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Zhong Y, Hao T, Liu X, Zhang X, Wu Y, Wang X, Luo D. Ethical Challenges in Information Disclosure and Decision-making in Prenatal Testing: A Focus Group Study of Chinese Health Professionals in Maternal and Child Health Services. JOURNAL OF BIOETHICAL INQUIRY 2024:10.1007/s11673-024-10376-6. [PMID: 39162943 DOI: 10.1007/s11673-024-10376-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 06/02/2024] [Indexed: 08/21/2024]
Abstract
The international community has proposed a comprehensive strategy to prevent congenital abnormalities. And China, with a high incidence of congenital diseases, has implemented measures including prenatal screening and diagnosis to reduce the morbidity of congenital abnormalities. However, ethical challenges arise in the practice of prenatal screening and diagnosis among healthcare professionals. Five focus group discussions were conducted with twenty-four health professionals working in maternal and child health services in Hunan Province, China, to explore the ethical challenges they encountered in prenatal testing decision-making and information disclosure practices, as well as their views on these challenges. Participants were selected through purposive sampling, ensuring maximum demographic diversity. Three main themes were identified: 1) balancing between information disclosure and privacy protection; 2) patient-oriented decision-making and tensions within family-oriented decision-making; 3) the disparity between the limited help clinical ethics committees (CECs) can provide and professionals' need for CECs. Ethical norms for information disclosure and autonomous decision-making within prenatal screening and diagnostic institutions must be established. Utilizing CECs is crucial to guide professionals in delivering prenatal testing services while simultaneously focusing on targeted improvement of communication skills among these professionals.
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Affiliation(s)
- Yuqiong Zhong
- School of Humanities, Central South University, Lushan South Road, Yuelu District, Changsha, 410012, People's Republic of China
- Xiangya Hospital, Central South University, 87 Xiangya Road, Kaifu District, Changsha, 410008, People's Republic of China
| | - Tianchi Hao
- School of Humanities, Central South University, Lushan South Road, Yuelu District, Changsha, 410012, People's Republic of China
| | - Xing Liu
- Office of International Cooperation and Exchanges, Xiangya Hospital, Central South University, 87 Xiangya Road, Kaifu District, Changsha, 410008, People's Republic of China
- Medical Humanities Research Center, Central South University, 87 Xiangya Road, Kaifu District, Changsha, 410008, People's Republic of China
| | - Xin Zhang
- Medical Humanities Research Center, Central South University, 87 Xiangya Road, Kaifu District, Changsha, 410008, People's Republic of China
- Xiangya Hospital, Central South University, 87 Xiangya Road, Kaifu District, Changsha, 410008, People's Republic of China
| | - Ying Wu
- School of Humanities, Central South University, Lushan South Road, Yuelu District, Changsha, 410012, People's Republic of China
| | - Xiaomin Wang
- Center for Clinical Pharmacology, The Third Xiangya Hospital of Central South University, 138 Tongzipo Road, Yuelu District, Changsha, 410013, People's Republic of China
| | - Dan Luo
- Department of Social Medicine and Health Management, Xiangya School of Public Health, Central South University, 172 Tongzipo Road, Yuelu District, Changsha, 410013, People's Republic of China.
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Collart C, Craighead C, Yao M, Rose S, Chien EK, Frankel RM, Coleridge M, Hu B, Edmonds BT, Ranzini AC, Farrell RM. Reducing decisional conflict in decisions about prenatal genetic testing: the impact of a dyadic intervention at the start of prenatal care. J Perinat Med 2024; 52:467-477. [PMID: 38669584 PMCID: PMC11143442 DOI: 10.1515/jpm-2023-0442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 03/19/2024] [Indexed: 04/28/2024]
Abstract
OBJECTIVES Decisional conflict and regret about prenatal genetic screening and diagnostic tests may have important consequences in the current pregnancy and for future reproductive decisions. Identifying mechanisms that reduce conflict associated with the decision to use or decline these options is necessary for optimal patient counseling. METHODS We conducted a cluster-randomized controlled trial of a shared decision-making tool (NEST) at the beginning of prenatal care. Enrolled patients completed follow-up surveys at the time of testing (QTT) and in the second-third trimester (QFF), including the Decision Conflict Scale (DCS). Total DCS scores were analyzed using a multivariate linear mixed-effect model. RESULTS Of the total number of participants (n=502) enrolled, 449 completed the QTT and QFF surveys. The mean age of participants was 31.6±3.8, with most parous at the time of study participation (n=321; 71.7 %). Both the NEST (the intervention) and control groups had lower median total DCS scores at QFF (NEST 13.3 [1.7, 25.0] vs. control 16.7 [1.7, 25.0]; p=0.24) compared to QTT (NEST 20.8 [5.0, 25.0] vs. control 18.3 [3.3, 26.7]; p=0.89). Participants exposed to NEST had lower decisional conflict at QFF compared to control (β -3.889; [CI -7.341, -0.437]; p=0.027). CONCLUSIONS Using a shared decision-making tool at the start of prenatal care decreased decisional conflict regarding prenatal genetic testing. Such interventions have the potential to provide an important form of decision-making support for patients facing the unique type of complex and preference-based choices about the use of prenatal genetic tests.
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Affiliation(s)
- Christina Collart
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Caitlin Craighead
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Meng Yao
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Susannah Rose
- Department of Biomedical Informatics and Center for Biomedical Ethics and Society, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward K. Chien
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Marissa Coleridge
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Bo Hu
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | | | - Angela C. Ranzini
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, The MetroHealth System, Cleveland, OH, USA
| | - Ruth M. Farrell
- Obstetrics and Gynecology Institute, Cleveland Clinic, Cleveland, OH, USA
- Genomic Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
- Center for Bioethics, Clinical Transformation, Cleveland Clinic, Cleveland, OH, USA
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3
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Lu D, Yang J, Shen W, Chen M. Attitudes toward uncertain results from prenatal exome sequencing: a national survey among healthcare professionals working in the prenatal setting. Front Med (Lausanne) 2024; 11:1335649. [PMID: 38813373 PMCID: PMC11133618 DOI: 10.3389/fmed.2024.1335649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
Objective The objective of this study was to investigate the attitudes of healthcare professionals (HPs) working in the prenatal setting toward uncertain results (UR) from prenatal exome sequencing (pES) in China. Methods We conducted a national survey among HPs working in the prenatal setting. UR in our study include variants of uncertain significance (VUS), variants with variable penetrance/expressivity (VVPE), and secondary findings unrelated to the indication for testing (SFs). A total of 285 questionnaires that met the inclusion criteria were collected. Data were analyzed using IBM SPSS Statistics 26. Results When performing the pre-test counseling, only 7.4% of HPs mentioned the possibility of VUS, 6.3% discussed the possibility of VVPE, and 7.4% introduced the SFs with parents with the option to not report these variants. In post-test counseling, 73.0-82.8% HPs discussed with the parents but did not make any recommendations for managing the pregnancy after reporting UR (73.0% for VUS, 82.8% for VVPE, 74.7% for SFs, respectively). Conclusion Most parents did not have the option of opting out of reporting UR from pES in pre-test counseling. UR did not influence the pregnancy recommendation made by most HPs. Establishing national guidelines for reporting UR from pES and developing strategies to improve counseling skills may help HPs manage UR.
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Affiliation(s)
- Dongfang Lu
- Department of Obstetrics, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, China
| | - Jing Yang
- Department of Obstetrics, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, China
| | - Wei Shen
- Department of Obstetrics, Affiliated Xiaoshan Hospital, Hangzhou Normal University, Hangzhou, China
| | - Min Chen
- Department of Obstetrics and Gynecology, Department of Fetal Medicine and Prenatal Diagnosis, Key Laboratory for Major Obstetric Diseases of Guangdong Province, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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Libman V, Friedlander Y, Chalk M, Hochner H, Shkedi-Rafid S. Receiving uncertain results from prenatal chromosomal microarray analysis: Women's decisions on continuation or termination of pregnancy. Prenat Diagn 2023; 43:773-780. [PMID: 36828779 DOI: 10.1002/pd.6337] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/18/2023] [Accepted: 02/20/2023] [Indexed: 02/26/2023]
Abstract
BACKGROUND Chromosomal microarray analysis (CMA) may detect variants of uncertain clinical significance (VUS) and susceptibility loci (SL) with incomplete penetrance for neurodevelopmental disorders. This qualitative study provides empirical data on women's experiences with receiving such findings in pregnancy and their decisions regarding continuation or termination of the pregnancy. METHODS Semi-structured interviews were conducted with women who received a VUS and/or SL from prenatal CMA in the last 2-4 years and were analyzed using Grounded Theory. RESULTS The vast majority of women recalled being stressed by the findings. All women sought further advice and information to be able to decide whether to continue or terminate their pregnancy. The three pregnancies that were terminated have in common a de novo SL with a 10%-20% penetrance. Similar reasoning (coping with uncertainty, the quest for a perfect child, and a chance for recurrence in future pregnancies) led different women to contradicting conclusions regarding their pregnancies. All women felt satisfied with their decisions. CONCLUSION Although uncertain/probabilistic information commonly involves a psychological burden, it may also be perceived as valuable and actionable. Pre-test parental choice regarding the disclosure of such information could allow personalized utilization of advanced genomic tests in pregnancy.
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Affiliation(s)
- Vitalia Libman
- Braun School of Public Health, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yechiel Friedlander
- Braun School of Public Health, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michal Chalk
- Department of Genetics, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Hagit Hochner
- Braun School of Public Health, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shiri Shkedi-Rafid
- Department of Genetics, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, Jerusalem, Israel
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Wang L, Li R, Zhai J, Zhang B, Wu J, Pang L, Liu Y. Whole exome sequencing combined with dynamic ultrasound assessments for fetal skeletal dysplasias: 4 case reports. Medicine (Baltimore) 2022; 101:e31321. [PMID: 36316869 PMCID: PMC9622563 DOI: 10.1097/md.0000000000031321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Fetal skeletal anomalies are one of the most common and potentially pathogenic developmental abnormalities detected by ultrasound screening. Any suspected fetal skeletal dysplasias often require further comprehensive evaluations. PATIENT CONCERNS Here 4 families with adverse fetal skeletal system histories were enrolled, including their histories of gestation, childbirth, familial skeletal abnormalities, and pregnancy outcomes. The corresponding diagnosis were done by whole exome sequencing (WES) combined with dynamic examination. DIAGNOSIS All of the families were definitively diagnosed through cytogenetics, molecular genetics, ultrasound, combined with multidisciplinary evaluation. Both of the fetuses in case 1 and case 2 were diagnosed with thanatophoric dysplasia type I, while the neonate in case 3 was diagnosed with Apert syndrome and a 3-years-old proband daughter with Crouzon syndrome in case 4. INTERVENTIONS We conducted karyotyping, copy number variation sequencing (CNV-seq), combined with WES to evaluate genetic conditions of abnormal fetus, neonate or proband patient. WES was preferred to obtain a relatively definitive diagnosis. OUTCOMES In cases 1 and 2, the families decided to choose termination of pregnancy due to fatal dysplasias. The couple in case 3, delivered a female baby diagnosed with Apert syndrome. Fortunately, in case 4, the family, which had a 3-years-old baby with Crouzon syndrome, gave birth to a healthy baby through prenatal diagnosis. LESSONS SUBSECTIONS Invasive prenatal diagnosis and dynamic assessments for the management of fetal skeletal dysplasias could contribute to revealing possible causes of fetal skeletal abnormalities and help clinicians conduct further genetic counseling in clinical practice.
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Affiliation(s)
- Li Wang
- Xuzhou Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Prenatal Diagnosis Medical Center, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Ruiqi Li
- The Second Clinical Medical School of Southern Medical University, Guangzhou, Guangdong, China
- Department of Prenatal Diagnosis Medical Center, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Jingfang Zhai
- Xuzhou Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Prenatal Diagnosis Medical Center, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
- * Correspondence: Jingfang Zhai, Xuzhou Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu 221009, China (e-mail: )
| | - Bei Zhang
- Xuzhou Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Prenatal Diagnosis Medical Center, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Jiebin Wu
- Xuzhou Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Prenatal Diagnosis Medical Center, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Libo Pang
- Xuzhou Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Prenatal Diagnosis Medical Center, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
| | - Ying Liu
- Xuzhou Clinical Medical School of Nanjing Medical University, Nanjing, Jiangsu, China
- Department of Prenatal Diagnosis Medical Center, Xuzhou Central Hospital, Xuzhou, Jiangsu, China
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González-Ramos Z, Zuriguel-Pérez E, Collado-Palomares A, Casadó-Marín L. 'My biggest fear is that people will forget about him': Mothers' emotional transitions after terminating their pregnancy for medical reasons. J Clin Nurs 2022. [PMID: 36047291 DOI: 10.1111/jocn.16504] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Zuleika González-Ramos
- Universitat Rovira i Virgili, Departament d'Infermeria, Avinguda Catalunya, Tarragona, Spain.,Hospital Vall d'Hebron, Passeig de la Vall d'Hebron, Barcelona, Spain
| | | | | | - Lina Casadó-Marín
- Universitat Rovira i Virgili, Departament d'Infermeria, Avinguda Catalunya, Tarragona, Spain
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Outram SM, Brown JEH, Zamora AN, Sahin-Hodoglugil N, Ackerman SL. Parental Hopes and Understandings of the Value of Prenatal Diagnostic Genomic Sequencing: A Qualitative Analysis. Front Genet 2022; 13:883225. [PMID: 35923691 PMCID: PMC9339950 DOI: 10.3389/fgene.2022.883225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022] Open
Abstract
Objective: To provide qualitative empirical data on parental expectations of diagnostic prenatal genomic sequencing and the value of the results to families. Methods: We interviewed 15 families—mothers and/or fathers—who had had prenatal genomic sequencing about their expectations and their respective evaluations of the benefits of genomic sequencing. Results: Families’ hopes for genetic sequencing clustered around three themes: hoping to identify the cause of the fetal anomaly in a terminated pregnancy; hopes for guidance as to the likely outcome of current pregnancy; and hopes for information to support future family planning. In addition, hopes were discussed in terms of the potential for results to be beneficial in acquiring greater knowledge, while at the same time recognizing that new knowledge may raise more questions. Assessment of the value of sequencing largely mirrored these expectations when positive results seen. Negative results can also be seen as valuable in ruling out a genetic cause and in providing certainty that families had done everything that they could to know about the cause of fetal demise. Conclusion: It would appear that with guidance from genetic counsellors, families were largely able to navigate the many uncertainties of prenatal genomic sequencing and thus see themselves as benefitting from sequencing. However, support structures are essential to guide them through their expectations and interpretations of results to minimize possible harms. Engaging in the process of genomic sequencing was seen as beneficial in of itself to families who would otherwise be left without any options to seek diagnostic answers.
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8
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Cancer patients' understandings of genetic variants of uncertain significance in clinical care. J Community Genet 2022; 13:381-388. [PMID: 35616809 PMCID: PMC9134724 DOI: 10.1007/s12687-022-00594-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 05/20/2022] [Indexed: 11/10/2022] Open
Abstract
Genetic variants of uncertain significance (VUSs) pose a growing challenge for patient communication and care in precision genomic medicine. To better understand patient perspectives of VUSs, we draw on qualitative analysis of semi-structured interviews with 22 cancer patients and individuals with cancer family history who received a VUS result. The majority of patients did not recall receiving VUS results and those who remembered expressed few worries, while respondents who were tested because of a family history of cancer were more concerned about the VUS results. Personal characteristics, medical condition, family history, expectations prior to testing, and motivations for pursuing testing influence the ways patients came to terms with the uncertainty of the VUS result. We conclude by discussing the relevance of the findings to the debate on the responsibility of the patient in checking back for VUS reclassification and to implications for genetic counseling that emphasizes tailoring the pre- and post-test discussion of VUS as appropriate to the patients’ informational as well as emotional needs.
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Talati AN, Gilmore KL, Hardisty EE, Lyerly AD, Rini C, Vora NL. Parental motivations for and adaptation to trio-exome sequencing in a prospective prenatal testing cohort: Beyond the diagnosis. Prenat Diagn 2022; 42:775-782. [PMID: 35132674 PMCID: PMC9175118 DOI: 10.1002/pd.6112] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 12/07/2021] [Accepted: 12/29/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE To understand motivations for and parental interpretation of results from trio-exome sequencing (ES) for fetal anomalies with a negative standard genetic diagnosis. METHODS Analysis of an ongoing, prospective prenatal trio-ES study of pregnancies with ultrasound-identified congenital anomalies and lack of a standard genetic diagnosis. After determination of pregnancy disposition, participants completed questionnaires and a semi-structured interview pre- and post-sequencing. Interviews were analyzed using a constructivist grounded theory methodology to identify themes. Associations between themes and ES result were also examined. RESULTS One hundred twenty-six trios have been sequenced. Of those, 45 (36%) resulted in fetal diagnosis. One hundred twenty-five women completed pre-sequencing surveys, and 91 women completed post-sequencing surveys. The main themes identified include (1) variable reasons to pursue ES, (2) limited expectations but high hopes from ES, (3) parental adaptation to uncertain results, (4) impact on personal health and reproduction, and (5) gratitude for the process. CONCLUSION Participants pursued ES for various reasons, most often to identify a diagnosis and guide reproduction. Post-sequencing, most participants described the process, their interpretation of results, and the impact of receiving the results. Less frequently, but of most concern, participants expressed anxiety about testing and implications for themselves, relationships, and other family members, thus identifying an area of high need for additional support among patients undergoing prenatal ES.
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Affiliation(s)
- Asha N. Talati
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Kelly L. Gilmore
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Emily E. Hardisty
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Anne D. Lyerly
- Department of Social Medicine and Center for Bioethics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Christine Rini
- Department of Medical Social Sciences, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Neeta L. Vora
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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Buchanan J, Hill M, Vass CM, Hammond J, Riedijk S, Klapwijk JE, Harding E, Lou S, Vogel I, Hui L, Ingvoldstad-Malmgren C, Soller MJ, Ormond KE, Choolani M, Zheng Q, Chitty LS, Lewis C. Factor's that impact on women's decision-making around prenatal genomic tests: An international discrete choice survey. Prenat Diagn 2022; 42:934-946. [PMID: 35476801 PMCID: PMC9325352 DOI: 10.1002/pd.6159] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 04/19/2022] [Accepted: 04/21/2022] [Indexed: 11/12/2022]
Abstract
OBJECTIVE We conducted a survey-based discrete-choice experiment (DCE) to understand the test features that drive women's preferences for prenatal genomic testing, and explore variation across countries. METHODS Five test attributes were identified as being important for decision-making through a literature review, qualitative interviews and quantitative scoring exercise. Twelve scenarios were constructed in which respondents choose between two invasive tests or no test. Women from eight countries who delivered a baby in the previous 24 months completed a DCE presenting these scenarios. Choices were modeled using conditional logit regression analysis. RESULTS Surveys from 1239 women (Australia: n = 178; China: n = 179; Denmark: n = 88; Netherlands: n = 177; Singapore: n = 90; Sweden: n = 178; UK: n = 174; USA: n = 175) were analyzed. The key attribute affecting preferences was a test with the highest diagnostic yield (p < 0.01). Women preferred tests with short turnaround times (p < 0.01), and tests reporting variants of uncertain significance (VUS; p < 0.01) and secondary findings (SFs; p < 0.01). Several country-specific differences were identified, including time to get a result, who explains the result, and the return of VUS and SFs. CONCLUSION Most women want maximum information from prenatal genomic tests, but our findings highlight country-based differences. Global consensus on how to return uncertain results is not necessarily realistic or desirable.
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Affiliation(s)
- James Buchanan
- Nuffield Department of Population Health, Health Economics Research Centre, University of Oxford, Oxford, UK.,National Institute for Health Research Oxford Biomedical Research Centre, Oxford, UK
| | - Melissa Hill
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, UK.,Genetic and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Caroline M Vass
- Manchester Centre for Health Economics, The University of Manchester, Manchester, UK.,RTI Health Solutions, Manchester, UK
| | - Jennifer Hammond
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, UK.,Genetic and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Sam Riedijk
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | | | - Eleanor Harding
- BSc Paediatrics and Child Health, The UCL Great Ormond Street Institute of Child Health, London, UK
| | - Stina Lou
- Center for Fetal Diagnostics, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,DEFACTUM - Public Health & Health Services Research, Central Denmark Region, Aarhus, Denmark
| | - Ida Vogel
- Center for Fetal Diagnostics, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
| | - Lisa Hui
- Reproductive Epidemiology Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia.,Department of Obstetrics and Gynaecology, Northern Health, Epping, Victoria, Australia
| | - Charlotta Ingvoldstad-Malmgren
- Center for Research and Bioethics, Uppsala University, Uppsala, Sweden.,Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Genetics, Karolinska Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Maria Johansson Soller
- Department of Clinical Genetics, Karolinska Hospital and Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Kelly E Ormond
- Department of Genetics and Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, California, USA.,Department of Health Sciences and Technology, Health Ethics and Policy Lab, ETH Zurich, Zurich, Switzerland
| | - Mahesh Choolani
- Department of Obstetrics & Gynaecology, National University Hospital, Singapore, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Qian Zheng
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, UK
| | - Lyn S Chitty
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, UK.,Genetic and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Celine Lewis
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, UK.,Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health, London, UK
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Levin Fridman A, Raz A, Timmermans S, Shkedi-Rafid S. Views of Israeli healthcare professionals regarding communication of genetic variants of uncertain significance to patients. J Genet Couns 2022; 31:912-921. [PMID: 35122362 PMCID: PMC9541910 DOI: 10.1002/jgc4.1560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 01/17/2022] [Accepted: 01/24/2022] [Indexed: 11/21/2022]
Abstract
While genomic medicine is becoming an important part of patient care with an ever‐increasing diagnostic yield, communicating variants of uncertain clinical significance (VUSs) remains a major challenge. We draw on qualitative analysis of semi‐structured interviews conducted in 2020 with 20 Israeli healthcare professionals and stakeholders involved in communicating the results of genome‐wide sequencing to patients. Respondents described four main strategies of communicating VUSs to patients: preparing the patient pre‐test for uncertainty; adapting the level of detail to the patient's needs; upgrading versus downgrading the VUS; and following up on the possible reclassification of VUSs. These strategies were expressed differently by physicians and genetic counselors, varying according to their specialty and perception of the patient's situation. We discuss the strategic management and communication of uncertain genomic test results with patients in the context of meeting patients' expectations and working toward genetic causality through genomic narration and designation.
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Affiliation(s)
- Alma Levin Fridman
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Aviad Raz
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | | | - Shiri Shkedi-Rafid
- Department of Genetics, Hadassah Medical Organization and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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12
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Hammond J, Klapwijk JE, Riedijk S, Lou S, Ormond KE, Vogel I, Hui L, Sziepe EJ, Buchanan J, Ingvoldstad-Malmgren C, Soller MJ, Harding E, Hill M, Lewis C. Assessing women’s preferences towards tests that may reveal uncertain results from prenatal genomic testing: Development of attributes for a discrete choice experiment, using a mixed-methods design. PLoS One 2022; 17:e0261898. [PMID: 35089945 PMCID: PMC8797177 DOI: 10.1371/journal.pone.0261898] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 12/14/2021] [Indexed: 11/19/2022] Open
Abstract
Prenatal DNA tests, such as chromosomal microarray analysis or exome sequencing, increase the likelihood of receiving a diagnosis when fetal structural anomalies are identified. However, some parents will receive uncertain results such as variants of uncertain significance and secondary findings. We aimed to develop a set of attributes and associated levels for a discrete-choice experiment (DCE) that will examine parents’ preferences for tests that may reveal uncertain test results. A two phase mixed-methods approach was used to develop attributes for the DCE. In Phase 1, a “long list” of candidate attributes were identified via two approaches: 1) a systematic review of the literature around parental experiences of uncertainty following prenatal testing; 2) 16 semi-structured interviews with parents who had experienced uncertainty during pregnancy and 25 health professionals who return uncertain prenatal results. In Phase 2, a quantitative scoring exercise with parents prioritised the candidate attributes. Clinically appropriate levels for each attribute were then developed. A final set of five attributes and levels were identified: likelihood of getting a result, reporting of variants of uncertain significance, reporting of secondary findings, time taken to receive results, and who tells you about your result. These attributes will be used in an international DCE study to investigate preferences and differences across countries. This research will inform best practice for professionals supporting parents to manage uncertainty in the prenatal setting.
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Affiliation(s)
- Jennifer Hammond
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, United Kingdom
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Sam Riedijk
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Stina Lou
- Center for Fetal Diagnostics, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Kelly E. Ormond
- Department of Genetics and Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, United States America
| | - Ida Vogel
- Center for Fetal Diagnostics, Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Lisa Hui
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
- Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia
- Department of Obstetrics and Gynaecology, Northern Health, Epping, VIC, Australia
| | - Emma-Jane Sziepe
- Reproductive Epidemiology, Murdoch Children’s Research Institute, Royal Children’s Hospital, Parkville, Victoria, Australia
- Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia
| | - James Buchanan
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, England, United Kindom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, England, United Kindom
| | - Charlotta Ingvoldstad-Malmgren
- Department of Clinical Genetics, Karolinska Hospital and Karolinska Institutet, Stockholm, Sweden
- Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Maria Johansson Soller
- Department of Clinical Genetics, Karolinska Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Eleanor Harding
- BSc Paediatrics and Child Health, The UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Melissa Hill
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, United Kingdom
- Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Celine Lewis
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, United Kingdom
- * E-mail:
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13
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Hart AR, Vollmer B, Howe D, Boxall S, Foulds N, de Lacy P, Vasudevan C, Griffiths PD, Piercy H. Antenatal counselling for prospective parents whose fetus has a neurological anomaly: part 1, experiences and recommendations for service design. Dev Med Child Neurol 2022; 64:14-22. [PMID: 34423423 DOI: 10.1111/dmcn.15022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 06/26/2021] [Accepted: 07/19/2021] [Indexed: 11/27/2022]
Abstract
Prospective parents whose fetus is diagnosed with a neurological anomaly go through a complex range of emotions. They describe their discussions of antenatal counselling from health care professionals as focusing too much on the nature of the anomaly involving unintelligible medical terminology, when what they really want is a picture of the best- and worst-case scenarios. Whilst information on the level of risk for their fetus is important, it is not the parents' primary concern. When statistics for risk are given, they may not be as well understood as the health care professionals think. This review discusses the published evidence on antenatal counselling and recommendations for explaining risk to parents of fetuses with neurological anomalies. From this data we make recommendations for the organization of antenatal counselling services.
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Affiliation(s)
- Anthony R Hart
- Department of Perinatal and Paediatric Neurology, Sheffield Children's NHS Foundation Trust, Ryegate Children's Centre, Sheffield, UK
| | - Brigitte Vollmer
- Clinical and Experimental Sciences, Faculty of Medicine, Paediatric and Neonatal Neurology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
| | - David Howe
- Department of Fetal Maternal Medicine, University Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK
| | - Sally Boxall
- Department of Fetal Maternal Medicine, University Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK
| | - Nicola Foulds
- Department of Clinical Genetics, University Southampton NHS Foundation Trust, Princess Anne Hospital, Southampton, UK
| | - Patricia de Lacy
- Department of Paediatric Neurosurgery, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Chakra Vasudevan
- Department of Neonatology, Bradford Royal Infirmary, Bradford, UK
| | - Paul D Griffiths
- Academic Unit of Radiology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Hilary Piercy
- The Centre for Health and Social Care, Sheffield Hallam University, Sheffield, UK
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14
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Experiencia de mujeres con infección prenatal por virus Zika que continuaron la gestación en Colombia. GACETA SANITARIA 2021; 35:465-472. [DOI: 10.1016/j.gaceta.2020.02.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 02/23/2020] [Accepted: 02/27/2020] [Indexed: 01/01/2023]
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15
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Kelley J, McGillivray G, Meagher S, Hui L. Increased nuchal translucency after low-risk noninvasive prenatal testing: What should we tell prospective parents? Prenat Diagn 2021; 41:1305-1315. [PMID: 34297420 DOI: 10.1002/pd.6024] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 06/08/2021] [Accepted: 07/21/2021] [Indexed: 12/15/2022]
Abstract
Three decades ago, the observation that first trimester fetuses with excess fluid accumulation at the back of the neck were more likely to be aneuploid, gave rise to a new era of prenatal screening. The nuchal translucency (NT) measurement in combination with serum biomarkers and maternal age, resulted in the first trimester combined screening (FTCS) program. The introduction of noninvasive prenatal testing (NIPT) over the past decade has introduced the option for parents to receive highly sensitive and specific screening information for common trisomy from as early as 10 weeks gestation, altering the traditional pathway FTCS pathway. The retention of the 11-13-week NT ultrasound remains important in the detection of structural anomalies; however, the optimal management of pregnancies with a low-risk NIPT result and an isolated increased NT measurement in an era of advanced genomic testing options is a new dilemma for clinicians. For parents, the prolonged period between the initial diagnosis in first trimester, and prognostic information at each successive stage of investigations up to 22-24 weeks, can be emotionally challenging. This article addresses the common questions from parents and clinicians as they navigate the uncertainty of having a fetus diagnosed with an increased NT after a low-risk NIPT result and presents suggested approaches to management.
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Affiliation(s)
- Joanne Kelley
- Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia
| | - George McGillivray
- Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia.,Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Simon Meagher
- Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia.,Monash Ultrasound for Women, Monash IVF Group, Melbourne, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
| | - Lisa Hui
- Department of Perinatal Medicine, Mercy Hospital for Women, Heidelberg, Victoria, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, Victoria, Australia
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16
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Lou S, Jensen AH, Vogel I. How are uncertain prenatal genetic results perceived and managed two years after they were received? A qualitative interview study. J Genet Couns 2021; 30:1191-1202. [PMID: 33830585 DOI: 10.1002/jgc4.1402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/18/2020] [Accepted: 02/06/2021] [Indexed: 11/05/2022]
Abstract
Chromosomal microarray has considerably improved our ability to identify or dismiss genetic conditions in the unborn child. However, this detailed analysis also reveals copy number variants (CNVs) of unknown or uncertain significance, in which the specific child's prognosis can be difficult to predict. Little is known about the longer-term impacts of receiving an uncertain prenatal CNV result. Our qualitative study explored how such a result was perceived and managed in everyday life, 2 years after it was received. From an original sample of 16 couples, nine women participated in a semi-structured follow-up phone interview. Transcripts were analyzed using thematic analysis. The results show that these women did not perceive the CNV result to be a part of their everyday lives. They managed the CNV result by focusing on the child's positive development, by not sharing the CNV information in wider social networks, and by emphasizing parental values such as taking life as it comes, welcoming human variation, and accepting that dealing with a child's struggles is an inherent part of parenthood. Overall, the women expressed a positive attitude toward prenatal genetic information about serious disorders but considered 'their' CNV to be close to normal; several women suggested that such findings should not be reported. However, they also recognized the difficulties in making such decisions, given variable penetrance and that couples' definitions of 'serious' could vary significantly. The diagnostic process during pregnancy was remembered as being highly stressful, and many expressed a need for more control in a future pregnancy. Our study provides insight into how mothers reconfigure CNV results to fit their values and everyday lives. When delivering uncertain CNV results in a prenatal setting, genetics healthcare providers should present and discuss long-term coping strategies with expecting parents.
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Affiliation(s)
- Stina Lou
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark.,DEFACTUM-Public Health & Health Services Research, Central Denmark Region, Aarhus, Denmark
| | - Amalie Hahn Jensen
- DEFACTUM-Public Health & Health Services Research, Central Denmark Region, Aarhus, Denmark
| | - Ida Vogel
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
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17
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Abstract
For decades, prenatal testing has been offered to evaluate pregnancies for genetic conditions. In recent years, the number of testing options and range of testing capabilities has dramatically increased. Because of the risks associated with invasive diagnostic testing, research has focused on the detection of genetic conditions through screening technologies such as cell-free DNA. Screening for aneuploidy, copy number variants, and monogenic disorders is clinically available using a sample of maternal blood, but limited data exist on the accuracy of some of these testing options. Additional research is needed to examine the accuracy and utility of screening for increasingly rare conditions. As the breadth of prenatal genetic testing options continues to expand, patients, clinical providers, laboratories, and researchers need to find collaborative means to validate and introduce new testing technologies responsibly. Adequate validation of prenatal tests and effective integration of emerging technologies into prenatal care will become even more important once prenatal treatments for genetic conditions become available.
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Affiliation(s)
- Blair Stevens
- McGovern Medical School at UTHealth in Houston, Department of Obstetrics, Gynecology and Reproductive Sciences, Houston, Texas 77030, USA
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18
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Hammond J, Klapwijk JE, Hill M, Lou S, Ormond KE, Diderich KEM, Riedijk S, Lewis C. Parental experiences of uncertainty following an abnormal fetal anomaly scan: Insights using Han's taxonomy of uncertainty. J Genet Couns 2020; 30:198-210. [PMID: 32638447 PMCID: PMC8432163 DOI: 10.1002/jgc4.1311] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 06/05/2020] [Accepted: 06/15/2020] [Indexed: 11/16/2022]
Abstract
For a number of prospective parents, uncertainty during pregnancy starts when an anomaly is found during a routine fetal anomaly scan. This may be followed by numerous tests to determine the etiology and nature of the anomaly. In this study, we aimed to understand how prospective parents perceive and manage uncertainty after being confronted with a structural anomaly during their routine ultrasound. Han's taxonomy of uncertainty was used as a framework to identify and understand the different types of uncertainty experienced. Interviews were held in the UK (n = 8 women and n = 1 male partner) and in the Netherlands (n = 7 women) with participants who had experienced uncertainty in their pregnancy after a fetal scan. Data were analyzed using thematic analysis, and the uncertainties experienced by parents were mapped against the dimensions of the Han taxonomy (sources, issues, and locus). Participants' experience of uncertainty was relevant to all dimensions and subcategories of the Han taxonomy, showing its applicability in the prenatal setting. Sources of uncertainty included receiving probabilistic or ambiguous information about the anomaly, or information that was complex and challenging to understand. Issues of uncertainty included were those that were scientific—such as a probable diagnosis with no further information, personal—such as the emotional impact of uncertainty, and practical—such as limited information about medical procedures and practical aspects of care. Additionally, participants described what helped them to manage uncertainty. This included active coping strategies such as searching for information on the Internet, external coping resources such as seeking social support, and internal coping resources such as using positivity and hope. Several recommendations for the healthcare professional to minimize uncertainty and help the patient deal with uncertainty have been proposed based on these findings.
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Affiliation(s)
- Jennifer Hammond
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetic and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | | | - Melissa Hill
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetic and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Stina Lou
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark
| | - Kelly E Ormond
- Department of Genetics and Stanford Center for Biomedical Ethics, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Sam Riedijk
- Department of Clinical Genetics, Erasmus MC, Rotterdam, The Netherlands
| | - Celine Lewis
- North Thames Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Population, Policy and Practice Department, UCL Great Ormond Street Institute of Child Health, London, UK
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19
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Family-Centered Management of Birth Defects Diagnosis and Referral in Hospital Settings in Florida. Matern Child Health J 2020; 24:777-786. [DOI: 10.1007/s10995-020-02914-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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20
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Lou S, Petersen OB, Lomborg K, Vogel I. How do geneticists and prospective parents interpret and negotiate an uncertain prenatal genetic result? An analysis of clinical interactions. J Genet Couns 2020; 29:1221-1233. [PMID: 32453502 DOI: 10.1002/jgc4.1290] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 04/16/2020] [Accepted: 04/23/2020] [Indexed: 11/06/2022]
Abstract
Variants of unknown significance (VUS) and susceptibility loci (SL) are a challenge in prenatal genetic counseling. The aim of this study was to explore how such uncertain genetic results are communicated, negotiated, and made meaningful by genetics healthcare providers and couples in the actual clinical setting where results are delivered. The study was based on an anthropological approach and the material consisted of observations and audio-recordings from 16 purposively sampled genetic counseling sessions where prenatal testing had identified an inherited or de novo VUS or SL result. Field notes and transcripts from audio-recordings were analyzed using thematic analysis. The analysis identified a number of specific interpretations and strategies that clinical geneticists and couples collectively used for dealing with the ambiguity of the result. Thus, the analysis resulted in a total of three themes, each with 3-4 subthemes. The theme 'Setting the scene' describes the three-stage structure of the consultation. The theme 'Dealing with uncertainty' includes 'normalizing strategies' that emphasized the inherent uncertainty in human life in general and 'contextualizing strategies' that placed the result in relation to the surrounding society, where technological developments lead to new and unforeseen challenges. The theme 'Regaining control' includes interpretations that made the knowledge useful by focusing on the value of being prepared for potential, future challenges. Other strategies were to book an extra scan-to reconfirm fetal structural health and to reconnect to the pregnancy. Finally, inquiring about the sex was clearly a way for the couple to signal their investment in the pregnancy. Based on the analysis, we propose that these interpretations served to transform and reduce ambiguity through a process of reconfiguring the biomedical information into knowledge that resonated with the couples' lifeworlds. In this process, both geneticist and couples drew on wider social and moral concerns about uncertainty and responsibility.
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Affiliation(s)
- Stina Lou
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark.,DEFACTUM - Public Health & Health Services Research, Central Denmark Region, Aarhus, Denmark
| | - Olav Bjørn Petersen
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark.,Fetal Medicine Unit, Department of Obstetrics & Gynecology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Kirsten Lomborg
- Steno Diabetes Center Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Ida Vogel
- Center for Fetal Diagnostics, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Department of Clinical Genetics, Aarhus University Hospital, Aarhus, Denmark
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21
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Harding E, Hammond J, Chitty LS, Hill M, Lewis C. Couples experiences of receiving uncertain results following prenatal microarray or exome sequencing: A mixed-methods systematic review. Prenat Diagn 2020; 40:1028-1039. [PMID: 32362033 PMCID: PMC8425413 DOI: 10.1002/pd.5729] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 04/14/2020] [Accepted: 04/27/2020] [Indexed: 12/15/2022]
Abstract
Background Tests in pregnancy such as chromosomal microarray analysis and exome sequencing are increasing diagnostic yield for fetal structural anomalies, but have greater potential to result in uncertain findings. This systematic review investigated the experiences of prospective parents about receiving uncertain results from these tests. Methods A systematic search of three electronic databases was conducted. Data extraction was performed for studies that met the eligibility and quality criteria. Results were synthesised following the principles of thematic analysis. Results Fourteen studies (10 qualitative, 4 quantitative) were included. Findings were grouped into three overarching themes. Sources of uncertainty included the testing procedure, the diagnosis and prognosis, and health professionals' own uncertainty. The clinical impact of the uncertainty included parents struggling to make clinical decisions with the information available, the emotional impact included decisional‐regret, shock, worry and feeling overwhelmed. To manage the uncertainty, parents sought support from healthcare professionals, friends, family, the internet and other parents as well as remaining hopeful. Conclusions Prospective parents experience a myriad of uncertainties in the prenatal setting, which must be handled sensitively. Future research should explore optimal ways of managing uncertainty to minimise harm. Recommendations are made for discussing uncertainty during pre‐ and post‐test counseling.
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Affiliation(s)
- Eleanor Harding
- BSc Paediatrics and Child Health, The UCL Great Ormond Street Institute of Child Health, London, UK.,London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Jennifer Hammond
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, The UCL Great Ormond Street Institute of Child Health, London, UK
| | - Lyn S Chitty
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, The UCL Great Ormond Street Institute of Child Health, London, UK
| | - Melissa Hill
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, The UCL Great Ormond Street Institute of Child Health, London, UK
| | - Celine Lewis
- London North Genomic Laboratory Hub, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, The UCL Great Ormond Street Institute of Child Health, London, UK
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22
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Laza-Vásquez C, Cortés-Martínez KV, Cano-Rivillas JP. "It was God's will": Continuing pregnancy after perinatal infection by Zika virus. Rev Lat Am Enfermagem 2020; 28:e3310. [PMID: 32876288 PMCID: PMC7458580 DOI: 10.1590/1518-8345.3485.3310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 03/27/2020] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to understand the influence of the religious beliefs on the decision of a group of women residing in the Huila Department to continue their pregnancies despite perinatal infection by the Zika virus. METHOD a focused ethnography. The participants were 21 women who had presented a perinatal infection by the Zika virus and whose babies were born with congenital microcephaly. 2 discussion groups and 6 semi-structured interviews were conducted, and thematic analysis was used for data treatment. RESULTS three themes emerged, namely: "God, why me?" is the initial questioning of the women to God for the prenatal diagnosis of microcephaly in their babies, "Clinging to a divine miracle" describes how the women did not lose their faith and begged for a divine miracle for their babies to be born healthy, and "It was God's will" means acceptance, resignation, and respect for God's will, as well as the denial to abort despite the medical recommendations. CONCLUSION religiosity and religious beliefs were determinant factors in the women's decision to continue their pregnancies. It becomes necessary to continue investigating this theme to understand their experiences and to generate follow-up and support actions from nursing care.
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Affiliation(s)
- Celmira Laza-Vásquez
- Facultad de Enfermería y Fisioterapia, Universitat de Lleida, Lleida, Cataluña, Spain
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23
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Hart AR, Embleton ND, Bradburn M, Connolly DJA, Mandefield L, Mooney C, Griffiths PD. Accuracy of in-utero MRI to detect fetal brain abnormalities and prognosticate developmental outcome: postnatal follow-up of the MERIDIAN cohort. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 4:131-140. [PMID: 31786091 PMCID: PMC6988445 DOI: 10.1016/s2352-4642(19)30349-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/15/2019] [Accepted: 10/17/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND In utero MRI (iuMRI) detects fetal brain abnormalities more accurately than ultrasonography and provides additional clinical information in around half of pregnancies. We aimed to study whether postnatal neuroimaging after age 6 months changes the diagnostic accuracy of iuMRI and its ability to predict developmental outcome. METHODS Families enrolled in the MERIDIAN study whose child survived to age 3 years were invited to have a case note review and assessment of developmental outcome with the Bayley Scales of Infant and Toddler Development, the Ages and Stages Questionnaire, or both. A paediatric neuroradiologist, masked to the iuMRI results, reviewed the postnatal neuroimaging if the clinical report differed from iuMRI findings. Diagnostic accuracy was recalculated. A paediatric neurologist and neonatologist categorised participants' development as normal, at risk, or abnormal, and the ability of iuMRI and ultrasonography to predict developmental outcome were assessed. FINDINGS 210 participants had case note review, of whom 81 (39%) had additional investigations after age 6 months. The diagnostic accuracy of iuMRI remained higher than ultrasonography (proportion of correct cases was 529 [92%] of 574 vs 387 [67%] of 574; absolute difference 25%, 95% CI 21 to 29; p<0·0001). Developmental outcome data were analysed in 156 participants, and 111 (71%) were categorised as normal or at risk. Of these 111 participants, prognosis was normal or favourable for 56 (51%) using ultrasonography and for 76 (69%) using iuMRI (difference in specificity 18%, 95% CI 7 to 29; p=0·0008). No statistically significant difference was seen in infants with abnormal outcome (difference in sensitivity 4%, 95% CI -10 to 19; p=0·73). INTERPRETATION iuMRI remains the optimal tool to identify fetal brain abnormalities. It is less accurate when used to predict developmental outcome, although better than ultrasonography for identifying children with normal outcome. Further work is needed to determine how the prognostic abilities of iuMRI can be improved. FUNDING National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Anthony R Hart
- Department of Paediatric and Perinatal Neurology, Sheffield Children's Hospital NHS Foundation Trust, Ryegate Children's Centre, Sheffield, UK
| | - Nicholas D Embleton
- Newcastle Neonatal Service, Ward 35 Neonatal Unit, Royal Victoria Infirmary, Newcastle Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michael Bradburn
- Clinical Trials Research Unit, School Health and Related Research, University of Sheffield, Sheffield, UK
| | - Daniel J A Connolly
- Department of Paediatric Neuroradiology, Sheffield Children's Hospital NHS Foundation Trust, Western Bank, Sheffield, UK
| | - Laura Mandefield
- Clinical Trials Research Unit, School Health and Related Research, University of Sheffield, Sheffield, UK
| | - Cara Mooney
- Clinical Trials Research Unit, School Health and Related Research, University of Sheffield, Sheffield, UK.
| | - Paul D Griffiths
- Academic Unit of Radiology, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
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Hashiloni-Dolev Y, Nov-Klaiman T, Raz A. Pandora's pregnancy: NIPT, CMA, and genome sequencing-A new era for prenatal genetic testing. Prenat Diagn 2019; 39:859-865. [PMID: 31161621 DOI: 10.1002/pd.5495] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/06/2019] [Accepted: 05/30/2019] [Indexed: 12/15/2022]
Abstract
OBJECTIVES We delineate in this article a shift from the "traditional" technologies of karyotyping in PND to the current phase of advanced genetic technologies including noninvasive prenatal testing (NIPT), chromosomal microarray analysis (CMA), and whole-exome sequencing (WES) with their higher detection rate and related abundance of uncertain data. METHODS Conceptual analysis based on seminal works that shaped the socioethical discourse surrounding the experiences of parents as well as professionals with prenatal diagnosis in the last 30 years. RESULTS We consider the implications of this new era of PND for patients and health professionals by drawing on previous studies documenting how probability and uncertainty affect informed consent/choice, health risks communication, customer satisfaction and decision making, and parent-child bonding. CONCLUSIONS We argue that these changes move us beyond the idioms and realities of the tentative pregnancy and moral pioneering, to uncertainty, probability-based counseling, and moral/translational gambling. We conclude by discussing what is needed to maintain hope in the era of Pandora's pregnancy.
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Affiliation(s)
- Yael Hashiloni-Dolev
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Tamar Nov-Klaiman
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Beersheba, Israel
| | - Aviad Raz
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Beersheba, Israel
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25
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Brew CE, Castro BA, Pan V, Hart A, Blumberg B, Wicklund C. Genetics professionals' attitudes toward prenatal exome sequencing. J Genet Couns 2019; 28:229-239. [PMID: 30888706 DOI: 10.1002/jgc4.1112] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 02/11/2019] [Accepted: 12/21/2019] [Indexed: 11/11/2022]
Abstract
Prenatal exome sequencing (ES) currently has limited use in the clinical setting, but research suggests that it has added diagnostic utility over karyotyping and array techniques for prenatal diagnosis of fetuses presenting with ultrasound abnormalities. The purpose of this study was to assess the attitudes of genetics professionals toward the clinical implementation of prenatal ES in order to guide development of professional guidelines. A survey was developed using themes identified in previous qualitative studies and was distributed to members of the American College of Medical Genetics and Genomics (ACMG), the American Society of Human Genetics (ASHG), and the National Society of Genetic Counselors (NSGC). A total of 498 participants completed some portion of the survey. There was consensus among participants that there would be clinical utility of prenatal ES when used for diagnosis, pregnancy management, and termination decisions. The majority also agreed that prenatal ES was distinct from its current use in the pediatric and adult settings. There were many areas of contention regarding which types of results should be returned to families and whether or not the current ACMG guidelines for return of incidental findings should also apply to the prenatal setting. Overall, professional guidance is needed to address the continuing concerns surrounding prenatal ES as its utilization in this setting is expected to grow.
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Affiliation(s)
- Casey E Brew
- Division of Genetics, Birth Defects and Metabolism, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
| | | | - Vivian Pan
- Kaiser Permanente Research Bank, Oakland, California
| | - Alexa Hart
- Fetal and Neonatal Medicine Center, Rush University Medical Center, Chicago, Illinois
| | - Bruce Blumberg
- Kaiser Permanente School of Medicine, Pasadena, California
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26
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Young JL, Pantaleao A, Zaspel L, Bayer J, Peters JA, Khincha PP, Bremer RC, Loud JT, Greene MH, Achatz MI, Savage SA, Werner-Lin A. Couples coping with screening burden and diagnostic uncertainty in Li-Fraumeni syndrome: Connection versus independence. J Psychosoc Oncol 2019; 37:178-193. [PMID: 30591002 PMCID: PMC6584025 DOI: 10.1080/07347332.2018.1543376] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE Li-Fraumeni Syndrome (LFS) is an inherited tumor predisposition syndrome with lifetime cancer risks approaching 100% and evolving risk-management strategies. This study evaluated couples' coping with LFS-related burdens. RESEARCH APPROACH Constructivist grounded theory and anticipatory loss frameworks guided design and analysis. SAMPLE AND METHODS Twenty-six individuals enrolled in the NCI LFS Family Study completed semi-structured interviews with their partner during annual screening visits. An interdisciplinary team completed open and focused coding to identify patterns of coping and adaptation. FINDINGS Couples described living with ambiguous danger, a state of chronic apprehension resulting from LFS-associated uncertainties. Most couples communicated openly and alternated shouldering the burden, while others engaged in protective buffering to shield each other from distress and sustain the appearance of normalcy. INTERPRETATION Optimally, coping reduces shared psychosocial distress, yet some strategies may inadvertently increase disconnection. IMPLICATIONS Mental health support is critical for both partners coping with LFS, together and separately.
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Affiliation(s)
- Jennifer L. Young
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
- Family Science Department, School of Public Health, University of Maryland, College Park, Maryland, USA
| | - Ashley Pantaleao
- Family Science Department, School of Public Health, University of Maryland, College Park, Maryland, USA
| | - Lori Zaspel
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jessica Bayer
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - June A. Peters
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Payal P. Khincha
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Renee C. Bremer
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Jennifer T. Loud
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Mark H. Greene
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Maria Isabel Achatz
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Sharon A. Savage
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
| | - Allison Werner-Lin
- Clinical Genetics Branch, Division of Cancer Epidemiology and Genetics, National Cancer Institute, Rockville, Maryland, USA
- School of Social Policy and Practice, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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27
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Durham L, Papanna R, Stevens B, Noblin S, Rodriguez-Buritica D, Hashmi SS, Krstic N. The utilization of prenatal microarray: A survey of current genetic counseling practices and barriers. Prenat Diagn 2019; 39:351-360. [PMID: 30734934 DOI: 10.1002/pd.5435] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 12/29/2022]
Abstract
OBJECTIVE We evaluated what prenatal genetic counselor's (GCs) practices, attitudes, and barriers are in regards to prenatal microarray since the publication of the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine (SMFM) guidelines for microarray use. METHODS This was a survey-based cross-sectional study of English-speaking, board certified or eligible GCs who currently practice prenatal genetic counseling. RESULTS Of 192 respondents, 183 (95%) have incorporated chromosome microarray (CMA) into clinical practice, with 64% believing that the benefits of CMA outweigh the harms and 52% agreeing that CMA should be offered to all women regardless of indication. Those who reported being experts/comfortable in their knowledge of CMA (85%) and familiar with current clinical guidelines (86%) were significantly more likely to offer CMA to patients undergoing invasive testing and patients with fetal anomalies. Patient-specific concerns were the largest reported barrier (51%) when GCs do not offer CMA to patients. CONCLUSION Our study demonstrates GCs follow guidelines for CMA use when specific indications are involved, but further guidelines are needed regarding CMA use for other routine indications where utility of CMA is not clearly understood. On this basis, ACOG and SMFM should continue revising their guidelines as more information comes to light regarding utility of prenatal CMA for all indications, and organizations like the National Society of Genetic Counselors (NSGC) should consider publishing guidelines on prenatal CMA that are specialized to the GCs sphere of practice.
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Affiliation(s)
- Leslie Durham
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, University of Texas, Houston, Texas.,Department of Pediatric Development and Rehabilitation, Randall Children's Hospital at Legacy Emanuel, Portland, Oregon
| | - Ramesha Papanna
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Blair Stevens
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, University of Texas, Houston, Texas.,Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Sarah Noblin
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, University of Texas, Houston, Texas.,Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - David Rodriguez-Buritica
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - S Shahrukh Hashmi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas
| | - Nevena Krstic
- The University of Texas MD Anderson Cancer Center UTHealth Graduate School of Biomedical Sciences, University of Texas, Houston, Texas.,Department of Obstetrics, Gynecology, and Reproductive Sciences, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, Texas.,Department of Obstetrics and Gynecology, Morsani College of Medicine, University of South Florida, Tampa, FL
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28
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Farrell RM, Mercer M, Agatisa PK, Coleridge MB. Balancing Needs and Autonomy: The Involvement of Pregnant Women's Partners in Decisions About cfDNA. QUALITATIVE HEALTH RESEARCH 2019; 29:211-221. [PMID: 30182811 DOI: 10.1177/1049732318796833] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Cell-free fetal DNA (cfDNA) screening is used to identify the presence of fetal genetic variants early in pregnancy. Patients' informed decision-making is central to the success of this new screen in clinical practice. Although research has focused on pregnant women's decision-making, little is known about partners' role and preferences as a member of the decision-making dyad. Using a grounded theory approach, this study analyzed 23 in-depth interviews to examine partners' perspectives about cfDNA screening and preferences with respect to their role in the decision-making process. Participants wished to be actively involved in testing decisions. They articulated a distinct set of needs and preferences in the decision-making process. Such involvement was hindered by several biological and logistical barriers. This study demonstrates the need to develop mechanisms that foster informed decision-making for cfDNA screening and related new reproductive genetic technologies that focus on not just the pregnant woman but also the decision-making dyad that includes her partner as well.
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29
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Desai P, Haber H, Bulafka J, Russell A, Clifton R, Zachary J, Lee S, Feng T, Wapner R, Monk C, Chung WK. Impacts of variants of uncertain significance on parental perceptions of children after prenatal chromosome microarray testing. Prenat Diagn 2018; 38:740-747. [PMID: 29956345 PMCID: PMC6312184 DOI: 10.1002/pd.5323] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 05/30/2018] [Accepted: 06/21/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE There are concerns regarding the potential harms in receipt of prenatal chromosome microarray (CMA) results, particularly variants of uncertain significance (VUS). We examined the influence that the return of genomic results had on parental well-being and perceptions of children's development. METHODS Parents (n = 138) of 83 children who underwent prenatal chromosomal microarray testing completed questionnaires assessing perception of children's development, parent-child attachment, parental mood, parenting competence, martial satisfaction, satisfaction with the decision to undergo testing, and attitudes about genetics at age 12 and/or 36 months. Responses were compared between parents who received normal/likely benign results and VUS results. RESULTS Compared to normal/likely benign results, parents who received VUS results rated their child as less competent on the BITSEA scale at 12 (β = -1.65, P = .04) though not 36 months (P = .43). There were no differences in parent mood, marital satisfaction, or parenting competence. At 36 months, parents in the VUS group reported less satisfaction with their decision to undergo genetic testing (β = 1.51, P = .02). CONCLUSION Chromosome microarray VUS results have limited impact on parental well-being and perception of children's development. However, the initial diminished perception of child competency and later dissatisfaction with genomic testing indicate the need to assist parents in coping with ambiguous results.
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Affiliation(s)
- Preeya Desai
- New York State Psychiatric Institute, New York, NY, USA
| | | | - Jessica Bulafka
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Amita Russell
- Department of Obstetrics & Gynecology, Columbia University, New York, NY, USA
| | | | | | - Seonjoo Lee
- Division of Biostatistics, New York State Psychiatric Institute, New York, NY, USA
- Department of Biostatistics, Columbia University, New York, NY, USA
| | - Tianshu Feng
- Division of Biostatistics, New York State Psychiatric Institute, New York, NY, USA
| | - Ronald Wapner
- Department of Obstetrics & Gynecology, Columbia University, New York, NY, USA
| | - Catherine Monk
- New York State Psychiatric Institute, New York, NY, USA
- Department of Obstetrics & Gynecology, Columbia University, New York, NY, USA
- Department of Psychiatry, Columbia University, New York, NY, USA
| | - Wendy K Chung
- Department of Pediatrics, Columbia University, New York, NY, USA
- Department of Medicine, Columbia University, New York, NY, USA
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30
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Wou K, Weitz T, McCormack C, Wynn J, Spiegel E, Giordano J, Wapner RJ, Chung WK. Parental perceptions of prenatal whole exome sequencing (PPPWES) study. Prenat Diagn 2018; 38:801-811. [PMID: 30035818 DOI: 10.1002/pd.5332] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 05/06/2018] [Accepted: 07/11/2018] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The objective of the study is to investigate the experiences of couples who underwent prenatal whole-exome sequencing (WES) for fetal anomalies and the amount/type of information couples want from prenatal WES. METHOD Participants in the Fetal Sequencing Study who had genetic testing for fetal anomalies were invited for a semistructured interview about their experience with prenatal WES. A constructivist grounded theory approach with an inductive coding style was used for coding and analysis. RESULTS We interviewed 29 participants from 17 pregnancies. Two pregnancies had positive prenatal WES results, and 4 were terminated prior to receipt of WES results. The main themes were anxiety and stress around the time of diagnosis, education and consent for WES, coping and support while waiting for results, and receiving genetic testing results. In response to hypothetical scenarios probing the desire for uncertain results, 86% would like to be told about results for which the provider had some degree of uncertainty, and the percent desiring results decreased as the certainty of the results decreased. CONCLUSION Participants' experience with exome sequence was similar to other prenatal genetic diagnostic tests, except for the longer wait time for results. When probed with hypothetical scenarios, participants desired more results than were provided in the study, including uncertain results that might diagnose the fetal condition. This highlights the need for specialized prenatal genetic counseling to have nuanced discussions of multiple dimensions of uncertainty with implementation of prenatal WES.
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Affiliation(s)
- Karen Wou
- Department of Pediatrics, Division of Clinical Genetics, Columbia University, New York, NY, USA
| | - Talia Weitz
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Clare McCormack
- Department of Psychiatry, Division of Behavioral Medicine, Columbia University, New York, NY, USA
| | - Julia Wynn
- Department of Pediatrics, Division of Clinical Genetics, Columbia University, New York, NY, USA
| | - Erica Spiegel
- Department of Obstetrics and Gynecology, Division of Reproductive Genetics, Columbia University, New York, NY, USA
| | - Jessica Giordano
- Department of Obstetrics and Gynecology, Division of Reproductive Genetics, Columbia University, New York, NY, USA
| | - Ronald J Wapner
- Department of Obstetrics and Gynecology, Division of Reproductive Genetics, Columbia University, New York, NY, USA
| | - Wendy K Chung
- Department of Pediatrics, Division of Clinical Genetics, Columbia University, New York, NY, USA.,Department of Pediatrics, Division of Molecular Genetics, and Department of Medicine, Columbia University, New York, NY, USA
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31
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Lie MLS, Graham RH, Robson SC, Griffiths PD. MRI for Fetal Developmental Brain Abnormalities: Perspectives From the Pregnant Patient. QUALITATIVE HEALTH RESEARCH 2018; 28:1295-1307. [PMID: 29580171 DOI: 10.1177/1049732318764390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
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.
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Affiliation(s)
- Mabel L S Lie
- 1 Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Ruth H Graham
- 1 Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Paul D Griffiths
- 2 University of Sheffield, Sheffield, United Kingdom
- 3 Royal Hallamshire Hospital, Sheffield, United Kingdom
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32
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Hodgson J, McClaren BJ. Parental experiences after prenatal diagnosis of fetal abnormality. Semin Fetal Neonatal Med 2018; 23:150-154. [PMID: 29258838 DOI: 10.1016/j.siny.2017.11.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
For many pregnant women, prenatal testing is a routine component of contemporary pregnancy care. Receiving a prenatal diagnosis is frequently associated with intense feelings of shock and grief; the extent of which may be unrelated to the pregnancy gestation or the condition diagnosed. During this time of crisis, parents are often faced with important choices about their pregnancy. Levels of understanding and experiences of professional support throughout this time likely impact decisions that are made and how they are subsequently perceived. Despite considerable advances in prenatal testing technologies over the last 20 years there is a paucity of research examining parental experiences in-depth. Future advances such as prenatal exome sequencing will further increase the scope of prenatal testing and numbers of parents who receive a prenatal diagnosis. It is imperative that large-scale studies are performed to ensure that protocols are in place to adequately support couples at this time.
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Affiliation(s)
- Jan Hodgson
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Genetics Education and Health Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia.
| | - Belinda J McClaren
- Department of Paediatrics, University of Melbourne, Melbourne, Victoria, Australia; Genetics Education and Health Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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33
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Richardson A, Ormond KE. Ethical considerations in prenatal testing: Genomic testing and medical uncertainty. Semin Fetal Neonatal Med 2018; 23:1-6. [PMID: 29033309 DOI: 10.1016/j.siny.2017.10.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Prenatal diagnostic testing has recently progressed from karyotype to routinely available chromosomal microarray, and the potential for fetal whole exome sequencing, both through invasive diagnostic testing and, in some cases, non-invasive prenatal testing. These tests bring beneficence through providing a higher diagnostic yield, often with lower risks of miscarriage than previously available testing, but also raise the question of harms related to an increase in uncertain and unknown results. Some parents-to-be report a desire to learn as much information as possible prenatally, and there may be beneficence in providing them with this information. However, the potential uncertainty these tests may create may raise anxiety and may complicate pregnancy decision-making for both patients and providers. This article reviews current prenatal technologies and the growing research on the clinical and ethical aspects of uncertainty as it relates to expanding prenatal testing options.
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Affiliation(s)
- Anastasia Richardson
- Lucile Packard Children's Hospital Stanford, Fetal and Pregnancy Health Program, Palo Alto, CA, USA
| | - Kelly E Ormond
- Stanford University School of Medicine, Department of Genetics and Stanford Center for Biomedical Ethics, Stanford, CA, USA.
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34
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Abstract
The clinical integration of prenatal genetic technologies raises a series of important medical and ethical considerations for patients, families, health care providers, health care systems, and society. It is critical to recognize, understand, and address these issues in conjunction with the continued development of new prenatal genetic screens and tests. This article discusses some of the lead ethical issues as a starting point to further understanding their ramifications on patients, families, communities, and health care providers.
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Expert Knowledge Influences Decision-Making for Couples Receiving Positive Prenatal Chromosomal Microarray Testing Results. Cult Med Psychiatry 2017; 41:382-406. [PMID: 28132396 DOI: 10.1007/s11013-017-9521-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
To assess how participants receiving abnormal prenatal genetic testing results seek information and understand the implications of results, 27 US female patients and 12 of their male partners receiving positive prenatal microarray testing results completed semi-structured phone interviews. These interviews documented participant experiences with chromosomal microarray testing, understanding of and emotional response to receiving results, factors affecting decision-making about testing and pregnancy termination, and psychosocial needs throughout the testing process. Interview data were analyzed using a modified grounded theory approach. In the absence of certainty about the implications of results, understanding of results is shaped by biomedical expert knowledge (BEK) and cultural expert knowledge (CEK). When there is a dearth of BEK, as in the case of receiving results of uncertain significance, participants rely on CEK, including religious/spiritual beliefs, "gut instinct," embodied knowledge, and social network informants. CEK is a powerful platform to guide understanding of prenatal genetic testing results. The utility of culturally situated expert knowledge during testing uncertainty emphasizes that decision-making occurs within discourses beyond the biomedical domain. These forms of "knowing" may be integrated into clinical consideration of efficacious patient assessment and counseling.
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36
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Agatisa PK, Mercer MB, Mitchum A, Coleridge MB, Farrell RM. Patient-Centered Obstetric Care in the Age of Cell-Free Fetal DNA Prenatal Screening. J Patient Exp 2017; 5:26-33. [PMID: 29582008 PMCID: PMC5862378 DOI: 10.1177/2374373517720482] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose The clinical introduction of innovative prenatal genetic technologies challenges patients and providers to find new ways of fostering informed decision-making in a setting characterized by complexity and uncertainty. As prenatal genetic technology advances, important questions remain about how to structure patient-centered conversations that effectively prepare pregnant patients to make informed choices about the different genetic conditions for which this new form screening may be used. Methods Focus groups were conducted with 23 pregnant women to identify informational needs and decision-making preferences regarding emerging and anticipated applications of cell-free fetal DNA screening, the newest form of prenatal genetic screening. Results Participants were in favor of obtaining more genetic information about the fetus than provided by conventional screens but acknowledged the challenges inherent in navigating the unique complexities of the decision-making process. The provider-patient relationship was seen as an important resource to navigate the associated uncertainties at each stage of the screening process. Participants emphasized the need for initiatives to support a personalized, accurate, and unbiased discussion about prenatal genetic risk and assessment. Conclusion Continued advances in prenatal genetic screening call for new approaches to structure patient-centered communication to facilitate increasingly complex decisions about fetal genetic risk and assessment.
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Affiliation(s)
- Patricia K Agatisa
- Department of Bioethics, Cleveland Clinic, Cleveland, OH, USA
- Obstetrics, Gynecology and Women's Health Institute, Cleveland, OH, USA
| | - Mary Beth Mercer
- Office of Patient Experience, Cleveland Clinic Center for Personalized Genetic Healthcare, Cleveland, OH, USA
| | - Ariane Mitchum
- Department of Bioethics, Cleveland Clinic, Cleveland, OH, USA
| | - Marissa B Coleridge
- Genomic Medicine Institute, Obstetrics, Gynecology and Women's Health Institute, Cleveland, OH, USA
| | - Ruth M Farrell
- Department of Bioethics, Cleveland Clinic, Cleveland, OH, USA
- Obstetrics, Gynecology and Women's Health Institute, Cleveland, OH, USA
- Genomic Medicine Institute, Obstetrics, Gynecology and Women's Health Institute, Cleveland, OH, USA
- Ruth M Farrell, OB/GYN and Women's Health Institute, 9500 Euclid Ave, A81, Cleveland, OH 44195, USA.
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37
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Werner-Lin A, McCoyd JLM, Bernhardt BA. Balancing Genetics (Science) and Counseling (Art) in Prenatal Chromosomal Microarray Testing. J Genet Couns 2016; 25:855-67. [PMID: 27207687 DOI: 10.1007/s10897-016-9966-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2016] [Accepted: 04/28/2016] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Allison Werner-Lin
- School of Social Policy and Practice, University of Pennsylvania, 3701 Locust Walk, Caster Building, Philadelphia, PA, 19104, USA.
| | - Judith L M McCoyd
- School of Social Work, Rutgers: The State University of New Jersey, New Brunswick, NJ, USA
| | - Barbara A Bernhardt
- Translational Medicine and Medical Genetics, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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38
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"Something Extra on Chromosome 5": Parents' Understanding of Positive Prenatal Chromosomal Microarray Analysis (CMA) Results. J Genet Couns 2016; 25:1116-26. [PMID: 26940446 DOI: 10.1007/s10897-016-9943-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 02/25/2016] [Indexed: 12/21/2022]
Abstract
This study aims to explore how couples' understanding of the nature and consequences of positive prenatal chromosomal microarray analysis (CMA) results impacts decision-making and concern about pregnancy. We interviewed 28 women and 12 male partners after receiving positive results and analyzed the transcripts to assess their understanding and level of concern about the expected clinical implications of results. Participant descriptions were compared to the original laboratory interpretation. When diagnosed prenatally, couples' understanding of the nature and consequences of copy number variants (CNVs) impacts decision-making and concern. Findings suggest women, but less so partners, generally understand the nature and clinical implications of prenatal CMA results. Couples feel reassured, perhaps sometimes falsely so, when a CNV is inherited from a "normal" parent and experience considerable uncertainty when a CNV is de novo, frequently precipitating a search for additional information and guidance. Five factors influenced participants' concern including: the pattern of inheritance, type of possible phenotypic involvement, perceived manageability of outcomes, availability and strength of evidence about outcomes associated with the CNV, and provider messages about continuing the pregnancy. A good understanding of results is vital as couples decide whether or not to continue with their pregnancy and seek additional information to assist in pregnancy decision-making.
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