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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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Hautier S, Kermorvant E, Khen-Dunlop N, de Wailly D, Beauquier B, Corroenne R, Milani G, Bonnet D, James S, Vinit N, Blanc T, Aigrain Y, Colmant C, Salomon L, Ville Y, Stirnemann J. [Prenatal path of care following the diagnosis of a malformation for which a novel prenatal therapy is available]. ACTA ACUST UNITED AC 2020; 49:172-179. [PMID: 33166705 DOI: 10.1016/j.gofs.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Fetal therapy is part of the available care offer for several severe malformations. The place of these emergent prenatal interventions in the prenatal path of care is poorly known. The objective of this study is to describe the decision-making process of patients facing the option of an emergent in utero intervention. METHODS We have conducted a retrospective monocentric descriptive study in the department of maternal-fetal medicine of Necker Hospital. We collected data regarding eligibility or not for fetal surgery and the pregnancy outcomes of patients referred for myelomeningocele, diaphragmatic hernia, aortic stenosis and low obstructive uropathies. RESULTS All indications combined, 70% of patients opted for fetal surgery. This rate was lower in the case of myelomeningocele with 21% consent, than in the other pathologies: 69% for diaphragmatic hernias, 90% for aortic stenoses and 76% for uropathy. When fetal intervention was declined, the vast majority of patients opted for termination of pregnancy: 86%. In 14% of the considering fetal surgery, the patient was referred too far. CONCLUSION The acceptance rate for fetal surgeries depends on condition. It offers an additional option and is an alternative for couples for which termination of pregnancy (TOP) is not an option. Timely referral to an expert center allows to discuss the place of a fetal intervention and not to deprive couples of this possibility.
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Affiliation(s)
- S Hautier
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - E Kermorvant
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - N Khen-Dunlop
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - D de Wailly
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - B Beauquier
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - R Corroenne
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - G Milani
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - D Bonnet
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - S James
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - N Vinit
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - T Blanc
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Y Aigrain
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - C Colmant
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - L Salomon
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - Y Ville
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France
| | - J Stirnemann
- Maternité et médecine fœtale, hôpital Necker-Enfants-Malades, 149, rue de Sèvres, 75015 Paris, France.
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Riggan KA, Collura CA, Pittock ST, Ruano R, Whitford KJ, Allyse M. Ethical considerations of maternal-fetal intervention in a twin pregnancy discordant for anomalies. J Matern Fetal Neonatal Med 2019; 34:1312-1317. [PMID: 31189438 DOI: 10.1080/14767058.2019.1631793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recent evidence suggests prenatal fetoscopic tracheal occlusion (FETO) may improve the survival and long-term morbidity of neonates with congenital diaphragmatic hernia, yet little guidance exists in the medical literature as to the ethical permissibility of performing a maternal-fetal surgical intervention in a twin pregnancy discordant for a structural abnormality. CASE Here, we present a case of a twin pregnancy with an unaffected twin (Twin A) and a twin diagnosed with severe congenital diaphragmatic hernia (Twin B). A proposed fetoscopic tracheal occlusion (FETO) procedure may improve the likelihood of survival and postnatal outcome of Twin B; however, balloon placement may also initiate very preterm birth at 28 weeks of gestation. The Fetal Ethics Advisory Board was asked to provide guidance on the permissibility of FETO in this pregnancy. DISCUSSION A literature review identified one brief mention of FETO in a 34-week dichorionic twin pregnancy in the medical literature, which resulted in the rupture of fetal membranes in the sac of the nonsurgical twin. Only one paper specifically addressed the question of whether it would be ethically permissible to subject a healthy twin to the risks of maternal-fetal surgery for the benefit of a compromised twin, finding that any risk to the unaffected twin would be an ethical contraindication. We offer our own analysis of moral weight and risk/benefit considerations of this proposed intervention, and present our findings on the circumstances in which it may be ethically permissible to perform a maternal-fetal intervention in a twin pregnancy. CONCLUSION While FETO was not ethically advisable in this pregnancy, we find that in limited circumstances, certain maternal-fetal surgical interventions may be ethically permissible in a twin pregnancy discordant for a structural abnormality if the risks to the unaffected twin are minimal and the procedure would improve the likelihood of survival and postnatal outcome of a critically compromised co-twin.
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Affiliation(s)
- Kirsten A Riggan
- Biomedical Ethics Research Program, Mayo Clinic Rochester, Rochester, MN, USA
| | - Christopher A Collura
- Division of Neonatal Medicine, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Siobhan T Pittock
- Division of Pediatric Endocrinology and Metabolism, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodrigo Ruano
- Division of Maternal and Fetal Medicine, Department of Obstetrics & Gynecology, Mayo Clinic, Rochester, MN, USA
| | - Kevin J Whitford
- Department of Internal Medicine, Division of Hospital Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Megan 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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Abstract
Fetal surgery involves unique ethical issues because the interests of fetus and mother may conflict but, regardless, they are inextricably interconnected. Controversial questions currently include what kinds of surgery should be permitted, who should decide, and whether this surgery should be restricted to specialized centers. Clinical questions include the degree to which mothers should have decision-making authority, the extent, if any, to which mothers should be protected from pressure from family members, and whether physicians should be non-directive. This article discusses these questions and their answers' competing rationales. It also presents recent data from attachment studies of mothers and infants and from neuroscience, which suggest that mothers and infants are more interdependent physiologically and psychologically than has been understood. The paper describes how these findings may apply to the mother and fetus long before it is born. The major implication of this analysis is that mothers should, perhaps, have greater decision making authority.
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Affiliation(s)
- Edmund G Howe
- Department of Psychiatry, Uniformed Services University of the Health Sciences, Bethesda, MD 20814-4799, USA.
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