Abstract

PIP: Fetal reduction techniques, experiences at Northwestern University of Evanston, Illinois, USA, and ethical issues are discussed. The use of fetal reduction pertains to higher order multiple pregnancies due to successful fertility treatments. The risk associated with multifetal pregnancy is preterm delivery i.e., 29-31 weeks for quadruplets. In addition, survivors often have a high risk of congenital abnormalities and complications related to prematurity. 1978 marked the 1st time selective termination was possible. Other terms include "selective" birth, reduction, feticide, abortion, and multiple pregnancy reduction. The procedure takes place in the 1st or 2nd trimester, and procedures are similar to an elective abortion but with different techniques. Although there are many techniques, the preferred one is transabdominal cardiac puncture and injection of potassium chloride. A highly skilled ultrasonographer is essential for a successful technique. The complexity of the technique is one where the physician from a 2-dimensional screen must envision a 3-dimensional picture of the uterus and contents. Accurate needle placement is important. The reports from 7 clinical trials using the intracardiac potassium chloride technique are presented. The Northwestern experience includes 25 reductions between 1987-91 using fentanyl and midazolidocaine analgesia and general anesthesia with 1% lidocaine. Gestational age ranged from 9 to 13 weeks. There was total loss in 2 cases and deliveries in 8 cases including neonatal death of a very preterm set of twins. At or = 37 weeks, there were 11 pregnancies. 11 patients were or = 35 years, and 4 of the 20 30 years. In 33% of cases, only 1 pregnancy was left, which is dissimilar to other studies. Many difficulties may be faced with a complete pregnancy loss where there is a lack of support for the decision for fetal reduction. 2 concerns are mentioned in the ethical debate: the adequacy of counseling and the criteria for determining how many reductions per pregnancy. Difficulties arise in physician counseling when patients are unable to assimilate complex and detailed information, and physicians may not accurately convey information. Institutions may bias patient counseling. When an abnormality exists, the decision is easy; but with multiple normal development, the recommendation is twins. The Northwestern recommendation involves patient and family decisions and joint discussion of risk. The likelihood of severely premature delivery and maternal morbidity should also be considered, as well as the medical cost incurred with delivery and care of preterm multiple infants i.e., 1.2 million dollars for delivery of quads at 27 weeks. Science should be directed to reducing multiple pregnancies by refining technique and using fetal reduction as an interim technique. Fetal reduction is not appropriate for all multiple pregnancies.