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Thread: Selective Reduction (triplets)

  1. #1
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    Smile Selective Reduction (triplets)

    my wife and I are pregnant with triplets (started off with quads but mother nature took one of them). Anyone out there have experience with the question of selective reduction.

    Most of the numbers out there say doing so increases risk of miscarriage but decreases risk of premature births for the ones that make it.

    We have to decide in about 10 days.
    Last edited by walkanotherday; 11-25-2006 at 02:54 AM.

  2. #2
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    Quote Originally Posted by walkanotherday
    my wife and I are pregnant with triplets (started at with quads but mother nature took one of them). Anyone out there have experience with the question of selective reduction.

    Most of the numbers out there say doing so increases risk of miscarriage but decreases risk of premature births for the ones that make it.

    We have to decide in about 10 days.
    Oh my....what a choice to have to make.

    I have no experience at this but wish you the best in whatever decision you make.

    ((((hugs)))))
    T12-L2; Burst fracture L1: Incomplete walking with AFO's and cane since 1989

    My goal in life is to be as good of a person my dog already thinks I am. ~Author Unknown

  3. #3
    Senior Member justadildo's Avatar
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    i do not have ANY knowledge in this subject, but i would ask that no one hijack this thread and turn it into a moral or political tirade...this question concerns walkanotherday's wife and childrens lives and health...please think before you respond...

  4. #4
    walkanotherday,

    I am so sorry to hear about this. What you are facing is very common and a very difficult decision.

    Let me try to summarize the risks involved.
    1. What is the risk of immaturity?. The normal gestational time is 40 weeks. Generally, birth earlier than 37 weeks is considered to be "premature". The risk of having premature birth of triplets is 68%. The average gestational time for a triplet is 34 weeks. Quadruplets average 31 weeks and quintuplets are born on average around 28.5 weeks (Source). Some 88% of triplet births involve one or more of the babies with birth weights less than 5.5 lb. Premature birth weights are a virtual certainty with quadruplets and quintuplets. Generally, birthweights of less than 5 pounds 8 ounces are considered "low birthrates".
    2. Why are premature births bad?. Premature babies that are born with low birth weights have a higher risk of developmental and other health problems, including respiratory distress syndrome (RDS), brain hemorrhage, a heart abnormality called patent ductus arteriosus, and intestinal problem called necrotizing enterocolitis (NEC) which may require surgery to correct, retinopathy of prematurity (ROP) in babies born before 32 weeks but this often can recover by itself or with laser surgery (Source).
    3. What is the procedure of selective reduction? It is usually an outpatient procedure that is done between 10-12 weeks. Potassium chloride is usually injected into one of the fetuses through a procedure that is similar to what is done during amniocentesis. According to a brochure from the Eastern Virginia School of Medicine Ob/Gyn clinic, "most women report minimal discomfort and cramping during and after the procedure but otherwise little symptoms (Source). Usually, the dead fetus is reabsorbed.
    4. What is the risk of selective reduction? The risk of reducing triplets to twins has a pregnancy loss risk of 6-8%, according to one study done in Greece (Source). According to a WebMD article, triplet to twin reductions are associated with the following risks and benefits:
      • Percent of planned baby born and taken home. With reduction, 93%. Without reduction 78.6%.
      • Premature birth before 32 weeks. With reduction 10.1%. Without reduction 20.3%.
      • Premature birth before 28 weeks. With reduction 2.9%. Without reduction 8.4%.
      • Miscarriage before 24 weeks. With reduction 5.6%. Without reduction 11.5%.
      • One more fetal deaths during pregnancy. With reduction 27 per 1000. Without reduction 92 per 1000.
    5. What is the risk of a triplet birth for the mother?. This is a complex question because it depends on the mother's health, age, size, and other factors. Most studies unfortunately focus only on the babies and not the mother. Although rare nowadays, 2000 maternal mortality rate is 17 per 100,000 births in the United States. According to (Wikipedia), low birth weights increases risk for the mother:
      Low birth weight of the child increases the risk of maternal death from cardiovascular disease. Subtracting one pound of infant birth weight doubles the risk of maternal death. Therefore, the heavier the birth weight of child, the lower the risk of maternal death.
    6. What other factors influence the outcome of prematurity?. Bigger mothers have a lower probability of low-birthweight babies (Source). One study by Feldman and Feidelman (Source) compared triplets against singletons and twins, reporting that less maternal attention and triplets showing less cognitive skills at 12-24 months, suggesting that triplets are at a higher risk of cognitive delay.


    How does one translate percentage risks into decisions? The decision cannot be totally rational and often is dominated by ethical or religious concepts. However, people should understand the meaning of the statistics so that the decisions are not based on a misunderstanding. Psychological studies suggest that people view percentage figures differently from numerical figures of risk. So, for example, a 10% risk of death may sound different to people compared to a restatement of the probability to 1 out of 10. In a situation of multiple risks, people may have trouble balancing risks that are overlapping.

    So, let me vocalize the two cases, one for and one against selective reduction of triplets to twins.
    For selective reduction of triplets. The risk of premature birth of triplets is very high, on the order of 68% of prematurity (7 out of 10 cases) and 88% of low birth weight (9 out of 10 cases). Premature birth is associated with a higher risk of developmental complications and deaths of one or more of the triplets. In addition, the remaining triplets have a higher risk of slower cognitive and other development, as well as other health problems. Premature birth also poses a higher risk of maternal death. Triplets also represent a significant strain on the resources of the parents.
    Against selective reduction of triplets. While the risk of premature birth is very high, the risk of actual complications is much lower. There is a 78.6% (4 out of 5) chance that the parents will be able to take the triplets back home without selective reduction, compared to 93% of twins with the selective reduction procedure. One can perhaps view it in another way. A selective reduction has a 100% probability of killing one of the fetuses and 6-8% chance of inducing a miscarriage while not doing selective reduction has a 21.2% chance of resulting in serious complications. Many of the complications of prematurity can be dealt with medically or surgically.

    There may be extenuating circumstances. For example, if the mother has a high risk condition such as small hips, diabetes, and a history of difficult births, these should be taken into consideration. The age of the mother should be considered. Familial resources to take care of triplets should also be considered. It is an excruciating decision. Please note that I have simply collected the data from internet and that you need to discuss the data with your doctor.

    Wise.
    Last edited by Wise Young; 11-24-2006 at 02:15 PM.

  5. #5
    Wow. Another subject about which I was unaware, and about which Walkanotherday will become an unwilling expert (I wish we were all still ignorant about SCI!).

    Walkanotherday, I wish you the best in making your decision, and whatever it is, please, never regret it.

    Wise, you quoted
    Low birth weight of the child increases the risk of maternal death from cardiovascular disease. Subtracting one pound of infant birth weight doubles the risk of maternal death. Therefore, the heavier the birth weight of child, the lower the risk of maternal death.
    But is that cause or effect? If effect, it should not be a considering factor.
    - Richard

  6. #6
    Quote Originally Posted by rfbdorf
    Wow. Another subject about which I was unaware, and about which Walkanotherday will become an unwilling expert (I wish we were all still ignorant about SCI!).

    Walkanotherday, I wish you the best in making your decision, and whatever it is, please, never regret it.

    Wise, you quoted But is that cause or effect? If effect, it should not be a considering factor.
    - Richard
    Richard, you are correct that correlation does not imply causation. On the other hand, we should not err in the opposite direction and conclude that it rules out causation. Thus, I considered omitting the data but decided that to include the data because we don't know and also because triplet births may very well increase the probability of birth complications. I was unable to find good data on the subject of triplet risk for maternal death.

    I gave some consideration to not mentioning it at all because the risk is so low. With 17 maternal deaths per 100,000 births in the United States and the definition of 5.5 lb as "low birthrate", that means that a 4.5 lb birthweight pose a risk of 34 maternal deaths per 100,000 births. This is substantially less than 0.001%. So, perhaps I should have left out the data.

    Wise.
    Last edited by Wise Young; 11-24-2006 at 02:11 PM.

  7. #7
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    Wise,
    Thank you very much for the post. We have done quite a bit of research, but there were still some statistics in your post we were unaware of.

    Thankfully, my wife and I both have great family support. Therefore, I am not really worried about the resource constraints as much as I am about the health of the babies and my wife. My wife is only 30 but I would imagine having 3 is a strain no matter what the age.

    The risk that one of the triplets would be disabled is of particular concern to me. With first hand knowledge about living with a disability, I don't know if I have the strength to see one of my own in the same situation.

    Something else that I've noticed from research is that deciding on selective reduction with quadruplets or more is no question. However, once you get to 3 or less, more people decide to just let nature do its thing.

    I guess when it comes down to it, there is no right or wrong decision. At this point we just try to remind ourselves how lucky and happy we are to be pregnant.


    WaD
    Last edited by walkanotherday; 11-25-2006 at 03:00 AM.

  8. #8
    As has been said, reduction has 100% possibility of killing one of the babies. The statistics for successful birth of all three is very high with today's technology.

    This couple http://www.kcci.com/family/10315455/detail.html was encouraged to do the same with their seven they were pregnant with. They were born early but now, nine years later, they are all doing well with two having slight problems.

    It's you and your wife's decision, but consider the possible short-term consequences and long-term effects.
    C2/3 quad since February 20, 1985. Find out more of my life as a quad, and other topics, at www.joelvm.com.

  9. #9
    WaD~
    Truly hard decision. I have delievered 2 very premature boys and miscarried 4 times. One miscarriage was a twin to my youngest. I can't say I have any words of wisdon but can attest to the difficulties of a high risk pregnancy. It is stressful beyond belief while bringing great joy as well as sadness. My oldest was less than 4 lbs ad more than 8 weeks premature. Risks to males are greater (gender is significant). He has cerebral palsy but really beat most of the odds. He is an amazing young man, who has struggled but is coming into his own. He had paralysis of his throat muscles and was tube fed for almost 9 years. With lots of therapy he was weened and can today swallow most foods but still has many fears due to prior aspirations and choking. He takes growth hormones due to fetal growth retardation and has struggled in school due to incomplete brain formation. His diagnosis is spastic quadparisis.

    All that being said, he runs, walks, swallows, talks, plays travel baseball, is applying to top level private high schools, does well academically, is social, well adjusted and loving kid. Did we struggle, you bet. Would we turn back, no way. Do we wish we could have bypassed it all---hell yeah. I was a para when I found out I was expecting him. It was recommended I terminate as I was in the process of miscarrying. We decided to wait and see.

    In the early days, my biggest heartache was knowing the struggles of living with a disability. We managed, set the tone, he followed our lead. He doesn't consider himself to have a disability nor would most who know him. It doesn't define him as a person nor does it hinder him much.

    My youngest son, was a twin but I worked hard to maintain that pregnancy. I was 40, SCI and in pre-term labor. Plenty of complications but we managed. I am glad we rode the rollercoaster.....they are my joy as well as my angst.

    It is a very personal decision. Plenty of stats and good plus bad stories. In the end it is up to you and your wife. Know that what ever you choose, folks here wish you well. If you need an ear or a shoulder, feel free to PM. I have ridden that rollercoaster but have also done peer support with other families.

    You might want to tap into Dogger as well, he is the dad to 3 monStars aka: triplets. Oh yeah, all healthy!

    You will be in my thoughts and prayers. The very best in whatever you decide.
    Every day I wake up is a good one

  10. #10
    Senior Member Jeff B's Avatar
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    Thank you for the good info Wise.

    It is interesting that low birth rate is harder on mothers. I would tend to think the opposite, but I guess that an unhealthy fetus is hard on the mother.

    Good luck with your decision walkanotherday. There are definately no clear cut answers. You will have to decide which option will likely have you second guessing yourself the least down the road.

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