Experimental method lowers multifetal risk.

Experimental method lowers multifetal risk

The joyful news of a pregnancy can turn to anguish for women who learn they are carrying a dangerously large number of fetuses. In the past, such women faced a draconian dilemma: They either aborted the entire pregnancy or carried the fetuses to term under the threat of premature delivery of very tiny babies plagued with severe health problems.

Last year, researchers at the Mount Sinai School of Medicine in New York City reported a controversial study of 17 twin pregnancies in which they terminated a severely defective fetus in the uterus, leaving its healthy twin undisturbed (SN: 5/6/89, p.278). Now, in separate reports in the May OBSTETRICS AND GYNECOLOGY, the Mount Sinai team and a California physician describe using variations of the same experimental method to terminate one or more healthy fetuses in the first trimester of risky multifetal pregnancies. The technique gives both mothers and surviving fetuses an improved shot at a normal pregnancy and a healthy future, but it also raises ethical questions.

Lauren Lynch, Richard L. Berkowitz and their colleagues at Mount Sinai studied 85 pregnant women who elected the procedure while carrying three to nine fetuses. All 85 had conceived after treatment with fertility drugs or in vitro fertilization, either of which can increase the odds of a multifetal pregnancy.

Using an ultrasound scanner to visualize fetal position, the researchers inserted a needle into the chest of a fetus and injected potassium chloride to stop the fetal heart. In most cases, the team continued the procedure until only two living fetuses remained in the uterus. The dead fetuses shriveled and were expelled during regular delivery.

In 45 of the 85 cases studied, the women went on to have healthy babies; another 32 women had not yet delivered at the time of data analysis. The remaining eight women miscarried, but the researchers say those losses did not result from the procedure. There were no infant deaths during delivery or during the risky first week after birth, and no adverse physical effects among the mothers, the team says.

Khalil M.A. Tabsh of the School of Medicine at the University of California, Los Angeles, used the same procedure with 40 women carrying triplets, quadruplets or quintuplets. In all but two cases, the women elected to have their pregnancy reduced to twins. Most of the 28 women who had delivered by the time Tabsh analyzed his data bore healthy infants. Two babies died, one due to severe prematurity, he adds.

While the two reports focus on safety factors, many believe the ethical aspects of the still-experimental procedure add a new facet to the abortion debate. Most medical experts agree that four or more fetuses crowded together in the uterus raise the risk that some will die soon after birth and others will survive with permanent disabilities. Such pregnancies also strain the mother's overall health and can result in life-threatening complications such as hemorrhage.

But the medical aspect of the risk-benefit equation becomes murkier for triplet pregnancies. In those cases, there is conflicting scientific evidence regarding the risk to the mother or the fetuses. "You are then off in the realm of parental preference," says ethicist Susan M. Wolf of the Hastings Center in Briarcliff Manor, N.Y. In the United States, mothers may elect to terminate fetuses for any reason during the first trimester, she adds.

Lynch says parents considering the experimental procedure knew nothing about the gender or genetic characteristics of the fetuses, and the decision regarding which fetuses to terminate is based solely on their proximity to the mother's abdominal wall, a safety factor in the procedure.

In an editorial accompanying their report, Lynch and Berkowitz suggest calling the procedure "multifetal pregnancy reduction." They say the term used in the past, "selective reduction," upsets parents and misleads the public by implying the procedure involves a kind of "Sophie's choice."