Impact of miscarriage and termination of pregnancy on subsequent pregnancies: A longitudinal study of maternal and paternal depression, anxiety and eudaimonia

BACKGROUND

Although miscarriage and termination of pregnancy affect maternal mental illnesses on subsequent pregnancies, their effects on the positive mental health (e.g., eudaimonia) of both first-time and multi-time parents have received minimal attention, especially for fathers. This longitudinal study examines the effects of experiences of miscarriage and termination on parental well-being in subsequent pregnancies from prenatal to postpartum years, while simultaneously considering parity.

METHODS

Pregnant women and their partners were recruited during early prenatal visits in Taiwan from 2011 to 2022 and were followed up from mid-pregnancy to 1 year postpartum. Six waves of self-reported assessments were employed.

RESULTS

Of 1813 women, 11.3 % and 14.7 % had experiences of miscarriage and termination, respectively. Compared with the group without experiences of miscarriage or termination, experiences of miscarriage were associated with increased risks of paternal depression (adjusted odds ratio = 1.6, 95 % confidence interval [CI] = 1.13-2.27), higher levels of anxiety (adjusted β = 1.83, 95 % CI = 0.21-3.46), and lower eudaimonia scores (adjusted β = -1.09, 95 % CI = -1.99 to -0.19) from the prenatal to postpartum years, particularly among multiparous individuals. Additionally, experiences of termination were associated with increased risks of depression in their partner.

LIMITATIONS

The experiences of miscarriage and TOP were self-reported and limited in acquiring more detailed information through questioning.

CONCLUSIONS

These findings highlight the decreased well-being of men whose partners have undergone termination of pregnancy or experienced miscarriage, and stress the importance of interventions aimed at preventing adverse consequences among these individuals.

Termination of pregnancy due to fetal anomaly: A qualitative study from Turkey on women's experiences

BACKGROUND

Termination of pregnancy due to fetal anomaly is an unexpected traumatic event for women. It can cause serious complications that can negatively affect both the physical and psychological health of women.

AIM

This study aims to examine the experiences of women who underwent medical termination for fetal anomaly in the second trimester.

METHODS

The study included 12 women whose pregnancies were terminated due to fetal anomaly. Data were collected through in-depth interviews until data sufficiency was reached. Thematic analysis method was used to analyze the data. This study was conducted using an inductive qualitative design. The women's statements were examined and double-coded. By examining the codes, main themes were created after sub-themes.

RESULTS

Women's experiences were analyzed in five themes: difficulty in decision-making (1), emotional impact (2), stigmatization (3), dilemma between hope and anxiety (4), and post-termination care and support needs (5). Participants stated that they experienced many emotions such as indecision, sadness, helplessness, guilt, and remorse during the medical termination process. Hope, anxiety, fear, social pressure and support needs were also frequently experienced in this process.

CONCLUSION

Termination of pregnancy in the second trimester due to fetal anomaly caused significant psychological symptoms. In order to prevent long-term health complications, it will be important for health professionals to provide interventions designed to meet the demands of women diagnosed with fetal anomaly.

Comparing the outcomes of termination of second trimester pregnancy with a live fetus using intravaginal misoprostol between women with and without previous cesarean section

OBJECTIVE

To compare the outcomes of termination of pregnancy with live fetuses in the second trimester (14-28 weeks), using misoprostol 400 mcg intravaginal every 6 h, between women with previous cesarean section (PCS) and no previous cesarean section (no PCS).

METHODS

A comparative study was conducted on a prospective database of pregnancy termination in the second trimester, Chiang Mai university hospital. Inclusion criteria included: (1) singleton pregnancy; (2) gestational age between 14 and 28 weeks; and (3) pregnancy with a live fetus and medically indicated for termination. The participants were categorized into two groups; PCS and no PCS group. All were terminated using misoprostol 400 mcg intravaginal every 6 h. The main outcomes were induction to fetal delivery interval and success rate, defined as fetal delivery within 48 h.

RESULTS

A total of 238 women, including 80 PCS and 158 no PCS, were recruited. The success rate of fetal delivery within 48 h between both groups was not significantly different (91.3% vs. 93.0%; p-value 0.622). The induction to fetal delivery interval were not significantly different (1531 vs. 1279 min; p-value > 0.05). Gestational age was an independent factor for the success rate and required dosage of misoprostol. The rates of most adverse effects of misoprostol were similar. One case (1.3%) in the PCS group developed uterine rupture during termination, ending up with safe and successful surgical removal and uterine repair.

CONCLUSION

Intravaginal misoprostol is highly effective for second trimester termination of pregnancy with PCS and those with no PCS, with similar success rate and induction to fetal delivery interval. Gestational age was an independent factor for the success rate and required dosage of misoprostol. Uterine rupture could occur in 1.3% of PCS, implying that high precaution must be taken for early detection and proper management.

SYNOPSIS

Intravaginal misoprostol is highly effective for termination of second trimester pregnancy with a live fetus, with a comparable success rate between women with and without previous cesarean section, with a 1.3% risk of uterine rupture among women with previous cesarean section.

Feticide Before Termination of Pregnancy in Singleton Pregnancy - Trends in England and Wales 2012-2020, a Cross-sectional Study

Feticide is the practice of inducing fetal demise before the termination of pregnancy. In England and Wales, it is recommended for terminations of pregnancy beyond 21+6 weeks of gestation. This project analyses the trends in feticide in singleton pregnancy in England and Wales between 2012 and 2020. This project was a retrospective study that analysed data extracted from the Health and Social Act 4 (HSA4) forms submitted to the Department of Health and Social Care (DHSC). The data extracted by the DHSC included the prevalence of feticide, methods of feticide and termination, statutory grounds, gestation, service provider, maternal age, ethnicity and obstetric history. In addition, data analysis was carried out to identify trends. Between 2012 and 2020, there were 9310 feticides in England and Wales, undertaken in 0.5% of all abortions. The prevalence of feticide fluctuated; however, there was an overall decrease from 1084 cases in 2012 to 1000 cases in 2020. Intracardiac injection of potassium chloride was the most frequent method of achieving feticide (67.2%). Just over half (55.8%) of feticides took place under Ground E of the Abortion Act 1967, with the main indication being congenital malformations of the nervous system. Two-fifths (40.2%) of feticides took place at 23 weeks, 22.8% at 22 weeks and 13.5% between 20 and 21 weeks. The remainder occurred at later gestations: 17.5% at 24-29 weeks and 5.9% beyond 29 weeks. During our study period, it was more common for feticides to be carried out as part of a medical termination than a surgical termination and 60.3% occurred in NHS hospitals. Women undergoing feticide were mostly aged 30-34 years (38.3%) and of White ethnicity (78.6%). Feticide is an essential component of comprehensive abortion care for women undergoing late second and third-trimester abortions. This study provides insight into how feticide is carried out in England and Wales and demonstrates the effect of the COVID-19 pandemic on reducing feticide prevalence. Future research should analyse in more detail the use of the different methods of feticide.

Termination of pregnancy in lupus nephritis: A bioethical analysis with the integrative method

BACKGROUND AND OBJECTIVE

Termination of pregnancy in patients with rheumatic diseases is controversial and a bioethical analysis is rarely performed. In this study we analysed the case of a pregnant patient with lupus nephritis unresponsive to treatment, for whom termination of pregnancy is considered.

METHODS

The integrative model was applied combining different normative ethical theories.

RESULTS

From a utilitarian perspective, termination of pregnancy is justifiable, seeking the greatest benefit for the greatest number of stakeholders. Deontology justifies both terminating and continuing the pregnancy, focusing on the action itself and on autonomy. In virtue ethics the importance of decisions rests with the person who performs the action seeking flourishing; termination of pregnancy would be justifiable.

DISCUSSION AND CONCLUSIONS

Interruption of pregnancy is a justifiable solution following the integrative model. Bioethical analysis of paradigmatic cases is essential to ensure the best possible action and as a precedent for future similar situations in rheumatology.

Grief trajectories after loss in pregnancy and during the neonatal period

Distinguishing patterns of grief over time in parents with a loss in pregnancy or during the neonatal period is important for identification of parents with severe grief symptoms, who may need additional support. Our aim was to describe grief in this population and to examine variations by type of loss in a large prospective cohort. We used questionnaire data from the Danish longitudinal cohort, Life After the Loss, which contains information on parents with a loss in pregnancy (from 14 weeks) or during the neonatal period. Parents completed the Prolonged Grief-13 scale at 1, 7, and 13 months after their loss. We applied Latent Growth Mixture Modelling to identify prolonged grief trajectories and used multinomial regression models to assess factors associated with class membership. Three distinct trajectories were identified in 676 parents: resilience (73.1%), recovery (16.9%), and chronic (10%). The distribution varied by type of loss, and the chronic group were overrepresented by parents with stillbirths (16.2%) and neonatal deaths (16.1%) in contrast to parents with spontaneous abortions (8.2%) and termination of pregnancy due to fetal anomalies (6.2%). Furthermore, not having a living child or being a woman was associated with following the chronic trajectory. These results underline that, while most bereaved parents are resilient, 10% experience consistently high levels of grief symptoms during the first year after the loss. Information on type of loss, gender, and whether the parent has living children are meaningful indicators of grief class membership.

Cardiovascular complications following medical termination of pregnancy: An updated review

BACKGROUND

Around 1 million cases of medical termination of pregnancy (MTP) take place yearly in the United States of America with around 2 percent of this population developing complications. The cardiovascular (CVD) complications occurring post MTP or after stillbirth is not very well described.

AIM

To help the reader better understand, prepare, and manage these complications by reviewing various cardiac comorbidities seen after MTP.

METHODS

We performed a literature search in PubMed, Medline, RCA, and google scholar, using the search terms "abortions" or "medical/legal termination of pregnancy" and "cardiac complications" or "cardiovascular complications".

RESULTS

The most common complications described in the literature following MTP were infective endocarditis (IE) (n = 16), takotsubo cardiomyopathy (TTC) (n = 7), arrhythmias (n = 5), and sudden coronary artery dissection (SCAD) (n = 4). The most common valve involved in IE was the tricuspid valve in 69% (n = 10). The most observed causative organism was group B Streptococcus in 81% (n = 12). The most common type of TTC was apical type in 57% (n = 4). Out of five patients developing arrhythmia, bradycardia was the most common and was seen in 60% (3/5) of the patients. All four cases of SCAD-P type presented as acute coronary syndrome 10-14 d post termination of pregnancy with predominant involvement of the right coronary artery. Mortality was only reported following IE in 6.25%. Clinical recovery was reported consistently after optimal medical management following all these complications.

CONCLUSION

In conclusion, the occurrence of CVD complications following pregnancy termination is infrequently documented in the existing literature. In this review, the most common CVD complication following MTP was noted to be IE and TTC.

Factors influencing the risk of repeat termination of pregnancy: A register-based study in Finland

OBJECTIVE

This study aimed to assess how factors such as sociodemographic characteristics, termination of pregnancy (TOP) related factors and contraception affect the risk of repeat TOP.

MATERIALS AND METHOD

This is a nationwide register-based study of 193,741 women who had TOP(s) during 1987-2015, using the Finnish Register of Induced Abortions. The risk of various factors, such as age, marital status, residence, parity, TOP related factors and contraception, was assessed separately for each repeat TOP. Cox proportional hazard model was used to estimate risk of different factors for repeat TOPs.

RESULTS

21% of the women having TOP had repeat TOPs during the years 1987-2015. Among women with repeat TOPs, more than 70% had one repeat TOP and the rest had two or more. Older, married and rural or semi-urban women had reduced risk of repeat TOPs. Adjusted risk for one repeat TOP was higher among parous women (HR 1.67, 95% CI 1.61-1.72). No significant risk for repeat TOP was observed by method in sub-analysis for the recent period after 2006. Women using less reliable (HR 1.14, 95% CI 1.06-1.23) and unreliable (HR 1.33, 95% CI 1.23-1.43) contraception had increased risk of repeat TOP than women using reliable contraception.

CONCLUSION

Older age, being married, residing in rural or semi-urban areas and using reliable contraception were found to be protective factors for repeat TOPs whereas, parous women had higher risk for repeat TOPs. Proper counselling regarding contraception and use of reliable contraception immediately after TOP should be encouraged.

Evaluation of a pregnancy loss education intervention for undergraduate nursing students in Northern Ireland: A pre- and post-test study

BACKGROUND

Research highlights the importance of compassionate communication, adequate delivery of information, and professional support to help alleviate parental distress following pregnancy loss. However, many healthcare professionals do not feel sufficiently trained to deal with pregnancy loss in practice. We aimed to address this deficiency with an evidence-informed educational intervention to increase knowledge, skills, self-awareness, and confidence regarding pregnancy loss among UK nursing students.

METHODS

Educational resources, which included an 82-minute podcast and 40-minute online lecture were developed. The podcast focused on the lived experiences of three women who had experienced miscarriage, stillbirth, and termination of pregnancy for medical reasons. The pre-recorded lecture included definitions of types of pregnancy loss, discussion of the importance of communication, and information on the clinical management of pregnancy loss. Students were presented with both the lecture and podcast as a self-directed element of existing curricula. A pre-test/post-test cross-sectional survey design was used to investigate the impact of the educational intervention. The Perinatal Bereavement Care Confidence Scale (PBCCS) was completed by 244 first year BSc Nursing students before and up to a week after receiving the intervention. Quantitative data were analysed using a Paired Samples Wilcoxon test. Responses to open-ended questions, which allowed students to give feedback on the intervention content and delivery were analysed using Qualitative Content Analysis.

RESULTS

96% (n = 235) of the sample reported having no prior experience or training in the management and support of those experiencing pregnancy loss. At pre-test, 88% (n = 215) of students rated themselves as not confident in dealing with pregnancy loss in a professional capacity. Post-test, we found statistically significant effects for perceived competency on all learning outcomes (p < .001). Qualitative analysis of n = 745 individual text responses to open-ended questions indicated four categories related to the perceived value of using real-life stories for learning, demystifying a taboo subject, and providing tools for practice. Respondents suggested the inclusion of more information on memory-making, support networks, and mental health following pregnancy loss.

CONCLUSIONS

The educational intervention increased student nurses' perceived knowledge, confidence, and skills in caring for families experiencing pregnancy loss. This offers potential for increased quality of care for those experiencing pregnancy loss in healthcare settings, increased patient satisfaction, and improved mental health-related outcomes.

Pregnancy loss following miscarriage and termination of pregnancy for medical reasons during the COVID-19 pandemic: a thematic analysis of women's experiences of healthcare on the island of Ireland

BACKGROUND

Losing a baby during pregnancy can be a devastating experience for expectant parents. Many report dedicated, compassionate healthcare provision as a facilitator of positive mental health outcomes, however, healthcare services have been severely impacted during the COVID-19 pandemic.

AIM

To explore women's experiences of healthcare service provision for miscarriage and termination of pregnancy for medical reasons (TFMR) on the island of Ireland during the COVID-19 pandemic.

METHODS

Findings combine data from elements of two separate studies. Study 1 used a mixed methods approach with women who experienced miscarriage and attended a hospital in Northern Ireland. Study 2 was qualitative and examined experiences of TFMR in Northern Ireland and Ireland. Data analysed for this paper includes open-ended responses from 145 women to one survey question from Study 1, and semi-structured interview data with 12 women from Study 2. Data were analysed separately using Thematic Analysis and combined for presentation in this paper.

RESULTS

Combined analysis of results indicated three themes, (1) Lonely and anxiety-provoking experiences; (2) Waiting for inadequate healthcare; and (3) The comfort of compassionate healthcare professionals.

CONCLUSIONS

Women's experiences of healthcare provision were negatively impacted by COVID-19, with the exclusion of their partner in hospital, and delayed services highlighted as particularly distressing. Limited in-person interactions with health professionals appeared to compound difficulties. The lived experience of service users will be helpful in developing policies, guidelines, and training that balance both the need to minimise the risk of infection spread, with the emotional, psychological, and physical needs and wishes of parents. Further research is needed to explore the long-term impact of pregnancy loss during a pandemic on both parents and health professionals delivering care.

'The tabloid test': a qualitative interview study on the function and purpose of termination of pregnancy review committees in Victoria, Australia

BACKGROUND

Termination of pregnancy (TOP) is not an uncommon procedure. Availability varies greatly between jurisdictions; however, additional institutional processes beyond legislation can also impact care and service delivery. This study serves to examine the role institutional processes can play in the delivery of TOP services, in a jurisdiction where TOP is lawful at all gestations (Victoria, Australia). As per the Abortion Law Reform Act 2008, TOPs post-24 weeks require the approval of two medical practitioners. However, in Victoria, hospitals that offer post-24 week TOPs generally require these cases to additionally go before a termination review committee for assessment prior to the service being provided. These committees are not stipulated in legislation. Information about these committees and how they operate is scarce and there is minimal information available to the public.

METHODS

To trace the history, function, and decision-making processes of these committees, we conducted a qualitative interview study. We interviewed 27 healthcare professionals involved with these committees. We used purposive sampling to gain perspectives from a range of professions across 10 hospitals. Interviews were transcribed verbatim, identifying details removed and inductive thematic analysis was performed.

RESULTS

Here, we report the three main functions of the committees as described by participants. The functions were to protect: (1) outward appearances; (2) inward functionality; and/or, (3) service users. Function (1) could mean protecting the hospital's reputation, with the "Herald Sun test"-whether the TOP would be acceptable to readers of the Herald Sun, a tabloid newspaper-used as a heuristic. Function (2) related to logistics within the hospital and protecting the psychological wellbeing and personal reputation of healthcare professionals. The final function (3) related to ensuring patients received a high standard of care.

CONCLUSIONS

The primary functions of these committees appear to be about protecting hospitals and clinicians within a context where these procedures are controversial and stigmatized. The results of this study provide further clarity on the processes involved in the provision of TOPs at later gestations from the perspectives of the healthcare professionals involved. Institutional processes beyond those required by legislation are put in place by hospitals. These findings highlight the additional challenges faced by patients and their providers when seeking TOP at later gestations.

Associated factors with parental pregnancy decision-making and use of consultation after a prenatal congenital heart disease diagnosis

BACKGROUND

Prenatal diagnosis of congenital heart disease (CHD) often leads affected families to experience psychological stress. Pediatric cardiology consultation is important in providing parents with sufficient information and reducing their anxiety to make an informed pregnancy decision. Involving a fetal nurse coordinator may optimize fetal anomaly care. Our study aimed to identify factors associated with parental decision-making for choosing to use pediatric cardiology consultations and pregnancy termination.

METHODS

From September 2017 to December 2018, all fetal CHD cases diagnosed in the second trimester from a primary screening clinic in Taiwan were included (n = 145). Univariate and multivariate logistic regression were performed to analyze maternal, fetal, and medical factors for predictors of parental decisions for consultation use and pregnancy termination.

RESULTS

Acceptance for fetal nurse coordinator care and pediatric cardiology consultation were 84.8% (n = 123) and 83.4% (n = 121), respectively. Predictors for termination of pregnancy included the following: multiple anomalies (OR: 10.6; 95% CI: 3.6-35.7), chromosomal/genetic abnormalities (OR: 20.2; 95% CI: 3.1-395.8), severe CHDs (OR: 9.8; 95% CI: 4.3-23.4), CHDs that required surgery (OR: 32.4; 95% CI: 11.4-117.8), and physiological single-ventricle (OR: 47.3; 95% CI: 12.4-312.5). Parents who had pediatric cardiology counseling were less likely to terminate the pregnancy (OR: 0.1; 95% CI: 0.0-0.7). Parents with fetal diagnosis having multiple anomalies (OR: 0.2; 95% CI: 0.1-0.7) or chromosomal/genetic abnormalities (OR: 0.1; 95% CI: 0.03-0.9) were less likely to make use of cardiology consultation. Parents who accepted fetal nurse coordinator care were more likely to have pediatric cardiology consultation before pregnancy decision (OR: 149.5, 95% CI: 37.8-821.5).

CONCLUSIONS

Anomaly complexity appeared to be a strong predictor for termination of pregnancy beyond non-acceptability of prenatal cardiology consultation. Prenatal cardiology counseling may help support the parental decision to continue with the pregnancy. Incorporation of a fetal nurse coordinator care into the multidisciplinary fetal medicine team improved the acceptability of prenatal consultation.

Prenatal diagnosis of tuberous sclerosis complex: Echocardiography, cranial magnetic resonance, and genetic testing of 40 cases with fetal cardiac tumors

Objective

To explore the relationship between Tuberous sclerosis complex (TSC) and cardiac tumors at our institution over the past five years and to evaluate the value of imaging technologies and genetic testing in the prenatal diagnosis of TSC.

Methods

Fetal echocardiography (FE) was performed in the whole population between 2016 and 2020. Fetuses detected with cardiac tumor(s) were included. Fetal cranial magnetic resonance imaging (MRI) and gene mutation tests were further examined. Those who declined genetic testing were excluded in the final analysis.

Results

A total of 40 fetuses were included in our study. There were 27 cases performed cranial magnetic resonance imaging (MRI) and the rest of 13 cases refused. Among 10 fetuses with cranial lesions detected by MRI, all of them were eventually diagnosed with TSC. And for 17 fetuses without cranial lesions, none of them were identified with a pathogenic variation in gene TSC1/2. The prevalence of TSC was significantly higher in the multiple tumors group than in the solitary group (9/20 vs. 2/20, P = 0.034). 11 fetuses had TSC1 (n = 3) or TSC2 (n = 8) causative or suspected causative mutations, of which 9 were sporadic mutations and 2 were familial mutations.

Conclusion

Fetal cranial MRI should be recommended to evaluate brain lesions, and genetic mutation should be examined, if possible, especially for those with multiple heart tumors. When typical cardiac tumors and cranial lesions are detected, the diagnosis of TSC can almost be made even without genetic mutation results.

The decision-making process of pregnant individuals offered termination of pregnancy for serious congenital abnormalities

OBJECTIVES

This study aimed to explore the decision-making process of patients with pregnancies affected by serious congenital abnormalities.

METHODS

The study design was an exploratory qualitative study. The sample for this study was pregnant individuals who had a prenatal diagnosis of a serious congenital abnormality and were offered termination of pregnancy. Semi-structured face-to-face interviews with closed and open-ended questions, recorded and transcribed verbatim, were used to collect the data; this was then analyzed using a thematic data analysis approach.

RESULTS

Five topics were developed: "Health care services", "Home", "Being a mother", "Finding meaning", and "The aftermath". The first four topics describe the decision-making process where the participants filtered through multiple factors to reach their final decision. Although the participants consulted with their families, partners, and community, they made the final decision themselves. The final topics describes activities which were necessary for closure and coping.

CONCLUSION

This study has provided valuable insight into the decision-making process, which can be used to improve services offered to patients.

PRACTICE IMPLICATIONS

Information should be communicated clearly with follow-up appointments to discuss further. Healthcare professional should show empathy and assure the participants that their decision is supported.

[Medical termination of pregnancy for isolated intrauterine growth retardation beyond 24 weeks and more than 450g]

INTRODUCTION

Fetal growth restriction (FGR) is an obstetric complication responsible for increased perinatal morbidity and mortality. In some severe and early FGR situations, termination of pregnancy (TOP) may be considered. The main objective of our study was to describe the population of fetuses for whom a TOP was performed for isolated FGR beyond 24 days' gestation and for a birth weight>450g and to analyze the immediate outcome, at 2 and 5 years, of term- and weight-matched neonates born in a context of severe FGR after 24 weeks' gestation and over 450g.

MATERIAL AND METHODS

We conducted an observational, descriptive, retrospective, uni-centric study between 2008 and 2018. The primary endpoint was survival at maternity discharge, 2 years and 5 years in these children. Secondary endpoints were assessment of immediate and longer-term postnatal morbidity. Twenty-five patients (36%) were selected for the study with a fetus weight>450g and term>24 weeks. Each fetus with an TOP was matched (on gestational age and weight) with two live-born children from the perinatal network cohort to assess immediate discharge outcome, and then at 2 and 5 years.

RESULTS

The mortality rate was 24%. In neonatal management, for 67% (n=17) of the newborns the evolution was complicated by death or at least two sequelae (bronchopulmonary dysplasia, hyaline membrane disease stage≥2, intraventricular of grade 3 and 4, ulcerative colitis requiring surgery, retinopathy of prematurity stage 2 and more) at discharge. In 32% (n=8) of cases, there was at least one sequela at discharge. Regardless of gestational age at birth, development at 2 years was normal for 48% (n=11/23) of them and abnormal for 22% (n=5) and development at 5 years was normal for 56% (n=9/16) of them and abnormal for 19% (n=5).

CONCLUSION

An ultrasound evaluation in a reference center as well as additional information by the obstetrician and neonatologist ensures the most appropriate informed involvement of the couple in the medical decisions before and after birth.

Perinatal survival among very preterm singletons born after detection of early-onset fetal growth restriction with or without maternal hypertensive disorders: A population-based study in France

OBJECTIVE

To investigate the management and survival of very preterm singletons born because of fetal growth restriction (FGR) with or without maternal hypertensive disorders in France.

STUDY DESIGN

From a population-based cohort of very preterm births between 22 and 31 weeks in France in 2011, the study population included all non-anomalous singleton pregnancies delivered because of detected FGR with or without maternal hypertensive disorders. Antenatal detection of FGR was defined as an estimated fetal weight <10th percentile with or without fetal Doppler abnormalities or growth arrest. All fetuses were alive at the time of detection of FGR. Indicators of active perinatal management (antenatal steroids, pre-labor cesarean and birth in level 3 maternity unit) and fetal/neonatal outcomes (terminations of pregnancy (TOP), stillbirths, neonatal deaths and survival to discharge) were compared by gestational age between FGR associated with maternal hypertensive disorders and isolated FGR.

RESULTS

Overall, 398 pregnancies delivered before 32 weeks for FGR associated with hypertensive disorders and 234 for isolated FGR. Active perinatal care was rare before 26 weeks in both groups and about one in five cases associated with maternal hypertensive disorders received steroids and was born by prelabor cesarean compared to none for isolated FGR. Before 25 weeks of gestation age, more pregnancies resulted in TOP when FGR was associated with hypertensive disorders compared to isolated FGR (respectively, 76.2 % vs 28.0 % at 22-23 weeks, P = 0.002 and 57.9 % vs 21.1 % at 24 weeks, P = 0.028) whereas stillbirths were more common among isolated FGR (respectively, 23.8 % vs 72.0 % at 22-23 weeks, P = 0.002 and 36.8 % vs 73.7 % at 24 weeks, P = 0.030). Survival to discharge was higher at any gestational age when the cause of birth was FGR associated with hypertensive disorders compared to isolated FGR.

CONCLUSION

The management and pregnancy outcomes differed when FGR was associated with maternal hypertensive disorders or isolated. The proportion of TOP was higher when FGR was associated with hypertensive disorders and the proportion of stillbirths was higher in isolated FGR.

Life-limiting fetal conditions: Are Australian student midwives prepared? A mixed-methods survey

AIM

To document current teaching methods, curriculum, and perceived educational preparation related to the teaching of life-limiting fetal conditions, termination, and perinatal palliative care to Australian student midwives.

BACKGROUND

Australian women receiving a diagnosis of a life-limiting fetal condition are generally offered a choice between termination of pregnancy and perinatal palliative care. Midwives are often involved with caring for these women. What Australian student midwives are being taught about life-limiting fetal conditions, termination of pregnancy, and perinatal palliative care during their entry-to-practice program is unknown.

DESIGN

This study utilised a mixed-methods descriptive approach for data collection and analysis.

METHODS

Academic Leads of all Australian entry-to-practice midwifery programs received a questionnaire exploring topics taught, teaching time, teacher role, and perceived effectiveness of student preparation. Data was analysed statistically and thematically.

RESULTS

Twelve of 24 Academic Leads responded (50%); only five stated their programs taught all three areas. More respondents taught about termination of pregnancy (10/12) than perinatal palliative care (7/12). On average 5.8 ( ± 2.8) total hours was spent teaching about life-limiting fetal conditions, termination of pregnancy, and perinatal palliative care during the entire midwifery program, with a range of 1 - 10 h. The free-text data identified three central themes: lack of value within the curriculum; disconnect between the university and the placement hospital; and preparation for practice. Most (10/12) Academic Leads did not believe student midwives are prepared to care for affected families.

CONCLUSIONS

Entry-to-practice midwifery programs vary considerably in their education surrounding life-limiting fetal conditions, however teaching hours overall were low and most Academic leads did not feel (or know if) their students were adequately prepared. Further research is required to determine if early career midwives find their university education in life-limiting fetal conditions adequate preparation for practice, and to then remediate identified deficiencies.

Parental information about the option to apply for pregnancy termination after the detection of a congenital abnormality and factors influencing parental decision-making: a cohort study

BACKGROUND

The detection of an abnormality during prenatal screening implies that the parents are informed about possible treatment and management of the pregnancy, birth, and postnatal course. This information should enable the parents to make decisions regarding the pregnancy, especially in cases where termination of pregnancy may be an option. The objectives of this study were to investigate how often doctors informed parents about pregnancy termination when the fetus had an anomaly and which demographic factors were related to parental decision-making.

METHODS

This was a retrospective cohort study with prospectively collected data of fetuses diagnosed with an abnormality during prenatal screening between 2014 and 2016 in Denmark. We categorized the abnormalities into five long-term prognosis groups and analyzed their association with the doctor provided information about termination. We tested the association between demographic variables and parental decisions using univariate and multivariate statistical analyses.

RESULTS

Three hundred and twenty fetuses were diagnosed with an abnormality. In 67% of these cases, the parents were informed about termination. All parents whose fetus had a lethal prognosis were informed about termination. By comparison, the parents of 98% of fetuses with genetic disorders, 96% of fetuses with poor prognosis, 69% of fetuses with uncertain prognosis, and 12% of fetuses with good prognosis were informed about termination. Of these parents, 92% chose to terminate. A lethal long-term prognosis was the only factor related to parental decision to terminate a pregnancy.

CONCLUSIONS

Doctors mainly informed parents about the option of pregnancy termination for conditions with a poor or lethal long-term prognosis or for genetic disorders. Only conditions with a lethal prognosis were significantly related to the parental decision to terminate the pregnancy.

Abortion policy implementation in Ireland: successes and challenges in the establishment of hospital-based services

Objective

To describe successes and highlight remaining challenges in the establishment of hospital-based abortion services after legal change in the Republic of Ireland.

Methods

We conducted a mixed-methods study on the implementation of abortion policy in Ireland. In this manuscript, we present the results from a qualitative analysis of in-depth interviews conducted with hospital-based providers, service users, and key informants. We used Dedoose software to conduct a thematic analysis of the data.

Results

We report findings from interviews with 28 obstetrician gynecologists, midwives, psychiatrists, anesthesiologists, and nurses; a subset of 7 service users who sought care in hospitals; and 27 key informants. In this analysis, we describe how key themes that pertain to information, capacity and power, facilitated and hindered the implementation of hospital-based abortion services. We found that individual champions are key to establishing the service, but their motivation is not always sufficient to integrate abortion into existing clinical services, and conscientious objection is a persistent barrier to expanding abortion services. The main challenges highlighted here are lack of abortion provision at some hospitals and limited access to surgical abortion at most hospitals due to provider-level, logistical, and infrastructure barriers.

Conclusions

This study presents new information on how abortion policy is implemented on the ground in hospital settings. Its findings can inform public health officials and providers in Ireland and other countries wishing to establish abortion services.

Factors influencing parental decisions to terminate pregnancies following prenatal diagnoses of major fetal anomalies at Ramathibodi Hospital, Bangkok, Thailand

Background

The rate of termination of pregnancy (TOP) for fetal anomalies and the factors affecting TOP vary among different populations. Optimisation of prenatal care and counselling requires understanding the factors influencing parental decisions in the relevant population. This study aimed to evaluate the rate of TOP after diagnoses of major fetal anomalies and assess factors associated with TOP-related decisions at a university hospital in Thailand.

Methods

A retrospective chart review was conducted at the Fetal Anomaly Clinic of Ramathibodi Hospital, Bangkok, Thailand. Medical records of all women with singleton pregnancies prenatally diagnosed with major fetal anomalies before 24 gestational weeks between 2010 and 2020 were reviewed.

Results

During the study period, 461 cases of major fetal anomalies were diagnosed, and 264 (57.3%) of these pregnancies were terminated. Three factors influencing parental TOP decisions were lethal anomalies (odds ratio [OR], 197.39; 95% confidence interval [CI], 49.95–779.95; p < 0.001), presence of genetic abnormalities (OR, 10.19; 95% CI, 4.17–24.87; p < 0.001) and gestational age at diagnosis (OR, 0.74; 95% CI, 0.65–0.84; p < 0.001).

Conclusions

Over half of the pregnant women whose records were reviewed and who were prenatally diagnosed with major fetal anomalies terminated their pregnancies. Fetal factors, particularly lethality, genetic abnormalities and early gestational age at diagnosis, showed the most powerful associations with parental TOP decisions. Other maternal background factors were not key considerations.

Accuracy and clinical utility of standard postmortem radiological imaging after early second trimester termination of pregnancy

OBJECTIVE

This study aims to assess accuracy and clinical utility of postmortem radiological exams [Magnetic Resonance Imaging (MRI), Computed Tomography (CT) and Radiography (XR)] after termination of pregnancy at <23 weeks' gestation for congenital fetal malformations in comparison to autopsy.

STUDY DESIGN

This a prospective single-center study on fetuses underwent termination of pregnancy for fetal defects. Overall concordance between any radiological exam and autopsy was evaluated. For postmortem MRI only, the following subgroups were analyzed: 1) total agreement; 2) agreement for main findings; 3) agreement for main findings but major relevant additional findings at autopsy; 4) total disagreement.

RESULTS

174 cases were collected. The overall concordance with autopsy for main findings was 71% (115/163) for postmortem MRI and 99% (173/174) for prenatal ultrasound (US). Postmortem MRI detection rate was high for central nervous system (CNS) defects (98%), gastrointestinal, genitourinary and respiratory defects (100%), while it was poor for cardiovascular and musculoskeletal defects (25% and 42%, respectively). For musculoskeletal abnormalities, the performance of postmortem XR and postmortem CT exams improved the detection rate from 42% for postmortem MRI alone to 92%.

CONCLUSIONS

Postmortem MRI has a good overall concordance for fetal defects after termination of pregnancy performed at <23 weeks. Along with autopsy, postmortem MRI may be offered for all cases of CNS defects in order to prevent inconclusive exams due to autolysis of the brain tissue, while postmortem CT and postmortem XR are indicated for musculoskeletal defects. In the presence of multiple abnormalities or cardiac defects the couple should be counseled on the poor performance of radiological investigations.

Termination of pregnancy for fetal anomaly: a systematic review of the healthcare experiences and needs of parents

BACKGROUND

Improved technology and advances in clinical testing have resulted in increased detection rates of congenital anomalies during pregnancy, resulting in more parents being confronted with the possibility of terminating a pregnancy for this reason. There is a large body of research on the psychological experience and impact of terminating a pregnancy for fetal anomaly. However, there remains a lack of evidence on the holistic healthcare experience of parents in this situation. To develop a comprehensive understanding of the healthcare experiences and needs of parents, this systematic review sought to summarise and appraise the literature on parents' experiences following a termination of pregnancy for fetal anomaly.

REVIEW QUESTION

What are the healthcare experiences and needs of parents who undergo a termination of pregnancy following an antenatal diagnosis of a fetal anomaly?

METHODS

A systematic review was undertaken with searches completed across six multi-disciplinary electronic databases (Medline, Embase, PsycINFO, CINAHL, Web of Science, and Cochrane). Eligible articles were qualitative, quantitative or mixed methods studies, published between January 2010 and August 2021, reporting the results of primary data on the healthcare experiences or healthcare needs in relation to termination of pregnancy for fetal anomaly for either, or both parents. Findings were synthesised using Thematic Analysis.

RESULTS

A total of 30 articles were selected for inclusion in this review of which 24 were qualitative, five quantitative and one mixed-methods. Five overarching themes emerged from the synthesis of findings: (1) Contextual impact on access to and perception of care, (2) Organisation of care, (3) Information to inform decision making, (4) Compassionate care, and (5) Partner experience.

CONCLUSION

Compassionate healthcare professionals who provide non-judgemental and sensitive care can impact positively on parents' satisfaction with the care they receive. A well organised and co-ordinated healthcare system is needed to provide an effective and high-quality service.

TRIAL REGISTRATION

PROSPERO registration number: CRD42020175970 .

Attachment to which child?

PURPOSE

To evaluate emotional distress and prenatal attachment throughout a subsequent pregnancy after Termination of Pregnancy (TOP) for fetal abnormality.

METHODS

Observational study, in a French Tertiary Maternity.

POPULATION

25 women in a subsequent pregnancy after a medical termination of pregnancy for foetal abnormality, 18-year-old and older. Prenatal Interviews at 20 Gestationnal weeks (GW), 27 GW and 35 GW and Postnatal at 3 months and at each time self-administered questionnaires of anxiety, post-traumatic stress syndrome (PCLS) depressive symptoms (EPDS), prenatal attachment (PAI) and Perinatal Grief Scale (PGS).

RESULTS

Pregnancy onset, i.e. before 20 GW, showed increased prevalence of anxiety (16/23, 66.7%), depression (7/23, 30.4%) and post-traumatic stress symptoms (4/16, 25%). Total score on PGS is higher in onset of pregnancy than in the third trimester (p=0.005). Prenatal attachment was lower during early pregnancy (p = 0.003) and correlated inversely with grief intensity (p = 0.022). During late pregnancy, emotional symptoms decrease, and prenatal attachment stopped increase positively, specifically among women whose foetal abnormality in previous pregnancies were diagnosed late, at an average of 25 GW.

CONCLUSION

This research shows the specific dynamics of pregnancies following TOP and highlights the necessity for early prenatal psychological support. One should also pay special attention to prenatal attachment during late pregnancy even after knowing that the fetus is healthy.

Uptake of prenatal genetic diagnosis and termination of pregnancy by Omani Muslim families at risk of genetic disorders: experience over a 9-year period

Studies on the acceptance of prenatal diagnosis and termination of pregnancy for single gene disorders within Islamic societies in the Middle East are limited. A few have examined the attitudes toward pregnancy termination for fetal indications, but a dearth of published data exists on actual behavior and uptake. This study reports on all prenatal diagnosis requests for single gene disorders, from the Sultanate of Oman, over 9 years. A retrospective study was conducted during which the medical records of all women who performed prenatal diagnoses for single gene disorders were reviewed. A total of 148 invasive procedures were performed for 114 families. The total number of yearly requests for prenatal diagnosis increased exponentially from three in 2012 to 21 in 2020. Sixty-four different diagnoses were tested for with the majority being autosomal recessive in nature. Seventy-one percent (28/39) of cases where an affected pregnancy was identified were terminated. Fifty-two of the 114 women (45.6%) repeated prenatal diagnosis in a future pregnancy. Seventy-two couples (63%) were consanguineous parents related as second cousins or closer. The majority of tests performed were for couples from Muscat (27%), Albatinah (27%), and Alsharqiya (20.3%) governorates in Oman. The findings of this study provide evidence that prenatal diagnosis is an acceptable reproductive option to prevent the occurrence of genetic disorders that meet termination eligibility criteria as outlined by the Islamic Jurisprudence (Fiqh) Council Fatwa, among Omani Muslim couples.

Attitudes and experiences with termination of pregnancy among Irish obstetrics & gynaecology trainees in the context of recent legal change: A survey study

Objective

This study examines Irish obstetrics and gynaecology trainees’ experiences with and opinions of termination of pregnancy (ToP) after legal change.

Study design

We invited obstetrics & gynaecology non-consultant hospital doctors (NCHDs) to participate in a web-based survey through a professional e-mail listserv. We conducted descriptive statistical analyses of responses using Stata SE Version 16.

Results

A total of 102/202 (50.5%) trainees responded to the survey. Of these, 61.8% believed that ToP should be allowed on request up to 12 weeks and in limited circumstances thereafter (in line with current law), and 19.6% believe ToP should be allowed on request even after 12 weeks. Knowledge about the abortion law was high (70.6% achieved a perfect knowledge score). Since the new law came into effect, 61.8% of trainees reported participation in abortion care, though only 25.5% had performed surgical procedures. More than 75% of respondents would like to receive more training in all clinical skills related to ToP. In the future, 67.6% of respondents would be willing to provide TOP in all circumstances allowed by law.

Conclusion

Irish obstetrics & gynaecology NCHDs are generally supportive of the legislation. Few trainees have performed surgical abortions, and most would like to receive additional clinical training related to ToP.

Use of Remifentanil Associated with Lidocaine for Feticides in Late Terminations of Pregnancy: A Randomized Clinical Trial

INTRODUCTION

In France, performance of a termination of pregnancy is legally possible without any gestational age limit. After 22 weeks of gestation, a feticide is ethically performed using usually sufentanil and lidocaine. The aim of this study was to compare the use of remifentanil, a fast-acting morphine-derivating product, instead of sufentanil.

METHODS

This 2-center randomized, controlled, single-blinded phase-III treatment trial had 2 parallel arms: an experimental group using remifentanil with lidocaine versus a control group receiving sufentanil associated with lidocaine. This trial took place over a 40-month period. The primary outcome was time to fetal asystole after lidocaine injection. The secondary outcome measures were the procedure's success rate, the rate of serious maternal side effects, and the presence of cellular or tissue modifications.

RESULTS

The study included 66 women, randomized into 2 groups of similar size and characteristics. Time to fetal asystole did not differ significantly between the groups, with a delay of 4 min (Q1-Q3, 2-11) in the sufentanil group and 4 min (Q1-Q3, 1-10) in the remifentanil group (p = 0.84). Similarly, the success rate of the procedure did not differ significantly. Fetal asystole was procured in <2 min and persisted >1 min for 16 (25.8%) women in our total population: 7 (22.5%) in the sufentanil group and 9 (29.0%) in the remifentanil group, p = 0.77. No severe maternal side effects were observed. Among the 49 fetopathological examinations performed, the few tissue and cell modifications observed did not cause any interpretation difficulties in either group.

DISCUSSION/CONCLUSION

Use of remifentanil instead of sufentanil for feticide procedure did not improve time to fetal asystole. No harmful effect was observed for either maternal tolerance or interpretation of the histologic slides.

It's a small bit of advice, but actually on the day, made such a difference…: perceptions of quality in abortion care in England and Wales

BACKGROUND

Quality of care (QOC) is increasingly identified as an important contributor to healthcare outcomes, however little agreement exists on what constitutes quality in abortion care or the recommended indicators from the service-user perspective. Our study aimed to explore perceptions and experiences of abortion QOC in England and Wales.

METHODS

We performed in-depth interviews (via phone or in-person) with participants who had an abortion at a nationwide independent sector provider in the previous 6 months. We explored their experiences of the abortion service at each point in the care pathway, their perspectives on what contributed to and detracted from the experience meeting their definitions of quality, and their reflections on different aspects of QOC. We used content analysis to generate themes.

RESULTS

From December 2018 to July 2019, we conducted 24 interviews. Ten participants had a surgical and 14 had a medical abortion. Seventeen (71%) were treated in the first 12 weeks of pregnancy and 7 (29%) beyond that, with an average gestational age of 10 weeks + 5 days (range 5-23 + 6). We identified 4 major themes that contributed to participant's perception of high quality care: (1) interpersonal interactions with staff or other patients, (2) being informed and prepared, (3) participation and choices in care and (4) accessibility. Nearly all participants identified interpersonal interactions with staff as an important contributor to quality with positive interactions often cited as the best part of their abortion experience and negative interactions as the worst. For information and preparation, participant described not only the importance of being well prepared, but how incongruencies between information and the actual experience detracted from quality. Participants said that making choices about their care, for example, method of abortion, was a positive contributor. Finally, participants identified access to care, specifically in relation to waiting times and travel, as an important aspect of QOC.

CONCLUSIONS

Participants situated quality in abortion care in 4 domains: interpersonal aspects of care, information and preparation, choices, and accessibility. Indicators identified can be used to develop standard metrics to ensure care meets service-user needs.

Association between preconceptional air pollution exposure and medical purposes for selective termination of pregnancy

BACKGROUND

Exposure to air pollutants is associated with adverse pregnancy outcomes. But evidence on the effects of preconceptional air pollution exposure on the risk of termination of pregnancy (TOP) caused by pregnancy losses and congenital malformations is lacking.

METHODS

The distributed lag nonlinear model (DLNM) was used to evaluate the impact of short-term air pollutants exposure on the risk of TOP. Stratified analyses by age (<35 years old, ≥ 35 years old) and season (warm season, cold season) were further conducted. Relative risk (RR) and 95 % confidential interval (95 % CI) were calculated for per interquartile range (IQR) increment in air pollutants during the study period.

RESULTS

PM_2.5, PM₁₀, and O₃ exposure were significantly associated with elevated risk of TOP. The risk of TOP was associated with PM_2.5 exposure from lag11 to lag15 in the single-pollutant model, and the strongest association was observed at lag13 (RR = 1.021, 95%CI:1.002-1.040). PM₁₀ exposure from lag10 to lag15 was associated with increased TOP risk, with the corresponding peak association being at lag13 (RR = 1.020, 95%CI: 1.004-1.037). For O₃, the single-day lag association appeared to be statistically significant from lag26 to lag27, with the highest RR of TOP cases being at lag27 (RR = 1.044, 95%CI: 1.005-1.084). Similar results were observed for pregnancy losses (PL). However, no significantly association between air pollution exposure and the risk of congenital malformations (CM) was found in this study. Stratified analyses showed that pregnant women with more advanced ages were more susceptible to PM_2.5, PM₁₀, and O₃ exposure. The effect of PM_2.5 exposure was statistically significant in cold season subgroups.

CONCLUSION

The findings suggest that exposure to PM_2.5, PM₁₀, and O₃ before pregnancy are associated with the risk of TOP in Lu'an, China, reflecting the significance of preconceptional environmental exposure in the development of adverse pregnancy outcomes.

Omphalocele: national current birth prevalence and survival

PURPOSE

The increase in prenatal diagnosis together with the high rates of associated anomalies in omphalocele has led to increased rates of termination of pregnancies. The aim of this study was to examine the national Swedish birth prevalence and survival rates among these patients.

METHODS

This study is based on a nationwide population-based cohort of all children born in Sweden between 1/1/1997 and 31/12/2016. All omphalocele cases were identified though the Swedish National Patient Register and the Swedish Medical Birth Register. Outcome of malformations and deaths were retrieved from the Swedish Birth Defects Register and the Swedish Causes of Death Register.

RESULTS

The study included 207 cases of omphalocele (42% females). The birth prevalence for omphalocele was 1/10,000 live births. About 62% of the cases had associated malformations and/or genetic disorders; most common was ventricular septal defect. The mortality within the first year was 13%. The rate of termination of pregnancy was 59%.

CONCLUSION

The national birth prevalence for omphalocele in Sweden is 1/10,000 newborn, with high termination rates. Over half of the pregnancies with prenatally diagnosed omphalocele will be terminated. Among those who continue the pregnancy, 1-year survival rates are high.

TYPE OF STUDY

National register study LEVEL OF EVIDENCE: III.

Effects of the implementation of second-line prenatal cell-free DNA testing on termination of pregnancy in a French perinatal network

OBJECTIVE

To evaluate the impact of implementing cell-free DNA (cfDNA) testing on gestational age (GA) at termination of pregnancy in a French perinatal network.

METHODS

We conducted a retrospective study. All women having undergone a termination of pregnancy between 1 January 2012 and 31 December 2017 were included. We compared the periods before and after the introduction of second-line cfDNA testing, which started on 1 January 2015. Throughout the study period, the invasive procedures were foetal karyotyping and chromosomal microarray analysis. The primary study outcome was GA at termination. The secondary outcomes were GA at termination for trisomy 21 and the frequency and GA at the time of invasive procedures.

RESULTS

During the 6-year study period, 840 women underwent termination. The median GA at termination before and after the implementation of cfDNA testing was 19.4 and 19.0 weeks, respectively (p = 0.38). Although the frequency of termination for trisomy 21 increased significantly from 23% to 32% (p < 0.01), the median GA at termination did not change significantly (p = 0.80). The implementation of cfDNA testing was associated with a decrease in the frequency of invasive procedures in general and chorionic villus sampling in particular (p = 0.04).

CONCLUSION

The introduction of cfDNA testing does not increase the GA at termination for trisomy21.

Identification of optimal thalassemia screening strategies for migrant populations in Thailand using a qualitative approach

Background

Thalassemia is a common inherited hemoglobin disorder in Southeast Asia. Severe thalassemia can lead to significant morbidity for patients and economic strain for under-resourced health systems. Thailand’s thalassemia prevention and control program has successfully utilized prenatal screening and diagnosis to reduce the incidence of severe thalassemia in Thai populations, but migrant populations are excluded despite having high thalassemia prevalence. We sought to identify key barriers to and facilitators of thalassemia screening and to develop tailored recommendations for providing migrants with access to thalassemia prevention and control.

Methods

We conducted 28 in-depth interviews and 4 focus group discussions (FGDs) in Chonburi, Thailand with Myanmar and Cambodian migrants, Thai healthcare providers, Thai parents of children affected by thalassemia, and migrant agents.

Results

Participant narratives revealed that migrants’ lack of knowledge about the prevalence, manifestations, severity, and inherited nature of thalassemia led to misconceptions, fear, or indifference toward thalassemia and screening. Negative perceptions of pregnancy termination were based in religious beliefs but compounded by other sociocultural factors, presenting a key obstacle to migrant uptake of prenatal screening. Additionally, structural barriers included legal status, competing work demands, lack of health insurance, and language barriers. Participants recommended delivering public thalassemia education in migrants’ native languages, implementing carrier screening, and offering thalassemia screening in convenient settings.

Conclusions

An effective thalassemia prevention and control program should offer migrants targeted thalassemia education and outreach, universal coverage for thalassemia screening and prenatal care, and options for carrier screening, providing a comprehensive strategy for reducing the incidence of severe thalassemia in Thailand and establishing an inclusive model for regional thalassemia prevention and control.

Perinatal post-mortem magnetic resonance imaging (MRI) of the central nervous system (CNS): a pictorial review

Central nervous system (CNS) abnormalities cause approximately 32–37.7% of terminations of pregnancy (TOP). Autopsy is currently the gold standard for assessing dead foetuses and stillborn. However, it has limitations and is sometimes subject to parental rejection. Recent studies have described post-mortem foetal magnetic resonance imaging (MRI) as an alternative and even complementary to autopsy for CNS assessment. Radiologists now play a key role in the evaluation of perinatal deaths. Assessment of foetal CNS abnormalities is difficult, and interpretation of foetal studies requires familiarisation with normal and abnormal findings in post-mortem MRI studies as well as the strengths and limitations of the imaging studies. The purpose of this pictorial review is to report our experience in the post-mortem MRI evaluation of the CNS system, including a description of the protocol used, normal CNS findings related to post-mortem status, abnormal CNS findings in our sample, and the correlation of these findings with histopathological results.

Cancer during pregnancy: Factors associated with termination of pregnancy and perinatal outcomes

BACKGROUND

Cancer during pregnancy is rare (about 1/1000 pregnancies) and its diagnosis raises the question of whether or not to continue the pregnancy.

OBJECTIVES

The primary objective of our study was to evaluate associated factors with termination of pregnancy in cases of cancer during pregnancy. Secondary objectives were to evaluate maternal and neonatal outcomes when pregnancy is continued.

STUDY DESIGN

We conducted a retrospective, single-center study between January 2009 and December 2019 including 2 groups of patients those who underwent termination of pregnancy and those who continued pregnancy. Patients were distributed in 3 categories breast cancer, blood cancer and other cancers.

RESULTS

A total of 71 pregnancies associated with cancer were included. Twenty patients (28.16 %) underwent termination of pregnancy. The median gestational age at diagnosis was significantly earlier in the termination of pregnancy group compared with the ongoing pregnancy group (9 vs 22 weeks, p < 0.01). Blood cancer was more frequent in the termination group 7 (35 %) compared to continuous pregnancy 8 (15.7 %) as other cancers 8 (40 %) in the termination group vs 5 (9,8 %). Conversely breast cancer what was less frequent in the termination group 5 (25 %) vs 38 (74,5 %) (p < 0.01). In the continued pregnancy group, there was a high rate of induced prematurity (35.5 %) and scheduled delivery to optimize maternal oncologic management (78.4 %).

CONCLUSION

The rate of termination of pregnancy remains high particularly in case of non-breast cancer and early pregnancy detection. Scheduled preterm birth is frequent when pregnancy is continued in order to optimize of cancer management.

Temporal changes in epidemiological profile and fetal indications for late termination of pregnancy: a retrospective single-center study

PURPOSE

To explore whether epidemiological shifts regarding reproduction and pregnancy have influenced the spectrum of indications for late termination of singleton pregnancies (TOP) above 17 weeks of gestation and to evaluate temporal changes in maternal demographics and fetal indications over the last 16 years.

METHODS

Retrospective single-center cohort study involving all late TOPs preceded by feticide between 1 January 2004 and 31 December 2019 at a tertiary referral hospital in Austria. Outcome variables were retrieved and a time trend assessed between two 8-year intervals (2004-2011 versus 2012-2019).

RESULTS

Between January 2004 and December 2019, a total of 209 singleton pregnancies (50.7% male; 46.9% female fetuses, 2.4% no disclosed sex) were terminated medically at a median gestational age of 25⁺¹ (17⁺³-37⁺¹) weeks at our institution. Predominant conditions legally justifying the late medical abortion were abnormaltities of the brain/central nervous system (n = 83; 39.7%), chromosomal aberrations (n = 33; 15.8%), complex malformations (n = 31; 4.8%) and abnormaltities of the musculosceletal system including diaphragmatic hernias (n = 18; 8.6%), as reflected by the ICD-10-categories "Congenital malformation of the central nervous system", "Other congenital malformations" and "Chromosomal abnormalities". No changes were observed with regards to maternal age (30.1 ± 5.9 vs. 31.0 ± 6.0 years;  p = 0.315) nor frequency of assisted reproductive technologies (7.0% vs. 8.5%; p = 0.550). Despite a 2.5-fold increase in incidence of late TOPs, no epidemiological changes in maternal or fetal characteristics were observed over the last 16 years.

CONCLUSION

Population profile and indications for late TOPs followed by feticide remain unchanged over time.

Termination of pregnancy: Staff knowledge and training

OBJECTIVES

In January 2019, Termination of Pregnancy (TOP) services were introduced in Ireland allowing the termination of pregnancies < 12 weeks. This study aimed to investigate staff knowledge and training on early TOP and views regarding challenges to successful integration of the service within a large maternity hospital.

STUDY DESIGN

A questionnaire, modelled on interim clinical guidance and previous studies on the topic, was distributed to clinical staff in a large maternity hospital in 2019. Descriptive analysis and a hierarchical multiple regression were performed using SPSS.

MAIN OUTCOME MEASURES

Levels of knowledge on TOP among staff, training received and main challenges to the service.

RESULTS

Of the total of participants (n = 133), just one-quarter correctly answered all questions on the current legislation and 63.2% on complications. Male gender, education level (diploma/certificate), and age (<30 years) negatively contributed to overall knowledge. 'Medical' job position positively contributed to knowledge levels. Most respondents (88%) had not received training prior to introduction of TOP services. Of those who did, few (9%) believed it to be sufficient. The main identified challenges to the service were lack of training and education, staffing and resources.

CONCLUSIONS

Low levels of knowledge among staff suggests that training is required to ensure the provision of a safe and effective TOP service. Our findings indicate that updated and clearer clinical guidance on TOP services is also needed.

Termination of pregnancy data completeness and feasibility in population-based surveys: EN-INDEPTH study

BACKGROUND

Termination of pregnancy (TOP) is a common cause of maternal morbidity and mortality in low- and middle-income countries. Population-based surveys are the major data source for TOP data in LMICs but are known to have shortcomings that require improving. The EN-INDEPTH multi-country survey employed a full pregnancy history approach with roster and new questions on TOP and Menstrual Restoration. This mixed methods paper assesses the completeness of responses to questions eliciting TOP information from respondents and reports on practices, barriers, and facilitators to TOP reporting.

METHODS

The EN-INDEPTH study was a population-based cross-sectional study. The Full Pregnancy History arm of the study surveyed 34,371 women of reproductive age between 2017 and 2018 in five Health and Demographic Surveillance System (HDSS) sites of the INDEPTH network: Bandim, Guinea-Bissau; Dabat, Ethiopia; IgangaMayuge, Uganda; Kintampo, Ghana; and Matlab, Bangladesh. Completeness and time spent in answering TOP questions were evaluated using simple tabulations and summary statistics. Exact binomial 95% confidence intervals were computed for TOP rates and ratios. Twenty-eight (28) focus group discussions were undertaken and analysed thematically.

RESULTS

Completeness of responses regarding TOP was between 90.3 and 100.0% for all question types. The new questions elicited between 2.0% (1.0-3.4), 15.5% (13.9-17.3), and 11.5% (8.8-14.7) lifetime TOP cases over the roster questions from Dabat, Ethiopia; Matlab, Bangladesh; and Kintampo, Ghana, respectively. The median response time on the roster TOP questions was below 1.3 minutes in all sites. Qualitative results revealed that TOP was frequently stigmatised and perceived as immoral, inhumane, and shameful. Hence, it was kept secret rendering it difficult and uncomfortable to report. Miscarriages were perceived to be natural, being easier to report than TOP. Interviewer techniques, which were perceived to facilitate TOP disclosure, included cultural competence, knowledge of contextually appropriate terms for TOP, adaptation to interviewee's individual circumstances, being non-judgmental, speaking a common language, and providing detailed informed consent.

CONCLUSIONS

Survey roster questions may under-represent true TOP rates, since the new questions elicited responses from women who had not disclosed TOP in the roster questions. Further research is recommended particularly into standardised training and approaches to improving interview context and techniques to facilitate TOP reporting in surveys.

Factors contributing to men's grief following pregnancy loss and neonatal death: further development of an emerging model in an Australian sample

Background

Historically, men’s experiences of grief following pregnancy loss and neonatal death have been under-explored in comparison to women. However, investigating men’s perspectives is important, given potential gendered differences concerning grief styles, help-seeking and service access. Few studies have comprehensively examined the various individual, interpersonal, community and system/policy-level factors which may contribute to the intensity of grief in bereaved parents, particularly for men.

Methods

Men (N = 228) aged at least 18 years whose partner had experienced an ectopic pregnancy, miscarriage, stillbirth, termination of pregnancy for foetal anomaly, or neonatal death within the last 20 years responded to an online survey exploring their experiences of grief. Multiple linear regression analyses were used to examine the factors associated with men’s grief intensity and style.

Results

Men experienced significant grief across all loss types, with the average score sitting above the minimum cut-off considered to be a high degree of grief. Men’s total grief scores were associated with loss history, marital satisfaction, availability of social support, acknowledgement of their grief from family/friends, time spent bonding with the baby during pregnancy, and feeling as though their role of ‘supporter’ conflicted with their ability to process grief. Factors contributing to grief also differed depending on grief style. Intuitive (emotion-focused) grief was associated with support received from healthcare professionals. Instrumental (activity-focused) grief was associated with time and quality of attachment to the baby during pregnancy, availability of social support, acknowledgement of men’s grief from their female partner, supporter role interfering with their grief, and tendencies toward self-reliance.

Conclusions

Following pregnancy loss and neonatal death, men can experience high levels of grief, requiring acknowledgement and validation from all healthcare professionals, family/friends, community networks and workplaces. Addressing male-specific needs, such as balancing a desire to both support and be supported, requires tailored information and support. Strategies to support men should consider grief styles and draw upon father-inclusive practice recommendations. Further research is required to explore the underlying causal mechanisms of associations found.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-020-03514-6.

Pregnant people, inseminators and tissues of human origin: how ectogenesis challenges the concept of abortion

The potential benefits of an alternative to physical gestation are numerous. These include providing reproductive options for prospective parents who are unable to establish or maintain a physiological pregnancy, and saving the lives of some infants born prematurely. Ectogenesis could also promote sexual equality in reproduction, and represents a necessary option for women experiencing an unwanted pregnancy who are morally opposed to abortion. Despite these broad, and in some cases unique benefits, one major ethical concern is the potential impact of this emerging technology on abortion rights. This article will argue that ectogenesis poses a challenge to many common arguments in favour of a pregnant woman's right to choose, but only insomuch as it highlights that their underlying justifications for abortion are based on flawed conceptions of what the foetus and pregnancy actually are. By interrogating the various interests and relationships involved in a pregnancy, this article will demonstrate that the emergence of artificial gestation need not impact existing abortion rights or legislation, nor definitions of independent viability or moral status.

Parental expectations of raising a child with disability in decision-making for prenatal testing and termination of pregnancy: A mixed methods study

OBJECTIVE

To examine attitudes toward prenatal testing and termination of pregnancy (TOP) among parents and obstetric providers in relation to their views on raising a child with disability.

METHODS

An explanatory sequential mixed methods study. A survey among 274 parents and 141 providers was followed by interviews with 26 parents and 10 providers. Using multivariate analysis, the relationships between attitudes were examined. Thematic analysis was used to identify the reasons behind the attitudes.

RESULTS

In comparison with providers, parents reported more positive attitudes toward raising a child with disability and more moral views about TOP. Providers reported more variations in attitudes toward offering prenatal testing and TOP. Significant associations were found between attitudes toward prenatal testing, raising a child with disability, reproductive autonomy, and TOP. Three major themes were identified: (1) meanings of parenthood from genetic tests; (2) views toward TOP and parental responsibility; and (3) implications of advanced extended prenatal genetic testing.

CONCLUSIONS

Perceived social-cultural norms of disabilities and parental expectations of raising a child with disability influence decision-making regarding TOP.

PRACTICE IMPLICATIONS

As more conditions of the fetus are able to be detected, the social-cultural implications of the technology and disabilities need to be addressed in antenatal care.

Experiences of fathers having faced with termination of pregnancy for foetal abnormality

The development of medical ultrasound techniques and progress in prenatal diagnosis allows foetus malformations to be discovered during pregnancy. These outcomes may force parents to be faced with the decision of termination of pregnancy for foetal abnormality (TOP). According to the literature, some parents will develop somatic or psychological troubles during and after the TOP, differently depending on sex. Moreover, fathers feel sometimes isolated during TOP. It seems important to propose a specific support for fathers throughout this event. Aim of this qualitative study is to describe how fathers perceive the TOP, their feelings about caregivers and their strategies for coping. Our study was performed in the Maternity Department of the Nancy University Hospital, between April and December 2016 and concerns TOP beyond 22 weeks of amenorrhea. Semi-structured interview was offered to the father the day after the TOP. These semi-structured interviews were transcribed, and text thus obtained were subjected to inductive thematic analysis. Eight men agreed to participate in this study. Results show that fathers have gone through intense emotional strain throughout the TOP. They experienced a fear of losing their partner, feelings of anger, loneliness and exclusion. They used internalisation, minimisation and avoidance by distraction. In addition, they all insisted on their desire to be beside their partners throughout the TOP. As found in recent literature, the midwives and other caregivers have a role to play in supporting the couple: during the TOP and after the procedure, because consequences may appear after several months.

Artificial Womb Technology and the Choice to Gestate Ex Utero: Is Partial Ectogenesis the Business of the Criminal Law?

It is frequently claimed that artificial wombs (AWs) could alleviate the burdens placed exclusively on women in reproduction. In this article, I demonstrate how AWs used for the partial gestation of preterm neonates could introduce new choices for women by changing perceptions of tolerable risks in gestation. In light of advancing medical technology, it is necessary to consider whether the current legal framework in England and Wales would support increased choice for women about alternative forms of gestation. I examine the ill-defined offence of 'unlawfully procuring miscarriage' in the Offences Against the Person Act 1861 and demonstrate that different conclusions about the legal significance of ending a pregnancy are evident, depending on the analytical lens adopted in interpreting ambiguities. Furthermore, I demonstrate that the defences available to pregnancy termination under the Abortion Act 1967 are too narrow to support choices about alternative forms of gestation, even if they become physically and medically possible. Therefore, we should decriminalise termination of pregnancy, or, if it is assumed that gestation is the business of the criminal law, specific reforms to the legal framework are necessary. The offence of unlawfully procuring miscarriage is too uncertain and broad, and the defences available are too restrictive.

Intrauterine versus post-mortem magnetic resonance in second trimester termination of pregnancy for central nervous system abnormalities

OBJECTIVE

To evaluate if limiting factors of intrauterine magnetic resonance imaging (iuMRI) performed in the early second trimester of pregnancy (19-23 weeks) affect its accuracy in comparison to post-mortem MRI (pmMRI) in fetuses that underwent termination of pregnancy (TOP) for central nervous system (CNS) defects.

STUDY DESIGN

This is a secondary analysis of a 10 years prospective observational study. Cases of TOP < 23 weeks for CNS malformation that had undergone neurosonography (NSG), iuMRI, pmMRI and autopsy were included. The agreement between iuMRI and pmMRI was calculated. The autopsy represented the gold-standard.

RESULTS

Overall, 143 TOPs for fetal congenital anomaly underwent the post-mortem diagnostic protocol. Of these, 31 cases underwent iuMRI and pmMRI for CNS abnormality. Three cases were excluded due to brain autolysis at autopsy. Corpus callosum defects were the most represented (16/28; 57 %). In only one case of posterior fossa defect, pmMRI identified the presence of vermian hypoplasia not diagnosed at iuMRI. In 2 cases (7%), iuMRI added clinically relevant additional findings to NSG, that were posteriorly confirmed by pmMRI.

CONCLUSIONS

The study shows that, at 19-23 weeks and for CNS defects, limiting factors that might influence the performance of iuMRI have little influence on iuMRI accuracy. This finding is particularly important for professionals who work in countries with legal bound for TOP in the early second trimester.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Resilience or detachment? Coping strategies among termination of pregnancy health care providers in two South African provinces

There is global recognition that competent and willing health care providers remain the most important determinant of safe abortion or termination of pregnancy services. The psychosocial well-being of providers is critical to the provision of responsive termination of pregnancy services. In light of the dearth of scholarly attention on termination of pregnancy providers' coping strategies in low- and middle-income countries, this paper explores coping strategies among these providers in the urban Gauteng and the mixed rural-urban North West provinces of South Africa. During 2015, in-depth interviews were conducted with 30 termination of pregnancy providers working at abortion facilities in these provinces. Questions focused on providers' lived experiences of abortion service provision, the meanings they attached to their work and their reported coping strategies. Interpretative phenomenological analysis was used to analyse the interviews. Interviewees' mean age was 45.8 years, all were professional nurses and the majority were female (82%), working for an average of 3.6 years in abortion services. Four overlapping themes emerged in relation to reported coping strategies: silence and concealing emotions; seeking support; detachment or disengagement; and belief systems. Study findings point to the need for effective, sustainable employee wellness programmes, within an overall context of positive practice environments.

Ethical and Legal Dilemmas Around Termination of Pregnancy for Severe Fetal Hydrocephalus, Spina Bifida Aperta and Meningomyelocoella

Introduction:

There are many ethical and moral dilemmas regarding the termination of pregnancy(TOP) with severe fetal anomalies.

Aim:

Our aim is to present a case of severe fetal hydrocephalus (HCP), spina bifida aperta and, meningomyelocoella (MMC).

Case report:

A gynecologist examined a 23-year-old patient with vital pregnancy of 24/25 week of gestation (WG) with the anomaly of the fetus. At the Perinatological Medical Advisory Board, a decision was made that the pregnancy should be continued and monitored bearing in mind that pregnancy exceeded the legal framework for TOP. Medical Advisory Board’s ultrasound examination showed the following: severe hydrocephalus (HCP), spina bifida aperta, hyperehogen intestine, pes equinovarus. Via multidisciplinary consultation it was decided to make a delivery with the elective caesarian section (CS) causing as little trauma to the fetus as possible, with 37 WG completed due to the pelvic presentation and fetal anomalies. The patient gave birth via CS to a live female newborn–birth weight 3920 grams, birth length 56 cm, head circumference 48 cm, and Apgar score 8/8. The head was hydrocephalic with spaced suture. There was thoracolumbar defect of spina bifida aperta and meningomyelocele (MMC) 10x12 cm in size. An urgent surgical procedure - the external ventricular derivation of the liquor, and then the successful resection and plastic meningomyelocele was performed by a team of neuro and plastic surgeons. During the fourth postoperative day due to a suspicion of abscess collection and febrility of the mother a relaparotomy is performed and the abscess collection of Retzius space was found. Due to the fall in blood count, blood transfusion in a total dose of 580 ml was given. The patient was discharged on a home treatment as she had a regular general and local status. After the surgery, the condition of the newborn resulted in deterioration, the progression of HCP and dehiscence of head wounds and the thoracolumbar region, in spite of all the measures taken. At that time a decision was made to provide palliative care and this decision was conveyed to the mother. The child had a prolonged apnoeic episode and was not resuscitated. The child died in hospital after surviving for two months postpartum.

Conclusion:

Indication of TOP based on fetal anomalies could be a medical decision but also a personal moral choice of the mother related to legal rules, socio-cultural values and religious beliefs.

Lack of consensus in the choice of termination of pregnancy for Turner syndrome in France

BACKGROUND

The observed rate of termination of pregnancy (TOP) for Turner syndrome varies worldwide and even within countries. In this vignette study we quantified agreement among ten multidisciplinary prenatal diagnosis centers in Paris.

METHODS

We submitted online three cases of Turner syndrome (increased nuchal translucency, normal ultrasound, aortic coarctation) to fetal medicine experts: one obstetrician, one pediatrician and one geneticist in each of the ten Parisian centers. Each case was presented in the form of a progressive clinical history with conditional links dependent upon responses. The background to each case was provided, along with the medical history of the parents and the counseling they got from medical staff. The experts indicated online whether or not they would accept the parents' request for TOP. We assessed the percentage of agreement for acceptance or refusal of TOP. We also used a multilevel logistic regression model to evaluate differences among obstetrician-gynecologists, pediatricians and cytogeneticists.

RESULTS

Overall agreement among the experts to accept or refuse TOP was, respectively, 25 and 28%. The percentage of disagreement was 47%. The percentage of agreement to accept TOP was 33, 8 and 33% for obstetrician-gynecologists, pediatricians and cytogeneticists, respectively. The respective percentages of agreement to refuse TOP were 19, 47 and 26%.

CONCLUSION

Our results show the lack of consensus with regard to decisions related to termination of pregnancy for Turner Syndrome. This lack of consensus in turn underscores the importance of multidisciplinary management of these pregnancies in specialized fetal medicine centers.

Indications for genetic testing leading to termination of pregnancy

PURPOSE

In this study, we aimed to assess the distribution of genetic abnormalities leading to termination of pregnancy and its fluctuation during the past 8 years in light of those technical advances.

METHODS

Our cohort consisted of all pregnant women who underwent termination of pregnancy because of genetic aberrations in their fetuses from January 2010 through April 2018 in our medical center. The information that was gathered included: maternal age, results of the nuchal scan, results of the first- and second-trimester biochemical screening, ultrasonographic findings, reasons for conducting a genetic evaluation, gestational age at which termination of pregnancy was carried out, and the type of genetic aberration.

RESULTS

816 women underwent termination of pregnancy at our institution due to genetic aberrations, most of them because of positive biochemical screening (n = 297, 36%) or because of maternal anxiety (n = 283, 35%). Findings in chromosomal microarray led to termination of pregnancy in 100 women (100/816, 12%). Chromosomal microarray had been performed due to maternal choice and not because of accepted medical indications among most of the women who underwent termination of pregnancy due to findings on chromosomal microarray (69/100, 69%).

CONCLUSION

Performing chromosomal microarray on a structurally normal fetus and identifying abnormal copy number variants may give the parents enough information for deciding on the further course of the pregnancy.

Diagnostic assessment of foetal brain malformations with intra-uterine MRI versus perinatal post-mortem MRI

PURPOSE

To evaluate differences in diagnostic yield of intra-uterine foetal (iuMR) and post-mortem MRI (PMMR) for complex brain malformations, using autopsy as the reference standard.

METHODS

In this retrospective, multicentre study spanning 2 years, we reviewed 13 terminated singleton pregnancies with a prenatal ultrasound finding of complex foetal cerebral abnormalities, referred for both iuMR and PMMR. The iuMR and PMMR studies of the brain were reported independently by two groups of radiologists, blinded to each other's reports. Descriptive statistics were used to compare differences in intracranial abnormalities with autopsy (and genetic testing, where present) as reference standard.

RESULTS

The median gestational age at termination was 24.6 weeks (IQR 22-29) with median time between delivery and PMMR of 133 h (IQR 101-165). There was full concordance between iuMR and PMMR findings and autopsy in 2/13 (15.3%) cases. Partial concordance between both imaging modalities was present in 6/13 (46.2%) and total discordance in the remainder (5/13, 38.5%). When compared to autopsy, PMMR missed important key findings specifically for neuronal migration and cerebellar anomalies, whereas iuMR appeared to overcall CSF space abnormalities which were less crucial to reaching the final overall diagnosis.

CONCLUSIONS

iuMR should be performed to improve foetal phenotyping where there is a prenatal ultrasound for complex foetal brain abnormalities. Reliance on PMMR alone is likely to result in misdiagnosis in a majority of cases.