Discovery of soft markers on fetal ultrasound: maternal implications

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.

First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers

Background

The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers.

Methods

We undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual.

Findings

From 7076 hits, we included 80 papers (1994–2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings.

Conclusion

Though antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered.

The importance of information and support following a suspected second-trimester anomaly that is later discarded: A qualitative study of women's experiences

INTRODUCTION

A second-trimester anatomy scan may identify a suspected minor fetal anomaly and/or "soft marker," such as choroid plexus cysts or femoral shortening. Such findings can raise a medical concern, as they could indicate severe fetal disease; however, they are also often transient or a "false alarm." The aim of this study was to explore the experiences of pregnant women, where a medical concern was raised at the second-trimester ultrasound scan and later discarded after follow-up examinations and diagnostic testing.

MATERIAL AND METHODS

This study consists of qualitative, in-depth interviews with nine women, where a minor anomaly/soft marker was identified at the second-trimester scan and a severe anomaly was later ruled out. Data were analyzed using thematic analysis.

RESULTS

The main source of worry was uncertainty about the possible implications for the pregnancy and the baby, particularly concerns about potential termination of pregnancy for a severe fetal condition. The women described four strategies to manage worry and uncertainty during the diagnostic process: (a) seeking additional information to feel more in control, and (b) using social networks to share their concerns. Some women tried to (c) mentally distance themselves from the pregnancy during the diagnostic period, while (d) extra scans could relieve worry and support attachment. The women appreciated when the fetal medicine specialist pointed to normal features in the pregnancy and the baby, as this provided some counterbalance to the sense of uncertainty. In general, the women expressed satisfaction with the information received during the diagnostic process. However, all of them were worried during the diagnostic process, and where this process was prolonged, such worry lingered even after the minor anomaly/soft marker had been discarded.

CONCLUSIONS

Diagnostic uncertainty cannot be avoided in obstetric ultrasound and the women concerned appreciated being informed about the suspected findings even if it caused increased worry. Expedient diagnostic processes may alleviate worry, but are not always possible. Women in a prolonged diagnostic process may benefit from psychological and social support in parallel with, and even beyond, the obstetric investigation. However, further research is warranted.

Indeterminate Prenatal Ultrasounds and Maternal Anxiety: A Prospective Cohort Study

INTRODUCTION

Prenatal ultrasounds often yield indeterminate (incomplete or minor abnormality) findings with limited clinical utility. We evaluate impact of indeterminate findings on maternal anxiety.

METHODS

A single-U.S.-center prospective cohort study administered the Perinatal Anxiety Screening Scale (PASS; control mean = 13.4; > 20 denotes clinically significant anxiety) before and after prenatal ultrasounds in February-May 2017. Ultrasound reports were coded as: normal; indeterminate; or major abnormality. Primary outcome was anxiety after indeterminate vs. normal ultrasounds. Secondary outcomes included anxiety change from pre-to-post-ultrasound and relative to women's characteristics. Linear regression adjusted for confounders.

RESULTS

Of 286 ultrasounds, 51.0% were normal, 40.5% indeterminate (22.0% incomplete; 18.5% minor abnormality), and 8.0% major abnormalities. Indeterminate findings were unrelated to age, race, parity, infertility, or psychiatric history, but associated with gestational age (26.6%/45.0%/52.5% for first/second/third trimesters; p < 0.001), and obesity (48.8 vs. 37.0%; p = 0.031). Pretest anxiety was highest in second/third trimesters (p = 0.029), and in subjects aged age ≤ 24 or younger(p < 0.001), with a history of anxiety (p < 0.001),) or with prior pregnancy loss (p = 0.011). Mean anxiety score decreased pre-to-posttest across all groups. Indeterminate findings were associated with higher PASS scores than normal findings: pretest 20.1 vs. 16.4 (p = 0.026) and posttest 16.9 vs. 12.2 (p = 0.009; adjusted-p = 0.01). Versus normal ultrasounds, incomplete findings were associated with higher post-ultrasound anxiety (p = 0.007; adjusted-p = 0.01) and smaller decreases from pre-to-posttest (adjusted-p = 0.03), whereas minor abnormalities had higher pretest anxiety (p = 0.029) with larger pre-to-posttest decreases (adjusted-p =0.010).

DISCUSSION

Indeterminate ultrasounds, especially incomplete findings, are associated with significantly higher anxiety than normal findings, suggesting need for evidence-based counseling, management and strategies for decreasing number of indeterminate results.

A qualitative study of the work experiences of midwives performing obstetric ultrasound in Norway

BACKGROUND

Performing obstetric ultrasound is part of midwifery practice in Norway. Knowledge of these midwives' working situation can enhance understanding of what their work involves and the challenges they encounter in their practice. The aim of this study was to gain insight into how midwife sonographers perceive their work in obstetric ultrasound.

METHODS

A qualitative study with individual interviews was conducted in 2018. Midwives (n = 13) with a postgraduate ultrasound qualification who performed obstetric ultrasound in private clinics and/or the public health sector were included. All four regional health authorities in Norway were represented. The data gathered were analysed using content analysis.

RESULTS

The analysis resulted in three main themes. (1) Working as a midwife sonographer involves a holistic approach. By practising their competence, in both midwifery and sonography, they could answer questions and reassure pregnant women. The participants also had a feeling of great responsibility in their work. (2) Being part of a professional environment in obstetric ultrasound was important for professional interaction, belonging and learning. (3) Developing and maintaining competence as a midwife sonographer had a positive influence on midwives' motivation and confidence, and allowed for more variety in their work.

CONCLUSIONS

Holistic care of the pregnant woman, her partner and the unborn baby was an important part of the participants' work. They wanted to meet colleagues within their field, develop their expertise and have influence over their work situation. Organizational factors seemed to affect the participants' overall ability to practise their skills and thus also their job satisfaction.

Towards a better understanding of risk selection in maternal and newborn care: A systematic scoping review

Globally, millions of women and their children suffer due to preventable morbidity and mortality, associated with both underuse and overuse of maternal and newborn care. An effective system of risk selection that differentiates between what care should be provided and who should provide it is a global necessity to ensure women and children receive appropriate care, at the right place and the right time. Poor conceptualization of risk selection impedes evaluation and comparison of models of risk selection across various settings, which is necessary to improve maternal and newborn care. We conducted a scoping review to enhance the understanding of risk selection in maternal and newborn care. We included 210 papers, published over the past four decades, originating from 24 countries. Using inductive thematic analysis, we identified three main dimensions of risk selection: (1) risk selection as an organisational measure to optimally align women's and children's needs and resources, (2) risk selection as a practice to detect and assess risk and to make decisions about the delivery of care, and (3) risk selection as a tool to ensure safe care. We found that these three dimensions have three themes in common: risk selection (1) is viewed as both requiring and providing regulation, (2) has a provider centred focus and (3) aims to avoid underuse of care. Due to the methodological challenges of contextual diversity, the concept of risk selection needs clear indicators that capture the complexity of care to make cross-setting evaluation and comparison of risk selection possible. Moreover, a comprehensive understanding of risk selection needs to consider access disparity, women's needs, and unnecessary medicalization.

Effects of ultrasound on anxiety and psychosocial adaptation to pregnancy

Ultrasound is a common medical care procedure during pregnancy which has psychological implications. Research has found that it reduces the mother's level of anxiety, but there is not enough literature on the effects of the ultrasound in relation to the trimester it is done (first, second, and third) and the effects on the psychosocial adaptation to pregnancy. The purpose of this study was to investigate the effects of the ultrasound in the first, second, and third trimester on anxiety and variables related to psychosocial adaptation to pregnancy. A pre-post intervention design was used. Participants were 111 pregnant women attending a prenatal diagnosis ultrasound scan procedure, State-Trait Anxiety Inventory (STAI), and Prenatal Self-Evaluation Questionnaire (PSEQ) were used to measure anxiety and psychosocial adaptation to pregnancy, respectively. Previous history was obtained through an interview. Results indicated that anxiety diminished after the ultrasound regardless of the trimester in which the ultrasound took place. However, first trimester ultrasound showed an additional benefit favoring the mother's psychosocial adaptation to pregnancy, identification with the motherhood role, and the quality of the relationship with the partner. These findings suggest that in addition to the medical value of the ultrasound, it also has an important psychological value that has to be considered in order to guarantee an integral care of the pregnant women, especially in the first trimester.

Ro/SSA autoantibody-positive pregnancy: reactions to serial fetal Doppler echocardiographic surveillance

OBJECTIVE

The risk for congenital heart block (CHB) associated with maternal Ro/SSA autoantibodies is low, but the possibility of treating early stages of disease has seen the introduction of Doppler echocardiographic surveillance programs with serial examinations during the CHB susceptibility weeks of pregnancy. The aim of the present study was to understand how Ro/SSA autoantibody-positive women having undergone Doppler echocardiographic surveillance programs and giving birth to children without CHB experienced their pregnancy and frequent ultrasound examinations.

METHODS

A validated questionnaire based on data from an interview-study was distributed to Ro/SSA-positive women supervised with Doppler examinations during their pregnancy (n = 100).

RESULTS

The response rate was 79%. The majority of the women (61%) reported that the increased number of ultrasound examinations influenced their pregnancy, but in a positive way, with qualified information and additional support from health care personnel in conjunction with the examinations. Further, the visits to the clinic provided opportunities to see the ultrasound picture of the expected infant. However, one-third of the women also reported stress in relation to the examinations.

CONCLUSIONS

Fetal echocardiographic surveillance holds many and predominantly positive effects for Ro/SSA-positive women during pregnancy in addition to the medical advantages.

Ultrasonographic fetal soft markers in a low-risk population: prevalence, association with trisomies and invasive tests

OBJECTIVE

To investigate the prevalence of soft markers identified at second trimester ultrasound in a low-risk population and the association of these markers with trisomies and invasive testing.

DESIGN

Prospective observational study.

SETTING

Swedish University Hospital.

POPULATION

All women with fetuses examined by ultrasound at 15(+0) -22(+0)  weeks gestation between July 2008 and March 2011.

METHODS

Cases with soft markers were compared with non-cases with regard to trisomies and invasive testing.

MAIN OUTCOME MEASURES

Prevalence of soft markers, likelihood ratio for trisomies and risk ratio for invasive tests after detection of soft markers.

RESULTS

Second trimester ultrasound was performed on 10 710 fetuses. Markers were detected in 5.9% of fetuses. 5.1% were isolated, 0.7% were multiple and 0.1% were combined with an anomaly. Presence of markers showed a positive likelihood ratio for Down syndrome, but the association (likelihood ratio = 7.1) was only statistically significant for the combined category of any marker (isolated, multiple or combined with anomaly). The risk ratio for invasive testing after the second trimester ultrasound was 24.0 in pregnancies with isolated soft markers compared with those without markers.

CONCLUSION

In a low-risk population, soft markers were found in 5.9% of fetuses at second trimester ultrasound. The likelihood ratio for Down syndrome was significant only for any marker (isolated, multiple or combined with anomaly). The presence of soft markers increased the incidence of invasive procedures substantially. Soft markers should be noted when information on second trimester ultrasound is formulated, and all units performing fetal ultrasound examinations should have established routines concerning information management when soft markers are identified.

Facts first, then reaction--expectant fathers' experiences of an ultrasound screening identifying soft markers

BACKGROUND

expectant fathers often attend pregnancy ultrasound but their needs are poorly examined, especially in connection with adverse findings.

OBJECTIVE

to explore men's expectations of routine ultrasound and experiences when soft markers were discovered.

DESIGN/SETTING

a qualitative study at Uppsala University Hospital in Sweden where semi-structured, in-depth interviews were conducted with 17 expectant fathers 6-12 weeks after the discovery of a soft marker at the routine ultrasound scan.

FINDINGS

five major themes emerged: (1) 'immediate reaction: frustration and thoughts about consequences', (2) 'need for facts to gain control', (3) 'concern about the partner', (4) 'in retrospect: almost okay but routines need changing' and (5) 'amniocenteses or not: a joint decision with several considerations'.

CONCLUSIONS AND IMPLICATIONS FOR PRACTISE

these findings contribute important knowledge about men's needs related to pregnancy ultrasound with unexpected findings, and their role in decision-making concerning fetal diagnostics. Our results show that men enter a role of a kind of fact manager and have both a psychological need as well as the capacity to perceive important information during the process following the detection of a soft marker in the fetus. Practitioners conducting pregnancy ultrasound should therefore have relevant knowledge to be able to provide immediate information about soft markers, including risk assessment for chromosomal defects. In addition to this, written information about soft markers should be available to expecting parents in this situation.

The experiences of pregnancy in women with SSA/Ro52 autoantibodies

OBJECTIVE

 Congenital heart block may develop in the foetus during pregnancy in SSA/Ro52 autoantibody-positive women. The aim of this study was to investigate how women with SSA/Ro52 autoantibodies experience their pregnancy in terms of the risk of developing foetal heart block, and in undergoing serial ultrasound Doppler echocardiography to detect early signs of congenital heart block.

METHODS

 Data were collected through individual semi-structured interviews with SSA/Ro52-positive women post-pregnancy (n = 14). The interviews were audio-taped, transcribed verbatim and analysed according to qualitative content analysis.

RESULTS

 Three categories emerged from the responses: information, emotional response and support. The information received prior to and during early pregnancy was focused on the need for attending a specialized antenatal clinic, and information on the risk for congenital heart block was scarce or missing. During gestational weeks 18-24, when the ultrasound/Doppler examinations were performed, all women described increased stress. However, the interaction with the caregivers made the women feel more safe and secure. Several women also said that they did not emotionally acknowledge the pregnancy until after gestational week 24. None had been offered psychological support.

CONCLUSION

 There is a need for structured information and organized programmes for the surveillance of women who are SSA/Ro52 positive during their pregnancy. Further, offering psychological support to the women and their families to manage the stress and to facilitate the early attachment to the child should be considered.

Did I really want to know this? Pregnant women's reaction to detection of a soft marker during ultrasound screening

OBJECTIVE

To investigate women's expectations of routine ultrasound and experiences when soft markers were discovered: what the disclosure meant, how it affected them, how they experienced the information given and why they did or did not choose amniocentesis.

DESIGN

Semi-structured, in-depth interviews were conducted with 11 women 25-30 weeks into the pregnancy, 7-13 weeks after the discovery of a soft marker.

FINDINGS

Women lacked knowledge about the potential of the scan and detection of soft markers created strong emotional reactions that women thought could have been alleviated by prior information about potential findings. Information in connection with the scan was perceived as insufficient. Decision about amniocentesis was affected by attitudes to disability, anxiety about fetal loss due to the procedure, need for certainty by a diagnostic test, and partner's opinion.

CONCLUSIONS

Women were shocked by the unexpected and sometimes unwanted information on elevated risk for a chromosomal aberration for which they lacked any preparation. Because this event often has long-lasting effects on the pregnancy, models of information that are efficient in promoting informed decisions are imperative.

PRACTICE IMPLICATIONS

Both women and their partners need relevant information before and in connection with ultrasound scan to be able to make informed choices.