Fetal Pain in the First Trimester

Investigating the neurobiology of maternal opioid use disorder and prenatal opioid exposure using brain organoid technology

Over the past two decades, Opioid Use Disorder (OUD) among pregnant women has become a major global public health concern. OUD has been characterized as a problematic pattern of opioid use despite adverse physical, psychological, behavioral, and or social consequences. Due to the relapsing-remitting nature of this disorder, pregnant mothers are chronically exposed to exogenous opioids, resulting in adverse neurological and neuropsychiatric outcomes. Collateral fetal exposure to opioids also precipitates severe neurodevelopmental and neurocognitive sequelae. At present, much of what is known regarding the neurobiological consequences of OUD and prenatal opioid exposure (POE) has been derived from preclinical studies in animal models and postnatal or postmortem investigations in humans. However, species-specific differences in brain development, variations in subject age/health/background, and disparities in sample collection or storage have complicated the interpretation of findings produced by these explorations. The ethical or logistical inaccessibility of human fetal brain tissue has also limited direct examinations of prenatal drug effects. To circumvent these confounding factors, recent groups have begun employing induced pluripotent stem cell (iPSC)-derived brain organoid technology, which provides access to key aspects of cellular and molecular brain development, structure, and function in vitro. In this review, we endeavor to encapsulate the advancements in brain organoid culture that have enabled scientists to model and dissect the neural underpinnings and effects of OUD and POE. We hope not only to emphasize the utility of brain organoids for investigating these conditions, but also to highlight opportunities for further technical and conceptual progress. Although the application of brain organoids to this critical field of research is still in its nascent stages, understanding the neurobiology of OUD and POE via this modality will provide critical insights for improving maternal and fetal outcomes.

Interdisciplinary collaborative eye examinations to protect preterm infant neurodevelopment: a quality improvement project

Introduction

Infants born <31 weeks gestational age with birth weight ≤ 1,500 grams receive routine eye examinations to screen for Retinopathy of Prematurity (ROP) while in the Neonatal Intensive Care Unit (NICU) to help prevent vision threatening complications; however, preterm infants' sensory systems are underdeveloped, and repeated exposure to painful stimuli is associated with worse developmental outcomes.

Methods

An interdisciplinary NICU team designed a collaborative eye exam model (CEEM) incorporating best practice recommendations for infant pain control during exams. Pain scores and vital signs were recorded before, during, and after exams. Two sets of mixed-effects regression models with a random intercept on infants were established to investigate relationships between the intervention, birth gestational age (BGA), postmenstrual age (PMA), and outcomes associated with painful stimuli. Survey feedback was elicited from NICU stakeholders about the CEEM.

Results

Thirty standard of care (SC) and 35 CEEM exams of 37 infants were included in final analysis. In infants of the same BGA, the number of desaturation events was significantly reduced in the CEEM group (p = 0.003) and became 1.53 times smaller with each additional week of BGA (p = 0.009). Probability of heart rate recovery within 15 min lowered significantly in the CEEM group (p = 0.04). In SC or CEEM or between infants of the same PMA, no differences were observed for bradycardia, heart rate range, chance of heart rate recovery, or pain scores. Increases in tachycardia (p < 0.001) events and desaturations p = 0.006 were discovered in the CEEM group. When considering interaction effects, the CEEM appeared to reduce the number of desaturations to a greater degree for infants at earliest BGAs with attenuation of this effect with greater BGA. Regarding PMA, bradycardia and tachycardia events were reduced for infants across PMAs in the CEEM, but the effect for tachycardia improves with age, while the effect for bradycardia diminishes with age. Stakeholders agreed that the infant's eye exam experience and the staff experience was "very much" improved by the CEEM.

Discussion

Despite variable findings in selected outcome measures, the CEEM was positively viewed by staff. Infants may benefit from the CEEM differently based on BGA and PMA.

Comparison of Professionally and Parentally Administered Analgesia Before Emergency Department Admission

BACKGROUND

Pediatric patients frequently present to emergency departments in pain.

AIM

A cross-sectional prospective study was conducted to investigate the prevalence of acute pain in children attending the ED and arriving by ambulance, as well as the initial ED management of pain. We describe pediatric pain management practices in the pediatric ED, as well as parental pain relief.

METHOD

Demographic data, medications, and type of transport to hospital were noted. Pain was assessed upon admission and 30 minutes after administration of analgesia. To standardize pain evaluations, only children aged 4 years or older were included in the study. A numeric rating scale was used to assess pain intensity.

RESULTS

The study group consisted of 124 patients. More than 80% of the patients suffered from trauma, injuries to the extremities were the most common cause of admission, and the patient population showed male predominance (62.1%). Over half of the patients (64.51%) were transported by ambulance. Analgesia was administered in 63.5% of the ambulance cases in contrast to only 13.3% of children brought by their parents. Treatment was significantly related to severity of pain.

CONCLUSIONS

Both medical emergency teams and parents administered prehospital analgesia insufficiently and without previous assessment. However, medical emergency teams used medications more often than parents. Analgesic therapy used in the emergency department resulted in significant pain reduction.

Human equality arguments against abortion

In this paper, I argue that a commitment to a very modest form of egalitarianism-equality between non-disabled human adults-implies fetal personhood. Since the most plausible bases for human value are in being human, or in a gradated property, and since the latter of which implies an inequality between non-disabled adult humans, I conclude that the most plausible basis for human equality is in being human-an attribute which fetuses have.

Indiscriminate slaughter of pregnant goats for meat in Enugu, Nigeria: Causes, prevalence, implications and ways-out

BACKGROUND

The indiscriminate slaughter of pregnant goats (SPGs) undermines meat production and food security especially in developing countries. It also connotes animal cruelty, depletion of goat population and may enhance the spread of zoonotic pathogens inhabiting the female reproductive tract during carcass processing. Consequently, this study determined the causes and prevalence of slaughtering pregnant goats for meat in Enugu, Nigeria. The study also estimated the economic losses associated with SPGs, discussed the negative public health consequences and suggested the ways-out.

METHODS

Structured, validated and pilot-tested questionnaire was used to ascertain the reasons for SPGs for meat among 78 willing and randomly selected respondents. The questionnaire survey was conducted in the form of interview. Pregnancy statuses of the goats slaughtered were ascertained by visual inspection and palpation of the eviscerated and longitudinally incised uteri and the horns for macroscopic evidence of pregnancy. Ages of the dams were estimated by dentition method. Estimation of the gestational age was performed by crown-rump length method. The study lasted for six months, comprised of three months (December to March) during the dry/hot season and another three months (May to August) during the wet/rainy season. Economic loss estimation was based on the current monetary values of a matured (30 kilogram) goat and one kilogram of chevon in Enugu, Nigeria; which was determined through market survey. Pearson's Chi-square test was used to determine whether there were significant (P<0.05) statistical associations between SPGs and age and season.

RESULTS

Major reasons adduced for SPGs were: economic hardship (41%), ignorance of the goat's pregnancy status (21%), increased demand for chevon (13%) and feed scarcity during drought (11%). Of the 1,658 does examined during the six months study, 589 (35.5%) were pregnant. The majority (876/1658, 52.8%) of the female goats slaughtered were in their active reproductive age of ≤ 4 years, while 782 (47.2%) were aged > 4 years. Similarly, majority (1007/1658, 60.7%) of the does/nannies were slaughtered during the dry/hot season. A total of 907 foetuses at first (n = 332, 36.6%), second (n = 486, 53.6%) and third (n = 89, 9.8%) trimesters of gestation were recovered from the 589 PGs. Singleton, twin and triplet pregnancies were observed in 312 (53%), 236 (40%) and 41 (7%) PGs, respectively. About ₦34.44 million ($83,390) would have been earned if the foetuses were born alive and raised to maturity. Additionally, 19,136 kg of chevon, valued at ₦47,841, 000 ($115,838), which would have accrued from the wasted foetuses was also lost.

CONCLUSION

Considering the economic, zoonotic and livestock production implications of this work, frantic efforts to reduce SPGs in Enugu, Nigeria is imperative. This could be achieved through advocacy, goat farmers' enlightenment, ante-mortem pregnancy diagnosis, provision of subsidized feed materials during the dry season and strict enforcement of the Nigerian Meat Edict law, which proscribes unapproved slaughter of gravid animals. These measures may improve food safety and security, improve goat reproduction and production, reduce protein malnutrition, limit dissemination of zoonotic pathogens during carcass processing and hence protect public health in Nigeria.

The fetal pain paradox

Controversy exists as to when conscious pain perception in the fetus may begin. According to the hypothesis of cortical necessity, thalamocortical connections, which do not form until after 24-28 weeks gestation, are necessary for conscious pain perception. However, anesthesiologists and neonatologists treat age-matched neonates as both conscious and pain-capable due to observable and measurable behavioral, hormonal, and physiologic indicators of pain. In preterm infants, these multimodal indicators of pain are uncontroversial, and their presence, despite occurring prior to functional thalamocortical connections, has guided the use of analgesics in neonatology and fetal surgery for decades. However, some medical groups state that below 24 weeks gestation, there is no pain capacity. Thus, a paradox exists in the disparate acknowledgment of pain capability in overlapping patient populations. Brain networks vary by age. During the first and second trimesters, the cortical subplate, a unique structure that is present only during fetal and early neonatal development, forms the first cortical network. In the third trimester, the cortical plate assumes this function. According to the subplate modulation hypothesis, a network of connections to the subplate and subcortical structures is sufficient to facilitate conscious pain perception in the fetus and the preterm neonate prior to 24 weeks gestation. Therefore, similar to other fetal and neonatal systems that have a transitional phase (i.e., circulatory system), there is now strong evidence for transitional developmental phases of fetal and neonatal pain circuitry.

Effectiveness of Non-Pharmacological Methods, Such as Breastfeeding, to Mitigate Pain in NICU Infants

Neonates do experience pain and its management is necessary in order to prevent long-term, as well as, short-term effects. The most common source of pain in the neonatal intensive care unit (NICU) is caused by medically invasive procedures. NICU patients have to endure trauma, medical adhesive related skin injuries, heel lance, venipuncture and intramuscular injection as well as nasogastric catheterization besides surgery. A cornerstone in pain assessment is the use of scales such as COMFORT, PIPP-R, NIPS and N-PASS. This narrative review provides an up to date account of neonate pain management used in NICUs worldwide focusing on non-pharmacological methods. Non-steroidal anti-inflammatory drugs have well established adverse side effects and opioids are addictive thus pharmacological methods should be avoided if possible at least for mild pain management. Non-pharmacological interventions, particularly breastfeeding and non-nutritive sucking as primary strategies for pain management in neonates are useful strategies to consider. The best non-pharmacological methods are breastfeeding followed by non-nutritive sucking coupled with sucrose sucking. Regrettably most parents used only physical methods and should be trained and involved for best results. Further research in NICU is essential as the developmental knowledge changes and neonate physiology is further uncovered together with its connection to pain.