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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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Shanahan MA, Aagaard KM, McCullough LB, Chervenak FA, Shamshirsaz AA. Society for Maternal-Fetal Medicine Special Statement: Beyond the scalpel: in utero fetal gene therapy and curative medicine. Am J Obstet Gynecol 2021; 225:B9-B18. [PMID: 34537158 DOI: 10.1016/j.ajog.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
With the recent advances in gene editing with systems such as CRISPR-Cas9, precise genome editing in utero is on the horizon. Sickle cell disease is an excellent candidate for in utero fetal gene therapy, because the disease is monogenic, causes irreversible harm, and has life-limiting morbidity. Gene therapy has recently been proven to be effective in an adolescent patient. Several hurdles still impede the progress for fetal gene therapy in humans, including an incomplete understanding of the fetal immune system, unclear maternal immune responses to in utero gene therapy, risks of off-target effects from gene editing, gestational age constraints, and ethical questions surrounding fetal genetic intervention. However, none of these barriers appears insurmountable, and the journey to in utero gene therapy for sickle cell disease and other conditions should be well underway.
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Affiliation(s)
- Matthew A Shanahan
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | - Kjersti M Aagaard
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
| | | | - Francis A Chervenak
- Society for Maternal-Fetal Medicine, 409 12 St. SW, Washington, DC 20024, USA.
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Ethical, Legal, and Social Implications of Fetal Gene Therapy. Clin Obstet Gynecol 2021; 64:933-940. [PMID: 34668890 DOI: 10.1097/grf.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
As fetal gene therapies move from experimental animal models to human in utero phase I clinical trials, there is a need to consider the ethical, legal, and social implications. While fetal gene therapies are attracting more regulatory oversight than previous fetal interventions such as fetal surgery, old sociological questions should be applied to this new context. As health care pathways around fetal therapy are shaped by the ways in which a pregnant person and the fetus are constituted, and as risks and benefits are evaluated, we cannot afford to lose sight of long-term consequences, especially those pertaining to social inclusion.
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Anesthesia for Fetal Interventions - An Update. Adv Anesth 2021; 39:269-290. [PMID: 34715979 DOI: 10.1016/j.aan.2021.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Åhman A, Edvardsson K, Fagerli TA, Darj E, Holmlund S, Small R, Mogren I. A much valued tool that also brings ethical dilemmas - a qualitative study of Norwegian midwives' experiences and views on the role of obstetric ultrasound. BMC Pregnancy Childbirth 2019; 19:33. [PMID: 30651083 PMCID: PMC6335783 DOI: 10.1186/s12884-019-2178-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Accepted: 01/04/2019] [Indexed: 02/03/2023] Open
Abstract
Background Midwives are the main providers of routine antenatal care services including the routine ultrasound examination in Norway. The ultrasound examination can be perceived by expectant parents not only as a medical examination but also as a social event facilitating attachment to their fetus. This study explores Norwegian midwives’ experiences and views on the role of ultrasound in clinical management of pregnancy. Methods A qualitative study design was applied. Twenty-four midwives who all performed obstetric ultrasound examinations were recruited for focus group discussions and individual interviews. Data collection took place in 2015 in five hospitals in two different regions of Norway. Data were analyzed using qualitative content analysis. Results Midwives described obstetric ultrasound examinations as very valuable although doing ultrasounds placed high demands on their operational and counselling skills. Increasing requests for ultrasound from pregnant women were mentioned. Advancements in ultrasound diagnosis were considered to have put the fetus in the position of a patient, and that pregnant women declining ultrasound could be viewed as irresponsible by some health professionals. Ethical concerns were raised regarding the possibility of pregnancy termination when fetal anomalies were detected. Fears were also expressed that prenatal diagnoses including those following ultrasound, might create a society where only ‘perfect’ children are valued. However, participants stressed that their intention in performing ultrasound was to optimize pregnancy outcome and thereby assist expectant couples and their unborn children. Conclusions Midwives in Norwegian maternity care services describe obstetric ultrasound as very valuable, playing a central role in pregnancy management by optimizing pregnancy outcomes. Although high demands are placed on operators’ technical skills and counseling, midwives described performing obstetric ultrasound as very satisfying work. However, midwives believed that expectant parents’ approach to the ultrasound examination, both its medical value and the precious images obtained of the fetus, could put extra strain on the midwives performing ultrasounds. The potential of ultrasound to detect fetal anomalies and the possibility that this may lead to termination of pregnancy, seemed to create some ambivalent feelings in midwives towards its use. Electronic supplementary material The online version of this article (10.1186/s12884-019-2178-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annika Åhman
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden
| | - Kristina Edvardsson
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden. .,Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.
| | - Tove Anita Fagerli
- National Center for Fetal Medicine, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Elisabeth Darj
- Department of Obstetrics and Gynecology, St Olavs Hospital, Trondheim, Norway.,Department of Public Health and Nursing, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Sophia Holmlund
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden
| | - Rhonda Small
- Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia.,Reproductive Health, Women's and Children's Health, Karolinska Institute, Stockholm, Sweden
| | - Ingrid Mogren
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden.,Judith Lumley Centre, La Trobe University, Melbourne, Victoria, Australia
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Nassr AA, Erfani H, Fisher JE, Ogunleye OK, Espinoza J, Belfort MA, Shamshirsaz AA. Fetal interventional procedures and surgeries: a practical approach. J Perinat Med 2018; 46:701-715. [PMID: 28599395 DOI: 10.1515/jpm-2017-0015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Accepted: 04/19/2017] [Indexed: 12/25/2022]
Abstract
Abstract
The identification of congenital birth defects and fetal malformations continues to increase during the antenatal period with improved imaging techniques. Understanding of how to treat specific fetal conditions continues to improve outcomes from these treatment modalities. In an effort to further improvement in this field, we provide a review that begins with a brief background of fetal surgery including the history of fetal surgery, ethics surrounding fetal surgery, and considerations of how to treat the fetus during intervention. A synopsis of the most commonly encountered disease processes treated by fetal intervention/surgery including definitions, treatment modalities, and outcomes following fetal intervention/surgery is then provided. Within the sections describing each disease process, methodology is described that has helped with efficiency and success of procedures performed at our institution.
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Affiliation(s)
- Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA.,Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Hadi Erfani
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - James E Fisher
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Oluseyi K Ogunleye
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Jimmy Espinoza
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, TX, USA
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Hospital Pavilion for Women, 6651 Main Street, Houston, TX 77030, USA,
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In case you missed it: The Prenatal Diagnosis
editors bring you the most significant advances of 2017. Prenat Diagn 2018; 38:83-90. [DOI: 10.1002/pd.5210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2018] [Accepted: 01/01/2018] [Indexed: 12/14/2022]
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Anesthesia for Fetal Intervention and Surgery. Anesthesiology 2018. [DOI: 10.1007/978-3-319-74766-8_29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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