Moral Distress and Feticide: Hearing the Voices of Maternal-Fetal Medicine Physicians.

We conducted in-depth interviews to investigate maternal-fetal medicine (MFM) physicians' feelings about their moral thoughts and dilemmas related to providing feticide for late-term abortion in Israel. We interviewed 14 MFM physicians (who constitute approximately 40 percent of MFM physicians who perform feticide in the country) from five hospitals in Israel during 2018 and 2019. They were recruited via personal acquaintance and snowball sampling. Findings reveal that despite their clear recognition that feticide is a necessary procedure, all describe themselves as suffering from some features of moral distress related to the process. The reasons for these difficulties are rooted in the Israeli law regarding late abortions, as well as in some of the organizational procedures for making this kind of medical decision. They also come from professional and emotional dilemmas that the physicians encounter. The findings reveal a strong need for more open discussions and sharing of doubts with colleagues regarding each case of feticide. These findings build on existing knowledge and may be useful in developing strategies to support clinicians who provide these essential but sometimes difficult services.

[ENDOMETRIAL-PATTERN IN EARLY PREGNANCY AND CORRELATION WITH ECTOPIC-PREGNANCY].

INTRODUCTION: Ectopic-pregnancy is a leading cause of pregnancy-related maternal death in the first trimester. Early sonographic diagnostic ability of ectopic-pregnancy is limited. There is an increasing need to identify sonographic markers that can assist with the diagnosis. OBJECTIVES: To characterize the endometrial-pattern by transvaginal-ultrasound as an early marker for ectopic-pregnancy, before demonstration of tubal mass. METHODS: A multicenter prospective study that included 52 women with a positive HCG test, referred to the ultrasound-unit with a diagnosis of pregnancy of unknown location. A transvaginal ultrasound was performed focusing on the endometrial-pattern, and classifying findings into four categories: homogeneous, heterogeneous, three-laminar and existence of fluid collection within the endometrial cavity. RESULTS: A total of 38 women were diagnosed with ectopic-pregnancy. Three women demonstrated normal intrauterine pregnancy, 3 others had an early miscarriage and 8 women were excluded from the study. No statistically significant differences were found between the groups in terms of demographic, clinical, or laboratory characteristics. Three-laminar pattern had 94% positive predictive value and 18% negative predictive value for ectopic-pregnancy, with sensitivity and specificity of 42% and 83%, respectively. Changes in the endometrial-pattern were demonstrated during subsequent tests when performed. CONCLUSIONS: The use of transvaginal-ultrasound to identify the endometrial-pattern in early pregnancy does not require significant expertise. The identification of three-laminar endometrium in pregnancies of an unknown location, should raise the suspicion of ectopic-pregnancy. DISCUSSION: Three-laminar pattern has high PPV for predicting ectopic pregnancy in women with pregnancy of an unknown location. The changes in the endometrial-pattern during subsequent tests, especially the transition of three-laminar into homogeneous pattern, a phenomenon not reported in previous studies, raised the need for further studies.

[TURNING THE PYRAMID IN PRENATAL CARE].

Most complications of pregnancy manifest towards the latter part of pregnancy. Nevertheless, present day diagnostic techniques, such as sonography, Doppler, biochemical screening tests, and the newly developed ability to study free fetal DNA in maternal blood, enables early identification of high risk groups for maternal and fetal morbidity, as well as fetal genetic and anatomical pathology. Dr. Nicolaides has coined this changing trend with the term "Turning the Pyramid". Early screening enables earlier and more directed follow-up with the application of relevant diagnostic tests. Obvious advantages include the potential to reduce maternal-fetal morbidity before it becomes apparent clinically. Additionally, the earlier diagnosis of fetal pathology, allows more time for parents and medical staff to assess the situation, and reach a decision regarding the continuation of the pregnancy. A possible drawback of such an approach, of early identification of high risk groups, is the uncertainty it arouses, sometimes for a long duration, with the accompanying apprehension and stress parents have to endure. A multidisciplinary team, consisting of specialists in fetal-maternal medicine, genetics, ultrasound, and perinatology, will be needed in order to best deal with the often complex information, which is becoming increasingly available at a very early stage of pregnancy.