Observed to expected lung area to head circumference ratio (O/E LHR) in fetuses with congenital anomalies of the kidney and urinary tract (CAKUT): assessment and evaluation as predictive factor for acute postnatal outcome-a single center study.

Introduction: To assess the observed to expected lung area to head circumference ratio (O/E LHR) in fetuses with congenital anomalies of the kidney and urinary tract (CAKUT) and to explore its value as a potential predictive factor for postnatal outcome. Methods: A retrospective single-center study was conducted on pregnancies complicated by CAKUT between 2007 and 2018. The lung-to-head ratio (LHR) was calculated for each fetus by two independent observers. Correlations between O/E LHR and various perinatal outcome factors were assessed with Spearman's rank correlation. Furthermore, nominal logistic regression was performed to assess O/E LHR as predictive factor for respiratory distress in newborn. Results: Of 64 pregnancies complicated by CAKUT, 23 were terminated. In the 41 cases of continuation of pregnancy, newborn presenting respiratory distress with need for respiratory support in the delivery room showed earlier gestational age at onset of amniotic fluid abnormalities and at birth. Although median O/E LHR and median single deepest pocket (SDP) of amniotic fluid were significantly smaller in newborn that did develop respiratory distress with need of respiratory support in the delivery room, neither O/E LHR nor SDP were accurate predictors for the development of respiratory distress. Conclusions: Our data show that O/E LHR alone cannot serve as a predictive marker for fetal outcome in pregnancies complicated by CAKUT, though it might still be a helpful parameter together with detailed renal ultrasound evaluation, onset of amniotic fluid abnormality and SDP, particularly in its extreme values.

Wave intensity analysis of maternal arterial stiffness: augmentation index and pulse wave velocity in pregnancies complicated by diabetes or hypertension.

PURPOSE: The aim of our study was to compare the maternal arterial stiffness in pregnant women with diabetic disease, hypertension and those with normal pregnancies. METHODS: A cross-sectional study was performed involving 65 pregnant women with diabetic disease (DD group), 26 pregnant women with hypertension (RR group) and 448 women with normal pregnancies (control group). The augmentation index (AIx) and the pulse wave velocity (PWV) of the right carotid artery were assessed using non-invasive sonographic wave intensity analysis. Furthermore, the reliability of the measurements was evaluated in 21 healthy women. RESULTS: Compared with the controls, the AIx and PWV were increased in the DD group [11.0 (interquartile range, IQR 7.3, 15.2) vs. 5.7 (IQR 2.4, 9.3), P < 0.001; 5.7 (IQR 5.1, 6.4) vs. 5.2 (IQR 4.6, 6.1), P = 0.001; respectively] and the RR group [9.3 (IQR 6.6, 11.5) vs. 5.7 (IQR 2.4, 9.3), P < 0.001; 7.1 (6.3, 7.9) vs. 5.2 (IQR 4.6, 6.1), P < 0.001; respectively]. The intraclass and interclass correlation coefficients were good to excellent for the AIx (ICC: 0.91, P < 0.001 and 0.74, P < 0.002; respectively) and PWV measurements (ICC: 0.71, P < 0.004 and 0.70, P < 0.005; respectively). CONCLUSION: Pregnancies complicated by diabetic disease or hypertension are associated with increased maternal arterial stiffness. The importance of wave intensity analysis needs to be verified and larger studies are needed to establish both normal and cutoff values that may be relevant for clinical decisions.

Outcome of fetuses with gastroschisis after modification of prenatal management strategies : Prenatal management and outcome of gastroschisis.

PURPOSE: To improve the outcome of fetuses with gastrochisis several studies evaluated prenatal predictors. But there are different guidelines established and therefore the prenatal care is not standardized. With our study we wanted to evaluate the outcome of fetuses with gastroschisis after modification of prenatal management strategies at the Department of Obstetrics and Gynecology of the University Hospital Münster. METHODS: In this explorative retrospective study of 39 fetuses with gastroschisis, we compare the clinical outcome between two management groups. In the first group (group 1, n = 14) prenatal indication for delivery was confirmed by a subjective evaluation of the small bowel diameter and the wall thickness without established cut-off values for these parameters. In the second group (group 2, n = 25) certain limits for the small bowel diameter (25 mm) and the wall thickness (2.5 mm) were used for fetal surveillance. RESULTS: Noticeable differences between the two groups regarding birth weight, weight centile, arterial pH, small bowel diameter, wall thickness, adverse bowel condition and re-operations could not be observed. In group 2, delivery was earlier (p = 0.011), and a lower rate of prenatal complications was observed (p = 0.016). CONCLUSION: To avoid adverse prenatal complications we recommend the observation of fetuses with gastroschisis by sonographic monitoring of the small bowel diameter and the wall thickness.

Importance of Transvaginal Elastography in the Diagnosis of Uterine Fibroids and Adenomyosis.

PURPOSE: To evaluate normal uterine tissue with special regard to age and the presence of uterine fibroids and adenomyosis with transvaginal elastography. MATERIALS AND METHODS: In a prospective study elastographic data of the uterus were obtained in 206 unselected women with transvaginal ultrasound. Women who presented without any uterine pathology in ultrasonography were included in a control group, women with uterine fibroids in a uterine fibroid group, and women with adenomyosis in an adenomyosis group. In the control group strain values were measured at two regions of interest (ROIs) placed one upon the other in the anterior inferior uterine segment during a cycle of compression. The maximum strain ratio (ROI1 / ROI2) was stored as the "age index". In all groups strain values were measured at two ROIs placed side by side in a uterine fibroid (uterine fibroid group) or adenomyosis (adenomyosis group) or healthy homogeneous tissue (control group) and adjacent healthy tissue. Maximum strain ratios (ROI3 / ROI4) were stored as the "lesion index". RESULTS: The "age index" was significantly negatively correlated with the age of the women (r = -0.49, p < 0.001). The median "lesion indices" were significantly (p < 0.001) different between the uterine fibroid, adenomyosis and control groups. Median "lesion indices" were 2.65, 0.44 and 1.19, respectively. CONCLUSION: The "age index" shows that normal uterine tissue has a certain age-dependent stiffness that increases with age. The "lesion index" allows for the assessment of the presence of a uterine fibroid or adenomyosis and helps to differentiate between both focal findings. Thus the use of elastography in addition to conventional ultrasound could help to diagnose uterine focal lesions and may be useful in preoperative planning.

Disinfection of transvaginal ultrasound probes in a clinical setting: comparative performance of automated and manual reprocessing methods.

OBJECTIVES: Transvaginal and intracavitary ultrasound probes are a possible source of cross-contamination with microorganisms and thus a risk to patients' health. Therefore appropriate methods for reprocessing are needed. This study was designed to compare the standard disinfection method for transvaginal ultrasound probes in Germany with an automated disinfection method in a clinical setting. METHODS: This was a prospective randomized controlled clinical study of two groups. In each group, 120 microbial samples were collected from ultrasound transducers before and after disinfection with either an automated method (Trophon EPR®) or a manual method (Mikrozid Sensitive® wipes). Samples were then analyzed for microbial growth and isolates were identified to species level. RESULTS: Automated disinfection had a statistically significantly higher success rate of 91.4% (106/116) compared with 78.8% (89/113) for manual disinfection (P = 0.009). The risk of contamination was increased by 2.9-fold when disinfection was performed manually (odds ratio, 2.9 (95% CI, 1.3-6.3)). Before disinfection, bacterial contamination was observed on 98.8% of probes. Microbial analysis revealed 36 different species of bacteria, including skin and environmental bacteria as well as pathogenic bacteria such as Staphylococcus aureus, enterobacteriaceae and Pseudomonas spp. CONCLUSIONS: Considering the high number of contaminated probes and bacterial species found, disinfection of the ultrasound probe's body and handle should be performed after each use to decrease the risk of cross-contamination. This study favored automated disinfection owing to its significantly higher efficacy compared with a manual method. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

Diagnosis and Treatment of Hypertensive Pregnancy Disorders. Guideline of DGGG (S1-Level, AWMF Registry No. 015/018, December 2013).

Purpose: Official guideline published and coordinated by the German Society of Gynecology and Obstetrics (DGGG). Hypertensive pregnancy disorders contribute significantly to perinatal as well as maternal morbidity and mortality worldwide. Also in Germany these diseases are a major course for hospitalization during pregnancy, iatrogenic preterm birth and long-term cardiovascular morbidity. Methods: This S1-guideline is the work of an interdisciplinary group of experts from a range of different professions who were commissioned by DGGG to carry out a systematic literature search of positioning injuries. Members of the participating scientific societies develop a consensus in an informal procedure. Afterwards the directorate of the scientific society approves the consensus. Recommendations: This guideline summarizes the state-of-art for classification, risk stratification, diagnostic, treatment of hypertensive pregnancy disorders.

Quantitative elastography of the uterine cervix as a predictor of preterm delivery.

OBJECTIVE: To evaluate the correlation between preterm delivery before 37 weeks of gestation and ultrasound elastography strain measurement of cervical stiffness. STUDY DESIGN: In this prospective study, 182 pregnant women were examined vaginally by ultrasound elastography from a mid-sagittal plane. Cervical length was measured and strain was calculated in four regions of interest on the anterior cervical lip. First, the software was validated by intraobserver variability. Second, strain and strain ratios were calculated with adjusted software presets and correlated to the outcome of spontaneous preterm delivery (sPTD). RESULT: A total of 8928 regions of interest (ROIs) and 6696 ratios were evaluated. The median gestational age at examination was 26 ± 6.1 weeks. A median maternal age of 33 ± 5.6 and a medial parity of 1 ± 0.9 were observed. Intra-Class-Correlation values in validation phase ranged from 0.893 to 0.967. The prevalence of sPTD was 11.9%. Strain ratio Rselective was identified as the best predictor of preterm delivery. Rselective values >0.89 were associated with preterm delivery with a sensitivity of 0.59 and a specificity of 0.86 (odds ratio=1.474 for an increase of 0.1 in Rselective; P=0.002). CONCLUSION: Ultrasound elastography strain measurement of cervical stiffness is correlated with the predictability of preterm delivery.

Human placental transthyretin in fetal growth restriction in combination with preeclampsia and the HELLP syndrome.

Fetal growth restriction is a serious, still poorly understood pregnancy-related pathology often associated with preeclampsia. Recent studies speculate on the role of human transthyretin, a carrier protein for thyroxin and retinol binding protein, in the etiology of both pregnancy pathologies. Objective was to investigate the localization and abundance of transthyretin (TTR) in placentas of pregnancies suffering from fetal growth restriction with and without preeclampsia and HELLP. This was a retrospective case control study on human paraffin-embedded placentas from pregnancies with a gestational age at delivery between the 24th and 34th week of gestation. 16 placentas were included in this study, 11 cases and 5 from normotensive pregnancies as controls. Cases were divided into three groups: four from early onset idiopathic intrauterine growth restriction (IUGR), four from early-onset severe preeclampsia (PE), and three from early-onset IUGR with preeclampsia plus HELLP syndrome. Distribution and abundance of TTR were investigated by means of immunohistochemistry. Semi quantitative analysis of TTR staining of placental sections revealed that TTR was mostly expressed in the villous trophoblast covering placental villi. Only weak staining of TTR in villous stroma could be detected. The comparison of placentas revealed that in pure IUGR and severe PE there is a much stronger TTR reactivity compared to controls and cases with IUGR + PE + HELLP. Concluding, the study showed that TTR is dysregulated in cases of IUGR and severe early onset preeclampsia. Interestingly, TTR expression is not affected in cases with HELLP syndrome that reveal the same staining intensities as age-matched controls.

Reliability of cervix elastography in the late first and second trimester of pregnancy.

PURPOSE: To evaluate the reliability of cervical elastography as a new ultrasound tool for cervical stiffness assessment in pregnancy. MATERIALS AND METHODS: Pilot prospective cohort study including 10 consecutive unselected pregnancies in the late first and second trimester. Ultrasound was performed by two blinded experienced operators using a 9-MHz vaginal probe. One raw dataset per patient was acquired by each operator after two cycles of gentle compression and relaxation of the cervix. Strain values were independently assessed by each operator using commercial offline analysis software (TDI-Q: Tissue Doppler Imaging - Quantification, Toshiba Medical Systems). The interobserver reliability of strain measurements was evaluated using the intraclass correlation coefficient (ICC). RESULTS: The mean ± SD gestational week of the study population was 19 ±â€Š4.1.  Raw data acquirement and strain evaluation were feasible in all ten patients. In total, 40 strain measurements were performed: 20 for each operator (10 for self-acquired raw data and 10 for raw data acquired by the other operator). The mean strain value was 0.33 ±â€Š0.05, the mean of the differences among the measurements was 10.77 % ±â€Š4.41 %. The obtained interobserver ICC agreement values comparing the different subsets of strain measurement ranged between 0.91 and 0.96. CONCLUSION: Late first and second trimester cervical elastography was shown to be feasible and to have a high interobserver reliability. Its clinical value needs to be assessed in further studies on selected obstetric populations.

Sonographic assessment of the extra-abdominal fetal small bowel in gastroschisis: a retrospective longitudinal study in relation to prenatal complications.

OBJECTIVE: An explorative retrospective study following a case-series of fetuses with isolated gastroschisis, to evaluate if small-bowel dilatation may be indicative for emerging obstetric complications. The secondary aim was to establish preliminary normative curves for the external diameter and wall thickness of eventerated fetal small bowel in gastroschisis during the second and third trimester of pregnancy. METHODS AND MATERIALS: Fourteen fetuses with isolated gastroschisis were followed at a single center. Repeated ultrasound examinations for fetal surveillance with measurement of fetal small-bowel diameter and wall thickness over the course of pregnancy until delivery were performed. RESULTS: Longitudinal data analysis showed significantly increasing bowel diameter and wall thickness of eventerated small bowel with advancing gestation. Dilatation of small bowel more than 25 mm in the third trimester of pregnancy was associated with an increased risk of short-term prenatal complications as fetal distress or intrauterine fetal death (PPV 100%; 95% CI: 29.2-100%, NPV 100%; 95% CI: 71.5-100%). CONCLUSIONS: Dilatation of the extra-abdominal fetal small bowel in the third trimester may allow identifying fetuses with increased risk of fetal distress requiring closer monitoring of fetal well-being or delivery in a short interval to prevent impending fetal death.

Is there a seasonal variation in the frequency of gastroschisis?

PURPOSE: There have been conflicting reports on the incidence of gastroschisis and its seasonal variation. Studies have found an increased risk of gastroschisis in deliveries occurring in the winter months in the northern hemisphere. Other studies have not found a seasonal variation. To evaluate the existence of a seasonal variation in the incidence of gastroschisis in our patients, a retrospective database analysis was conducted. MATERIALS AND METHODS: Second and third trimester pregnancy screening was performed on 8031 patients between October 2001 und September 2005. Patients were evaluated throughout the year separately for their expected date of delivery and date of conception during the summer months (April-September) and the winter months (October-March). RESULTS: We diagnosed 17 fetuses having gastroschisis with a mean gestational age at diagnosis of 24 weeks (range 11-33). The number of second and third trimester screening examinations and the number of patients with an expected date of delivery was not different during summer and winter months, 3980 vs. 4051. The expected date of birth (corrected for early ultrasound measurement) of fetuses with gastroschisis was more common during the winter months (n=11) than during summer months (n=6). However, this difference is not statistically significant (p=0.21) as was also the case for the date of conception. CONCLUSION: There seems to be no seasonal variation in the frequency of gastroschisis depending on the estimated date of birth or date of conception.

[Tissue Doppler imaging of the fetal heart--a new parametric ultrasound technique in prenatal medicine]. / Tissue Doppler Imaging am fetalen Herzen--eine neue parametrische Ultraschalltechnik in der pränatalen Medizin.

Tissue Doppler imaging is a new ultrasound technique for the acquisition and analysis of myocardial velocity and deforming parameters in the human heart. In cardiology this innovative technique is used to identify ischemic regions and stunned areas after cardiac infarction and to diagnose dyssynchrony. In the last two years, our research group has been using this technique extensively on fetal hearts. It is possible to establish the fetal cardiac cycle clearly just by analyzing the typical courses of myocardial velocity curves. The quality of the curves is comparable to the results in adult cardiology. Consequently, many innovative analysis options can be acquired, e.g., the comparison of the kinetics of several myocardial regions in the cardiac cycle, the determination of pre- and post-systolic intervals (isovolumic contraction time, isovolumic relaxation time), the evaluation of diastolic function by analyzing the E(m) and A(m) waves and the detection of the atrial contraction. These parameters are currently used in cardiology for extended function analysis. Tissue Doppler imaging is the first step in parametric imaging of the fetal heart and consequently marks the beginning of a new era in fetal echocardiography.

[Current recommendations for the treatment of preeclampsia]. / Aktuelle Therapieempfehlungen bei Präeklampsie.

Low-dose aspirin, but not vitamin C and vitamin E, has small to moderate benefits when used for the prevention of preeclampsia. There is however little to suggest that the course of manifest preeclampsia can be substantially affected by drug treatment. Antihypertensive therapy increases the risk of fetal growth restriction and is only indicated in severe hypertension to reduce the risk of maternal cerebral hemorrhage. Magnesium sulfate is the drug of choice for the prevention and treatment of eclampsia. Volume expansion as well as the use of steroids in preeclamptic patients without HELLP syndrome have failed to show any improvement. Delivery as the only definitive treatment is always beneficial for the mother whereas expectant management is in favor of a premature fetus. Decision-making largely depends on gestational age and severity of the disease.

Implications of low vascular flow resistance in the umbilical artery--difference between the second and third trimester of pregnancy.

PURPOSE: An abnormally high (above 95th percentile) pulsatility index (PI) in the umbilical artery (UA) indicates impaired fetal outcome, whereas the impact of an ''abnormally'' low (below 5th percentile) PI in the second trimester is unknown. MATERIALS AND METHODS: Between 2001 and 2004, second trimester pregnancy screening was performed at our institution on 5220 patients, and additional UA Doppler ultrasound on 547 (10.5%) of these patients, between 16th and 25th week of pregnancy. Files were available for analysis in our electronic database (PIA Fetal Database (GE, USA)). To evaluate the association of a UA PI below the 5th percentile in the second trimester of pregnancy with fetal anomalies and outcome, a retrospective database analysis was conducted. RESULTS: In 25 fetuses (3.6%), a UA PI below the 5th percentile was found. In 7 of these fetuses (28%), abnormalities of the urogenital tract were diagnosed. There were multiple pregnancies in 7 cases (28%), consisting of two triplets, each including one fetus with malformation, as well as five monochorial twin pregnancies, including 2 fetuses with malformations. In 11 pregnancies (44%), second trimester screening showed no anomalies. CONCLUSION: Only in 11 cases (44%) of fetuses with UA PI below 5th percentile in the second trimester, course and outcome of pregnancy were favourable, if defined as live birth without fetal malformations and uneventful neonatal period. The aetiology of an abnormally low UA PI in the second trimester seems to be diverse. Possible aetiological mechanisms will be discussed.

Maternal serum free beta-hCG and PAPP-A in patients with habitual abortion-influence on first-trimester screening for chromosomal abnormalities.

OBJECTIVE: To explore if maternal serum free beta-hCG and pregnancy-associated plasma protein A (PAPP-A) levels in the first-trimester of pregnancy are altered in patients with habitual abortions and if there is an effect on first-trimester screening for Down syndrome. METHODS: A retrospective study was conducted on 913 normal singleton fetuses that underwent first-trimester combined screening for Down syndrome. Maternal serum PAPP-A and free beta-hCG were compared between patients with (n = 64) and without habitual abortions (n = 849). RESULTS: The medians +/- SD log(10) MoM of PAPP-A and free beta-hCG +/- SD in patients with and without habitual abortions were 0.063 +/- 0.28 versus - 0.014 +/- 0.27 and - 0.001 +/- 0.27 versus - 0.018 +/- 0.31, with a p value of 0.042 and 0.87, respectively. The screen positive rate setting the cut off at 1:350 looking at the background risk for trisomy 21 was 71.4% in women with and 81.2% in women without habitual abortion, after combined first-trimester screening it was 7.8% in women with and 10.1% in women without recurrent abortion. CONCLUSIONS: Patients with habitual abortions have slightly increased maternal serum PAPP-A levels in the first-trimester. This marginal difference seems not to effect risk calculation in combined first-trimester screening for trisomy 21.

Influence of maternal systemic lupus erythematosus on first-trimester combined screening for chromosomal abnormalities.

OBJECTIVE: To explore the effect of maternal systemic lupus erythematosus (SLE) on first-trimester screening markers for Down syndrome. METHODS: A retrospective study was conducted on 1150 normal singleton fetuses that underwent first-trimester combined screening for Down syndrome. Fetal delta nuchal translucency (NT), maternal serum PAPP-A and free beta-hCG were compared between pregnancies with SLE (n = 10) and without preexisting maternal disease (n = 1140). RESULTS: The medians +/- SD for delta NT, log(10) MoM of PAPP-A and free beta-hCG +/- SD in pregnancies with SLE and without maternal disease were - 0.18 +/- 0.29 versus - 0.18 +/- 0.33, 0.005 +/- 0.32 versus 0.02 +/- 0.26, and 0.22 +/- 0.19 versus - 0.014 +/- 0.28, with a p value of 0.7, 0.98 and 0.03, respectively. CONCLUSIONS: Patients with preexisting SLE have increased maternal serum-free beta-hCG levels in the first-trimester. But, because of the multimodal procedure of risk calculation there is no significant difference in the screen-positive rate after the combined first-trimester screening for trisomy 21.

Does vaginal bleeding influence first-trimester markers for Down syndrome?

OBJECTIVES: To examine the effect of early vaginal bleeding on first-trimester screening markers for Down syndrome. METHODS: A retrospective study was conducted on 1755 normal singleton fetuses that underwent first-trimester combined screening for Down syndrome on the basis of ultrasound and maternal serum markers. Fetal delta-nuchal translucency (NT), maternal serum pregnancy-associated plasma protein A (PAPP-A) and free beta-hCG were compared between pregnancies with (n = 252) and without (n = 1503) an episode of vaginal bleeding. Subgroup analysis for the intensity of bleeding (spotting n = 191; light n = 32; heavy n = 29) was performed. RESULTS: The median +/- SD (log(10)) for delta-NT, multiple of medians (MoM) PAPP-A and MoM free beta-hCG (corrected for maternal weight, smoking and ethnicity) was - 0.17 +/- 0.62, 1.10 +/- 0.28, 1.1 +/- 0.28 and - 0.15 +/- 0.51, 0.98 +/- 0.26, 0.94 +/- 0.3 in pregnancies with and without a history of early vaginal bleeding, which were not significantly different. Exclusion of patients with spotting from the vaginal bleeding group revealed significantly higher maternal serum free beta-hCG MoM values (median +/- SD (log(10))) compared to patients without bleeding, 1.29 +/- 0.27 vs 0.96 +/- 0.3(p = 0.011). Screen-positive (cut off of 1:350) rate after combined first-trimester screening was 28.1% in patients with light vaginal bleeding and 8.4% in patients without bleeding (p = 0.001). CONCLUSIONS: Light vaginal bleeding before first-trimester combined screening for Down syndrome leads to a higher screen-positive rate after combined first trimester screening, without a significant difference in serum levels of the screening markers.

Maternal posttraumatic stress response after the birth of a very low-birth-weight infant.

OBJECTIVE: For parents, the premature birth of a child represents a traumatic event for which they are poorly prepared. To date, the focus of scientific interest has been on maternal psychological stress responses, such as anxiety and depression, or on appropriate coping mechanisms, whereas only scant attention has been paid to the traumatic aspect of the maternal experience after very low-birth-weight (VLBW) birth. The present study is the first to investigate the posttraumatic stress response of mothers after the birth of a VLBW infant in a prospective longitudinal study. METHODS: Fifty mothers of VLBW infants were examined at four measuring time points (1-3 days pp, 14 days pp and 6 and 14 months pp) with respect to posttraumatic symptoms [Impact of Event Scale (IES-R)], psychiatric diagnosis (SKID I for DSM-IV) and the extent of depression [Beck Depression Inventory (BDI) and Montgomery Asberg Depression Scale (MADRS)] and anxiety [State-Trait Anxiety Inventory (STAI) and Hamilton Anxiety Scale (HAMA)]. The control group comprised a group of 30 mothers after the uncomplicated spontaneous birth of a healthy child. RESULTS: At all four measuring timepoints (except 6 months pp), the mothers of the premature infants recorded significantly higher values for traumatic experience and depressive symptoms and anxiety compared with the controls. In contrast to the mothers in the control group, the mothers of the premature infants displayed no significant reduction in posttraumatic symptoms (IES-total), even 14 months after birth. CONCLUSION: The results indicate that the situation of a mother who has given birth to a VLBW infant is a complex, with long-term traumatic event necessitating ongoing emotional support extending beyond the period immediately after the birth.

Grief after termination of pregnancy due to fetal malformation.

Termination of pregnancy for fetal malformation is a traumatic event which any woman finds hard to withstand and which entails the risk of severe and complicated grieving. This paper presents three cases illustrating the trauma and coping mechanisms. Grieving continued for over 6 months in all cases and included pathological anxiety and depression. We offer advice and counselling to such women.