Selective reduction in multiple pregnancy.

Contrary to the happy image in the media of multiple births the reality is often starkly different. Data on multiple pregnancy are limited, but a study of registered multiple births in England and Wales between 1975 and 1983 reported a 21% perinatal mortality and a 22% infant mortality.' (These figures do not include early loss of pregnancy, and the total fetal wastage is even higher.) Although numbers are small, perinatal mortality among sextuplets rose to 41% and infant mortality to 50%. Many surviving infants after multiple birth are extremely premature, and a third of babies born before 28 weeks' gestation are likely to be seriously handicapped.2 Hobbins described one case of quintuplets delivered at 27 weeks in which one baby died after two days, one had necrotising enterocolitis and was blind, one had post-haemorrhagic hydrocephalus, one had chronic lung disease, and the fifth had neonatal seizures because of perinatal ischaemia.3 The cost of neonatal care was $300 000. Over and above the depressing statistics for the babies mothers with multiple pregnancies have very high risks of pre-eclampsia, postpartum haemorrhage, and thrombophlebitis and often face great misery from hyperemesis and polyhydramnios. Furthermore, the social, financial, and emotional strains consequent on multiple births may be devastating, especially if one or more of the children are handicapped. In addition, multiple births may cause overcrowding in special care baby units, hindering the units' ability to provide an optimum service.4 High order multiple pregnancies have risen sharply in recent years, partly because of induction of ovulation but occasionally because of multiple embryo or oocyte replacements during in vitro fertilisation or gamete intrafallopian transfer.' Doctors participating in assisted reproduction have a responsibility to ensure that they limit high order multiple pregnancy to an absolute minimum. Nevertheless, a few high order multiple pregnancies will inevitably occur, and the doctor has to help the couple to decide on the best course of action. Many couples will accept the risks and continue with the pregnancy, but they may have to face disappointment and distress. Others may opt to terminate the entire pregnancy, but this too is an unhappy prospect, especially for infertile couples who desperately want children. A third option is selective reduction ofpregnancy, a choice which may be supported by several pragmatic obstetric arguments. Selective reduction was first used when one twin had a fetal abnormality, allowing the normal twin to continue to term.6 Berkowitz et al have …