Multifetal pregnancy reduction (MFPR) is a pregnancy termination procedure that reduces the number of fetuses in a HOM pregnancy to a lower and potentially
more viable number, thus increasing the chances for a positive pregnancy outcome. The rise in use of MFPR has paralleled the rising number of HOM pregnancies, particularly in older women using donor eggs (Evans & Britt, 2010). MFPR is typically performed in the late first trimester to terminate one or more fetuses. Nearly all procedures performed today use transabdominal needle insertion under ultrasound guidance. The patient is placed in the lithotomy position, and a 22-gauge needle is inserted transabdominally into the fetal heart. Asystole is achieved following injection of 2 to 3 mL of potassium chloride and is confirmed by ultrasound. Antibiotics are given, and the woman may have abdominal cramping, vaginal spotting, and leaking of amniotic fluid (Little, 2010). Although MFPR is sometimes called selective reduction, the terms are not synonymous. Selective reduction applies to situations in which a specific fetus is targeted for reduction because of a known anomaly, aneuploidy, or a risk identified with nuchal translucency (NT) screening. Reduction of a single fetus in an MC pair requires occlusion of umbilical cord blood flow to prevent interfetal transfusion. Recently, radio frequency ablation has been used to destroy cord tissue for selective reduction of an MC twin (Paramasivam et al., 2010).

There have been many studies comparing pregnancy outcomes following MFPR. The literature is conflicting regarding the outcomes of reduced and unreduced triplets (Wimalasundera, 2010), and a 2009 Cochrane review reconfirmed that there are “insufficient data available to support a policy of pregnancy reduction procedures for women with a triplet or higher order multiple pregnancy” (Dodd & Crowther, 2010). Generally, outcomes following reduction to twins appear comparable to outcomes for twins conceived spontaneously or by ART, but study findings about the risks and benefits associated with reduction procedures are not as clear (Dodd & Crowther, 2005). Complications include procedural complications (e.g., infection or incomplete procedure), total pregnancy loss, and a continued risk for preterm birth. Collaborative data from several centers have shown that higher starting numbers of fetuses (≥6) correspond with poorer outcomes after reduction; total pregnancy loss rates prior to 24 weeks’ gestation are 4.5% for triplets, 8% for quadruplets, 11% for quintuplets, and 15% for sextuplets or more (Evans, Ciorica, Britt, & Fletcher, 2005). All reduced pregnancies have been shown to have an ongoing increased risk for preterm birth, except for pregnancies reduced to singletons (Evans et al., 2005). Generally, there is an increased risk for lower birth weights in the remaining fetuses post-MFPR, with an inverse correlation to starting numbers (American College of Obstetricians and Gynecologists [ACOG], 2007; Stone et al., 2008). Without prenatal diagnostic testing prior to MFPR, there is the possibility of terminating a healthy fetus while leaving an abnormal one. Some centers are combining the use of rapid chromosome analysis following chorionic villus sampling (CVS) with MFPR (Evans & Britt, 2010). The ASRM recommends that MFPR should be performed only in specialized centers with fetal medicine practitioners experienced in the procedure (ASRM, 2012).

MFPR presents a difficult dilemma for most couples. They often face conflicting values as they consider reduction after years of desiring fertility and must weigh the medical/obstetric/neonatal risks and the psychosocial/moral/economic impact on their family (Elliott, 2005a). The seemingly (and often actually) arbitrary choice as to which fetus should live and which should die is distressing (Bryan, 2005). Further, the decision for reduction must be made in a short time between diagnosis and the optimal timing for the procedure. The decision has been described as highly stressful, psychologically traumatic, frightening, painful, overwhelming, confusing, and a surreal experience (Bergh, Möller, Nilsson, & Wikland, 1999; Bryan, 2005; Collopy, 2004). The following responses from women indicate their inner conflicts about the decision: “I believe reduction saved one of my children. It’s the not knowing that kills me.” “If I tried to carry all of the babies, I would most definitely lose them all. I also look at my survivor knowing she probably would have been chosen for reduction. This also wracks me with guilt” (from a mother who spontaneously lost some of her fetuses and did not have to reduce) (Pector, 2004, p. 716). There is also evidence from interviews with patients that viewing fetuses on ultrasound just prior to or during reduction made the reduction more difficult (Maifeld, Hahn, Titler, & Mullen, 2003; Schreiner-Engel, Walther, Mindes, Lynch, & Berkowitz, 1995). Studies have shown that persistent feelings of sadness and guilt may continue after the MFPR procedure; however, most women believe their choice was correct and that reduction was necessary for them to achieve their goal of motherhood (Collopy, 2004). The grief response with MFPR may not fit the classic process and may be more complicated or delayed. Wang and Yu Chao (2006) interviewed six Taiwanese women undergoing MFPR over 8 to 10 weeks. Although the women were able to move past the reduction and adjust to a normal pregnancy experience, the researchers found that MFPR created psychological distress through exposure to moral and ethical dilemmas. More research is needed to determine long-term psychological outcomes, cultural responses, and effects on parent-child bonding and responses of child survivors.

The reduction debate also can be problematic for clinicians. With the improvements in neonatal care and long-term outcomes for preterm infants, some clinicians may be unwilling to accept that medical risks
are sufficient grounds for reducing a triplet pregnancy (Bryan, 2005). Another consideration is the first trimester spontaneous loss rate for multiple gestations, which might make MFPR unnecessary. One study found that spontaneous loss of one or more gestational sacs or embryos occurred before the 12th week of gestation in 65% of quadruplet pregnancies, 53% of triplets, and 36% of twins (Dickey et al., 2002). The controversy is likely to continue. Some have proposed that future debates will no longer be over reduction of HOMs and triplets but over a routine offer of reduction of all twins (Evans & Britt, 2010). ACOG concludes that patients should not be given the impression that multifetal pregnancies are without problems because fetal reduction is available (ACOG, 2007).

Nurses have much to contribute in the care of women considering and undergoing MFPR. Establishing a rapport, exploring treatment options, and assisting with decision making with a consistently available primary nurse has been recommended (Collopy, 2004). Patient education includes written instructions, a list of symptoms that would indicate a need for medical care, postprocedure self-care, and grief counseling (Little, 2010).