How dangerous a world is it?

In the Western world approximately 2–3% of all pregnancies result in an infant with a major malformation. Inevitably the parents of such children undergo a period of grieving for “the loss of their normal child” and as a part of that grief they seek to apportion blame. If ocular involvement is a feature of the malformation then it is during the period of their grief that we as ophthalmologists are likely to come into contact with the family. We need to understand this process and during our early contact with the family avoid the twin problems of either being dismissive of their search for a causative agent or, alternatively, being too eager to support their proposal that a particular action or event has been responsible for the outcome of the pregnancy. We are rarely aided in this by the attentions of the “popular press” where the demands of investigative journalism are incompatible with a studied evaluation of possible cause and effect. When trying to identify the effect of a possible teratogen on a pregnancy, there are well established criteria which help in the attribution of blame.

The possible association is often first recognised through case reporting (and that remains a major value of the isolated case report), but these can be misleading. The picture of affected pregnancies in cocaine addicted mothers is a case in point, …