Book Review: Iatrogenic Multiple Pregnancy: Clinical Implications
Authors: Alyson Hunter, Peter Soothill
Journal: Journal of the Royal Society of Medicine (2001)

Individuals may pay large sums of money for assisted conceptions but it is usually the State that picks up the extra bill for neonatal care. In Iatrogenic Multiple Pregnancy, an attractive book full of personality, Blickstein and Keith offer a bold reminder that pregnancy at any cost is not necessarily in the best interests of couples, their children or society.

We liked the way they allowed their contributors to express clear opinions. Although the needs of women undergoing assisted conception are sensitively acknowledged, a recurrent theme throughout the book is the risk associated with multiple pregnancy. In the USA the rate of multiple pregnancy has risen, though the role of assisted reproductive technologies in this is uncertain. The authors call for wider reporting, particularly of oral ovulation agent induced pregnancies. They particularly advocate limitation of higher-order multiple gestations, to improve outcome, and they stress that these difficult pregnancies should be managed in large units with specialist experience. Clearly, care should be transferred at the time of the diagnosis, not when the woman is in labour.

The chapters on recognition of multiple pregnancies, planning of the pregnancy, diagnosis of abnormality, fetal reduction and multiple pregnancy delivery are all useful. Much stress is rightly put on early diagnosis of the pregnancy number, by careful uterine mapping and determination of chorionicity by ultrasound. Screening for fetal abnormality is also best undertaken early. We felt that the nuchal translucency issues were rather superficially described (e.g. without description of the different calculations by chorionicity). Especially important chapters are those on counselling parents and the implications for families of having high-order pregnancies—sometimes serious even if all the infants are born in good medical condition. There is a good account of the views of various religious faiths on assisted reproduction and the ethical considerations facing parents and health professionals involved in the care of these pregnancies. Finally, the legal implications of iatrogenic higher-order pregnancies are reviewed.

The book is unusually illustrated with striking, nonscientific, black and white photographs (mostly of twins) which adorn each chapter and the cover. These are surprising, attractive and even at times distracting; on balance we felt they did not add to the book although they do remind the reader of the wonder of reproduction. The price is not so high that one resents this artistic addition. Another unusual feature is the inclusion of numerous ‘inserts’, including case histories, controversial discussions (such as cloning) and diagnostic pitfalls. This structure can break the reading flow, especially when a substantial proportion of a chapter is in these separate boxes. Sometimes the inserts give the impression they are updates, with references more recent than those in the body of the text. At other times the inserts seem to reflect difficulties with the structure of the book. For example, at the end there are eight ‘left-over’ sections on controversial points such as prolonged delayed delivery between multiples and discordant growth, grouped together. We felt that these sections would have been better integrated into the main text.

Those with a particular interest in this area will wish to read Iatrogenic Multiple Pregnancy from cover to cover. It will also be a valuable occasional reference for any specialist involved in reproductive, fetal or maternal medicine as well as for neonatologists and some midwives.