O3240: The Impact of Changing Reproductive Policy on Perinatal Decision-Making: A Case Study

Introduction: Persons receiving care in states with restrictive reproductive health laws may be more likely to carry pregnancies to term with significant fetal anomalies. Fetal anomalies associated with poor prognosis are often referred to Perinatal Palliative Care. We present a case uniquely impacted by such laws.

Case Description: A 35 year old woman was seen for prenatal care in the state of Texas at 27 weeks gestation. She had reportedly undergone a normal anatomic ultrasound with her prior obstetric team. A subsequent ultrasound at our institution revealed multiple anomalies to include an omphalocele, rocker bottom feet, clenched fists, scalp edema, enlarged scrotum, and a suspected outlet ventricular septal defect. Genetic testing yielded normal results. The patient chose to pursue termination of the pregnancy which was not offered in Texas due to state reproductive health laws. The procedure was scheduled in a nearby state several weeks later to accommodate travel. Two days prior to her planned travel she presented to our Texas hospital for preterm premature rupture of membranes, and subsequently the infant was born at 32 weeks and 5 days. He was found to have full-body edema, macroglossia, low-set ears, retrognathia, an umbilical hernia with overlying skin, and abnormal limbs and digits. Familial decision-making was complicated by the unanticipated delivery in light of their previously expressed goals. Early life-sustaining intervention was provided at their request. His neonatal course was characterized by respiratory failure requiring intubation with refractory hypoxemia, apnea, bradycardia, and posturing. Perinatal Palliative Care was consulted for assistance with decision-making around life-prolonging measures. The parents expressed worry about his quality of life related to potentially limiting physical differences and an inability to afford his care needs. This informed a consideration for adoption. They struggled with uncertainty while awaiting genetic results to aid in prognostication. The infant continued to deteriorate, culminating in a family meeting where the family chose to pursue compassionate extubation out of concern for his suffering and poor clinical trajectory. The infant died peacefully shortly after extubation.

Discussion: Families receiving complex medical diagnoses in the prenatal setting are faced with many difficult decisions. In our case, several external factors influenced familial decision making, to include their geographic location in a state with reproductive laws restrictive to their expressed goals. Though earlier detection of fetal anomalies may have allowed for more optimal planning or termination, access to termination care was delayed as a result of state specific reproductive laws.

Conclusion: This case highlights how reproductive health laws and socioeconomic factors can coalesce into an undoubtedly painful human experience, further complicating an already complex time for patients and families. Perinatal Palliative Care is uniquely poised to witness these circumstances, and to provide support when families are navigating them.