trimester biochemical markers for prediction of pre-eclampsia. Abstract conducted to evaluate the maternal and fetal outcomes of Background Higher-order multiple (HOM) pregnancies MFR procedure in patients with HOMs those managed in a are associated with increased incidences of pregnancy tertiary care hospital. complications mainly abortions, pre-eclampsia, preterm Methods and Material It was a prospective observational delivery and fetal death. Multifetal reduction (MFR) during study carried out in a tertiary care military hospital, India, first trimester and subsequent delivery of twins can reduce and all women with higher-order multiples (triplets or pregnancy associated morbidities. This study was more) conceived spontaneously or after infertility treat- ment (ovulation induction, intra-uterine insemination, or Madhusudan Dey is a Associate professor in the Department of in vitro fertilization) during the 3-year period from Jan Obstetrics and Gynecology; Monica Saraswat is a Clinical Tutor in 2014 to Dec 2016 were included for MFR. Demographic Department of Obstetrics and Gynecology. and clinical data, and obstetric and neonatal outcomes were tabulated. & Madhusudan Dey Results The study included 32 HOM pregnancies which [email protected] underwent MFR. 16% patients had pre-eclampsia and 12% 1 Department of Obstetrics and Gynecology, Armed Forces patients had gestational diabetes. The study had 2 Medical College, Pune 411040, India 123 The Journal of Obstetrics and Gynecology of India (July–August 2018) 68(4):264–269 Outcomes of Multifetal Reduction: A Hospital-Based Study pregnancy losses before 24 weeks period of gestation termination is performed later. Multifetal reduction has (POG). 70% patients underwent cesarean delivery with been shown to decrease the incidence of abortion, preterm mean gestational age of 35.5 weeks. Average birth weight delivery and low-birth-weight babies, but it is also asso- of newborn was 1820 gm and 80% of them required NICU ciated with fetal loss. This study was conducted to evaluate admission. the maternal and fetal outcomes of MFR procedure in Conclusion Favorable pregnancy outcomes can be patients with HOMs those managed in a tertiary care achieved after multifetal reductions during first trimester in hospital. higher-order multiples, but the procedure is not totally safe. Keywords Infertility Á Twin pregnancy Á Fetal reduction Á Methodology Pre-eclampsia Á Abortion This was a prospective observational study conducted in the fetal medicine division at a tertiary care teaching hos- Introduction pital, Pune, India. Institute ethical committee approved the study protocol. The study population included all women Multiple pregnancies and, in particular, higher-order mul- with higher-order multiples (triplets or more) conceived tiple (HOM) pregnancies (triplets, quadruplets, quintuplets) spontaneously or after infertility treatment (ovulation are high-risk pregnancies with higher risks for the mother induction, intra-uterine insemination, or in vitro fertiliza- and babies. The spontaneous occurrence of higher-order tion) during the 3-year period from Jan 2014 to Dec 2016. gestations is rare. Spontaneous quadruplet pregnancy is Women included in this study were followed up till very uncommon with an incidence rate of 1 in 512,000–1 1 month post-delivery. Last MFR was carried out in the in 677,000 births [1]. Ovulation induction with clomiphene month of May 2016. citrate, FSH, and human menopausal gonadotropin (hMG) Prior to the MFR procedure patient counseling, all remarkably enhances the likelihood of multiple ovulations, possible risks were explained to them and a written thus increasing the chances of HOMs especially by timed informed consent was taken. An ultrasound examination intra-uterine insemination. The incidence of twin gestation was performed prior to the procedure to know the number with clomiphene citrate ranges from 6 to 8.4%, 0.55% for of fetus, cardiac activity, to determine the chorionicity, to triplets and 0.3% for quadruplets but with hMG incidences establish the relationship of the gestational sacs to each are increased to 16-66% for twins, 3.5% for triplets and 1% other and also to determine which of the fetuses were most for quadruplets [2]. In general with IVF, the risk of HOMs accessible to needle insertion. MFR procedure was carried is related to the number of embryos transferred. Virtually, out between 11- to 14-week period of gestation. All the all of quadruplets are born preterm, 90% for triplets and pregnancies underwent nuchal translucency and nasal bone 60% for twins [3]. Women with multiple pregnancies have scan (NT/NB scan) and determination of chorionicity prior an increased risk of miscarriage, anemia, hypertensive to the procedure. In case of any abnormality, the anoma- disorders, hemorrhage, operative delivery, and postnatal lous fetus was chosen for reduction; otherwise, the fetus illness. In general, maternal mortality associated with which was easily accessible to the needle in trans-abdom- multiple births is 2.5 times that for singleton births. The inal approach usually that closest to the anterior uterine overall stillbirth rate in multiple pregnancies is higher than wall and/or the fundus was reduced while that near the in singleton pregnancies, and it can be as high as 12.3 per cervix was avoided. Pre-procedure single dose of cefo- 1000 twin births and 31.1 per 1000 triplet and higher-order taxime and single dose of progesterone 100 mg were given multiple births, compared with 5 per 1000 singleton births to all the patients. [4]. In addition to these adverse outcomes, there is Under ultrasound guidance, using 21-gauge spinal nee- increased risk of congenital malformations in higher-order dle, the procedure was performed trans-abdominal (TA) by multiples, and this increased risk is for each fetus not injection of 2–3 ml of potassium chloride (2 meq/ml) into because there are more fetuses per pregnancy. The risk of the fetal thorax. Potassium chloride was injected slowly so peripartum hysterectomy is also increased 24-fold for tri- as not to dislodge the needle tip. The cardiac activity is plets or quadruplets as compared to threefold for twins [5]. carefully observed for at least 2 min, and if cardiac activity Multifetal reduction (MFR) is the termination in the first persists, more potassium chloride is injected. Asystole was trimester or early second trimester of one or more fetuses in seen within 1–2 min of injection of potassium chloride, and a multiple pregnancy, performed to increase the chances of total procedure was complete within 5 min. Reduction of survival of the remaining fetuses and to decrease long-term second fetus was carried out with a separate needle prick. morbidity of the remaining fetuses. Selective reduction Out of the four quadruple pregnancies, two of them were implies early pregnancy intervention, whereas selective reduced to twins in the same sitting and two of them were 123 265 Dey et al. The Journal of Obstetrics and Gynecology of India (July–August 2018) 68(4):264–269 reduced on next day. After the procedure, the patients were patients had slight bleeding and history of watery discharge observed for 1 h for pain, leaking, bleeding, or any other following the procedure. complications related to the procedure. A repeat ultrasound Pregnancy outcomes of MFR procedure are tabulated in was performed 1 h after the procedure to confirm asystole Table 3. Out of 32 MFR carried out during the study period in the reduced fetus (es) and cardiac activity in the non- had two abortions. One abortion was at 13 weeks and reduced fetus (es). All patients were scheduled for ultra- another was at 19 weeks 3 days period of gestation. The sound examination after 1 week of procedure for fetal pregnancy which was aborted at 13-week period of gesta- well-being and cervical length assessment. Patients were tion was a quadruple pregnancy. Sixty-seven percent of followed up regularly in fetal medicine division till deliv- patients had preterm delivery with median period of ges- ery. During the follow-up period at 28-week period of tation of delivery was 35.5 weeks. Seventy percent of gestation, all of them received two doses of Inj patients underwent cesarean delivery. Average birth weight Betamethasone 12 mg, 24 h apart for fetal lung maturity as of newborn was 1820 gm, and 80% of them required NICU per institute protocol of management of multiple preg- admission mainly due to prematurity, low birth weight, and nancies. Maternal data, sonographic findings, and MFR hypoglycemia. procedure details were noted down. Sociodemographic data, maternal characteristics, number of fetuses, chorion- icity, duration of pregnancy, mode of delivery, and Discussion neonatal outcomes were collected and analyzed by using Epi-info 2008 software. As it is a well-known fact that assisted reproductive tech- nology (ART) is one of the main reasons for increasing number of HOMs. In our study also shown that out of 32 Result HOMs, 30 of them were due to some form of infertility treatment.
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