Foetal Reduction in Plural Pregnancies

Abstract

Objectives: Fetal reduction procedure was introduced over 4 decades ago. This review provides updates on the practice of fetal reduction and the associated ethical challenges. Methods: A systematic search was conducted on two bibliographic databases: MEDLINE and PUBMED, and supplemented with grey literature searches to extract information on different aspects of fetal reduction since the introduction. Results: The two forms of fetal reduction namely selective feticide and multifetal pregnancy reduction were introduced into clinical practice in the late 70’s and late 80s respectively. The indication has evolved from strictly medical, to accommodate couples’ wish and social reasons, thereby contributing to increased utilization. Multifetal pregnancy reduction in higher order pregnancies is the commoner of the two forms. Ultrasonography is the primary modality to assess fetus before reduction, and to provide continuous intra-procedure guide. Transabdominal intrathoracal or intracardiac injection of KCl between 8-10 weeks is the recommended technique because of the safety and overall success. It is however not done < 8 weeks because of technical difficulty of the size and distance of fetus from abdominal wall. It is also discouraged after 2^nd trimester because of higher risk of miscarriage and preterm birth. Transvaginal aspiration and needling methods are associated with higher complication rates: sepsis, bleeding and miscarriage. Mild spotting occurs in about 1/3^rd of procedures, while procedure-related miscarriage was reported in 4-33% as the most distressing complication. Reduction to twin is the target in higher order pregnancy and to singleton in twin pregnancy. Reduction to singleton is most ideal because of the additional 2 weeks gestational age gained over twins. Ethical challenge is becoming less opinionated because of changing perspective of fetal reduction from one of ‘life or death’, to ‘quality of life’. Conclusions: Fetal reduction is safe in expert hands and should be offered to women based on standard criteria