The (mis)use of fetal viability as the determinant of non-criminal abortion in the Netherlands and England and Wales

Time plays a fundamental role in abortion regulation. In this article, we compare the regulatory frameworks in England and Wales and the Netherlands as examples of the centrality accorded to viability in the determination of the parameters of non-criminal abortion, demonstrating that the use of viability as a threshold renders the law uncertain. We assess the role played by the concept of viability, analysing its impact upon the continued criminalization of abortion and categorization of abortion as a medical matter, rather than a reproductive choice. We conclude that viability is misconceived in its application to abortion and that neonatal viability (relating to treatment of the premature infant) and fetal viability (related to the capacity to survive birth) must be distinguished to better reflect the social context within which the law and practice of abortion operate. We show how viability thresholds endanger pregnant people.

Melatonin administration during the first half of pregnancy improves the reproductive performance of rabbits: Emphasis on ovarian and placental functions

This study was designed to investigate the roles of melatonin administration during different sensitive windows of the first half of pregnancy in the function and gene expression of the ovary and placenta, hormone profile, and pregnancy outcomes in rabbits. Four equal experimental groups of 20 rabbits each were used. The first (FW), second (SW), and third (F + SW) groups comprised rabbits that orally received 0.7-mg melatonin/kg body weight during the first week, second weeks, and during both weeks of pregnancy; and the fourth group served as the control group (C). The total number of visible follicles significantly increased in all melatonin-treated groups compared with that in the C group. In all melatonin-treated groups, the number of absorbed fetuses was significantly reduced, whereas the weights of embryonic sacs and fetuses were higher than in the C group. The placenta efficiency was significantly increased in the F + SW group compared with that in the C group, followed by the SW group, whereas no significant difference in the placenta efficiency was found between the FW and C groups. Melatonin treatments significantly improved the expression of antioxidants, gonadotropin receptors, and cell cycle regulatory genes in the ovary, whereas only FW treatment upregulated steroidogenic acute regulatory gene. Compared with the C and FW groups, melatonin treatments during the SW and F + SW significantly upregulated the expression of most genes in the placenta. The concentrations of estradiol were significantly higher in the SW and F + SW groups than in the FW and C groups. The concentrations of progesterone were significantly increased in the FW group compared with those in the C and SW groups, whereas the F + SW group showed intermediate values. The litter size and weight at birth significantly increased in all melatonin-treated groups compared with those in the C group. The second week of pregnancy seems to be a sensitive window for melatonin actions during pregnancy. Thus, melatonin administration during the second week of pregnancy can be effective in improving pregnancy outcomes in rabbits.

[Severely injured pregnant women-The obstetrical perspective!]

The treatment of severely injured pregnant women places the highest demands on interdisciplinary cooperation in order to adequately account for maternal and fetal requirements. In the preclinical stage the mother must be optimally stabilized and treated. Important is the correct left lateral position (15° to relieve the vena cava) during the transfer to the trauma unit. On arrival at the hospital, obstetricians and neonatologists should be involved in the diagnostic and therapeutic measures at an early stage. In principle, all methods that are used in non-pregnant polytrauma patients should also be used without hesitation, especially in the initial routine diagnostics in order to establish the best treatment plan. The question of emergency delivery depends on the gestational age, the acute situation of the fetus and the mother as well as the risks resulting from the next therapeutic steps with respect to monitoring and intervention options in favor of the child.

Premature rupture of the membranes at 16 weeks: report of a successful outcome of pregnancy and review of the literature

Prelabor rupture of the fetal membranes (premature rupture of membranes, PROM) before or at the limit of fetal viability is condition associated with significant and serious pediatric morbidity and mortality. It is a rare problem, with an estimated incidence between 0.1 and 0.7%. Management of this condition is one of the most challenging clinical situations in obstetrics. We report the case of a pregnant woman presenting at 16 weeks gestation with ruptured membranes. The course of pregnancy was further complicated by complete placenta previa. Expectant management was undertaken, with term delivery and successful outcome of pregnancy. Expectant management is a reasonable approach in properly selected patients. Better understanding of the mechanisms of spontaneous membrane resealing is needed in order to improve poor outcomes. More published data and evidence are necessary to standardize treatment options for this rare condition.

[Antenatal management in case of preterm premature rupture of membranes before fetal viability: CNGOF Preterm Premature Rupture of Membranes Guidelines]

OBJECTIVES

To evaluate the maternal, perinatal and long-term prognosis in the event of previable premature rupture of the membranes (PROM) and to specify the interventions likely to reduce the risks and improve the prognosis.

METHODS

The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted.

RESULTS

Previable PROM is a rare event whose frequency varies from 0.3 to 1% according to estimates (NP4). When occurring as a complication of amniocentesis, the prognosis is generally better than when spontaneous (NP3). Between 23 and 39% of women will deliver in the week following PROM and nearly 40% of women will not have given birth 2 weeks after (NP3). The frequency of medical termination of pregnancy varies greatly according to the studies (NP4), as does that of fetal death (NP4). Hospital survival and survival rates without major morbidity as a proportion of conservatively treated patients range from 17-55% and 26-63%, respectively (NP4). Neonatal prognosis is largely dominated by prematurity and its complications (NP3). The frequency of maternal sepsis varies from 0.8 to 4.8% in the most recent studies (NP4). Only one case of maternal death is reported, although 3 cases were identified in France between 2007 and 2012 (NP3). Information is a major component of the care to be provided to women and their partners (Professional consensus). An initial period of hospitalization may be proposed after previable PROM (Professional consensus). Thereafter, there is no argument to recommend hospital management rather than extra-hospital management when there is no argument in favour of intrauterine infection (Professional consensus). An evaluation of the amount of amniotic fluid by ultrasound may be proposed at the initial consultation and after a period of 7 to 14 days if pregnancy continues (Professional consensus). Prophylactic antibiotic treatment is recommended as soon as PROM is diagnosed (Professional consensus). The gestational age at which corticosteroid therapy may be proposed will depend on the thresholds selected for neonatal resuscitation care. In particular, it will take into account parental positioning (Professional consensus). From the time of the decision to perform neonatal resuscitation until the gestational age of 32 weeks, it is recommended to administer MgSO₄ to the woman whose delivery is imminent (Grade A). Tocolysis is not recommended in this context (Professional consensus). In certain situations, meeting strictly the conditions mentioned by the CSP article L. 2213-1, a maternal request for medical interruption of pregnancy may be discussed.

CONCLUSION

The levels of evidence of scientific work on the management of previable PROM are low, therefore, most of the recommendations proposed here are based on professional agreement by "reasonable" extension of recommendations valid for later gestational ages.

Opinions of Brazilian resuscitation instructors regarding resuscitation in the delivery room of extremely preterm newborns

OBJECTIVE

To describe the opinions of pediatricians who teach resuscitation in Brazil on initiating and limiting the delivery room resuscitation of extremely preterm infants.

METHOD

Cross-sectional study with electronic questionnaire (Dec/2011-Sep/2013) sent to pediatricians who are instructors of the Neonatal Resuscitation Program of the Brazilian Society of Pediatrics, containing three hypothetical clinical cases: (1) decision to start the delivery room resuscitation; (2) limitation of neonatal intensive care after delivery room resuscitation; (3) limitation of advanced resuscitation in the delivery room. For each case, it was requested that the instructor indicate the best management for each gestational age between 23 and 26 weeks. A descriptive analysis was performed.

RESULTS

560 (82%) instructors agreed to participate. Only 9% of the instructors reported the existence of written guidelines at their hospital regarding limitations of delivery room resuscitation. At 23 weeks, 50% of the instructors would initiate delivery room resuscitation procedures. At 26 weeks, 2% would decide based on birth weight and/or presence of fused eyelids. Among the participants, 38% would re-evaluate their delivery room decision and limit the care for 23-week neonates in the neonatal intensive care unit. As for advanced resuscitation, 45% and 4% of the respondents, at 23 and 26 weeks, respectively, would not apply chest compressions and/or medications.

CONCLUSION

Difficulty can be observed regarding the decision to not resuscitate a preterm infant with 23 weeks of gestational age. At the same time, a small percentage of pediatricians would not resuscitate neonates of unquestionable viability at 26 weeks of gestational age in the delivery room.