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Multifetal pregnancy reduction and selective termination

INTRODUCTION

The incidence of high order multifetal gestation (ie, triplets or more) increased dramatically over the past three decades, primarily due to widespread use of assisted reproductive technology (ART) (eg, in vitro fertilization, ovulation induction), but has fallen significantly in the past few years [1]. The increase in high order multifetal gestation is important because these pregnancies are at higher risk of maternal, fetal, and neonatal complications than singleton pregnancies. The two most serious risks are (1) complete pregnancy loss and (2) preterm birth, with its potential sequelae including perinatal mortality, respiratory and gastrointestinal complications, infection, and long-term neurologic impairment. The risks of prematurity are discussed in detail separately:

When matched for gestational age at birth, the neonatal outcome of multifetal gestations is similar to that of singleton gestations [2,3]; however, the unadjusted risk of adverse neonatal outcome is not equivalent because the incidence of preterm birth is much higher in multifetal gestations than in singleton gestations (table 1A-B). In 2006, the average length of gestation for singletons, twins, triplets, quadruplets, and quintuplets or higher in the United States was 38.7, 35.2, 32.0, 29.3, and 29.4 weeks of gestation, respectively [4].

Multifetal pregnancy reduction (MPR) and selective termination (ST) are two procedures specifically developed to mitigate risks and address problems unique to multifetal gestations. The goal of MPR is to reduce the risk of adverse outcomes in survivors of higher order pregnancies by decreasing the number of fetuses in the gestation, since the risk of complications is proportional to the number of fetuses in utero. By comparison, the goal of ST is to prevent the survival of a specific anomalous fetus of a multifetal pregnancy in which the fetuses are discordant for anomalies.

This topic will discuss MPR and ST. Prevention of multifetal pregnancy and other aspects of management of multifetal gestation are reviewed separately.
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