Single center experience in selective feticide in high-order multiple pregnancy: clinical and ethical issues

Quadruplet pregnancy outcome with and without fetal reduction: Danish national cohort study (2008-2018) and comparison with dichorionic twins

OBJECTIVES

To perform a nationwide study of quadrichorionic quadriamniotic (QCQA) quadruplet pregnancies and to compare the pregnancy outcome in those undergoing fetal reduction with non-reduced quadruplets and dichorionic diamniotic (DCDA) twin pregnancies from the same time period.

METHODS

This was a retrospective Danish national register-based study performed using data from the national Danish Fetal Medicine Database, which included all QCQA quadruplets and all non-reduced DCDA twin pregnancies with an estimated due date between 2008 and 2018. The primary outcome measure was a composite of adverse pregnancy outcomes, including pregnancy loss or intrauterine death of one or more fetuses. Secondary outcomes included gestational age at delivery, the number of liveborn children, preterm delivery before 28, 32 and 37 gestational weeks and birth weight. Data on pregnancy complications and baseline characteristics were also recorded. Outcomes were compared between reduced and non-reduced quadruplet pregnancies, and between DCDA pregnancies and quadruplet pregnancies reduced to twins. A systematic literature search was performed to describe and compare previous results with our findings.

RESULTS

Included in the study were 33 QCQA quadruplet pregnancies, including three (9.1%) non-reduced pregnancies, 28 (84.8%) that were reduced to twin pregnancy and fewer than three (6.1%) that were reduced to singleton pregnancy, as well as 9563 DCDA twin pregnancies. Overall, the rate of adverse pregnancy outcome was highest in non-reduced quadruplets (66.7%); it was 50% in quadruplets reduced to singletons and 10.7% in quadruplets reduced to twins. The proportion of liveborn infants overall was 91.1% of the total number expected to be liveborn in quadruplet pregnancies reduced to twins. This was statistically significantly different from 97.6% in non-reduced dichorionic twins (P = 0.004), and considerably higher than 58.3% in non-reduced quadruplets. The rates of preterm delivery < 28, < 32 and < 37 weeks were decreased in quadruplets reduced to twins compared with those in non-reduced quadruplet pregnancies. Quadruplets reduced to twins did not achieve equivalent pregnancy outcomes to those of DCDA twins.

CONCLUSION

This national study of QCQA quadruplets has shown that multifetal pregnancy reduction improves pregnancy outcome, including a decreased rate of preterm delivery and higher proportion of liveborn children. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Induced abortion and COVID-19 as contributing factors to declining fertility in Sardinia

OBJECTIVES

Decreasing fertility implies considerable public health, societal, political, and international consequences. Induced abortion (IA) and the recent COVID-19 pandemic can be contributing factors to it but these have not been adequately studied so far. The purpose of this paper is to explore the relation of IA incidence and the COVID-19 pandemic to declining rates of delivery, as per our Sardinian experience.

METHODS

We analyzed the registered data from the official Italian statistics surveys of deliveries and IA in the last 10 years from 2011 to 2020 in Sardinia.

RESULTS

A total of 106,557 deliveries occurred and a progressive decrease in the birth rate has been observed. A total of 18,250 IA occurred and a progressive decline has been observed here as well. The ratio between IA and deliveries remained constant over the decade. Between 2011 and 2019 a variation of -4.32% was observed for IA while in the last year, during the COVID-19 pandemic the decrease of the procedures was equal to -12.30%. For the deliveries, a mean variation of the -4.8% was observed between the 2011 and the 2019 while in the last year, during the COVID-19 pandemic the decrease was about -9%. Considering the about 30% reduction of live births between 2011 and 2020, there is an almost proportional reduction in IA.

CONCLUSIONS

Public policy responses to decreasing fertility, especially pronatalist ones, would be provided with evidence base about trends in delivery and IA and women's decision making.

Prenatal screening diagnosis and management in the era of coronavirus: the Sardinian experience

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a new coronavirus, was first identified in December 2019 in Wuhan, China and spread rapidly, affecting many other countries. The disease is now referred to as coronavirus disease 2019 (COVID-19).The Italian government declared a state of emergency on 31st January 2020 and on 11th March World Health Organization (WHO) officially declared the COVID-19 outbreak a global pandemic. Although the COVID-19 incidence remained considerably lower in Sardinia than in the North Italy regions, which were the most affected, the field of prenatal screening and diagnosis was modified because of the emerging pandemic. Data on COVID-19 during pregnancy are so far limited. Since the beginning of the emergency, our Ob/Gyn Department at Microcitemico Hospital, Cagliari offered to pregnant patients all procedures considered essential by the Italian Ministry of Health. To evaluate the influence of the COVID-19 pandemic on the activities of our center, we compared the number of procedures performed from 10th March to 18th May 2020 with those of 2019. Despite the continuous local birth rate decline, during the 10-week pandemic period, we registered a 20% increment of 1st trimester combined screening and a slight rise of the number of invasive prenatal procedures with a further increase in chorionic villi sampling compared to amniocentesis. Noninvasive prenatal testing remained unvariated. The request for multifetal pregnancy reduction as a part of the growing tendency of voluntary termination of pregnancy in Sardinia increased. The COVID-19 pandemic provides many scientific opportunities for clinical research and study of psychological and ethical issues in pregnant women.

Transabdominal fetal reduction: a report of 124 cases

To prevent fetal loss, preterm delivery, and perinatal morbidity of multifetal pregnancies (MPs), fetal reduction (FR) is offered to some patients. We retrospectively analysed the data of 124 MPs that underwent transabdominal FR to twin (n = 63) and singleton (n = 61) pregnancies at a mean gestational age of 12 + 6 weeks between December 2006 and January 2018. FR was performed transabdominally with the injection of potassium chloride into the intracardiac or intrathoracic space of the fetus or fetuses after ultrasound screening for nuchal translucency and anatomical defects. The initial number of embryos were 48 twins, 63 triplets, 11 quadruplets, and 2 quintuplets. The procedure-related pregnancy loss rate was 0.8% (1/124), the overall pregnancy loss rate was 2.4% (3/124), the fetal loss rate was 1.6% (2/124), and the neonatal death rate was 0.8% (1/124). The baby take-home rates were 96% for twin pregnancies and 96.7% for singletons. This study shows that transabdominal FR is an effective and safe procedure with a pregnancy loss rate of 2.4%.Impact statementWhat is already known on this subject? The incidence of multifetal pregnancies has increased over the years. Because multifetal pregnancies increase perinatal morbidity and mortality due to prematurity, fetal reduction is offed to some patients.What the results of this study add? The results of this study add to the growing body of research on fetal reduction. The study showed that transabdominal fetal reduction is a safe procedure with a pregnancy loss rate of 2.4%.What the implications are of these findings for clinical practice and/or further research? The results of this study can be used in counselling couples with multifetal pregnancies who are considering fetal reduction. Further research is needed to confirm the current findings.

Transabdominal selective feticide in dichorionic twins: Ten years' experience at a single center

AIM

The present study investigates the procedure-related fetal loss rate and obstetrical outcomes of selective feticide in dichorionic twins.

METHODS

We retrospectively analyzed the data of 44 cases of dichorionic twins. Two different indications for selective feticide were set: (i) the presence of genetic or congenital anomaly; and (ii) an obstetrical indication specified as a past maternal history of preterm delivery that caused fetal death or cerebral palsy of the child. Primarily, data on procedure-related fetal loss and obstetrical outcomes were retrieved. Additionally, data on obstetrical outcomes by reduction time and by indication of SF were obtained.

RESULTS

Selective feticide was performed in 44 cases - specifically, in 23 cases with genetic or congenital anomaly and in 21 cases with obstetrical indications. The median gestational age at delivery was 38 + 4 weeks. One pregnancy loss (2.3%, 1/44) occurred within 4 weeks after the procedure. The overall pregnancy loss rate throughout the pregnancy term was 2.3% (1/44). When selective feticide was performed at 15 weeks and beyond, the birth weight was significantly decreased compared with when selective feticide was performed earlier than 15 weeks.

CONCLUSION

Transabdominal ultrasound-guided selective feticide in dichorionic twins is an effective and safe procedure. If a patient desires to maximize her chances of having a healthy child and decrease the risk of prematurity, the option of selective feticide should be considered in certain cases of twin pregnancies. Selective feticide may be a reasonable alternative to expectant management or termination of the whole twin pregnancy.

From Prenatal to Preimplantation Genetic Diagnosis of β-Thalassemia. Prevention Model in 8748 Cases: 40 Years of Single Center Experience

The incidence of β-thalassemia in Sardinia is high and β-39 is the most common mutation. The prevention campaign started in 1977 and was performed in a single center (Microcitemico Hospital, Cagliari, Sardinia, Italy). It was based on educational programs, population screening by hematological and molecular identification of the carriers. Prenatal and pre-implantation diagnosis was offered to couples at risk. 8564 fetal diagnosis procedures using different invasive approaches and analysis techniques were performed in the last 40 years. Trans-abdominal chorionic villous sampling was preferred due to lower complication risks and early diagnosis. Chorionic villous DNA was analyzed by PCR technique. 2138 fetuses affected by β-thalassemia were diagnosed. Women opted for termination of the pregnancy (TOP) in 98.2% of these cases. Pre-implantation genetic diagnosis (PGD) was proposed to couples at risk to avoid TOP. A total of 184 PGD were performed. Initially, the procedure was exclusively offered to infertile couples, according to the law in force. The success rate of pregnancies increased from 11.1% to 30.8% when, crucial law changes were enacted, and PGD was offered to fertile women as well. Forty years of β-thalassemia prevention programs in Sardinia have demonstrated the important decrease of this severe genetic disorder.