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

Journal of Perinatology volume 29, pages 662–667 (2009)Cite this article

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.

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References

  1. Menahem S, Grimwade J . Counselling strategies in the prenatal diagnosis of major heart abnormality. Heart Lung Circ 2004; 13 (3): 261–265.

    Article  Google Scholar 

  2. Menahem S, Gillam L . Fetal diagnosis—obligations of the clinician. Case studies in the prenatal diagnosis of major heart abnormality. Fetal Diagn Ther 2007; 22 (3): 233–237.

    Article  Google Scholar 

  3. Tibballs J, Cantwell-Bartell A . Outcomes of management decisions by parents for their infants with hypoplastic left heart syndrome born with and without a prenatal diagnosis. J Paediatr Child Health 2008; 44 (6): 321–324.

    Article  Google Scholar 

  4. Evans MI, Goldberg JD, Dommergues M, Wapner RJ, Lynch L, Dock BS et al. Efficacy of second-trimester selective termination for fetal abnormalities: international collaborative experience among the world's largest centers. Am J Obstet Gynecol 1994; 171 (1): 90–94.

    Article  CAS  Google Scholar 

  5. Challis D, Gratacos E, Deprest JA . Cord occlusion techniques for selective termination in monochorionic twins. J Perinat Med 1999; 27: 327–338.

    CAS  PubMed  Google Scholar 

  6. Hecher K, Hackeloer BJ, Ville Y . Umbilical cord coagulation by operative microendoscopy at 16 weeks' gestation in an acardiac twin. Ultrasound Obstet Gynecol 1997; 10: 130–132.

    Article  CAS  Google Scholar 

  7. Jolly M, Taylor M, Rose G, Govender L, Fisk NM . Interstitial laser: a new surgical technique for twin reversed arterial perfusion sequence in early pregnancy. Br J Obstet Gynaecol 2001; 108: 1098–1102.

    CAS  Google Scholar 

  8. Shevell T, Malone FD, Weintraub J, Thaker HM, D'Alton ME . Radiofrequency ablation in a monochorionic twin discordant for fetal anomalies. Am J Obstet Gynecol 2004; 190: 575–576.

    Article  Google Scholar 

  9. Lewi L, Gratacos E, Ortibus E, Van Schoubroeck D, Carreras E, Higueras T . Pregnancy and infant outcome of 80 consecutive cord coagulations in complicated monochorionic multiple pregnancies. Am J Obstet Gynecol 2006; 194: 782–789.

    Article  Google Scholar 

  10. Ville Y, Hyett JA, Vandenbussche FP, Nicolaides KH . Endoscopic laser coagulation of umbilical cord vessels in twin reversed arterial perfusion sequence. Ultrasound Obstet Gynecol 1994; 4: 396–398.

    Article  CAS  Google Scholar 

  11. Deprest JA, Audibert F, Van Schoubroeck D, Hecher K, Mahieu-Caputo D . Bipolar cord coagulation of the umbilical cord in complicated monochorionic twin pregnancy. Am J Obstet Gynecol 2000; 182: 340–345.

    Article  CAS  Google Scholar 

  12. Nicolini U, Poblete A, Boschetto C, Bonati F, Roberts A . Complicated monochorionic twin pregnancies: experience with bipolar cord coagulation. Am J Obstet Gynecol 2000; 185: 703–707.

    Article  Google Scholar 

  13. Weiss JJ, Cleary-Goldman J, Budorick N, Tanji K, D Alton ME . Multicystic encephalomalacia after first trimester intrauterine fetal demise in monochorionic twins. Am J Obstet Gynecol 2004; 190: 563–565.

    Article  Google Scholar 

  14. Sairam S, Costeloe K, Thilaganathan B . Prospective risk of stillbirth in multiple-gestation pregnancies: a population based analysis. Obtest Gynecol 2002; 100: 638–641.

    Google Scholar 

  15. Kahn B, Lumey LH, Zybert PA . Prospective risk of fetal death in singleton, twin, and triplet gestations: implications for practice. Obstet Gynecol 2003; 102: 685–692.

    PubMed  Google Scholar 

  16. Stewart KS . Congenital abnormalities in twins: selective termination. Curr Opin Obstet Gynecol 1997; 9 (2): 136–139.

    Article  CAS  Google Scholar 

  17. Evans MI . Ethical issues surrounding multifetal pregnancy reduction and selective termination. Clin Perinatol 1996; 23 (3): 437–451.

    Article  CAS  Google Scholar 

  18. Chervenak FA, McCullough LB, Skupski D, Chasen ST . Ethical issues in the management of pregnancies complicated by fetal anomalies. Obstet Gynecol Survey 2003; 58 (7): 473–483.

    Google Scholar 

  19. Shinebourne EA . Edgar Mannheimer lecture. Termination, consent and innovation: ethical and legal aspects of paediatric cardiology. Cardiol Young 1998; 8 (4): 428–436.

    Article  CAS  Google Scholar 

  20. Wernovsky G . Improving neurologic and quality-of-life outcomes in children with congenital heart disease: past, present, and future. J Thorac Cardiovasc Surg 2008; 135 (2): 240–242.

    Article  Google Scholar 

  21. Chervenak FA, Farley MA, Walters L, Hobbins JC, Mahoney MJ . When is termination of pregnancy during the third trimester morally justifiable? N Engl J Med 1984; 310: 501–504.

    Article  CAS  Google Scholar 

  22. Sozos J, Fasouliotis MD, Joseph G, Schenker MD . Maternal–fetal conflict. Eur J Obstet Gynecol Reprod Biol 2000; 89: 101–107.

    Article  Google Scholar 

  23. Gillam L . Prenatal diagnosis and discrimination against the disabled. J Med Ethics 1999; 25 (2): 163–171.

    Article  CAS  Google Scholar 

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Author information

Authors and Affiliations

  1. Department of Neonatalogy, Monash Medical Centre, Melbourne, Australia

    A Malhotra

  2. Fetal Cardiac Unit, Monash Medical Centre, Melbourne, Australia

    S Menahem & P Shekleton

  3. Department of Pediatrics and Psychological Medicine, Monash University, Melbourne, Australia

    S Menahem

  4. Murdoch Children's Research Institute, Melbourne, Australia

    S Menahem & L Gillam

  5. Children's Bioethics Centre, Royal Children's Hospital, Melbourne, Australia

    L Gillam

Authors
  1. A Malhotra
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  2. S Menahem
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  3. P Shekleton
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  4. L Gillam
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Corresponding author

Correspondence to S Menahem.

Additional information

Presented in part to the Perinatal Society of Australia and New Zealand, Australia, April 2008.

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Malhotra, A., Menahem, S., Shekleton, P. et al. Medical and ethical considerations in twin pregnancies discordant for serious cardiac disease. J Perinatol 29, 662–667 (2009). https://doi.org/10.1038/jp.2009.88

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  • DOI: https://doi.org/10.1038/jp.2009.88

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