IN THE LIT

R. M. Pauli, MD, Ph.D.

A Passage through Grief - the Western Australian Rural Pregnancy Loss Team. Knowles S. BMJ 309:1705-1708, 1994.

This chatty article describes an outreach program for a part of rural Australia. A group of 5 health care and social workers, committed to understanding intrauterine death and supporting families who have experienced such losses, fly to country centers to provide educational programs for health care providers, pastors and the public (including considerable emphasis on media coverage). Most of what they describe is traditional and appropriate. It sounds like a wonderful program. I am pessimistic that any such program could currently find funding in this country.

One suggestion made by this group I found particularly intriguing: a "plain language post-mortem report" is given to families summarizing the important findings but avoiding jargon that could be misinterpreted by the family.

Preliminary Experience with Endoscopic Laser Surgery for Severe Twin-Twin Transfusion Syndrome. Ville Y, Hyett J, Hecher K, Nicolaides K. N Engl J Med 332:224-227, 1995.

Twin-twin transfusion is one of the relatively few specific causes of intrauterine death for which efforts at intervention have been moderately successful. The authors report their experience in 45 monochorionic diamnionic twin pregnancies in which there was evidence for twin-twin transfusion syndrome (severe, asymmetric hydramnios of one twin sac, bladder distension of the recipient and oligohydramnios in the donor, all by ultrasound).

In each they used endoscopy, entered the recipient twin’s amniotic cavity and used laser coagulation to destroy identified crossing vessels (i.e. vessels which crossed the double amniotic membrane between the two fetuses). After coagulation of all suspicious vessels, amniotic fluid was withdrawn through the fetoscope as well.

Of 45 pregnancies, 16 resulted in two live births, 16 in one live birth (usually - 12 times - these were deaths of the donor fetus) and 13 in which both fetuses died. In addition 6 more babies died after livebirth as a consequence of complications of the fetofetal transfusion. So, overall, 42 survivors resulted from these 45 pregnancies. This compares favorably with the authors’ historical controls of fetuses treated with repeated amniotic fluid drainage. Furthermore the incidence of CNS sequelae in survivors seems to be much less after laser coagulation surgery than for those treated with repeated amniotomy.

There are similar studies which have demonstrated the potential utility of these techniques. A randomized trial of treatment would certainly be more convincing than the use of historical controls. It does not appear that the benefits of the laser surgery are so unquestionably greater that a controlled trial would in any way be unethical.

Aggressive Intrapartum Management of Lethal Fetal Anomalies: Beyond Fetal Beneficence. Spinnato JA, Cook VD, Cook CR, Voss DH. Obstet Gynecol 85:89-92, 1995.

The authors discuss, by way of case studies, what alternatives for intrapartum care may be appropriate in situations in which fetal lethality is virtually assured. Previous management strategies have emphasized offering choices to families only based upon the level of one’s beneficence-based obligations to the fetus (e.g. Obstet Gynecol 75:311, 1990). Traditionally, when fetal/neonatal lethality appears certain based on prenatal diagnostic studies, guidelines for care have thus included only the options "to terminate a pregnancy before the third trimester and avoid exposure of the patient [mother] to unnecessary risks, or in cases of continuing pregnancies, to not use therapeutic modalities that increase maternal risk without a reasonable hope of fetal survival or cognitive function." The current article describes families who voiced objection to such nonaggressive management even when the fetal outcome was certain. Some patients have a strong desire to avoid an intrapartum stillbirth. These patients appear to take comfort in a livebirth, even if the baby then dies within minutes or hours. It is in such patients that offering only conservative management options (e.g. avoidance of C-section when there is no hope for long term fetal/infant survival) seems both parentalistic and problematic. The authors suggest that guidance, but not coercion, should direct families to the decisions generally viewed as appropriate, but that there may be a place for consideration of the psychological harm not allowing alternative choices would entail.