Decision-Making after Ultrasound Diagnosis of Fetal Abnormality

"A Picture Paints a Thousand Words"-A Systematic Review of the Ethical Issues of Prenatal Ultrasound

Prenatal ultrasound is a non-invasive diagnostic examination. Despite the recognized diagnostic value, this technology raises complex ethical questions. The aim of this study is to provide a comprehensive analysis that coherently maps the ethical challenges raised by prenatal ultrasound examination, both 2D and 3D. We performed a systematic literature review. Six databases were systematically searched. The results highlight how concerns related to beneficence, informed consent, and autonomy are mainly related to routine use of prenatal ultrasound in the clinical context, while considerations linked to overmedicalization of pregnancy, discrimination, and fetal ontology were often reported in relation to the impact ultrasound is having on medicine and society. Ethical issues in the context of pre-abortion ultrasound, obstetric practices in low-income settings, and keepsake ultrasound imaging were also greatly discussed. Since prenatal ultrasound practices critically impact pregnant people's autonomy and their role within pregnancy, we conclude that information providing strategies should be developed to appropriately inform pregnant people about the nature, purpose, risks, and choices revolving around prenatal ultrasound. In addition, as it is becoming increasingly difficult to separate the social and clinical dimensions of prenatal ultrasound, future research should focus on examining if and how such dimensions should be reconciled.

Specialist perinatal palliative care: a retrospective review of antenatal referrals to a children's palliative care service over 14 years

BACKGROUND

Perinatal palliative care is an emerging branch of children's palliative care. This study sought to better understand the pattern of antenatal referrals and the role of a specialist paediatric palliative care (PPC) team in supporting families throughout the antenatal period.

METHODS

A single-centre retrospective chart review of all antenatal referrals to a quaternary children's palliative care service over a 14-year period from 2007 to 2021.

RESULTS

One hundred fifty-nine antenatal referrals were made to the PPC team over a 14-year period, with increasing referrals over time. Referrals were made for a broad spectrum of diagnoses with cardiac conditions (29% of referrals) and Trisomy 18 (28% of referrals) being the most prevalent. 129 referrals had contact with the PPC team prior to birth and 60 had a personalised symptom management plan prepared for the baby prior to birth. Approximately one third (48/159) died in utero or were stillborn. Only a small number of babies died at home (n = 10) or in a hospice (n = 6) and the largest number died in hospital (n = 72). 30 (19% of all referrals) were still alive at the time of the study aged between 8 months and 8 years.

CONCLUSIONS

Specialist PPC teams can play an important role in supporting families during the antenatal period following a diagnosis of a life-limiting fetal condition and demand for this service is increasing. A large proportion of the cases referred will not survive to the point of delivery and a number of babies may survive much longer than predicted. PPC teams can be particularly helpful navigating the uncertainty that exists in the antenatal period and ensuring that plans are made for the full spectrum of possible outcomes.

Mapping parents' journey following prenatal diagnosis of CHD: a qualitative study

OBJECTIVE

To better understand parents' accounts of their prenatal and postnatal experience after prenatal diagnosis of CHD - particularly emotional processing and coping mechanisms - to identify strategies to improve support.

METHODS

This single-centre, longitudinal qualitative study included pregnant mothers and their support persons seen in Fetal Cardiology Clinic at Vanderbilt Children's Hospital from May through August 2019 for probable complex CHD. Twenty-seven individuals from 17 families participated in 62 phone interviews during pregnancy and postpartum: 27 conducted after the initial prenatal cardiology consultation, 15 after a follow-up prenatal visit, and 20 after birth. Applied thematic analysis approach was used to code and analyse transcribed interviews. Coding and codebook revisions occurred iteratively; intercoder reliability was >80%.

RESULTS

Patients included mothers (16 [59%]), fathers (8 [30%]), and other support persons (3 [11%]). Initial fetal diagnoses included a range of moderate to severe CHD. Prenatally, parents sought to maintain hope while understanding the diagnosis; planning for the future rather than focusing on day-to-day was more common if prognoses were better. Postnatally, with confirmation of prenatal diagnoses, parents' sense of control expanded, and they desired more active engagement in clinical decision making.

CONCLUSIONS

To enhance effective communication and support, understanding how parents conceptualise hope in relation to diagnosis and how that may evolve over time is critical. Expectant parents whose child has a significant risk of mortality may demonstrate hope by focusing on positivity. As prognostic uncertainty diminishes postpartum, the parental role on the team may shift, requiring clinicians to provide different support.

A review on deep-learning algorithms for fetal ultrasound-image analysis

Deep-learning (DL) algorithms are becoming the standard for processing ultrasound (US) fetal images. A number of survey papers in the field is today available, but most of them are focusing on a broader area of medical-image analysis or not covering all fetal US DL applications. This paper surveys the most recent work in the field, with a total of 153 research papers published after 2017. Papers are analyzed and commented from both the methodology and the application perspective. We categorized the papers into (i) fetal standard-plane detection, (ii) anatomical structure analysis and (iii) biometry parameter estimation. For each category, main limitations and open issues are presented. Summary tables are included to facilitate the comparison among the different approaches. In addition, emerging applications are also outlined. Publicly-available datasets and performance metrics commonly used to assess algorithm performance are summarized, too. This paper ends with a critical summary of the current state of the art on DL algorithms for fetal US image analysis and a discussion on current challenges that have to be tackled by researchers working in the field to translate the research methodology into actual clinical practice.

A Novel Framework for Abnormal Risk Classification over Fetal Nuchal Translucency Using Adaptive Stochastic Gradient Descent Algorithm

In most maternity hospitals, an ultrasound scan in the mid-trimester is now a standard element of antenatal care. More fetal abnormalities are being detected in scans as technology advances and ability improves. Fetal anomalies are developmental abnormalities in a fetus that arise during pregnancy, birth defects and congenital abnormalities are related terms. Fetal abnormalities have been commonly observed in industrialized countries over the previous few decades. Three out of every 1000 pregnant mothers suffer a fetal anomaly. This research work proposes an Adaptive Stochastic Gradient Descent Algorithm to evaluate the risk of fetal abnormality. Findings of this work suggest that proposed innovative method can successfully classify the anomalies linked with nuchal translucency thickening. Parameters such an accuracy, recall, precision, and F1-score are analyzed. The accuracy achieved through the suggested technique is 98.642.%.

'My biggest fear is that people will forget about him': Mothers' emotional transitions after terminating their pregnancy for medical reasons

AIMS AND OBJECTIVES

To explore women's emotional responses throughout the process of terminating a pregnancy for medical reasons.

BACKGROUND

Making the choice to terminate a desired pregnancy for medical reasons has a negative impact on women's health, as it is a distressing process that involves making hard decisions and readjusting one's expectations of an idealised pregnancy.

METHODS

A qualitative phenomenological study was conducted following the COREQ checklist. Fifteen semi-structured interviews and two focus groups were conducted with women who had terminated their pregnancies for medical reasons, previous to and during the COVID-19 lockdown. Subsequently, we analysed the content.

RESULTS

One main category, emotional journey during the process of terminating the pregnancy, and six subcategories were identified: (I) representation and desire to become a mother, (II) main concerns, (III) impact of the news, (IV) decision-making, (V) emotional responses before termination for medical reasons and (VI) emotional responses after termination for medical reasons. All contributed to understanding the specificities of the different phases that make up the emotional journey of terminating a pregnancy for medical reasons.

CONCLUSIONS

The findings of this study suggest that there are a number of predominant emotions that professionals need to be aware of in order to help women work through them and lessen the impact of pregnancy termination on their mental health. COVID-19 had different connotations depending on the women's experiences.

RELEVANCE TO CLINICAL PRACTICE

Our results highlight how important the role of healthcare staff is in caring for these women and their partners, which involves recognising their emotions throughout the process. Our results also underline how useful it is to conduct qualitative studies in this context, since they constitute a set of activities and interventions that result in the administration of nursing care in itself.

PATIENT OR PUBLIC CONTRIBUTION

The ultimate goal of the action research study is to design a positive mental health intervention. Participants will contribute to the design and final approval of the intervention.

End-of-life decisions in neonates and infants: a nationwide mortality follow-back survey

OBJECTIVES

Neonatology has undergone important clinical and legal changes; however, the implications for end-of-life decision-making in seriously ill neonates to date are unknown. Our aim was to examine changes in prevalence and characteristics of end-of-life decisions (ELDs) in neonatology.

METHODS

We performed a nationwide mortality follow-back survey in August 1999 to July 2000 and September 2016 to December 2017 in Flanders, Belgium. Data were linked to information from death certificates. For each death under the age of 1, physicians were asked to complete an anonymous questionnaire about which ELDs were made preceding death.

RESULTS

The response rate was 87% in 1999-2000 (253/292) and 83% in 2016-2017 (229/276). The proportion of deaths of infants born before 26 weeks' gestation was increased (14% vs 34%, p=0.001). Prevalence of ELDs remained stable at 60%, with non-treatment decisions occurring in about 35% of all deaths. Use of medication with an explicit life-shortening intention was prevalent in 7%-10% of all deaths. In early neonatal death (<7 days old) medication with an explicit life-shortening intention decreased from 12% to 6%, in late neonatal death (7-27 days old), it increased from 0% to 26%, and in postneonatal death (>27 days old), it increased from 2% to 10%.

CONCLUSIONS

Over a timespan of 17 year, the prevalence of neonatal ELDs has remained stable. A substantial number of deaths was preceded by the intentionally hastening of death by administrating medication. While surveying solely the physician perspective in this paper, there is a need for an open multidisciplinary debate, including, for example, nursing staff and family members, based on clinical as well as ethical and jurisdictional reflections to discuss the need for international guidelines.

Addressing Perinatal Mental Health Risk within a Fetal Care Center

Diagnosis of a fetal anomaly in pregnancy increases the risk for perinatal mental health difficulties, including anxiety, depression, and traumatic stress among expectant parents. Common emotional challenges include uncertainty about the diagnosis/prognosis, anticipated neonatal course, fears of fetal or neonatal demise, loss of a typical, uncomplicated pregnancy and postpartum course, and disruption of family roles due to medical care-related activities and restrictions. Psychologists in multidisciplinary fetal care centers are uniquely positioned to assess mental health risks and address the needs of expectant parents. Psychologists bring additional expertise in screening and assessment, clinical interventions to promote coping and symptom reduction while preparing for birth and a complicated neonatal course, consultation and effective communication, and programmatic development. This review paper provides an overview of the challenges and behavioral health risks for expectant parents carrying a fetus with a birth defect and the unique role psychologists play to support patients and families within fetal care settings.

On the Epistemic Status of Prenatal Ultrasound: Are Ultrasound Scans Photographic Pictures?

Medical imaging is predominantly a visual field. In this context, prenatal ultrasound images assume intense social, ethical, and psychological significance by virtue of the subject they represent: the fetus. This feature, along with the sophistication introduced by three-dimensional (3D) ultrasound imaging that allows improved visualization of the fetus, has contributed to the common impression that prenatal ultrasound scans are like photographs of the fetus. In this article we discuss the consistency of such a comparison. First, we investigate the epistemic role of both analogic and digital photographic images as visual information-providing representations holding a high degree of objectivity. Second, we examine the structure and process of production of ultrasound scans and argue that a comparison between two-dimensional (2D) ultrasound and photography is justified. This is in contrast to 3D ultrasound images that, due to the intensive mathematical processing involved in their production, present some structural issues that obfuscate their ontological and epistemic status.

Prenatal diagnosis of syndromic alobar holoprosencephaly associated with digynic triploidy fetus

Holoprosencephaly (HPE) is a dramatic human brain malformation sequence with an extreme variable phenotypic spectrum and genetic heterogeneity, variable degree of severity and unknown etiology, in many cases. HPE is classified into syndromic, chromosomal, and non-syndromic, non-chromosomal. The most cases of HPE are syndromic. We present an atypical case of syndromic alobar HPE associated with digynic triploidy fetus, prenatally diagnosed, early at 18 weeks of gestation, by ultrasound (US) and complex genetic investigations. The US examination was performed with a specialized US machine, General Electric Voluson E10 OLED BT18, using two-dimensional (2D) scanning, three-dimensional (3D) image reconstruction, four-dimensional (4D) spatiotemporal image methodology and the highest power Doppler US technology. A detailed US examination of the fetus revealed several major abnormalities of the fetal head and severe facial malformations. Based on the antenatal US findings, the fetus was diagnosed with alobar HPE. After a careful examination and genetic counseling, additional cytogenetic investigations and molecular genetic analyses were performed, which revealed an abnormal number of 69 chromosomes, digynic triploidy (69,XXY). Two days later, the parents choose to interrupt the current gestation because of major fetal malformations. The pathological examination of the embryo reaffirmed the antenatal diagnostics.

Healthcare professionals' attitudes towards termination of pregnancy at viable stage

INTRODUCTION

Upon prenatal diagnosis of congenital malformations, termination of pregnancy (TOP) may be an option, sometimes at a gestational age when the fetus is already viable (late TOP). We aimed to study attitudes towards late TOP of all tertiary healthcare professionals involved in late TOP practice.

MATERIAL AND METHODS

A mail survey was conducted among all physicians and paramedical professionals involved in late TOP decision-making in all eight centers with a Neonatal Intensive Care Unit in Flanders, Belgium (N = 117). The questionnaire contained general and case-based attitude items.

RESULTS

Response rate was 79%. Respondents were either physicians (51.1%) or paramedical professionals (49.9%). The composition of professionals involved in late TOP decision-making was heterogeneous between the eight centers. Late TOP was highly accepted in both lethal fetal conditions (100%) and serious (but not lethal) fetal conditions (95.6%). Where the fetus is healthy, 19.8% of respondents agreed with late TOP for maternal psychological problems and fewer respondents (13.2%) agreed with late TOP in the case of maternal socio-economic problems (P = .002). Physicians more often preferred feticide over neonatal palliative care in the case of non-lethal fetal conditions compared with paramedical professionals (68.1% vs 53.2%, P = .013). Almost nine out of ten respondents (89.1%) agreed that in the event of a serious (non-lethal) neonatal condition, administering drugs with the explicit intention to end neonatal life was acceptable. Behavioral intentions indicate that even in situations with an unclear diagnosis and unpredictable prognosis, 85.6% of professionals would still consider late TOP.

CONCLUSIONS

Healthcare professionals practicing late TOP in Flanders, Belgium have a high degree of tolerance towards late TOP, irrespective of sociodemographic factors, and are demanding legislative change regarding active life-ending in the fetal and neonatal periods. Further research should explore the correlation of attitudes to late TOP with actual medical decisions taken in daily clinical practice.

Uncertainty of Prenatally Diagnosed Congenital Heart Disease: A Qualitative Study

IMPORTANCE

Parents who receive a prenatal diagnosis of congenital heart disease may experience more short- and long-term stress than those who receive a postnatal diagnosis. To identify potential interventions to ameliorate that stress, the longitudinal emotional experience of parents must first be understood.

OBJECTIVE

To better understand parents' accounts of their own prenatal experience, particularly aspects they found to be stressful or challenging, and to identify strategies to improve support.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study included analysis of transcripts of audio recorded telephone interviews with pregnant mothers and their support persons, as applicable, who were referred to and seen at the Fetal Cardiology Clinic at Vanderbilt Children's Hospital from May 2019 to August 2019 with an initial likely diagnosis of complex congenital heart disease at any gestational age. Data analysis was conducted from August 2019 to November 2019.

MAIN OUTCOMES AND MEASURES

An applied thematic analysis approach was used to code and analyze professionally transcribed interviews. Coding and codebook revisions occurred iteratively; intercoder reliability was assessed and confirmed routinely. One author coded all transcripts; a second author independently reviewed one-fifth of the transcripts at fixed intervals to ensure that interrater reliability remained greater than 80%.

RESULTS

Twenty-seven individuals from 17 families participated in 42 phone interviews during pregnancy, 27 conducted at the first time point after the initial prenatal cardiology consultation and 15 at the second time point after a follow-up prenatal cardiology visit. Most interviewees were mothers (16 interviewees [59%]; median [interquartile range] age, 30.0 [27.3-34.8] years) or fathers (8 interviewees [30%)], with a few support individuals (3 interviewees [11%]) (median [interquartile range] age of family member or support individual, 30.0 [26.0-42.0] years). Initial fetal diagnoses included a range of severe congenital heart disease. Uncertainty was identified as a pervasive central theme and was related both to concrete questions on scheduling, logistics, or next steps, and long-term unknown variables concerning the definitiveness of the diagnosis or overall prognosis. Practitioners helped families through their framing of uncertainty at various time points including before, during, and after the clinic visit.

CONCLUSIONS AND RELEVANCE

Families walk an uncertain path following a fetal diagnosis of severe congenital heart disease. The challenges faced by the cardiologists caring for them overlap in many ways with those experienced by pediatric palliative care practitioners. Potential future interventions to improve parental support were identified in the areas of expectation setting before the referral visit, communication in clinic, and identity formation after the new diagnosis.

Neonatologists and neonatal nurses have positive attitudes towards perinatal end-of-life decisions, a nationwide survey

AIM

Perinatal death is often preceded by an end-of-life decision (ELD). Disparate hospital policies, complex legal frameworks and ethically difficult cases make attitudes important. This study investigated attitudes of neonatologists and nurses towards perinatal ELDs.

METHODS

A survey was handed out to all neonatologists and neonatal nurses in all eight neonatal intensive care units in Flanders, Belgium in May 2017. Respondents indicated agreement with statements regarding perinatal ELDs on a Likert-scale and sent back questionnaires via mail.

RESULTS

The response rate was 49.5% (302/610). Most neonatologists and nurses found nontreatment decisions such as withholding or withdrawing treatment acceptable (90-100%). Termination of pregnancy when the foetus is viable in cases of severe or lethal foetal problems was considered highly acceptable in both groups (80-98%). Physicians and nurses do not find different ELDs equally acceptable, e.g. nurses more often than physicians (74% vs 60%, p = 0.017) agree that it is acceptable in certain cases to administer medication with the explicit intention of hastening death.

CONCLUSION

There was considerable support for both prenatal and neonatal ELDs, even for decisions that currently fall outside the Belgian legal framework. Differences between neonatologists' and nurses' attitudes indicate that both opinions should be heard during ELD-making.

Perinatal Palliative Care Birth Planning as Advance Care Planning

Purpose of Review: A significant number of pregnancies are complicated by a fetus with a life-limiting diagnosis. As diagnoses are made earlier in the pregnancy, families experience anticipatory grief and are faced with navigating goals of care for a baby that has yet to be born. With the support of the care team, families can begin to grieve, plan, and make meaningful memories during the duration of the pregnancy, the birth of their baby, and life of the child. Creating a palliative care birth plan, which expands beyond the traditional concept for delivery planning to include prenatal, perinatal, and neonatal care has become an important method for parents to process the diagnosis, for parents to document their wishes, and for members of the care team to communicate with the goal of supporting and enhancing the experience of the family. This articles reviews recent and relevant literature on the importance of birth planning and the role of perinatal palliative care when a life-limiting fetal diagnosis is made. Recent Findings: The process of birth planning is an important component of perinatal palliative care. Through this process, families can express their fears, values, hopes, and wishes. It also offers an opportunity for providers to communicate these wishes for the remainder of the pregnancy, the delivery, birth, and time afterwards. This has been demonstrated to decrease maternal stress and promote family centered care. Summary: Perinatal birth planning is an important component of perinatal palliative care when a fetus has a life-limiting diagnosis. The process of birth planning can be supportive and therapeutic as well as an important communication tool. With multiple practices and designs of perinatal palliative care programs, there are no standard tools even though important components have been identified. Ultimately, the strategies outlined here can be used as advance care planning tools.

Psychosocial Profile and Reproductive Decisions of Women Undergoing Pregnancy Termination for Medical Reasons-A Cross-Sectional Study

BACKGROUND

The study aims to define the profile of women who decide to exercise their right to terminate a pregnancy and their future reproductive plans.

METHODS

Patients found eligible for termination for medical reasons between 2014 and 2016 were asked to complete an anonymous survey consisting of sixty questions examining the determinants of the decision to terminate a pregnancy. In total, 150 completed surveys were returned (62.5%).

RESULTS

Environmental factors, such as age, education, place of residence, marital status and financial status did not affect the decision-making process. The majority of the respondents were females under 35 years of age (71.3%). In most cases, the pregnancies had been planned and long-awaited (62.7%). The study also indicated that 22.6% of the patients who had been against abortion changed their mind when they encountered problems themselves. In addition, 20% of them changed their views on the acceptability of abortion. Termination had an impact on the participants future reproductive plans. Eighteen percent of the patients said they were definitely not planning more pregnancies. The majority (84.09%) of these women said that the reason was the traumatic experiences related to their pregnancy.

CONCLUSIONS

The personal experience of a pregnancy termination procedure changed women's opinions about pregnancy termination and modified further reproductive plans.

Epistemic Virtue, Prospective Parents and Disability Abortion

Research shows that a high majority of parents receiving prenatal diagnosis of intellectual disability terminate pregnancy. They have reasons for rejecting a child with intellectual disabilities-these reasons are, most commonly, beliefs about quality of life for it or them. Without a negative evaluation of intellectual disability, their choice makes no sense. Disability-based abortion has been critiqued through virtue ethics for being inconsistent with admirable moral character. Parental selectivity conflicts with the virtue of acceptingness (the commitment to welcome whatever child comes naturally) and exhibits the vice of wilfulness (the project of picking and choosing what children one will take). In this paper I claim that, beyond failures of moral virtue, disability abortion often involves failures of epistemic virtue on the part of parents. I argue two things: parents believe something false, or at least contested, about life with intellectual disability-and they do so because they are not epistemically conscientious. I first explain why a central motivation for disability abortion-that it prevents harm to the child-is mistaken. I next give a brief account of intellectual virtue and culpable ignorance. I then indicate why many parents fail to be intellectually virtuous when choosing to terminate pregnancy. I focus on elimination of intellectual disability and have little to say about physical and sensory impairments.

Perinatal Palliative Care: A qualitative study evaluating the perspectives of pregnancy counselors

BACKGROUND

A prenatal diagnosis of a life-limiting disease raises complex ethical, emotional, and medical issues. Studies suggest that 40%-85% of parents decide to continue the pregnancy if given the option of Perinatal Palliative Care. However, structured Perinatal Palliative Care programs are missing in many European countries. In Germany, parents have the right to free psychosocial support from pregnancy counseling services after the prenatal diagnosis of a life-limiting disease.

AIM

We aimed to investigate whether German professional pregnancy counselors perceive the need for structured Perinatal Palliative Care and if so, how it should be conceived.

DESIGN

This is a qualitative interview study with purposeful sampling. The interviews were analyzed with the coding method of Saldaña.

SETTING/PARTICIPANTS

A total of 10 professionals from three different pregnancy counseling services participated in the study.

RESULTS

The main topics raised by the professionals were as follows: (1) counseling and parental support during the decision-making process; (2) fragmented or missing support infrastructure for parents; and (3) challenges, hesitations, and barriers, particularly from the different stakeholders, regarding a Perinatal Palliative Care framework. They highlighted the importance of the integration of Perinatal Palliative Care in existing structures, a multi-professional approach, continuous coordination of care and education for all healthcare providers involved.

CONCLUSION

A structured Perinatal Palliative Care program is considered as necessary by the pregnancy counselors. Future research should focus on (1) needs reported by concerned parents; (2) attitude and role of all healthcare providers involved; (3) strategies to include stakeholders in the development of Perinatal Palliative Care networks; and (4) outcome parameters for evaluation of Perinatal Palliative Care frameworks.

"He looks gorgeous" - iuMR images and the transforming of foetal and parental identities

The MERIDIAN study examined whether in-utero MRI (iuMRI) improves the accuracy of diagnosis of foetal brain abnormalities, when used as an adjunct to ultrasound anomaly scanning. A diagnostic iuMRI differs from routine ultrasound screening because of its infrequent use and scanning procedure. Nested within this trial, this sociological study explored the acceptability of iuMRI as a technology and its contribution to parental decision-making. Our sociological interpretation of the role of iuMR images in prenatal diagnosis draws on narrative interviews with women (and some partners) who underwent MRI imaging at three different centres. Overall, participants found iuMRI helpful in decision-making because it either confirmed or disconfirmed previous results, or provided additional information. Expectant couples experienced the iuMR imaging process as informative, but also as having emotive and practical value. Our paper extends the existing sociological literature on antenatal testing and visualising the foetus, by using iuMR diagnostic imaging to further explore the concept of the unborn entity. Our data suggest that alongside the iuMR images, the 'parental gaze' and accompanying commentary are used by parents to construct and transform foetal and parental identities despite ongoing uncertainties about, and shifting social contexts to their pregnancy.

Role of Social and Informational Support while Deciding on Pregnancy Termination for Medical Reasons

Background: Poland is a country with restrictive laws concerning abortion, which is only allowed if the mother’s life and health are in danger, in case of rape, and severe defects in the fetus. This paper specifies the forms of support expected by women considering termination from their family, people in their surroundings and professional medical personnel. Methods: Between June 2014 and May 2016 patients eligible to terminate a pregnancy for medical reasons were asked to complete an anonymous survey consisting of sixty questions to determine patient profile and forms of support expected from the society, family and professional medical personnel as well as to assess informational support provided. Results: Women do not take into consideration society’s opinion on pregnancy termination (95%). The majority of the respondents think that financial support from the state is not sufficient to provide for sick children (81%). Despite claiming to have a medium standard of life (75%), nearly half of the respondents (45%) say that they do not have the financial resources to take care of a sick child. The women have informed their partner (97%) and closest family members (82%) and a low percentage have informed friends (32%). Nearly one third (31%) have not talked to the attending gynecologist about their decision. Conclusions: The decision to terminate a pregnancy is made by mature women with a stable life situation—supported by their partner and close family. They do not expect systemic support, as they believe it is marginal, and only seek emotional support from their closest family. They appreciate support provided by professional medical personnel if it is personal.

Challenging issues arising in counseling families experiencing holoprosencephaly

The provision of information and support to families experiencing holoprosencephaly (HPE) in a loved one is unequivocally challenging, even for the most experienced clinicians. It deserves the balance of pertinent information coupled with medical guidance that forms the basis for shared decision-making; all of which is ideally contained within a supportive environment. It requires a willingness to carefully listen to the specific concerns of the parents and family allowing them to revisit challenging issues as much as needed to encourage existing road blocks to be resolved. It necessitates that professionals see each and every family as unique, without preconceived notions about what is or is not important and being prepared to accept thoughts and decisions that may not fit with the professional's own beliefs. To some, this may sound impractical, inefficient, or even impossible within the time constrained models of modern day clinical services. However, in practice, this patient-focused approach is arguably the most essential step in providing "personalized medicine" to the populations we encounter. This manuscript is intended to provide a brief review of relevant literature and case discussions to highlight issues for families learning of the diagnosis of HPE during a pregnancy, at birth, during childhood or more rarely, in adolescence.

A post-mortem population survey on foetal-infantile end-of-life decisions: a research protocol

BACKGROUND

The death of a child before or shortly after birth is frequently preceded by an end-of-life decision (ELD). Population-based studies of incidence and characteristics of ELDs in neonates and infants are rare, and those in the foetal-infantile period (> 22 weeks of gestation - 1 year) including both neonates and stillborns, are non-existent. However, important information is missed when decisions made before birth are overlooked. Our study protocol addresses this knowledge gap.

METHODS

First, a new and encompassing framework was constructed to conceptualise ELDs in the foetal-infantile period. Next, a population mortality follow-back survey in Flanders (Belgium) was set up with physicians who certified all death certificates of stillbirths from 22 weeks of gestation onwards, and infants under the age of a year. Two largely similar questionnaires (stillbirths and neonates) were developed, pilot tested and validated, both including questions on ELDs and their preceding decision-making processes. Each death requires a postal questionnaire to be sent to the certifying physician. Anonymity of the child, parents and physician is ensured by a rigorous mailing procedure involving a lawyer as intermediary between death certificate authorities, physicians and researchers. Approval by medical societies, ethics and privacy commissions has been obtained.

DISCUSSION

This research protocol is the first to study ELDs over the entire foetal-infantile period on a population level. Based on representative samples of deaths and stillbirths and applying a trustworthy anonymity procedure, the research protocol can be used in other countries, irrespective of legal frameworks around perinatal end-of-life decision-making.

MRI for Fetal Developmental Brain Abnormalities: Perspectives From the Pregnant Patient

Ultrasound is routinely used as a prenatal screening and diagnostic tool but has limitations. Some anomalies in the developing fetal brain can be difficult to detect, and in utero magnetic resonance imaging (iuMRI) is increasingly used as an adjunct to ultrasound. However, understandings of patient perspectives of iuMRI technology are still developing. Our qualitative study of 41 mothers who experienced iuMRI was embedded in a diagnostic accuracy trial and aimed to inform policy recommendations that might stem from the clinical findings. Our analysis suggests that iuMRI is seen as useful, offering valuable additional information and helping women make decisions about care options at a difficult time. However, patients' experiences demonstrated the uncertainty and anxiety associated with the prenatal diagnosis (PND) process relating to brain anomalies including the challenges of their embodied contributions. Our findings suggest more could be done to reduce the impact on pregnant women during an already difficult, anxious period.

Diagnosis of a severe congenital anomaly: A qualitative analysis of parental decision making and the implications for healthcare encounters

Objective

To explore parental decision making following diagnosis of a severe congenital anomaly, and implications for healthcare encounters.

Design

Qualitative semi‐structured interviews with 38 parents‐to‐be were collated and triangulated with data generated from consultation recordings.

Analysis

Data were analysed using a constant comparative‐based approach.

Setting

Recruitment was undertaken across four fetal medicine sites in two tertiary referral trusts.

Participants

Parents‐to‐be whose pregnancy was suspected or diagnosed as being affected by a severe congenital anomaly. This sample was purposive to include known factors affecting the decision to terminate or continue the affected pregnancy.

Findings

In trying to make a decision about how to proceed with their pregnancy, parents‐to‐be typically had to work hard to negotiate multiple uncertainties around the diagnosis and prognosis of the suspected anomaly. This was influenced by parents’ capacity to cope with uncertainty and the way in which uncertainty was managed by the clinical team. This negotiation of uncertainty was enacted within a fluid, nonlinear three‐phase process: “information seeking,” reflecting the way parents‐to‐be face the uncertainty associated with a fetal diagnosis and associated prognosis; “implications,” where consideration is given to future consequences of the decision; and “decision making,” which reflects the way in which the decision is made (head‐ or heart‐led). Spectrums of responses were apparent within each phase.

Conclusions

This study provides important insights into how parents‐to‐be make decisions following diagnosis or suspicion of a severe congenital anomaly. The impact of these on healthcare encounters is discussed, alongside recommendations for clinical practice.

Norwegian obstetricians' experiences of the use of ultrasound in pregnancy management. A qualitative study

OBJECTIVE

To explore obstetricians' experiences and views of the use of obstetric ultrasound in clinical management of pregnancy.

METHODS

A qualitative interview study was undertaken in 2015 with obstetricians (N = 20) in Norway as part of the CROss Country Ultrasound Study (CROCUS).

RESULTS

Three categories developed during analyses. 'Differing opinions about ultrasound and prenatal diagnosis policies' revealed divergent views in relation to Norwegian policies for ultrasound screening and prenatal diagnosis. Down syndrome screening was portrayed as a delicate and frequently debated issue, with increasing ethical challenges due to developments in prenatal diagnosis. 'Ultrasound's influence on the view of the fetus' illuminated how ultrasound influenced obstetricians' views of the fetus as a 'patient' and a 'person'. They also saw ultrasound as strongly influencing expectant parents' views of the fetus, and described how ultrasound was sometimes used as a means of comforting women when complications occurred. 'The complexity of information and counselling' revealed how obstetricians balanced the medical and social aspects of the ultrasound examination, and the difficulties of 'delivering bad news' and counselling in situations of uncertain findings.

CONCLUSION

This study highlights obstetricians' experiences and views of ultrasound and prenatal diagnosis in Norwegian maternity care and the challenges associated with the provision of these services, including counselling dilemmas and perceived differences in expectations between caregivers and expectant parents. There was notable diversity among these obstetricians in relation to their support of, and adherence to Norwegian regulations about the use of ultrasound, which indicates that the care pregnant women receive may vary accordingly.

Early unexpected diagnosis of fetal life-limiting malformation; antenatal palliative care and parental decision

INTRODUCTION

Conjoined twins are an infrequent occurrence in obstetric practice. Live-conjoined twins on a late preterm triplet pregnancy is an even rarer event.

OBJECTIVE

The objective of this study is to emphasize the critical importance of perinatal palliative care and non-directive parental counseling, informed decision making and respect for autonomy following full disclosure of findings, fetal life-limiting diagnosis, treatment alternatives, maternal-fetal potential complications, and most likely perinatal outcomes.

METHODS

Early surprise prenatal diagnosis, comprehensive parental counseling, palliative care, and perinatal care of a set of conjoined twins and a singleton.

RESULTS

Cesarean delivery of a set of conjoined twins and a singleton at 34 weeks' gestation. Immediate neonatal death of the conjoined twins, intact survival, and discharge of the singleton. Review of the database on previously reported similar cases. It is very important to utilize simple and direct language for parents to understand the grave prognosis to the pregnancy. Care alternatives in view of the maternal physical risks and psychological impact of carrying a high order abnormal multiple pregnancy, along with the possible side effects on the singleton.

Breaking bad news in prenatal medicine: a literature review

BACKGROUND

The diagnosis of a fetal anomaly in perinatal medicine forces expectant parents and healthcare providers to face the difficult process of breaking bad news.

OBJECTIVES

This exploratory literature review was aimed at providing a medical and psychological view of the psychological experience in expectant parents and physicians in the context of prenatal diagnosis of a fetal anomaly.

METHOD

An exploratory search of PubMed and PsycINFO/PsycARTICLES databases performed by an interdisciplinary team composed of a physician and psychologists. Search terms were: prenatal diagnosis AND bad news; prenatal diagnosis AND psychological consequences; prenatal diagnosis AND psychological sequelae; prenatal diagnosis AND fetal abnormality. The processing of selected articles followed a standardised five-step procedure.

RESULTS

A total of 860 articles were screened of which 32 were retained for analysis. Four main themes emerged from the explanatory content analysis: (1) parents' subjective experience; (2) physicians' subjective experience; (3) encounters between expectant parents and professionals; and (4) ethical challenges in breaking bad news in prenatal medicine.

CONCLUSION

Expectant parents go through a complex and multidimensional experience when the diagnosis of a fetal anomaly is disclosed. Simultaneously, physicians consider breaking bad news as a very stressful event and are poorly prepared in this regard. A better knowledge of factors underlying psychological adjustment of the parental dyad and on the subjective experience of physicians delivering these diagnoses could enable better adaptation for both patients and professionals.

Coping strategies of pregnant women following unexpected ultrasound results, Alexandria, Egypt

BACKGROUND

Receiving a diagnosis of a potential fetal anomaly causes severe stress to a pregnant woman. Little is known about the coping strategies used by these women, especially in Egypt.

OBJECTIVE

This study explored the coping strategies used by women following unexpected findings in routine antenatal ultrasound scan in Alexandria, Egypt.

PATIENTS AND METHODS

A mixed method (convergent parallel) quantitative and qualitative approach was used to target pregnant women at 20-32 weeks of gestation. The quantitative study included 93 women, whereas the qualitative one included a purposively chosen subsample of 30 women representing diverse diagnoses. A 10-item questionnaire was used in the quantitative part to assess active, avoidant, and negative coping strategies. In the qualitative part, coping was assessed by analyzing the transcripts of women's experiences.

RESULTS

Although women used equal numbers of avoidant and active strategies (3.34±0.56 vs. 3.30±0.73, Z=0.273, P=0.78), the reported effectiveness of active strategies ranked higher than that of the avoidant ones (χ=54.64, P<0.001). Women with an education level up to high school or higher perceived high effectiveness of active and/or avoidant strategies compared with women with less education (χ=4.087, P<0.05).

CONCLUSION AND RECOMMENDATIONS

Women concurrently used more than one coping strategy. The effectiveness of active strategies was higher than that of the avoidant ones. The educational level was the only factor associated with perceived high effectiveness of active and/or avoidant strategies. Helping future mothers acquire active coping skills through counseling sessions and support groups are recommended.

When fetal hydronephrosis is suspected antenatally--a qualitative study

Background

The information about fetal malformation findings during the ultrasound examination often comes unexpectedly, and the women and their partners may not necessarily receive any conclusive statement on the prognosis. A finding such as fetal hydronephrosis range from being a soft markers or mild anomaly, to a serious condition associated with neonatal morbidity and mortality. The aim of this study was to explore women’s reactions to the discovery of fetal hydronephrosis in the context of uncertainty regarding the prognosis.

Methods

Ten women were interviewed and the interviews were conducted six to twelve months after the women gave birth. They had experience of suspected fetal hydronephrosis in gestational week 18–20. The interviews were recorded, transcribed verbatim and analysed using constant comparative analysis.

Results

The core category, ‘Going through crisis by knowing that you are doing the right thing’ illustrates the meaning of women’s reactions and feelings. It illuminates the four categories: ‘When the unexpected happens’– on the one hand, women had positive views that the suspicious malformation could be discovered; however, on the other hand, women questioned the screening. ‘To live in suspense during pregnancy’ – the suspicious malformation caused anxiety and was a stressful situation. ‘Difficulties in understanding information’ – the women thought they had limited knowledge and had difficulties in understanding the information. ‘Suppress feelings and hope for the best’ – the women tried to postpone the problem and thought they should deal with it after delivery.

Conclusions

Women are worried irrespective of suspicious or severe malformations, and in need of information and counselling tailored to their individual needs. Other sources of support could be: written information, links to reliable sources on the Internet and possibilities for ongoing follow-ups.

Renal oligo- and anhydramnios: cause, course and outcome--a single-center study

PURPOSE

To evaluate the outcome of patients with renal oligohydramnios and explore the impact of patient variables on outcome and prognosis.

METHODS

A retrospective single-center study was conducted analyzing 104 pregnancies complicated by oligohydramnios of renal origin from 2001 to 2011. Statistical analysis was performed to assess the influence of pre- and postnatal data on pregnancy outcome, morbidity and mortality.

RESULTS

Prenatal renal diagnoses were as follows: hydronephrosis/megaureter: n = 21 (20.2 %), aberrance in renal form or location: n = 7 (6.7 %), cystic renal disease: n = 28 (26.9 %), renal dysplasia: n = 24 (23.1 %), renal agenesis: n = 42 (30.4 %), posterior urethral valves: n = 11 (10.6 %). Hydronephrosis/megaureter and late onset of oligohydramnios were prognostic factors for fetal survival, whereas renal agenesis and associated anomalies had a negative impact on pregnancy outcome. Prenatal interventions did not improve prognosis.

CONCLUSIONS

Pregnancies complicated by renal oligohydramnios still have a poor outcome. Careful weighing of prognostic factors is necessary to decide about further therapeutic measures.

The experience of pregnant women with a diagnosis of fetal lower urinary tract obstruction (LUTO)

OBJECTIVE

to gain insight into the experiences and perspectives of pregnant women diagnosed antenatally with fetal lower urinary tract obstruction (LUTO) participating in an interventional fetal medicine randomised controlled trial (RCT).

DESIGN

a qualitative study using semi-structured interviews. Interviews were analysed using Riessman's narrative analysis.

SETTING

fetal medicine clinics within the United Kingdom National Health Service (NHS).

PARTICIPANTS

five pregnant women who were recruited as part of an RCT and two additional women who were recruited after the trial was terminated before completion.

FINDINGS

three themes were identified and form the basis of this article: the use of technology in pregnancy, the loss of a normal pregnancy, and decision making in uncertainty.

IMPLICATIONS AND CONCLUSIONS

undertaking qualitative research within an RCT can illuminate the experience of the condition being studied. Women's experience of a pregnancy where LUTO was diagnosed in the fetus entailed an emotional journey following the visualisation of the abnormality through the use of routine ultrasound screening. Women tried to make sense of the diagnosis in order to make the best, albeit less than ideal, decisions for themselves, their baby, and their family. Midwives are in a good position to support women through the emotional distress of diagnosis and to help them negotiate the uncertain terrain in which they make decisions.

Lack of institutional pathways for referral: results of a survey among pediatric surgeons on prenatal consultation for congenital anomalies

OBJECTIVE

This paper aimed to assess pathways through which pediatric surgeons receive couples for prenatal consultation after prenatal diagnosis.

METHOD

A questionnaire was mailed to pediatric surgical centers to assess the following: (1) surgical caseload per year; (2) number of centers in which prenatal consultation is offered; (3) presence of a 'structured' prenatal consultation clinic; (4) number of consultations per year; (5) pathways for referral to the pediatric surgeon; and (6) the availability of psychological counseling.

RESULTS

Response rate was 81%, (42/52 centers). Thirty-eight centers (93%) offered prenatal consultation. Seven centers (18%) reported to have a 'structured' clinic in terms of time and location. In 13 centers (34%), 1-9 consultations were carried out, from 10 to 19 in 18 centers (47%), from 20 to over 50 in 7 centers (18%). In 34 centers, internal referrals from the obstetric departments were counseled, and in 28 centers, there were also external referrals. Eleven centers reported that couples were self-referred. Information regarding prenatal counseling was available on the institutional website in 10/38 (26%) centers. Psychological counseling was available in 36 centers.

CONCLUSION

Despite the fact that the majority of pediatric surgical centers provides prenatal consultation, caseloads are very variable as are referral modalities.

Decision-making after prenatal diagnosis of a syndrome predisposing to intellectual disability: what prospective parents need to know and the importance of non-medical information

BACKGROUND

Recently researchers have suggested that non-medical information may impact the decision to continue or terminate a pregnancy after a prenatal diagnosis. This study is an investigation of what type of information prospective parents need for this decision-making in the case of a condition predisposing to intellectual disability.

METHOD

Semistructured interviews were conducted in France, Belgium, and Germany with 33 parents whose children have a syndrome that predisposes to intellectual disability.

RESULTS

The essential information related to three dimensions: (1) the foetus as a future child and an individual person; (2) the couple as future parents; and (3) the social environment of the future child and his or her parents, and especially the ability of the social environment to provide support.

CONCLUSIONS

The findings introduce a new perspective on these prospective parents' essential needs, highlighting that these needs are not limited to medical information but encompass non-medical information and institutional patterns.

What parents say about disclosing the end of their pregnancy due to fetal abnormality

OBJECTIVE

to describe men's and women's experiences of deciding whether to tell people in their social network, including their children, about their pregnancy loss following a termination for fetal abnormality.

DESIGN

secondary analysis of qualitative narrative interview data informed by a critical realist approach.

SETTING

respondents were recruited throughout the United Kingdom and interviewed at home between 2004 and 2005.

PARTICIPANTS

twenty-eight women and nine men who had ended a pregnancy diagnosed with a fetal abnormality and who talked about disclosing or not disclosing the termination to others.

FINDINGS

few respondents reported having any advice or information about whether or how to disclose their termination. None said they completely concealed their decision from adults in their social network; most said they disclosed selectively, telling close friends and family they had terminated and acquaintances they had miscarried. Most respondents reported telling their young children that the baby had died but did not reveal that they had chosen to end the pregnancy. A minority had not told their existing offspring about the pregnancy loss. Common reasons given for (partially) concealing a termination were: guilt over the decision; to avoid being judged; and to protect other people's feelings. Common reasons for disclosure were: others knew of the pregnancy; needing time off work; needing practical help and/or emotional support during diagnosis and termination; and wanting recognition of their loss. Positive consequences of disclosure were said to be getting more support and less criticism than expected; negative consequences included not getting the anticipated support and empathy; and encountering disapproval. Some respondents felt that concealing their pregnancy loss from their children had resulted in their confusion over the cause of their parents' distress. Some men said they found it hard to access emotional support from their social networks because of expectations about how men 'should' deal with emotions.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

midwives have to make difficult judgements about what, how and when to provide information when trying to support and advise parents who have ended a pregnancy due to fetal abnormality. Further education and training in this area could be of benefit. Midwives could signpost parents to existing sources of advice around disclosure, taking into account parents' individual preferences, help parents to consider the potential implications of disclosure and concealment and different ways of disclosing. They could also recommend alternative sources of emotional support, bearing in mind that men in particular may find it harder to access support from their social networks.

Trends in fetal indications for termination of pregnancy between 2002 and 2010 at a tertiary referral centre

OBJECTIVE

We reviewed the data of the termination of pregnancy (TOP) cases between 2002 and 2010 to evaluate the changes in fetal indications for both early and late TOPs in this period.

MATERIAL AND METHODS

The data of 962 TOP cases were analysed in two groups according to the periods as in 2002-2006 and 2007-2010. The women were also subdivided into two categories according to their gestational age; <23 weeks' gestation (early termination) and ≥23 weeks' gestation (late termination).

RESULTS

Four hundred and fifty-eight (47.6%) of TOPs were performed between 2002 and 2006 (Group 1) and 504 (52.3%) were performed between 2007 and 2010 (Group 2). The number of early (<23 weeks) and late (≥23 weeks) terminations were 583 (60.6%) and 379 (39.3%), respectively. The vast majority of anomalies were central nervous sytem malformations (51.8%). They were followed by multiple anomalies (10.2%) and chromosomal anomalies (9.4%). Chromosomal and cardiovascular system anomalies were significantly higher in 2007-2010 in comparison to 2002-2006 (p<0.0001 and p=0.002, respectively). There was no statistically significant difference between the fetal indications that led to early termination compared to those that led to late termination.

CONCLUSION

The distribution of indications for TOP was influenced by the development in prenatal screening policy, resulting in a significant increase in terminations due to chromosomal and cardiovascular system anomalies. Cultural, educational, religious and legal factors cause differences in the indications for TOP as well as the gestational age that TOPS are performed.

Systematic review of the literature: parental outcomes after diagnosis of fetal anomaly

Advancing technology has made detecting fetal abnormalities in the first and second trimesters a reality. Few families are prepared for the difficult decisions that must be made if their unborn children are diagnosed with a life-limiting condition. Expectant parents are compelled to make decisions on the basis of limited options. A systematic review of the literature is presented with an aim to inform clinicians of parental experiences and outcomes after diagnosis of a fetal anomaly. The review focused on patients given a diagnosis for fetal anomalies for the 40-year period from 1970 to 2010 by using the key words such as fetal anomaly, congenital malformations, pregnancy termination, perinatal palliative care, and perinatal hospice. Regardless of the option taken, women often experienced intense grief reactions. Both giving birth to a child with a life-limiting condition and termination of pregnancy for fetal anomaly can be emotionally traumatic life events, both associated with psychological morbidity. Nonaggressive obstetric management, allowing natural birth without life-sustaining therapeutics, is an option for families. Couples presented with a coordinated perinatal palliative care model may opt to continue their pregnancy. Families who experienced perinatal hospice/palliative care report positive feedback, but more research is needed to explore the psychological outcomes of this choice.