Accepting or declining the offer of prenatal screening for congenital defects: test uptake and women's reasons

OBJECTIVES: Prenatal screening for Down syndrome has become standard practice in many western countries. In the Netherlands, however, prenatal screening tests for congenital defects are not offered routinely. The present study aims to assess test uptake in a large, unselected population of pregnant women, and to give more insight into the decision for or against prenatal screening through nuchal translucency measurement or maternal serum screening. PATIENTS AND METHODS: The study is part of a randomized controlled trial with two groups, each being offered a different prenatal screening test, and a control group. Pregnant women received postal questionnaires at three stages of their pregnancy. RESULTS: Of the women being offered the nuchal translucency measurement or the second trimester maternal serum test, 53 and 38% respectively accepted the test offer. The main reasons for accepting were 'gaining knowledge about the health of the foetus/curiosity' (50%), 'favourable characteristics of the screening test' (18%), and 'increased risk of having a child with DS' (15%). The main reasons for declining were 'unfavourable characteristics of the screening test' (42%), 'not applicable/not necessary' (35%), 'anxiety/uncertainty' (36%), 'adverse characteristics of the invasive tests' (32%), and 'being against abortion' (15%). DISCUSSION: The uptake of prenatal screening was relatively low, and different distributions of reasons were reported, compared to other studies. These differences may be due to the specific Dutch situation in which prenatal screening is not part of standard prenatal care. The question arises as to whether informed decision-making would be reduced if prenatal screening became routinised.     

A context for HIV testing in pregnancy

The use of the human immunodeficiency virus (HIV) antibody test for women of childbearing age is discussed. Serological tests used to determine HIV status are reviewed. Practitioners should be aware of the legal and ethical issues involved in testing. Psychological responses to knowledge of test results are considered. The goal of the counseling session is to provide sufficient information for the woman to make an informed decision about reproductive choices. The format and content of pre- and post-test sessions are outlined, and checklists that may assist the practitioner in post-test counseling appear in the Appendixes.     

Ten reasons to oppose the criminalization of HIV exposure or transmission

Recent years have seen a push to apply criminal law to HIV exposure and transmission, often driven by the wish to respond to concerns about the ongoing rapid spread of HIV in many countries. Particularly in Africa, some groups have begun to advocate for criminalization in response to the serious phenomenon of women being infected with HIV through sexual violence or by partners who do not reveal their HIV diagnoses to them. While these issues must be urgently addressed, a closer analysis of the complex issues raised by criminalization of HIV exposure or transmission reveals that criminalization is unlikely to prevent new infections or reduce women's vulnerability to HIV. In fact, it may harm women rather than assist them, and have a negative impact on public health and human rights. This paper is a slightly revised version of a document originally released in December 2008 by a coalition of HIV, women's and human rights organizations. It provides ten reasons why criminalizing HIV exposure or transmission is generally an unjust and ineffective public policy. The obvious exception involves cases where individuals purposely or maliciously transmit HIV with the intent to harm others. In these rare cases, existing criminal laws – rather than new, HIV-specific laws – can and should be used.     

Spontaneous abortions in couples declining multifetal pregnancy reduction

Multifetal pregnancy reduction (MFPR) has clearly improved the outcomes of multifetal gestations. Several recent reports have also suggested improved outcomes in nonreduced cases, but there have been methodologic concerns about the denominators, i.e. have all cases been included and is there a 'hidden mortality' of unknown lost cases. Here we assessed the outcome of patients telephoning to discuss MFPR, but who chose not to have the procedure. Over a 3-year period, 446 patients had MFPR by one operator. Nineteen patients chose not to have the procedure. There were 11 preterm births, 1 term delivery, and 5 spontaneous losses (7 of 17) prior to 24 weeks, a loss rate of 35%. Two patients delivering triplets had a loss of 1 fetus/neonate. These data suggest that the loss rates of nonreduced pregnancies may be higher than generally thought, making the improvements with MFPR even bigger than generally realized.     

HIV in pregnancy

Human immunodeficiency virus is becoming increasingly common among childbearing women. Through federally recommended testing programs, obstetricians will soon be identifying pregnant women in their practices who are HIV infected. Hence obstetricians must be prepared to face the social, ethical, and medical dilemmas brought on by HIV infection in pregnancy.     

Prediction of placental abruption by testing for C-reactive protein and chlamydial antibody levels in early pregnancy

Objective  Placental abruption may be a manifestation of acute and chronic inflammatory process. We wanted to assess the association of first-trimester serum C-reactive protein (CRP), Chlamydia pneumoniae antibodies, Chlamydia trachomatis antibodies or chlamydial heat-shock protein 60 (CHSP60) antibodies to placental abruption.
Design  Retrospective case–control study.
Setting  University Hospital.
Population  A total of 181 women with subsequent placental abruption and 261 control women with normal pregnancy.
Methods  Serum samples collected at first trimester (mean 10.4 gestational weeks) were analysed for CRP levels, C. pneumoniae -specific immunoglobulin G (IgG) and immunoglobulin A (IgA) antibodies and C. trachomatis -specific IgG, IgA and CHSP60 antibodies.
Main outcome measure  Placental abruption.
Results  The levels of CRP showed no difference between the cases and the controls (median 2.35 mg/l [interquartile range {IQR} 1.09–5.93] versus 2.28 mg/l [IQR 0.92–5.01], not significant). C. pneumoniae -specific IgG and IgA as well as C. trachomatis -specific IgG, IgA and CHSP60 antibody frequencies were similar between the groups. There was no association between CRP levels and chlamydial antibodies.
Conclusion  These markers of inflammation in early pregnancy failed to predict subsequent placental abruption.     

HIV in pregnancy

PURPOSE OF REVIEW: This review discusses recent articles on various aspects of the prevention of mother-to-child transmission during pregnancy and delivery. RECENT FINDINGS: Rapid human immunodeficiency virus (HIV) testing of women in labour whose status is not known allows the prompt treatment of mother and baby to reduce transmission risk. The feared clinical resistance in the mother after treatment with a single dose of nevirapine has been confirmed. Strategies are required to minimize this resistance and allow the use of nevirapine for treatment of the mother. There are new findings of mitochondrial toxicity in babies who have been exposed to anti-retroviral medicines during pregnancy or delivery, but the clinical implications are not clear. Long-term follow-up of exposed children is required. Resource-poor countries are starting to use multiple drugs to further reduce transmission to the infant. These efforts are reducing the rates of transmission to the level found in affluent countries. SUMMARY: Improvements in treatment continue to reduce the risk of HIV transmission from mother to child in resource-poor countries, but subsequent maternal resistance continues to be a problem since treatment for the mother's health is now possible. The long-term effects on the infant are still not understood.     

The reasons for termination of pregnancy in the third trimester

Objective To analyse the process in making decisions leading to termination of pregnancy in the third trimester and to evaluate the maternal morbidity associated with this procedure.
Design Retrospective study.
Setting The Maternité Port Royal University Hospital, Paris, France.
Population A consecutive series of 956 terminations of pregnancy performed for fetal anomalies in singleton pregnancies, 305 of which were in the third trimester and 651 in the second.
Main outcome measures Indications for termination of pregnancy; process leading to late termination of pregnancy; maternal morbidity.
Results One hundred and thirteen (37%) third trimester terminations of pregnancy were associated with false negative resulted from the results of earlier screening tests. In 15 terminations (15%), the decision was postponed, although the poor fetal prognosis was established earlier. In 55 (18%) the diagnosis was not possible earlier than the third trimester, and in 122 (40%) the diagnosis was possible earlier but the poor prognosis for the fetus was not established until the third trimester. Maternal morbidity due to termination of pregnancy was similar in the second and third trimester.
Conclusion One-third of late terminations of pregnancy could have been avoided by more efficient screening in the second trimester. However, because fetal prognosis is not always clear when a malformation is diagnosed, postponing the decision until fetal development allows more thorough evaluation and may avoid unnecessary termination of pregnancy in the second trimester. This could be the main beneficial aspect of not setting a limit to the gestational age for performing termination of pregnancy. To analyse the process in making decisions leading to termination of pregnancy in the third trimester and to evaluate the maternal morbidity associated with this procedure. The Maternit6 Port Royal University Hospital, Paris, France.     

Anti-M antibody in pregnancy

Our three cases represent the spectrum of findings when maternal anti-M is present. In the first case, the father's genetic makeup (NN) indicated no disease would occur. In the second case, despite antibody capable of crossing the placenta, the infant did not become sick. In the third case, hemolytic anemia required transfusion of the newborn, despite a negative direct Coombs' (DAT). In summary, anti-M antibody is an uncommon cause of hemolytic disease of the newborn. When anti-M, IgG optimally reactive at 37 degrees C, is identified in the maternal blood, the paternal blood must be checked for the presence of M antigen. If the father has M antigen the fetus may be at risk. Since there is no documented body of experience that titers of anti-M predict severity of disease, our recommendation is that amniotic fluid bilirubin studies be done, in spite of the fact that only one prior case of hemolytic disease due to anti-M was found reported from the United States. Anti-M is an unpredictable antibody and serial antibody titers are not reliable. After delivery the infant's MN antigen status should be determined, because a negative direct Coombs' test may be found even when M antigen is present in the infant and hemolysis is occurring. Further studies are needed to determine the clinical impact of anti-M antibody on unrecognized hemolytic disease of the newborn.     

The reasons for termination of pregnancy in the third trimester.

OBJECTIVE: To analyse the process in making decisions leading to termination of pregnancy in the third trimester and to evaluate the maternal morbidity associated with this procedure. DESIGN: Retrospective study. SETTING: The Maternité Port Royal University Hospital, Paris, France. POPULATION: A consecutive series of 956 terminations of pregnancy performed for fetal anomalies in singleton pregnancies, 305 of which were in the third trimester and 651 in the second. MAIN OUTCOME MEASURES: Indications for termination of pregnancy; process leading to late termination of pregnancy; maternal morbidity. RESULTS: One hundred and thirteen (37%) third trimester terminations of pregnancy were associated with false negative resulted from the results of earlier screening tests. In 15 terminations (5%), the decision was postponed, although the poor fetal prognosis was established earlier. In 55 (18%) the diagnosis was not possible earlier than the third trimester, and in 122 (40%) the diagnosis was possible earlier but the poor prognosis for the fetus was not established until the third trimester. Maternal morbidity due to termination of pregnancy was similar in the second and third trimester. CONCLUSION: One-third of late terminations of pregnancy could have been avoided by more efficient screening in the second trimester. However, because fetal prognosis is not always clear when a malformation is diagnosed, postponing the decision until fetal development allows more thorough evaluation and may avoid unnecessary termination of pregnancy in the second trimester. This could be the main beneficial aspect of not setting a limit to the gestational age for performing termination of pregnancy.     

Moral dilemmas of women undergoing pregnancy termination for medical reasons in Poland

Objectives: We explored the religious views and dilemmas of Polish women making the decision to terminate a pregnancy. The article discusses the highly restrictive legislation and significant influence of the Church on the lives of Polish citizens.

Methods: This study was designed to investigate the effect of religious and political beliefs, social and moral conditioning and professional support on the decision to abort a fetus. A 65-item questionnaire was administered to 60 participants at the time of their pregnancy termination.

Results: Pregnancy termination was performed outside the resident county in 32% of cases. Approximately 88% of respondents declared themselves Catholic, but only 22% intended to admit to the pregnancy termination during confession. Five percent of respondents feared the reaction of the priest, while the remaining respondents did not perceive termination of pregnancy for medical reasons as a sin. Of the women who had previously opposed pregnancy termination, 27% changed their mind once they were personally involved.

Conclusions: The decision to abort a pregnancy for medical reasons is sensitive to religious and social determinants, especially in the current political situation in which abortion may become prohibited in Poland. The high response rate (100%) was probably the result of the patients’ attitudes: they repeatedly emphasised they were thankful for the help and empathy of the medical personnel and for being allowed to undergo the procedure. In Poland, the majority of centres use conscience clauses to justify their refusal to terminate a pregnancy.