When do you do selective reduction

Despite technologic advancements in neonatology, reports vary regarding whether there has been an improvement in outcomes for infants born before 26 weeks of gestation over the past decade 12 13 14 , and optimal neonatal care is not available equally to all pregnant women and their newborns, even in the United States. The risks of perinatal morbidity and mortality increase with the presence of each additional fetus.

Reducing the pregnancy by one or more fetuses decreases the spontaneous pregnancy loss rates for all multifetal pregnancies, with the most dramatic survival benefits seen with reductions from higher initial starting numbers of fetuses in higher-order multifetal pregnancies Maternal risks of multifetal pregnancies include hypertension, preeclampsia, gestational diabetes, and postpartum hemorrhage Patients should be counseled that reduction to a lower-order pregnancy triplet to twin or twin to singleton reduces the risk of medical complications associated with maintaining a higher-order multiple pregnancy.

However, the risks remain somewhat increased in higher-order pregnancies that are reduced to twin or singleton compared with pregnancies that started out as twin or singleton 8 18 Medical costs to parents and society are quadrupled for twins and fold higher for triplets Additional economic challenges include a need for additional child care, greater household and medical expenditures, and the possibility that one of the parents will be unable to return to the workforce Parents of multiples are at an increased risk of severe stress and a compromised quality of life 22 Higher rates of maternal depression and child abuse also have been reported in families raising multiples, particularly when one or more of the children has special needs 24 , and rates of divorce among parents of multiples also may be increased 21 25 Ethical principles serve to illustrate the moral complexities inherent in decisions pertaining to multi-fetal pregnancy reduction, and they offer guidance to obstetrician—gynecologists as they counsel patients regarding the management of these pregnancies.

Moral, religious, social, cultural, and economic factors all play a role in how these ethical principles are understood and weighed by a given woman in her unique decision-making process. A more detailed discussion of the role of ethical principles and other ethical perspectives in decision making can be found elsewhere The principles of beneficence and nonmaleficence are particularly complex when applied to the context of multifetal pregnancy.

On the other hand, multifetal pregnancy reduction does cause the loss of one or more fetuses and, in rare cases, may result in the loss of the entire pregnancy. This complex balance of relative risks and benefits compels the availability of factual and comprehensive counseling regarding selective fetal reduction for women with multifetal pregnancies. When assisted reproduction in the United States is viewed through the lens of justice, inequities become apparent.

Women who live in states that mandate insurers to cover infertility treatment have better access to fertility services, as do women of higher socioeconomic status. Such women often can avoid treatments such as controlled ovarian hyperstimulation in favor of more expensive treatments such as IVF, which is associated with a lower risk of higher-order multifetal gestations. When cost is less of a concern, for example, women are more likely to limit the number of embryos transferred in a given IVF cycle, knowing that they have the resources to attempt another treatment cycle if needed.

Indeed, a review of IVF cycles across the country found that there was a significant decrease in the percentage of triplet pregnancies in states with comprehensive insurance coverage for fertility treatments Some individuals may apply the concept of justice by suggesting that multifetal pregnancy reduction should be a covered medical service.

Others may feel that better insurance coverage for IVF and a limit on the number of embryos transferred, while limiting patient and physician autonomy, would lead to maximal justice by significantly reducing the incidence of multifetal pregnancies and the need for multifetal pregnancy reduction.

Ideally, access to infertility treatment and multifetal pregnancy reduction should be equitably distributed. Nondirective patient counseling should be offered to all women with higher-order multifetal pregnancies and should include a discussion of the risks unique to multi-fetal pregnancy as well as the option to continue or reduce the pregnancy. Obstetrician—gynecologists who have the appropriate clinical knowledge and expertise to discuss the risks of higher-order multifetal pregnancy and options for continuation of the pregnancy or multifetal pregnancy reduction may provide this counseling.

Alternatively, obstetrician—gynecologists may refer to other specialists such as maternal—fetal medicine physicians. It is important to note that there is a narrow window of time during which multifetal pregnancy reduction can be performed. As such, it is critical that referral for counseling occur in a timely manner in order to ensure that women are able to benefit from the full range of options regarding continuing or reducing their multifetal pregnancies.

Such information should be presented in a manner understandable to the patient It is often particularly difficult to convey the risks of a multifetal pregnancy to patients with a history of infertility, many of whom fear that they might never bear children. For some patients with a history of infertility, the arrival of twins or more may be perceived as a positive outcome, and the physician must convey the risks to patients who often are willing, and even eager, to carry a multifetal pregnancy.

Understanding the unique viewpoint of the infertility patient is crucial to help her make an informed decision. When possible, social workers or other mental health professionals with experience in this arena should be incorporated into the patient care team. Patients being counseled regarding multifetal pregnancy reduction should be made aware that the technology exists to test the fetuses for aneuploidy and morphologic and genetic anomalies before the reduction is performed.

The results of such tests may assist patients in making their decisions about intervention. Once the physician provides medical recommendations, the patient should then be given space to assess her personal value system and determine a course of action. Physicians can serve as guides and resources, helping each individual patient explore her values when faced with carrying a multifetal pregnancy.

Understanding these values will help the patient make the decision most appropriate for her. These are decisions that only the woman can make. She may wish to consult with others whose advice and counsel are important to her Her reproductive liberty, as defined by respect for her autonomy, should be at the center of the ethical decision-making process.

If a patient is in a clinical situation in which discussion of the option of multifetal pregnancy reduction is appropriate and her physician is not comfortable providing information regarding the medical risks of a multifetal pregnancy, the potential medical benefits of multifetal pregnancy reduction, and the complex ethical issues inherent to multifetal pregnancy reduction, then the physician should provide referral in a timely fashion to a physician experienced in counseling about multifetal pregnancy reduction, or performing multifetal pregnancy reductions, or both.

In these instances, referral also may be warranted if a viable patient—physician relationship cannot be established. For more information, see Committee Opinion No. Selective reduction is somewhat different than multifetal pregnancy reduction. In multifetal pregnancy reduction, the fetus es to be reduced is are chosen based on technical considerations, such as which is most accessible to intervention.

This doctor takes care of women who may have a problem in their pregnancy. You may have more tests than you would in a pregnancy with one fetus. You may avoid the emotional stress that some people feel about reducing the number of fetuses. You have a lower risk of infection. Multiple pregnancy increases the mother's risk of problems such as gestational diabetes, preeclampsia, and anemia. Personal stories about multifetal pregnancy reduction These stories are based on information gathered from health professionals and consumers.

What matters most to you? Reasons to have fetal reduction Reasons to carry triplets or more. I want to increase the chance of having two healthy babies. I want to try to have all my babies. I want to lower my chance of having a problem like preeclampsia. I don't think I can take care of a child with a disability. I can take care of a child with a disability. I can't afford to raise three or more children. I have the resources to raise several children.

My other important reasons: My other important reasons:. Where are you leaning now? Fetal reduction Having triplets or more. What else do you need to make your decision? Check the facts. Yes You're right. A fetal reduction lowers the chance that your remaining baby or babies will have a disability.

It also lowers the chance of a fetus or infant dying or being ill. No Sorry, that's not right. A fetal reduction does lower the chance that your remaining baby or babies will have a disability. I'm not sure It might help to go back and read "What are the benefits of a multifetal pregnancy reduction? Yes Sorry, that's not right. The risk of miscarriage is higher from having triplets or more than it is from having a fetal reduction. No You're right. I'm not sure It may help to go back and read "What are the risks of multifetal pregnancy reduction?

Either choice can be emotional and complex. You may feel guilty if you reduce the number of fetuses.

But you may have a hard time raising multiples. I'm not sure It may help to go back and read "Compare your options. Decide what's next. Yes No. I'm ready to take action. I want to discuss the options with others. I want to learn more about my options. Use the following space to list questions, concerns, and next steps. Your Summary. Your decision Next steps. Which way you're leaning. How sure you are. Your comments. Your knowledge of the facts Key concepts that you understood. Key concepts that may need review.

Getting ready to act Patient choices. What matters to you. Print Summary. Credits and References Credits. Multiple gestation: Clinical characteristics and management. In RK Creasy et al. Philadelphia: Saunders Elsevier. Cunningham FG, et al. Multifetal gestation. In Williams Obstetrics, 23rd ed. New York: McGraw-Hill. Get the facts Compare your options What matters most to you? Get the Facts Your options Carry a pregnancy with three or more fetuses.

Compare your options Have fetal reduction Carry three or more fetuses What is usually involved? You will have an ultrasound test to make sure that the fetus or fetuses to be reduced are in their own amniotic sac. You will see your doctor more often during your pregnancy. Check the facts 1. Yes No I'm not sure. This information is for women who are pregnant with three or more fetuses.

It's also for their partners. Multifetal pregnancy reduction is a procedure to reduce the number of fetuses in a pregnancy—usually from three, four, or five fetuses to two. This may help the two fetuses survive and help you have a healthy pregnancy.

This procedure is most often done early in the first trimester or early in the second trimester. It can be done after genetic testing to find out if the fetuses have any problems. It's usually done through the belly. Using ultrasound as a guide, the doctor puts a needle into the uterus to the selected fetus or the umbilical cord.

The doctor injects the fetus or the cord with a medicine that stops the heart. The dead embryo or fetus is absorbed by the mother's body. This is similar to what happens with vanishing twin syndrome. Reduced risk for mother. The procedure reduces the mother's risk of problems.

These risks include gestational diabetes , pre-eclampsia , and anemia. These risks increase with each added fetus. Reduced risk for infants. The procedure may improve your chances of carrying your pregnancy longer and your chances of delivering one or more healthy babies. Carrying triplets or more increases the risk of miscarriage, stillbirth, premature birth, and disability. Reduced stress related to infant care.

Caring for three or more babies can be stressful, especially if any of them has health problems. Some couples choose to implant fewer embryos to reduce the chance of a pregnancy of triplets or more, rather than consider having this procedure. These stories are based on information gathered from health professionals and consumers. They may be helpful as you make important health decisions. When my husband and I learned we were expecting three babies, we were thrilled.

But along with that news we heard about the risks for them and me. I'm already at risk for pregnancy problems, since I've had gestational diabetes before. So we decided to have a multifetal pregnancy reduction.

What convinced me was the knowledge that the miscarriage rate is higher for triplet pregnancy than it is for the twins after the procedure. And it went well for us. We took the risk, and the babies and I are doing well.

Because of my age, our fertility doctor encouraged us to have four embryos transferred for my in vitro. We were surprised that all of them took and were worried about the risks. After talking for a few days about having a multifetal pregnancy reduction, my husband and I decided not to have one.

We were more comfortable with letting nature take its course. And it did—by the second trimester, two were gone, and I was carrying twins.

I just couldn't bring myself to have a multifetal pregnancy reduction, even though my doctor told me that my pregnancy was high-risk. I'll never know whether it would have gone better if I'd had the procedure, but trying to carry the four babies didn't go well.

One died after birth, and now we have the challenge of raising triplets, one of which is disabled. Your personal feelings are just as important as the medical facts. Think about what matters most to you in this decision, and show how you feel about the following statements. I may not have any problems.

But if I do, my doctor and I can decide about treatment then. My ethical and spiritual values wouldn't allow me to have fetal reduction. Now that you've thought about the facts and your feelings, you may have a general idea of where you stand on this decision. Show which way you are leaning right now. How sure do you feel right now about your decision? Use the following space to list questions, concerns, and next steps.

Here's a record of your answers. You can use it to talk with your doctor or loved ones about your decision. My ethical and spiritual values would allow me to have fetal reduction. Does a fetal reduction lower the chance that your remaining baby or babies will have a disability? Is your risk of having a miscarriage higher with a fetal reduction than it is with having triplets or more?

Are you clear about which benefits and side effects matter most to you? Do you have enough support and advice from others to make a choice? Author: Healthwise Staff. This information does not replace the advice of a doctor. Healthwise, Incorporated, disclaims any warranty or liability for your use of this information.