Ideally, access to infertility treatment and multifetal pregnancy reduction should be equitably distributed. Nondirective patient counseling should be offered to all women with higher-order multifetal pregnancies and should include a discussion of the risks unique to multi-fetal pregnancy as well as the option to continue or reduce the pregnancy. Obstetrician—gynecologists who have the appropriate clinical knowledge and expertise to discuss the risks of higher-order multifetal pregnancy and options for continuation of the pregnancy or multifetal pregnancy reduction may provide this counseling.
Alternatively, obstetrician—gynecologists may refer to other specialists such as maternal—fetal medicine physicians. It is important to note that there is a narrow window of time during which multifetal pregnancy reduction can be performed.
As such, it is critical that referral for counseling occur in a timely manner in order to ensure that women are able to benefit from the full range of options regarding continuing or reducing their multifetal pregnancies. Such information should be presented in a manner understandable to the patient It is often particularly difficult to convey the risks of a multifetal pregnancy to patients with a history of infertility, many of whom fear that they might never bear children.
For some patients with a history of infertility, the arrival of twins or more may be perceived as a positive outcome, and the physician must convey the risks to patients who often are willing, and even eager, to carry a multifetal pregnancy. Understanding the unique viewpoint of the infertility patient is crucial to help her make an informed decision.
When possible, social workers or other mental health professionals with experience in this arena should be incorporated into the patient care team. Patients being counseled regarding multifetal pregnancy reduction should be made aware that the technology exists to test the fetuses for aneuploidy and morphologic and genetic anomalies before the reduction is performed.
The results of such tests may assist patients in making their decisions about intervention. Once the physician provides medical recommendations, the patient should then be given space to assess her personal value system and determine a course of action. Physicians can serve as guides and resources, helping each individual patient explore her values when faced with carrying a multifetal pregnancy.
Understanding these values will help the patient make the decision most appropriate for her. These are decisions that only the woman can make. She may wish to consult with others whose advice and counsel are important to her Her reproductive liberty, as defined by respect for her autonomy, should be at the center of the ethical decision-making process.
If a patient is in a clinical situation in which discussion of the option of multifetal pregnancy reduction is appropriate and her physician is not comfortable providing information regarding the medical risks of a multifetal pregnancy, the potential medical benefits of multifetal pregnancy reduction, and the complex ethical issues inherent to multifetal pregnancy reduction, then the physician should provide referral in a timely fashion to a physician experienced in counseling about multifetal pregnancy reduction, or performing multifetal pregnancy reductions, or both.
In these instances, referral also may be warranted if a viable patient—physician relationship cannot be established. For more information, see Committee Opinion No. Selective reduction is somewhat different than multifetal pregnancy reduction. In multifetal pregnancy reduction, the fetus es to be reduced is are chosen based on technical considerations, such as which is most accessible to intervention.
In selective reduction, fetuses are chosen based on health status. As with all pregnancies, when a woman with a multifetal pregnancy has ultrasonography or genetic evaluation that identifies a fetus with an abnormality or disease risk, patient counseling should include the most current knowledge regarding the abnormality or disease risk as well as information about the available management options, thus allowing a woman to make the decision that is best for her.
Although some will critique the appropriateness of selective reduction based on potential future disability, an analysis of such considerations is beyond the scope of this Committee Opinion Physicians should be aware that state and federal laws may affect the provision of selective reduction and should consult legal counsel for the facility at which they provide care.
Before multifetal pregnancy reduction, some patients will undergo chorionic villus sampling or amniocentesis. In such cases, information on the sex of the fetuses will be available.
This information should not be withheld from the pregnant woman who requests it. The patient may not wish to know the sex of the fetus or fetuses that will be reduced. This preference should be respected whenever possible. When two or more fetuses are equally accessible and there is no medical benefit to reducing one over another, the physician should randomly select the fetus to be reduced, therefore eliminating physician bias or subtle discrimination in making this determination. The use of sex alone as a consideration in determining which fetus to reduce, poses ethical challenges that are beyond the scope of this Committee Opinion and are discussed by others elsewhere Life felt spectacularly unfair.
We were left with one singleton, a baby boy due in January. He is healthy. He is growing. I feel him kicking now, and I am so grateful for his little nudges on my belly. Separating loss and grief from my happiness for my baby boy is one of the hardest things I've ever had to do. It's one thing to know that this was the right choice; it's quite another to live with the reality of two dead fetuses in your womb. They will eventually be absorbed into my body, which is what usually happens to a deceased fetus after multifetal reduction.
But I could not, and would not, risk all of their lives when I knew one could thrive. As a mother, it was the only choice I had. It was a sacrifice beyond what I thought I was capable of making, but, as parents know, that's part of being a parent. Going through same situation. Crying myself to sleep everynight. I feel guilty. Reduction scheduled next week. I was faced with this option when I was pregnant with my triplets 15 years ago.
I made the best decision to keep them. Although, my pregnancy lasted 32 weeks. Tough decisions all around and everything you said hit the nail on the head. Anyone who takes the time to publicly shame a women grieving, and uses God as back up to their argument should really take a good look back at the Bible.
Kristen, you made a decision that was both devastating and brave. Thank you for sharing your story for those who will be in a similar position in the future. Your love for all of your babies is evident and you just your first difficult decision in parenting. I know you and your husband will be strong enough to face the many more that come with raising a child.
I don't normally comment, and I don't know if you will ever see this, but after seeing the other appalling comment I just wanted to say that you are so strong. That had to be a heartbreaking decision, one that no should be able to comment on unless they've been in the same position.
Congratulations on your healthy baby boy, every time you hold him you will know you made the right decision. Lots of love! As a woman, the gift of pregnancy is priceless and special. Kelly Ross was stunned to discover that she was pregnant with not just one, but three babies. The long-awaited news "I'm pregnant" now came with a mixed bag of emotions and concerns. All of a sudden I found myself with three babies," says Ross, who is the director of pediatric hospitalist medicine at Missouri Baptist Medical Center.
Though she had knowingly transferred three embryos during her in vitro fertilization, the chances of all of the embryos taking was only about 3 percent, so Ross never even considered the possibility that she would have to deal with triplets. Increased use of in vitro fertilization techniques has made Ross's situation increasingly common. Given the high cost and failure rate of fertility treatments, some couples try to increase their chances of getting pregnant by using multiple embryos and end up facing an unexpected challenge of twins, triplets, or higher multiples -- a challenge some feel they cannot handle, emotionally or financially.
There is a way out of this challenge, but it is one that is seldom discussed among mommies-to-be: selective reduction. In cases of high multiple pregnancies, doctors will often recommend selective reduction for purely medical reasons. Early in the pregnancy, one or more of the fetuses are aborted from within the womb to increase the likelihood that the remaining babies and the mother will survive and thrive.
There are numerous health concerns to both mother and infants associated with carrying multiples. Fetal wellbeing was assessed with the use of cardiotocography, and the results were unremarkable. Emergency cesarean section was done whereby female twins in breech and cephalic presentation were delivered weighing 1. Cervical cerclage was removed intraoperatively. She fared well, and was discharged 72 hours post-delivery. This case involved multifetal gestation that happened spontaneously.
The reported incidence of spontaneous triplets is low [ 1 ], indicating that our case is rare. Chorionicity does have a significant role in the outcome of multifetal pregnancy with reports suggesting that monochorionic and dichorionic triplet pregnancies have higher rates of poor perinatal and neonatal outcomes as compared with trichorionic pregnancy [ 15 , 16 ].
For our case, the fetuses had variable weights, and spontaneous fetal reduction happened, indicating the increase in risks with shared chorion, prompting extensive care in these cases. Higher-order pregnancies are associated with complications, with fetal loss and preterm birth being major ones for triplet pregnancy [ 4 ]. In our case, spontaneous labor occurred at gestational age of 19 weeks, that is, before 24 weeks, and after thorough assessment of our patient, different measures were taken to stop labor without success.
Some case reports had shown spontaneous fetal reduction happening without any signs and symptoms of labor, and others even needed removal of cervical cerclage [ 4 ].
Other studies have shown retention of placenta, abruptio placentae , and postpartum hemorrhage as maternal complications in delayed interval delivery involving twins and triplets [ 14 ]. However, none of these happened in our case.
Our client was managed with antibiotics and synthetic progestogens in addition to Macdonald cervical cerclage, and extended time was days. Her course of management was as an outpatient from day 2 post cervical cerclage to the time of cesarean section. Different studies have indicated controversies with cervical cerclage, even reporting it as the source of chorioamnionitis for the remaining fetus, hence prompting short duration of delayed interval delivery [ 12 , 17 ].
Some case reports advocated inpatient management during the extended interval until delivery; however, some other case reports showed success with outpatient management.
For cases that reported outpatient management, the hospital stay before discharge after loss of first fetus was no less than 1 week [ 4 , 17 ]. Delayed interval delivery is recommended in carefully selected cases and can be done even in limited-resource setting, and it is recommended for better neonatal outcome especially in these areas since caring for extreme preterm babies carries higher neonatal mortality rate.
Spontaneous triplet pregnancy and trap sequence, case report. BMC Pregnancy Childbirth. Triplet pregnancy—UpToDate [Internet]. Trends in the incidence and mortality of multiple births by socioeconomic deprivation and maternal age in England: population-based cohort study.
BMJ Open. Ghorbani M, Moghadam S. A triplet pregnancy with spontaneous delivery of a fetus at gestational age of 20 weeks and pregnancy continuation of two other fetuses until week Glob J Health Sci [Internet]. Perinatale Probleme von Mehrlingen.
Deutsches Arzteblatt. Google Scholar. Complications in multiple gestation pregnancy: a cross-sectional study of ten maternal-fetal medicine centers in China. Oncotarget [Internet]. Goodnight W, Newman R. Optimal nutrition for improved twin pregnancy outcome. Obstetrics Gynecol. Comparative analysis of perinatal outcome of spontaneous pregnancy reduction and multifetal pregnancy reduction in triplet pregnancies conceived after assisted reproductive technique.
J Hum Reprod Sci [Internet]. Effect of parity on gestational age at delivery in multiple gestation pregnancies. J Perinatol [Internet].
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