Transabdominal chorionic villus biopsy in second and third trimesters of pregnancy to determine fetal karyotype.

Transabdominal chorionic villus biopsy is an established method of obtaining material for analysing fetal chromosomes in the first trimester of pregnancy but has not been widely used for karyotyping in the second and third trimesters, when rapid results are required. The technique was evaluated in two groups of patients, comprising 106 at risk of having a fetus with chromosomal anomalies (105) or X linked disease (one) studied between 13 and 22 weeks (median 15 weeks) of gestation (group 1) and 21 with abnormal fetal findings on ultrasonography studied between 13 and 38 weeks (median 27 weeks) (group 2). Chorionic tissue was collected at the first attempt in 109 patients and at the second attempt in a further 17 independent of the position of the placenta. In one case from group 1 sufficient material for analysis could not be obtained. Seven abnormal karyotypes (six in group 1 and one in group 2) were diagnosed. Karyotyping was unsuccessful in two cases in group 1 (at 17 and 18 weeks'' gestation) and in two in group 2 (at 29 and 38 weeks'' gestation). Follow up of group 1 four weeks after sampling showed no signs of adverse fetal development apart from one unexplained intrauterine fetal death. The findings suggest that chorionic sampling is a safe and valuable additional technique for the late detection of chromosomal defects.     

Life support for 10 weeks with successful fetal outcome after fatal maternal brain damage.

A 31 year old woman in whom subarachnoid and intracerebral haemorrhage occurred during the second trimester of pregnancy was sustained in intensive care with a respirator for 10 weeks. Computed tomography of the brain showed bilateral intraventricular haemorrhages. Because of drug resistant hypotonic episodes at 31 weeks'' gestation caesarean section was performed, and a boy was delivered. The woman died of spontaneous cardiac arrest two days after caesarean section, and the boy showed normal development. Life support can be continued for several weeks in a modern intensive care unit after fatal insult to the brain even in a pregnant woman without affecting the fetus.     

Comparison of medical abortion with surgical vacuum aspiration: women's preferences and acceptability of treatment.

OBJECTIVES--To assess women''s preferences for, and the acceptability of, medical abortion and vacuum aspiration in the early first trimester. DESIGN--Patient centred, partially randomised trial. Medical abortion was performed with mifepristone 600 mg followed 48 hours later by gemeprost 1 mg vaginal pessary. Vacuum aspiration was performed under general anaesthesia. SETTING--Teaching hospital in Scotland. PATIENTS--363 women undergoing legal induced abortion at less than nine weeks'' gestation. MAIN OUTCOME MEASURES--Women''s preferences for method of abortion before abortion; acceptability judged two weeks after abortion by recording the method women would opt to undergo in future and by semantic differential rating technique. RESULTS--73 (20%) women preferred to undergo medical abortion, and 95 (26%) vacuum aspiration; 195 (54%) were willing to undergo either method, and were allocated at random. Both procedures were highly acceptable to women with preferences. Gestation had a definite effect on acceptability in randomised women; at less than 50 days there were no differences, but between 50 and 63 days vacuum aspiration was significantly more acceptable. CONCLUSIONS--Women who wish to use a particular method should be allowed their choice, regardless of gestation. Women of 50-63 days'' gestation without preferences for a particular method are likely to find vacuum aspiration more acceptable. A patient centred, partially randomised trial design may be a useful tool in pragmatic research.     

Feto-maternal haemorrhage in therapeutic abortion

The incidence of feto-maternal haemorrhage in induced abortion has been studied with the Kleihauer technique. All four methods of termination used were shown to result in such haemorrhages. The incidence below 12 weeks'' gestation, however, was very small and there seems to be no reason for offering routine rhesus-immunoglobulin to these women. When it is essential to terminate a pregnancy of 12 weeks'' size or more in a rhesus-negative woman immunoglobulin should be given.     

The Viable Violinist

In the aftermath of the Kermit Gosnell trial and Giubilini and Minerva's article ‘After‐birth abortion’, abortion‐rights advocates have been pressured to provide an account of the moral difference between abortion, particularly late‐term abortion, and infanticide. In response, some scholars have defended a moral distinction by appealing to an argument developed by Judith Jarvis Thomson in A defense of abortion. However, once Thomson's analogy is refined to account for the morally relevant features of late‐term pregnancy, rather than distinguishing between late‐term abortion and infanticide, it reinforces their moral similarity. This is because late‐term abortion requires more than detachment – it requires an act of feticide to ensure the death of the viable fetus. As such, a Thomsonian account cannot be deployed successfully as a response to Giubilini and Minerva. Those wishing to defend late‐term abortion while rejecting the permissibility of infanticide will need to provide an alternative account of the difference, or else accept Giubilini and Minerva's conclusion.     

Endpiece: The noble profession

ObjectivesTo assess whether bacterial vaginosis or chlamydial infection before 10 weeks'' gestation is associated with miscarriage before 16 weeks.DesignProspective cohort study.Setting32 general practices and five family planning clinics in south London.Participants1216 pregnant women, mean age 31, presenting before 10 weeks'' gestation.Results121 of 1214 women (10.0%, 95% confidence interval 8.3% to 11.7%) miscarried before 16 weeks. 174 of 1201 women (14.5%, 12.5% to 16.5%) had bacterial vaginosis. Compared with women who were negative for bacterial vaginosis those who were positive had a relative risk of miscarriage before 16 weeks'' gestation of 1.2 (0.7 to 1.9). Bacterial vaginosis was, however, associated with miscarriage in the second trimester at 13-15 weeks (3.5, 1.2 to 10.3). Only 29 women (2.4%, 1.5% to 3.3%) had chlamydial infection, of whom one miscarried (0.32, 0.04 to 2.30).ConclusionBacterial vaginosis is not strongly predictive of early miscarriage but may be a predictor after 13 weeks'' gestation. The prevalence of Chlamydia was too low to assess the risk, but it is unlikely to be a major risk factor in pregnant women.

What is already known on this topic

Miscarriages are common and associated with considerable morbidity and costsBacterial vaginosis is associated with miscarriage after 16 weeks'' gestation and preterm birth but the role of chlamydial infection is uncertain

What this study adds

Bacterial vaginosis is not a strong predictor of miscarriage before 16 weeks'' gestation but may be associated with miscarriage at 13-15 weeks'' gestationThe prevalence of chlamydial infection was too low for it to be a major risk factor for miscarriage in this population of healthy pregnant womenNon-invasive screening for bacterial vaginosis and chlamydial infection by using self administered vaginal swabs is feasible in pregnant women in the community     

Changing prognosis for babies of less than 28 weeks' gestation in the north of England between 1983 and 1994. Northern Neonatal Network.

OBJECTIVE: To investigate the changing prognosis for babies of less than 28 weeks'' gestation. DESIGN: A prospective, collaborative, population based survey. SETTING: The former Northern Regional Health Authority. SUBJECTS: All the births between 1983 and 1994 at 22 to 27 completed weeks'' gestation to women normally resident in the region. MAIN OUTCOME MEASURES: Miscarriage, stillbirth, death in the first year of life, and disability in survivors. RESULTS: There were 479070 registered births in the study period. No baby of 22 weeks'' gestation survived; only eight (4%) of the 197 babies of 23 weeks who were alive at the onset of labour survived for a year-a proportion that did not change during the study period. Survival among other babies of less than 28 weeks improved progressively between 1983-6 and 1991-4, but administration of artificial surfactant to babies requiring ventilation from mid-1990 was associated with further improvement in survival only in those over 25 weeks'' gestation. Babies of 24 weeks required three times as much high dependency care per survivor as babies of 27 weeks (76 v 26 days). The rate of severe disability in the one year survivors of less than 26 weeks'' gestation (30/123; 24%) was similar to that seen in the sampled survivors of 26 and 27 weeks (29/108; 27%); the proportion disabled did not change significantly during the study period. All the children born in 1983, 1987, and 1991 were later reassessed in greater detail: 10% (13/136) seemed destined for a continuing life of total dependency. CONCLUSIONS: Gestation, if accurately assessed, can give a woman facing very preterm delivery a clear indication of the prognosis for her baby and help her judge the appropriateness of accepting obstetric intervention and sustained perinatal support.     

Is routine induction of labour at term ever justified?

Balancing the risks of prolonged gestation against those of induced labour is difficult. Risks to the fetus increase slightly after 42 weeks'' gestation but women having labour induced are more likely to have instrumental deliveries or babies with low Apgar scores. Since many women are now expressing a preference for minimal interference in childbirth the most acceptable management of post-term pregnancy seems to be increased fetal surveillance. Each case needs to be considered individually and it is important that the woman is involved in the decision to induce.     

Prognosis for infants born at 23 to 28 weeks' gestation.

The survival and neurodevelopmental outcome of 356 extremely preterm infants born at 23 to 28 weeks'' gestation were reported by week of gestation. Their corrected 1 year survival improved from 7% at 23 weeks to 75% at 28 weeks. The overall incidence of impairment was 19% and of major disability 12%. Boys had a significantly lower normal survival than girls. Multiple births had a significantly lower survival and higher incidence of impairment than singleton births. Predictions of outcome were made before delivery, after resuscitation, and at 1 week to aid the development of guidelines on when perinatal intensive care is justified, whether obstetric intervention for fetal reasons is warranted, and what initial and ongoing prognoses to give to parents. Intensive care for progressively smaller and more immature infants, many of whom were previously considered non-viable, needs to be carefully monitored by every perinatal centre.     

Bottom-up advocacy strategies to abortion access during the COVID-19 pandemic: Lessons learned towards reproductive justice in Brazil

In Brazil, abortion is only allowed in cases of rape, serious risk to a woman's life or fetal anecephaly. Legal abortion services cover less than 4% of the Brazilian territory and only 1,800 procedures are performed, in average, per year. During the COVID-19 pandemic, almost half of the already few Brazilian abortion clinics shut down and women had to travel even longer distances, reaching abortion services at later gestational ages. In this paper, we describe three bottom-up advocacy strategies that emerged from difficulties deepened during the COVID-19 pandemic at a single abortion service in Brazil, amidst anti-gender policies from the federal government. Telemedicine abortion, outpatient surgical abortion and the provision of abortion after 20 weeks' gestation are important strategies that may reduce inequalities that impact the most vulnerable populations, such as black and indigenous women, children, adolescents and women experiencing domestic violence.     

Requests for late termination of pregnancy: Tower Hamlets, 1983.

The case histories of all women seeking late (more than 20 weeks'' gestation) abortion in the NHS district of Tower Hamlets in 1983 were assessed. Of 12 women requesting late abortion, seven underwent termination of pregnancy. All the women had severe social or psychological problems, or both. The main reasons for late presentation were denial of pregnancy, youth, and mental disorder. In a small group of atypical women late abortion seems to be justified for reasons other than fetal abnormality.     

Primary care and abortion legislation in Chile: A failed point of entry

While Chile's partial decriminalization of abortion in 2017 was a long overdue recognition of women's sexual and reproductive rights, nearly four years later the caseload remains well below expectations. This pattern is the product of standing barriers in access to abortion-related health services, especially at the primary care point of entry. This study seeks to identify and describe these barriers. The findings presented here were obtained through a qualitative, exploratory study based on 19 semi-structured interviews with relevant actors identified through non-random sampling and snowballing techniques. Coding was inductive and complemented by semantic content analysis. The authors find that the key barriers in primary care to accessing legal abortion are unfamiliarity with the law, insufficient practitioner training, intersectoral discrimination, and the stigma surrounding abortion. They conclude that the government needs to exercise its constitutional mandate as guarantor of public health and act promptly to safeguard and guarantee the abortion rights of Chilean women.     

Masking of fetal supraventricular tachycardia by electronic monitoring artefact.

In a fetus of 42 weeks'' gestation electronic monitoring demonstrated a heart rate of 120 beats/min that lacked the normal variability. Auscultation with a fetoscope revealed the true rate to be 240 beats/min. When used in the external Doppler mode the fetal monitor had a 250-ms refractory period after the recognition of a fetal cardiac event. This precluded recognition of the next beat and produced the artefactual halving of the heart rate. With the increasing reliance upon electronic fetal monitoring, those practising obstetrics should be aware of the possibility of artefacts and ensure that they can recognize truly representative information about the fetus.     

Antenatal diagnosis of sphingolipid and mucopolysaccharide storage diseases.

In 4 years of 24 fetuses at risk for various sphingolipid and mucopolysaccharide storage diseases were examined. Amniocentesis at 16 weeks'' gestation was followed in most cases by culture of amniotic fluid cells and measurement in the cells of the activity of the enzyme suspected to be deficient. Six fetuses were affected; five were examined morphologically and biochemically after abortion. Two fetuses had Tay-Sachs disease, two had GM1 gangliosidosis and one had Hurler''s syndrome. Although in each affected detus the specific enzyme activity was absent, we found in the placenta 5 to 50% of the normal activity.     

High incidence of preterm births and early losses in pregnancy after in vitro fertilisation. Australian in vitro fertilisation collaborative group.

A fertilisation cohort of 244 pregnancies resulting from in vitro fertilisation was reported to a national register by eight units specialising in in vitro fertilisation. Early pregnancy losses were high, with 5% tubal ectopic pregnancies, 18% biochemical pregnancies, and an incidence of spontaneous abortion of 27%. Among pregnancies of at least 20 weeks'' gestation 22% were multiple, with 26 pairs of twins and four sets of triplets. The incidence of preterm births was more than three times higher than in the general population. Low birthweight rates were also higher, owing both to preterm births and to multiple pregnancies. The sex ratio and the incidence of major congenital malformations were similar to those in naturally conceived pregnancies. In this series the high fetal losses at all stages of pregnancy suggested maternal reproductive causes and should not be interpreted as being due to factors peculiar to in vitro fertilisation. Further analysis will be necessary when larger numbers are available.     

Antenatal diagnosis of thalassaemia major.

Haemoglobin synthesis was studied in fetal blood samples obtained at 17 to 20 weeks'' gestation in 22 women at risk of carrying a fetus with homozygous beta-thalassaemia. A presumptive diagnosis of homozygous beta-thalassaemia was made in four cases, and the pregnancy was terminated. An inconclusive answer was obtained in one case, and the patient also chose to have her pregnancy terminated. Two fetuses were lost as a result of the procedure. Of the remaining 15 pregnancies, 13 proceeded to term and two to 36 weeks; in each case a normal infant or one heterozygous for beta-thalassaemia was delivered. Current efforts should be directed towards improving the blood sampling technology so that fetal blood sampling can be used widely in those countries where thalassaemia is a major problem.     

Rh isoimmunization during pregnancy: antenatal prophylaxis.

Of 3533 Rh-negative women who began a pregnancy without detectable Rh antibodies, 62 (1.8%) demonstrated evidence of Rh isoimmunization during pregnancy or within 3 days after delivery. All denied transfusions as well as abortions or previous pregnancies not followed by the administration of Rh immune globulin. Rh isoimmunization during pregnancy or within 3 days after delivery, which will not be prevented by the administration of Rh immune globulin after delivery, is the most important cause of residual Rh isoimmunization. A clinical trial of antenatal administration of Rh immune globulin, initially at 34 weeks''s and subsequently at 28 and 34 weeks'' gestation, in 1357 Rh-negative pregnant women who were delivered of Rh-positive babies, was effective in preventing the development of Rh isoimmunization during pregnancy or within 3 days after delivery. Antenatal prophylaxis with Rh immune globulin will be necessary if the incidence of Rh isoimmunization is to be reduced to its lowest possible level. Antenatal prophylaxis at 28 weeks'' gestation is now an insured service in Manitoba.     

Locating the beginnings of pain

This paper examines the question of whether a fetus can feel pain. The question is divided into four sub questions: What is pain? What is the neurology of pain processing? What is the fetus? Are there good reasons for holding that fetuses feel pain? Pain is suggested to be a multi-dimensional phenomenon drawing on emotional and sensory processes – a consequence of a gradual development involving a number of noxious events rather than an automatic consequence of injury or disease. The non-automaticity of pain is emphasised in the discussion of pain neurology that defies explanations based on a specialised neuronal ‘pain-centre’. The development of the fetus is considered with respect to developmental neurobiology, behavioural and neurological responses to stimulation, and hormonal and neurochemical responses to noxious stimulation. While acknowledging that the development of the fetus is complex, especially after 26 weeks gestation, considerable development is still to occur, even after birth. The fetal pain literature is criticised for tending to exaggerate fetal development. Finally, the difficulty of explaining the subjectivity of pain in materialist terms is discussed. Pain is suggested to arise with development of the necessary neurological, cognitive and emotional structures. Pain experience is placed at approximately 12 months of age, though this is within the context of a continuum of awareness rather than a straight ‘on-off’ switch. The major moral implication of this stance is to place the burden of proof for analgesic use onto clinical measures, rather than relying upon the, so far, poorly supported assumption of pain awareness.     

Avoiding the Personhood Issue: Abortion,Identity, and Marquis's ‘Future‐Like‐Ours’ Argument

One reason for the persistent appeal of Don Marquis' ‘future like ours’ argument (FLO) is that it seems to offer a way to approach the debate about the morality of abortion while sidestepping the difficult task of establishing whether the fetus is a person. This essay argues that in order to satisfactorily address both of the chief objections to FLO – the ‘identity objection’ and the ‘contraception objection’ – Marquis must take a controversial stand on what is most essential to being the kind of entity that an adult human being is. Such a stand amounts to a controversial account of personhood. To the extent that FLO's success depends on accepting such a controversial metaphysical view, one apparent attraction of FLO proves illusory.