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Rousseau AC, Riggan KA, Schenone MH, Whitford KJ, Pittock ST, Allyse MA. Ethical considerations of maternal-fetal surgery. J Perinat Med 2022; 50:519-527. [PMID: 35092654 DOI: 10.1515/jpm-2021-0476] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022]
Abstract
The practice of maternal-fetal surgery (MFS) has expanded from lethal fetal conditions to conditions which are significantly disabling but not a lethal fetal abnormality. The inclusion of myelomeningocele within the scope of MFS in the 1990s sparked a renewed debate over the ethics of MFS. While demonstrating increasing efficacy and range of application, MFS continues to be ethically fraught due to the inherent tension between maternal and fetal interests. Ethical issues central to MFS include the patienthood of the fetus; the balance of risks and benefits between the woman and fetus; informed consent for experimental procedures; and determination of conditions that meet ethical qualifications for MFS intervention. These concerns are likely to persist and evolve as perinatal medicine continues to advance. Here we summarize the current state of MFS ethics, highlighting the major positions in the literature thus far as well as examine future directions. It is essential robust discussions of these important issues continue both to ensure ethical medical practice and to provide support to clinicians, pregnant women, and their families.
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Affiliation(s)
- Abigail C Rousseau
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA
| | - Kirsten A Riggan
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA
| | - Mauro H Schenone
- Department of Obstetrics & Gynecology, Division of Maternal and Fetal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Department of Internal Medicine, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Siobhan T Pittock
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Endocrinology and Metabolism, Mayo Clinic, Rochester, MN, USA
| | - Megan A Allyse
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA.,Department of Obstetrics and Gynecology, Mayo Clinic, Rochester, MN, USA
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2
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McCullough LB, Coverdale JH, Chervenak FA. Professional integrity in maternal - fetal innovation and research: an essential component of perinatal medicine. J Perinat Med 2021; 49:1027-1032. [PMID: 34013678 DOI: 10.1515/jpm-2021-0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 04/14/2021] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Clinical innovation and research on maternal-fetal interventions have become an essential for the development of perinatal medicine. In this paper, we present an ethical argument that the professional virtue of integrity should guide perinatal investigators. METHODS We present an historical account of the professional virtue of integrity and the key distinction that this account requires between intellectual integrity and moral integrity. RESULTS We identify implications of both intellectual and moral integrity for innovation, research, prospective oversight, the role of equipoise in randomized clinical trials, and organizational leadership to ensure that perinatal innovation and research are conducted with professional integrity. CONCLUSIONS Perinatal investigators and those charged with prospective oversight should be guided by the professional virtue of integrity. Leaders in perinatal medicine should create and sustain an organizational culture of professional integrity in fetal centers, where perinatal innovation and research should be conducted.
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Affiliation(s)
- Laurence B McCullough
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
| | - John H Coverdale
- Department of Psychiatry and Behavioral Sciences and Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, TX, USA
| | - Frank A Chervenak
- Department of Obstetrics and Gynecology, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, NY, USA
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3
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Roets E, Dierickx S, Deliens L, Chambaere K, Dombrecht L, Roelens K, Beernaert K. Healthcare professionals' attitudes towards termination of pregnancy at viable stage. Acta Obstet Gynecol Scand 2020; 100:74-83. [PMID: 32740906 DOI: 10.1111/aogs.13967] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Revised: 06/29/2020] [Accepted: 07/23/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Upon prenatal diagnosis of congenital malformations, termination of pregnancy (TOP) may be an option, sometimes at a gestational age when the fetus is already viable (late TOP). We aimed to study attitudes towards late TOP of all tertiary healthcare professionals involved in late TOP practice. MATERIAL AND METHODS A mail survey was conducted among all physicians and paramedical professionals involved in late TOP decision-making in all eight centers with a Neonatal Intensive Care Unit in Flanders, Belgium (N = 117). The questionnaire contained general and case-based attitude items. RESULTS Response rate was 79%. Respondents were either physicians (51.1%) or paramedical professionals (49.9%). The composition of professionals involved in late TOP decision-making was heterogeneous between the eight centers. Late TOP was highly accepted in both lethal fetal conditions (100%) and serious (but not lethal) fetal conditions (95.6%). Where the fetus is healthy, 19.8% of respondents agreed with late TOP for maternal psychological problems and fewer respondents (13.2%) agreed with late TOP in the case of maternal socio-economic problems (P = .002). Physicians more often preferred feticide over neonatal palliative care in the case of non-lethal fetal conditions compared with paramedical professionals (68.1% vs 53.2%, P = .013). Almost nine out of ten respondents (89.1%) agreed that in the event of a serious (non-lethal) neonatal condition, administering drugs with the explicit intention to end neonatal life was acceptable. Behavioral intentions indicate that even in situations with an unclear diagnosis and unpredictable prognosis, 85.6% of professionals would still consider late TOP. CONCLUSIONS Healthcare professionals practicing late TOP in Flanders, Belgium have a high degree of tolerance towards late TOP, irrespective of sociodemographic factors, and are demanding legislative change regarding active life-ending in the fetal and neonatal periods. Further research should explore the correlation of attitudes to late TOP with actual medical decisions taken in daily clinical practice.
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Affiliation(s)
- Ellen Roets
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Ghent, Belgium.,Department of Obstetrics, Women's Clinic, University Hospital Ghent, Ghent, Belgium
| | - Sigrid Dierickx
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Laure Dombrecht
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kristien Roelens
- Department of Obstetrics, Women's Clinic, University Hospital Ghent, Ghent, Belgium
| | - Kim Beernaert
- End-of-Life Care Research Group, Ghent University & Vrije Universiteit Brussel, Ghent, Belgium.,Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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4
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Power S, Meaney S, O'Donoghue K. An assessment of the general public's knowledge of fatal fetal anomalies. Prenat Diagn 2018; 38:883-890. [PMID: 30144106 DOI: 10.1002/pd.5348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 07/13/2018] [Accepted: 08/13/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE The objective of the study is to evaluate the general population's knowledge of fatal fetal anomaly (FFA). METHODS Descriptive statistics were utilised to describe the data. Chi-square tests assessed associations with knowledge of FFA, termination of pregnancy (TOP) for FFA, and perinatal palliative care (PPC). RESULTS Nine hundred seventy adults of the Irish population selected by random digit dialling with 83.9% (n = 814) agreed to partake. Only 30% could correctly define FFA with little knowledge demonstrated regarding the classification of FFA. Almost half of the respondents were unaware that medical intervention was required for survival once born. Half of respondents stated that they did not know if PPC could commence at diagnosis, once the baby reached 24 weeks or not until the baby was born alive. One in 5 had knowledge that medical follow-up after TOP for FFA was available, and a third were unaware that bereavement care was available following a TOP for FFA. CONCLUSION This study identifies lack of accurate knowledge on FFA, its classification, diagnosis, survival, and supports available following a diagnosis of FFA among the general public. This knowledge deficit highlights the need for improved health information about FFA in antenatal education and public health campaigns to facilitate informed decision-making following a FFA diagnosis.
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Affiliation(s)
- Stacey Power
- Pregnancy Loss Research Group, The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland
| | - Sarah Meaney
- Pregnancy Loss Research Group, The Irish Centre for Fetal and Neonatal Translational Research (INFANT), University College Cork, Cork, Ireland.,National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
| | - Keelin O'Donoghue
- National Perinatal Epidemiology Centre, University College Cork, Cork, Ireland
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5
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Frati P, Fineschi V, Di Sanzo M, La Russa R, Scopetti M, Severi FM, Turillazzi E. Preimplantation and prenatal diagnosis, wrongful birth and wrongful life: a global view of bioethical and legal controversies. Hum Reprod Update 2017; 23:338-357. [PMID: 28180264 DOI: 10.1093/humupd/dmx002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 01/11/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Prenatal diagnosis based on different technologies is increasingly used in developed countries and has become a common strategy in obstetric practice. The tests are crucial in enabling mothers to make informed decisions about the possibility of terminating pregnancy. They have generated numerous bioethical and legal controversies in the field of 'wrongful life' claims (action brought by or on behalf of a child against the mother or other people, claiming that he or she has to endure a not-worth-living existence) and 'wrongful birth' claims (action brought by the mother or parents against the physician for being burdened with an unwanted, often disabled child, which could have been avoided). OBJECTIVE AND RATIONALE The possibility which exists nowadays to intervene actively by programming and deciding the phases linked to procreation and birth has raised several questions worldwide. The mother's right to self-determination could be an end but whether or not this right is absolute is debatable. Freedom could, with time, act as a barrier that obstructs intrusion into other people's lives and their personal choices. Therapeutic choices may be manageable in a liberal sense, and the sanctity of life can be inflected in a secular sense. These sensitive issues and the various points of view to be considered have motivated this review. SEARCH METHODS Literature searches were conducted on relevant demographic, social science and medical science databases (SocINDEX, Econlit, PopLine, Medline, Embase and Current Contents) and via other sources. Searches focused on subjects related to bioethical and legal controversies in the field of preimplantation and prenatal diagnosis, wrongful birth and wrongful life. A review of the international state of law was carried out, focusing attention on the peculiar issue of wrongful life and investigating the different jurisdictional solutions of wrongful life claims in a comparative survey. OUTCOMES Courts around the world are generally reluctant to acknowledge wrongful life claims due to their ethical and legal implications, such as existence as an injury, the right not to be born, the nature of the harm suffered and non-existence as an alternative to a disabled life. Most countries have rejected such actions while at the same time approving those for wrongful birth. Some countries, such as France with a law passed in March 2002, have definitively excluded Wrongful Life action. Only in the Netherlands and in three states of the USA (California, Washington and New Jersey) Wrongful Life actions are allowed. In other countries, such as Belgium, legislation is unclear because, despite a first decision of the Court allowing Wrongful Life action, the case is still in progress. There is a complete lack of case law regarding wrongful conception, wrongful birth and wrongful life in a few countries, such as Estonia. WIDER IMPLICATIONS The themes of 'wrongful birth' and 'wrongful life' are charged with perplexing ethical dilemmas and raise delicate legal questions. These have met, in various countries and on certain occasions, with different solutions and have triggered ethical and juridical debate. The damage case scenarios result from a lack of information or diagnosis prior to the birth, which deprives the mother of the chance to terminate the pregnancy.
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Affiliation(s)
- Paola Frati
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy
- Malzoni Clinical Scientific Institute, Via Carmelo Errico 2, 83100 Avellino, Italy
| | - Vittorio Fineschi
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy
- Malzoni Clinical Scientific Institute, Via Carmelo Errico 2, 83100 Avellino, Italy
| | - Mariantonia Di Sanzo
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy
| | - Raffaele La Russa
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy
- Malzoni Clinical Scientific Institute, Via Carmelo Errico 2, 83100 Avellino, Italy
| | - Matteo Scopetti
- Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Viale Regina Elena 336, 00161 Rome, Italy
| | - Filiberto M Severi
- Obstetrics and Gynecology, Department of Molecular and Developmental Medicine, University of Siena, Via Aldo Moro 2, 53100 Siena, Italy
| | - Emanuela Turillazzi
- Section of Legal Medicine, Department of Clinical and Experimental Medicine, University of Foggia, Viale degli Aviatori, 71100 Foggia, Italy
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6
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Phithakwatchara N, Nawapun K, Panchalee T, Viboonchart S, Mongkolchat N, Wataganara T. Current Strategy of Fetal Therapy I: Principles of In-utero Treatment, Pharmacologic Intervention, Stem Cell Transplantation and Gene Therapy. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0129-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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7
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Kett JC, Wolfe E, Vernon MM, Woodrum D, Diekema D. The multidisciplinary fetal center: clinical expertise is only part of the experience. Acta Paediatr 2017; 106:930-934. [PMID: 28258594 DOI: 10.1111/apa.13812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/20/2017] [Accepted: 02/28/2017] [Indexed: 11/27/2022]
Abstract
AIM Multidisciplinary foetal centres have recently emerged in partnership with children's hospitals throughout the United States. The aim of this investigation was to describe the patient experience of pregnant women who were referred to our foetal centres for the evaluation of foetal congenital anomalies. METHODS A qualitative interview study of women referred to our foetal centres was conducted using semi-structured telephone interviews. The data were coded and analysed using thematic networks analysis. RESULTS Six themes were identified (i) foetal centre evaluations had a far-reaching impact on participants' lives, (ii) participants appreciated both expertise and support from providers, (iii) participants recognised the need to cope with uncertainty, (iv) participants sought additional support from multiple arenas, (v) participants specifically looked to the Internet for both information and support and (vi) participants had pre-established views about pregnancy termination. CONCLUSION Multidisciplinary foetal centres can provide a unified source of clinical expertise to women who are carrying a foetus with a suspected or identified congenital anomaly. Despite this diagnostic acumen, uncertainty is pervasive and patients seek support and additional information from a variety of other sources. This investigation is an important initial step in the evaluation of this emerging model of care.
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Affiliation(s)
| | | | | | - David Woodrum
- Seattle Children's Hospital; Seattle WA USA
- University of Washington; Seattle WA USA
| | - Douglas Diekema
- Seattle Children's Hospital; Seattle WA USA
- University of Washington; Seattle WA USA
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8
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Farrugia MK. Fetal bladder outlet obstruction: Embryopathology, in utero intervention and outcome. J Pediatr Urol 2016; 12:296-303. [PMID: 27570093 DOI: 10.1016/j.jpurol.2016.05.047] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/17/2016] [Indexed: 11/17/2022]
Abstract
Fetal bladder outlet obstruction (BOO), most commonly caused by posterior urethral valves (PUV), remains a challenging and multi-faceted condition. Evolving techniques, and refinement in ultrasound, optics and instrumentation, have increased our rate of prenatal diagnosis, and enabled valve ablation not only in smaller newborns, but also in fetuses. Long-term outcome studies have raised our awareness of the silent damage caused by bladder dysfunction and polyuria and encouraged their proactive management. In spite of our best efforts, the proportion of boys with PUV who progress to chronic and end-stage renal disease (ESRD) has not changed in the last 25 years. Evidence suggests a reduction in perinatal mortality following prenatal intervention, probably resulting from amelioration of oligohydramnios at the crucial time of lung development between 16 and 28 weeks' gestation, but no improvement in postnatal renal outcome. There are no bladder functional outcome studies in patients who have undergone prenatal intervention and hence the long-term effect of in utero defunctionalisation of the bladder is not known. This aim of this review is to revisit the embryopathology of fetal BOO, in particular the renal and bladder structural and functional changes that occur with in utero obstruction. The effect of earlier prenatal diagnosis, and therapy, on postnatal outcome is also explored and compared with outcomes published for traditional postnatal treatment.
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Affiliation(s)
- Marie-Klaire Farrugia
- Chelsea Children's Hospital at the Chelsea & Westminster Hospital Foundation Trust, London SW10 9NH, UK.
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9
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Moreira de Sá RA, Nassar de Carvalho PR, Kurjak A, Adra A, Dayyabu AL, Ebrashy A, Pooh R, Sen C, Wataganara T, Stanojevic M. Is intrauterine surgery justified? Report from the working group on ultrasound in obstetrics of the World Association of Perinatal Medicine (WAPM). J Perinat Med 2016; 44:737-743. [PMID: 26124046 DOI: 10.1515/jpm-2015-0132] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Fetal surgery involves a large number of heterogeneous interventions that vary from simple and settled procedures to very sophisticated or still-in-development approaches. The overarching goal of fetal interventions is clear: to improve the health of children by intervening before birth to correct or treat prenatally diagnosed abnormalities. This article provides an overview of fetal interventions, ethical approaches in fetal surgery, and benefits obtained from antenatal surgeries.
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10
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Kose S, Altunyurt S, Yıldırım N, Keskinoğlu P, Çankaya T, Bora E, Erçal D, Özer E. Termination of pregnancy for fetal abnormalities: main arguments and a decision-tree model. Prenat Diagn 2015. [DOI: 10.1002/pd.4662] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Affiliation(s)
- Semir Kose
- Division of Perinatology, Department of Obstetrics and Gynecology; Dokuz Eylul University School of Medicine; Izmir Turkey
| | - Sabahattin Altunyurt
- Division of Perinatology, Department of Obstetrics and Gynecology; Dokuz Eylul University School of Medicine; Izmir Turkey
| | - Nuri Yıldırım
- Division of Perinatology, Department of Obstetrics and Gynecology; Dokuz Eylul University School of Medicine; Izmir Turkey
| | - Pembe Keskinoğlu
- Department of Biostatistics; Dokuz Eylul University School of Medicine; Izmir Turkey
| | - Tufan Çankaya
- Departments of Medical Genetics; Dokuz Eylul University School of Medicine; Izmir Turkey
| | - Elçin Bora
- Departments of Medical Genetics; Dokuz Eylul University School of Medicine; Izmir Turkey
| | - Derya Erçal
- Departments of Medical Genetics; Dokuz Eylul University School of Medicine; Izmir Turkey
| | - Erdener Özer
- Department of Pathology; Dokuz Eylul University School of Medicine; Izmir Turkey
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11
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Luks FI, Johnson A, Polzin WJ. Innovation in maternal-fetal therapy: a position statement from the North American Fetal Therapy Network. Obstet Gynecol 2015; 125:649-652. [PMID: 25730229 DOI: 10.1097/aog.0000000000000689] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
For conscientious practitioners, innovative medical therapy often occupies an uncomfortable space between formal research and established clinical practice. Newer and more rapid methods of information dissemination increase the risk of advertising unproven therapies. These and other concerns should not stifle medical progress and innovation but require guidelines and boundaries. The problem is not unique to fetal therapy, but rarely do other fields consider the well-being of two individuals at the same time. Herein, the North American Fetal Therapy Network offers expanded guidelines and suggestions regarding medical innovation that are particular to maternal-fetal therapy.
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12
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Howe D. Ethics of prenatal ultrasound. Best Pract Res Clin Obstet Gynaecol 2013; 28:443-51. [PMID: 24374013 DOI: 10.1016/j.bpobgyn.2013.10.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2013] [Revised: 09/23/2013] [Accepted: 10/15/2013] [Indexed: 11/16/2022]
Abstract
Prenatal ultrasound has opened new opportunities to examine, diagnose and treat the fetus, but these advances bring with them ethical dilemmas. In this chapter, I address the ethical principles that need to be considered when treating both mother and fetus as patients, and how these can be applied in practice. In particular, ultrasound practitioners have an ethical duty to maintain their theoretical knowledge and practical skills to ensure they advise parents correctly. I also discuss the ethical issues in carrying out intrauterine therapy, ultrasound-related research, and termination of pregnancy for fetal abnormality.
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Affiliation(s)
- David Howe
- Wessex Fetal Medicine Unit, Princess Anne Hospital, Southampton SO16 5YA, UK.
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13
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Chalouhi GE, Marangoni MA, Quibel T, Deloison B, Benzina N, Essaoui M, Al Ibrahim A, Stirnemann JJ, Salomon LJ, Ville Y. Active management of selective intrauterine growth restriction with abnormal Doppler in monochorionic diamniotic twin pregnancies diagnosed in the second trimester of pregnancy. Prenat Diagn 2012; 33:109-15. [PMID: 23280487 DOI: 10.1002/pd.4031] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE This study aims to compare outcomes of active management of monochorionic diamniotic twin pregnancies complicated with severe intrauterine growth restriction (IUGR) of one twin before 24 weeks with continuous or intermittent absent or reversed end-diastolic flow (AREDF) in the umbilical artery, with or without twin-to-twin transfusion syndrome (TTTS). METHOD This study is a retrospective comparison of 45 consecutive cases of severe selective IUGR (s-IUGR) defined as an estimated fetal weight at or below the fifth centile with a >25% weight discordance and AREDF in the umbilical artery before 24 weeks and 166 consecutive cases of TTTS stage III, with AREDF in the donor (TTTS3D) and also with s-IUGR. These were treated by either selective laser photocoagulation of chorionic vessels (SLPCV) or cord coagulation (CC). RESULTS The 166 cases of TTTS3D were treated by SLPCV, whereas 23 and 22 cases of s-IUGR were treated by SLPCV and CC, respectively. Overall survival was 52.17% or 45.45% in s-IUGR treated by SLPCV or CC, respectively, and 48.49% in TTTS3D. The survival of appropriately grown for gestational age (AGA) twins following CC (90.9%) was higher than that following SLPCV in s-IUGR (74%) or in recipient twins of TTTS3D (55.42%) (p = 0.001). Survival of the IUGR twin was 30% and 41.56% with SLPCV in s-IUGR and TTTS3D, respectively. CONCLUSIONS Active management of severe IUGR with AREDF in the umbilical artery seems beneficial. Survival rates with SLPCV were similar in s-IUGR and TTTS3D. However, there was a trend for higher survival rates in the AGA twin for CC. The choice of the technique should be driven by objective counseling on survival of both IUGR and AGA twins and therefore by the utility-based ethical values expressed by the pregnant woman.
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Affiliation(s)
- G E Chalouhi
- National Referral Centre for Management of Complicated Monochorionic Pregnancies, Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker-Enfants-Malades, 75015, Paris, France
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14
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Gembruch U, Geipel A, Müller A, Bartmann P, Berg C. Intrauterine minimalinvasive Therapie. Monatsschr Kinderheilkd 2012. [DOI: 10.1007/s00112-012-2729-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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15
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Khen-Dunlop N, Sarnacki S, Révillon Y. [When congenital lung malformations have to be operated?]. REVUE DE PNEUMOLOGIE CLINIQUE 2012; 68:101-109. [PMID: 22366487 DOI: 10.1016/j.pneumo.2012.01.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/19/2011] [Indexed: 05/31/2023]
Abstract
Both technical and anatomical features and the need for a long follow-up, usually over several years, explain the specificity of lung surgery in children. Apart from the oncological resections, the main indications for this surgery are congenital lung anomalies (cystic adenomatoid malformation, bronchopulmonary sequestration, lobar emphysema), symptomatic postinfectious lesions (bronchiectasis, atelectasis, abscess) and pneumothorax. Advances in miniaturization of the surgical equipment are used to carry the majority of these interventions by thoracoscopy, except when performed at the neonatal period. In the newborn, for which the indications for lung surgical resections are exceptional, ventilatory conditions and the tightness of the chest lead to still prefer open surgery. Pulmonary malformations can also be managed prenatally when they affect lung development or cause heart failure because of compressive complications. These interventions, performed after the 30th week of gestation, are not intended to remove the lesions, but to release the compression. But these procedures are still under evaluation and, in light of possible fetal and maternal complications, they should only be performed in tertiary centers and in the context of specific protocols.
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Affiliation(s)
- N Khen-Dunlop
- Service de chirurgie pédiatrique viscérale, hôpital Necker-Enfants malades, 149 rue de Sèvres, Paris, France.
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16
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Nicolaides KH, Chitty LS. Fetal therapy: progress made and lessons learnt. Prenat Diagn 2011; 31:619-20. [PMID: 21660999 DOI: 10.1002/pd.2809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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