How do you balance the psychological impact of antepartum testing with its clinical benefits?

Balancing Psychological Impact with Clinical Benefits of Antepartum Testing

The key to balancing psychological impact with clinical benefits is strict risk stratification: reserve antepartum testing exclusively for high-risk pregnancies where benefits clearly outweigh harms, while actively avoiding testing in low-risk pregnancies where false-positive results cause unnecessary anxiety, interventions, and iatrogenic prematurity without improving outcomes. 1

Risk-Based Testing Algorithm

Low-Risk Pregnancies: Avoid Routine Testing

• Do not perform antepartum testing in low-risk pregnancies as there is no convincing evidence that routine testing improves perinatal outcomes, and false-positive results lead to unnecessary interventions including increased cesarean delivery and complications from premature delivery 1
• A comprehensive negative history for all major risk factors (hypertensive disorders, diabetes, prior stillbirth, intrauterine growth restriction, advanced maternal age, obesity, chronic medical conditions) should be explicitly documented to confidently classify pregnancies as low-risk and avoid the cascade of unnecessary testing 2
• Testing low-risk women has the potential to cause iatrogenic prematurity secondary to preterm delivery for false-positive results, directly harming both maternal quality of life and neonatal outcomes 1, 2

High-Risk Pregnancies: Implement Structured Surveillance

For pregnancies with documented risk factors, antepartum testing is warranted as high-risk pregnancies face a 2-fold to 40-fold increased risk of stillbirth compared to low-risk pregnancies 3

Specific High-Risk Indications:

• Maternal conditions: hypertensive disorders, diabetes, chronic renal disease, systemic lupus erythematosus, thrombophilia, thyroid disorders, cholestasis, hemoglobinopathies, history of unexplained stillbirth 1
• Fetal conditions: intrauterine growth restriction (strongest evidence for benefit), structural anomalies, genetic syndromes, fetal arrhythmias, multiple gestations 1, 3
• Pregnancy complications: decreased fetal movement, oligohydramnios, polyhydramnios, postdates pregnancy, abnormal maternal serum markers 1

Testing Modality Selection to Minimize Psychological Burden

Choose Tests with Highest Negative Predictive Value

• All standard antepartum tests share high negative predictive values (>99.9%), meaning a normal result provides strong reassurance that stillbirth is unlikely within the next week 1, 3
• The Biophysical Profile (BPP) has a stillbirth rate of only 0.8 per 1,000 within one week of a normal test, providing excellent reassurance to reduce maternal anxiety 1
• The Modified Biophysical Profile (mBPP) performs comparably to full BPP with similar negative predictive value (<1 per 1,000), offering a less time-intensive option that may reduce testing burden 1

Timing and Frequency Considerations

• Initiate testing at 32-34 weeks for most high-risk conditions, but individualize based on specific risk factors and likelihood of neonatal survival 1, 3
• For highest-risk patients (intrauterine growth restriction, superimposed preeclampsia, diabetes with complications), begin testing when intervention becomes appropriate, typically around 26 weeks 4
• Weekly or twice-weekly testing has become standard practice, though this frequency is not based on rigorous scientific evidence and should be balanced against the psychological burden of frequent visits 1, 3

Managing Abnormal Results to Minimize Unnecessary Intervention

Before Term Gestation

• Weigh risks of prematurity against risks of intrauterine death when test results are abnormal before term 3
• Repeat testing or use alternative tests rather than proceeding immediately to delivery, as this approach reduces unnecessary preterm births while maintaining safety 3
• A BPP score of 6 or mBPP with nonreactive nonstress test warrants further evaluation but not necessarily immediate delivery in preterm pregnancies 1

At Term Gestation

• Delivery is warranted for abnormal antenatal testing at term, as the risks of continued pregnancy outweigh the minimal risks of term delivery 1
• Although false-positive results do occur, delivery for abnormal testing at term is appropriate because the alternative (continued pregnancy with compromised fetus) carries unacceptable mortality risk 1

Critical Limitations to Communicate

Set Realistic Expectations

• Antepartum testing cannot predict stillbirth related to acute events such as placental abruption or cord accidents, which account for a significant proportion of stillbirths 1
• Up to half of all stillbirths occur in patients without recognized risk factors, meaning even comprehensive testing cannot eliminate all risk 1, 2
• There is limited evidence from randomized controlled trials that antepartum fetal testing decreases the risk of fetal death, though observational data suggests benefit in high-risk populations 1

Common Pitfalls That Increase Psychological Harm

Avoid Testing Creep in Low-Risk Populations

• Do not expand testing to women with isolated advanced maternal age or obesity without additional well-established risk factors, as baseline stillbirth rates in these groups before 39 weeks are already lower than stillbirth rates achieved with current testing protocols 5
• The expansion of testing protocols to include additional risk factors without good-quality data linking such testing to improved outcomes increases anxiety and intervention rates without proven benefit 5

Prevent Cascade of Interventions

• False-positive results in low-risk pregnancies lead to a cascade: increased anxiety → repeat testing → abnormal findings → preterm delivery → neonatal complications, all without improving mortality outcomes 1
• Use of amniotic fluid index (AFI) rather than maximal vertical pocket results in more diagnoses of oligohydramnios and more obstetric interventions without improving perinatal outcomes, unnecessarily increasing maternal anxiety 1

Counseling Framework to Address Psychological Impact

For High-Risk Patients Undergoing Testing

• Emphasize the extremely high negative predictive value (>99.9%) of normal testing to provide strong reassurance and reduce anxiety between tests 1, 3
• Explain that testing identifies fetuses who may benefit from delivery but cannot prevent all stillbirths, particularly those from acute unpredictable events 1
• Discuss that the goal is to balance the small risk of stillbirth against the risks of premature delivery, with decisions individualized based on gestational age and specific risk factors 3

For Low-Risk Patients Requesting Testing

• Clearly explain that testing in low-risk pregnancies causes more harm than benefit through false-positive results leading to unnecessary interventions 1
• Document the comprehensive negative history that establishes low-risk status, providing reassurance through the absence of risk factors rather than through testing 2
• Redirect anxiety toward evidence-based reassurance: fetal movement awareness, appropriate prenatal care intervals, and education about warning signs requiring evaluation 2