Medical and ethical considerations in twin pregnancies discordant for serious cardiac disease

Factors That Influence Parents' Decision-Making Regarding Termination of Pregnancy After Prenatal Diagnosis of Fetal Congenital Heart Disease

OBJECTIVE

To explore factors that influence parents' decisions regarding the termination of pregnancy after the detection of fetal congenital heart disease (CHD).

DESIGN

A prospective descriptive study.

SETTING

The Institute of Pediatric Cardiology in the Schneider Children's Medical Center.

PARTICIPANTS

One hundred twenty couples (240 participants) with fetuses prenatally diagnosed with CHD, which was defined as conditions requiring surgical treatment.

METHODS

We obtained data from a structured questionnaire for the pediatric cardiologist, the medical records, and structured self-report questionnaires for the participants.

RESULTS

Thirty-six of 120 couples (30%) decided to terminate the pregnancy after a prenatal diagnosis of fetal CHD. The main factors associated with the decision to terminate were low gestational age (OR = 0.83 per week, 95% confidence interval [CI] [0.75, 0.96]), severe cardiac malformation (OR = 2.23, 95% CI [1.40, 3.53]), religious affiliation (OR = 10.0 for secular participants vs. others, 95% CI [4.61, 22.46], population group (OR = 2.96 for Jewish participants vs. others, 95% CI [1.63, 11.3]), and education (OR = 1.34 per year of education, 95% CI [1.15, 1.55]).

CONCLUSIONS

Our findings describe the profiles of couples who decided to terminate their pregnancies after a prenatal diagnosis of fetal CHD. Early identification of the couple's decision can help health care providers provide adequate support, counseling, and guidance. Future research is needed to understand parents' needs for support through the process of decision-making, with attention to their religious and cultural values and contexts.

Differences between selective termination of pregnancy and fetal reduction in multiple pregnancy: a narrative review

Although selective termination of pregnancy and fetal reduction in multiple pregnancy both involve the termination in utero of the development of live fetuses, these two procedures are different in several aspects. Nevertheless, several authors tend to amalgamate and confuse their psychosocial consequences and the ethical issues they raise. Therefore, this narrative review, derived from a comparative analysis of 91 articles, shines a light on these amalgamations and confusions, as well as on the medical, contextual, experiential and ethical differences specific to selective termination and fetal reduction.

Should clinicians advise terminating a pregnancy following the diagnosis of a serious fetal cardiac abnormality?

An 18-year-old single mother presented for counseling following the diagnosis of a hypoplastic left heart syndrome in the fetus. Despite being encouraged by her family members to terminate the pregnancy, the clinicians involved endeavored to provide information in a non-directive manner in accordance with widely accepted norms for antenatal counseling. Following the consultation, however, the clinicians wondered whether they should have provided more directive advice. In this report, we review the ethics of counseling following the diagnosis of a severe fetal cardiac abnormality. We assess the general and specific arguments in favor of providing directive advice, at least in some circumstances. There may be legitimate concerns about harms to the fetus, to the mother, or to the wider community from continuing a pregnancy. While these arguments yield rare exceptions to the generally accepted practice that antenatal counseling should not be directive, they may still not apply to the more severe forms of congenital cardiac abnormalities.

Ethical issues in fetal management: a cardiac perspective

The ethical issues behind the management of a fetus with a serious abnormality and the decisions made in relation to the outcome of the pregnancy are complex. This reflective paper deals with the ethical principles of managing a pregnancy with a congenital anomaly, with particular emphasis on the fetus with a serious cardiac abnormality. One major ethical concern is whether the fetus is or is not independent being to whom obligations of beneficence are owed. We review the debate on this matter, and suggest that it is ethically more appropriate for physicians who are involved in management of fetal abnormality not to adopt and insist on their own position on this matter. Rather, the appropriate course is to respect the pregnant woman's own view of her fetus and how it should be regarded. This is an application of the principle of respect for autonomy. Within this framework, we discuss the difficulties in counselling a pregnant woman or expectant couple in this situation, and recommend three key steps in ethically sound counselling.