Termination of pregnancy following a Down Syndrome diagnosis: decision-making process and influential factors in a Muslim but secular country, Turkey

OBJECTIVES

This study aims to present the termination of pregnancy (TOP) rates and elucidate the decision-making process following a prenatal diagnosis of Trisomy 21 in Turkey.

METHODS

This retrospective single-center study was conducted with 146 pregnant women between January 2016 and December 2019 in a tertiary hospital. Data on maternal characteristics, sonographic findings, indications for chromosome analysis, and educational, religious, and economic factors that can influence the parental decision process were collected.

RESULTS

The TOP rate of Down syndrome (DS) in our center was 78.8%. We concluded that maternal age, earlier diagnosis, indication for chromosome analysis, and previous pregnancies had no effect on the TOP decision. On the other hand, not having a minor or a major sonographic sign, employed mothers, middle- and high-income families, and families having a secondary or higher education tended to terminate the pregnancy affected by DS at statistically higher rates.

CONCLUSIONS

There are many studies worldwide investigating the TOP preferences for DS. However, there is limited data about TOP rates and influential factors affecting the decision-making process in Muslim countries. This study contributes by clarifying the factors in the decision-making process and elucidating perspectives about TOP in a Muslim country with a unique status: Turkey.

Perinatal grief following neonatal comfort care for lethal fetal condition

BACKGROUND

The objective of the study was to assess perinatal grief experienced after continuing pregnancy and comfort care in women diagnosed with lethal fetal condition compared with termination of pregnancy for fetal anomaly (TOPFA).

METHODS

This was a retrospective observational study which included women who chose to continue their pregnancy after the diagnosis of lethal fetal condition with comfort care support at birth at the Prenatal Diagnosis Center of Rennes Hospital from January 2007 to January 2017. Women were matched with controls who underwent TOPFA for the same type of fetal anomaly, gestational age at diagnosis and year. Women were evaluated by a questionnaire including the Perinatal Grief Scale.

RESULTS

There were 28 patients in the continuing pregnancy group matched with 56 patients in the TOPFA group. Interval between fetal loss and completion of questionnaire was 6±3 years. Perinatal grief score was similar at 61±22 vs 58±18 (p = 0.729) in the continuing pregnancy and TOPFA groups, respectively. Women in the TOPFA group expressed more guilt. The cesarean-section rate in the continuing pregnancy group was 25%.

CONCLUSION

Perinatal grief experienced by women opting for continuing pregnancy and comfort care after diagnosis of a potentially lethal fetal anomaly is not more severe than for those choosing TOPFA.

A survey of health professionals' views on acceptable gestational age and termination of pregnancy for fetal anomaly

Termination of pregnancy for fetal anomaly is legal in the UK with no upper limit, if two doctors, in good faith, agree "there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped". This is Clause E of the Human Fertlisation and Embryology Act. The most commonly sighted Clause is C, which states "the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman". This study aimed to investigate health professionals' views on gestational age and acceptable termination of pregnancy for fetal anomaly (TOPFA). We undertook a questionnaire survey of UK health professionals working in fetal medicine, obstetrics and gynaecology and neonatology. A study pack consisting of a self-completion questionnaire, an invitation letter, participant information sheet, and a stamped addressed return envelope, were sent to health professionals. We used four fetal anomalies as case study examples in the questionnaire: isolated cleft lip, hypoplastic left heart, spina bifida and trisomy 21. These anomalies were chosen as they differed in terms of the type of anomaly, the type of impairment, and the perceived severity. Forty-one study packs were returned. For anomalies deemed less serious, later gestational ages were an important consideration when deciding acceptable TOPFA. The prognosis of an anomaly was considered an important factor in deciding whether a TOPFA was acceptable alongside gestational age. Clause C of the current UK legislation, which allows a legal termination prior to 24 weeks gestational age if continuing with the pregnancy would impact the mental health of the mother, was deemed a reasonable option for termination when parents are requesting a TOPFA. For each case study example, health professionals responded that TOPFA at '25 weeks and over' was acceptable (cleft lip n = 1; hypoplastic left heart n = 19; spina bifida n = 13 and Trisomy 21 n = 10). Professionals also distinguished between their personal and professional views. These findings offer new insight into how gestational age considerations influence professionals' conceptualisation of acceptable TOPFA.

"I Would Do It All Over Again": Cherishing Time and the Absence of Regret in Continuing a Pregnancy after a Life-Limiting Diagnosis

Parents, after learning of a life-limiting fetal condition (LLFC), experience emotional distress and must consider options that impact the remainder of the pregnancy, their future lives, and family members. For those who continue, little is known about their long-term presence or absence of regret about their choice, the reasons for this feeling, or its impact on their life. The aim of this research was to examine the concept of decision regret in parents who opted to continue a pregnancy affected by an LLFC. The contextual factors, conditions, and consequences surrounding the presence or absence of regret were analyzed. Data were retrieved from a cross-sectional study using the Quality of Perinatal Palliative Care and Parental Satisfaction Instrument. Participants were parents (N = 405) who experienced a life-limiting prenatal diagnosis and opted to continue their pregnancy. Secondary data analysis examined qualitative responses (121/402) to an item addressing regret. Dimensional analysis was used to examine data, identifying context, conditions, and consequences associated with the presence or absence of regret. Absence of regret was articulated in 97.5 percent of participants. Parents valued the baby as a part of their family and had opportunities to love, hold, meet, and cherish their child. Participants treasured the time together before and after the birth. Although emotionally difficult, parents articulated an empowering, transformative experience that lingers over time.

Vulnerability, therapeutic misconception and informed consent: is there a need for special treatment of pregnant women in fetus-regarding clinical trials?

Historically, pregnant women have generally been excluded from clinical trials. One of the reasons for this exclusion has been the belief that pregnant women are vulnerable as research participants. Although this view has now largely fallen into disfavour, this article argues that in the situation where the pregnant woman is newly diagnosed with a fetal condition for which the only option, other than watchful waiting, is enrolment in a clinical trial, she should be considered a cognitively and medically vulnerable research participant. This is because she is in a highly stressed emotional state and so less able to decide completely freely whether or not to participate in the clinical trial. In other words, she is under a higher risk of therapeutic misconception and of not understanding what she is consenting to. This article suggests that in order for the consent of these women to be given freely and without emotional pressure, it has to be ensured that strategies are developed to ensure they are fully informed and actually understand the information. This surpasses the requirements of the English law of informed consent and also of General Medical Council (GMC) guidance on consent to research but such an approach would help safeguard that, despite these women's poor bargaining position, their trial participation is really free, voluntary and informed.

Attentional bias for smoking-related information in pregnant women: relationships with smoking experience, smoking attitudes and perceived harm to foetus

According to recent models of drug dependence, attentional bias for drug cues provides an index of vulnerability to drug-taking and relapse. The present study examined attentional bias for smoking-related information in pregnant women and its relationship with smoking experience and attitudes. Participants were 71 pregnant women (35 without smoking experience; 36 with experience of smoking, of whom 16 reported currently smoking). Attentional bias was assessed from the interference index of smoking-related words on a modified Stroop task. The attentional bias for smoking cues was positively associated with smoking experience, and with more favourable general attitudes to smoking (i.e. incentive-related bias). The bias was also greater in women who perceived greater harm of passive smoking to their foetus (i.e. threat-related bias), which was independent of smoking experience. Results indicate that attentional bias for smoking-related cues is independently associated with both incentive-related (reward) and threat-related (aversive) evaluations of cigarette smoking in pregnant women. This work highlights the need for longitudinal research to investigate whether the attentional bias provides a cognitive index of vulnerability for persistent smoking behaviour both during and after pregnancy.

Survey of physicians' approach to severe fetal anomalies

OBJECTIVE

Standards of care regarding obstetric management of life-threatening anomalies are not defined. It is hypothesised that physicians' management of these pregnancies is variable and influenced by demographic factors.

DESIGN

A questionnaire was mailed to members of the Society of Maternal-Fetal Medicine with valid US addresses assessing obstetric management of both 'uniformly lethal' (eg, anencephaly, renal agenesis) and 'uniformly severe, commonly lethal' (eg, trisomy 13 and 18) anomalies. Respondents were asked to answer as if not limited by state/institutional restrictions. Fisher's exact or χ(2) tests were used as appropriate and correction made for multiple comparisons in analyses that were not prespecified.

RESULTS

The response rate was 36% (732/2038). Nearly 100% of respondents discuss termination for both uniformly and commonly lethal anomalies. In continuing pregnancies, with patient request for obstetric non-intervention 99% of providers would comply for either uniformly or commonly lethal anomalies. The majority 'encourage' such management, but some were non-directive or discouraged this management. In continuing pregnancies, with patient request for full obstetric intervention the majority of respondents was willing to comply for both uniformly (71%) and commonly (82%) lethal anomalies. While most practitioners 'discouraged' full intervention, some were non-directive or encouraged this management. Demographics and severity of anomaly influenced counselling.

CONCLUSION

Discrepancies exist regarding the management of life-threatening fetal anomalies. Patients may be offered different options based on practitioner demographics. The majority of physicians comply with patient wishes. Differences were noted when comparing the management of lethal with that of severe commonly lethal anomalies, suggesting that practitioners make a distinction when counselling patients.

Responsibly counselling women about the clinical management of pregnancies complicated by severe fetal anomalies

Heuser, Eller and Byrne provide important descriptive ethics data about how physicians counsel women on the clinical management of pregnancies complicated by severe fetal anomalies. The authors present an account of what such counselling ought to be based on, the ethical concept of the fetus as a patient and the professional responsibility model of obstetric ethics. When there is certainty about the diagnosis and either a very high probability of either death as the outcome of the anomaly or survival with severe and irreversible deficit of cognitive developmental capacity as a result of the anomaly diagnosed, the pregnant woman should be offered the alternatives of aggressive and non-aggressive obstetric management and induced abortion before viability. It is also ethically permissible to offer feticide followed by termination of pregnancy after viability in such cases. This ethically justified approach will reduce the variation in the actual practices of specialists in maternal-fetal medicine described by Heuser, Eller and Byrne.

Fatal fetal paternalism

Heuser and colleagues' survey of obstetricians provides a valuable insight into the current management of severe fetal anomalies in the United States. Their survey reveals two striking features - that counselling for these anomalies is far from neutral, and that there is significant variability between clinicians in their approach to management. In this commentary I outline the reasons to be concerned about both of these. Directiveness in counselling arguably represents a form of paternalism, and the evident variability in practice is likely the result of physician personal values. However, Heuser's survey may, by shining a light on practice, provide an important step towards a more consistent approach.

Acceptance, reliability and confidence of diagnosis of fetal and neonatal virtuopsy compared with conventional autopsy: a prospective study

OBJECTIVES

To compare prospectively maternal acceptance of fetal and neonatal virtuopsy with that of conventional autopsy and to determine the confidence with which magnetic resonance (MR) virtuopsy can be used to diagnose normality/abnormality of various fetal anatomical structures.

METHODS

MR and/or computed tomography virtuopsy and conventional autopsy were offered to 96 women (102 fetuses/neonates) following termination of pregnancy (TOP), intrauterine fetal death (IUFD) or neonatal death. Multivariable logistic regression analysis was used to investigate the effect on maternal acceptance of virtuopsy and/or conventional autopsy of the age of the mother, gestational age at TOP or delivery after IUFD, order of pregnancy, parity, religion, type of caregiver obtaining consent and reason for death. When parents consented to both MR virtuopsy and conventional autopsy of fetuses ≥ 20 weeks of gestation or neonates, the confidence with which MR virtuopsy could be used to diagnose normality/abnormality of various anatomical structures was determined on a scale in which conventional autopsy was considered gold standard. On autopsy we classified fetuses/neonates as having either 'normal' or 'abnormal' anatomical structures; these groups were analyzed separately. At virtuopsy, we indicated confidence of diagnosis of normality/abnormality of every anatomical structure in each of these two groups defined at autopsy, using a scale from 0 (definitely abnormal) to 100 (definitely normal).

RESULTS

Of the 96 women, 99% (n = 95) consented to virtuopsy and 61.5% (n = 59) to both conventional autopsy and virtuopsy; i.e. 36 (37.5%) consented to virtuopsy alone. Maternal acceptance of conventional autopsy was independently positively related to singleton pregnancy, non-Moslem mother, earlier gestation at TOP or delivery afer IUFD and a maternal-fetal medicine specialist obtaining consent. Thirty-three fetuses ≥ 20 weeks of gestation had both conventional autopsy and MR virtuopsy, of which 19 had a full autopsy including the brain. In fetuses with normal anatomical structures at conventional autopsy, MR virtuopsy was associated with high diagnostic confidence (scores > 80) for the brain, skeleton, thoracic organs except the heart, abdominal organs except the pancreas, ureters, bladder and genitals. In fetuses with abnormal anatomical structures at autopsy, MR virtuopsy detected the anomalies with high confidence (scores < 20) for these same anatomical structures. However, in three cases, virtuopsy diagnosed brain anomalies additional to those observed at conventional autopsy.

CONCLUSION

MR virtuopsy is accepted by nearly all mothers while conventional autopsy is accepted by about two-thirds of mothers, in whom refusal depends mainly on factors over which we have no control. Although conventional autopsy remains the gold standard, the high acceptance of virtuopsy makes it an acceptable alternative when the former is declined.

Prenatal ultrasound screening: false positive soft markers may alter maternal representations and mother-infant interaction

BACKGROUND

In up to 5% of pregnancies, ultrasound screening detects a "soft marker" (SM) that places the foetus at risk for a severe abnormality. In most cases, prenatal diagnostic work-up rules out a severe defect. We aimed to study the effects of false positive SM on maternal emotional status, maternal representations of the infant, and mother-infant interaction.

METHODOLOGY AND PRINCIPAL FINDINGS

Utilizing an extreme-case prospective case control design, we selected from a group of 244 women undergoing ultrasound, 19 pregnant women whose foetus had a positive SM screening and a reassuring diagnostic work up, and 19 controls without SM matched for age and education. In the third trimester of pregnancy, within one week after delivery, and 2 months postpartum, we assessed anxiety, depression, and maternal representations. Mother-infant interactions were videotaped during feeding within one week after delivery and again at 2 months postpartum and coded blindly using the Coding Interactive Behavior (CIB) scales. Anxiety and depression scores were significantly higher at all assessment points in the SM group. Maternal representations were also different between SM and control groups at all study time. Perturbations to early mother-infant interactions were observed in the SM group. These dyads showed greater dysregulation, lower maternal sensitivity, higher maternal intrusive behaviour and higher infant avoidance. Multivariate analysis showed that maternal representation and depression at third trimester predicted mother-infant interaction.

CONCLUSION

False positive ultrasound screenings for SM are not benign and negatively affect the developing maternal-infant attachment. Medical efforts should be directed to minimize as much as possible such false diagnoses, and to limit their psychological adverse consequences.

Psychological reactions and coping strategies of Sri Lankan women carrying fetuses with lethal congenital malformations

INTRODUCTION

Termination of pregnancy is a popular option for pregnancies complicated by lethal congenital malformations (LCMs). In Sri Lanka, where abortion laws are restrictive, this is not available. We studied the psychological responses and coping strategies of women who had to continue their pregnancies knowing the baby had a LCM.

SETTING

A teaching hospital in Sri Lanka.

STUDY DESIGN

Qualitative inquiry.

METHOD

We conducted a semi-structured interview of 10 women whose fetuses were diagnosed to have a LCM.

RESULTS

All women showed a grief reaction on hearing the news and were distressed about having to carry a futile pregnancy. Eight women were grateful they knew of the abnormality because it prepared them for the birth better, while the other two wished they had not known. They all found having to share facilities with 'normal' women to be painful. Seven women who received 'routine' antenatal care felt that the doctors were ill-equipped to deal with their situation. All felt that abortion should be legalised for LCMs. All engaged in religious rites believed to have miraculous powers, hoping that these will result in a normal baby. Two required specialised counselling.

CONCLUSIONS

The diagnosis of a LCM causes severe distress and psychological reactions, which the staff dealing with these women should be aware of. Ideally, they should be provided care with minimum contact with other women, taking into account the futility of the pregnancy. Engagement in religious rites, even though with unreal expectations, may possibly help them in the long term bereavement process.

Parents' worried state of mind when fetal ultrasound shows an unexpected finding: a comparative study

OBJECTIVE

Most parents yearn for a second-trimester ultrasound examination and feel excitement about it, but some also worry about what the examination will show. According to prior research, using only generic instruments or specific questionnaires, anxiety decreases when the ultrasound findings are normal. The aim of this study was to compare parents' worry (Parents' Expectations, Experiences, and Reactions to Ultrasound [PEER-U] State of Mind Index) and sense of coherence before and after a routine second-trimester ultrasound examination when it showed normal or abnormal findings.

METHODS

A 1-year cohort study was performed at a Swedish university hospital. A total of 2049 parents who had their second-trimester ultrasound examinations there filled in a questionnaire consisting of 2 parts before and after the examinations.

RESULTS

Parents with normal ultrasound findings were less worried than parents with abnormal findings. The group with normal findings also showed less worry after the examination than before. A sex analysis showed similar patterns.

CONCLUSIONS

Parents with abnormal ultrasound findings are more worried and anxious. The new instrument, the PEER-U State of Mind Index, not only measures parents' worry but can also expose what influences their ultrasound examination experience.

[Prenatal diagnostics and information to parents]

New screening and prenatal diagnostic techniques, require the Medicine professionals have a clear purpose for its realization, since the intention determined the act is determined in accordance with the values of the Medicine or becoming an event eugenics act by means of "therapeutic abortion". The Family Physician information about these techniques to pregnant women must be based on the status of science, facilitating the risk of loss fetal and false data positive informing of therapeutic possibilities and facilitating respect for the pregnant woman's decision of non-fulfillment of the screening. The information update according to the state of science, should be provided in writing and the informed consent of the patient should be obtained by all professionals involved in testing, with respect shows for the autonomy of the patient.

Pregnancy interrupted: loss of a desired pregnancy after diagnosis of fetal anomaly

Prenatal diagnostic techniques both enable and force women and couples to make decisions about whether to continue a pregnancy where the fetus has an anomaly. Few studies have explored the decision-making and bereavement processes of women who terminate a desired pregnancy after the discovery of a fetal anomaly. This reports the qualitative results of a study designed to explore these processes while placing them within the context of the societal milieu. Findings are reported as themes that emerged from the 30 intensive interviews conducted with women at varying stages after this experience. These include mythical expectations based on denial that anomaly could occur, misconceptions about the nature of prenatal testing and inaccurate expectations about the experience and duration of grief. Further, the contradictory norms in society are defined as creating additional dilemmas for women as they attempt to gain support and understanding following their loss. Suggestions for how providers may assist women with their grief are incorporated.

Unexpected diagnosis of fetal abnormality: women's encounters with caregivers

BACKGROUND

It is acknowledged that health professionals have difficulty with breaking bad news. However, relatively little research has been conducted on the experiences of women who have had a fetal anomaly detected at the routine pregnancy ultrasound examination. The study objective was to explore women's experiences of encounters with caregivers after the diagnosis of fetal anomaly at the routine second trimester ultrasound scan.

METHODS

The theoretical perspective of symbolic interactionism guided this study design. A purposive sample of 38 women, at low risk of fetal abnormality, who received a diagnosis of a fetal abnormality in a tertiary referral center in Ireland, were recruited to participate. An in-depth interview was conducted within 4-6 weeks of the diagnosis. Data were collected between April 2004 and August 2005 and analyzed using the constant comparative method.

RESULTS

Six categories in relation to women's encounters with caregivers emerged: information sharing, timing of referral, getting to see the expert, describing the anomaly, availability of written information, and continuity of caregiver. Once an anomaly was suspected, women wanted information quickly, including prompt referral to the fetal medicine specialist for confirmation of the diagnosis. Supplementary written information was seen as essential to enhance understanding and to assist women in informing significant others. Continuity of caregiver and empathy from staff were valued strongly.

CONCLUSIONS

The way in which adverse diagnoses are communicated to parents leaves room for improvement. Health professionals should receive specific education on how to break bad news sensitively to a vulnerable population. A specialist midwifery or nursing role to provide support for parents after diagnosis is recommended.

"All the rest is normal". A pilot study on the communication between physician and patient in prenatal diagnosis

The aim of the study was to verify in the context of prenatal diagnosis if the communicative style in consultations is modified in relation to the seriousness of the diagnosis. Videoed consultations after executing amniocentesis and ultra-sound scanning of II level were included in the study with the consent of participants. Only visits with Italian speaking couples without psychiatric problems were analyzed for the study. Selected visits were grouped into "low" (L, minor anomalies) and "high" (H, serious anomalies) visits. A modified version of the RIAS tailored for the specific context was used in the analysis. 27 visits, respectively 13 H and 14 L, were studied. Analysis of the communicative structure of the consultations did not show significant differences between the two groups. The communication during the consultation seems to be mostly influenced by a highly disease-centered model that is not dependent on the content of the consultation itself. Only emotional exchanges showed a marginally significant decrease in the H visits (t = 1.995, p = 0.057), suggesting the probable difficulty of the disease-centered model to manage emotional items during a highly dramatic consultation. Due to the exploratory nature of the study, further research is needed to test the preliminary results.

Seeing baby: women's experience of prenatal ultrasound examination and unexpected fetal diagnosis

OBJECTIVE

Although prenatal ultrasound (US) is a common clinical undertaking today, little information is available about women's experience of the procedure from the perspective of women themselves. The objective of this study was to explore women's experience of undergoing a routine prenatal US examination associated with an unexpected fetal diagnosis.

STUDY DESIGN

Qualitative methods were used to explore the prenatal US experience of 13 women. Five women were given unexpected news of multiple pregnancy and eight women were given unexpected news of congenital fetal abnormality. One in-depth audio-taped interview was conducted with each woman. Content analysis of interview data identified themes common to women's experience of US.

RESULTS

Identified themes of women's experience of routine prenatal US examination associated with an unexpected fetal diagnosis are: experiencing the setting, sensing information, feeling connected/disconnected, the power of the image, and communication rules.

CONCLUSIONS

Women's experience of prenatal US examination is influenced by physical and environmental factors and by the behaviors of the US examiner. Behaviors of the examiner contribute to a woman's labeling of the US experience as positive or negative. Women identify being objectified by the examination and experience poor communication patterns after a fetal US diagnosis. Women's description of the US screen image as a baby suggests it is a powerful influence on subsequent clinical and ethical decision-making about the pregnancy.

Outcomes of children with infantile spasms after perinatal stroke

The object of this study was to describe the outcomes of children with infantile spasms resulting from perinatal stroke. We used International Classification of Diseases, Ninth Revision (ICD-9) searches of billing records to identify 110 children with infantile spasms examined at our hospital from 1998 through 2005. Five of the 99 with symptomatic spasms (5%) had perinatal stroke. An additional five children with spasms caused by perinatal stroke were identified from pediatric stroke clinic records. Seven of the 10 children with spasms due to perinatal stroke presented with stroke as neonates. Three initially appeared healthy but were diagnosed with "presumed perinatal stroke" after radiographic imaging for their spasms evaluation. Median age at last follow-up was 6.3 years: 9 (90%) had epilepsy, 8 (80%) manifested cognitive impairment, and all (100%) had cerebral palsy. The three children who had delayed presentation of "presumed perinatal stroke" had better epilepsy and cognitive outcomes than the seven with neonatal presentation (P = 0.03). Perinatal stroke accounts for 5% of symptomatic spasms and results in high rates of chronic disability similar to those observed with other types of symptomatic spasms. However, a subgroup of children with spasms caused by delayed presentation of "presumed perinatal stroke" appears to have better epilepsy and cognitive outcomes.

Parental Decision-Making after Ultrasound Diagnosis of a Serious Foetal Abnormality

OBJECTIVE

The purpose of this article is to provide clinicians who are involved in the field of foetal medicine with a comprehensive overview of theories that are relevant for the parental decision-making process after ultrasound diagnosis of a serious foetal abnormality.

METHODS

Since little data are available of parental decision-making after ultrasound diagnosis of foetal abnormality, we reviewed the literature on parental decision-making in genetic counselling of couples at increased genetic risk together with the literature on general decision-making theories. The findings were linked to the specific situation of parental decision-making after an ultrasound diagnosis of foetal abnormality.

RESULTS

Based on genetic counselling studies, several cognitive mechanisms play a role in parental decision-making regarding future pregnancies. Parents often have a binary perception of risk. Probabilistic information is translated into two options: the child will or will not be affected. The graduality of chance seems to be of little importance in this process. Instead, the focus shifts to the possible consequences for future family life. General decision-making theories often focus on rationality and coherence of the decision-making process. However, studies of both the influence of framing and the influence of stress indicate that emotional mechanisms can have an important and beneficial function in the decision-making process.

CONCLUSION

Cognitive mechanisms that are elicited by emotions and that are not necessarily rational can have an important and beneficial function in parental decision-making after ultrasound diagnosis of a foetal abnormality. Consequently, the process of parental decision-making should not solely be assessed on the basis of its rationality, but also on the basis of the parental emotional outcome.

A 9-year-old boy with a history of large perinatal stroke, infantile spasms, and high academic achievement

The prognosis for intellectual development in children with symptomatic infantile spasms is usually poor. We report a 9-year-old boy with a history of a large, presumed perinatal, left middle cerebral artery infarct discovered when he developed infantile spasms at 6 months of age. The infantile spasms responded to treatment with adrenocorticotropic hormone. He attained cognitive milestones at normal times, requiring only speech therapy for dysarthric speech. At 9 years of age, he has seizures and a severe right hemiparesis but is an articulate honor roll student in advanced English classes. The development of infantile spasms after large-branch middle cerebral artery stroke does not always predict future mental retardation.

Counselling following a diagnosis of congenital heart disease

Counselling the parents following a diagnosis of fetal congenital heart disease (CHD) is as important a task for the fetal cardiologist, as the skill involved in achieving an accurate diagnosis. The counsellor will base prognosis not only on the diagnosis itself but also on the security of diagnosis, the stage in gestation and potential for change, the association with extracardiac malformations and the known results of treatment. Depending on the gestational age and legal situation the counsellor is operating in, termination of pregnancy may be one of the options to consider and one that should always be raised in discussion. Thus, the parents may be in the position of making a crucial decision concerning the management of the pregnancy on the basis of the information received, so it is vital that the counsellor is truly able to communicate with them, whatever be their level of understanding.

Comparison of attitudes towards prenatal diagnosis and termination of pregnancy for haemophilia in Iran and Italy

Prenatal diagnosis (PND) is an important issue in the comprehensive care of haemophiliacs. As a consequence of technological progress made in the field of PND, the early detection of an affected fetus provides the expectant couple with a chance to terminate pregnancy. This study was undertaken to assess the attitudes of two different haemophilic populations in Iran and Italy towards PND and termination of pregnancy. This study series included 59 Iranians (38 haemophilia A patients and 21 mothers) and 50 Italians (27 haemophilia A patients, 16 mothers and seven fathers). All the 109 participants received a questionnaire including demographic characteristics and evaluating the psychological effects stemming from PND and termination of pregnancy. Approximately 84.7% of the Iranians and 35.4% of the Italians were not familiar with the possibilities afforded by PND for haemophilia (P < 0.001). Termination of pregnancy appeared to be accepted by 58.2% of the Iranian and 16.7% of the Italian participants (P < 0.001). The greater rate of acceptability of abortion in Iranians may be due to differences in the quality of patient care in the two countries.

Antenatal diagnosis of diaphragmatic hernia: parents' emotional and cognitive reactions

PURPOSE

The aim of this study was to assess parent's emotional and cognitive reactions to the prenatal diagnosis of diaphragmatic hernia in their prospective children.

METHODS

A survey was conducted by means of a questionnaire. In the period ranging from 1997 to 2002, 40 couples in whom an established diagnosis of diaphragmatic hernia was made in their fetus were seen for prenatal consultation at a tertiary referral center.

RESULTS

Overall response rate was 93% (37 couples). Mean period since diagnosis for compilation of the questionnaire was 2 weeks. Mean gestational age at diagnosis was 25 weeks (range, 16 to 35 weeks). All parents lacked prediagnostic knowledge of diaphragmatic hernia and consider a single consultation with the paediatric surgeon inadequate to have a clear understanding of the anomaly. Only 1 mother and 1 father reported they understood all the information given by the surgeon. The most frequent (75%) feeling during and after the consultation was fear. Most parents (70%) referred to the intense emotions as the factor that made it difficult to follow the surgeon's explanations as well as to ask questions.

CONCLUSIONS

Because of the incompatibility of emotional distress and optimum learning, impairment of early comprehension of information about diaphragmatic hernia is unavoidable. Therefore, we believe that follow-up antenatal consultations and provision of written and visual illustration are extremely important to facilitate informed choices.

Striatal level of regulation of learned forepaw movements in rats

The role of the striatal adenylyl cyclase (AC) and cholinergic systems in the learning and expression of new forepaw movements (reaching with prolonged pushing on a fixed piston) was studied in male Wistar rats. Motor learning processes, prenatal hypoxia, and cholinergic drugs changed the properties of the AC system in the striatum. After learning, the striatal basal AC activity was decreased compared to untrained control rats. In addition, the AC activity was more decreased in animals with a good ability to learn compared to poor learners (up to 31 % and 51 %, correspondingly; p<0.01). Rats subjected to prenatal hypoxia (13-14th days of embryogenesis) had a lower ability to learn the new movements requiring tactile control and the striatal AC activity in these rats was 1.8 times higher (p<0.001) than controls. In vitro application of the cholinergic agonist carbachol (CARB) 10-5 M (corresponding to approximately 0.3 microg), as well as the antagonist scopolomine (SCOP) 10(-5) M (approximately 0.3 microg) decreased AC activity in the synaptosomal fraction of the striatum. In vivo injections of CARB (0.3-3 microg/1microl) or SCOP (0.3-3 microg/1microl) into the ventral striatum (nucleus accumbens) modified the newly learned sensorimotor skill. After CARB injections the rats performed slower movements with more prolonged pushing. After SCOP the rats could not retain the learned pushing movement. These in vivo and in vitro data suggest that the cholinergic mediator system of the striatum is involved in learning sensory-controlled forepaw movements as well as the regulation of new motor skills by modulating the AC signal transduction process in the striatum. The data confirmed that modification of the striatal AC system resulted in the modulation of reaching behavior and better expression of the learned reflex.

Providing letters and audiotapes to supplement a prenatal diagnostic consultation: effects on later distress and recall

OBJECTIVES

Information provided at a mid-trimester fetal scan aims to improve patients' knowledge and minimize anxiety. This randomized controlled trial conducted at the Fetal Medicine Centre at Birmingham Women's Hospital aimed to assess the relative value of providing 1.standard information: a consultation and computer-generated ultrasound report (n = 29); 2.standard information plus a post scan written non-technical letter (n = 29); 3.standard information plus audiotapes of the consultation (n = 29); 4.standard information plus both non-technical letters and audiotapes (n = 30). It also aimed at exploring whether severity of diagnosis (none; mild; moderate-severe) interacted with the type of information provided to affect subsequent anxiety, depression and recall of information.

PARTICIPANTS

Women (n = 550) referred with suspected fetal anomalies (without a previous history of anomaly or known psychiatric illness) were sent information regarding this study. One hundred and seventeen women consented and were randomly assigned to one of four information groups. The groups were similar with regard to age, education and marital status.

MAIN OUTCOME MEASURES

State anxiety and depression were evaluated with the self-report State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory (BDI) prior to consultation and two weeks post-scan. A structured telephone interview assessed recall of information approximately two weeks later.

RESULTS

Two weeks after the initial consultation, women who received an audiotaped recording of the consultation reported significantly less anxiety than the control group (mean STAI 41.44 [95% CI 35.63-47.26] versus 44.92 [39.32-50.52]; difference = 10.70 [3.56-17.83], p < 0.01). Women who received a non-technical letter also reported less anxiety than the control group, an effect that approached significance (mean STAI 39.08 [95% CI 32.85-45.30]; difference = 6.48 [0.21-13.16], p = 0.058). There were no differences between the information groups on depression scores or recall of information. Women with a more severe abnormality reported higher anxiety and depression two weeks post-consultation, and had greater free recall but less cued recall of information.

CONCLUSIONS

Provision of additional material (particularly an audiotape) following a prenatal scan appears to minimise anxiety compared with standard practice. Provision of audiotapes and non-technical letters do not appear to affect patient recall.

Parental attitudes: antenatal diagnosis of cystic fibrosis

In order to understand attitudes to antenatal diagnosis of cystic fibrosis (CF), we interviewed parents from 19 families, who already had one child with CF. Nine women had chorion villus sampling in a subsequent pregnancy and 6/19 said they would consider termination of pregnancy if the result confirmed CF. These results differ from the results of antenatal screening studies of previously unaffected families, where most couples opt for termination.

Experiences with a psychological help service for women following a prenatal diagnosis: results of a follow-up study

The aim of this study is to provide a description of a psychological help service for women following a prenatal diagnosis at the Division of Prenatal Diagnosis and Therapy at Vienna University Hospital. The investigation group consisted of 77 psychologically treated women. The follow-up took place six months after the first contact. For baseline evaluation the State-Trait Anxiety Inventory, a mood scale and a documentation instrument were used. In the follow-up patients were again investigated by the test inventory and the Freiburger Coping Behavior Scale and a special follow-up instrument. The women showed extreme high scores of general mood scale and state anxiety compared with a normal population. After six months the scores had decreased significantly. Approximately 56% of the patients showed former prenatal incidents in their case histories. A significant correlation was found between the use of negative coping strategies and the development of somatic problems and changes in the private life in the follow-up period. In total 97% of the women quoted the psychological treatment as very important for coping with the prenatal incident and 100% of the women stressed the implementation of a permanent psychological help service. In conclusion, psychological treatment should be available in the event of a prenatal diagnosis, if necessary with the partner. Special attention should be given to women traumatized by a former prenatal incident.

Antenatal minimal hydronephrosis: is its follow-up an unnecessary cause of concern?

The aim of this study was to determine if follow-up of antenatally diagnosed minimal hydronephrosis (anteroposterior renal pelvis diameter <10 mm) is justified or if it is an unnecessary cause of concern for the parents involved. A case-control study, with subjects and controls selected from the Wessex Antenatally Detected Anomalies Register was performed. Information regarding antenatal and postnatal follow-up, renal tract morbidity and degree of concern was obtained from a parental questionnaire. 70 of the 115 subjects contacted (60.9 per cent) and 52 of the 81 controls (64.2 per cent) returned the questionnaire. 65 of the 70 subjects (92.9 per cent) were rescanned postnatally when 28 cases (43.1 per cent) had resolved. Coexisting ureteric and/or calyceal dilatation was evident postnatally in 12 cases and this group was significantly more likely to have underlying pathology than the group with isolated renal pelvis dilatation. Subjects were significantly more likely than controls to have a UTI. The degree of concern was significantly greater in the subject group and subject parents thought about the result significantly more often than controls. From our results we concluded that the follow-up of minimal hydronephrosis can be modified. There is no need for repeated antenatal scanning, a change that could reduce the level of parental anxiety. Postnatal follow-up is required in all patients to exclude an underlying uropathy but again this can be modified, with the majority of patients requiring only an ultrasound scan. This reduced intensity of investigation accompanied with careful explanation to the parents should help to minimize their concerns.

Prenatal hypoxia-ischemia alters expression and activity of nitric oxide synthase in the young rat brain and causes learning deficits

Inhibition of nitric oxide synthase (NOS) is known to possibly impair learning and memory. Our previous studies have demonstrated that prenatal hypoxia-ischemia (HI) decreases NOS expression and NOS activity in the neonatal rat brain. To investigate whether effects of prenatal HI on NOS expression continue and whether prenatal HI affects learning and memory in young rats, NOS expression and NOS activity were determined in the hippocampus of rat brains at 28 days of age following a prenatal HI insult on G17. Performances in the passive avoidance test and the Morris water maze test were also studied in these young rats prior to sampling. Rat fetuses were subjected to either a 30-min prenatal HI insult or a sham operation (SH) on gestation day 17 and rat pups were delivered naturally. Increased locomotor activity was observed in the prenatal HI rats as compared to the SH rats on postnatal days 13 and 15, but not on postnatal days 20 and 30. Prenatal HI affected learning ability in these young rats at 28 days of age, as indicated by a delayed acquisition of passive avoidance and by longer escape latency in the Morris water maze test as compared to the SH group. Prenatal HI did not affect retention of passive avoidance and spatial memory. Concomitant with these learning deficits, expression of neuronal NOS and endothelial NOS mRNAs as well as Ca2(+)-dependent NOS activity in the hippocampus of the prenatal HI rat brain were significantly decreased as compared to the SH group. These results suggest that a 30-min prenatal HI insult on gestation day 17 in rats has long-lasting effects on NOS expression and NOS activity in the offspring brain and on learning ability of these young rats. The learning deficit in offspring is possibly associated with the reduction in expression of NOS mRNA and NOS activity in the hippocampus of these animals.

[Termination of pregnancy on embryopathic grounds--means to medical decision-making]

Now that german legislators have dispensed with explicit formulation of an embryopathic indication, such cases are covered by the unlimited medical indication as defined under Sec. 218a para, 2 of the German Criminal Code. Determining such an indication "in accordance with medical findings" presents the physician with an extremely difficult diagnostic task. Since basic social consensus does not exist with regard to the content of decisions based on embryopathic grounds, quality assurance measures can only target the decision-making process. The central means that the physician has of determining the extent of the related conflict consists of discussion with the patient of her assessment of the situation. Seen in this context, abolition of the patient's obligation to seek counselling in such cases, as arising in connection with relinquishment of explicit formulation of the embryopathic indication, constitutes an incorrect legislational decision that contradicts the entire concept of the law. On the physician's part, this can be countered by guaranteeing that the patient is provided with comprehensive medical information and encouraging her to partake of in social counselling.

The consequences of a positive prenatal HIV antibody test for women

As more women of childbearing age are affected by the human immunodeficiency virus (HIV), many providers have demanded routine perinatal HIV screening, arguing that the medical benefits of testing outweigh the socioeconomic, medical, and psychological risks of a positive HIV test for women. In this primarily urban poor population, we used a semistructured interview to evaluate differences in health care discrimination, economic losses, risk behaviors, relationships changes, and psychological status in 20 HIV-positive and 20 HIV-negative mothers matched for HIV risk, race, income, and delivery date. Many (35%) seropositive and no seronegative women cited health care discrimination due to HIV status. Although seropositive women reported greater satisfaction with social support from friends (100%) and family (80%), many women had not disclosed their HIV status to any friends (65%) or family (25%), indicating fear of abandonment. Only 56% of HIV positive and 44% of seronegative women knew their partners' HIV status, and many HIV-positive and HIV-negative women reported having sex without condoms after the HIV test. Mean standardized anxiety (p < 0.05) and depression scores were higher in seropositive women. Despite added social support and medical treatments, HIV-positive women showed higher levels of health care discrimination, personal isolation, and psychological sequelae than their seronegative counterparts. As the medical benefits to prenatal HIV testing increase, we will need to develop focused medical, social, and mental health services addressing the needs of HIV-positive women.

Molecular prenatal exclusion of familial partial androgen insensitivity (Reifenstein syndrome)

In a large family with Reifenstein syndrome, we previously performed molecular analysis of the androgen receptor gene. Direct sequencing showed a G-A point mutation at position 2818 of exon 7, which was responsible for an arginine-histidine substitution at position 840 of the androgen receptor. In this family, the proband's mother became pregnant and wished to know whether she was carrying an unaffected fetus. Polymerase chain reactions of the sex-determining region of the Y chromosome (the SRY gene) on trophoblastic DNA at week 14 revealed a 46,XY genotype. Sequencing analysis showed the canonical sequence (CGT, encoding an Arg residue), suggesting that the fetus was not affected. The expectation of normal male sexual development was confirmed by detection of normal male external genitalia through ultrasonography at week 24. These data confirm that sequence analysis of the androgen receptor gene on trophoblastic DNA is the most reliable method for prenatally diagnosing or excluding androgen insensitivity syndrome in high-risk families.

Prenatal protein malnutrition and hippocampal function: partial reinforcement extinction effect

Developing rats were either malnourished or well-nourished during the prenatal period by feeding their dams diets of low (6% casein) or adequate (25% casein) protein content 5 weeks prior to mating and throughout pregnancy. All pups were well-nourished from the day of birth onwards. Male offspring aged 107 days were gradually reduced to 80% of their free-feeding weight. When weights were stable they were trained to run in an alley for food rewards given on every trial (continuous reinforcement, CR) or on a random 50% of trials (partial reinforcement, PR), then the running response was extinguished. A very clear and similar partial reinforcement extinction effect (PREE) was demonstrated in the previously malnourished and control rats when reward was discontinued. That is, PR groups showed greater persistence as compared with CR groups. During acquisition, however, differences in running speed were observed in the goal section between 6-25 PR and 25-25 PR groups, and between 6-25 CR and 25-25 CR groups. The latter may be due to differences between the nutritional groups in food motivation.

Maternal hypothyroxinemia: psychoneurological deficits of progeny

Maternal thyroid function was evaluated clinically, by reproductive history, and by serial measurements of serum butanol-extractable iodine (thyroxine-like iodine), two before and two after 24 gestational weeks during 1,349 pregnancies. Three percent of the women were hypothyroxinemic. Developmental, intellectual, and motor abilities of progeny born to (Group I) 210 euthyroxinemic, (Group II) 15 hypothyroxinemic given adequate thyroid replacement therapy, and (Group III) 21 inadequately treated hypothyroxinemic women were compared. The groups of mothers exhibited no significant differences in intelligence, years of education, or chronological age. Mean developmental and intellectual scores at eight months, four and seven years of Group II progeny evidenced remarkably consistent similarity to scores of siblings and controls. At each age, mean developmental and intellectual scores were lower for Group III progeny, and motor scores of the latter were lowest. Some progeny of Group II mothers, treated only after 12 or 29 weeks, failed the ball catch and line walk tests; some had strabismus and other ocular disturbances. Could these deficits have originated with maternal hypothyroxinemia during first semester weeks before the thyroid-pituitary axis matures? Now in 1990-1991, early findings fit into the modern concepts of significant maternal gestational transfer of thyroxine to the fetus. The authors encourage prenatal and/or early gestational screening for maternal hypothyroxinemia and urge prescription of adequate thyroid replacement therapy for hypothyroxinemic women.