Distress associated with prenatal screening for fetal abnormality

Providing recurrence risk counselling for parents after diagnosis of a serious genetic condition caused by an apparently de novo mutation in their child: a qualitative investigation of the PREGCARE strategy with UK clinical genetics practitioners

BACKGROUND

Diagnosis of a child with a genetic condition leads to parents asking whether there is a risk the condition could occur again with future pregnancies. If the cause is identified as an apparent de novo mutation (DNM), couples are currently given a generic, population average, recurrence risk of ~1%-2%, depending on the condition. Although DNMs usually arise as one-off events, they can also originate through the process of mosaicism in either parent; in this instance, the DNM is present in multiple germ cells and the actual recurrence risk could theoretically be as high as 50%.

METHODS

Our qualitative interview study examined the views and reflections on current practice provided by UK practitioners working in clinical genetics (n=20) regarding the potential impact of PREcision Genetic Counselling And REproduction (PREGCARE)-a new preconception personalised recurrence risk assessment strategy.

RESULTS

Those interviewed regarded PREGCARE as a very useful addition to risk management, especially for cases where it revised the risk downwards or clarified that a couple's personalised recurrence risk meets National Health Service thresholds for non-invasive prenatal testing, otherwise inaccessible based on the generic DNM recurrence risk.

CONCLUSION

Participants said it could release some couples requiring reassurance from undergoing unnecessary invasive testing in future pregnancies. However, they regarded mosaicism and PREGCARE as complex concepts to communicate, requiring further training and additional appointment time for pre-test genetic counselling to prepare couples for all the possible outcomes of a personalised risk assessment, including potentially identifying the parental origin of the DNM, and to ensure informed consent.

A Cross-Sectional Study of the Marital Attitudes of Pregnant Women at Risk for Cystic Fibrosis and Psychological Impact of Prenatal Screening

Cystic fibrosis (CF) is one of the most frequent genetic disorders in those with Northern European ancestry. Prenatal testing for cystic fibrosis may be used to plan and prepare for the birth of a child with the disease or to determine whether to terminate the pregnancy. The accessibility of prenatal detection for women with a high genetic risk of delivering a child with cystic fibrosis is determined by CF carriers and those affected by the disease. Moreover, prenatal testing for CF is mainly dependent on invasive diagnostic tests that can influence the mental health of the pregnant woman, and it is assumed that the birth of a CF child will have a serious influence on the couple’s subsequent family planning and marital behavior. The purpose of this research was to examine the marital attitudes of women at risk for cystic fibrosis and the psychological effect of screening for CF among pregnant women. The study followed a cross-sectional design with five questionnaires comprising Prenatal Attachment Interview (PAI), Maternal Antenatal Attachment Scale (MAAS), Pregnancy-Related Anxiety Questionnaire (PRAQ-R2), the Prenatal Psychosocial Profile (PPP), and the Marital Intimacy Questionnaire (MIQ). A total of 84 pregnant women were included in the “carriers” group for CFTR and 91 in the “non-carrier” group. CFTR-carrier mothers were likely to be more affectionate to the fetus, with better maternal–fetal quality and intensity of attachment. The same group of pregnant women was less scared of giving birth or worried about bearing a physically or mentally handicapped child compared to women who were expecting the prenatal diagnosis test for being at risk of delivering a newborn with malformations. CFTR-carrier pregnant women did not score significantly different results in the Prenatal Psychosocial Profile regarding stress levels, social support, and self-esteem. It was also found that intimacy and consensus problems inside the marriage were significantly more often experienced by CFTR carriers. Based on the current findings, it is likely that CFTR-carrier mothers have a better perception of the possible pregnancy outcomes by knowing their abnormal gene carrier status. Therefore, the psychological impact of invasive diagnostic tests is lower in this category compared with those who are unaware of the possible pregnancy outcomes. However, we promote a future analysis for pregnant women with moderate risk of giving birth to a child with single-gene mutations such as cystic fibrosis or other congenital malformations that undergo noninvasive prenatal diagnosis tests, as they become more accurate and might cause lower pre-diagnosis stress levels.

Decision-making factors in prenatal testing: A systematic review

This review examines the factors that affect the decision-making process of parental couples evaluating prenatal screening and diagnostic tests. A systematic search was performed using PubMed and PsycInfo databases. The 46 included studies had to: investigate the decision-making process about prenatal testing; focus on tests detecting trisomy 21, 18, 13, and abnormalities of sex chromosomes; be published in English peer-reviewed journals. The decision-making process seems composed of different levels: an individual level with demographic, clinical, and psychological aspects; a contextual level related to the technical features of the test and the information received; a relational level involving family and society.

The Psychological Well-being of Pregnant Women Undergoing Prenatal Testing and Screening: A Narrative Literature Review

Prenatal screening and testing are preference-based health care options. They are offered so that pregnant women and their partners can learn genetic information about the developing fetus. In this literature review, I summarize studies of women's and their partners' psychological responses to prenatal testing and screening. These studies investigate the experiences of pregnant women, largely in the United States, who have access to health care services. Although the results indicate that these women are receptive to prenatal testing and screening and seem to have limited negative psychological consequences, pregnant women without access to these services are not represented and may have different experiences. With that caveat in mind, based on the evidence, women generally do well psychologically as they manage the options that arise for them in the prenatal context.

Balancing Genetics (Science) and Counseling (Art) in Prenatal Chromosomal Microarray Testing

Genetic counselors frequently are called upon to assist patients in understanding the implications of prenatal testing information for their pregnancies and their family's lives. The introduction of highly sensitive testing such as chromosomal microarray has generated additional kinds of uncertainty into the prenatal period. Counselors may feel uncomfortable or inadequately prepared to engage in discussions with prospective parents who are faced with making critical, and timely, decisions about a pregnancy based on uncertain information. As highly sensitive prenatal testing becomes routine in prenatal care, counselors may be in search of approaches to prenatal counseling, as well as specific skills to approach, engage with, and help families find resolution in such challenging circumstances. To assist genetic counselors, we describe practice skills and provide language for approaching conversations with prospective parents. When clinicians regularly provide care to patients and families making life-altering decisions under conditions of significant uncertainty, discomfort is common and compassion fatigue is likely. We make recommendations directly to the genetic counselor working in reproductive and perinatal settings to enhance training and self-care and to decrease discomfort in balancing the scientific- and art- demands of genetic counseling.

Improved health perception after genetic counselling for women at high risk of breast and/or ovarian cancer: construction of new questionnaires--an Italian exploratory study

BACKGROUND

Subjects referred to genetic counselling for cancer may have heightened perceptions of illness and death, even though they are healthy and this may cause anxiety and reluctance to follow through with consultation. We investigated such perceptions before and after counselling and genetic testing for cancer in a cohort of Italian women. We sought to understand the situation of the women referred by designing questionnaires administered to women at high risk of breast and/or ovarian cancer (those who had had a pathogenic mutation identified in a family member via diagnostic testing). We also assessed women after the diagnosis of breast cancers, but free of disease, to help determine risks in their families.

METHODS

The first questionnaires were administered before initial counselling, and the second were completed within 20 days after the counselling. When a genetic test was proposed, the individual was asked to fill in a third questionnaire; the final questionnaire was administered after the person had received the results of the genetic test.

RESULTS

We evaluated 204 subjects. Before counselling, 89 % of the subjects were worried about their risk of disease, 52 % felt "different" because of their personal and family history, and 39 % declared that their life choices were influenced by their fear of cancer. After counselling, 82 % of the subjects felt more relived about their pre-existing fears and stated that this process of being seen in a clinic with genetic expertise had clarified the meaning of disease risk for them, and for 50 %, this experience had positively influenced their life choices. Thirty percentage of the subjects had a positive test; all of them felt safer in being cared for by specifically trained staff. Fifty percentage had a less informative test (e.g. "wild-type" gene found); 84 % of them were not worried by the uncertainty, and overall, 96 % considered counselling to be very useful.

CONCLUSION

Candidates for genetic counselling frequently had heightened their perception of being ill, which influenced their ability to make life decisions. Genetic counselling often improves this perception, especially in subjects who have negative tests and this knowledge facilitates their life plans. After testing, most women felt satisfied and safer because of being properly followed by professionally trained and sympathetic staff. In conclusion, knowledge of the real individual risk, the presence of a professional team, and the possibility of entering a programme of controlled screening enable patients rather than living in fear and uncertainty to be less anxious about their state of health and to live with the knowledge that they are doing everything possible to care for themselves, aided by a specialized team, and that, if necessary, they would be able to take part in investigational studies.

Predicting birth outcomes: together, mother and health care provider know best

OBJECTIVE

To examine contributors to perceived risk in pregnancy and its utility in predicting lower birth weight and earlier delivery in conjunction with health care providers' assessment of obstetric risk.

METHODS

165 pregnant women at high (n=34) or low (n=131) obstetric risk completed assessments of perceived risk, stress, optimism, and health behaviors using well-validated instruments and measures designed for this study. Medical charts were abstracted for gestational age at delivery and birth weight.

RESULTS

40% of the sample perceived their risk status differently than their health care provider. Stress, poor reproductive history, provider assigned risk, and unhealthful behaviors were significant, independent predictors of perceived risk (R(2)=.37). The greatest difference in birth weight (p=.003) and gestational age (p=.05) was between women considered at low risk by both self and provider and women considered at high risk by both. Perceived risk improved prediction of adverse birth outcomes, especially lower birth weight, in women considered by providers to be at low risk.

CONCLUSION

Women's perceptions of risk are an important contributor to prediction of birth outcomes, but the combination of information from both a woman and her health care provider is superior. Incorporating women's perceptions into obstetric risk determination may help to reduce the number of women identified as high risk who subsequently have a normal birth outcome (false positives), and more importantly, the number of women considered to be at low risk who ultimately experience an adverse outcome (false negatives).

Levels and associations among self-esteem, fertility distress, coping, and reaction to potentially being a genetic carrier in women with diminished ovarian reserve

OBJECTIVE

To measure the level of distress and its relationship with other psychologic factors in women with diminished ovarian reserve (DOR) who participated in a fragile X genetics study.

DESIGN

Longitudinal data analyzed with structural equation modeling.

SETTING

Four U.S. private and academic fertility centers.

PATIENT(S)

Sixty-two infertile patients with DOR.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Fertility Problem Inventory, Coping Scale for Infertile Couples, Rosenberg Self-Esteem, Health Orientation Scale.

RESULT(S)

Nineteen percent had low fertility distress, 56% had average fertility distress, and 24% had high fertility distress. Thirty-six percent self-reported a "favorable" or "very favorable" emotional response to potentially being a fragile X carrier (termed "emotions"), 53% were "ambivalent," and 11% had an unfavorable reaction. Three months after learning that they were not a carrier, these percentages were 91%, 9%, and 0%, respectively. Emotions at this second time point were significantly more positive than at pretesting. At baseline, higher self-esteem was a significant predictor of reduced fertility distress both directly and indirectly through emotions. Fertility distress was not associated with coping. Self-esteem, fertility distress, pretesting emotions, and coping were unrelated to posttesting emotions.

CONCLUSION(S)

The potential of having an explanation for one's DOR condition may have a beneficial impact on women's psychologic states during the process of genetic testing, and this appeared to be especially true for women with higher self-esteem. Psychologic interventions targeted to women with low self-esteem may reduce distress and improve reactions to genetic testing.

Preparation for prenatal decision-making: a baseline of knowledge and reflection in women participating in prenatal screening

OBJECTIVE

This prospective study gathered baseline information about knowledge and intentions regarding prenatal testing from women attending their nuchal translucency (NT) ultrasound and first sequential blood screen.

METHOD

Surveys including questions about pregnancy history and hypotheticals about fetal diagnoses were distributed to all willing participants at an urban hospital and a suburban medical building during the waiting time for the NT (N = 659).

RESULTS

The majority "never thought anything could be wrong" with their fetus and had not talked with the father or the health providers about that possibility. Presented with varied fetal diagnoses, the larger group nearly always "had the baby", except in the case of a fatal condition where 28% said they would have the baby in contrast to 26% who would end the pregnancy (remainder undecided). Hypotheticals about varied fetal conditions were generally "undecided" by a quarter to nearly half of the respondents.

CONCLUSION

Women's baseline knowledge and reflection about the nature of prenatal screening and diagnosis are minimal in contrast to the large impact positive results could have on their lives. Providers need to weigh the benefit of priming decision-making by exposing women to the possibility of fetal diagnosis, against the cost of raised anxiety.

Emotional distress following genetic testing for hereditary breast and ovarian cancer: a meta-analytic review

OBJECTIVE

Meta-analysis was used to synthesize results of studies on emotional consequences of predictive genetic testing for BRCA1/2 mutations conferring increased risk of breast and ovarian cancer.

DESIGN

Studies assessing anxiety or cancer-specific distress before and after provision of test results (k = 20) were analyzed using a random-effects model. Moderator variables included country of data collection and personal cancer history of study participants.

MAIN OUTCOME MEASURES

Standardized mean gain effect sizes were calculated for mutation carriers, noncarriers, and those with inconclusive results over short (0-4 weeks), moderate (5-24 weeks), or long (25-52 weeks) periods of time after testing.

RESULTS

Distress among carriers increased shortly after receiving results and returned to pretesting levels over time. Distress among noncarriers and those with inconclusive results decreased over time. Some distress patterns differed in studies conducted outside the United States and for individuals with varying cancer histories.

CONCLUSION

Results underscore the importance of time; changes in distress observed shortly after test-result disclosure frequently differed from the pattern of distress seen subsequently. Although emotional consequences of this testing appear minimal, it remains possible that testing may affect cognitive and behavioral outcomes, which have rarely been examined through meta-analysis. Testing may also affect understudied subgroups differently.

Inequalities in the reported offer and uptake of antenatal screening

OBJECTIVE

The objective of this study was to identify whether there is a different pattern of reported offer and uptake of antenatal screening tests across social groups.

DESIGN

Prospective cohort study.

SETTING

Two large maternity hospitals in Northern Ireland.

SAMPLE

Women booking for antenatal care were recruited consecutively over a 3-month period commencing 1 September 2003. In total, 711 women were recruited at booking: 359 at Hospital 1 and 352 at Hospital 2. Six hundred and sixty-six women completed both interviews.

METHODS

Two semi-structured interviews were arranged with consenting participants. The first interview was conducted at the booking appointment, and the second interview took place after 23 weeks of gestation after all screening, including anomaly ultrasound, would have been offered.

MAIN OUTCOME MEASURES

Reported offer and uptake of all screening tests were explored in relation to key sociodemographic indicators: level of education; mother's occupation; partner's occupation; single parent status; car ownership; religious denomination; and Townsend Deprivation Index.

RESULTS

With the exception of screening for Down's syndrome and neural tube defects, virtually all of the women were offered and underwent screening tests. Further analysis of data from Hospital 1 showed that, after controlling for other sociodemographic factors, women with a lower level of education had a lower odds of reporting Down's syndrome screening being offered Down's syndrome screening. Women having private antenatal care had a higher odds of accepting the offer of a test for Down's syndrome.

CONCLUSIONS

While the majority of antenatal screening tests are offered to all pregnant women in Northern Ireland, screening for Down's syndrome and NTD reflects a different pattern of offer and uptake. This paper provides evidence of variations in offer and uptake that exist even when it is hospital policy to offer screening to all women.