The psychosocial sequelae of a second-trimester termination of pregnancy for fetal abnormality

The Medical Process in Pregnancy Terminations for Fetal Anomaly: An Analysis of Counselling and Bereavement

Pregnancy termination for fetal anomaly (TOPFA) is a possible outcome of a pregnancy complicated by a fetal anomaly detected during routine prenatal care. Limited research is available on the quality of the counselling offered to women, in terms of enabling them to make an informed decision. The goal of this descriptive cohort study was to examine the medical process offered to a cohort of 151 women who underwent TOPFA in 2018 in a single tertiary mother and child hospital to identify areas for potential quality improvement (QI). Statistical analysis comprised basic statistical tests, Pearson's χ² test, and logistic regression. Counselling was evaluated by two fetal health specialists who found that the counselling process was minimal in 42% of cases. Counselling referrals to pediatric specialists were made in 26% of cases, with many potential explanations for this finding. Complicated bereavement was present in 39% of cases. Risk factors for complicated bereavement were explored and were found to be insufficient social support (odds ratio [OR] 6.5; 95% CI 2.0-21.0, P < 0.001), history of a mood disorder (OR 3.4; 95% CI 1.3-8.8, P < 0.01), and history of another TOPFA (OR 6.2; 95% CI 1.2-31.0, P = 0.01). Viewing the fetus after termination was not correlated with a significant reduction in complicated bereavement. The evaluation of the counselling as minimal in 42% of cases and the high prevalence of complicated bereavement call for quality improvement (QI) in the process for women who undergo TOPFA. Clinicians should be able to screen women most at risk for complicated bereavement to best orient preventive 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.

Ethics in genetic counselling

Difficult ethical issues arise for patients and professionals in medical genetics, and often relate to the patient's family or their social context. Tackling these issues requires sensitivity to nuances of communication and a commitment to clarity and consistency. It also benefits from an awareness of different approaches to ethical theory. Many of the ethical problems encountered in genetics relate to tensions between the wishes or interests of different people, sometimes even people who do not (yet) exist or exist as embryos, either in an established pregnancy or in vitro. Concern for the long-term welfare of a child or young person, or possible future children, or for other members of the family, may lead to tensions felt by the patient (client) in genetic counselling. Differences in perspective may also arise between the patient and professional when the latter recommends disclosure of information to relatives and the patient finds that too difficult, or when the professional considers the genetic testing of a child, sought by parents, to be inappropriate. The expectations of a patient's community may also lead to the differences in perspective between patient and counsellor. Recent developments of genetic technology permit genome-wide investigations. These have generated additional and more complex data that amplify and exacerbate some pre-existing ethical problems, including those presented by incidental (additional sought and secondary) findings and the recognition of variants currently of uncertain significance, so that reports of genomic investigations may often be provisional rather than definitive. Experience is being gained with these problems but substantial challenges are likely to persist in the long term.

Stigma in the context of pregnancy termination after diagnosis of fetal anomaly: associations with grief, trauma, and depression

Termination of pregnancy after diagnosis of fetal anomaly (TOPFA) is a contested issue and stigma may negatively impact affected women's psychological reactions. This study examined the influence of perceived and internalized stigma on women's long-term adjustment to a TOPFA. One hundred forty-eight women whose TOPFA dated back 1 to 7 years responded to self-report questionnaires. The associations between perceived stigma at the time of the TOPFA, current internalized stigma and symptoms of grief, trauma and depression were modeled using multiple linear regression. The proportion of participants reporting scores above the cutoffs on the respective scale was 17.6% for grief, 18.9% for posttraumatic stress, and 10.8% for depression. After controlling for time since the TOPFA, pre-TOPFA mental health and obstetric variables, higher levels of current internalized stigma were related to higher levels of grief, trauma, and depression. Mediation analyses suggested that the effect of perceived stigma at the time of the TOPFA on symptoms of grief and trauma was mediated by current internalized stigma, but the cross-sectional design limited causal interpretation of results. Internalized stigma is associated with long-term psychological distress following a TOPFA. Perceived stigma at the time of the TOPFA may contribute to increased trauma and grief symptomatology, but results need to be validated in longitudinal studies. Health care providers and public initiatives should aim at reducing stigma among affected women.

‘Yes!—A Chance to Tell My Side of the Story’: A Case Study of a Male Partner of a Woman Undergoing Termination of Pregnancy for Foetal Abnormality

Interpretative phenomenological analysis (IPA) was used to analyse data from one man whose partner underwent a third-trimester termination of pregnancy for foetal abnormality. This case study examines the data from the participant and aspects of grief are examined qualitatively from a male perspective. The importance of the male role, management of his own particular needs and coping mechanisms are discussed in the context of society’s expectations and current thinking on grief counselling. The impact of a new technique in obstetric management is highlighted in this case.

Pregnancy continuation and organizational religious activity following prenatal diagnosis of a lethal fetal defect are associated with improved psychological outcome

OBJECTIVE

The aim of the article is to examine the psychological impact, specifically symptoms of grief, post-traumatic stress and depression, in women and men who either terminated or continued a pregnancy following prenatal diagnosis of a lethal fetal defect.

METHOD

This project investigated a diagnostically homogeneous group composed of 158 women and 109 men who lost a pregnancy to anencephaly, a lethal neural tube defect. Participants completed the Perinatal Grief Scale, Impact of Event Scale - Revised and Beck Depression Inventory-II, which measure symptoms of grief, post-traumatic stress and depression, respectively. Demographics, religiosity and pregnancy choices were also collected. Gender-specific analysis of variance was performed for instrument total scores and subscales.

RESULTS

Women who terminated reported significantly more despair (p = 0.02), avoidance (p = 0.008) and depression (p = 0.04) than women who continued the pregnancy. Organizational religious activity was associated with a reduction in grief (Perinatal Grief Scale subscales) in both women (p = 0.02, p = 0.04 and p = 0.03) and men (p = 0.047).

CONCLUSION

There appears to be a psychological benefit to women to continue the pregnancy following a lethal fetal diagnosis. Following a lethal fetal diagnosis, the risks and benefits, including psychological effects, of termination and continuation of pregnancy should be discussed in detail with an effort to be as nondirective as possible.

Pregnancy and postpartum following a prenatal diagnosis of fetal thoracoabdominal malformation: the parental perspective

PURPOSE

The study's aim was to evaluate how information related to a prenatal diagnosis of fetal malformation could modify parenthood experience descriptions during pregnancy and after the child's birth.

METHODS

A longitudinal case-control clinical study was conducted. Data on parenthood experience descriptions collected using a validated semantic differential technique during pregnancy and after the child's birth were compared between seven couples of parents receiving a prenatal diagnosis of fetal malformation and seven couples without any fetal diagnosis.

RESULTS

Our results show that during pregnancy parents in the clinical group describe themselves as more fragile, passive, and timid [p=0.007] than those in the control group. On the other hand, after the child's birth, there are no significant differences between groups.

CONCLUSIONS

Data are discussed with reference to better knowledge of the psychological dynamics involved in becoming a parent and to rational planning of support for parents receiving a diagnosis of fetal malformation.

Women's experiences of coping with pregnancy termination for fetal abnormality

Pregnancy termination for fetal abnormality (TFA) can have significant psychological consequences. Most previous research has been focused on measuring the psychological outcomes of TFA, and little is known about the coping strategies involved. In this article, we report on women's coping strategies used during and after the procedure. Our account is based on experiences of 27 women who completed an online survey. We analyzed the data using interpretative phenomenological analysis. Coping comprised four structures, consistent across time points: support, acceptance, avoidance, and meaning attribution. Women mostly used adaptive coping strategies but reported inadequacies in aftercare, which challenged their resources. The study's findings indicate the need to provide sensitive, nondirective care rooted in the acknowledgment of the unique nature of TFA. Enabling women to reciprocate for emotional support, promoting adaptive coping strategies, highlighting the potential value of spending time with the baby, and providing long-term support (including during subsequent pregnancies) might promote psychological adjustment to TFA.

Psychological correlates of decision-making during prenatal diagnosis: a prospective study

OBJECTIVE

Decision-making during prenatal diagnosis has not been extensively studied. We aimed to determine psychological correlates and level of decisional conflict following prenatal diagnosis.

METHOD

A total of 159 pregnant women were consecutively enrolled. All participants completed three questionnaires (the Hospital Anxiety and Depression scale, the Berlin Social Support scales and the Decisional Conflict scale) at three time points (T1 - waiting period between prenatal testing and disclosure of the results; T2 - decision phase within 3 days from test result disclosure; T3 - digestion period within 3 weeks from disclosure).

RESULTS

Women with fetal anomaly who terminate pregnancy were significantly more anxious and depressed than controls at each time point. Additionally, women with a normal fetus who terminate pregnancy presented higher level of anxiety and depression compared with controls at T2. Women who terminated pregnancy showed increased uncertainty scores at T2 and T3. Anxious and depressed individuals at T2 (decision period) were more uncertain about their choice at T3 compared to women with normal levels of anxiety and depression.

CONCLUSION

The decision to terminate pregnancy, irrespective of test results, may determine emotional distress and psychiatric morbidity. Women who were anxious and depressed at decision appeared to be more uncertain about their choices as time passed by. A careful assessment of women during prenatal diagnosis should be useful to identify women who may benefit from psychological support.

Complicated grief after perinatal loss

The loss of an infant through stillbirth, miscarriage, or neonatal death is recognized as a traumatic life event. Predictors of development of complicated grief after prenatal loss include lack of social support, pre-existing relationship difficulties, or absence of surviving children, as well as ambivalent attitudes or heightened perception of the reality of the pregnancy. Risk of complicated grief was found to be especially high after termination of a pregnancy due to fetal abnormality. Studies have revealed that men and women show different patterns of grief, potentially exacerbating decline in a relationship. Although it is clear that prenatal loss has a large psychological impact, it is concluded that there is a substantial lack of randomized controlled studies in this field of research,

Decision making following a prenatal diagnosis of Down syndrome: an integrative review

INTRODUCTION

Prenatal screening for Down syndrome (DS) is a routine part of prenatal care in many countries, and there is growing interest in the choices women make following a prenatal diagnosis of DS. This review describes what is known about actual and hypothetical decision making following a prenatal diagnosis of DS and adds understanding about the factors that influence women's decision making.

METHODS

A search of empirical studies was conducted through electronic databases, major journals, and reference lists that were published in English between January 1999 and September 2010. Inclusion criteria were that the research explored attitudes toward continuation of pregnancy or induced abortion for DS and included at least 1 variable that explored factors influencing women's decision making following a prenatal diagnosis of DS. Studies that did not specify DS, unpublished manuscripts, review articles, and book chapters were excluded.

RESULTS

A total of 11 studies were identified that met the inclusion criteria. The decision to undergo an induced abortion varied depending on whether participants were prospective parents recruited from the general population (23%-33% would terminate), pregnant women at increased risk for having a child with DS (46%-86% would terminate), or women who received a positive diagnosis of DS during the prenatal period (89%-97% terminated). Multiple factors influence women's decision making following a diagnosis of DS, including demographic factors such as religion, maternal age, gestational age, number of existing children, and history of induced abortion. Psychosocial factors including perceived parenting burden/reward, quality of life for a child with DS, attitudes toward and comfort with individuals with disabilities, and support from others also are important influences.

DISCUSSION

Multiple factors influence the decisions pregnant women make following the diagnosis of fetal DS. Therefore, it is critical that health care providers who work with pregnant women are aware of these factors.

Spiritual needs of couples facing pregnancy termination because of fetal anomalies

The spiritual needs of couples (9 mothers and 5 fathers) who were planning to terminate wanted second trimester pregnancies because of serious fetal anomalies were surveyed. Their greatest needs were for a "guidance from a higher power" and for "someone to pray for them." Unlike other reported groups of patients, they did not want or expect their healthcare team to discuss their faith, or to pray with them. Most would prefer support from their own pastors, but their religious community was involved to only a small extent. They would welcome support from hospital chaplains, who could play a substantive and unique pastoral role in this clinical context.

Adjustment to termination of pregnancy for fetal anomaly: a longitudinal study in women at 4, 8, and 16 months

OBJECTIVE

We studied psychological outcomes and predictors for adverse outcome in 147 women 4, 8, and 16 months after termination of pregnancy for fetal anomaly.

STUDY DESIGN

We conducted a longitudinal study with validated self-completed questionnaires.

RESULTS

Four months after termination 46% of women showed pathological levels of posttraumatic stress symptoms, decreasing to 20.5% after 16 months. As to depression, these figures were 28% and 13%, respectively. Late onset of problematic adaptation did not occur frequently. Outcome at 4 months was the most important predictor of persistent impaired psychological outcome. Other predictors were low self-efficacy, high level of doubt during decision making, lack of partner support, being religious, and advanced gestational age. Strong feelings of regret for the decision were mentioned by 2.7% of women.

CONCLUSION

Termination of pregnancy for fetal anomaly has significant psychological consequences for 20% of women up to > 1 year. Only few women mention feelings of regret.

[Women and the painful experience of therapeutic abortion]

OBJECTIVE

When the antenatal diagnosis reveals a serious anomaly of the fetus, the couple can envisage a therapeutic abortion. This qualitative study aims to bring a better understanding of emotional impact and perinatal grief after a therapeutic abortion.

PATIENTS AND METHODS

Seven women who have had a therapeutic abortion participated in a semidirective interview.

RESULTS

The analysis of the collected data reveals the psychological trauma caused by a therapeutic abortion, the significant distress of the mothers accentuated by omnipresent guilt feelings, persistent symptoms of depression and anxiety. Different reactions within the couple are perceived and can lead to marital conflict.

DISCUSSION AND CONCLUSION

Results show a need for a psychological follow-up of the individual as well as the couple.

The health-care experiences of families given the prenatal diagnosis of trisomy 18

OBJECTIVE

The objective of this study was to examine parent-reported experiences in the health care system after receiving the prenatal diagnosis of trisomy 18 and to identify factors that contribute to satisfaction with care.

STUDY DESIGN

Nineteen families who received the diagnosis between 2002 and 2005 were given semistructured telephone interviews. Of the 19 families, 11 continued the pregnancy while the remaining 8 chose induced abortion. Classical content analysis was utilized to identify themes among subject responses.

RESULT

We identified several specific aspects of care as key in either being highly satisfied or dissatisfied: expressions of empathy from provider, continuity of care, communication, valuing the fetus and participation in medical decision-making.

CONCLUSIONS

Aspects of care that were identified as reasons for dissatisfaction are potentially modifiable by training, education or team-based approaches. Further studies are necessary to determine how we can improve the quality of services during prenatal diagnosis.

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.

An evaluation of a shared experience group for women and their support persons following prenatal diagnosis and termination for a fetal abnormality

OBJECTIVES

Support after fetal diagnosis of abnormality (SAFDA), is a facilitated shared experience group for women and their partners or support person, in Victoria, Australia, who have had a pregnancy termination for a fetal abnormality. The objective of this study was to evaluate the SAFDA-facilitated group.

METHODS

A questionnaire-based study was undertaken between 2001 and 2005 to evaluate SAFDA. A deidentified self-completed questionnaire was given to participants at the end of each group and included questions relating to the referring professional, participants' prior expectations of the group, helpfulness of participation, preferred group format, length, and venue. In addition, there was also opportunity for participants to make general comments on their experiences of participating in SAFDA.

RESULTS

A total of 85 participants (100% response) completed the questionnaire. Seventy-one participants (84%) considered it 'very helpful' to participate in the group. Seventy-eight participants (92%) considered that a shared-experience group was the most beneficial format. Comments written by participants affirmed that the present format of SAFDA was a highly valued opportunity to listen to and share experiences in a confidential small group.

CONCLUSION

SAFDA is a beneficial forum for women and their partners or support person to share their experiences after having had a pregnancy termination for a fetal abnormality. Further, SAFDA provides information and insights for health professionals who are considering how best to support women.

A prospective study on parental coping 4 months after termination of pregnancy for fetal anomalies

OBJECTIVE

To identify short-term factors influencing psychological outcome of termination of pregnancy for fetal anomaly, in order to define those patients most vulnerable to psychopathology.

STUDY DESIGN

A prospective cohort of 217 women and 169 men completed standardized questionnaires 4 months after termination. Psychological adjustment was measured by the Inventory of Complicated Grief (ICG), the Impact of Event Scale (IES), the Edinburgh Postnatal Depression Scale (EPDS), and the Symptom Checklist-90 (SCL-90).

RESULTS

Women and men showed high levels of posttraumatic stress (PTS) symptoms (44 and 22%, respectively) and symptoms of depression (28 and 16%, respectively). Determinants of adverse psychological outcome were the following: high level of doubt in the decision period, inadequate partner support, low self-efficacy, lower parental age, being religious, and advanced gestational age. Whether the condition was Down syndrome or another disability was irrelevant to the outcome. Termination did not have an important effect on future reproductive intentions. Only 2% of women and less than 1% of men regretted the decision to terminate.

CONCLUSION

Termination of pregnancy (TOP) for fetal anomaly affects parents deeply. Four months after termination a considerable part still suffers from posttraumatic stress symptoms and depressive feelings. Patients who are at high risk could benefit from intensified support.

Prenatal care: the patient's perspective. A qualitative study

OBJECTIVES

To investigate the subjective experiences and perceptions of the prenatal care system for women following a prenatal diagnosis and to assess the factors related to dissatisfaction with medical treatment.

METHODS

Data derived from a follow-up investigation in fifty women following a prenatal diagnosis is presented. Women were asked to give written comments concerning their feelings and experiences during their time at the prenatal care unit. A qualitative content analysis was performed in order to examine the patients' perceptions and expectations of the prenatal care management and to seek potential associations of certain attitudes with socio-demographic, clinical, or psychological characteristics. Womens' comments were coded within established categories including 'satisfaction', 'dissatisfaction' and 'communicated emotionality'.

RESULTS

A high proportion of women were found to be dissatisfied with the physicians' attitudes (42%), the amount of information provided (46%), and medical staffs' attitudes (30%). One criticism, in particular, concerned a lack of communication skills in doctors and medical staff members. Forty-eight percent of our study population mentioned that they had benefited from psychological support. 'Nullipara' was the only variable associated with dissatisfaction with the received prenatal care.

CONCLUSIONS

The results of the study suggest that the high degree of discontent found in prenatal care patients could at least in some part be alleviated by implementation of communication training and supervision services for prenatal care workers. Moreover, nullipara may constitute a particular vulnerable subgroup that may need special attention and support. However, given the qualitative nature of our study, our results warrant replication in further empirically based research.

Psychological consequences of prenatal diagnosis in a case of familial Angelman syndrome

Angelman Syndrome (AS), characterized by mental retardation, absence of speech, seizures and motor dysfunction, is caused by genetic defects leading to loss of expression of the maternal copy of the chromosome 15q11-13 imprinted region. Most cases are sporadic, being caused by de novo deletion of maternal chromosome 15q11-13 (75%) or by paternal uniparental disomy (3-4%). Familial cases can occur, due to mutations in the UBE3A gene or in the imprinting center. We describe the case of a pregnant woman having two nephews with AS caused by a UBE3A mutation; lack of communication within the family led the woman to be completely unaware of the risk of disease recurrence until 15 weeks of gestation. UBE3A genetic testing revealed she carried the familial mutation 892-893delCT. Prenatal diagnosis was performed on amniotic fluid and demonstrated that the fetus had inherited the mutation. The unexpected diagnosis and the subsequent termination of the pregnancy caused the woman to undergo acute psychological distress showing relevant psychopathological symptoms. Nevertheless, at 2-year follow-up, adverse consequences were minimized, and the couple was planning a new pregnancy. Factors affecting the psychological outcome of abortion and the role of psychological support in reducing the risk of long-term unfavorable consequences are discussed.

Supervision of Psychosocial Skills in Genetic Counseling

Little has been written about how genetic counseling supervisors can help students develop psychosocial skills in their clinical rotations. The authors describe several approaches supervisors can use, ranging from preventive measures (e.g., normalizing anxiety), to skill-enhancing interventions (e.g., modeling and thinking aloud), to more direct approaches (e.g., immediacy, confrontation) that may be necessary for students who are reluctant, or even resistant, to using psychosocial skills with their clients.

Termination of pregnancy for fetal abnormality incompatible with life: women's experiences in Brazil

Fetal abnormality incompatible with life is a fact and the options for dealing with it are abortion or birth followed by death. This paper reports a qualitative study of the experience of ten women who had a pregnancy termination in a university hospital in Brazil for fetal abnormality incompatible with life. The women were interviewed approximately 40 days after the procedure. The experience was marked by strong emotions for the women, who had a terrible shock on learning of the diagnosis, which was given between 13 and 25 weeks into their pregnancies. They cried, and experienced fear, despair, anguish, a sense of uselessness and refusal to accept the situation. When they took the decision to terminate their pregnancies, the women experienced sadness, despair and guilt, and all these feelings caused them intense suffering. The killing of the fetus was the most difficult part of the termination for them. Nevertheless, afterwards they were satisfied with the decision taken and believed that it was the correct one, despite the anguish it caused. The inclusion of fetal abnormality incompatible with life in the Brazilian law on pregnancy termination would help to reduce women's suffering and contribute to the provision of supportive care by the health services.

Trauma and grief 2-7 years after termination of pregnancy because of fetal anomalies--a pilot study

The aim of the study was to obtain information on the long-term posttraumatic stress response and grief several years after termination of pregnancy due to fetal malformation. We investigated 83 women who had undergone termination of pregnancy between 1995 and 1999 and compared them with 60 women 14 days after termination of pregnancy and 65 women after the spontaneous delivery of a full-term healthy child. Women 2-7 years after termination of pregnancy were expected to show a significantly lower degree of traumatic experience and grief than women 14 days after termination of pregnancy. Contrary to the hypothesis, however, the results showed no significant intergroup differences with respect to the degree of traumatic experience. With the exception of one subscale (fear of loss), this also applied to the grief reported by the women. However, both groups differed significantly in their posttraumatic stress response from women who had given spontaneous birth to a full-term healthy child. The results indicate that termination of pregnancy is to be seen as an emotionally traumatic major life event which leads to severe posttraumatic stress response and intense grief reactions that are still detectable some years later.

Psychological consequences of termination of pregnancy for fetal anomaly: similarities and differences between partners

OBJECTIVE

We examined the psychological responses to termination of pregnancy (TOP) for fetal anomaly from both men and women. The aim was to find risk factors for poor psychological outcome both for the individuals and for the couple.

METHODS

A cross-sectional study was performed in 151 couples 2-7 years after TOP. We used standardized and validated questionnaires to investigate grief, symptoms of posttraumatic stress, somatic complaints, anxiety, and depression.

RESULTS

Most couples adapted well to their loss, although several patients had pathological scores on posttraumatic stress symptoms and depression. Differences between men and women were slight. Higher education, good partner support, earlier gestational age, and life-incompatibility of the disorder positively influenced the outcomes, more for women than for men. Men and women with pathological scores rarely had such scores simultaneously.

CONCLUSION

We emphasize the importance of equally involving both parents in the counselling because the outcomes of grief and posttraumatic stress symptoms between men and women only moderately differ and post-TOP psychopathology occurs in men as well. Good adjustment to TOP in women seems dependent on the level of support that they perceive from their partners. The intracouple results of the study suggest a mutual influence in the process of grieving between the partners.

Long-term psychological consequences of pregnancy termination for fetal abnormality: a cross-sectional study

OBJECTIVE

We examined women's long-term psychological well-being after termination of pregnancy (TOP) for fetal anomaly in order to identify risk factors for psychological morbidity.

METHODS

A cross-sectional study was performed in 254 women, 2 to 7 years after TOP for fetal anomaly before 24 weeks of gestation. We used standardised questionnaires to investigate grief, posttraumatic symptoms, and psychological and somatic complaints.

RESULTS

Women generally adapted well to grief. However, a substantial number of the participants (17.3%) showed pathological scores for posttraumatic stress. Low-educated women and women who had experienced little support from their partners had the most unfavourable psychological outcome. Advanced gestational age at TOP was associated with higher levels of grief, and posttraumatic stress symptoms and long-term psychological morbidity was rare in TOP before 14 completed weeks of gestation. Higher levels of grief and doubt were found if the fetal anomaly was presumably compatible with life.

CONCLUSION

Termination of pregnancy for fetal anomaly is associated with long-lasting consequences for a substantial number of women. Clinically relevant determinants are gestational age, perceived partner support, and educational level.

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.

Grief after termination of pregnancy due to fetal malformation

Termination of pregnancy for fetal malformation is a traumatic event which any woman finds hard to withstand and which entails the risk of severe and complicated grieving. This paper presents three cases illustrating the trauma and coping mechanisms. Grieving continued for over 6 months in all cases and included pathological anxiety and depression. We offer advice and counselling to such women.

Coping with termination of pregnancy for fetal abnormality in a supportive environment

OBJECTIVES

To study the feelings of parents during and after termination of pregnancy (TOP) for fetal anomalies.

METHODS

Semi-structured interviews were conducted before TOP, after six weeks and six months after TOP. The study group consisted of 89 couples, treated at our institution between 1994 and 1998, who terminated their pregnancy in the second and third trimester. Eighty-six of them participated in at least one of the three interviews.

RESULTS

Most parents were able to cope with the decisions they had to make, although a struggle between reason and emotion often occurred. Seeing the dead baby and saying farewell gave all parents a good feeling afterward. Feelings such as doubt, guilt, failure, shame, anger, anxiety and relief were experienced during the period of TOP and the following weeks but practically disappeared after six months; these feelings were more prevalent in women. Most of the couples mentioned that their relationship grew closer as a result of the loss and the grief. Relatives offered good support to most parents in the first weeks after delivery, but parents felt that this support lasted too short a time.

CONCLUSIONS

Seeing the child and saying farewell and the medical and psychosocial support received from professional caregivers were of great value for the interviewees. Parents found the interviews helpful in the grieving process.

The impact of abnormal fetal echocardiography on expectant parents' experience of pregnancy: a pilot study

To examine the impact of an abnormal fetal echocardiogram (echo) on parental attitudes, emotions and coping strategies. Group interviews were performed for women and their male partners who had a fetal echo and were found to have a fetal congenital heart defect. The women and men were separated into four different focus groups. The interviews were tape recorded, transcribed and analyzed. The women expressed strong emotions of guilt, fear and sadness or hopelessness. They coped by attaching and bonding to the fetus, and were realistic about the future. The women began grieving at the time of the fetal echo. The men experienced emotions of anger and anxiety. They coped by remaining optimistic, and focused on supporting their wives. Men grieved after the birth of the baby. The fetal echo was felt to be beneficial and not harmful by the parents. The fetal echo led to significant changes in the couples' perceptions of themselves and their relationships. Clinicians performing fetal imaging must be aware of parental affective responses and coping mechanisms in order to provide the required psychological support.

[Opinions of couples on care during medical termination of pregnancy]

OBJECTIVES

To study the medical care, staff attitudes and patients' satisfaction from the decision to the post-intervention medical visit for termination of pregnancy for fetal abnormalies.

PATIENTS AND METHODS

All patients and their spouses having a termination of pregnancy at the "Unite de Medecine Foetale" in Port-Royal Hospital between November 1996 and July 1997 were contacted for the study. A self-administered questionnaire was mailed six to eight weeks after intervention. Forty seven women and 42 men returned a completed questionnaire, the response rates were respectively 68% and 61%.

RESULTS

The patients and their spouses rated globally very high their satisfaction about the care received. The delay before intervention, the length and pain of labour were rated less positively. The factors associated with satisfaction were the quality of the relationship with the staff, and of information. Positive feelings about delivery were linked with the consideration and relief of pain. Most respondents mentioned that their physical and psychological state has improved at the moment of the survey but the psychological distress subsisted or has increased in one fourth of the cases. On the whole the answers made within the couples were correlated.

CONCLUSION

The positive results should be moderated by the number of non-respondents. In a context of very high rates of satisfaction, psychological distress is still present for one respondent out of four, six to eight weeks after termination of pregnancy for fetal abnormalies.

Prenatal diagnosis of fetal abnormality: psychological effects on women in low-risk pregnancies

When given an adverse prenatal diagnosis, parents are deeply shocked and experience acute grief. This review considers the psychological outcomes for parents whether they opt to terminate the pregnancy or continue, either through choice or because termination is not an option. It covers the full spectrum of malformation from treatable, through those carrying a risk of significant handicap, to lethal. It draws on two types of studies: those that are retrospective and qualitative, describing feelings and aspects of care, and those that are prospective and assess psychological state with standardized measures of grief, anxiety and depression. The relationship between psychological outcome and possible associated variables, such as individual characteristics, nature of the abnormality and obstetric factors is described and evaluated. In addition, the authors draw on both scientific and support group literature to summarize good practice for the care of parents receiving an unexpected diagnosis of fetal abnormality.

Genetic abortion: considerations for patient care

Women who receive abnormal prenatal diagnosis results potentially face two emotionally difficult decisions. In this article, the first decision--whether or not to terminate the pregnancy--is presented with a discussion of the factors that may influence a women's choice. Women who choose to terminate the pregnancy face a second decision when more than one type of abortion procedure is available. Two second trimester abortion procedures--dilation and evacuation and labor induction--are compared and contrasted to delineate potential advantages and disadvantages of each. The decision-making process is examined, emphasizing the individual ways in which women may weigh this information to make a fully informed decision. In addition, a number of recommendations are offered to health care providers in the role of discussing options and supporting women in their choices.

The value of sonography in early pregnancy for the detection of fetal abnormalities in an unselected population

OBJECTIVE

To determine the value of early pregnancy sonography in detecting fetal abnormalities in an unselected obstetric population. DESIGN Prospective cross-sectional study. All women initially underwent transabdominal sonography and when the anatomical survey was considered to be incomplete, transvaginal sonography was also performed (20.1%). Nuchal translucency was measured and karyotyping was performed as appropriate.

SETTING

University Department of Obstetrics and Gynaecology.

PARTICIPANTS

6634 sequential unselected women (mean maternal age 29.9 years, range 13-50; mean gestational age 12+4 weeks, range 11+0-14+6), carrying 6443 live fetuses participated in this study.

MAIN OUTCOME MEASURE

Detection rate of fetal anomalies and the associated cost per case detected in early pregnancy.

RESULTS

The incidence of anomalous fetuses was 1.4% (92/6443) including 43 chromosomal abnormalities. The detection rate for structural abnormalities was 59.0% (37/63, 95% CI 46.5-72.4) and the specificity was 99.9% in early pregnancy. When the first and second trimester scans were combined, the detection for structural abnormalities was 81.0% (51/63, 95% CI 67.7-89.2). Seventy-eight percent (31/40) of chromosomal abnormalities (excluding three cases of XXY) were diagnosed at 11-14 weeks, either because of a nuchal translucency greater than or equal to the 99th centile for gestational age (43%; 17/40, 95% CI 27.4-60.4), or due to the presence of structural abnormalities (35%; 14/40, 95% CI 21.2-52.8). Sixty-five percent (15/23) of cases of trisomy 21 were also diagnosed either because of having a nuchal translucency greater than or equal to the 99th centile (57.0%; 13/23) or due to the presence of a structural abnormality (9.0%; 2/23). Overall, the detection rate of structurally abnormal fetuses was 59% (37/63) in early pregnancy and 81% in combination with the second trimester scan. The cost per abnormality diagnosed in early pregnancy is estimated to be pound sterling 6258 per structurally abnormal fetus, pound sterling 7470 per chromosomal abnormality and pound sterling 4453 per anomalous fetus.

CONCLUSION

The majority of fetal structural and chromosomal abnormalities can be detected by sonographic screening at 11-14 weeks, but the second trimester scan should not be abandoned.

First trimester sonographic detection of chromosomal abnormalities in an unselected population

OBJECTIVE

To investigate the role of first trimester sonography in detecting chromosomal abnormalities in an unselected obstetric population.

METHODS

2281 women (mean maternal age 30 years [range 16-47]; mean gestational age 12(+3) weeks [range 11-14]) underwent transabdominal scanning to assess fetal structure and, if anatomical survey was considered to be incomplete (31% of cases), transvaginal sonography was also performed. Measurement of nuchal translucency was included and karyotyping performed as considered appropriate.

RESULTS

There were 16 chromosomal abnormalities; 13 (81%) were diagnosed at 11-14 weeks either because of a nuchal translucency greater than or equal to the 99th centile for gestational age (7/16; 44% [95% CI 25-63]) or due to the presence of structural abnormalities (6/16; 38% [95% CI 14.2-61.8]). Seventy-five percent of cases of trisomy 21 were also diagnosed either because of having a nuchal translucency greater than or equal to the 99th centile (5/8; 63%) or due to the presence of a structural abnormality (1/8; 13%).

CONCLUSIONS

A significant proportion of fetal chromosomal abnormalities can be detected by first trimester sonographic screening to assess fetal structural appearance. The sensitivity of detection can be improved by combining measurement of nuchal translucency with detailed examination of fetal anatomy.

One day you're pregnant and one day you're not: pregnancy interruption for fetal anomalies

OBJECTIVE

To systematically explore the processes operating within the experience of women undergoing 2nd-trimester pregnancy interruption for fetal anomalies.

DESIGN

Phenomenology was used to conduct the study and analyze audiotaped interviews.

SETTING

Informants were recruited through a private perinatal practice providing prenatal diagnosis and management to women experiencing high-risk pregnancies at an urban tertiary care center in the Pacific Northwest.

PARTICIPANTS

Three women who had undergone pregnancy interruption for fetal anomalies in the 2nd trimester.

RESULTS

The experience of women undergoing 2nd trimester pregnancy interruption can be described as "one day you're pregnant and one day you're not." This summarizes the changes involved in the transition from being a pregnant woman with hopes for the infant and the future to a woman dealing with a loss of innocence. This transition can be described in two intertwined processes entitled "The Hardest Thing We Ever Did" and "Saying Hello and Goodbye."

CONCLUSIONS

The decision to interrupt an abnormal pregnancy is a profound experience that permeates all areas of a woman's life. Interventions specific to this type of loss are suggested. Future research is recommended, using a larger sample size to elaborate on concepts identified in this pilot study.