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ences in values between counselors and counselees. However, I do not follow the logic of saying that if values of counselors and counselees concur then directiveness is the preferred counseling strategy. If both counselor and counselee value nondirectiveness, should the counselor then be directive? Also, one person's values may be similar to another's yet their needs, longings, and wishes may differ. I suggest that these are the aspects of the person's cognitive and affective functioning which need to be understood by the counselor in personal counseling. Values may change as intrapsychic and interpersonal circumstances and needs change. Also, the values one holds are only a part of the person, not the whole. Sampling a few of the person's values, as the Paukers do, neither leads to the elucidation of all the values the person holds nor does it elucidate the determinants of which values are favored at a specific point in time. From the point of view of quality counseling practices, counselors would probably do better to focus on the core rather than the periphery.

Seymour Kessler1 University of California San Francisco

The Impact of Ultrasound To the Editor:

The inaugural issue of this journal contained a number of thoughtprovoking articles and opens an exciting new venue for dialogue among genetics professionals. We are particularly interested in the findings reported by Dr. Rita Beck Black (1992) regarding the impact of ultrasound examinations on parents who experience adverse pregnancy outcomes. The use of sonography has become accepted as a routine part of prenatal care. This technology offers valuable information about fetal well-being and development. Unlike other prenatal diagnostic procedures (CVS, amniocentesis, PUBS, and MSAFP), however, sonograms are performed without informed consent or formal discussion of the possibility that a se1Correspondence should be directed to Seymour Kessler, P.O. Box 7702, Berkeley, California 94707.

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rious, or even lethal, fetal abnormality might be detected. At a time of heightened discussion in the genetic counseling community about reproductive options and the importance of informed consent prior to screening tests, the ultrasound examination and its emotional impact have rarely been addressed. Expectant parents who have no previous history of pregnancy loss or a fetal abnormality look forward to their sonogram as an opportunity to see and bond with their baby. Some look forward to learning about the baby's sex, their due date, or the presence of twins. Few, however, are prepared to hear bad news. Unlike the invasive procedures of CVS, amniocentesis or PUBS, sonography carries no known risks of maternal or fetal harm. Yet, even a level I sonogram may reveal information for which parents may not be ready or may not want at all to receive during the pregnancy, if given the choice. Adding to the parents' frustration is the fact that sonography often produces a description without a diagnosis, sometimes even necessitating further testing. The detection of an unexpected abnormality during sonography creates a crisis situation often apparent to the sonographer and the patient simultaneously. Even if the sonographer is a technician who is not permitted to give medical information, the patient may note subtle changes in the latter's demeanor. When the sonographer is a physician who is able to discuss the findings immediately with the patient, the two are generally strangers and the bearer of the bad news does not have the advantage of any prior knowledge of the patient's family and reproductive histories or personal circumstances. Ideally, the sonography unit will have a close affiliation with a genetics service so that a genetic counselor can be immediately available to see the parents, provide support and counseling, and assume the role of case manager for the duration of the pregnancy and beyond. This is a well-established role for which genetic counselors have received national attention over the past decade. In her article, Dr. Black states that physicians and technicians who perform sonograms should not only be aware of the anxiety and strong emotions that accompany this test, but should also take an active role in educating patients about these sequelae. Advances in prenatal diagnosis have shaped an era marked by heightened parental expectations for a positive pregnancy outcome. High expectations, however, may result in a lack of parental preparedness for an adverse outcome and its emotional impact. Since sonography is a routine procedure that may have an immediate and devastating effect on expectant parents, we believe that it is genetic counselors who should take a more active role in parental preparation.

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Because it is impractical, as well as impossible, for a genetic counselor to see every patient in the U.S. prior to a sonogram we are developing a pre-sonography fact sheet. This resource will distinguish level I from level II sonography, discuss procedural limitations, and encourage parents to anticipate the possibility that a fetal abnormality may be found and that they may be faced with tough choices. The anxiety and strong emotional reactions aroused for some patients by the ultrasound examination will also be described. We are currently aware of only one other such resource for patients (Massachusetts Genetics Program, 1990) and would therefore appreciate learning about any others."

Judith L. Benkendorf a Georgetown University Medical Center Washington, D.C. Helen Travers IG Laboratories, Inc. Miami, Florida

REFERENCES Black, R (1992). Seeing the baby: The impact of ultrasound technology. J. Genet. Counsel. 1:45-54. Massachusetts Genetics Program and New England Regional Genetics Group (1990). Ultrasound. Prenatal Tests 7-8.

1Correspondence should be directed to Judith L. Benkendorf, Division of Genetics, Department of Obstetrics and Gynecology, Georgetown University Medical Center, 3800 Reservoir Road, NW, Washington, D.C. 20007-2197.

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