Variation in physician approach to obstetrical management of life threatening fetal anomalies

Standards of care regarding obstetrical management of life-threatening anomalies are not defined. We hypothesize that physicians' management of these pregnancies is variable and influenced by demographic factors. A questionnaire was mailed to SMFM members to assess obstetrical management of both “uniformly lethal” (e.g. anencephaly, renal agenesis) and “uniformly severe, commonly lethal” (e.g. Trisomies 13 & 18) anomalies. Respondents were asked to answer as if not limited by state/institutional restrictions. Fisher's exact or chi-square was used as appropriate. Response rate was 36% (732/2038 surveys). Nearly 100% of respondents discuss pregnancy termination for lethal or severe anomalies. 45% place gestational age restrictions on termination in the setting of lethal anomalies and 59% do so for severe anomalies (p<0.01). Younger physicians (p=0.04) and those in academic practice (p<0.01) were more likely to offer both induction of labor or D&E. In continuing pregnancies, women were more likely than men to “encourage” obstetric non-intervention, for both lethal (p<0.01) and severe anomalies (p=0.04). However, nearly all providers would ultimately comply with this patient request. When full obstetric intervention is requested for lethal anomalies, 73% “discourage” this management, 11% “encourage/support” and 17% are non-directive as compared to 66%, 11%, and 23% for severe anomalies (p=0.02). However, 71% of providers ultimately comply with patient requests for full obstetric intervention in uniformly lethal versus 82% for severe anomalies (p<0.01). Discrepancies exist regarding management of severe life threatening fetal anomalies. Patients may be offered different options based on practitioner demographics. The majority of physicians comply with patient wishes. Differences were noted when comparing management of lethal to that of severe, commonly lethal anomalies, suggesting that practitioners make a distinction when counseling patients.