Late Antenatal Booking in Advanced Maternal Age Pregnancy with Suspected Fetal Abnormality and Medico-Legal Considerations

Abstract

Advanced maternal age is associated with increased maternal and fetal risks and warrants timely antenatal assessment. A 37-year-old gravida 7 para 4+2 woman first booked for antenatal care at 22 weeks and 3 days of gestation, after the optimal first-trimester screening period. Prenatal screening and diagnostic options for fetal chromosomal abnormality were discussed and offered at booking, but the patient declined because she considered that the result would not change her decision to continue the pregnancy at that gestation. Specialist assessment subsequently showed a small-for-gestational-age fetus with polyhydramnios, followed by persistent fetal growth restriction with normal doppler findings. At 34 weeks, she developed hypertension with 2+ proteinuria and was managed as pre-eclampsia; concern regarding an underlying chromosomal abnormality was also documented. At 36 weeks and 6 days, emergency caesarean delivery was performed for breech presentation in labour. The 1.47-kg neonate had dysmorphic features suggestive of a severe congenital or chromosomal disorder and died on day 7 without cytogenetic confirmation. The case highlights how early prenatal assessment may provide a wider timeframe for diagnostic clarification, counselling, and consideration of pregnancy-management options, including lawful termination where Malaysian statutory criteria are fulfilled.