The reasons for termination of pregnancy in the third trimester

Personhood Begins at Birth: The Rational Foundation for Abortion Policy in a Secular State

The struggle over legal abortion access in the United States is a religious controversy, not a scientific debate. Religious activists who believe that meaningful individual life (i.e., "personhood") begins at a specific "moment-of-conception" are attempting to pass laws that force this view upon all pregnant persons, irrespective of their medical circumstances, individual preferences, or personal religious beliefs. This paper argues that such actions promote a constitutionally prohibited "establishment of religion." Abortion policy in a secular state must be based upon scientifically accurate biology, not unprovable theological presuppositions. The scientific facts regarding human pregnancy do not support the position that personhood begins with fertilization-at which point a pregnancy does not yet even exist. Abortion policy should regard the embryo/fetus as part of the pregnant individual's body until delivery. We argue that individual "personhood" only begins when the latent potentialities of the fetal nervous system are actualized in the newborn after delivery. The paper argues that instantiating non-scientific beliefs concerning embryonic/fetal "personhood" into the law as the basis for abortion policy establishes a state-sponsored religion. The protection of religious liberty requires that abortion be decriminalized. Abortion should be treated like any other medical procedure and regulated similarly. To protect both religious freedom and sound medical practice, individual legal personhood should be recognized as beginning only at birth.

Acute symptoms of depression and traumatic stress in men and women who terminate pregnancy after the detection of fetal anomaly: A prospective observational study

OBJECTIVE

To assess acute and long-term stress in men and women after the detection of fetal anomalies leading to pregnancy termination.

DESIGN

Prospective observational study.

SETTING

Tertiary referral centre for fetal medicine.

POPULATION

From the initial sample of 180 pregnant women with a fetal anomaly detected by ultrasound examination, a total of 87 women terminated their pregnancy, with 72 partners included in the sample. At the time of detection, the group of women (n = 93) and their partners (n = 81) who did not terminate the pregnancy following a diagnosis were included as a comparison group.

METHODS

These women and their partners were asked to complete the Edinburgh Postnatal Depression Scale (EPDS) and the Impact of Events Scale (IES) questionnaires, both at the time of initial detection and at 6 weeks after the termination of the pregnancy.

MAIN OUTCOME MEASURES

Responses to the EPDS and the IES at the time of initial detection and at 6 weeks after pregnancy termination.

RESULTS

Women who underwent pregnancy termination reported higher symptom levels of depression, but not traumatic stress, prior to the termination than women who chose not to terminate their pregnancy. Among men, there was a difference across depression and all subscales of traumatic stress (e.g. IES intrusion: mean difference 5.31; 95% CI 2.32-8.31). Women experienced more depressive symptoms over time than men (β = 4.33, P < 0.001) and higher symptom levels on all subscales of traumatic stress (e.g. IES intrusion: β = 5.27; P < 0.001).

CONCLUSIONS

Overall, our study underscores the heightened levels of depression and traumatic stress experienced by prospective parents, particularly prior to the decision to terminate a pregnancy following the detection of a fetal anomaly. Although women generally report more pronounced symptoms, it is noteworthy that men also experience considerable traumatic stress during this challenging time.

Impact of a Potential 20-Week Abortion Ban on Likelihood of Completing Required Views in Second-Trimester Fetal Anatomy Ultrasound

OBJECTIVE

The aim of this study was to quantify the likelihood of assessing all mandated fetal views during the second-trimester anatomy ultrasound prior to the proposed federal 20-week abortion ban.

STUDY DESIGN

Retrospective cohort study of a random sample of 1,983 patients undergoing anatomy ultrasound in 2017 at a tertiary referral center. The difference in proportion of incomplete anatomic surveys prior compared with after 20-week gestation was analyzed using X 2 and adjusted logistic regression; difference in mean days elapsed from anomaly diagnosis to termination tested using t-tests and survival analysis.

RESULTS

Incomplete views were more likely with initial ultrasound before 20 weeks (adjusted relative risk: 1.70; 95% confidence interval: 1.50-1.94); 43.5% versus 26.1% were incomplete before and after 20 weeks, respectively. Fetal structural anomalies were identified in 6.4% (n = 127/1,983) scans, with 38.0% (n = 49) identified at follow-up after initial scan was incomplete. 22.8% (n = 29) with an anomaly terminated.

CONCLUSION

A complete assessment of fetal views during an anatomy ultrasound prior to 20-week gestation is often not technically feasible. Legislation limiting abortion to this gestational age would greatly impact patient's ability to make informed choices about their pregnancies.

KEY POINTS

· It is often not technically possible to complete anatomy ultrasound prior to 20-week gestation.. · Often, anomalies are missed during early, incomplete anatomy ultrasounds.. · After the diagnosis of a structural anomaly, one in five chose to terminate the pregnancy..

Labour induction for termination of pregnancy with severe fetal anomalies after 24 weeks' gestation: a case series and systematic review of the literature

PURPOSE

Under some circumstances, individuals choose to undergo pregnancy termination for foetal anomalies in the second half of pregnancy. This report provides objective information on the clinical management of such cases and a systematic review of the literature on labour induction outcomes for third-trimester abortion using mifepristone-misoprostol.

MATERIALS AND METHODS

The study is a case series describing outcomes for labour induction abortion for foetal anomalies, at gestational age 24 weeks and beyond. A systematic review was performed, searching PubMed, Embase, and Cochrane databases. Two independent authors reviewed and quality assessed the data from the articles.

RESULTS

During a two-year period, 15 patients met inclusion criteria. Fourteen patients received mifepristone and misoprostol, and one received oxytocin. All delivered vaginally. Thirteen patients delivered within 24 hours of the first misoprostol dose, and half delivered within 12 hours. The average interval from misoprostol initiation to foetal expulsion was 15.5 hours in our series. The systematic review identified nine articles for inclusion, all retrospective studies. Labour induction protocols for mifepristone-misoprostol, reporting of gestational age, and key comparisons varied greatly.

CONCLUSIONS

The case series illustrates successful termination of pregnancy primarily using combined mifepristone-misoprostol. Certainty of current evidence is low, based on the GRADE framework. Future research is necessary on third-trimester outcomes with mifepristone-misoprostol.

Evaluation of prenatal central nervous system anomalies: obstetric management, fetal outcomes and chromosome abnormalities

Objective

To study the outcomes of fetuses who were diagnosed with central nervous system (CNS) anomalies during prenatal period and to describe the obstetric management of those pregnancies.

Methods

In this retrospective study, fetuses who were detected to have central nervous system anomalies by prenatal ultrasound from January 2010 to December 2019 were recruited. Data regarding prenatal diagnosis and obstetric outcomes were retrieved from maternal and paediatric records. The prognosis of fetuses who were born alive was classified based on their neurodevelopmental outcome within two years of life.

Results

There were a total of 365 fetuses with CNS anomalies within the 10-year study period, with a mean gestational age of 24.65±7.37 weeks at diagnosis. Ventriculomegaly (23.36%) was the commonest CNS anomalies seen. 198 (54.20%) of these fetuses had associated extra-CNS anomalies, with cardiovascular being the most common system involved. Fetal karyotyping was performed in 111 pregnancies, with chromosomal aberrations detected in 53 (49.07%) cases and culture failure in 3 cases. Majority of the chromosomal abnormalities were Edward syndrome (trisomy 18) and Patau syndrome (trisomy 13). Fetuses with congenital CNS anomalies and abnormal chromosomal karyotyping were more likely to be diagnosed earlier by prenatal ultrasound and tend to have poorer obstetric and neurocognitive prognosis. Prenatally, 86 (23.56%) of the cases were lost to follow up and likely to deliver elsewhere. Among the 279 cases whom their pregnancy outcomes were available, 139 (49.82%) pregnancies resulted in live births, 105 (37.63%) pregnancies were electively terminated, while the remaining 35 (12.54%) pregnancies ended in spontaneous loss. The decision of termination of pregnancy largely depends on mean diagnostic gestational age, presence of chromosomal aberrations and abnormal amniotic fluid volume in those fetuses. Two years after delivery, only 75 (53.96%) children out of 139 live births were still alive, 43 (30.93%) died and 21 (15.11%) cases were lost to follow-up. 32 (23.02%) children with prenatally diagnosed CNS anomalies had normal neurodevelopmental outcome. The presence of multiple CNS anomalies and involvement of extra-CNS anomalies indicated a poorer neurodevelopmental prognosis.

Conclusion

Less than 50% of fetuses with prenatally diagnosed CNS anomalies resulted in live births. Even if they survive till delivery, 36.45% of them passed away within 2 years and 62.79% of children who survived till 2 years old had neurodevelopmental disability.

Delivery after fetal death in women with earlier cesarean section. A review

The clinical management of intrauterine fetal demise (IUFD) in women with a previous cesarean delivery presents a dilemma for the obstetrician. With the current reluctance of obstetricians to perform vaginal birth after cesarean (VBAC) and the paucity of data to counsel women regarding maternal risks, management options are limited by physician's clinical experience and biases. In the setting of fetal demise, maternal safety becomes the primary concern. Medicolegal pressures may prevent physicians from attempting a trial of labor in this situation. In this review we will a focus on frequency of birth with IUFD after cesarean section (CS), we discuss the options (VBAC vs CS), different complications, methods for induction of vaginal birth as well as risk factors of vaginal birth and cesarean delivery.

Evolution of third-trimester pregnancy terminations in France

OBJECTIVE

To study changes in the reasons for third-trimester termination of pregnancy (TOP) for fetal anomalies over a 20-year period in France.

STUDY DESIGN

We compared a consecutive series of third-trimester TOPs from a single centre in 2005-2014 to those performed by Dommergues et al. in a similar centre in 1986-1994, using the same criteria.

MAIN OUTCOME MEASURES

The process leading to late TOP, using the same categories in both studies.

RESULTS

In the present series, 205 of 1409 TOPs were performed in the third trimester, vs. 305/956 in the historical series. There were 33 (16.1 %) diagnoses missed at the screening before the third trimester, 55 (26.8 %) cases in which the anomaly was impossible to diagnose until the third trimester, 86 (42 %) cases in which fetal prognosis could not be established until the third trimester despite earlier diagnosis, 31 (15.1 %) TOPs postponed to allow more time for the women/couples to contemplate, versus respectively 113 (37 %), 55 (18 %), 122 (40 %), and 15 (5%) in the historical series.

CONCLUSION

There was a significant drop in the rate of anomalies missed earlier. The increase in late TOP due to couples requiring additional time for contemplation might result from changes in counselling processes.

Retrospective analysis of indications for termination of pregnancy

This is a retrospective study of 139 termination of pregnancies (TOPs) between November 2015 and November 2017 to demonstrate the indications. We have shown that 60.4%, 34.5% and 5% of the terminations were performed because of genetic disorders, foetal or obstetrical problems, and maternal causes, respectively. Congenital abnormalities (43.8%), anhydramniosis (17.2%) and chromosomal abnormalities (15.1%) were the most frequent causes of the TOPs. The central nervous system seemed to be the most frequent indicator found in our study. The critical finding is the presence of nine (6.4%) terminations because of foetal reasons beyond the 24th gestational week. A vaginal termination occurred in 91.4% of cases, whereas a hysterotomy was performed in 8.6% of the cases. Previous uterine surgery was the most significant risk factor for a hysterotomy. Knowing the foetal indications is essential to know the aetiological and medico-legal backgrounds of the TOPs for better planning and medical counselling. Impact statement What is already known on this subject? Congenital anomalies are most common cause of termination of wanted pregnancies. Terminations beyond 24 weeks are also evaluated as unethical and create an ethical concern. The legal limitations differ between countries in terms of the legal limit in pregnancy for terminations. What do the results of this study add? We have demonstrated the congenital anomalies are the most common reason for pregnancy terminations after excluding fetal demise and unwanted pregnancies. We also showed that congenital anomalies and chromosomal abnormalities are most common indications for terminations of pregnancies beyond 24 weeks. The legal arrangements related to the termination of pregnancies in Turkey are described. Prior uterine surgery is a significant risk factor for hysterotomies in the termination of pregnancies. What are the implications of these findings for clinical practice and/or further research? It is critical to know the aetiological background of termination of pregnancies for better planning and consultation.

Termination of pregnancy following prenatally diagnosed central nervous system malformations

PURPOSE

To analyze fetal cerebral malformations with late termination of pregnancy (TOP) and to evaluate the rate of cases that could have been detected earlier using international recommended requirements of sonographic examination of the fetal central nervous system (CNS).

MATERIALS AND METHODS

Cases of singleton pregnancies above 18 + 0 weeks of gestation ending in late TOP due to fetal CNS malformations between 2002 and 2011 were retrospectively reviewed. The cases were divided into isolated and non-isolated cerebral malformations. Prevalence and timing of TOP were assessed relative to the identified malformations.

RESULTS

During this 10-year period, 212 (20.8%) out of 1017 late TOPs were performed in pregnancies with fetal cerebral malformations. 59 cases were excluded because of chromosomal anomalies. 86 (56.2%) of the remaining 153 cases were isolated cerebral malformations while 67 (43.8%) were non-isolated. TOP after viability (≥ 24 + 0 weeks of gestation) was performed in 61.4% (94/153). Substantial morbidity (n = 80; 52.3%) and mental retardation (n = 33, 38.4%) made up the leading prognostic groups. In about 80% of detectable anomalies, diagnosis of CNS malformation could have been made earlier by following international guidelines of fetal CNS examination at second trimester scan.

CONCLUSION

General implementation of ultrasound screening in maternity care can significantly reduce the number of late TOPs in Germany.

The Experience of Genetic Counselors Working with Patients Facing the Decision of Pregnancy Termination after 24 Weeks Gestation

Prenatal genetic counselors are health care professionals who counsel women making reproductive decisions which include decisions such as terminating pregnancies due to fetal anomalies. Little is known about the experiences and practices of prenatal genetic counselors working with women who have the option of termination after 24 weeks gestation. In this national survey of 168 genetic counselors who have practiced prenatal genetic counseling, we asked about their general practice patterns, including indications for which termination is offered and types of abortion care services that are coordinated by genetic counselors. We report respondents' self-assessments of level of understanding of federal abortion law and abortion procedures. Seventy-six percent of respondents have offered and counseled on termination after 24 weeks and 93% of respondents believe it is the responsibility of the counselor to discuss this option with patients. However, one-third report that they have some or no understanding of the procedures and three-quarters report that they have some or no understanding of federal abortion law. The results of this study provide insight into knowledge and experiences of genetic counselors working with these patients, allowing for improved genetic counselor training and continuing education to provide better guidance and develop more effective means of assisting patients.

[Ultrasound screening for birth defects: A medico-economic review]

OBJECTIVES

The systematic use of ultrasound during pregnancy aims at birth defect detection. Our objective was to assess the economic efficiency of prenatal ultrasound screening for fetal malformations.

METHODS

We carried out a literature review on Medline via PubMed between 1985 and 2015, from the economic perspective of the prenatal ultrasound screening for fetal malformations.

RESULTS

The literature on this subject was sparse and we selected only twelve articles presenting relevant economic data, of which only eight were proper medico-economic studies. We found arguments for the economic effectiveness of ultrasound screening for fetal malformation detection, which is largely linked to the terminations of pregnancies and to the cost of the handicaps "avoided". However, none of the reviewed articles could reach medico-economic conclusions. Additionally, we highlighted various elements making economic analyses more complex in this field: the choice of the method, the uncertainty around two essential parameters (the efficiency of ultrasound and the costs of procedures) and the difficulties to compare or to generalize results. We also noticed important methodological heterogeneity among the studies and the absence of French study.

CONCLUSIONS

Previously published data are insufficient to assess the economic efficiency of prenatal ultrasound screening for fetal malformations.

Spinal cord malformations

Malformations of the spinal cord are one of the most frequent malformations. They should be clearly divided into two completely different families of malformations: open dysraphisms and occult dysraphisms. Open dysraphism mostly consists in myelomeningocele (MMC). Its incidence is 1/1000 live births with a wide variation. Folic acid supplementation has been shown to reduce its risk. In most cases, the diagnosis is done prenatally by serum screening and ultrasound and may lead to termination of pregnancy. In case of decision to continue pregnancy, surgical treatment must be achieved during the first days of life, and in 50 to 90% of cases, a ventricular shunt must be installed. The follow-up of these children must be continued throughout life looking for late complications (Chiari II and syringomyelia, vertebral problems, neuropathic bladder, tethered cord). Occult dysraphisms are a heterogeneous group of malformations. Lipomas (filum and conus) are the most frequent and their treatment remains controversial. Diastematomyelia, neurenteric cysts, dermal sinus, and more complex forms (Currarino syndrome) belong to this group. Most of them can and must be diagnosed prenatally or at birth by careful examination of the lower back for the cutaneous stigmata of the disease to decrease the risk of neurological, urological, or orthopedic permanent handicap.

Clinical and socioeconomic predictors of pregnancy termination for fetuses with congenital heart defects: a population-based evaluation

OBJECTIVES

This study aims to (1) evaluate the probability and timing of termination of pregnancy for fetal anomaly (TOPFA) for all congenital heart defects (CHD) and categories of CHD and (2) assess clinical and socioeconomic predictors of TOPFA for isolated CHD excluding ventricular septal defects (VSD).

METHODS

Using population-based data from the Paris Registry of Congenital Malformations, we assessed the probability of TOPFA and gestational age at TOPFA. We used logistic regression to estimate the adjusted effects of maternal characteristics, clinical factors (CHD type, fetal growth restriction, nuchal translucency measurement and gestational age at prenatal diagnosis) on the odds of TOPFA.

RESULTS

The proportion of TOPFA for prenatally diagnosed CHD was 46% for all CHD combined, 82% for CHD associated with chromosomal anomalies and 27% for isolated CHD-VSD excluded. Isolated CHD-VSD excluded diagnosed before 22 weeks of gestational age had a 3.2-fold higher odds of TOPFA (adjusted OR 3.2, 95%CI 1.4-7.1). Maternal occupation was not associated with the odds of TOPFA. Women of African origin had a tenfold lower odds of TOPFA than women of French origin (adjusted OR 0.1, 95%CI 0.02-0.4).

CONCLUSION

In addition to severity of CHD, early prenatal diagnosis and maternal characteristics were highly associated with the probability of TOPFA for CHD.

Prevalence and distribution of congenital abnormalities in Turkey: differences between the prenatal and postnatal periods

The aim of this study was to determine the distribution of cases associated with congenital abnormalities during the following three periods: pregnancy, birth, and the neonatal period. This was a retrospective study of cases between 2002 and 2006. All abnormal pregnancies, elective terminations of pregnancies, stillbirths, and births with congenital abnormalities managed in the Neonatology Unit were classified based on the above distribution scheme. During the 5-year study period, 1906 cases with congenital abnormalities were recruited, as follows: 640 prenatally detected and terminated cases, with most abnormalities related to the central nervous system, chromosomes, and urogenital system (56.7%, 12.7%, and 8.9%, respectively); 712 neonates with congenital abnormalities (congenital heart disease [49.2%], central nervous system abnormalities [14.7%], and urogenital system abnormalities [12.9%]); and hospital stillbirths, of which 34.2% had malformations (220 prenatal cases [34.4%] had multiple abnormalities, whereas 188 liveborn cases [26.4%] had multiple abnormalities). The congenital abnormalities rate between 2002 and 2006 was 2.07%. Systematic screening for fetal anomalies is the primary means for identification of affected pregnancies.

Prenatal testing for Down syndrome: comparison of screening practices in the UK and USA

Prenatal testing for Down Syndrome is a topic covered in every genetic counselor's training as it constitutes the main workload of genetic counselors in prenatal settings. Most Western countries nowadays offer some type of testing for Down Syndrome. However, practices vary according to country with regards to what tests are offered, insurance coverage and the legal situation concerning the option of terminating an affected pregnancy. In view of the growing interest in international genetic counseling issues, this article aims to compare prenatal testing practices in two English-speaking countries: the United Kingdom and the United States of America. A case will be presented to highlight some of the differences in practice. The topic underlines important implications for genetic counseling practice, such as patients' understanding of testing practices, risk perception, counseling provision and impact of prenatal testing results.

Understanding feticide: an analytic review

The medical procedure of 'feticide' has been used in clinical practice since the early 1990s in the UK. The procedure constitutes a sensitive aspect of late termination of pregnancy (TOP), an issue that is in itself contentious. The procedure has attracted attention from academic and policy commentators, but recently the medical profession has expressed some uncertainty with respect to the legal position of live birth following TOP, and professional discretion in providing feticide. To understand the meaning of these comments better, we argue that it is helpful to acknowledge the rhetoric that shapes the academic discourse on feticide. In this paper, we review how feticide has been conceptualised within academic discourse, demonstrating that the concept has multiple meanings, some of which could be considered politically charged. We then consider some examples of the comments made about the legal uncertainties of feticide, highlighting assumptions made about the problematic nature of professional discretion. Ultimately, we suggest that a better understanding of the context of feticide is needed to ensure that future research in this area of health care engages adequately with issues of professional discretion.

Termination of pregnancy for fetal anomaly

OBJECTIVES

To assess the indications of termination of pregnancy (TOP) for fetal anomaly beyond 22 weeks of gestation.

METHODS

All pregnant women who underwent TOP for fetal anomaly between January 2002 and December 2006 were divided into 2 groups: group 1 (< or =22 weeks of gestation); and group 2 (>22 weeks of gestation). A comparative analysis of the prenatal diagnosis, established by ultrasound, and the results of postmortem findings was performed.

RESULTS

There were 249 (53.8%) and 214 (42.6%) cases in group 1 and group 2, respectively. TOP was performed at a mean gestational age of 22.1+/-5.37 weeks. The majority of group 2 TOPs (78%) were performed because of central nervous system defects, multiple malformations, and chromosomal diseases.

CONCLUSION

A substantial proportion of TOPs for fetal anomaly beyond 22 weeks of gestation could have been performed earlier with timely diagnosis.

Is there a role for psychiatry in late termination of pregnancy?

The aim of the present review was to explore the role of the psychiatrist in late terminations of pregnancy. A literature review was conducted using MEDLINE and psycINFO databases, focussing on articles that explored (i) existing decision-making processes in late terminations; (ii) psychological sequelae of both early and late termination of pregnancy; (iii) the role of psychiatry in both early and late termination of pregnancy; and (iv) the involvement of psychiatry in complex medical decisions. The decision to perform a late termination of pregnancy is complex. Contributing to its complexity is an array of political, legal, societal, and ethical factors. The literature regarding psychological sequelae is frequently confusing and weakened by methodological problems. Methods of assisting in this decision-making process include the involvement of committees and psychiatrists. There are precedents for the involvement of psychiatrists in such a setting. Historically, psychiatrists played a role in screening women who requested an early termination. Psychiatrists are often involved in ethically challenging and complex clinical decisions in the general hospital setting. The involvement of psychiatry in this complex decision-making process has potential advantages and disadvantages. It is timely for psychiatrists to consider their position on their discipline's involvement.

Evaluation of 2407 fetuses in a Turkish population

OBJECTIVES

Congenital anomalies and intrauterine fetal death (IUFD) are frequent problems in pregnancies. Detection of the etiology is important for genetic counseling, and presenting the geographic distribution of the causes of disorders is necessary for a national policy on precautions. Here, we report the findings of terminated fetuses due to IUFD and congenital anomalies in Turkish population.

METHODS

Physical examinations of fetuses and genetic evaluations of families were done. X-ray studies and autopsy were done in the event of necessity. Findings of these studies were combined with prenatal ultrasound results. All cases were classified according to ICD-10.

RESULTS

The number of fetuses examined was 2407. Out of these, 1268 fetuses had congenital anomalies. Neurologic anomalies and musculoskeletal system malformations were the most frequent disorders. Specific diagnoses were possible in 64% of all multiple malformation syndromes. Abnormal findings were detected in 18.8% of IUFD fetuses. Nine percent had congenital anomalies and 5.2% had cord complications. The percentage of twins and triplets was 7.5% and 13% of them had anomalies.

CONCLUSION

Postmortem evaluation is useful to detect findings necessary for genetic counseling. Our protocol is effective especially in fetuses with congenital anomalies but it can detect only some of the fetal reasons in IUFD cases. A more detailed protocol is needed to investigate IUFD cases.

Fetal abnormalities leading to termination of singleton pregnancy: the 7-year experience of a single medical center

OBJECTIVE

To assess the distribution of fetal indications leading to termination of pregnancy (TOP) in our institute.

METHODS

All pregnant women with singleton pregnancies who underwent TOP due to fetal abnormalities in our institute between January, 1998 and December, 2004 were divided between early TOP (<23 weeks' gestation) and late TOP (> or =23 weeks' gestation).

RESULTS

There were 328 (71%) and 134 (29%) early and late TOPs, respectively. The TOPs were performed at a mean gestational age of 20.1 +/- 4.8 weeks. The groups varied significantly in the indications for TOP (p = 0.04), which were primarily structural abnormalities (mostly CNS) followed by chromosomal/genetic defects. Fetal structural abnormalities were more common in the late TOP group (62.7% vs 54.2%) while chromosomal-genetic defects were more common in the early TOP group (40% vs 29.1%, respectively). Fetal infection (mostly cytomegalovirus) was similar ( approximately 4%) for both groups. The early TOP group had significantly more hydrops, gastrointestinal, face and neck abnormalities, while the late TOP group had significantly more cardiovascular abnormalities (p < 0.01).

CONCLUSIONS

The impact of early chromosomal/genetic screening contributes to early TOPs, while midgestation anomaly and cardiac scanning significantly contribute to late TOPs. Fetal infection contributes equally to both categories of TOPs.

Termination of pregnancy for fetal neurological abnormalities

INTRODUCTION

Prenatal screening for fetal abnormalities may identify conditions likely to result in perinatal death or in survival with a risk of handicap, for which termination of pregnancy is legal in many countries.

DISCUSSION

When considering termination of pregnancy, it is crucial that prenatal diagnosis be as accurate as possible and that the prognosis of the condition diagnosed in utero is thoroughly understood by the parents. Our ability to predict postnatal outcome in borderline cases should not be overestimated. Parents should not precipitate their decision, and in some European countries, the absence of a gestational age limit at which a termination may be performed is viewed as a guarantee against hasty terminations. Maternal morbidity potentially associated with termination should be kept as low as possible. This includes maternal analgesia, and avoiding uterine trauma to preserve fertility and to prevent obstetrical complications in subsequent pregnancies. Bereavement should also be taken into account. Tests that could contribute to confirming the diagnosis or to establishing the aetiology of the abnormality, such as fetal karyotype or platelet count, should be implemented when appropriate, since post-termination genetic counselling relies on such data. Post-mortem examination is often crucial for genetic counselling and should include X-rays and gross examination of the fetus as well as brain and spine examination by a neuropathologist with expertise in the field of fetal medicine. Specific post-mortem procedures sometimes need to be planned before termination, for instance, in fetal akinesia sequence. First trimester surgical techniques and second or third trimester medical techniques of termination of pregnancy are reviewed.

Target-controlled sedation-analgesia using propofol and remifentanil in women undergoing late termination of pregnancy

Twenty-one women undergoing termination of pregnancy for severe fetal abnormality received remifentanil and propofol using a target-controlled infusion system and were studied prospectively. Target concentrations were initially set at 1 ng.mL(-1) for remifentanil and 0.8 microg.mL(-1) for propofol. Remifentanil concentration was adjusted to obtain visual analog scores <50 mm with preservation of ventilation. Visual analog scores assessed by the patients and physiologic data were recorded every 15 min until delivery. The median duration of administration was 150 min [10th-90th centiles: 42-282 min). Visual analog scores decreased within the first 5 min (P < 0.05) and remained under 50 mm for 91.7% of time. The median rate of infusion of remifentanil was 0.056 microg.kg(-1) min(-1) [10th-90th centiles: 0.037-0.15 ng.mL(-1)]. At delivery, the median target concentration was 2.2 ng.mL(-1) [10th-90th centiles: 1.25-4 ng.mL(-1)] for remifentanil and 0.8 microg.mL(-1) [10th-90th centiles: 0.32-1.12 microg.mL(-1)] for propofol. Remifentanil requirements were statistically correlated to gestational age, parity and duration of labor. No episodes of ventilatory depression, nausea, vomiting or pruritus were noted. Patients scored analgesia as excellent in 12 cases, good in 7 cases and moderate in 2 cases. Further studies are required to determine the place and the best regimen of remifentanil infusion for pain management in labor in those cases when epidural analgesia is contraindicated.

Prenatal sonographic findings of thalamic cavernous angioma

A cavernous angioma of the thalamus is a rare congenital brain tumor. We report the perinatal management and follow-up to 2 years in a case diagnosed in utero at 37 weeks of gestation, and review the literature.

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.