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Multifetal pregnancy fetal reduction

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Multifetal pregnancy fetal reduction

  1. 1. “Multifetal pregnancy reduction without the use of cardio-toxic agent” Dr Santosh Gupta MBBS,MS,FIRM Reproductive medicine consultant
  2. 2. Prevention is better than cure
  3. 3. Eager Patients Overzealous Doctor
  4. 4. Is this the Happiness??
  5. 5. Best Among Worst Options
  6. 6. Fetal reduction • Selective fetal reduction • Multifetal pregnancy reduction
  7. 7. 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 ?
  8. 8. Various techniques Early Late Route Transvaginal Transabdominal Method Intracardiac Intracranial With KCl or without KCl
  9. 9. 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
  10. 10. 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)Egypt Intracardiac 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
  11. 11. 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
  12. 12. 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
  13. 13. 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 asystole confirmed • HOMP reduced to twins • Next day rescan to confirm the reduction • All pts follwed till delivery
  14. 14. 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%)
  15. 15. 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
  16. 16. 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
  17. 17. 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%
  18. 18. 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
  19. 19. Meta -Analysis by Nicolaides et al ,hum repr 2006 miscarriage preterm
  20. 20. First quintuplets known to survive infancy
  21. 21. 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
  22. 22. 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

Editor's Notes

  • Like to remind the age old saying
  • Is it really something to celebrate?
  • Then what are the options?
  • Before starting discussion I would like to mention the lines quoted by Dr Evans
  • Aspiration may result trophoblastic detachment,aspiration makes ebry difficult to visualize,by not doing saves time & manipulation ,less traumatic
  • Timor –tvs only when obesity,abd scars, TA NOT POSSIBLE
  • All tvs reduction Lee et al
  • Canadian sisters first quinteplets known to survive infancy
  • We have to decide at what level we should correct?
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