After missing one menstrual period Mrs van Tonder performs a pregnancy test and is thrilled to know that she is pregnant. Dr Lombard advises her to continue with folic acid supplementation that she had started prior to conception and to attend all her antenatal visits. Dr Lombard based this advice on the results of various randomized controlled trials and a systematic review that demonstrated the efficacy of administering folate supplements to periconceptual women. At eight weeks of gestation, she has a “dating scan” performed by ultrasound in order to visualise the fetus and its surrounding membranes. The size of the fetus, site of the placenta and the amount of liquor appear normal. Towards the end of her first trimester, a repeat ultrasound is performed to check nuchal translucency. The images reveal a small midline cystic mass overlying the vertebral column in the lumbosacral region. Once Dr Lombard sees these results he explains to the van Tonders that there is a defect in the baby’s vertebral column, which he calls “spina bifida cystica”. He counsels the couple on their options, including termination of pregnancy. He felt it necessary to advise them that if they choose this option that he will refer them to another doctor as he does not perform abortions. He felt it necessary to advise them that if they choose this option that he will refer them to another doctor as he does not perform abortions. The couple decide to continue with the pregnancy.

Dr Lombard explains that further tests need to be performed and at 16 weeks of gestation, blood is drawn from Mrs van Tonder and for various laboratory tests. The results show a raised alpha- feto-protein (AFP). The pregnancy continues uneventfully and at the advice of Dr Lombard, a Caesarian section is performed at 38 weeks gestation. On the birth of the baby the parents see a large “raw” lump protruding from their baby’s lower back. The also notice that the baby’s legs are bowed and that both feet are twisted inwards. The paediatrician explains to them that there is nerve involvement of the lower limbs and discusses the immediate and long-term options. Even though Mrs Van Tonder earns a good salary, she and her husband are anxious because these treatment options will involve high, long-term medical costs.