The "Critical Element of Genetic Evaluation and Genetic Counseling" was written and approved by genetic professionals and perinatologists within the state of Washington. The document is to act as an aid to medical geneticists, genetic counselors, and perinatologists who practice within our state. This Critical Element of Genetic Evaluation and Genetic Counseling does not define the applicable standard of care, nor is it intended to dictate an exclusive course for the diagnosis, counseling, treatment or management of genetic conditions or birth defects. The authors acknowledge that appropriate clinical practices may vary depending upon a number of factors including, among others, the needs and choices of the individual patient, the resources available, and limitations unique to the particular institution or type of practice.

1. Review mother/family questions; reason for referral; knowledge base; perception and impact of ultrasound findings and/or risk; what diagnoses have been considered; perceived notion of causation; assess need for professional interpreter:

2a. Using standard symbols, obtain family history (1st and 2nd degree relatives to consultand, and further removed as appropriate). Note ethnic background, consanguinity, ongoing pregnancies, and other significant family history.

b. Additional directed family history: miscarriages, neonatal death, known or suspected chromosome abnormalities, individuals with multiple anomalies/MR.

c. Obtain relevant medical records on mother/affected family member(s), including records on appropriate diagnostic testing/evaluation: ultrasound report, maternal serum screening, AFAFP, ACHE testing, karyotype and genetic evaluations, and on other family members as needed:

3. Obtain mother's past and current pregnancy history documenting: gestational age, Rh, prenatal exposures, pregnancy complications and pertinent prenatal testing to date.

4. Obtain parents' past medical history.

5. Obtain information on education, employment and social functioning as appropriate.

6. Assess family functioning and use of community resources, as appropriate. Assess personal (e.g. social, ethnocultural, religious) issues, including feelings about prenatal testing and consequences.

7. Assess ethical issues, such as confidentiality, insurability, discrimination and non-paternity.

8. Other issues to consider:

(this may occur in a series of multiple patient visits)

1a. Discuss ultrasound findings, limitations of ultrasound examination; consider appropriateness of repeating ultrasound examination.

b. Discuss differential diagnoses based on ultrasound findings and available information. Discuss likelihood of each.

c. Arrange for additional tests/evaluations on mother and/or father of the baby, or other family members, if indicated:

d. Discuss general background risk for birth defects, including any additional risk based on family history/ethnicity/maternal age/maternal disease/maternal exposure/others: :increased recurrence risk is identified for the couple with a child with a neural tube defect, or other family members, maternal predisposing factors i.e. history of diabetes mellitus, teratogen exposure, single gene disorders and chromosome abnormalities

2a. Review additional prenatal testing options based on differential diagnosis, probability of diagnosis, gestational age, and availability:

b. Discuss risks and limitations of prenatal testing options, including sensitivity/specificity of test method(s); specific diagnostic testing not available for all condition; availability of specific diagnostic test may be dependent on gestational age: Although level of defect may be related to motor/sensory function mental impairment cannot be predicted in utero.

3. Explore psychosocial impact of testing vs. non-testing, ethical issues, and discuss the decision making process. Refer to outside resources as appropriate to help with decision making. (Process includes the discussion of outcomes/results; additional testing; option and availability of termination of pregnancy and discussion of methods; grief and supportive counseling; pediatric follow up; and support groups): refer to pediatric neurosurgeon; serial US as appropriate

4. Make plans for relaying results and/or arrangements for follow-up tests if desired/indicated; and/or additional prenatal testing as indicated.

5a. Discuss the following prenatal and perinatal issues related to this pregnancy: diagnosis or possible diagnoses, fetal prognosis including expected course during gestation, anticipated possible maternal or fetal medical complications, and management of pregnancy and delivery, or arrangements for termination of pregnancy if desired and as available:

b. Discuss the following postnatal issues related to the natural course after delivery: prognosis, anticipated possible medical complications, developmental outcomes/intellectual functioning: Mental retardation/learning disabilities, motor and sensory loss, development of hydrocephalus, mode of delivery, polyhydramnios, post-dates

c. Discuss follow-up evaluation after delivery: consider: medical genetics evaluation, photographs, appropriate lab/imagining/diagnostic studies, autopsy if non-viable condition.

d. Discuss inheritance pattern of disorder(s) based on final diagnosis, including risk for future pregnancies and the availability of prenatal diagnosis. Refer to prenatal and clinical CE if diagnosis made: recurrence risk will be dependent upon etiology of NTD

6. Document status of decision(s) by mother/partner.

7. Consider referral to specific community resources and support groups.March of Dimes, Spina Bifida Association, Spina Bifida Clinics

8. Document each clinic visit, including persons present, and subsequent substantive contacts (e.g. clinic note, +/- letter to referring source, +/- letter to family, other). Contact referring health care provider as appropriate.

9. Other issues to consider: preconceptional folic acid supplementation in all future pregnancies; mode/place of delivery; need for fetal autopsy if appropriate

10. References and/or other protocols: