Medical and ethical considerations in twin pregnancies discordant for serious cardiac disease

Abstract

Objective: Prenatal ultrasound has led to the early diagnosis of major anomalies. However, the ready availability of this technology has led to increasing challenges for physicians counseling affected parents, which is all the more difficult in a twin pregnancy with only one affected fetus. This paper reviews the medical and ethical considerations in twin pregnancies discordant for a serious cardiac condition.Study Design: Six recent twin pregnancies discordant for a serious cardiac condition and their outcomes are presented. Options considered in the management of the pregnancy were to continue or terminate the pregnancy, selectively terminate the affected twin or to decide whether to treat the affected twin once delivered. An approach to decision making in such situations has been formulated after critical analysis of the factors involved.Results: Four of the six pregnancies were monochorionic twins. Two sets of parents decided to terminate the pregnancy. In the four that continued, two opted for the affected twin to be appropriately managed once delivered. A further two considered selective termination but opted to continue the pregnancy because of the risk of premature labor and/or cerebral hypoxia following such intervention. They sought a commitment, however, that they be given the option whether to treat the affected twin following delivery. Eventually both elected to have their babies treated, one of whom died in the postoperative period.Discussion: Medical considerations included the risks of continuation of the pregnancy for the mother and her twins, the safety of termination (total or selective), and the risks to the unaffected fetus. Ethical issues revolved around concepts of autonomy, beneficence and justice from the standpoint of the family and the twins. The gestation and the viability of the twins played an important role in decision making and approaches, taking into account the local legal and other considerations. Conclusion:Attention is drawn to the complexities of the issues involved in twin pregnancies complicated by a serious cardiac condition in one of the twins. Optimal counseling requires sound clinical knowledge about the medical risks to the mother and her twins, and a clear understanding of the key ethical considerations. Such an approach will assist parents in their very difficult decision making.

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

“…DCDA twins have lower Mental Processing Composite Scale scores at 5 years of age compared to matched dichorionic twins [47] . Therefore, selective feticide may be more specifically indicated as an intervention for the unaffected twin in such cases [48] .…”

Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review

“…As previously explained, selective termination, selective feticides that are indicated in the context of multiple pregnancies, most of the time involving twins (Legendre et al, 2009;Middeldorp et al, 2008), will be used to interrupt the development of one of the fetuses affected by a serious and incurable pathology (del Río et al, 2005;Malone et al, 1996;Paramasivam et al, 2010;Picone and Dommergues, 2004;Rustico et al, 2005) or in the case of less severe pathologies affecting the fetus, which could be prejudicial to the development of the healthy fetus or fetuses (Sepulveda et al, 2011). It is the case, for example for pathologies involving severe polyhydramnios (Dommergues, 2002b;Lust et al, 2008), that the indication of selective termination is not the termination of an affected fetus' life, but the safeguarding of one or both of the healthy co-twins' lives (Bryan, 2005;Malhotra et al, 2009;Rochon and Stone, 2003). Consequently, to ensure the birth of at least one healthy child, the mother will have to carry, during the remainder of the pregnancy, the fetus or fetuses whose development has been interrupted.…”

“…Selective termination may be less risky for the healthy fetus than the continuation of pregnancy. As already men-tioned in the discussion of medical indications, the evolution of certain fetal pathologies can engender a risk to the development and/or survival of the healthy co-twin(s), thus threatening the whole pregnancy (Malhotra et al, 2009;Moise et al, 2008). Concerning the risks, it is also of paramount importance to distinguish between monochorionic and dichorionic pregnancies, because the technical aspect is tremendously different.…”

“…From an ethical point of view, selective termination produces a conflict of interest between the twins (Bernard et al, 2006;Dommergues, 2002a;Malhotra et al, 2009) because, in both cases, the obstetrician and parents are placed in a situation where an [. .…”

Ethical Issues in Fetal Management: A Cardiac Perspective

“…We have discussed this issue in detail in a separate paper [30]. To summarise, dealing with the management of a twin pregnancy where one fetus has a serious anomaly is one of the most challenging and confronting issues a clinician faces.…”