By N. C. Nevin (auth.), James O. Drife MD, FRCSEd, FRCOG, Dian Donnai MBBS, FRCP, DCH, DObst, RCOG (eds.)
In few components of drugs is growth extra astounding than within the box of prenatal analysis. New scientific recommendations akin to chorion villus sampling, exact ultrasound scanning and cordocentesis are being evaluated via obstetricians, and refinement of biochemical checking out is widening the scope of maternal serum screening. within the laboratory, dramatic advances in molecular biology are taking place: households liable to genetic ailment may be investigated with gene probes, and preimplantation prognosis of the embryo is now becom ing a fact. those technical advances have very important moral and useful implications, between to be able to be an extra raise in public expectancies of the criteria required of antenatal companies. Clini cians will want a excessive measure of ability to notify fit ladies in regards to the recommendations for screening basic pregnancies, and to suggestions high-risk girls in regards to the advantages and barriers of prenatal prognosis. Obstetricians, scientists and overall healthiness provider managers will face the tricky activity of determining how prenatal analysis could be made on hand to girls in a worrying and low-priced manner. Recognising the swift development during this box, the Royal university of Obstetricians and Gynaecologists made prenatal prognosis the topic of its twenty third research team. a world panel of best researchers, whose services ranged from molecular biology to philosophy, used to be invited to take part in a 3 day workshop, with time for in-depth dialogue in addition to the presentation of papers.
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There are, nevertheless, dangers and disadvantages inherent in the development of mUltiple different "ad hoc" monitoring schemes for gauging the impact of differing antenatal screening programmes. We believe very firmly that a single comprehensive regionally based system with enough funding to be reasonably accurate and complete has the advantage of being able to produce regular, prompt, local feed back, and that without such feed back the whole raison d'etre of monitoring is lost. The Interpretation of Selected Ultrasound Problems The usual way of looking at the problem of congenital abnormality is to start with the number of children confirmed as having a specific abnormality after delivery, and then to look retrospectively to see if anything had been suspected before delivery, and, if so, what.
3. Identification and management of abdominal wall defects in the Northern Region 19851989 (excluding 35 cases with chromosome defects, or other complex lethal abnormality) Cases diagnosed ante natally (83% delivered vaginally) Miscarriage Termination Antepartum SB Intrapartum SB Neonatal death 1st year death Survivors on social grounds to comply with family views rhesus hydrops no other anomaly unexplained fetal death in early labour severe prematurity bowel gangrenous at birth late surgical complications (no apparent handicap) Cases not diagnosed antenatally (86% delivered vaginally) 2 Miscarriage 2 1 1 Antepartum SB second twin (fetus papyraceous) with anophthalmos no other anomaly Neonatal death bowel gangrenous at birth 1st year death unrelated cot death at 6 months (no apparent handicap) 1 1 2 35 (74%) Survivors 1 1 3 1 28 (78%) A larger review of all the births in the region between 1981 and 1989 with an anterior abdominal wall defect has failed to show a single live birth or intrapartum death where there was trauma to the fetus, and in particular to the fetal liver or bowel, during birth, although there were two cases where the exomphalos itself probably ruptured during delivery, and only 15% (17/117) of all the viable babies with a diagnosed or undiagnosed anterior abdominal wall defect alive at the onset of labour were delivered by caesarean section in those years.
Such monitoring is expensive and labour-intensive, however, and we urgently need to identify the best way of utilising the limited resources available to us. Audit is, in any case, the current watchword. We cannot afford the luxury of continuing to employ unvalidated screening routines, and we cannot assume that what is shown to work in a specialised research setting, with skilled and motivated research staff, still works reliably when employed in everyday clinical practice. It is possible that some screening programmes currently do more harm than good.