1. Multifetal Pregnancy
Reduction
Prof Aboubakr elnashar
Benha University Hospital, Egypt

2. Multiple pregnancy
(MP)
1.Incidence
2.Maternal Hazards
3.Fetal Hazards
4.Prevention

3. 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.

4. 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.

5. 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
QuadrupletTripletTwin
70%85%98%Survival
50%10%5%Impairment
28-2930-3335-38Average gestation (W)

7.  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 .

8.  Financial
 Emotional
 Medical costs: extremely high.

9. Multiple pregnancy in Egypt
Medical oversight: lax
Fertility drugs: cheap
Efficient NICU: rare
Overpopulation
Effective method for prevention of PTL in
multiple pregnancy:
No

10. 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.

11. 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.

12. 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

13. 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

14. 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

15. 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.

16. 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

17. 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

18. For all starting numbers, including twins,
reduction to a lower number of fetuses:
 Reduces:
 fetal losses
 prematurity
 infant mortality and morbidity.
(Prenat Diagn. 2005)

19. 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.
‫أألجنه‬ ‫عدد‬ ‫تخفيض‬
‫شرعا‬ ‫جائز‬
‫الضرر‬ ‫اقل‬
‫المتعدد‬ ‫الحمل‬ ‫منع‬ ‫يجب‬
‫أألول‬ ‫م‬ ‫المقا‬ ‫في‬
‫تبيح‬ ‫الضرورات‬
‫المحظورات‬
‫حمل‬ ‫حدث‬ ‫اذا‬
‫كل‬ ‫من‬ ‫الرغم‬ ‫متعددعلي‬
‫يتم‬ ‫قد‬ ‫الوقائية‬ ‫التدابير‬
‫أألجنه‬ ‫عدد‬ ‫تخفيض‬
‫فقه‬ ‫لمبادئ‬ ‫تطبيقا‬
‫يسمح‬ ‫الذي‬ ‫الضرورة‬
‫واختيار‬ ‫بالمحظور‬
‫أألقل‬ ‫الضرر‬.

20. 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
.1‫قابليه‬ ‫احتمال‬ ‫كان‬ ‫اذا‬
‫صغيره‬ ‫للحياه‬ ‫الجنين‬
.2‫صحة‬ ‫أو‬ ‫حياة‬ ‫كانت‬ ‫ما‬ ‫إذا‬
‫خطر‬ ‫في‬ ‫األم‬.
.3‫بنية‬ ‫ليس‬ ‫ذلك‬ ‫تنفيذ‬ ‫يتم‬
‫ولكن‬ ‫اإلجهاض‬ ‫على‬ ‫الحث‬
‫األجنة‬ ‫حياة‬ ‫على‬ ‫للحفاظ‬
‫المضاعفات‬ ‫وتقليل‬ ‫المتبقية‬
‫لألم‬.

21. ‫يخ‬‫ش‬‫ل‬‫ا‬/‫العيىس‬ ‫فهد‬ ‫بن‬ ‫سلامين‬(‫إمام‬‫ل‬‫ا‬ ‫جبامعة‬ ‫يس‬‫ر‬‫تد‬‫ل‬‫ا‬ ‫ئة‬‫ي‬‫ه‬ ‫عضو‬.)
‫اب‬‫و‬‫اجلـ‬:
،‫امحليل‬ ‫سمم‬‫لت‬‫ا‬ ‫ية‬‫ن‬‫اك‬‫م‬‫إ‬‫ا‬‫و‬ ،‫م‬‫أ‬‫ل‬‫ا‬ ‫عىل‬ ً‫ا‬‫ر‬‫خط‬ ‫شلك‬‫ي‬ ‫جنة‬‫أ‬‫أ‬ ‫بعة‬‫ر‬‫أ‬‫أ‬‫ب‬ ‫امحلل‬ ‫ن‬‫أ‬‫أ‬ ‫دام‬ ‫ما‬-‫ورد‬ ‫كام‬
‫ال‬‫ؤ‬‫س‬‫ل‬‫ا‬ ‫يف‬-‫تخفيض‬‫ل‬‫ا‬ ‫هذا‬ ‫ن‬‫أ‬‫أ‬‫و‬ ،‫بيب‬‫لط‬‫ا‬ ‫قرره‬ ‫كام‬ ‫رضورة‬ ‫امحلل‬ ‫ختفيض‬ ‫ن‬‫أ‬‫أ‬‫و‬ ،(‫ي‬‫أ‬‫أ‬:
‫امحلل‬ ‫بعض‬‫ل‬ ‫إسقاط‬‫ل‬‫ا‬)‫متام‬ ‫قبل‬ ‫سيمت‬(120)‫ي‬‫أ‬‫أ‬ ً‫ا‬‫يوم‬:‫و‬‫أ‬‫أ‬ ‫نني‬‫جل‬‫ا‬ ‫يف‬ ‫الروح‬ ‫نفخ‬ ‫قبل‬
‫كذكل‬ ‫مر‬‫أ‬‫ل‬‫ا‬ ‫اكن‬ ‫ذا‬‫إ‬‫ا‬ ،‫امحلل‬ ‫من‬ ‫شهر‬‫أ‬‫أ‬ ‫بعة‬‫ر‬‫أ‬‫أ‬ ‫بعد‬ ‫الروح‬ ‫فيه‬ ‫نفخ‬‫ت‬ ‫نني‬‫جل‬‫ا‬ ‫ن‬‫أ‬‫ل‬ ‫جنة؛‬‫أ‬‫ل‬‫ا‬
،‫رضورة‬ ً‫ا‬‫رشع‬ ‫جائز‬ ‫امحلل‬ ‫بعض‬ ‫إسقاط‬‫ا‬‫ف‬ ‫ال‬‫ؤ‬‫س‬‫ل‬‫ا‬ ‫يف‬ ‫جاء‬ ‫اذلي‬‫و‬ ‫ته‬‫ر‬‫ذك‬ ‫اذلي‬ ‫يل‬‫تفص‬‫ل‬‫اب‬
‫عمل‬‫أ‬‫أ‬ ‫وهللا‬ ،‫احملظورات‬ ‫تبيح‬ ‫ات‬‫ر‬‫فالرضو‬.

22. Indications
1. Quadruplets and higher order multiple:
widely accepted
2. Twins
generally not acceptable

23. 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].

24. 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.

25. 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

26. 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

27. 2. Rh
3. US:
Number
Locations
sizes of fetuses and gestational sacs.
Fetal heart beats: confirmed in each fetus
Any sign of fetal abnormality

28. 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}

29. 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

30. 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)

31. 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

32. 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.

33. Post operative
1. Antibiotic
2. Analgesics
3. Anti D if indicated
4. Follow-up ultrasound examination after one
week.
video

34. 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.

35. Transabdominal MFPR
more associated with a poor outcome than
transvaginal MFPR
video

36. 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.

37. 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.

38. 1. Pregnancy loss
4-5%: miscarry as a result of the procedure
Lower than that for HOMP.
Pregnancy loss rate (%)
4.5Triplets
8quadruplets
11quintuplets
15sextuplets

39. 2. PTL .
lower than it is for HOMP
3. Infection
of the abdomen or uterus (rare).

40. 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.

41. 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

42.  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

43. Thank you