Problems in the control of genetic disorders

Preventive genetics services based on population screening are now an integral part of maternal and child health programmes. New developments in DNA technology, ultrasound scanning, and assay of factors in maternal blood are greatly increasing their potential to improve human health. If these services are to be delivered fairly to populations, there must be much more emphasis on community information, professional education, and service monitoring.

[Perinatal mortality in placental insufficiency]

The review of 55 cases of placental failure and the results obtained reveal a 54% mortality rate.

A 1 and 6 month follow-up of prenatal diagnosis patients who lost pregnancies

This paper reports results of an exploratory study of prenatal diagnosis patients who experienced voluntary terminations of pregnancy following the detection of an abnormality or spontaneous miscarriages. The 121 participants were part of the national collaborative Chorionic Villus Sampling and Amniocentesis Study. They completed semi-structured telephone interviews and mailed questionnaires at 1 month and 6 months after the pregnancy losses. Scores on the Profile of Mood States showed that mood levels improved significantly over time. However, there were some declines in loss-related support from partners and others. The persisting distress and difficulties of a minority highlight the variability in women's responses to pregnancy losses. Women who lost pregnancies later in gestation, showed the greatest mood disturbances at initial assessments, used professional mental health assistance after the loss, or reported less satisfactory loss-related support from significant others showed the greatest levels of mood disturbance at the six-month assessment. Follow-up contacts with patients who lose pregnancies should be used to inform women about the variation in possible grief reactions, to assess the extent of support the women are receiving from their partners and significant others, and to provide additional follow-up or referral of those experiencing the greatest distress.

Selective termination of multiple gestations

Twenty-two selective terminations in multiple gestations were performed by a number of different methods. In 17 dichorionic pregnancies there was a successful delivery in surviving singletons or twins. In five monochorionic pregnancies undergoing selective termination there was a successful delivery in only one and a pregnancy loss in the other four. Six of the 18 delivered pregnancies were complicated by premature labor and delivery. Among the several methods used for selective termination, intracardiac potassium chloride injection appears to be the procedure of choice in dichorionic pregnancies.

Intraamniotic infection with Candida albicans associated with a retained intrauterine contraceptive device: a case report

Intrauterine infection with Candida albicans is a rare occurrence in pregnancy. We report the association of an intrauterine contraceptive device with such an infection in an asymptomatic patient. This infection, discovered incidentally at the time of genetic amniocentesis for advanced maternal age, resulted in a spontaneous abortion at 18 weeks' gestation.

Judgment, 7 July 1987

The plaintiff was a pregnant woman just under the age of 36 who consulted her physician on having an amniocentesis performed because of her age. Her physician advised her against this, emphasizing the danger to the fetus and the fact that she had just had a healthy child and that her present pregnancy was progressing well. When the plaintiff subsequently gave birth to a child suffering from Down's syndrome, she sued the physician for maintenance of the child claiming that she would have had an abortion had she known that the child was defective. The Federal Court of the Federal Republic of Germany reversed the decision of the lower court and dismissed her claim. It held that she had not proved that she had been inadequately counselled by the defendant since he had counselled her about the dangers of Down's syndrome during her previous pregnancy sufficiently for her to have obtained a second opinion about having the amniocentesis performed and since it was standard practice not to perform an amniocentesis on women who were under the age of 36.

Judgment, 28 July 1988

The High Regional Court at Dusseldorf, Federal Republic of Germany, held that a physician is required to provide advice to a patient about age-related risks in pregnancy, including advice on possible birth defects and tests that can help the patient decide whether to continue the pregnancy. The physician also must not oversimplify explanations of risks or overemphasize the dangers involved in amniocentesis. The Court ruled that a physician was negligent in giving advice when he, in fact, dissuaded a patient over the age of 40 from undergoing amniocentesis, with the result that she gave birth to a child suffering from Down's syndrome. It ordered him to pay support for the child.

Judgment, 8 November 1988

The Federal Court of the Federal Republic of Germany held that a medically unnecessary delay in performing an amniocentesis to test for chromosomal damage, with the result that a second necessary amniocentesis could not be performed before the time limit for undergoing an abortion expired, constituted medical negligence. The first amniocentesis had produced inconclusive results, and the plaintiff had given birth to a child suffering from Down's syndrome. The Court ruled that the physician who had caused the delay was negligent and remanded the case for determination of damages.

Reproductive patterns and thalassaemia major

A study of families affected by thalassaemia major demonstrated that before antenatal diagnosis became an option, premature curtailment of reproduction was the most common parental response to their understanding of the genetic implications of the diagnosis. Subsequently parents of younger patients used antenatal diagnosis to meet or almost meet their birth expectations. There was no evidence that antenatal diagnosis contributed to any process of ‘compensating’ for existing affected offspring.

A conceptual explanation of risk-reduction behavior and intervention development

This study used a new conceptual model of health behavior to examine a specific risk-reduction response. Known to be at risk for fetal abnormalities because of maternal age, 203 women were examined for their acceptance or rejection of an amniocentesis test on the basis of individual characteristics and external significant factors. The multivariate approach to analysis offered a fuller explanation for nonuse of prenatal diagnosis than was previously available. In addition to specific client factors, environmental factors such as financial support for the procedure, multiple information sources, social support, and aspects of the client-provider interaction were determined to be important in explaining client acceptance or rejection of the test. More importantly, the study demonstrated the advantages of using a conceptual model to direct the development of interventions.

[Termination of pregnancy on the grounds of foetal indication--seen from a gynaecologist's viewpoint]

As far as the Federal Republic of Germany is concerned, the legal basis of "foetal" indication is, under the aspects of legal philosophy, exclusively directed at the question whether continuation or termination of pregnancy can be expected of, or tolerated by, the pregnant mother. This creates both for the parents and for the physician who is expected to become active or to remain inactive, a particularly tragic conflict arising from the confrontation with the child, which is either certain to be, or suspected of being, seriously diseased, handicapped or deformed or teratoid; this is, so to say, a second dimension of the indication for induced abortion. The conflict situation between the doctor, the patient and the child is analysed in this article on the basis of consultation talks; in such discussions, the doctor is unable to pass any verdict on the value of diseased human life, using medical categories of thinking. The article points out the necessity of acquiring a firm mental hold on the possibilities of prenatal diagnosis and the foetal indication for termination of pregnancy; in this connection, the article explains which of the relevant diseases can be diagnosed by the intrauterine route, with particular emphasis on the rapid development of improved methods of diagnosis which are likely to evolve in the foreseeable future.

Antenatal genetic diagnosis in Newcastle: experience of 1200 requests

A consecutive series of 1200 specimens of amniotic fluid obtained by amniocentesis from patients requesting antenatal diagnosis coming to a regional genetic advisory service is reviewed. The analysis identifies the conditions that most frequently come for antenatal diagnosis, picks out the conditions showing the highest frequency of affected fetuses on termination, and examines the success of the procedure as regards the accuracy of the genetic diagnosis and the ensuing normality of the pregnancy.

[Peculiarities of pregnancies in women in the fifth decade of life (author's transl)]

From 1974-1978, 101 women in the fifth decade of life were delivered. The course of the pregnancy was more often complicated by pre-eclampsia. Premature and dysmature deliveries were not more common than in younger women. The sex ratio was more in favor of females than usual. Despite shorter duration of labor and delivery the Apgar ratings at 1 and 5 minutes were less favorable in the new borns of older pregnant women. The infants required more often intubation and transfer to the pediatric hospital. The perinatal mortality was 4.2%. Down syndrome occured in 4.2% of the infants and abnormalities occured in 4.9%. Routine genetic amniocentesis and intensive pregnantal care should lower the fetal morbidity and mortality in these cases. Urinary total estrogen determinations are proposed as a parameter for the monitoring of the these risk cases besided ultra-sound and fetal monitoring.