This document discusses techniques for multifetal pregnancy reduction (MFPR) without using potassium chloride (KCl), a cardiotoxic agent. It summarizes a study of 51 women with triplet or higher-order pregnancies who underwent MFPR using intracardiac puncture and aspiration until asystole was confirmed, without KCl. The technique resulted in an abortion rate of 7.8%, with most deliveries (80%) occurring after 34 weeks gestation. The average birth weight was 2.3kg. The study suggests MFPR without KCl has better outcomes than techniques using KCl, with lower rates of preterm birth and abortion. The conclusion is that MFPR should be offered to women with high-

1. “Multifetal pregnancy reduction without
the use of cardio-toxic agent”
Dr Santosh Gupta
MBBS,MS,FIRM
Reproductive medicine consultant

2. Prevention is better than cure

3. Eager Patients
Overzealous
Doctor

4. Is this the Happiness??

6. Best Among Worst Options

7. Fetal reduction
• Selective fetal reduction
• Multifetal pregnancy reduction

8. 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 ?

9. Various techniques
Early
Late
Route
Transvaginal
Transabdominal
Method
Intracardiac
Intracranial
With KCl or without KCl

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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%)

16. 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

17. 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

18. 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%

19. 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

20. Meta -Analysis by Nicolaides et al ,hum repr 2006
miscarriage
preterm

25. First quintuplets known to survive infancy

26. 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

27. 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