Art f reduction

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Information about Art f reduction
Health & Medicine

Published on March 20, 2014

Author: elnashar



Risks of multiple pregnancy
Multifetal pregnancy reduction

Multifetal Pregnancy Reduction Prof Aboubakr elnashar Benha University Hospital, Egypy

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 Twin Triplet Quadruplet Survival 98% 85% 70% Impairment 5% 10% 50% Average gestation (W) 35-38 30-33 28-29

 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. ‫ألنجنه‬ ‫عدد‬ ‫تخفيض‬ ‫شرعا‬ ‫نجائز‬ ‫الضرر‬ ‫اقل‬ ‫المتعدد‬ ‫الحمل‬ ‫منع‬ ‫يجب‬ ‫أللول‬ ‫م‬ ‫المقا‬ ‫في‬ ‫تبيح‬ ‫الضرلورات‬ ‫المحظورات‬ ‫حمل‬ ‫حدث‬ ‫اذا‬ ‫كل‬ ‫من‬ ‫الرغم‬ ‫متعددعلي‬ ‫يتم‬ ‫قد‬ ‫الوقائية‬ ‫التدابير‬ ‫ألنجنه‬ ‫عدد‬ ‫تخفيض‬ ‫فقه‬ ‫لمبادئ‬ ‫تطبيقا‬ ‫يسمح‬ ‫الذي‬ ‫الضرلورة‬ ‫لواختيار‬ ‫بالمحظور‬ .‫ألقل‬ ‫الضرر‬

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 1.‫قابليه‬ ‫احتمال‬ ‫كان‬ ‫اذا‬ ‫صغيره‬ ‫للحياه‬ ‫الجنين‬ 2.‫صحة‬ ‫ألو‬ ‫حياة‬ ‫كانت‬ ‫ما‬ ‫إذا‬ .‫خطر‬ ‫في‬ ‫الم‬ 3.‫بنية‬ ‫ليس‬ ‫ذلك‬ ‫تنفيذ‬ ‫يتم‬ ‫لولكن‬ ‫النجهاض‬ ‫على‬ ‫الحث‬ ‫المتبقية‬ ‫النجنة‬ ‫حياة‬ ‫على‬ ‫للحفاظ‬ .‫للم‬ ‫المضاعفات‬ ‫لوتقليل‬

) /‫عضو‬ ‫العيسى‬ ‫فهد‬ ‫بن‬ ‫سليمان‬ ‫الشيخ‬ .(‫المام‬ ‫بجامعة‬ ‫التدريس‬ ‫هيئة‬ :‫الجـواب‬ ‫يشكل‬ ‫أجنة‬ ‫بأربعة‬ ‫الحمل‬ ‫أن‬ ‫دام‬ ‫ما‬ ‫التسمم‬ ‫وإمكانية‬ ،‫الم‬ ‫على‬ ‫خطرا‬ - -‫وأن‬ ، ‫السؤال‬ ‫في‬ ‫ورد‬ ‫كما‬ ،‫الحملي‬ ‫قرره‬ ‫كما‬ ‫ضرورة‬ ‫الحمل‬ ‫تخفيض‬ : )‫أي‬ ‫التخفيض‬ ‫هذا‬ ‫وأن‬ ،‫الطبيب‬ (‫تمام‬ ‫قبل‬ ‫سيتم‬ ‫الحمل‬ ‫لبعض‬ ‫السقاط‬ )120: (‫في‬ ‫الروح‬ ‫نفخ‬ ‫قبل‬ ‫أي‬ ‫يوما‬ ‫فيه‬ ‫تنفخ‬ ‫الجنين‬ ‫لن‬ ‫الجنة؛‬ ‫أو‬ ‫الجنين‬

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

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 (%) Triplets 4.5 quadruplets 8 quintuplets 11 sextuplets 15

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

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