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

OBJECTIVES: 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. METHODS: Statistical analysis comprised basic statistical tests, Pearson's χ2 test, and logistic regression. Counselling was evaluated by two fetal health specialists. RESULTS: The counselling process was found to be 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. CONCLUSION: The evaluation of the counselling as minimal in 42% of cases and the high prevalence of complicated bereavement call for quality improvement 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.

Changes in perinatal hospital deaths occurring outside the neonatal intensive care unit over a decade.

AIM: Perinatal deaths occurring outside the neonatal intensive care unit (NICU) are rarely recorded in outcome studies, despite having a direct impact on perinatal statistics. Our aim was to investigate the timing and modes of perinatal deaths that occurred outside the NICU and changes over time. METHOD: We reviewed all perinatal deaths from 22 weeks of gestation onwards, without NICU admissions, during two periods in a Canadian tertiary mother and baby hospital and categorised deaths according to nine specific categories. RESULTS: There were 444 perinatal deaths that satisfied the inclusion criteria. The total number of perinatal deaths increased from 2000 to 2002 (n = 197) and 2007 to 2010 (n = 247). The proportion of foetuses alive at the time of their mother's hospital admission, but then stillborn, decreased. There was a significant increase in terminations for congenital anomalies in the second cohort and a decrease in deaths following induction of labour and comfort care for foetal anomalies. CONCLUSION: Approaches to end-of-life care changed between the two study periods. Paediatricians should be aware of the epidemiology of perinatal mortality in their own practice, as it has a direct impact on the denominator in NICU outcome studies.

Association between Fetal Cerebral Ventriculomegaly and Platelet Alloimmunisation.

INTRODUCTION: Fetal and neonatal alloimmune thrombocytopenia (FNAIT) is a rare condition that may lead to intracerebral haemorrhage (ICH) in the fetus or neonate. Platelet alloimmunisation causing FNAIT has been described in association with fetal cerebral ventriculomegaly (VM), presumably due to subclinical ICH. The objective of this study was to assess the association between fetal VM and platelet alloimmunisation. METHODS: This is a case series of pregnancies with fetal VM screened for platelet alloantibodies from 2003 to 2012. Cases of multiple pregnancies, structural anomalies, aneuploidies, or congenital infection were excluded. RESULTS: Of 45 pregnancies with fetal VM that were screened for platelet alloantibodies, 5 (11%) were positive. There was only one antenatal ICH, with confirmed fetal severe thrombocytopenia before termination of pregnancy. The other cases were treated with intravenous immunoglobulins without prior fetal blood sampling. No other case of neonatal thrombocytopenia was confirmed. CONCLUSIONS: The prevalence of platelet alloimmunisation was high in this series of fetal VM. Prospective large studies are needed to confirm the role of platelet alloimmunisation in fetal VM.

First-trimester prediction of birth weight.

OBJECTIVES: To determine whether the parameters used in first-trimester screening for aneuploidies contribute significantly to the prediction of birth weight. METHODS: In this retrospective cohort study (n = 4110), nuchal translucency (NT), free ß-chorionic gonadotropin (fß-hCG), and pregnancy-associated plasma protein-A (PAPP-A) blood concentrations were measured between 11 + 0 and 13 + 6 weeks. Multiple pregnancies, chromosomal anomalies, major fetal defects, and deliveries before 24 weeks were excluded. RESULTS: NT (0.95 versus 0.98 multiples of the expected median [MoM], p < 0.001) and PAPP-A (0.93 versus 1.06 MoM, p = 0.005) were significantly lower in small-for-gestational-age (SGA) newborns (<10th percentile) than the unaffected group, but not fß-hCG (0.89 versus 0.93 MoM, p = 0.113). NT was significantly higher (1.03 versus 0.98 MoM, p < 0.001) in the large-for-gestational-age (LGA) group (>90th percentile) compared with the unaffected group, and biomarkers did not differ. After controlling for gestational age, maternal weight, smoking status, ethnicity, and fetal sex, first-trimester markers contributed to the prediction of birth weight in a multiple linear model but did not significantly improved the prediction of SGA and LGA compared with maternal characteristics alone. CONCLUSIONS: Parameters used in first-trimester screening for aneuploidies contribute to the prediction of birth weight but their clinical utility to detect women at risk of SGA or LGA baby is limited.

Singleton breech at term: two continents, two approaches.

Breech presentation is a complication in 3% to 4% of singleton pregnancies at term. On the strength of a large study published in the early 2000s, the American College of Obstetricians and Gynecologists (ACOG) recommended Caesarean section be routinely performed in such cases. However, French gynaecologists continue to perform vaginal breech deliveries. Through various observational studies, they have shown that their management approach, although different from the one used in North America, is safe. In 2006, the ACOG declared that vaginal delivery of a breech presentation may be acceptable under specific circumstances. In this analysis, we compare North American and French practices and present a protocol of care for the management of term breech presentation based on French recommendations.

Perinatal listeriosis: Canada's 2008 outbreaks.

BACKGROUND: Listeriosis is one of the most severe foodborne illnesses worldwide. Most infections with Listeria are sporadic, but outbreaks do occur. Pregnant women exposed to this organism are at increased risk of chorioamnionitis, preterm labour, prematurity and intrauterine fetal demise. Severe neonatal infection can also occur. CASES: Two recent outbreaks in Canada prompted a reassessment of the prevalence and the perinatal impact of this disease. We describe here three cases of perinatal listeriosis. The aim of our report is to demonstrate the variable clinical presentations and to emphasize the difficulty in diagnosing perinatal listeriosis. CONCLUSION: Perinatal listeriosis is a severe disease with many possible clinical presentations. Clinical diagnosis may be difficult, so clinicians must maintain a high index of suspicion.