Fetal Reduction: 25 Years' Experience

Evans, Mark I.; Andriole, Stephanie; Britt, David W.

doi:10.1159/000357974

Cited by 73 publications

(62 citation statements)

References 55 publications

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“…This has to be compared with the delay in obtaining the final diagnosis, which is a downside for patients considering reduction. With the understanding that reduction may not be an option for many individuals due to personal reasons, our experience shows that CVS and reduction are safe, effective, and significantly improve out-comes in appropriate cases [5,129] . There is extensive literature, as cited in this review, which supports that conclusion.…”

Section: Discussionmentioning

confidence: 98%

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Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

Dziadosz

Evans²

2017

Fetal Diagn Ther

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Background/Objectives: Multiple pregnancies have tripled in the United States over the past 3 decades. Attributed to increasing maternal age at delivery but more so assisted reproductive technological advances, an effort has been made to decrease twinning through elective single embryo transfer. We sought to review and evaluate risks of monochorionic twinning as a predictable consequence of increasing utilization of elective single embryo transfer on perinatal outcomes. Primary outcomes included twinning rates, fetal anomalies, growth, preterm birth, and mortality. Secondary outcomes included neurological and pulmonary disability, intrauterine growth restriction, and congenital cardiac anomalies and twin-twin transfusion syndrome. Data sources: PubMed and Embase. Results: A total of 106 studies identified by systematic search met the inclusion criteria. The trend for lower numbers of embryos transferred has inadvertently led to an increase in monochorionic twinning. This is associated with worse outcomes compared to dichorionic twinning and singleton gestations for all outcomes studied. Discussion: Of great concern for monochorionic twins is the risk profile of significant morbidity and mortality. Transfer of 2 embryos should be considered to avoid higher risks inherent to the shared placental phenomena related to monochorionic twins.

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Section: Discussionmentioning

confidence: 98%

“…If this option is chosen over eSET, then testing the health of both fetuses can be entertained. If desired, reduction to a singleton can be employed to further optimize maternal and neonatal outcomes [5] .…”

Section: Single Embryo Transfer · Monochorionic Twins · Dichorionic Tmentioning

confidence: 99%

Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

Dziadosz

Evans²

2017

Fetal Diagn Ther

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“…SR via intravascular KCl injection is the primary method for selective feticide in dichorionic twins [1], but is contraindicated in monochorionic, diamniotic twin gestations due to the increased risk of co-twin injury or death [2]. There are several potential mechanisms for co-twin injury after intravascular KCl injection in monochorionic twins.…”

Section: Discussionmentioning

confidence: 99%

“…KCl injection is technically simple (outpatient) and associated with minimal procedure-related complications [1]. The procedure is less invasive, as KCl injection is typically performed with a 22-gauge needle, while cord occlusion requires a probe (17-18 G) or endoscope (up to 3.8 mm in diameter) to complete [8].…”

Section: Discussionmentioning

confidence: 99%

Selective Reduction Using Intravascular Potassium Chloride Injection after Laser Surgery for Twin-Twin Transfusion Syndrome

et al. 2015

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Selective reduction (SR) via intravascular potassium chloride (KCl) injection is contraindicated in monochorionic twins due to the presence of placental vascular communications, which may serve as a conduit for inter-twin passage of KCl or allow exsanguination of the living twin into the demised twin. After successful selective laser photocoagulation of communicating vessels (SLPCV) for twin-twin transfusion syndrome (TTTS), the twins' circulatory systems are rendered independent. Theoretically, intravascular KCl injection into one twin after successful SLPCV should not result in passage of the feticidal agent nor cause hemodynamic alterations in the co-twin. We describe 3 cases of 1,069 patients (0.3%) that underwent SLPCV for TTTS between 2003 and 2013 and subsequent SR. SLPCV was successfully completed at 18⁰, 22⁶, and 23⁰ weeks' gestational age for Quintero stages III, IV, and III TTTS, respectively. SR via intravascular KCl injection was later performed at maternal request due to the risk of neurological compromise in one twin at 22⁶, 25⁴, and 23⁶ weeks' gestational age. All co-twins survived after SR, and no neurological sequelae were suspected after birth. Further study is necessary before SR can be routinely considered after laser surgery for TTTS.

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“…All patients in our program have formal genetic counseling before any procedure [10], so the discussion of the option of aCGH with its benefits and limitations was added to the routine. We reflected on our own patients' decisions regarding whether to have the aCGH test or not after agreeing to have either a chorionic villus sampling (CVS) or amniocentesis.…”

Section: Introductionmentioning

confidence: 99%

Integrating Microarrays into Routine Prenatal Diagnosis: Determinants of Decision Making

Cordoba

Andriole²,

Evans³

et al. 2016

Fetal Diagn Ther

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Objectives: The explosion in genetic technologies, including array comparative genomic hybridization (aCGH), has increased the complexity of genetic counseling. We now offer chorionic villus sampling (CVS) and aCGH to all first-trimester patients, as this allows the prenatal diagnosis of an additional 1% of anomalies not otherwise detectable and can detect genetic copy number variants at a much higher resolution than conventional cytogenetics. Here, we explored some of the determinants of how patients are deciding to use or not use this new technology and evaluate risk-benefit analyses for that decision. Methods: This is a retrospective case-control study of singleton and multiples pregnancies at our center. Those having aCGH testing along with CVS were defined as ‘testers' and those who declined aCGH but had the CVS were ‘nontesters'. Results: Demographic data of 181 educated women who chose CVS were compared. Among those carrying singletons (n = 144), older women, defined as over 35 years of age (or ‘advanced maternal age'; AMA), were more likely to choose the aCGH than younger women. Further, women who had a prior history of genetic testing and who wanted to know the gender of the fetus were more likely to choose the aCGH test. In women carrying multiples (n = 37), AMA ceases to be a predictor of choice. Having had prior genetic counseling remains a strong predictor for choosing aCGH, as does wanting to know the gender of the fetus. Neither prior abortions nor having prior children were significant for women carrying singletons or multiples. Conclusion: Offering pregnant couples an individualized choice regarding aCGH seems an appropriate approach. There are discrete patterns associated with the choice of taking the aCGH that varied depending on whether the patient was carrying a singleton or multiples.

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Fetal Reduction: 25 Years' Experience

Cited by 73 publications

References 55 publications

Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

Re-Thinking Elective Single Embryo Transfer: Increased Risk of Monochorionic Twinning - A Systematic Review

Selective Reduction Using Intravascular Potassium Chloride Injection after Laser Surgery for Twin-Twin Transfusion Syndrome

Integrating Microarrays into Routine Prenatal Diagnosis: Determinants of Decision Making

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