Reader TTS

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. Access through your institution Buy or subscribe This is a

preview of subscription content, access via your institution ACCESS OPTIONS Access through your institution Subscribe to this journal Receive 12 print issues and online access $259.00 per

year only $21.58 per issue Learn more Buy this article * Purchase on SpringerLink * Instant access to full article PDF Buy now Prices may be subject to local taxes which are calculated

during checkout ADDITIONAL ACCESS OPTIONS: * Log in * Learn about institutional subscriptions * Read our FAQs * Contact customer support SIMILAR CONTENT BEING VIEWED BY OTHERS CONJOINED

TWINS: AN OBSTETRICIAN’S GUIDE TO PRENATAL CARE AND DELIVERY MANAGEMENT Article 22 June 2021 ASSOCIATION BETWEEN PARENTAL DECISIONS REGARDING ABORTION AND SEVERITY OF FETAL HEART DISEASE

Article Open access 01 July 2024 PERINATAL OUTCOMES OF TWIN PREGNANCIES WITH PRETERM PREMATURE RUPTURE OF THE MEMBRANES AT 24–34 WEEKS’ GESTATION Article Open access 03 December 2021

REFERENCES * 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  * 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  * 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  * 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 

* 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  * 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  * 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  * 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  * 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  * 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  * 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  * 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  * 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  * 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  * 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  * Stewart KS . Congenital abnormalities in twins:

selective termination. _Curr Opin Obstet Gynecol_ 1997; 9 (2): 136–139. Article  CAS  Google Scholar  * Evans MI . Ethical issues surrounding multifetal pregnancy reduction and selective

termination. _Clin Perinatol_ 1996; 23 (3): 437–451. Article  CAS  Google Scholar  * 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  * 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  * 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  * 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  * Sozos J, Fasouliotis MD, Joseph G,

Schenker MD . Maternal–fetal conflict. _Eur J Obstet Gynecol Reprod Biol_ 2000; 89: 101–107. Article  Google Scholar  * Gillam L . Prenatal diagnosis and discrimination against the disabled.

_J Med Ethics_ 1999; 25 (2): 163–171. Article  CAS  Google Scholar  Download references AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Neonatalogy, Monash Medical Centre,

Melbourne, Australia A Malhotra * Fetal Cardiac Unit, Monash Medical Centre, Melbourne, Australia S Menahem & P Shekleton * Department of Pediatrics and Psychological Medicine, Monash

University, Melbourne, Australia S Menahem * Murdoch Children's Research Institute, Melbourne, Australia S Menahem & L Gillam * Children's Bioethics Centre, Royal

Children's Hospital, Melbourne, Australia L Gillam Authors * A Malhotra View author publications You can also search for this author inPubMed Google Scholar * S Menahem View author

publications You can also search for this author inPubMed Google Scholar * P Shekleton View author publications You can also search for this author inPubMed Google Scholar * L Gillam View

author publications You can also search for this author inPubMed Google Scholar CORRESPONDING AUTHOR Correspondence to S Menahem. ADDITIONAL INFORMATION Presented in part to the Perinatal

Society of Australia and New Zealand, Australia, April 2008. RIGHTS AND PERMISSIONS Reprints and permissions ABOUT THIS ARTICLE CITE THIS ARTICLE 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 Download citation *

Received: 30 September 2008 * Revised: 14 April 2009 * Accepted: 08 May 2009 * Published: 23 July 2009 * Issue Date: October 2009 * DOI: https://doi.org/10.1038/jp.2009.88 SHARE THIS ARTICLE

Anyone you share the following link with will be able to read this content: Get shareable link Sorry, a shareable link is not currently available for this article. Copy to clipboard

Provided by the Springer Nature SharedIt content-sharing initiative KEYWORDS * cardiac disease * fetus * ethics * termination * twins