Pregnant Women Who Have Termination of Pregnancy due to Congenital Fetal Anomaly

Background: Congenital disorders are a global problem with a greater incidence in developing countries. Knowing the presence of congenital abnormalities in pregnancy is a bad experience that is very unpleasant. In fact, it is Bed Breaking News which is very difficult for a pregnant woman to accept. A special approach is needed to inform patients and their families. Especially if the pregnancy termination will be carried out. Methods: A case report of a 26-year-old second pregnant woman, with multiple congenital fetal anomaly Results and Discussion: The mental stress experienced before and after the termination of pregnancy proved to be a serious problem. Knowing that there are congenital and multiple abnormalities in the baby they are carrying, pregnant women experience shock, sadness, and do not want to accept it, let alone termination of pregnancy. The patient even had time to seek a second opinion to reassure him. After the termination of pregnancy, the patient has just entered a recovery period and is gradually improving. Conclusion: Although it takes time, the patient is ready to accept the results of the examination and agrees to terminate the pregnancy.


I. INTRODUCTION
The reported incidence of congenital fetal anomaly (CFA) is 3.8% worldwide. Each year approximately 150,000 pregnant women in the United States are diagnosed with CFA, with 47% to 90% choosing to terminate their pregnancy [1], [2]. The use of high-frequency transvaginal ultrasound and advances in technology improve detailed anatomic visualization in early pregnancy and leading to increased detection rates of severe fetal structural anomalies.
The mental stress experienced before and after the termination of pregnancy has proven to be a serious problem. One study found that 44% of women who had pregnancy termination had posttraumatic stress levels 10 times higher than women who had a vaginal delivery [3]. In addition, the level of sadness and persistence of posttraumatic stress symptoms in women after the termination of pregnancy due to CFA was found to be constant when measured between two years and seven years after termination [4].
The five stages of grief theory by Kubler-Ross was often used initially to describe the response of patients with a terminal illness to their impending death: denial, anger, bargaining, depression, and acceptance. In subsequent developments, this theory is often used also widely to describe a person's grieving response in various conditions [5].
Effective interventions for pregnant women who are about to undergo termination of pregnancy for CFA are urgently needed. Women who will and have gone through the process of termination of pregnancy need professional support. The cognitive-behavioral model in Figure 1, can be a useful guide for determining the direction of intervention. This model has a psychotherapeutic approach with two central themes, namely, cognition can control emotions and behavior; and Behavior can greatly influence thought patterns and emotions. This model guides clinicians to understand the relationship between thoughts, emotions, and behavior and can be used to develop effective interventions.

II. CASE PRESENTATION
A woman, 26 years old, Hindu, Balinese, with a bachelor's degree, was consulted to a mental polyclinic for evaluation of mental readiness to undergo the process of termination of pregnancy. The patient is currently diagnosed with a second pregnancy at 28 weeks of gestation, with multiple congenital fetal anomalies namely Atrioventricular Septal Defect (AVSD), Spine Skeletal Distortion, Dextrocardia, Cleft Lip, Flat Nose, Micrognathia). The patient came accompanied by his husband, seemed calm, and could answer questions smoothly. During the interview occasionally looked sad and tried to contain his emotions. The patient already knew that his baby had abnormalities from the results of an ultrasound examination (ultrasonography) 2 months ago by an obstetrician that the fetus had a body deformity The patient felt very shocked and sad when he heard the news, had cried continuously for the first 2 days. I couldn't believe it because so far I had never experienced any complaints or abnormalities during her pregnancy, I had followed all the doctor's advice. The patient had tried to seek a second opinion from another obstetrician in the hope that the explanation from the first doctor was not correct, but after going to the second doctor he got the same result.
Regarding this condition, the patient and husband held discussions with the extended family to determine the next steps. Currently the patient is calm and can accept his condition. The patient said that he was ready to undergo the termination procedure because he felt this was the best decision and way.

III. DISCUSSION
The diagnosis of multiple congenital abnormalities is only known for the first time without any prior suspicion. The patient did not expect to get this news when it came to the obstetrician's control. When he was first told about the diagnosis, he was in shock, sadness and disbelief. At that point the patient is in the denial phase. There was a cognitive reaction in the patient in the form of thoughts that appeared "So far the results of previous controls have always been good, why is it suddenly like this?", "There must be something wrong because so far I have never had complaints or abnormalities during pregnancy. I always follow the doctor's advice." In this phase, emotional reactions are also obtained where the patient feels shock and extraordinary sadness so that it leads to a behavioral reaction where the patient cries for 2 days and doubts the results of the diagnosis.
In the next phase, namely the confirmation phase, the patient's cognitive reaction is obtained in the form of thoughts that appear "Is my fetus really experiencing abnormalities? Is this doctor's diagnosis wrong?" In this phase, the patient begins to face the diagnosis of CFA, he has not received the diagnosis of CFA but begins to look for what is wrong such as maybe the doctor's diagnosis is wrong, maybe the ultrasound device is problematic. In this phase other emotional reactions begin to appear in the patient, he hopes to get more evidence to show that this diagnosis is wrong, there is still hope that the fetus is okay. This encourages behavioral reactions where he begins to seek and collect information based on his cognitive and emotional reactions. The patient tries to visit another obstetrician to seek a second opinion in the hope of getting different results.
After passing the confirmation phase where the patient received the same diagnosis from a second opinion, he entered the next phase, namely the decision-making phase. In this phase, the patient's cognitive reaction was obtained where after collecting information and a second opinion, he finally received a diagnosis of CFA and elicited a cognitive reaction "Currently the fetus has abnormalities, what should I do? How is the process of this pregnancy going on?". At this time, the patient reviews the doctor's explanation regarding the choice of actions that can be taken and discusses it with his husband and extended family as a behavioral reaction. Here the patient experiences a difficult process in making decisions. After considering the pros and cons and going through a long discussion the patient made the decision to undergo the termination process. In this phase, the patient's emotional reactions are more intense where he feels sad, helpless, and loses hope.
When the termination process has been carried out, the patient will enter the recovery phase. In this phase the patient will have various cognitive reactions such as "I have lost my baby, how can I adapt now. What about my next pregnancy?" The patient when asked to discuss this said that he was not afraid to get pregnant again. However, she doesn't want to get pregnant again in the near future, maybe 2-3 years and now she just wants to focus on taking care of her first child who is only 1.5 years old. And if later she plans to get pregnant again, she will consult more intensively with her obstetrician to prepare for it." In this phase it is very important for the patient to get support from the surrounding environment.

IV. CONCLUSION
It has been reported a case of a pregnant woman with 28 weeks of pregnancy, her second child, with multiple congenital fetal anomalies (AVSD, Spine Skeletal Distortion, Dextrocardia, Cleft Lip, Flat Nose, Micrognatia) who will undergo a pregnancy termination process. On evaluation, it was found that the patient was able to accept his condition and was ready to undergo the pregnancy termination procedure. It is important to carry out a mental evaluation in each phase of the cognitive-behavioral model to determine the direction of intervention so that the patient can finally be ready and accept his situation before the pregnancy termination process is carried out.