“Multifetal pregnancy reduction without the use of cardio-toxic agent”

Dr Santosh Gupta

MBBS,MS,FIRM

Reproductive medicine consultant

Prevention is better than cure

Eager Patients

Overzealous Doctor

Is this the Happiness??

Best Among Worst Options

Fetal reduction

• Selective fetal reduction

• Multifetal pregnancy reduction

Dr Evans

“When reducing one to zero is permissible what is wrong in reducing high order to lesser number”

Issues

- Should we ?

- When ?

- How ?

- Why ?

Various techniques

EarlyLateRouteTransvaginalTransabdominalMethodIntracardiacIntracranial

With KCl or without KCl

Remember before injecting a poison!!

• Potassium Chloride injected will not remain limited to cardia ,may diffuse elsewhere and adjacent sacs also

• Cases of limb amputation (Roze et al 1989)

- Anencephaly (Boulot et al 1992)

- Total preg. loss (Tabsh et al 1990)

• Remaining embryonic tissue and necrotic tissue may evoke inflammation and release of PGs and CK

• Increase incidence of periventricular leukomalacia in preterm surviving twin

Various modifications ……

• G Iberico et al(hum reprod 2000)Intracardiac punture till asystole without KCl

Any aspiration of embryonic tissue was avoided

Done between 7-9 wks(7.8)---149cases abortion rate 7.3%,

1.3%chorioamnionitis

Mansour et al(fert ster 1999)EgyptIntracardiac punture f/b asiration of embryo by 20cc syringe

KCl vs embryo aspiration grp(6-9wks)

KCl grp 30% abortion rate vs 8.8%

Aspiration of embryonic tissue –minimal necrotic tissue &inflammation

KCl induced damage

Trans-abdominal vs Transvaginal

• Dechaud etal(fetal diag ther 1998)

- 2756cases of MFPR

- Loss rate were 16.7%TA, 24.8% TC ,10.9% TV (p= .o3)

- Transvaginal route is safer

• Ilan E Timor etal (AJOG,2004)

- 290 cases of MFPR, 203 TA ,75 TV ,12 both

- Total pregnancy loss 3.5% TA (7/203) & 13.3%(10/75)TV

- P value =.oo4, favours transabdominal route

Patients & Method

• 51 women triplet or higher order multiple pregnancy requesting for fetal reduction

• Study period : june 2010 to july 2012

• Study design : prospective study

• Setting : tertiary level infertility set up

• Inclusion : no cardiotoxic agent (KCl) used for MFPR

• Exclusion : twins requesting for fetal reduction

: KCl is used

Methods

• Antibiotic prophylaxis

• Vaginal cleaning 10% Pov Iodine & NS

• TVS guidance with OPU needle

• Most accessible sac chosen

• Intracardiac puncture f/b aspiration 20cc syringe till asystoleconfirmed

• HOMP reduced to twins

• Next day rescan to confirm the reduction

• All pts follwed till delivery

GSMH Study

• 20(39%) OI/IUI, ,31(61%) IVF/ICSI/FET/IVM• Mean age : 30.12 yrs (25-45)• Average gest age of fetal reduction 9.45wks(8-11.6)

• 51 cases : lost for F/u 6cases-- : abortion 4 (7.8%)

:22-28 wks 1 ( 1.96%): 28-32 wks 1( 1.96%): 32-36wks 6( 11.76%): >=36 wks 27(53 %):Ongoing >28wks 6 (11.76%)

Observations

- Abortions : 4 cases- 2cases within 48 hrs- 1 cases after 48hrs but before 7 days

- 1 case 18wks ,d/t APH(>4wks after procedure)

- No procedure failure ,only 1 case fetal reduction done in 2 steps because of quintuplet pregnancy

Observations

• Babies born 68

• Average gest age 35.5 wks

• Mean birth wt 2.33kg(0.5-3.25)

< 1kg 1

1.1 -1.5 3

1.51 -2 8

>2 kg 56*1 baby died immediately after birth severe IUGR, 500gms at 28 wks, other surviving twin had prolonged NICU admission

Discussion…..

GSMH study Lee et al 2008 Chen et al 2007 Hesho et al 2012

Maternal age 30.1 30.6 31 30.4

Gest age 9.45 wks 7.8

Abortion rate 7.8%(4/51) 18%(13/72) 8.2%(6/73) 4.3%(3/70)

Del <28 wks 1.96%(1/51) 1.6%(1/72) 16.4%(12/73) 2.9%(2/70)

Del <=32wks 1.96%(1/51) 4.1%(4/73) 7.1%(5/70)

Del >34wks 80% 86% 71% 86%

Av gest at del 35.5 wks 35.9 35.7wks

Birth wt 2.3 2.3 2.2kg

THBR 90% 86% 90.4%

MFPR by KCL method : retrospective data

GSMH KCl GSMH no KCl

Total cases 19 51

Mean age 29 30.1

Mean gest age 34.5 35.5

Abortion rate 3/19(15.8%) 4/51(7.8%)

<24wks 1/19(5.2%) 1/51(1.96%)

24 -28 wks 0 0

28 -32wks 0 1(1.96%)

32.-36 wks 8(42.1%) 6(11.76%)

>36 wks 7(36.8%) 27(69%)

Birth wt 2.1 2.3kg

Meta -Analysis by Nicolaides et al ,hum repr 2006

miscarriage

preterm

First quintuplets known to survive infancy

conclusion

• Fetal reduction is an effective option for the women with HOMP

• MFPR by transvaginal route without using cardiotoxic agent like KCl is more promising

Take home message

MFPR should be offered to all women with triplet and higher order pregnancy

KCl

Counselling is very important as a small percentage may have total pregnancy loss inspite of MFPR