Opt For Termination Of Pregnancy Research Articles

Women\u2019s attitudes, beliefs and values about tests, and management for hypertensive disorders of pregnancy

BackgroundAdvances in research suggest the possibility of improving routine clinical care for preeclampsia using screening (predictive) and diagnostic tests. The views of women should be incorporated into the way in which such tests are used. Therefore, we explored the views of women with experience of preeclampsia and other hypertensive disorders in pregnancy (HDPs) about predictive and diagnostic tests, treatment risks, and expectant management.MethodEight hundred and seven women with experience of preeclampsia or other HDPs completed an online questionnaire. These women were participants in the Preeclampsia Registry (USA). The questionnaire contained 22 items to elicit women’s views about predictive tests (n = 8); diagnostic tests (n = 5); treatment risks (n = 7), and expectant management (n = 2). An optional text box allowed participants to add qualitative open-ended comments. Levels of agreement with the statements were reported descriptively for the sample as a whole, and a preliminary investigation of the role of lived experience in shaping women’s views was conducted by comparing subgroups within the sample based on time of HDP delivery (preterm/term). The qualitative data provided in the optional text box was analysed using inductive thematic analysis to examine participants’ responses.ResultsWomen generally favored predictive and diagnostic testing, although not because they would opt for termination of pregnancy. Participants generally disagreed that taking daily low-dose aspirin (LDA) would make them nervous, with disagreement significantly higher in the preterm delivery subgroup. A high proportion of participants, especially in the preterm delivery subgroup, would take LDA throughout pregnancy. The majority of participants would be more worried about the possibility of preeclampsia than about the risks of treatments to their health (60%), and that proportion was significantly higher in the preterm delivery subgroup. There were no differences between subgroups in the views expressed about expectant management, although opinion was divided in both groups. Overall, most participants opted to put the baby’s interests first.ConclusionWomen with experience of hypertensive disorders were enthusiastic about improved predictive and diagnostic tests. However, varied views about treatment options and expectant management suggest the need for a shared decision-making tool to enable healthcare professionals to support pregnant women’s decision-making to maximize the utility of these tests and interventions.

'We did everything we could'- a qualitative study exploring the acceptability of maternal-fetal surgery for spina bifida to parents.

ObjectiveTo explore the concepts and strategies parents employ when considering maternal-fetal surgery (MFS) as an option for the management of spina bifida (SB) in their fetus, and how this determines the acceptability of the intervention.MethodsA two-centre interview study enrolling parents whose fetuses with SB were eligible for MFS. To assess differences in acceptability, parents opting for MFS (n = 24) were interviewed at three different moments in time: prior to the intervention, directly after the intervention and 3-6 months after birth. Parents opting for termination of pregnancy (n = 5) were interviewed only once. Themes were identified and organised in line with the framework of acceptability.ResultsTo parents opting for MFS, the intervention was perceived as an opportunity that needed to be taken. Feelings of parental responsibility drove them to do anything in their power to improve their future child’s situation. Expectations seemed to be realistic yet were driven by hope for the best outcome. None expressed decisional regret at any stage, despite substantial impact and, at times, disappointing outcomes. For the small group of participants, who decided to opt for termination of pregnancy (TOP), MFS was not perceived as an intervention that substantially could improve the quality of their future child’s life.ConclusionProspective parents opting for MFS were driven by their feelings of parental responsibility. They recognise the fetus as their future child and value information and care focusing on optimising the child’s future health. In the small group of parents opting for TOP, MFS was felt to offer insufficient certainty of substantial improvement in quality of life and the perceived severe impact of SB drove their decision to end the pregnancy.

Do non-invasive prenatal tests promote discrimination against people with Down syndrome? What should be done?

By implementation of non-invasive prenatal testing (NIPT) for the diagnosis of Down syndrome (DS) in maternity care, an ethical debate is newly inflamed how to deal with this information. Fears of the consequences of an increased use of NIPT are justified with the same arguments when amniocentesis and preimplantation genetic diagnosis (PGD) were introduced decades ago. It can be expected that the prevalence of people with DS would significantly increase in Western societies as a result of the increasing age of pregnant women and the improved medical care for people with DS. The net effect as to whether an increasing uptake of NIPT will result in more abortions of fetuses with trisomy 21 cannot be reliably estimated. This holds true since more and more couples will use results of NIPT for information only, but will not opt for termination of pregnancy. Although parents love their children with DS, in a society where reproductive autonomy is seen as an achievement, access to NIPT cannot be limited. On this background, comprehensive and qualified pretest counseling is vital, also to avoid possible stigmatization of people with DS and as the resulting consequence to avoid feared deterioration in their living conditions, for which, however, there is no evidence to date. The personal view of a mother of a child with DS illustrates the complexity in dealing with NIPT, which does not allow simple answers and must be understood as a challenge for society as a whole.

ISUOG consensus statement on current understanding of the association of neurodevelopmental delay and congenital heart disease: impact on prenatal counseling.

An association between congenital heart disease (CHD) and neurodevelopmental delay (NDD) has long been recognized, but remains poorly understood. It is almost certainly multifactorial1-8. A number of abnormal magnetic resonance imaging (MRI), magnetic resonance spectroscopy (MRS) or sonographic findings, specifically abnormal or delayed sulcation, reduced brain biometry and volumes and abnormal brain biochemistry, have been described in fetuses and neonates with some forms of CHD9-17. This suggests that genetic factors3 and the prenatal environment play an important role in the determination of postnatal neurodevelopmental function, in contrast to traditional concepts attributing adverse neurodevelopmental outcomes to postnatal events such as perinatal hypoxia and perisurgical damage. Furthermore, some large cohort trials have demonstrated an increased risk of NDD mainly – but not only – in children and young adults with univentricular circulation and, to a lesser extent, in those with transposition of the great arteries (TGA)14, 18-21. The increasing supportive evidence in this field has led to the publication of an official scientific statement by the American Heart Association22, in which the conclusions are that: ‘Children with CHD are at increased risk of developmental disorder or disabilities or developmental delay’ and, therefore, ‘…surveillance, screening evaluation and re-evaluation during childhood’ are recommended to diagnose and, if possible, treat the various aspects of these disabilities. Experience in the interpretation of any prenatal imaging modality is paramount in assessing its ability to detect real disease and, hence, its true clinical importance. This can be gained only in the setting of well-designed studies. Furthermore, the full extent of clinically important NDD cannot be determined during the first years of a child's life; thus, these studies also require adequate follow-up. The deficiencies in current published studies have raised genuine and widespread concerns that a discussion of possible adverse neurodevelopmental outcomes linked to CHD may lead couples to opt for termination of pregnancy in those cases of isolated CHD that are usually associated with low mortality and low long-term morbidity, such as TGA. However, the available evidence would suggest that it is neither possible nor ethical to ignore this risk during prenatal counseling14, 17, 23. A recent survey, conducted by an ISUOG (International Society of Ultrasound in Obstetrics and Gynecology) Task Force to gauge the attitudes and perceptions of health professionals from leading referral units for CHD worldwide found significant differences in the way in which prenatal counseling is conducted, particularly between North American and European centers24. D. Paladini*, Z. Alfirevic†, J. S. Carvalho‡§, A. Khalil‡, G. Malinger¶, J. M. Martinez**, J. Rychik††, Y. Ville‡‡ and H. Gardiner§§, on behalf of the ISUOG Clinical Standards Committee. *Fetal Medicine & Surgery Unit, Istituto G.Gaslini, Genoa, Italy; †Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK; ‡Fetal Medicine Unit, St George's Hospital and St George's University of London, London, UK; §Centre for Fetal Cardiology, Royal Brompton Hospital, London, UK; ¶OB-GYN Ultrasound Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; **Fetal Medicine, Barcelona Center for Maternal Fetal and Neonatal Medicine, Hospital Clínic and Sant Joan de Déu, University of Barcelona, Barcelona, Spain; ††Fetal Heart Program, Children's Hospital of Philadelphia, Philadelphia, PA, USA; ‡‡Maternité, Hôpital Universitaire Necker-Enfants Malades, Université Paris Descartes, Assistance Publique-Hôpitaux de Paris, Paris, France; §§The Fetal Center, University of Texas Health Science Center at Houston, Houston, TX, USA

Barriers in referring neonatal patients to perinatal palliative care: a French multicenter survey.

BackgroundWhen an incurable fetal condition is detected, some women (or couples) would rather choose to continue with the pregnancy than opt for termination of pregnancy for medical reasons, which, in France, can be performed until full term. Such situations are frequently occurring and sometimes leading to the implementation of neonatal palliative care. The objectives of this study were to evaluate the practices of perinatal care french professionals in this context; to identify the potential obstacles that might interfere with the provision of an appropiate neonatal palliative care; and, from an opposite perspective, to determine the criteria that led, in some cases, to offer this type of care for prenatally diagnosed lethal abnormality.MethodsWe used an email survey sent to 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) at 48 multidisciplinary centers for prenatal diagnosis (MCPD).ResultsForty-two multidisciplinary centers for prenatal diagnosis (87.5%) took part. In total, 102 MFMs and 112 FCPs completed the survey, yielding response rate of 49.3%. One quarter of professionals (26.2%) estimated that over 20% of fetal pathologies presenting in MCPD could correspond to a diagnosis categorized as lethal (FCPs versus MFMs: 24% vs 17.2%, p = 0.04). The mean proportion of fetal abnormalities eligible for palliative care at birth was estimated at 19.30% (± 2.4) (FCPs versus MFMs: 23.4% vs 15.2%, p = 0.029). The degree of diagnostic certainty appears to be the most influencing factor (98.1%, n = 207) in the information provided to the pregnant woman with regard to potential neonatal palliative care. The vast majority of professionals, 92.5%, supported considering the practice of palliative care as a regular option to propose antenatally.ConclusionsOur study reveals the clear need for training perinatal professionals in perinatal palliative care and for the standardization of practices in this field.

PF.28 Spontaneous Resolution of Prenatally Detected Dural Sinus Thrombosis: Case Series

Dural sinus thrombosis (DST) is a rare fetal cerebral abnormality. We present 6 cases of DST detected prenatally with ultrasound and magnetic resonance imaging (MRI). In 4 cases, the DST...

THE PRENATAL MANAGEMENT OF NEURAL TUBE DEFECTS: TIME FOR A RE-APPRAISAL

The prevalence of neural tube defects (NTD) in Europe is around 9 per 10,000 births making it one of the most frequent congential anomalies affecting the central nervous system. NTD encompass all anomalies that are secondary to failure of closure of the neural tube. In this review, we will first summarize the embryology and some epidemiologic aspects related to NTDs. The review focuses on myelomeningocele (MMC), which is the most common distal closure defect. We will describe the secondary pathologic changes in the central and peripheral nervous system that appear later on in pregnancy and contribute to the condition's morbidity. The postnatal impact of MMC mainly depends on the upper level of the lesion. In Europe, the vast majority of parents with a fetus with prenatally diagnosed NTDs, including MMC, opt for termination of pregnancy, as they are apparently perceived as very debilitating conditions. Animal experiments have shown that prenatal surgery can reverse this sequence. This paved the way for clinical fetal surgery resulting in an apparent improvement in outcome. The results of a recent randomized trial confirmed better outcomes after fetal repair compared to postnatal repair; with follow up for 30 months. This should prompt fetal medicine specialists to reconsider their position towards this condition as well as its prenatal repair. The fetal surgery centre in Leuven did not have a clinical programme for fetal NTD repair until the publication of the MOMS trial. In order to offer this procedure safely and effectively, we allied to a high volume centre willing to share its expertise and assist us in the first procedures. Given the maternal side effects of current open fetal surgical techniques, we have intensified our research programmes to explore minimally invasive alternatives. Below we will describe how we are implementing this.

Twin pregnancy with complete hydatidiform mole and co-existent viable fetus

Twin pregnancy with complete hydatidiform mole and a co-existing normal pregnancy is a rare entity. Most patients opt for termination of pregnancy to reduce the risks of complications (Steller et a...

Knowledge and Attitudes Towards Haemophilia: The Family Side and Role of Haemophilia Societies

Objectives: A pilot study to evaluate the knowledge about haemophilia in the families enrolled in the Lucknow Haemophilia Society (India), and to assess their attitudes towards prenatal diagnosis (PND). Methods: A questionnaire to assess the knowledge about haemophilia (questionnaire A) and another questionnaire to assess the attitude towards PND (questionnaire B) were distributed. PND was performed by DNA-based linkage analysis. Results: There was a positive correlation between the knowledge about the disease and the frequency of attending the monthly meetings of the society. The majority of respondents felt that they would opt for termination of pregnancy if the fetus was affected. Conclusion: Haemophilia societies act as strong media in educating affected families. Multiple factors affect the attitude towards PND and abortion of affected fetuses.

Fetoscopy and fetal endoscopic surgery: review of the literature

The first attempt to visualise the fetus with a panendoscope was performed in 1954. Embryoscopy and fetoscopy were developed in the 1970's. They were introduced as a diagnostic tool to visualise external malformations of the fetus in the first, second and third trimesters of pregnancy as well as to obtain fetal tissue for diagnostic purposes and perform fetal intravascular transfusion.Diagnostic fetoscopy during the second and third trimester was abandoned in the late 80's due to the invasive nature of the technique and the development of high resolution ultrasound imaging. Percutaneous access to fetal blood and tissue sampling under continuous ultrasound guidance also became possible in the late eighties. Recently there has been renewed interest in embryo-fetoscopy due to the increasing use of ultrasound in the first trimester together with the development of new equipment, especially miniature fiberscopes. These have improved image resolution while being less invasive. Anomalies suspected in the first trimester often call for a rapid and complete fetal evaluation and microendoscopy allows for a sono-endoscopic assessment of fetal anatomy. This may help a couple to decide whether to carry on with the pregnancy or to opt for early termination of pregnancy (TOP). More recently, embryoscopy and fetoscopy have been used to operate on the placenta and membranes and also on the fetus itself.