EMBRYO REDUCTION procedure in multifetal pregnancy.pptx

embryo reduction procedure

1. EMBRYO REDUCTION

2. Incidence Maternal hazards Fetal hazards Prevention Multiple pregnancy

3. MP increased due to ART , Fertility drugs Higher order multiple pregnancies [triplets or greater] increased by 100 fold As a result of recent efforts of prevention , HOMP declined but still , a significant proportion of twins is there Incidence

4. Hyperemesis gravidarum Anemia Diabetes PIH Preterm labor Average length of pregnancy Singleton 39 weeks Twins 35 to 38 weeks Triplets 30 to 33 weeks Quadruplets 28 to 29 weeks Maternal risks

5. Placental abruption Cesarean section rate Pulmonary embolism PPH

6. Abortions Acute polyhydramnios Low birth weight Congenital malformations Cerebral palsy Infant mortality due to prematurity Fetal risks

7. Individualization of protocols of controlled ovarian stimulation based on age , and response to stimulation Multi follicular development is cancelled and converted to IVF Selective double embryo or single embryo transfer ART success rate should be measured as a singleton live birth rate not as pregnancy rate Prevention

8. Multi fetal pregnancy reduction or embryo reduction Health education to couples regarding MP and HOMP Convince reproductive medicine physicians regarding survival chances of singleton fetus

9. This should never be considered as a standard line for prevention of HOMP It is only a rescue if other methods fail in the prevention Multi fetal pregnancy reduction

10. 1) Multi fetal pregnancy reduction: - Termination of one or more of high order fetuses , hopefully leaving the rest to develop till full term Selective fetal reduction;- reduction of fetus with severe malformation or chromosomal defects or expected to die later in pregnancy ,or threaten life of other fetuses TYPES OF MFPR

11. Spontaneous fetal reduction ;-spontaneous reabsorption noted after USG visualization of fetal heart 90% occur upto 7weeks never after 13 weeks Fetal reduction is done once fetal heart is visualised

12. Reduce perinatal morbidity and mortality Reduces risk of maternal complications For all starting numbers including twins , reduction to a lower number of fetuses reduces fetal losses , prematurity , infant mortality and morbidity Why?

13. It is justified as it meets criterion of least harm and most potential good MP particularly HOMP should be prevented in first place But if it occurs inspite of it, MFPR is done as choice of lesser harm Ethical concern

14. MFPR is only allowed if prospect of carrying the pregnancy to viability is small Also when life or health of mother is threatened Performed not to induce abortion but to preserve life of remaining fetuses and minimize complications to mother

15. QUADRUPLETS and HOMP :widely accepted Twins generally not acceptable Triplets : this is controversial Recent advances in neonatal care & obstetric care have improved outcome of premature and Low bwt babies Therefore , MFPR to improve neonatal outcome might not be preferred in triplets Indications

16. Study on MFPR in triplets and their neonatal outcome This concluded that triplets can be offered MFPR to reduce severe prematurity , neonatal morbidity and cost of care per survivor Drugan et al 2013 study

17. Multiple pregnancy of higher order than twins involves danger to mother & fetuses and when such pregnancies arise,it may be considered ethically preferable to reduce number of fetuses than to do nothing FIGO Recommendation 2006.

18. Counselling: Risk of abortions ,preterm birth in MFP Offered the option of MFPR If they choose MFPR ,risks with the procedure are to be explained Informed consents Rh typing USG for number, size of G.sac & location of Fetuses, FHR of each fetus,any abnormalities in them Preoperative

19. Decision regarding number of fetuses to be reduced Which sac can be reached easier and with less trauma Approach Transvaginally or transabdominally Timing of procedure 8 to 13 weeks Transabdominally from 10 to 13 weeks Transvaginally Between 8 to 10 weeks Determine

20. Multifetal pregnancy reduction

21. Transvaginal Antibiotic prophylaxis Lithotomy position Vaginal preparation with 10% povidone iodine & rinsed with saline solution Procedure

22. Under USG guidance , selected fetus is approached Transvaginally with a 19 guaze needle Most easily accessible fetuses are selected for embryo reduction Alternatively,smaller fetal or G.sac size can be selected Smallest one and / or closest to fundus is selected

23. Cardiac puncture with aspiration: Aspiration of amniotic fluid or fetus if possible Suction is applied with 50ml syringe Only puncture of heart : till asystolia without any aspiration of fetus/ fluid Intracardiac injection of KCL : 1-2ml of KCL 2meq/ml In Monochorionic Twins when vascular anastamosis is present death of non injected fetus occurs immediately in this method Feticide

24. Injection of KCL

25. After ensuring ,that entire fetus is aspirated or until no Fetal heart beat has occurred for more than 1 minute , the needle is withdrawn Procedure is repeated for other G.sacs in case of HOMP

26. There is controversy regarding reduction of twin or higher-order multifetal pregnancies to a singleton. For some women, a multifetal pregnancy reduction to a singleton may be a desired option for medical reasons Reduction to a Singleton

27. Certain medical or obstetric considerations can increase the risks even in twin pregnancy compared to a singleton pregnancy. Eg: müllerian anomaly, H/O cervical insufficiency, preeclampsia with severe features in a previous pregnancy. Reduction to a singleton pregnancy is considered in such cases

28. Antibiotics Analgesics Anti D if indicated Repeat USG after 1 week at follow up visit Postoperative

29. Non KCL techniques have higher take home baby rate and lower risks prematurity or PPROM Early ,transvaginal ,Non KCL method has lower immediate fetal loss rate and considered better option for MFPR

30. Improved with Increased experience Better ultrasound Lower starting numbers Genetic diagnosis prior to reduction can improve overall outcome Success rates : 80%

31. 4 to 5% miscarry as a result of the procedure Preterm labor Infection Psychological impact: Guilt of undergoing fetal reduction Worrying about safety of remaining fetuses Greiving for lost fetus Risks

32. Experience of operator Starting numbers Finishing numbers Experienced operators with lower starting and finishing numbers have better outcome Twins have best viable pregnancy outcomes for cases starting with 3 or more Risks depend on

33. Multifetal pregnancies to be prevented whenever possible. Avoid the risk of higher-order multifetal pregnancy by limiting the number of embryos to be transferred But if they occur, decision regarding continuing or reducing multifetal pregnancies is to be taken Fetal reduction is justified and safe now in most cases Conclusion

34. Thank you