The Psychological Impact of Prenatal Diagnosis and Disclosure of Susceptibility Loci: First Impressions of Parents’ Experiences

Genomic microarray may detect susceptibility loci (SL) for neurodevelopmental disorders such as autism and epilepsy, with a yet unquantifiable risk for the fetus. The prenatal disclosure of susceptibility loci is a topic of much debate. Many health care professionals fear that reporting susceptibility loci may put a psychological burden on pregnant couples. It is our policy to disclose prenatal susceptibility loci as we recognize them as actionable for prospective parents. The aim of this report was to evaluate the psychological impact of disclosing a prenatal diagnosis of susceptibility loci. The psychological impact of disclosing susceptibility loci was evaluated in the first patients who received such results. Eight out of 15 women who had a susceptibility locus disclosed and four of their partners consented to share their experiences through a telephonic evaluation (n = 12). Follow-up time ranged from 3 to 15 months after their prenatal test result. The reporting of susceptibility loci was initially ‘shocking’ for five parents while the other seven felt ‘worried’. Ten out of 12 participants indicated they would like to be informed about the susceptibility locus again, two were unsure. Most had no enduring worries. Participants unanimously indicated that pregnant couples should have an individualized pre-test choice about susceptibility loci (non)disclosure. We observed no negative psychological impact with the prenatal diagnosis and disclosure of SL on participants. A key factor in mitigating parental anxiety with SL disclosure appears to be post-test genetic counseling. Our report confirms that pregnant women and their partners prefer an individualized choice regarding the scope of prenatal testing.


Introduction
Genomic microarray may detect more copy number variants (CNVs) that cause clinically relevant abnormalities and generates results faster than conventional karyotyping (CK) (Wapner and Jackson 2008;Wapner et al. 2012;Fiorentino et al. 2011). Therefore, we use SNP array instead of conventional karyotyping (CK) for routine cytogenetic analysis for all indications since July 2012 Van Opstal et al. 2015). Next to known microdeletion syndromes such as Prader-Willi syndrome, or Duchenne muscular dystrophy, array testing may also reveal susceptibility loci (SL) for neurodevelopmental disorders. Susceptibility loci (SL) were defined as following by Girirajan et al.: 'SL are copy number variants (CNVs) with an extreme phenotypic heterogeneity and/or of variable expressivity' (Van Opstal et al. 2015;Girirajan et al. 2012;Srebniak et al. 2014Srebniak et al. , 2015 associated with an unquantifiable risk of neurodevelopmental disorders such as epilepsy, autism and psychiatric disorders and can be found in about 1.4 % of fetuses without ultrasound anomalies (Van Opstal et al. 2015;Srebniak et al. 2015). SL are often inherited from (apparently) unaffected parents, but are more frequently detected in affected individuals as compared to control populations (Srebniak et al. 2014;Kaminsky et al. 2011;Rosenfeld et al. 2013;Srebniak 2013). Genetic counseling in pregnancies where SL are found is challenging as it is difficult to estimate the chance of expression and/or to predict the phenotype because most likely a second hit like another genetic or even non-genetic factor, like environment, may also influence the expression of the phenotypes (Veltman and Brunner 2010;Girirajan et al. 2010). Almost all information about SL phenotypes and penetrance that is available is based on postnatal ascertainment. There is currently no information available about the development of children in whom a SL was found prenatally.
The value of SNP array in fetuses who were prenatally diagnosed with ultrasound anomalies has been widely accepted (Wapner et al. 2012;Fiorentino et al. 2011), but its implementation for other indications has raised concerns among health care professionals, causing much debate regarding the disclosure of SL (de Jong et al. 2013;McGillivray et al. 2012;Vetro et al. 2012). Some classify these CNVs as variants of unknown clinical significance (VOUS) (Wapner et al. 2012), but because of their association with an abnormal phenotype, we have classified SL as pathogenic (Srebniak et al. 2014). In our opinion, SL are different from VOUS because the phenotypic effect of VOUS is unknown, whereas for an SL the association with a specific phenotype is known but has a highly variable penetrance and expression.
It has been argued that pregnant couples may wish not to be informed on findings of uncertain expression (Hillman et al. 2013) and that such findings should be withheld in order not to put burden on the pregnant couple (Rigter et al. 2013;de Jong et al. 2014). It has also been said, both for susceptibility loci and VOUS, that reporting them may create a false sense of autonomy (Brady et al. 2013), because an overload of information could deteriorate reproductive autonomy, or raise possible emotional harm such as distress (McGillivray et al. 2012). Some ethicists argued that genetic information of unclear meaning interferes with reproductive autonomy and should not be provided for this reason (de Jong et al. 2014).
On the other hand, others argue that it is paternalistic to try to prevent women from emotional harm and potential termination of a pregnancy, and that pregnant women are entitled to be informed of all genetic information (McGillivray et al. 2012) and that better tools for dealing with uncertainty should be developed (Vetro et al. 2012;Rigter et al. 2013;Wolf et al. 2008;Stark et al. 2013).
Although we are well aware of the burden that SL may represent psychologically for the pregnant couple, for several reasons we have chosen to disclose SL when prenatally detected. Firstly, we consider most SL to be actionable during and/or after pregnancy. For example, SL may be associated with congenital heart disease and an expert ultrasound examination during pregnancy can be offered. Secondly, if neurodevelopmental problems occur (either early or late onset), rapid diagnostics and more adequate care may be mobilized when parents have the knowledge of the SL (Govaerts et al., manuscript in preparation) (Dababnah and Parish 2015).
Since we implemented SNP array for all indications, we encountered 14 cases of SL in 1330 pregnancies without ultrasound abnormalities (Van Opstal et al. 2015). To date, no patient experiences regarding the psychological impact of SL on pregnant couples has been reported. To explore whether disclosure of SL indeed puts a heavy burden on the parents (McGillivray et al. 2012;Rigter et al. 2013;de Jong et al. 2014;Brady et al. 2013), we feel it is important to understand how SL disclosure affects pregnant couples. We report on the narratives of 12 parents' experiences with a prenatally disclosed SL.

Pre-Test Counselling by a Senior Obstetrician
All patients undergoing invasive prenatal diagnosis (PND) received pre-test counselling by a senior obstetrician and received a patient information leaflet which specified that 'all pathogenic results will be reported'. Pregnant couples were informed about array testing. The occasional occurrence of unexpected findings was discussed. These could either be pathogenic CNVs not related to the prior indication for invasive testing or susceptibility loci (SL), Patients received no detailed information regarding SL. Unexpected findings were discussed, but there was no strong emphasis on SL as a category of outcomes of invasive prenatal testing. SNP array testing was performed as a first-tier diagnostic test as described before Van Opstal et al. 2015).

Disclosing the Prenatal Test Result
When a SL was diagnosed pregnant couples were contacted directly by a clinical geneticist informing them that there was no causative chromosomal abnormality found, but a deviant finding that may require special attention. They were invited for extensive post-test counseling available the next day. For extensive information about our counseling methods and pregnancy management, see Govaerts et al. (manuscript in preparation), in short: 1. The nature of the particular SL was explained. Phenotypic examples (including pictures) from the postnatal literature were available.
2. An expert ultrasound examination was offered if the SL was associated with structural abnormalities. 3. We offered targeted parental SNP array in all cases because knowing whether an SL was inherited aided in evaluating the clinical implications of the SL within the family. 4. The couples were informed about the possibility for early postnatal intervention programs (www.mee.nl), and the option to terminate the pregnancy was discussed. 5. The pregnant women and their partners were offered support from a medical psychologist specialized in prenatal care.

Inclusion for the Psychological Evaluation
In this report we describe the experiences pregnant couples had when a susceptibility locus was found after invasive genetic testing, in the absence of ultrasound anomalies. Between July 2012 and December 2013, 14 couples received a prenatal diagnosis of a SL, and all of them were contacted. A clinical geneticist contacted them and asked whether they were willing to share their experiences by phone in order to assess the impact of disclosing a prenatal susceptibility locus. This interview was part of aftercare in order to learn about the long term psychological impact of SL disclosure in pregnancy. All patients proceeding with invasive prenatal testing, signed consent for further follow up during pregnancy and after delivery. Eight women and four of their partners agreed to share their experiences, see Fig. 1 for the participants. The prenatal testing indication and array findings in 8 fetuses of the parents that took part in the interview are shown in Table 1. None of the participants decided to terminate the pregnancy. The parents of live born children reported no congenital anomalies or dysmorphic features that were detected at birth. In Table 2, array results are displayed with phenotype and incidences based on the information the parents received. All couples were offered psychological support in dealing with the outcome after disclosure of SL, but none of them indicated they wanted to make use of this. The follow-up interview period between invasive PND and the contact ranged between 3 and 18 months. The mean time before the follow-up interview was 10 months after disclosure. Three participants were still pregnant at the time of follow-up.

Measures
Consenting participants were approached for a follow-up interview by phone, using semi-structured questions (mean duration: 30 min). Women and their partners were interviewed individually. In Table 3, all questions are summarized. All interviews were transcribed verbatim and translated from Dutch to English. Worries about the health and development of the child were measured on a scale of 1 to 10 (1 -not at all to 10 -very much so).

Analysis
Qualitative analysis was performed on the answers of all participants. A posteriori, three independent judges (SL; JV; SR) categorized the answers to the open-ended questions (see Table 4). Subsequently, the judges came to a consensus regarding which categories emerged from which questions. The three judges independently assigned a dichotomous score (0 not present; 1 present) to each theme per question.
The observed inter-judge agreement varied between α = .44 and α = 1.00. The inter-judge reliability ranged from acceptable to excellent, except for question 1, which had a poor inter-judge reliability (α = .44) (Field 2009

Results: Participant's Narratives Initial Experience when the SL was Disclosed
Qualitative analysis of the interviews showed that 7 out of 12 participants said they were 'worried', while the other 5 participants said 'it was real shock' to hear about the SL. We provide quotes to the answers by category. Participants marked with an asterisk (*) were still pregnant during follow-up.

Question 1 and 2
What was it like for you when you were told about the SL that was found? What was your first reaction?
Quotes of parents who were worried (7 out of 12) Quotes of parents who were shocked (5 out of 12)    Quote of a parent that experienced a stigma (1 out of 12) 'It is something that you keep carrying with you. If she behaves weirdly, then I immediately think that this behaviour is related to the SL. I also do not like the fact that she already had a medical file before she even was born.'(Participant 1, female) Worries about the health and development of the child ranged from 2 to 7 on a 10-point scale, see Table 4. Most participants mentioned that they now 'just have the normal worries any parent has'.

Discussion
Since it has been suggested that disclosure of SL may raise emotional harm, we evaluated the psychological impact of prenatal SL disclosure on pregnant couples. Women and their partners initially felt worried and shocked. Most parents indicated that the SL was not what they had expected from invasive PND, however some recalled being informed on such possibility during the pre-test counselling. Previous research showed that pregnant women are hardly ever ready for receiving abnormal prenatal test results, even if they are well informed (Bernhardt et al. 2013;Statham et al. 2000;Lalor et al. 2009).
After their initial reaction, parents were confused and had a high need for understanding these outcomes. Most were quite alarmed by the phone call of the geneticist telling them that there was a 'peculiar finding that needed explanation'. All parents indicated they appreciated that the post-test counselling was available the next day. Due to the highly variable penetrance and expression, the meaning of the particular finding remained uncertain for the parents. A few parents noted that this uncertainty was stressful to them at first. However, none of the parents made use of the psychological support they were offered. None of the participants felt that a termination of pregnancy was a personal option for them. The interviews revealed that some parents adopted a wait-and-see policy; that they will have to wait and see in which way their child will develop, with a positive state of mind. These parents seemed less distressed when talking about their experiences.
Parents seemed to have recovered from their initial feelings, and are now handling the knowledge about their child having a SL fairly well. They seem to base this on a seemingly normal phenotype, either after giving birth to a 'normal appearing' child or with the reassurance of a 'normal' expert fetal ultrasound examination. At the moment of the follow-up interview (mean time 10 months after disclosure), all born children had no congenital anomalies or dysmorphic features, but were still too young to be examined for neurological development. None of the fetuses had ultrasound anomalies. It is yet unknown whether these children will develop neurodevelopmental symptoms in the future. Most parents did not have lingering worries regarding the SL, except for one woman who experienced a stigma regarding her seemingly normal and healthy born daughter. She told that each time her daughter behaved aberrant, she immediately feared it might be caused by the SL. This is something that is also encountered in other studies on abnormal prenatal diagnoses, even if the child has seemingly normal appearance (Bernhardt et al. 2013). Other parents did not report stigma or enduring worries about the child's development, and mentioned they just have 'normal parental worries' now. The interviewed parents indicated feeling relieved after advanced ultrasound scanning revealed no visible anomalies. We also found that parents, identified as SL carriers themselves, were in a way relieved, because they had the feeling the child could be 'normal' like themselves. These parents used themselves or their partner as a reference for the interpretation of the SL in their fetus. The psychological reaction reported by the individuals in our clinic may have been milder as compared to the study of Bernhardt et al. (2013). In that study, 23 participants were interviewed after disclosure of abnormal prenatal microarray results, of which 9 were known pathogenic results and 14 were variants of unknown clinical significance (VOUS). As in our study Bernhardt observed that participants initially felt shocked and worried, and had a problem with understanding the uncertainty and unquantifiable risks. Participants also shared a high need for support to manage and understand their prenatal microarray results with the help of a health care professional. However, in our study all women and their partners were counselled by a senior geneticist, whereas in the study of Bernhardt such support was not offered in all cases which might explain to the enduring concerns and a lack of support to manage decisions about termination of pregnancy and/or birth.. In both Bernhardt's study and our own, a key factor in mitigating parental anxiety with SL disclosure appears to be post-test genetic counseling (Bernhardt et al. 2013). However, in our study, participants reactions seem milder. In the study of Bernhardt, most participants indicated that they felt their test result was 'toxic knowledge'. In our study however, most participants indicated that they 'just have normal parental worries now', which clearly is a different outcome. The fact that all but one woman would choose to be informed of prenatal SL again, is a strong indicator of this.
Nearly all parents indicated they would want to be informed of SL again if offered a choice. Parents who said they preferred to know about SL, said they did so because they could quickly mobilise adequate care if needed. For instance, if developmental problems would occur, they could have access to early interventions for i.e. autism. These findings are congruent with our earlier study in which we found that a vast majority of pregnant couples, when offered a choice during pretest genetic counseling, opted for SL disclosure (van der Steen et al. 2014). The parents we discussed in this paper indicated that they would prefer to have a choice regarding the (non)disclosure of SL. This paper supports earlier reports (de Jong et al. 2013;van der Steen et al. 2014;Boormans et al. 2010) that parents highly appreciate individualized choice on the scope of prenatal testing. We have not observed psychological burden, however it has to be taken into account that the number of interviewed patients is small. Furthermore, some participants were still pregnant at the time of the interview. It is therefore difficult to make long-term conclusions. In our study, there was no distinction between prenatal de novo and inherited findings, however, due to their different nature parents might cope with them in another way. It would be interesting to evaluate this. Research on a larger scale is much needed to gain more insight in how pregnant couples are coping with this type of prenatal information.

Conclusion
This small study showed that in our setting, there was no longterm psychological burden for pregnant couples whose fetus was diagnosed with a susceptibility locus. A key factor in mitigating parental anxiety with SL disclosure appears to be post-test genetic counseling. This paper confirms that parents highly appreciate an individualized choice on the scope of prenatal testing. We believe that if genomic microarray testing is offered, a chance of the detection of results like susceptibility loci should be routinely mentioned during pre-test counselling. An opt-out possibility may be sufficient to support the reproductive autonomy of pregnant couples.

Compliance with Ethical Standards
Conflict of Interest All authors declare no conflict of interest.
Human Studies and Informed Consent All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all patients for being included in the study. Additional informed consent was obtained from all patients for which identifying information is included in this article.
Animal studies No animal studies were carried out by the authors for this article.
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