Trans-abdominal fetal reduction in higher order multiple pregnancies: a pioneer cohort retrospective study in Nepal

Objective

To share the initial experience of trans-abdominal multifetal pregnancy reduction (MFPR) in Nepal.

Method

The procedure was performed in 108 patients in a private hospital over a period of 3 years. Under ultrasound guidance, intracardiac injection of 0.2-3.0 ml of 15% w/v (2 mEq/ml) potassium chloride (KCl) was administered via trans-abdominal route.

Results

A total of 108 fetal reduction procedures were carried out at the seventh to fifteenth weeks of gestation, a maximum of 44 (40.7%) of which were done at the ninth to tenth weeks of gestation. A total of 123 fetuses were reduced. Out of total 108 multifetal pregnancies, 96 (88.8%) were due to in-vitro fertilization (IVF). Eighty-five pregnancies (78.7%) underwent reduction from triplet to twin. The second-time reduction was needed in five cases. Two attempts (in the same sitting) were required in three cases. The inadvertent demise of the second fetus was noted in three cases of dichorionic tri-amniotic triplet pregnancy.

Conclusion

Ultrasound-guided trans-abdominal fetal reduction performed between the seventh and twelfth weeks of gestation is safe and effective.

Fetal Reduction by Potassium Chloride Infusion in Unruptured Heterotopic Pregnancy: A Comprehensive Review

This comprehensive review explores the practice of fetal reduction through potassium chloride infusion in unruptured heterotopic pregnancies. Heterotopic pregnancies, characterized by the simultaneous occurrence of intrauterine and extrauterine gestations, present unique challenges in reproductive medicine. The review defines fetal reduction and underscores its significance in mitigating risks associated with heterotopic pregnancies, including the threat of rupture, maternal morbidity, and adverse outcomes. The analysis encompasses the background, methods, efficacy, ethical considerations, and future directions related to the procedure. Findings highlight the efficacy and safety of potassium chloride infusion, emphasizing the importance of proper patient selection and counseling. Implications for clinical practice underscore the procedure's viability in specific cases where the benefits outweigh the associated risks. The review concludes with recommendations for future studies, encouraging further research on procedural techniques, alternative methods, and the psychosocial impact on patients. This work is a foundation for advancing the management of unruptured heterotopic pregnancies, providing insights for clinicians and researchers to improve clinical outcomes and patient care.

Clinical practice guidelines for the antenatal management of dichorionic diamniotic twin pregnancies: a systematic review

OBJECTIVE

This review aimed to identify guidelines with recommendations applicable to the antenatal management of dichorionic diamniotic twin pregnancies within high-income countries, appraise their methodological quality, and discuss the similarities and variability across guidelines.

METHOD

A systematic literature review of electronic databases was performed. Manual searches of guideline repositories and websites of professional organisations were performed to identify additional guidelines. The protocol for this systematic review was registered on PROSPERO (CRD42021248586, 25 June 2021). AGREE II and AGREE-REX tools were applied to assess the quality of eligible guidelines. A narrative and thematic synthesis described and compared the guidelines and their recommendations.

RESULTS

Twenty-four guidelines were included, from which 483 recommendations were identified across 4 international organisations and 12 countries. Guidelines addressed eight themes and recommendations were classified accordingly: chorionicity and dating (103 recommendations), fetal growth (105 recommendations), termination of pregnancy (12 recommendations), fetal death (13 recommendations), fetal anomalies (65 recommendations), antenatal care (65 recommendations), preterm labour (56 recommendations) and birth (54 recommendations). Guidelines showed significant variability in recommendations, with conflicting recommendations regarding non-invasive preterm testing, definitions surrounding selective fetal growth restriction, screening for preterm labour and the timing of birth. Guidelines lacked a focus on standard antenatal management of DCDA twins, management of discordant fetal anomaly and single fetal demise.

CONCLUSIONS

Specific guidance for dichorionic diamniotic twins is overall indistinct and access to guidance regarding the antenatal management of these pregnancies is currently difficult. Management of discordant fetal anomaly or single fetal demise needs greater consideration.

Perinatal and neurodevelopmental outcome in complicated monochorionic pregnancy after selective fetal reduction: radiofrequency ablation vs microwave ablation

OBJECTIVES

To summarize our experience in the application of radiofrequency ablation (RFA) and microwave ablation (MWA) for selective fetal reduction in complicated monochorionic pregnancies and compare the perinatal outcome of the two techniques.

METHODS

This was a retrospective study of data from a consecutive cohort of all monochorionic twin pregnancies that underwent selective fetal reduction with RFA or MWA at Peking University Third Hospital, Beijing, China from January 2012 to December 2018. All surviving cotwins were followed up to assess their neurodevelopment using the Age & Stage Questionnaire, Chinese version. Perinatal and neurodevelopmental outcomes were compared between the RFA and MWA groups. We also fitted multivariable models to test the association between procedure-related factors and the main perinatal outcomes, including preterm birth (PTB) < 37 weeks' gestation, intrauterine fetal death (IUFD) of the cotwin, adverse outcome (defined as occurrence of IUFD of the cotwin, termination of pregnancy or PTB < 28 weeks) and overall survival.

RESULTS

In total, 45 cases (42 twin and three triplet pregnancies) underwent RFA and 126 cases (105 twin and 21 triplet pregnancies) underwent MWA. The overall survival rates in monochorionic diamniotic twin pregnancies were similar between the RFA and MWA groups (61.0% vs 67.0%; P = 0.494). However, pregnancies whose indication for fetal reduction was selective intrauterine growth restriction or twin reversed arterial perfusion had higher overall survival rates (75.5% and 82.6%, respectively) compared with those in other indication groups. A total of 104 children were followed up (20 in the RFA group and 84 in the MWA group); four (20.0%) and eight (9.5%) children were assessed as having overall developmental delay in the RFA and MWA groups, respectively, with no significant difference between the two groups. Multivariable analyses showed that procedure indication, number of ablation cycles and gestational age at procedure were associated significantly with the main perinatal outcomes.

CONCLUSIONS

RFA and MWA for selective fetal reduction in complicated monochorionic pregnancies can achieve similar overall survival rate and neurodevelopmental outcome, but MWA is associated with a lower risk of preterm birth. Moreover, procedure-related factors are associated significantly with perinatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

A Costly Choice? In Vitro Fertilization and Those That Terminate: Working towards an Understanding in a Post-Roe America

Abortion continues to be a hotly debated topic in the United States, despite the majority of the populace endorsing it as a legal right. The June 2022 ruling from the Supreme Court turned the legal question about abortion back to the states, which will drastically reduce abortion services in the country and confine abortion access mainly to the coasts. The intersection between abortion and a pregnancy achieved using assisted reproductive technology is one that lacks understanding. While presumed to be rare, as data is not collected in the US about abortions, this intersection exists but is understudied. This paper illuminates the little that we know to date about this intersection as well as where our knowledge is profoundly lacking. Creating a better sense of understanding will enable clinics to counsel patients appropriately when the intersection arises.

A case of prenatal diagnosis of meckel-gruber syndrome in one of the dizygotic twin of a naturally conceived pregnancy

Meckel-Gruber syndrome in one twin of a naturally conceived dizygotic twin pregnancy is largely unknown and has not been reported till date. This report illustrates the sonographic features in a case of 20-week twin pregnancy where one twin had an occipital encephalocele, bilateral enlarged and cystic kidneys, hepatic cyst and oligohydramnios but the other twin was normal. The affected twin succumbed within few days after normal vaginal delivery while the normal twin survived and is healthy.

Terminating Twins: Survival of One/Twin Research Reviews: Twin Discordance for Primordial Dwarfism; Twin Study of Public Service Motivation; Four-Parameter Model for Twin Research; Global Twinning at a Peak; Germline Differences of Monozygotic Twins/In the News: Twins and Dyngus Day; Triplets Born in Austrian Displaced Persons' Camp; Superior, Film About Estranged Identical Twin Sisters; Adopting Own Twins After Surrogacy; Twins and Primordial Dwarfism Revisited

Selective termination is the term used for the elimination of an abnormal fetus. In contrast, multifetal pregnancy reduction refers to the termination of one or more members of a twin or higher-order multiple birth set, respectively, to reduce the high risks associated with these pregnancies. The procedure can also be used when a serious physical condition is detected prenatally in a member of a multiple birth set. In a minority of cases, selective termination has reduced two healthy fetuses to one when parents wanted just one additional child in the family. In the present article, the perspectives of a surviving twin whose family wished to terminate both healthy fetuses are examined. Next, past and present twin studies of primordial dwarfism, public service motivation, an analytical model, the global twinning rate and germline differences are summarized. The article concludes with a synopsis of twin-related news that covers twins and Dyngus Day, triplets born in an Austrian displaced persons' camp, the film Superior - about estranged identical twin sisters, a couple adopting their own twins after surrogacy and a new case of twins and primordial dwarfism, a condition introduced in the research reviews.