Consequences of fetal reduction for quintuplets after ICSI-embryo transfer- case report
Quintuplets are one of the higher order pregnancies which are rare (natural occurrence 1 in 55,000,000) and in the modern times occur most often due to assisted reproductive techniques. These pregnancies cause considerable maternal morbidity like early onset gestational hypertension, preeclampsia, eclampsia, gestational diabetes and abruption and perinatal morbidity and mortality due to prematurity and its consequences.
The average gestational age reported at delivery was 29.5 weeks for quadruplets and 29 weeks for quintuplets. The spontaneous pregnancy loss is estimated to be 25% for quadruplets and three times more than this for quintuplets. To decrease the foetal loss and complications associated, fetal reduction was introduced by Evans in 1988. The risk of fetal loss was reduced by 50% when fetal reduction was undertaken. Hence in modern days fetal reduction is performed to keep at least 2 fetuses.
A case was reported by Paapa Dasari and Ashraf M Ali describing the consequences of fetal reduction for quintuplets after ICSI-ET published in Indian Journal of Obstetrics and Gynecology Research.
A 30-year-old lady was admitted at 34 weeks of pregnancy with singleton fetus in breech presentation with Gestational diabetes and Gestational hypertension.
This pregnancy was following ICSI for male factor infertility of 3 years. She conceived Quintuplets after transfer of 5 frozen embryos at a time.
At 14 weeks she underwent fetal reduction of 3 foetuses but within a week only one FHR was documented. She was managed with progesterone support and underwent elective LSCS at 37 weeks for breech presentation. Her past USG (Ultra sonogram) did not report on the presence of fetus papyraceous.
After admission USG performed on 2 occassions reported placenta implanted on the anterior wall of the uterus on the upper segment, fetal biometry corresponding to the gestational age and fetus in breech presentation. Her haemogram was with in normal limits and PT/INR (Prothrombin time and International Normalised Ratio) was 16/1.5 performed one day prior to Elective LSCS (36+6 days Gestation). Elective LSCS was performed at 37 weeks and an alive male baby was extracted as breech with an Apgar of 8/10 at 1 min weighed 2.9 kg.
The placenta did not separate for 10 minutes after delivery of the baby and it was found to be adherent and was manually removed. There was profuse bleeding after removal of placenta and before uterine closure.
Uterus was exteriorised and uterine massage was given as it was felt little flabby and 40 IU of Oxytocin was added to normal saline and was infused at a faster rate. (200 ml /hour) Uterus was contracted well but there was persistent bleeding from the cavity.
Intrauterine examination by the operating Obstetrician did not find any retained placental bits or membranes. Examination of the placenta which was removed showed 3 fetus papyraecea along with cords.
Hence a retained fetus papyraceaus was suspected and again intrauterine examination was done by senior Obstetrician and it was found that the fetus payraceous was densely adherent to lateral wall of the uterus. The bleeding stopped after the removal of the fetus and uterine incision was closed in layers. Her postoperative period was normal and mother and baby were discharged on 7th post-operative day.
Higher order pregnancies are challenging to manage to the ART specialists and Obstetricians. SART and ASRM (Society for Assisted Reproductive Technology and American Society of Reproductive Medicine) have been publishing and updating the guidelines on Embryo transfer and recommend transfer of no more than 3 embryos in women less than 35 years of age and only one or two embryos to be transferred in the first cycle. The effect of implementation of these guidelines resulted in a dramatic decrease in the incidence of higher order multiple pregnancies.
The current trend is single embryo transfer (SET) or repeated SET to minimise the risk of multiple pregnancy without substantially reducing the likelihood of achieving live birth. ASRM recently issued guidance on "how many" and "how –to" in standardising the embryo transfer protocols. None of these practices were followed in this woman who underwent ICSI for the first time.
Current evidence supports the reduction of multifetal pregnancy to twins in order to improve pregnancy outcomes and this was performed in this lady. However there was a fear of losing all the foetuses which existed till delivery. Controversy still exists regarding to choose between embryo reduction or fetal reduction.
Though second trimester fetal reduction offers the advantage of choosing the structurally abnormal foetuses for reduction it remains to be seen whether embryo reduction is a better option to reduce the complications. Embryo reduction in triplet pregnancies decreases the take home baby rate per patient but improves the quality of the babies born.
The authors concluded, "In pregnancies following fetal reduction, loss of other fetuses can occur and postpartum haemorrhage can result due to retained fetus papyraceus. It is essential to examine the placenta or the uterine cavity to recognise and ensure the fetus papyraceus has been removed. It is desirable to follow the guidelines to decrease incidence of higher order pregnancies because of the complications associated with such pregnancies."
Source: Dasari and Ali / Indian Journal of Obstetrics and Gynecology Research 2021