Demand Still High for Fetal Reduction Procedure.
"There are a lot of women out there who are conceiving triplets or more even though there has been so much hoopla about trying to get the infertility doctors to reduce the number of these patients that are created," said Dr. Richard L. Berkowitz, professor and chairman of ob.gyn. at Mount Sinai School of Medicine, New York.
Indeed, in the past 2 years physicians at Mount Sinai have performed an average of 165 multifetal pregnancy reductions annually, nearly all in infertility patients, he said at a conference on obstetrics and gynecology sponsored by the University of Colorado.
The procedure's goal is to increase the potential for good quality of life for those fetuses left behind by getting them to be born at a later gestational age.
"The problem is that the human uterus was designed to have one fetus in it. The more you put in there, the earlier the patient is likely to deliver," Dr. Berkowitz explained.
The multifetal pregnancy reduction procedure is effective in achieving its goal. In the first 400 cases at Mount Sinai, the majority of which involved reduction of triplets or quadruplets to twins, the gestational age at delivery averaged 35.5 weeks. Overall, 88% delivered after 32 weeks.
Only 3% delivered at 24-28 weeks' gestation, the time that obstetricians and patients dread most because of the high rate of associated profound and irreversible damage that is compatible with a long but severely impaired life.
In contrast, in a recent large national series 9% of women with triplets viable at 24 weeks gave birth at 24-28 weeks. The mean gestational age at delivery in this 539-patient series was 33.3 weeks. Twenty-five percent of women gave birth before 32 weeks.
These outcomes of contemporary triplet pregnancies are virtually identical to those of 50 years ago.
"With all the tocolytics that we have, with all of our sophisticated monitoring tools, we do not do any better. That's because the mechanism associated with preterm labor in women with multiple gestations is probably totally different than the reason women who have singletons go into preterm labor. And the tools we've been using up until now just don't work," the ob.gyn. said.
This is the major impetus for multifetal pregnancy reduction. Another driving force is a growing appreciation of the maternal hazards of high-order multiple pregnancies. These include high rates of anemia, postpartum hemorrhage, severe endometritis, and a drastically increased incidence of fatty liver of pregnancy--a life--threatening condition--compared with twin or singleton pregnancies.
At Mount Sinai, 8% of women undergoing multifetal pregnancy reduction gave birth before 24 weeks and lost their entire pregnancy. However, the loss rate in the first month after the procedure was 1%, and that's the figure quoted to patients as procedure related.
The procedure is an emotionally wrenching experience for couples who've often tried desperately to achieve pregnancy. A Mount Sinai psychologist conducted 45-minute telephone interviews with 91 women years after they underwent the procedure. A total of 93% said they would do it again under the same circumstances. But 18% had lingering moderate-to-severe guilt and sadness and moderate anger about the procedure up to 7 years later.