Anxiety among women who have undergone fertility therapy and who are considering multifetal pregnancy reduction: trends and implications

Objective: Our primary objective was to evaluate the assumption that women carrying multiple fetuses and who have decided upon multifetal pregnancy reduction (MFPR) have a constant high level of anxiety. Methods: A total of 66 multigestation women considering MFPR were asked to consider how anxious they were when they first started fertility therapy. Using that level of anxiety as a reference point, and using their self-assessments as a vehicle for probing the meaning they attached to their emotional state through time, they then assessed their anxiety level at different points in their pregnancy. Results: Self-reported anxiety across time displayed considerable variation: there was a large drop in anxiety with pregnancy diagnosis. The women's anxiety rose to very high levels with the diagnosis of carrying multiples. Anxiety moderated again on average with consultation, rose sharply during the course of the procedure, and finally dropped to lower levels on average after the procedure was over. Conclusions: We conclude that women with multigestation experience considerable fluctuations in their level of anxiety from the time that they first start fertility therapy until they learn that they are carrying multiple embryos. Their expectations for the future of becoming pregnant seem at last fulfilled (becoming pregnant), become complicated (with multiples), appear salvageable (with consultation), but with a morally complicated resolution (MFPR) that seems at last to have put the pregnancy back on a normal track (post-MFPR). Those working with MFPR patients before, during and after the operation must understand the nature and variability of the anxiety that their patients are confronting, and how they are attempting to construct a safe passage through the moral dilemma associated with the multiple-gestation situation.     

Pregnancy outcome after multifetal pregnancy reduction.

OBJECTIVE: To study the effects of multifetal pregnancy reduction (MFPR) as a means to reduce the adverse outcome of multiple gestations. METHODS: This was a retrospective study evaluating the outcome of 334 multiple pregnancies after embryo reduction. RESULTS: In 313 multiple pregnancies in which MFPR was performed before 15 weeks, the rates of miscarriage, preterm delivery <33 weeks, preterm delivery <36 weeks and total fetal loss were 9.12%, 13.33%, 38.60% and 16.25%, respectively, and median gestational age at delivery was 35 weeks. There was a significant correlation between miscarriage and the finishing number of fetuses. In 185 triplets reduced to twins, miscarriage, preterm delivery <33 weeks, preterm delivery <36 weeks and total fetal loss occurred in 8.25%, 11.18%, 40.59% and 15.41% of cases, respectively, and median gestational age at delivery was 36 weeks. In the subgroup of 32 reduced triplet pregnancies that also had second-trimester amniocentesis, the risk of miscarriage (3.13%) was not significantly different from that in the rest of the group. Among 21 twin pregnancies that had selective termination at or after 15 weeks, the risk of preterm delivery <33 weeks was three times higher than in the group of 22 twin pregnancies with first-trimester procedures. CONCLUSION: MFPR resulted in at least one live neonate in 83.75% of cases and was effective in reducing the risks of pregnancy loss and severe prematurity in quadruplets and higher-order pregnancies. The risk of miscarriage increased with increasing finishing number of fetuses. In reduced triplets gestation was prolonged in comparison with average figures reported in the literature. In twin pregnancies selective termination in the first trimester carries a lower risk of severe preterm delivery and this emphasizes the need for first-trimester diagnosis.     

Pregnancy outcome after multifetal pregnancy reduction of triplets to twins versus reduction to singletons

Research questionDoes fetal reduction of triplet pregnancies to singleton result in superior obstetric and neonatal outcomes compared with triplets reduced to twins?DesignA historical cohort study including 285 trichorionic and dichorionic triplet pregnancies that underwent abdominal fetal reduction at 11–14 weeks in a single tertiary referral centre. The study population comprised two groups: reduction to twins (n = 223) and singletons (n = 62). Main outcome measures were rates of pregnancy complications, preterm delivery and neonatal outcomes. Non-parametric statistical methods were employed.ResultsTriplet pregnancies reduced to twins delivered earlier (36 versus 39 weeks, P < 0.001) with higher prevalence of Caesarean section (71.1% versus 32.2%, P < 0.001) compared with triplets reduced to singletons. Preterm delivery rates were significantly higher in twins compared with singletons prior to 37 weeks (56.9% versus 13.6%, P < 0.001), 34 weeks (20.2% versus 3.4%, P = 0.002) and 32 weeks (9.6% versus 0%, P = 0.01). No significant difference was found in the rate of pregnancy loss before 24 weeks (1.3% in twins versus 4.8% in singletons, P = 0.12) or in the rate of intrauterine fetal death after 24 weeks (0.4% versus 0%, P = 1.0). Both groups had comparable obstetrical complications and neonatal outcomes, except for higher rates of neonatal intensive care unit admission in twins (31.9% versus 6.8%, P < 0.001).ConclusionsReduction of triplets to singletons rather than twins resulted in superior obstetric outcomes without increasing the procedure-related complications. However, because the rate of extreme prematurity in pregnancies reduced to twins was low, the overall outcome of those pregnancies was favourable. Therefore, the option of reduction to singletons should be considered in cases where the risk of prematurity seems exceptionally high.     

Pregnancy outcome of early multifetal pregnancy reduction: triplets to twins versus triplets to singletons

Multifetal pregnancy reduction (MPR) of triplets to twins results in improved pregnancy outcomes compared with triplet gestations managed expectantly. Perinatal outcomes of early transvaginal MPR from triplets to twins were compared with reduction from triplets to singletons. Seventy-four trichorionic triplet pregnancies that underwent early transvaginal MPR at 6–8 weeks gestation were included. Cases were divided into two groups according to the initial procedure: reduction to twin (n = 55) or to singleton (n = 19) gestations. Infants from triplet pregnancies reduced to twins were delivered earlier (36.6 versus 37.9 weeks; P = 0.04) and had lower mean birth weights (2364 g versus 2748 g; P = 0.02) compared with those from triplets reduced to singleton gestations. The rates of pregnancy loss before 24 weeks (3.6% versus 5.3%), as well as of preterm delivery before 32 and 34 weeks of gestation (0% versus 5.3% and 7.3% versus 5.3%, respectively) were similar between the twin and singleton pregnancies. No significant difference was found in the prevalence of gestational diabetes (15.1% versus 5.6%) or gestational hypertension (24.5% versus 16.7%) between the groups. Selective reduction of triplet pregnancies to singleton rather than twin gestations is associated with improved outcomes.     

多胎妊娠减胎术发展现状

近30年多胎妊娠的发生率显著增加,对于母婴的围产期结局产生了极大的影响。多胎妊娠减胎术通过在妊娠中减去一个或多个胎儿,避免多胎分娩,可改善妊娠结局。影响减胎术后结局的临床因素主要为减胎孕周、手术方式、起始及最终胚胎的数量以及是否合并单绒毛膜多胎。此外,减胎术前的产前诊断对于选择减胎对象有着准确的指导。本文就多胎妊娠减胎术现状及影响其妊娠结局的相关临床因素做一综述。     

Midtrimester maternal serum inhibin A levels after multifetal pregnancy reduction

OBJECTIVE: To investigate the relationship between the maternal serum inhibin A concentrations and the number of fetuses. Further, the maternal serum inhibin A levels for twin pregnancies and multiple pregnancies reduced to twins in the second trimester were compared. METHODS: Three groups of women with pregnancies following in vitro fertilization and embryo transfer were recruited for this study. Groups 1, 2 and 3 included 20 singleton pregnancies, 37 twin pregnancies, and 35 multifetal pregnancies, respectively. In group 3, multifetal reduction was performed during 10-12 weeks of gestation. Blood samples were obtained longitudinally at 10th, 12th, 15th and 18th week of gestation. RESULTS: There was a significant association between the number of fetuses and maternal plasma inhibin A prior to multifetal reduction. The inhibin A levels were not significantly different between twin and multifetal reduced twin pregnancies at 15th and 18th weeks of gestation. CONCLUSION: In multifetal reduction to twin pregnancies, the maternal serum levels of inhibin A decrease to the level of twin pregnancies during the second trimester. Therefore, inhibin A may be effectively used as a marker for Down syndrome screening in cases of twin pregnancy following multifetal reduction.     

医源性多胎及多胎妊娠处理中的伦理问题

文章主要探讨医源性多胎产生的原因、预防及所涉及的社会伦理问题,并提出相应的处理对策和处理时所必须遵循的不伤害原则、有利原则,尊重原则和公正原则.     

Chorionic villus sampling before multifetal pregnancy reduction

OBJECTIVE: This study was undertaken to determine the technical feasibility and accuracy of chorionic villus sampling before multifetal pregnancy reduction and to determine whether sampling increases the pregnancy loss rate after the reduction procedure. STUDY DESIGN: Between January 22, 1986, and January 20, 2000, a total of 1183 patients underwent first-trimester multifetal pregnancy reduction at Mount Sinai Medical Center. Chorionic villus sampling was attempted in 86 patients before the reduction procedure. Information on the technical success and accuracy of chorionic villus sampling, as well as pregnancy outcome, was collected on all patients. Pregnancy loss rates before 24 weeks' gestation in patients undergoing chorionic villus sampling before multifetal pregnancy reduction were compared with rates in patients not undergoing sampling. RESULTS: Chorionic villus sampling was successfully completed in 85 (98.8%) of 86 patients in whom sampling was attempted. Of 166 fetuses, 165 (99.4%) were successfully sampled. Of 165 fetuses, 3 (1.8%) had karyotypic abnormalities. Sampling errors were probably made in 2 (1.2%) of 165 fetuses. Of the 73 patients who have been delivered or are beyond 24 weeks' gestation, only 1 patient (1.4%) had a pregnancy loss after the multifetal pregnancy reduction. CONCLUSIONS: Chorionic villus sampling before multifetal pregnancy reduction is technically feasible and accurate, with an acceptably low sampling error rate. Chorionic villus sampling before multifetal pregnancy reduction appears to be safe and does not increase the risk of loss after the reduction procedure.     

Perinatal outcome after multifetal reduction: A study of 12 cases

Objective

To study the perinatal outcome after fetal reduction in multiple gestations

Materials and Methods

This is a retrospective study of 12 patients who underwent fetal reduction for multiple gestations. The ultrasound-guided procedure was done transabdominally.

Results

Of the 12 patients who underwent fetal reduction, one had spontaneous abortion following the procedure while the other 11 delivered live babies.

Conclusion

Multiple gestations have an adverse neonatal outcome. By reducing the high-order pregnancies to twin gestations, the associated complications can be reduced. Ultrasound-guided fetal reduction is safe and effective method for reduction of multifetal gestations to twins or singleton, and improving the pregnancy outcome.     

Cervical length after multifetal pregnancy reduction in remaining twin gestations.

OBJECTIVE: Multifetal pregnancy reduction is associated with an increased risk of prematurity. Because cervical length correlates with preterm delivery risk, we sought to determine whether multifetal pregnancy reduction twin gestations are associated with shorter cervical lengths compared with non-multifetal pregnancy reduction twins. STUDY DESIGN: We compared an historic cohort of patients who underwent multifetal pregnancy reduction to twins (n = 35) to a control group of twin gestations without multifetal pregnancy reduction (n = 83) from July 1996 to January 2000. Both groups of patients were treated with identical protocols. Cervical lengths across gestation and pregnancy outcomes were compared. RESULTS: Study and control groups did not differ significantly in mean maternal age (37.8 +/- 4.9 years vs 35.5 +/- 6.2 years; P =.06), median parity (0 [range, 0-1] vs 0 [range, 0-2]; P =.56), or mean gestational age at delivery (36.2 +/- 2.6 weeks vs 35.8 +/- 3.8 weeks; P =.50). The proportion delivering before 35 weeks of gestation was not significantly different (14.3% vs 30.1%; P =.10) nor was delivery before 32 weeks of gestation (8.6% vs 8.4%; P =.98). Cervical length did not differ significantly between the 2 groups. At 14 to 19 weeks the median was 3.9 cm (range, 2.4-6.0 cm) in the multifetal pregnancy reduction group versus 3.7 cm (range, 3.1-4.7 cm) in the control subjects (P =.15); at 20 to 25 weeks, the medians were 3.2 cm (range, 2.2-5.4 cm) and 3.7 cm (range, 1.5-5.7 cm), respectively (P =.43); and at 26 to 31 weeks the medians were 3.5 cm (range, 1.2-5.9 cm) versus 3.8 cm (range, 1.2-5.3 cm), respectively (P =.56). CONCLUSION: Cervical length across gestation in twin pregnancies is not affected by multifetal pregnancy reduction, despite the likely inflammatory response expected to accompany this procedure.     

Spontaneous abortions in couples declining multifetal pregnancy reduction

Multifetal pregnancy reduction (MFPR) has clearly improved the outcomes of multifetal gestations. Several recent reports have also suggested improved outcomes in nonreduced cases, but there have been methodologic concerns about the denominators, i.e. have all cases been included and is there a 'hidden mortality' of unknown lost cases. Here we assessed the outcome of patients telephoning to discuss MFPR, but who chose not to have the procedure. Over a 3-year period, 446 patients had MFPR by one operator. Nineteen patients chose not to have the procedure. There were 11 preterm births, 1 term delivery, and 5 spontaneous losses (7 of 17) prior to 24 weeks, a loss rate of 35%. Two patients delivering triplets had a loss of 1 fetus/neonate. These data suggest that the loss rates of nonreduced pregnancies may be higher than generally thought, making the improvements with MFPR even bigger than generally realized.     

Demographic factors for utilization of invasive genetic testing after multifetal pregnancy reduction

OBJECTIVE: Pregnant infertility patients are commonly old enough to be offered prenatal diagnosis. However, they may be reluctant to undergo an additional invasive procedure. We, therefore, sought to determine what demographic factors, including race and ethnic group, influenced patients' decisions to undergo genetic testing in addition to multifetal pregnancy reduction (MFPR). METHODS: We retrospectively reviewed MFPR patients from July 1997 to June 1999 at our institution. Invasive genetic testing was routinely discussed. Maternal age, race, ethnicity, religion, egg source for in vitro fertilization (IVF) patients, and the remaining fetuses following MFPR were analyzed for invasive genetic testing determinants and were compared to our experiences with genetic referents to us for singleton pregnancies. 132 consecutive patients, of whom 49 were >/=35 years, including 15 having IVF with donor eggs, were included. RESULTS: Maternal age was the single most significant determinant of testing. In donor egg cases, donor age was significant. Ethnic background, previous children, and the remaining number of fetuses after MFPR were also significant determinants. CONCLUSION: MFPR patients share similar demographics to the advanced maternal age population. Despite the very stressful situations, our data suggest that maternal age, and therefore genetic risk, is the most important determinant of choosing whether or not to have testing. However, patients' decisions are, to varying degrees, modified by religious and ethnic considerations.     

Knowledge and use of emergency contraception in a tertiary referral unit in a developing country

Background: The promotion and availability of emergency contraception have the possibility of reducing the number of unwanted pregnancies, leading to fewer pregnancy terminations and possibly to reduced maternal morbidity and mortality.Methods: The aims of the study were to determine the knowledge and use of emergency contraception in two groups of women: those requesting emergency contraception after sexual misadventure and another group of women requesting termination of pregnancy. A retrospective analysis was performed on all files of patients who requested emergency contraception over a 12-month period. Telephone interviews were conducted 1 year later. Structured questionnaires regarding knowledge and usage of emergency contraception were also administered to patients requesting termination of pregnancy. Results: Seventy-six women requested emergency contraception over the 12-month period. Forty-one (53.9%) did not attend the follow-up visit. Only two patients used condoms. A total of 39 patients were contacted by telephone after 1 year. Of these, 18 did not use any contraception, although five were sexually active. In the group of women who requested termination of pregnancy, 44% had not previously used contraception. In all, 40% did not know about emergency contraception, 36% had not used it previously and 24% had used it previously. Conclusions: Lack of knowledge concerning emergency contraception can contribute to the number of legal abortions requested. There is an urgent need to address current education for users and providers on the use of emergency contraception.     

胚胎体内注射生理盐水在减胎术中的应用

目的探讨胚胎体内注射生理盐水减胎的可行性。方法将2000年1月至2004年12月因2胎或2胎以上孕8~10周的多胎妊娠在广州市第二人民医院接受减胎的孕妇32例,分成两组,一组采用胚胎体内注射生理盐水减胎,为注射组;另一组采用机械破坏法减胎,为机械组。比较两组的手术时间、感染率、流产率、早产率、足月产率、平均孕周。结果两组病例均1次减胎手术成功。注射组减灭1个胎儿所需的时间为(5.8±1.8)min,非常显著地少于机械组的(18.6±10.2)min(P<0.01)。注射组术后无感染发生,机械组有1例发生感染。注射组的流产率、早产率分别为5.6%(1/18)和27.8%(5/18),低于机械组的21.4%(3/14)和28.6%(4/14),但无统计学意义。注射组的足月产率为66.7%(12/18),高于机械组的50.0%(7/14),无统计学差异。注射组平均孕周为(35.2±3.6)周,显著长于机械组的(32.1±4.1)周(P<0.05)。结论与机械破坏法比较,胚胎体内注射生理盐水是一种安全、有效、可行的减胎方法,适用于妊娠8~10周需要减胎的多胎妊娠孕妇。     

Monochorionic high-order multiple pregnancies and multifetal pregnancy reduction

OBJECTIVE: To study the frequency and obstetric outcome of monochorionic multiple pregnancies in a population referred for fetal reduction. METHODS: Data charts of all patients with multifetal (> or =3) pregnancies referred for fetal reduction over the last 10 years were reviewed for the presence of monochorionic twin pairs or triplets. RESULTS: Twenty-nine of 239 high-order multiple pregnancies contained a monochorionic component (12.1%), eight of which were monochorionic triplets. Half of all naturally conceived pregnancies contained a monochorionic component. High-order multiple pregnancies with a monochorionic component resulted significantly more frequently from natural conceptions (7 of 29) than multichorionic pregnancies (7 of 210) (P =.001). Fetal reduction of the monochorionic twin pair in 21 pregnancies resulted in eight twin and 13 singleton pregnancies; mean gestational age at delivery was, respectively, 34.3 +/- 2.9 and 39.2 +/- 1.4 weeks. Pregnancy loss rate was one of 21 (4.8%). In the remaining eight multiple pregnancies with a monochorionic triplet present, three were complicated by a twin reversed arterial perfusion sequence, and two couples requested a first trimester termination of pregnancy. Fetal reduction of the monochorionic triplet in a dichorionic quadruplet pregnancy resulted in a normal pregnancy outcome. In two monochorionic triplet pregnancies, fetal reduction to monochorionic twin pregnancies with bipolar coagulation of the umbilical cord resulted in a favorable pregnancy outcome. CONCLUSION: Monochorionic twins or triplets are frequently part of naturally conceived high-order multiple pregnancies. Reduction of the monochorionic twin pairs improves pregnancy outcome. Monochorionic triplet pregnancies show a high complication rate, but may benefit from fetal reduction by cord coagulation.