Selective reduction in dichorionic triplet pregnancies
First trimester dichorionic triplets: framing the choice D Skupski Weill Cornell Medical Center, New York, NY, USA Linked article: This is a mini commentary on M Morlando et al., pp. 1053–1060. To view this article visit http:// dx.doi.org/10.1111/1471-0528.13348. Published Online 9 April 2015. In this issue of BJOG, Morlando et al. (BJOG 2015;122:1053–1060) present a systematic review comparing outcomes for the management of dichorionic triplet pregnancies. The options include expectant management and embryo/fetal reduction. As a result of the opposing risks of preterm birth and miscarriage, these couples might be characterised as desiring to become pregnant, but finding themselves in the unique situation of being ‘very pregnant’ (having triplets) and ‘not pregnant enough’ (short length of time). Two main conclusions can be drawn. First, the outcome data alone do not clearly favour one choice. Early miscarriage is lowest when severely preterm birth is highest, and vice versa, precluding a clear choice. Second, after counselling, the decision rests with the couple and depends on their primary goal – the lowest miscarriage risk or the lowest risk of severely preterm birth. Expectant management is the obvious choice if the goal is the lowest risk of miscarriage. Fetal reduction is the obvious choice if lowering the risk of preterm birth is the chosen goal. It is imperative that counselling
is comprehensive, including the risks of miscarriage and severely preterm birth, but also details of the severity and duration of the complications of prematurity. I admonish physicians to take a further step in counselling – ‘frame’ the choice for the couple. Optimally, outcome data are the sole driver of management recommendations but, in this situation, the data are sparse and the counselling of patients is problematic, and so we must find another way. ‘Framing’ has been shown to be extremely important in many fields (Kahneman. Frames and reality. In: Farrar, Straus, Giroux, editors. Thinking Fast and Slow. New York: Farrar, Straus and Giroux; 2011. Chapter 34). The ‘frame’ is the choice between the risks of miscarriage and severely preterm birth. When dealing with dichorionic triplets, counselling must be strictly nondirective for two reasons: the lack of superiority of any management plan and physician bias (Chervenak et al. Am J Obstet Gynecol 2009;201:560.e1– 6). Seeing the frequent disasters (severely preterm births) may lead physicians to view reduction as the
ª 2015 Royal College of Obstetricians and Gynaecologists
obvious ‘best’ choice. This ignores the not insubstantial risk of complete miscarriage, for which many women in this situation would take almost any risk to avoid. Physicians providing help for couples with dichorionic triplet pregnancies should begin with the identification of parental wishes in relation to the dichotomy between early miscarriage and severely preterm birth, thus setting the ‘frame’ for the couple. Their decision about management will stem from the relative strength of their desire to avoid either of these undesirable outcomes. I believe that the combination of outcome data presented by Morlando et al. and the admonition to focus first on how to ‘frame’ the counselling should allow us to provide couples with the best choice in order to be ‘just the right amount pregnant’.
Disclosure of interests None declared. Completed disclosure of interests form available to view online as supporting information. &
1061
First trimester dichorionic triplets: framing the choice D Skupski Weill Cornell Medical Center, New York, NY, USA Linked article: This is a mini commentary on M Morlando et al., pp. 1053–1060. To view this article visit http:// dx.doi.org/10.1111/1471-0528.13348. Published Online 9 April 2015. In this issue of BJOG, Morlando et al. (BJOG 2015;122:1053–1060) present a systematic review comparing outcomes for the management of dichorionic triplet pregnancies. The options include expectant management and embryo/fetal reduction. As a result of the opposing risks of preterm birth and miscarriage, these couples might be characterised as desiring to become pregnant, but finding themselves in the unique situation of being ‘very pregnant’ (having triplets) and ‘not pregnant enough’ (short length of time). Two main conclusions can be drawn. First, the outcome data alone do not clearly favour one choice. Early miscarriage is lowest when severely preterm birth is highest, and vice versa, precluding a clear choice. Second, after counselling, the decision rests with the couple and depends on their primary goal – the lowest miscarriage risk or the lowest risk of severely preterm birth. Expectant management is the obvious choice if the goal is the lowest risk of miscarriage. Fetal reduction is the obvious choice if lowering the risk of preterm birth is the chosen goal. It is imperative that counselling
is comprehensive, including the risks of miscarriage and severely preterm birth, but also details of the severity and duration of the complications of prematurity. I admonish physicians to take a further step in counselling – ‘frame’ the choice for the couple. Optimally, outcome data are the sole driver of management recommendations but, in this situation, the data are sparse and the counselling of patients is problematic, and so we must find another way. ‘Framing’ has been shown to be extremely important in many fields (Kahneman. Frames and reality. In: Farrar, Straus, Giroux, editors. Thinking Fast and Slow. New York: Farrar, Straus and Giroux; 2011. Chapter 34). The ‘frame’ is the choice between the risks of miscarriage and severely preterm birth. When dealing with dichorionic triplets, counselling must be strictly nondirective for two reasons: the lack of superiority of any management plan and physician bias (Chervenak et al. Am J Obstet Gynecol 2009;201:560.e1– 6). Seeing the frequent disasters (severely preterm births) may lead physicians to view reduction as the
ª 2015 Royal College of Obstetricians and Gynaecologists
obvious ‘best’ choice. This ignores the not insubstantial risk of complete miscarriage, for which many women in this situation would take almost any risk to avoid. Physicians providing help for couples with dichorionic triplet pregnancies should begin with the identification of parental wishes in relation to the dichotomy between early miscarriage and severely preterm birth, thus setting the ‘frame’ for the couple. Their decision about management will stem from the relative strength of their desire to avoid either of these undesirable outcomes. I believe that the combination of outcome data presented by Morlando et al. and the admonition to focus first on how to ‘frame’ the counselling should allow us to provide couples with the best choice in order to be ‘just the right amount pregnant’.
Disclosure of interests None declared. Completed disclosure of interests form available to view online as supporting information. &
1061
