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The impact of prenatal ultrasound screening on termination of pregnancy with and without feticide: a retrospective analysis

BMC Pregnancy and Childbirth volume 25, Article number: 508 (2025) Cite this article

Abstract

Background

Provision and uptake of antenatal screening is nonuniform in Austria, as there is no national screening program. The aim of the study was to evaluate the influence of prenatal ultrasound screening methods on the time of diagnosis and therefore the rate of feticide in pregnancies with fetal malformations.

Method

Retrospective data analysis of terminations of pregnancies (TOP) with and without feticide due to fetal structural anomalies at a single tertiary care referral center in Austria between 2007 and 2020.

Results

Over the study period, the number of TOPs increased overall, and a nonsignificant rise in the rate of feticide was observed. Women who underwent TOP without feticide significantly more often had first trimester screening; in particular, 588 (86%) cases compared to 121 (57%) with feticide (p < 0.001). Furthermore, in the subgroup of cases diagnosed after 20 weeks of pregnancy (WoP), a significant association between cases without a mid-trimester anomaly scan and TOP with feticide was found. Gestational age at diagnosis was influenced by the type of malformation and therefore the affected organ system.

Conclusion

First trimester screening is critical in early fetal assessment and preventing unnecessary late terminations and feticide. Mid-trimester anomaly scan further increases the early detection of fetal malformations, especially those that become apparent later in pregnancy. Consequently, comprehensive counselling regarding the benefits of prenatal ultrasound screening should be provided to all pregnant women.

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Background

Over the past decades, there have been major advances in ultrasound scanning. The use of ultrasound in pregnancy has made the detection of fetal anomalies possible. Moreover, developments in the field of fetal medicine, more precisely in the area of prenatal ultrasound, screening and genetic testing, have made the detection of a growing spectrum of fetal malformations and genetic diagnosis possible [1, 2].

Detection rates of fetal malformations are reported up to 60% in the first trimester by Syngelaki et al. and in general approximately 50% at around 18 weeks of gestation in a nonselective population with almost no false-positive diagnosis [3,4,5]. Therefore, it is assumed that the first trimester screening for aneuploidies will become increasingly important for the diagnosis of structural malformations at an early stage of pregnancy [4,5,6,7]. As a consequence, more expectant parents are faced with the decision of whether to terminate a pregnancy or continue the pregnancy. In most countries, women have the option to legally terminate their pregnancy. Up to 90% of terminations of pregnancy (TOP) are performed in the first trimester, less than 10% in the second trimester and the rest in the third trimester [8]. In particular, legal positions regarding late TOP after 23 weeks vary between European countries [9]. In Austria, TOPs after 15 weeks of pregnancy (WoP) are permitted at any stage of pregnancy in case of a serious risk for the woman’s health or life or if there is a strong possibility of severe mental or physical disabilities of the unborn child [10].

Depending on the time of diagnosis and decision making, feticide is necessary for a potentially viable fetus. TOP for fetal anomalies, especially feticides, has psychological consequences for women and their partners, such as depression and posttraumatic stress symptoms [1, 11]. Obviously, an attempt should be made to avoid feticide through screening at an early stage in pregnancy, as prenatal ultrasound at 11 to 14 weeks aims to screen for both major structural fetal anomalies and aneuploidy [5, 12]. However, the provision and uptake of antenatal screening programmes may vary, as may the rate of late pregnancy terminations. It has been shown that there are wide variations regarding antenatal screening programmes throughout Europe [13, 14]. Even though these data are from 2005 to 2008, screening programmes in Europe are still nonuniform. Currently, in Austria, there is no national screening programme, and the uptake of prenatal screening depends on the provision of the hospital the woman is planning to deliver and/or the financial capability of the pregnant woman to afford private antenatal screening.

Therefore, the aim of this study was to evaluate the performance of first trimester screening at 11–13 + 6 weeks and mid-trimester anomaly scan in the second trimester between 19 and 24 weeks and its impact on feticide rate over a period of 14 years in a single tertiary care referral center in Europe.

Materials and methods

Study population

This was a retrospective study of prospectively collected data on1060 terminations of pregnancy, including 809 TOPs without feticide and 251 with feticide for fetal anomalies or genetic abnormalities at a single tertiary care referral center in Europe between 2007 and 2020. Pregnant women with prenatally diagnosed fetal malformations and/or genetic defects who opted for TOP during this time period were included. Exclusion criteria comprised patients with missing data or missing follow-up data, as well as reductions and selective feticide in multiple pregnancies. TOPs due to serious maternal health conditions, such as a malignant disease or a severe cardiac condition and TOPs after positive genetic testing due toa known genetic disorder in the family history were excluded. This approach enabled the evaluation of the influence of prenatal ultrasound screening, which was not relevant in the excluded cases.

Prenatal screening programme

In our tertiary care referral center pregnancy booking occurred during the first trimester with all women routinely offered a first trimester screening (FTS) and mid-trimester anomaly scan according to the ISOUG practice guidelines, at no additional costs [12]. Maternal characteristics and medical history were recorded at booking, and all ultrasound examinations were performed by certified sonographers (Austrian Society of Ultrasound in Medicine; ÖGUM Level II).

FTS was offered between 11 + 0 and 13 + 6 weeks of gestation and included the measurement of nuchal translucency (NT) according to Fetal Medicine Foundation (FMF) standards, as well as additional markers such as nasal bone, ductus venosus flow, and tricuspid valve regurgitation. Although the primary goal of the FTS was screening for common aneuploidies (such as trisomy 21 13 and 18), particular attention was also given to the early detection of major structural anomalies.

In cases of increased risk for common aneuploidies and/or detection of major structural anomalies, an invasive procedure for genetic testing was offered to the patient.

The mid-trimester anomaly scan was performed between 19 + 0 and 22 + 6 weeks of gestation and included a detailed morphological assessment of the fetus, according to the ISUOG guidelines. Both the FTS and the mid-trimester anomaly scan were integrated into routine antenatal care, with an acceptance rate of > 95% over the study period (2007–2020).

In case of a referral at a later gestation, ultrasound examinations were reviewed to ensure adherence to FMF London protocols and ISUOG guidelines. Data from the ViewPoint perinatology database were retrospectively extracted to document the completion of FTS and/or mid-trimester anomaly scans for each case [12, 15].

Termination of pregnancy and feticide

Labor induction followed a standard protocol, with Mifepristone administered initially, followed by Misoprostol. Feticide was offered between 21 + 0 and 22 + 6 weeks for cases where the fetus was potentially viable and was mandatory beyond 23 + 0 weeks unless a lethal condition was confirmed. Feticide was mainly performed via intracardiac injection of potassium chloride or lidocaine; in rare cases, if the fetal heart was not accessible or in case of severe polyhydramnios the injection was administered through the umbilical cord. In Austria, TOP is legal without restriction within the first 12 weeks of pregnancy, later TOPs are permitted if there is a serious risk to the physical or mental health of the pregnant woman or if the fetus has been diagnosed with a severe or fatal anomaly. All cases were reviewed by a multidisciplinary internal ethics and clinical committee to ensure legal compliance adherence to ethical standards.

Counseling and psychological support

All women diagnosed with fetal malformations, regardless of whether they underwent TOP, were offered psychological support. Follow-up psychological care was available on a voluntary basis, with the extent of support decided by the woman or couple. Psychological support was routinely provided before and after TOP by psychologists, and follow-up care was offered even after discharge. Genetic counselling was provided not only for the current pregnancy but also for future family planning. Consultations with neonatologists or paediatricians of differentspecialities (e.g., neurology, paediatric cardiology, nephrology) were available as needed.

Statistical analysis

For statistical analysis metric variables were presented as mean +/- SD in case of standard distribution or median and IQR. Metric variables were compared using Student’s t-test and Mann-Whitney U-test in case of variables not following standard distribution. We used chi-square test to compare binary and categorical variables. Binary logistic regression was used to assess the associations between feticide rate and first trimester screening or mid-trimester anomaly scan. A two-sided p-value of < 0.05 was set for statistical significance. Statistical analyses were performed using IBM SPSS Static Version 23.

To evaluate the impact of the mid-trimester anomaly scan, cases diagnosed before 20 weeks were excluded for this subanalysis.

This manuscript was structured according to the STROBE guidelines (adapted for observational studies using routinely collected health data).

Results

In total, 1060 pregnancies with TOP between 2007 and 2020 at a single tertiary prenatal center, with an average of 2600 live births per year, were evaluated. The average maternal age of women having TOP was 32.1 years (SD ± 6.2), ranging from 13 to 49 years. Overall, 809 fetuses had a TOP at an average of 16.8 weeks of gestation, and in 251 cases, feticide was performed. After excluding cases that underwent TOP due to maternal health conditions and after targeted genetic diagnosis, a total of 965 cases, including 750 TOPs without feticide and 215 with feticide, remained for further calculations.

Overall, the numbers of TOPs increased steadily throughout the a 14-year period from 16 cases/year in 2007 to 111 cases/year in 2020, regardless of the number of annual bookings. Furthermore, the proportion of feticide accelerated slightly in these years (Fig. 1).

Fig. 1
figure 1

Development of numbers of termination of pregnancy (TOP) and feticide from 2007 to 2020

Full size image

To evaluate the rate of feticide throughout this period, years were grouped into three timeframes (2007–2010; 2011–2015, 2016–2020). The comparison of these three groups confirmed the rising trend of the ratio of feticide, from 107 (17.7%) over 274 (21.0%) to 370 (24.2%), respectively, but the calculation could not reach statistical significance.

In total, 852 (88.3%) women had a first trimester screening or mid-trimester anomaly scan during pregnancy. The proportion of women who had screening did not change throughout the time period. A total of 709 (73.5%) of all pregnant women had a first trimester screening. However, patients who solely had a first trimester screening exceeded patients who only had a mid-trimester anomaly scan by far (49.1% vs. 14.9%, p < 0,05), and 234 (24.2%) had both. An overview of all screening methods is shown in Table 1.

Table 1 Overview of screening methods patients underwent and median gestational at diagnosis depending on the screening methods
Full size table

Women who underwent FTS had significantly less often TOPs with feticide than those without; in particular, 121 (17.1%) cases compared to 90 (48.4%) cases with feticide (OR 0.220; 95% CI 0,155-0,330, p < 0.001) (Fig. 2). Overall, results of the FTS showed that the majority (62.5%) of TOPs without feticide had already anomalies detected during this early stage of pregnancy. Therefore, it should be emphasised that in case of abnormal FTS, only 2.5% of cases (11 of 430) had TOP with feticide. In all of these cases solely increased NT was present at first trimester and the final diagnosis could only be made later in pregnancy.

Fig. 2
figure 2

(A) Association between conducted first trimester screening (FTS) and feticide rate. (B) Influence of mid-trimester anomaly scan on the proportion of feticide

Full size image

To analyse a possible influence of the mid-trimester anomaly scan on the rate of feticide, a subset of cases with a diagnosis after 20 WoP (the timepoint after that these screening methods are applied) were evaluated. Feticide rate decreased significantly if women underwent mid-trimester anomaly scan (85.7% vs. 54.7%) (OR 0.201; 95% CI 0.082–0.492, p < 0.001).

Factors affecting the gestational age at diagnosis included whether the pregnant woman had a screening method. The highest median GA at diagnosis was observed in cases that did not have any screening method (neither FTS nor mid-trimester anomaly scan) compared to cases that had first trimester screening with a median of 14.57 weeks independent from the type of malformation diagnosed (Table 1). However, the type of malformation and the affected organ system also had influence on the timepoint of diagnosis (Table 2).

Table 2 Affected organ system in cases with and without feticide and median gestational age at diagnosis
Full size table

Late diagnosis and therefore highest rates of feticide were observed in cases with brain malformations and heart defects or complex fetal malformation affecting more than one organ system. In contrast, cases with fetal hydrops and urogenital malformations were diagnosed earlier in pregnancy and had lowest rates of feticide (Table 2).

Discussion

In this retrospective study, women without first trimester screening weresignificantly more likely to have a late termination of pregnancy with feticide, compared to women undergoing first trimester screening with 48.4% (90/186) vs. 17.1% (121/709) respectively. Additionally, in the subgroup of cases diagnosed with a congenital malformation after 20 WoP, a significant association between cases without a mid-trimester anomaly scan and TOP with feticide was found.

It is widely known that many severe fetal malformations can be detected in the first trimester screening [4]. Moreover, there was a rise in the number of fetal malformations that could be diagnosed between 11 and 13 weeks within recent years. This is due to the implementation of standardsxed protocols and improved quality of technology [5, 16]. However, it must be mentioned that there are still malformations that are only diagnosed at a later time point in pregnancy, regardless of the first trimester screening, as they develop later in pregnancy or just become apparent with advanced gestational age [4].

Optimised screening protocols may enhance early detection of fetal anomalies, particularly through improvements in first-trimester ultrasound techniques. These include enhanced operator training, standardized measurement protocols (as per Fetal Medicine Foundation and ISUOG guidelines), and the use of high-resolution imaging equipment. For pregnancies at increased risk—due to abnormal first-trimester screening (FTS) results or family history—incorporating additional modalities such as early fetal echocardiography may facilitate earlier diagnosis, intervention, and counselling. Implementation of such protocols depends on resource availability and specialist training. While FTS remains a valuable tool for early prenatal screening, individualised approaches that include targeted assessments (e.g., for cardiac and central nervous system anomalies) may be beneficial in selected cases. Further studies are required to assess the clinical utility, cost-effectiveness, and overall impact of these expanded screening strategies.

In our cohort, the main reasons for late TOP with feticide were brain malformation, followed by complex fetal malformation (> one organ systems affected) and congenital heart defects. This is concordant with previously published investigations [17,18,19,20]. Even if some brain abnormalities can be detected in the first trimester, such as alobar holoprosencephaly or acrania [21], the diagnosis of a relevant proportion is usually made after 20 weeks. This is related to fetal neurological development, which does not allow for a significantly earlier diagnosis of condtions such as cerebral haemorrhages, lissencephaly or agenesis of the corpus callosum [22, 23].

Moreover, in our study population, especially in cases with brain malformations but also other affected organ systems, additional fetal MRI was performed to confirm the diagnosis and help to establish a prognosis. Even though fetal MRI is known to add important information and the availability at the Medical University of Vienna is excellent, these additional investigations may delay the diagnosis in some cases. This may also explain, at least in part, the observed increase of feticides over time, which was found to be independent of the rate of first trimester screening and the rate of mid-trimester anomaly scan.

In that respect, the expansion of genetic work-up is another important factor. While at the beginning of the study period, only FISH analysis, karyotyping and Sanger sequencing were used for prenatal genetic diagnosis; over the course of the study period, chromosomal microarray analysis (since 2011) and additional exome sequencing (since 2016) were implemented. With a turnaround time of approximately 4–6 weeks, prenatal exome sequencing led and also will lead in the near future to a delayed time of diagnosis and consequently to the decision and execution of TOP at a later timepoint.

In addition, we demonstrated an overall increase in the number of TOPs over the years. This might be explained by the improvement of ultrasound screening techniques and subsequently the continuous rise of detection rates of congenital malformation, which was also reported previously [18, 24]. Another factor might also be the increasing age of women becoming pregnant and the associated higher rates of chromosomal aberrations [25, 26]. While the improvement in prenatal ultrasound has enabled early prenatal diagnosisand feticides might be prevented, the availability of precise ultrasound, additional MRI and the expansion of advanced genetic analysis could lead to a continuous increase in TOP in the future. Therefore, expectant parents will have to face significant psychological implications associated with late TOP and feticide. Late TOP and feticide have been shown to increase an additional emotional burden on parents already coping with a complex decision-making process, grief, anxiety, and long-term psychological distress. This impact is also felt by the healthcare professionals involved, who face increased emotional stress when managing such sensitive and ethically challenging procedures [8, 9, 27]. It could be shown that these psychological responses may persist over time, underscoring the need for support [28]. However, counselling and support for affected parents is important as this has a positive effect on their psychological outcomes. Kerns et al. explored the relationship between counselling quality, and psychological outcomes regarding anxiety, grief, and posttraumatic stress after second-trimester abortion for pregnancy complications. They could show that shared decision-making and decision satisfaction were associated with lower grief and post-traumatic stress symptoms following second-trimester TOP for pregnancy complications. This highlights the importance of patient-centred counselling approaches that actively involve patients in the decision-making process [29].

In general, counselling should be non-directive, ensuring that parents are fully informed about the diagnosis, prognosis, and all available options.

The main limitation of this study is the retrospective design with the risk of case selection. Another possible bias might be the availability of genetic analyses at different timepoints, such as whole exome sequencing which offers a higher diagnostic yield by enabling the detection of monogenic disorders. Another limitation to mention is, that the use of MRI was not standardised during the study period and was mainly offered in selected cases with suspected central nervous system anomalies, so that the influence on MRI could not be evaluated.

A major strength is the high sample size of this investigation in a single center when compared with most of the previously published investigations.

Conclusions

In conclusion, the present study highlights the importance of prenatal ultrasound screening, especially first trimester screening between 11 + 0 and 13 + 6 weeks, to avoid unnecessary late termination or even feticide in many cases. In addition, mid-trimester anomaly scan at 19–24 WoP also leads to earlier diagnosis of fetal malformations, particularly of certain abnormalities that only become visible during the course of the pregnancy. Avoiding unnecessary late TOP and feticide is of great importance because of the influence of late and very late TOP on the psychological burden of affected parents and increasing emotional stress to the medical and nursing staff as well [8, 9, 27]. Thus, all expecting women should be counselled about the importance of ultrasound screening methods in pregnancy.

Data availability

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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Funding

This study did not receive additional funding.

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Authors and Affiliations

  1. Department of Obstetrics and Gynaecology, Division of Obstetrics and feto-maternal Medicine, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, A-1090, Austria

    Theresa Reischer, Anja Catic, Charlotte Brennus, Christian Göbl & Gülen Yerlikaya-Schatten

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Contributions

Conceptualization, T.R., G.YS. and C.G.; methodology, T.R:.; validation, T.R., C.G.; formal analysis, T.R.; investigation, A.C.; data curation, A.C and C.B.; writing—original draft preparation, T.R.; writing—review and editing, G.YS.; visualization, T.R.; supervision, G: YS.;. All authors have read and agreed to the published version of the manuscript.

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Correspondence to Gülen Yerlikaya-Schatten.

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Ethical approval

Ethics approval was provided by the institutional ethics committee of the Medical University of Vienna (EK 1635/2021–9th of July 2021). The need for consent to participate was deemed unnecessary according to the ethics committee of the Medical University of Vienna due to the retrospective design of the study.

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Not applicable.

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The authors declare no competing interests.

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Reischer, T., Catic, A., Brennus, C. et al. The impact of prenatal ultrasound screening on termination of pregnancy with and without feticide: a retrospective analysis. BMC Pregnancy Childbirth 25, 508 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07611-2

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BMC Pregnancy and Childbirth

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