Parental reaction and adaptability to the prenatal diagnosis of fetal defect or genetic disease leading to pregnancy interruption

Decision-making and future pregnancies after a positive fetal anomaly screen: A scoping review

AIMS AND OBJECTIVES

To examine and consolidate literature on the experiences and decision-making of parents following a screen positive result for a potential fetal anomaly and/or diagnosis of an actual anomaly in a previous pregnancy.

BACKGROUND

Prenatal screening consists of any diagnostic modality that is aimed at acquiring information about a fetus or an embryo; however, the entire process is highly stressful for parents, especially if there was a previous screen positive result, but no abnormality was detected in the final result.

METHODS

Eight electronic databases (PubMed, Embase, CINAHL, PsycINFO, Scopus, Web of Science, ProQuest Theses and Dissertations and ClinicalTrials.gov) were searched from each database's inception until February 2022. This scoping review was guided by Arksey and O'Malley's framework and was reported in accordance with the PRISMA-ScR checklist. Braun and Clarke's thematic analysis framework was utilised.

RESULTS

Thirty-one studies were eligible for inclusion. Two main themes (reliving the fear while maintaining hope, and bridging the past and future pregnancies) and six subthemes were identified.

CONCLUSIONS

A fetal anomaly diagnosis in pregnancy had a mixed impact on the attitudes of parents toward a future pregnancy. Some parents were fearful of reliving a traumatic experience, while others were determined to have a healthy child and grow their family. Parents generally expressed a greater preference for non-invasive over invasive prenatal testing due to the procedural risks involved.

RELEVANCE TO CLINICAL PRACTICE

There is a need for healthcare professionals to provide psychosocial and emotional support to parents so that they can achieve resolution for their previous pregnancy. Healthcare professionals' ability to provide informational support also enables these parents to make informed decision and understand their reproductive outcomes. Additionally, healthcare administration and policymakers should reconsider current neonatal or pregnancy loss bereavement guidelines to improve the inclusivity of fathers.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Patients' preimplantation genetic testing decision-making experience: an opinion on related psychological frameworks

The process of deciding whether to pursue preimplantation genetic testing (PGT) of an embryo is highly stressful for individuals and couples and has adverse emotional consequences (e.g. distress and uncertainty). PGT influences patients’ lives in both positive and negative ways and is experienced at an individual level, as a dyadic unit, as a family member and as part of the society. Here, we argue that providing a conceptual framework with which to understand the `experience of decision making’ about PGT for monogenic disease (PGT-M) testing specifically, as well as the factors contributing to `decisional distress’ and `uncertainty’ that patients endure as a result—apart from what decision they make—is crucial to optimizing patient counseling, satisfaction and outcomes in the field of ART. Derived from psychological theory, the framework proposed here identifies three categories of contributing factors to decisional distress and uncertainty in considering PGT-M; namely, ‘intraindividual’, ‘interpersonal’ and ‘situational’ factors. We reviewed evidence from the PGT literature to inform our framework. Well-accepted theories of stress and health decision making were also reviewed for their relevance to PGT-M decision making, focusing on potential distress and uncertainty. Our novel conceptual framework can be used to inform clinical practice, to advance research and to aid the development of interventions for individuals and couples who are deciding whether or not to use PGT-M. Alleviating emotional distress and uncertainty can improve patients’ well-being during their reproductive journey.

Cases from the Undiagnosed Diseases Network: The continued value of counseling skills in a new genomic era

The "diagnostic odyssey" is well known and described in genetic counseling literature. Studies addressing the psychological, emotional, and financial costs of not having a diagnosis have shown how it permeates the lives of patients and families. The Undiagnosed Diseases Network aims to end this odyssey by providing diagnoses to individuals with undiagnosed conditions through multidisciplinary evaluations, whole exome and genome sequencing, and basic science research. It also provides an opportunity to learn from patients and families and to better understand their journeys and the impact of receiving a diagnosis. Seven cases are presented that outline challenges that come from working with chronically undiagnosed and newly diagnosed patients in a time when sequencing for clinical diagnosis is rapidly increasing. They illuminate the emotional journey of patients and families searching for a diagnosis and the mental health problems, financial distress, and chaos that can accompany not having answers. They also illustrate the surprising reactions patients and families can have to receiving a diagnosis, including anger, grief, and disappointment. While the lessons learned from these families are not novel, new strategies are presented for handling these challenges in undiagnosed and ultra-rare populations, groups that will increase with the rise of clinical sequencing.

Pregnancy continuation and organizational religious activity following prenatal diagnosis of a lethal fetal defect are associated with improved psychological outcome

OBJECTIVE

The aim of the article is to examine the psychological impact, specifically symptoms of grief, post-traumatic stress and depression, in women and men who either terminated or continued a pregnancy following prenatal diagnosis of a lethal fetal defect.

METHOD

This project investigated a diagnostically homogeneous group composed of 158 women and 109 men who lost a pregnancy to anencephaly, a lethal neural tube defect. Participants completed the Perinatal Grief Scale, Impact of Event Scale - Revised and Beck Depression Inventory-II, which measure symptoms of grief, post-traumatic stress and depression, respectively. Demographics, religiosity and pregnancy choices were also collected. Gender-specific analysis of variance was performed for instrument total scores and subscales.

RESULTS

Women who terminated reported significantly more despair (p = 0.02), avoidance (p = 0.008) and depression (p = 0.04) than women who continued the pregnancy. Organizational religious activity was associated with a reduction in grief (Perinatal Grief Scale subscales) in both women (p = 0.02, p = 0.04 and p = 0.03) and men (p = 0.047).

CONCLUSION

There appears to be a psychological benefit to women to continue the pregnancy following a lethal fetal diagnosis. Following a lethal fetal diagnosis, the risks and benefits, including psychological effects, of termination and continuation of pregnancy should be discussed in detail with an effort to be as nondirective as possible.

Mothers' adaptation to antenatal diagnosis of surgically correctable anomalies

OBJECTIVE

To assess the applicability of Drotar model when the diagnosis of congenital malformation is made antenatally.

METHODS

In a 3-year period (2000-2003) fifty mothers, counselled for fetal malformations amenable to surgical correction at birth, were interviewed. Statistical associations were sought between each stage of the adaptation process and type of anomaly, gestational age at diagnosis, maternal age, educational background and previous miscarriage. Emotional experience at each stage was studied as dichotomous variables.

RESULTS

Fetuses were affected by the following anomalies: abdominal wall defects (11), intestinal atresia (14) and diaphragmatic hernia (25). All mothers experienced stage one, two and three. No association was found between anger, type of anomaly, maternal age, educational background, and age at diagnosis. On the contrary, such association was statistically significant for previous miscarriage. Thirty-nine mothers reached the adaptation stage while none of them experienced that of reorganization.

CONCLUSION

Despite significant differences, the adaptation process proposed by Drotar to describe parents reactions is applicable in prenatal age.

Termination of pregnancy for fetal abnormality incompatible with life: women's experiences in Brazil

Fetal abnormality incompatible with life is a fact and the options for dealing with it are abortion or birth followed by death. This paper reports a qualitative study of the experience of ten women who had a pregnancy termination in a university hospital in Brazil for fetal abnormality incompatible with life. The women were interviewed approximately 40 days after the procedure. The experience was marked by strong emotions for the women, who had a terrible shock on learning of the diagnosis, which was given between 13 and 25 weeks into their pregnancies. They cried, and experienced fear, despair, anguish, a sense of uselessness and refusal to accept the situation. When they took the decision to terminate their pregnancies, the women experienced sadness, despair and guilt, and all these feelings caused them intense suffering. The killing of the fetus was the most difficult part of the termination for them. Nevertheless, afterwards they were satisfied with the decision taken and believed that it was the correct one, despite the anguish it caused. The inclusion of fetal abnormality incompatible with life in the Brazilian law on pregnancy termination would help to reduce women's suffering and contribute to the provision of supportive care by the health services.

Counselling following a diagnosis of congenital heart disease

Counselling the parents following a diagnosis of fetal congenital heart disease (CHD) is as important a task for the fetal cardiologist, as the skill involved in achieving an accurate diagnosis. The counsellor will base prognosis not only on the diagnosis itself but also on the security of diagnosis, the stage in gestation and potential for change, the association with extracardiac malformations and the known results of treatment. Depending on the gestational age and legal situation the counsellor is operating in, termination of pregnancy may be one of the options to consider and one that should always be raised in discussion. Thus, the parents may be in the position of making a crucial decision concerning the management of the pregnancy on the basis of the information received, so it is vital that the counsellor is truly able to communicate with them, whatever be their level of understanding.

Caregivers' experiences of interaction with families expecting a fetally impaired child

BACKGROUND

On the basis of earlier research, caregivers' actions when interacting with clients should be developed. However, nursing research has focused little attention on the interaction between caregivers and families expecting a fetally impaired child.

AIM

The study aimed at generating a practical family nursing theory of caregivers' interaction with families expecting a malformed child.

METHODS

A grounded theory study was undertaken at Tampere University Hospital in Finland in 1999-2000. Data consisted of semi-structured interviews with 22 (n=22) nurses and doctors. The data were analysed using the constant comparative method.

RESULTS

The interaction process starts when a caregiver informs the parents of the fetal impairment. The process is influenced by caregivers' attitude towards issues related to the family's life situation. Caregivers' views of their job, and of human coping and cultural attitudes towards these issues are also of importance. These factors account for their goals in the interaction, which, in turn, underlie their actions. When the caregiver's interpretation is that the family accepted the help provided, the outcome of the interaction is satisfaction with having been able to help. Correspondingly, in the case of an opposite interpretation, the caregiver experiences strain caused by inadequacy of the help he/she is providing. The core of interaction consists of two dimensions: gaining strength and losing strength in relation to impairment issues.

CONCLUSIONS

Caregivers' views of helpful interaction were consistent with earlier research on the subject, but the findings of this study showed that more attention should be focused on the family as a whole. Furthermore, caregivers rarely criticized their own actions, thus their interaction skills should be upgraded by focusing on systematic self-assessment through training. Nursing research deepening our understanding of why interaction fails is warranted.

RELEVANCE TO CLINICAL PRACTICE

The study results can be used in the family nursing practice as tools in reinforcing the caregivers' ability to helpful interaction with families expecting a fetally impaired child. The results may enhance caregivers' systematic self-evaluation and conscious use of the self.

Antenatal diagnosis of diaphragmatic hernia: parents' emotional and cognitive reactions

PURPOSE

The aim of this study was to assess parent's emotional and cognitive reactions to the prenatal diagnosis of diaphragmatic hernia in their prospective children.

METHODS

A survey was conducted by means of a questionnaire. In the period ranging from 1997 to 2002, 40 couples in whom an established diagnosis of diaphragmatic hernia was made in their fetus were seen for prenatal consultation at a tertiary referral center.

RESULTS

Overall response rate was 93% (37 couples). Mean period since diagnosis for compilation of the questionnaire was 2 weeks. Mean gestational age at diagnosis was 25 weeks (range, 16 to 35 weeks). All parents lacked prediagnostic knowledge of diaphragmatic hernia and consider a single consultation with the paediatric surgeon inadequate to have a clear understanding of the anomaly. Only 1 mother and 1 father reported they understood all the information given by the surgeon. The most frequent (75%) feeling during and after the consultation was fear. Most parents (70%) referred to the intense emotions as the factor that made it difficult to follow the surgeon's explanations as well as to ask questions.

CONCLUSIONS

Because of the incompatibility of emotional distress and optimum learning, impairment of early comprehension of information about diaphragmatic hernia is unavoidable. Therefore, we believe that follow-up antenatal consultations and provision of written and visual illustration are extremely important to facilitate informed choices.

Antenatal diagnosis of surgically correctable anomalies: effects of repeated consultations on parental anxiety

OBJECTIVE

To assess whether or not a correlation exists between antenatal consultations and parental anxiety.

STUDY DESIGN

In total, 31 couples undergoing prenatal consultation after a diagnosis of a surgically correctable anomaly were asked to fill in a questionnaire (Spielberger State-Trait Anxiety Inventory) measuring anxiety levels (AL) both after the first consultation and at birth. Prenatal counselling was done by a perinatal team including paediatric surgeon, obstetrician, and psychologist.

RESULTS

Malformations were: eight diaphragmatic hernias, 10 intestinal atresias, four abdominal masses, nine abdominal wall defects. Each fetus was subsequently followed up at regular intervals from diagnosis to birth. AL at birth were then compared with the number of antenatal consultations. A negative correlation (r=-0.688, p<0.001) was found between the number of consultations and the level of anxiety at birth. Patients having at least two consultations had significantly lower anxiety levels at birth.

CONCLUSION

Irrespective of the type of malformation, there is evidence that having more than one antenatal consultation may significantly reduce AL at birth. Therefore, early antenatal diagnosis should be encouraged in order to increase as much as possible chances of repeated consultations for the prospective parents.

Coping with termination of pregnancy for fetal abnormality in a supportive environment

OBJECTIVES

To study the feelings of parents during and after termination of pregnancy (TOP) for fetal anomalies.

METHODS

Semi-structured interviews were conducted before TOP, after six weeks and six months after TOP. The study group consisted of 89 couples, treated at our institution between 1994 and 1998, who terminated their pregnancy in the second and third trimester. Eighty-six of them participated in at least one of the three interviews.

RESULTS

Most parents were able to cope with the decisions they had to make, although a struggle between reason and emotion often occurred. Seeing the dead baby and saying farewell gave all parents a good feeling afterward. Feelings such as doubt, guilt, failure, shame, anger, anxiety and relief were experienced during the period of TOP and the following weeks but practically disappeared after six months; these feelings were more prevalent in women. Most of the couples mentioned that their relationship grew closer as a result of the loss and the grief. Relatives offered good support to most parents in the first weeks after delivery, but parents felt that this support lasted too short a time.

CONCLUSIONS

Seeing the child and saying farewell and the medical and psychosocial support received from professional caregivers were of great value for the interviewees. Parents found the interviews helpful in the grieving process.

Interaction between caregivers and families expecting a malformed child

BACKGROUND

Earlier research has shown that the care of families expecting a malformed child should be intensified and that the topic is understudied.

AIM

This study aimed at generating a practical nursing theory of interaction between caregivers and families expecting a malformed child, as experienced by families.

METHODS

A grounded theory study was undertaken at a university hospital, Finland. Data consisted of semi-structured interviews with 29 mothers and fathers, analysed using the constant comparative method.

FINDINGS

The interaction process starts with the confirmation of the diagnosis. It usually comes as a shock to the parents, and gives rise to questions about the nature of the malformation, family members' relationship with themselves, family relationships and relationships with people outside the family. These questions are crucial to the family's coping and form the core of interaction. Families' own coping strategies are either reinforced or undermined by caregivers' actions and are reflected in parents' expectations about caregivers, which in part account for their actions and experiences of interaction. The care system as an interactive environment is part of a process which results in the experiences of being helped or being left without help. The core of the interaction process comprises two dimensions: gaining strength and losing strength in relation to malformation issues.

CONCLUSIONS

The findings of the study are consistent with earlier research and complement it by providing a detailed delineation of the interaction from the perspective of the family. They can be used to formulate recommendations for improving caregivers' interactive skills and awareness of the topic through training. The care system should be developed to ensure that families receive psychological support and that the family as a whole receives proper care. Consideration of the viewpoint of siblings is a challenge for further research.

Fetal anomalies: ethical and legal considerations in screening, detection, and management

A number of ethical considerations arise with regard to screening for, detecting, and managing fetal anomalies. Some of these considerations involve the need to give attention to emotional distress the pregnant woman might be experiencing. The ethical principle of beneficence gives rise to a duty of the obstetrician to provide emotional support when needed in relation to screening, confirmatory testing, giving bad news, making abortion decisions, making management decisions after viability, and dealing with the grieving process. Other issues involve ethical decision-making, such as deciding what recommendations to make concerning management of fetal anomalies after viability. The ethical principle of autonomy creates a duty of the obstetrician to help the pregnant woman make informed management decisions based on her values and goals. A recommendation for a particular approach to management is sometimes ethically justifiable on the basis of an analysis of the risks and benefits to the mother and fetus. Legal considerations are relevant because they create requirements or prohibitions that must be taken into account in ethical decision-making. The discussion in this article does not exhaust the range of issues that arise. For example, sometimes a delivery procedure is considered that is traumatic to the fetus, such as cephalocentesis for vaginal delivery of a fetus with hydrocephaly. The reader is referred to other sources for a discussion of the ethics of delivery procedures that might injure or kill the fetus. Other issues involve deciding when there is a duty to offer new prenatal genetic tests, routinely or for high-risk couples, and whether to carry out maternal requests for prenatal tests for late-onset diseases and susceptibilities to diseases. These issues have been discussed elsewhere.

[Opinions of couples on care during medical termination of pregnancy]

OBJECTIVES

To study the medical care, staff attitudes and patients' satisfaction from the decision to the post-intervention medical visit for termination of pregnancy for fetal abnormalies.

PATIENTS AND METHODS

All patients and their spouses having a termination of pregnancy at the "Unite de Medecine Foetale" in Port-Royal Hospital between November 1996 and July 1997 were contacted for the study. A self-administered questionnaire was mailed six to eight weeks after intervention. Forty seven women and 42 men returned a completed questionnaire, the response rates were respectively 68% and 61%.

RESULTS

The patients and their spouses rated globally very high their satisfaction about the care received. The delay before intervention, the length and pain of labour were rated less positively. The factors associated with satisfaction were the quality of the relationship with the staff, and of information. Positive feelings about delivery were linked with the consideration and relief of pain. Most respondents mentioned that their physical and psychological state has improved at the moment of the survey but the psychological distress subsisted or has increased in one fourth of the cases. On the whole the answers made within the couples were correlated.

CONCLUSION

The positive results should be moderated by the number of non-respondents. In a context of very high rates of satisfaction, psychological distress is still present for one respondent out of four, six to eight weeks after termination of pregnancy for fetal abnormalies.

Genetic abortion: considerations for patient care

Women who receive abnormal prenatal diagnosis results potentially face two emotionally difficult decisions. In this article, the first decision--whether or not to terminate the pregnancy--is presented with a discussion of the factors that may influence a women's choice. Women who choose to terminate the pregnancy face a second decision when more than one type of abortion procedure is available. Two second trimester abortion procedures--dilation and evacuation and labor induction--are compared and contrasted to delineate potential advantages and disadvantages of each. The decision-making process is examined, emphasizing the individual ways in which women may weigh this information to make a fully informed decision. In addition, a number of recommendations are offered to health care providers in the role of discussing options and supporting women in their choices.

Prenatal screening and women's perception of infant disability: a Sophie's Choice for every mother

Prenatal screening can significantly benefit parents and the community. However, it has created a dilemma for women as it requires them to quickly decide whether to continue a pregnancy or terminate it should the test indicate a foetal abnormality. This can be psychologically traumatic for women torn between their connection to an unborn child with all its possible imperfections, and a desire to prevent its suffering as a disabled child in later life. A woman must also consider her own and her family's future welfare. Extensive research into the physical aspects of prenatal screening has not explored the meaning of the experience for women or whether termination is the most appropriate option. This article examines recent qualitative studies, concluding that women who terminate a pregnancy following prenatal screening may experience an acute grief reaction or be plagued by guilt and fear that can precipitate marital breakdown. Additionally, there is a risk that through striving to eradicate congenital disability, a community risks promoting a cult of perfectionism that may have discriminatory effects on disabled people.