Fetal abnormality Flashcards
What do we use for diagnosis in pregnancy?
Early scan NIPT CVS or Amniocentesis Anomaly scan (20/40) USS following reduced fetal growth concern At time of fetal death
What are some fetal abnormalities that may not be demonstrable at 23 weeks?
Renal Diaphragmatic hernia Congenital heart disease:-vsd, asd, pulmonary /aortic Stenosis, coarctation, microcephaly Dwarfism Cleft palate Hydrocephalus (if minor) oesophageal/dudenal/anal atresia Skin condition
What SHOULD we examine in 3rd Trimester?
Growth-AC/HC/FL/ Exclude IUGR/macrosomia Can detect dwarfism/microcephaly EFW Liquor Volume Placental site Brain /heart / stomach kidneys/ bladder /bowel
What some parental responses to fetal compromise?
Anxiety which is compounded by having to wait for results
Shock – most parents enter screening as though it is routine and are totally unprepared for a high risk result (Pilnik et al 2004) and unless diagnosis follows referral for a high risk screening result parents are unprepared for bad news
Poor growth does not normally suggest death to parent
Most women aren’t expecting to see abnormalities in scan, focused on getting nice photos of baby
Scans seen as a way to see the fetus and even if possibility of Down’s syndrome is considered women rarely aware that other fetal problems or death may be detected, therefore profound shock
If pregnancy continues in the presence of high risk scores or diagnosis - prenatal grief
An ongoing pregnancy where the outcome is uncertain is stressful and can affect other children
Grief and loss if the pregnancy ends in TOP or IUD
What were the paternal responses in the (Locock and Alexander 2006) study?
Decision for screening often made without consulting partner although partner generally present at scan
Men felt they were bystanders – not offered a chair in scan. (Excluded from decisions legally)
Protector and supporter – assuming role of communicator if woman is distressed or deciders and enforcers once joint decision made
Gatherers and guardians of facts
Grieving parents
Breaking bad news
If the baby has a problem which may lead to TOP or early delivery with poor chances of survival the mother has to make a rapid decision
The person breaking the bad news must be aware of the clear meaning of any results and what options are available. The trust screening midwife and neonatologist/paediatrician/obstetrician may do this
The genetic counselling team may be involved
Fragmentation of birth
Referral to fetal medicine unit
Becoming high risk
Changing booking to a hospital with NICU/paediatric surgery
Termination? (Ground E, Abortion Act, 1967, TOPFA)
Who should co-ordinate this care?–Screening midwife?–ANC sister?–The lead midwife they already know?
What are some unexpected anomalies found at birth?
Even with new better scans some problems are missed, occasionally major ones
Most commonly discovered at birth are missing or extra digits and tiny cleft palates
Also anal atresia, tiny umbilical hernias and unclear genitalia may have been missed
Birth mark
What is involved in telling parents in relation to obvious defects at birth?
As soon as possible Preferably both parents together - if not NEVER leave mum to tell dad Gentle introduction Let parents unwrap baby in their own time Clear explanation from a qualified professional as soon as possible Ensure no conflicting advice If available and appropriate offer : –before and after pictures –contact with a family affected –contact with support groups –support from experts in the field –any positive information
Possible defects
Have baby examined by a paediatrician as soon as possible
No whispering around corners
Debate on when mother should be told of suspicions - immediate - after getting to know baby
Tests on baby can only be done with informed consent
Some conditions are not apparent at birth
Some conditions cannot be easily diagnosed
Accurate information about prognosis, support, problems etc.
What are some parental reactions at birth?
Shock
Anger - self, spouse, hospital especially if defect missed prenatally
Guilt
Fear - of handicap, of family, of future coping, of future babies being affected
Revulsion
Shame
Challenge
Pity and protective love
Withdrawal and depression
Panic and confusion
Grief - loss of perfect baby, loss of dreams, maybe loss of baby
How should staff react?
Availability not avoidance
Honesty
Repetition of information as often as is necessary
Non - judgmental about outward response
