6

Fetal medicine

Chapter map

Multidisciplinary collaboration is the key to fetal medicine. Good contraceptive advice is important for the young person, while assisted conception allows more couples the joy of parenthood. Primarily an obstetric specialty, advice to the expectant couple often provides diagnostic and ethical problems, demanding input from paediatrics, genetics and surgery. You should understand that ultrasound, amniocentesis, chorionic villus sampling, fetal blood sampling, DNA analysis and fetoscopy allow assessment of fetal health, early detection of many anomalies and sometimes treatment of the fetus, taking Down syndrome and spina bifida as important examples.

6.1 Control of fertility

6.1.1 Contraception

6.1.2 Infertility treatment

6.2 Antenatal and pre-pregnancy care

6.3 Congenital malformations

6.3.1 Prenatal diagnosis (Table 6.2)

6.4 Embryonic and fetal growth and development

Summary

6.1 Control of fertility

6.1.1 Contraception

In developing countries, high birth rates and high child mortality tend to go hand in hand. Medical care reduces mortality from disease, but large family size threatens good nutrition, education, and socioeconomic growth. Safe, effective, cheap contraception coupled with education is key.

In Europe, the challenge of providing good, supportive advice to teenagers is widely acknowledged. The UK is now seeing a fall in the teenage pregnancy rate (around 40/1000 15–17 year olds), although it remains high compared with the rest of Europe.

PRACTICE POINT

Gillick competency: this important ethical concept arose when the courts decided that a teenager could obtain contraception without parental knowledge. The principle is that a competent teenager may seek treatment or advice as long as the treating doctor is convinced that the child understands the implications of their choice.

---

6.1.2 Infertility treatment

Methods of helping infertile couples continue to advance. Techniques of ovulation control, in vitro fertilization, prolonged storage of gametes and the embryo, and surrogacy permit the separation of functions previously regarded as inseparable:

• Production of ova and sperm
  
• Place of fertilization
  
• The uterus in which the fetus develops
  
• The adult(s) responsible for rearing the child.

The ovum could come from Ms A, be fertilized in the laboratory by sperm from Mr B, be implanted in the uterus of Ms C and be reared by Mr and Ms D. This may raise psychosocial and ethical issues. Limiting the number of embryos implanted has reduced multiple pregnancies. Some studies raise concern that congenital abnormality may be more common after induced pregnancy.

6.2 Antenatal and pre-pregnancy care

Preparation for a baby is aided by good physical and emotional health in both parents. Hereditary conditions should be discussed.

PRACTICE POINT

Women should be immunized against rubella before conception. All but the most essential drugs should be stopped before pregnancy. Smoking and alcohol should be avoided.

---

Some social and behavioural factors increase risk of problems:

• Socioeconomic deprivation: ↑ low birthweight; ↑ prematurity; ↑ perinatal mortality
  
• Young mothers: ↑ fetal growth problems; ↑ perinatal morbidity and mortality
  
• Older mothers: Down syndrome
  
• Obesity: ↑ gestational diabetes, ↑ perinatal mortality, ↑ difficult delivery
  
• Drug-abuse: effects of drugs on fetus and newborn
  
• Viral infection; HIV; hepatitis B and C.

Ideally, women should be in good health and prepared for pregnancy at the time of conception. The fetus may suffer long-term effects from early adverse influences (Figure 6.1).

Figure 6.1 Factors affecting fetal nutrition, growth and development.

Stay updated, free articles. Join our Telegram channel

Join