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

Optimizing prenatal diagnosis and referral of classic bladder exstrophy: Lessons from a single-institution experience

INTRODUCTION

Classic bladder exstrophy (CBE) is a malformation of the genitourinary system that occurs due to failure of abdominal wall closure. Unlike other malformations of similar incidence, prenatal diagnosis of CBE relies on suggested, rather than formal, diagnostic criteria.

OBJECTIVE

This report describes prenatal diagnosis of CBE in the largest single-institutional cohort to date and delineates key sonographic findings and protocols for specialist referral.

MATERIALS AND METHODS

A single-institutional database was reviewed for CBE patients born since 2000. Data on screening ultrasound use, gestational age at ultrasound, and abnormal findings were extracted. Where possible, time of prenatal diagnosis (pre- or postnatal and gestational age), ultrasound findings and other imaging data, specialist referral, institution of birth and closure, and outcome of primary closure attempt were compared.

RESULTS

Of 557 patients born with CBE between 2000 and 2022, 284 met inclusion criteria and complete data were available for 280 (229 born domestically and 51 born internationally) who were included for analysis. Abnormal sonography suggestive of CBE was present for 48% (n = 134) of patients, for whom absent bladder was the most common abnormal finding (76% [102/134]). Of domestic patients, 46% (n = 106) were diagnosed prenatally at a median gestational age of 22 weeks (inter-quartile range [IQR]: 20-24), and 14% (n = 32) underwent confirmatory fetal magnetic resonance imaging. Of domestic patients with abnormal prenatal findings, 75% (n = 80/106) consulted with maternal-fetal medicine and 58% (n = 62/106) consulted with pediatric urology. On univariate analysis, prenatal diagnosis was positively associated with primary repair at Association for the Bladder Exstrophy Community-recognized centers of excellence (54% vs. 38%, p = 0.02) and negatively associated with osteotomy at primary closure (41% vs 59%, p = 0.003) but not success of primary closure (74% vs. 82%, p = 0.07).

DISCUSSION

Rates of prenatal diagnosis in this cohort were similar to previous reports of smaller cohorts. Diagnosis allows for comprehensive pre- and postnatal follow-up with a pediatric urologist, with implications on birth planning and decisions on termination of pregnancy. Because of the previously-reported association between exstrophy and in vitro fertilization, these pregnancies should undergo detailed sonography. Any nonvisualization of the fetal bladder should prompt a detailed exam, and any finding characteristic of bladder exstrophy warrants referral to pediatric urology.

CONCLUSIONS

Although CBE is a rare disorder, it is underdiagnosed during pregnancy. Sonographers and obstetricians should be aware of characteristic findings and best practices following diagnosis. Early referral to pediatric urology and maternal-fetal medicine is important for counseling and postnatal planning.

The impact of diagnosed fetal anomaly, diagnostic severity and prognostic ambiguity on parental depression and traumatic stress: a prospective longitudinal cohort study

INTRODUCTION

The detection of a fetal anomaly during routine obstetric ultrasound is a potentially traumatic experience. The aim of this study is to examine longitudinally the impact of diagnosis of fetal anomaly on symptoms of depression and traumatic stress among mothers and fathers, and to examine how variations in psychological adjustment relate to diagnostic severity and prognostic ambiguity.

MATERIAL AND METHODS

In this prospective observational study conducted at a tertiary perinatal referral center, 81 mothers and 69 fathers with ultrasound findings of fetal anomaly completed the Edinburgh Postnatal Depression Scale (EPDS) and Impact of Events Scale (IES) at four time points in pregnancy (T1-T4) and 6 weeks after birth (T5). We compared this with depression and traumatic stress in a sample of non-affected parents (n = 110 mothers, 98 fathers).

RESULTS

Linear mixed effects models indicated that parents who received a diagnosis of fetal anomaly experienced higher levels of depression and traumatic stress over time, compared with non-affected parents. Depression: mean difference mothers = 4.46 ± 0.47, fathers = 2.80 ± 0.42. Traumatic stress: mean difference mothers = 20.04 ± 2.13, fathers = 12.66 ± 1.74. Parents with a more severe diagnosis experienced elevated symptoms compared with parents with a less severe diagnosis. Among mothers, prognostic ambiguity and changes in the anticipated diagnosis after birth were also associated with increased distress, regardless of whether the change was for the better or worse.

CONCLUSIONS

Diagnosis of fetal anomaly increases risk of depression and traumatic stress in expectant mothers and fathers, both acutely and over time.

Maternal and Paternal Representations in Assisted Reproductive Technology and Spontaneous Conceiving Parents: A Longitudinal Study

Aim of this study was to investigate whether parental mental representations during pregnancy and after delivery differed between parents who conceived after Assisted Reproductive Treatments (ART) and spontaneous conceiving (SC) parents. Effects of specific ART variables (previous ART attempts, treatment type and cause of infertility) were also taken into account. Seventeen ART couples and 25 SC couples were recruited at Santa Maria Nuova Hospital (Reggio Emilia, Italy). At both 32 weeks of gestation (T1) and 3 months postpartum (T2) participants completed the Semantic Differential of the IRMAG, a self-report tool which measures specific domains of mental representations pertaining either individual (Child, Self-as-woman/man, and Partner) or parental (Self-as-parent, Own parent) characteristics. Results showed that ART parents had significantly more positive representations of the child compared to SC parents, while the scores at Partner dimension improved from T1 to T2 for SC parents only. With regards to ART history, scores at the Self-as-woman/man dimension were significantly less positive for ICSI than IVF parents and improved substantially from T1 to T2 only in case of mothers with previous ART attempts and of fathers at the first ART cycle. The representation of own parents increased from T1 to T2 in case of infertility diagnosis due to male factors, while a decrease emerged when infertility was due to female factors. Findings suggest the need to investigate parental mental representations after ART, in order to improve the understanding on the transition to parenthood of infertile couples and to target more specific intervention for parenting support.

The Use of Lausanne Trilogue Play in Three Cases of Gastroschisis Diagnosed during Pregnancy

From pregnancy to the 1st years of a child’s life, families develop and increase representations and interactive competences toward the child. Prenatal diagnosis of a severe fetus’ defect could profoundly alter the parental perception and development of these representations. The aim of the study was to evaluate triadic interactions in families, whose baby was prenatally diagnosed with severe gastroschisis. Three families took part in the preliminary case study, which was carried out when the babies were 6 months old. The Lausanne Trilogue Play shows that prenatal diagnosis of fetal malformation may affect family triadic interactions as follows: (a) parents, especially mothers, tend to be intrusive during the play; (b) parents presents maladjustments in the child stimulations, especially during the third part, when both parents have to simultaneously interact with the baby; (c) parents experience difficulties in creating a space that allows them to communicate directly with each other, leaving the child in a peripheral position. Observational data and clinical implications are discussed.

Qualitative questionnaire on the psychosocial wellbeing of mothers of children with BEEC

INTRODUCTION

The bladder exstrophy-epispadias complex (BEEC) represents a spectrum of malformations that affect the anatomical and functional structure of the urogenital system. The parents of patients affected by this condition are subject to particularly stressful situations, such as worrying about their child's health, long hospital stays, concerns about the health and constant need for personal care for their children, that can profoundly compromise the quality of family life.

OBJECTIVE

The objective of this explorative qualitative study is to evaluate the social situation and the psychological strategies implemented by the mothers of children between 6 and 10 years of age who are affected by BEEC.

STUDY DESIGN

Fourteen mothers of children aged 6-10 years and affected by BEEC (9 boys and 5 girls) were interviewed. Data on the mothers' experiences were collected through semi-structured interviews (Table).

RESULTS

The qualitative analysis of the interviews showed that participants described experiences that were characterised by emotions such as fear and anger. Each mother had implemented a different and, sometimes, dysfunctional strategy in order to cope with the complex situation of the son/daughter. The aspects that most clearly emerged from mothers' descriptions were (1) the traumatic situation at the birth of the baby, (2) the sense of embarrassment concerning the pathological condition as the child was growing and the consequent sense of isolation of the mother, and (3) the fluctuation of feelings towards the multidisciplinary staff, which was sometimes seen as an important source of help and some other times as too destabilising and not helpful at all.

DISCUSSION

The study provided some insight into the psychological and social conditions experienced by mothers of children with BEEC, which could serve as a basis for developing multidisciplinary teams with greater awareness about families living with this condition and better timing in addressing their needs.

CONCLUSIONS

Mothers of children with BEEC show emotional and social difficulties. This is a crucial aspect to consider when planning a multidisciplinary approach to the treatment/therapy, especially considering that children examined in this study are approaching adolescence.

Repercussões maternas do diagnóstico pré-natal de anomalia fetal

Resumo Objetivo: Comparar modos de enfrentamento mediante diagnóstico pré-natal de anomalia fetal viável e inviável. Métodos: Estudo transversal de análise quantitativa em 120 gestantes realizado em centro de referência de medicina fetal, de janeiro a dezembro de 2014. Os dados foram obtidos por meio de entrevista semiestruturada contendo características sociodemográficas; antecedentes pessoais e obstétricos; e aplicação do inventário de estratégias de enfrentamento de coping. Teste qui quadrado, teste exato de Fisher ou razão de verossimilhança foram utilizados para comparar variáveis categóricas entre malformação viável e inviável. O teste t de Student foi usado para variáveis contínuas e quando necessária, foi aplicada a Análise de Variância. Resultados: Houve diferença significativa da estratégia autocontrole entre as gestantes com diagnóstico de inviabilidade fetal e as com fetos viáveis. Conclusão: As gestantes com diagnóstico de anomalia fetal inviável apresentaram maior tendência à estratégia de autocontrole que as com feto viável.

Identifying expectant parents at risk for psychological distress in response to a confirmed fetal abnormality

The aim of the study was to determine the incidence of psychological distress among expectant women carrying fetuses with prenatal diagnosed abnormalities and their partners. A 2-year retrospective medical chart review was completed of 1032 expectant mothers carrying fetuses with a confirmed anomaly, and 788 expectant fathers, who completed the CFDT Mental Health Screening Tool. Furthermore, 19.3 % of women and 13.1 % of men reported significant post-traumatic stress symptoms, and 14 % of men and 23 % of women scored positive for a major depressive disorder. Higher risk was noted among expectant parents of younger age and minority racial/ethnic status, and women with post-college level education and current or prior use of antidepressant medications. Heightened distress was noted within fetal diagnostic subgroups including neck masses, sacrococcygeal teratomas, neurological defects, and miscellaneous diagnoses. Incorporating screening tools into prenatal practice can help clinicians better identify the potential risk for psychological distress among expectant parents within high-risk fetal settings.

PRE- AND POSTNATAL MODIFICATIONS IN PARENTAL MENTAL REPRESENTATIONS IN THREE CASES OF FETAL GASTROSCHISIS DIAGNOSED DURING PREGNANCY

The aim of this study was to identify possible effects of gastroschisis on parents' intrapsychic dynamics by applying an observational clinical approach. More specifically, we intend to (a) evaluate the representational style of parents informed about the diagnosis of fetal gastroschisis during pregnancy using the Interview of Maternal Representations During Pregnancy and the Interview of Paternal Representations During Pregnancy (M. Ammaniti, C. Candelori, M. Pola, & R. Tambelli, ) and (b) observe whether the baby's birth influences the parents' representational styles through the application of the same tools (the Interview of Maternal Representations After the Birth, M. Ammaniti & R. Tambelli, , and the Interview of Paternal Representations After the Birth, M. Ammaniti & R. Tambelli, ), adapted to the postnatal period. During the prenatal period, all parents showed a restricted/disinvested style. Three parents-one mother and two fathers-changed their styles from restricted/disinvested to integrated between pregnancy and Month 6 after the birth of their child. Clinical data from the interviews and observations are discussed in an attempt at better defining intrapsychic dynamics of parents after a diagnosis of gastroschisis.