Ectogestation ethics: The implications of artificially extending gestation for viability,newborn resuscitation and abortion

Recent animal research suggests that it may soon be possible to support the human fetus in an artificial uterine environment for part of a pregnancy. A technique of extending gestation in this way (“ectogestation”) could be offered to parents of extremely premature infants (EPIs) to improve outcomes for their child. The use of artificial uteruses for ectogestation could generate ethical questions because of the technology’s potential impact on the point of “viability”—loosely defined as the stage of pregnancy beyond which the fetus may survive external to the womb. Several medical decisions during the perinatal period are based on the gestation at which infants are considered viable, for example decisions about newborn resuscitation and abortion, and ectogestation has the potential to impact on these. Despite these possible implications, there is little existing evidence or analysis of how this technology would affect medical practice. In this paper, we combine empirical data with ethical analysis. We report a survey of 91 practicing Australian obstetricians and neonatologists; we aimed to assess their conceptual understanding of “viability,” and what ethical consequences they envisage arising from improved survival of EPIs. We also assess what the ethical implications of extending gestation should be for newborn and obstetric care. We analyze the concept of viability and argue that while ectogestation might have implications for the permissibility of neonatal life-prolonging treatment at extremely early gestation, it should not necessarily have implications for abortion policy. We compare our ethical findings with the results of the survey.     

Perinatal outcome of pregnancies in women aged 40 and over

Perinatal outcome of pregnancies at forty and over was analyzed starting from the diagnosis of pregnancy to seven days following delivery. Retrospectively, pre-gestational health and reproduction status were dealt with, as well as the course of pregnancy, deliveries, and newborn children (study group). The control group was composed of pregnant women aged 20 to 29, who were identical to study group in terms of parity. Statistical data processing was done by means of chi2-test, and contingency 2 x 2 tables. The difference was significant if p < 0.05. Out of 2,099 diagnosed wanted pregnancies at forty and over, 415 (19.8%) had a miscarriage, in 33 (1.6%) an artificial abortion was performed after determining the fetus karyotype and 1,651 (78.2%) of pregnant women delivered. In 66.2% of pregnancies the fetus karyotype was determined and in 33 (2.5%) fetuses chromosomal abnormalities were found Incidence of deliveries at 40 and over is 1.38%, which is a 35.6-percent increase in the last ten years. Nullipara and pluripara had an increase, and multipara had a decrease. Pre-gestational health and reproduction status in study group is lower than in control group. Complications during pregnancy: threatened abortion, EPH gestosis, placenta praevia, gestational diabetes, late fetal death are more frequent than in control group (p < 0.05). In intrapartal terms, more frequent were induction of delivery, meconium-stained amniotic fluid, fetal distress, operative vaginal deliveries, and Cesarean section (p < 0.05). In neonatal outcome there are more premature infant, there are more VLBW, LBW, SGA, newborn with low Apgar index values, and the total perinatal death is greater than in the control group (p < 0.05). In perinatal terms, (from the diagnosis to the seventh day following delivery) 1,617 children survived (77.0%), meaning that perinatal loss was 482 (23.0%). Authors conclude that pregnancy at 40 and over is a high-risk pregnancy. There is a high risk of pre-gestational and gestational complications, and perinatal loss is high. Therefore, those pregnancies are not desirable from the medical point of view.     

Selective abortion in Brazil: the anencephaly case

This paper discusses the Brazilian Supreme Court ruling on the case of anencephaly. In Brazil, abortion is a crime against the life of a fetus, and selective abortion of non-viable fetuses is prohibited. Following a paradigmatic case discussed by the Brazilian Supreme Court in 2004, the use of abortion was authorized in the case of a fetus with anencephaly. The objective of this paper is to analyze the ethical arguments of the case, in particular the strategy of avoiding the moral status of the fetus, the cornerstone thesis of the Catholic Church.     

Pregnancy and viral infections: Mechanisms of fetal damage,diagnosis and prevention of neonatal adverse outcomes from cytomegalovirus to SARS-CoV-2 and Zika virus

Some maternal infections, contracted before or during pregnancy, can be transmitted to the fetus, during gestation (congenital infection), during labor and childbirth (perinatal infection) and through breastfeeding (postnatal infection). The agents responsible for these infections can be viruses, bacteria, protozoa, fungi. Among the viruses most frequently responsible for congenital infections are Cytomegalovirus (CMV), Herpes simplex 1–2, Herpes virus 6, Varicella zoster. Moreover Hepatitis B and C virus, HIV, Parvovirus B19 and non-polio Enteroviruses when contracted during pregnancy may involve the fetus or newborn at birth. Recently, new viruses have emerged, SARS-Cov-2 and Zika virus, of which we do not yet fully know the characteristics and pathogenic power when contracted during pregnancy.Viral infections in pregnancy can damage the fetus (spontaneous abortion, fetal death, intrauterine growth retardation) or the newborn (congenital anomalies, organ diseases with sequelae of different severity). Some risk factors specifically influence the incidence of transmission to the fetus: the timing of the infection in pregnancy, the order of the infection, primary or reinfection or chronic, the duration of membrane rupture, type of delivery, socio-economic conditions and breastfeeding. Frequently infected neonates, symptomatic at birth, have worse outcomes than asymptomatic. Many asymptomatic babies develop long term neurosensory outcomes.The way in which the virus interacts with the maternal immune system, the maternal-fetal interface and the placenta explain these results and also the differences that are observed from time to time in the fetal?neonatal outcomes of maternal infections. The maternal immune system undergoes functional adaptation during pregnancy, once thought as physiological immunosuppression. This adaptation, crucial for generating a balance between maternal immunity and fetus, is necessary to promote and support the pregnancy itself and the growth of the fetus. When this adaptation is upset by the viral infection, the balance is broken, and the infection can spread and lead to the adverse outcomes previously described. In this review we will describe the main viral harmful infections in pregnancy and the potential mechanisms of the damages on the fetus and newborn.     

'Beyond being': emergent narratives of suffering in Vietnam

Intertwining ethnographic and literary accounts, this article explores the mutual relationship between suffering and agency. The article describes how young Vietnamese women use narrative to find meaning in the suffering that a late-term abortion causes. Seeking to further develop anthropological use of the concept of social suffering, the article argues that existing scholarship has tended to neglect the importance of human agency and imagination, hinging as it does on suffering as entrenched within structural forces. The article contends that this neglect must be understood in the context of the particular epistemological and ethical conditions under which anthropological studies of human suffering are produced, and that closer attention to the human engagements out of which ethnographic accounts are fashioned may bring into analysis not only the harm that social forces can inflict on people, but also their capacities for action and imagination.     

Guidelines for the Retention,Storage, and Use of Residual Dried Blood Spot Samples after Newborn Screening Analysis: Statement of the Council of Regional Networks for Genetic Services

These guidelines provide scientific information for policy development by state health departments considering appropriate use of newborn screening specimens after screening tests are finished. Information was collected, debated, and formulated into a policy statement by the Newborn Screening Committee of the Council of Regional Networks for Genetic Services (CORN), a federally funded national consortium of representatives from 10 regional genetics networks. Newborn screening programs vary widely in approaches and policies concerning residual dried blood spot samples (DBS) collected for newborn screening. Recognition of the epidemiological utility of DBS samples for HIV seroprevalence surveys and a growing interest in DBSs for DNA analysis has intensified consideration of issues regarding retention, storage, and use of residual DBS samples. Potentially these samples provide a genetic material “bank” for all newborns nationwide. Their value as a resource for other uses has already been recognized by scientists, administrators, and judicial officials. Programs should promulgate rules for retention and use of residual newborn screening DBS samples based on scientifically valid information. Banking of newborn samples as sources of genetic material should be considered in light of potential benefit or harm to society.     

Protecting Future Children from In‐Utero Harm

The actions of pregnant women can cause harm to their future children. However, even if the possible harm is serious and likely to occur, the law will generally not intervene. A pregnant woman is an autonomous person who is entitled to make her own decisions. A fetus in‐utero has no legal right to protection. In striking contrast, the child, if born alive, may sue for injury in‐utero; and the child is entitled to be protected by being removed from her parents if necessary for her protection. Indeed, there is a legal obligation for health professionals to report suspected harm, and for authorities to protect the child's wellbeing. We ask whether such contradictory responses are justified. Should the law intervene where a pregnant woman's actions risk serious and preventable fetal injury? The argument for legal intervention to protect a fetus is sometimes linked to the concept of ‘fetal personhood’ and the moral status of the fetus. In this article we will suggest that even if the fetus is not regarded as a separate person, and does not have the legal or moral status of a child, indeed, even if the fetus is regarded as having no legal or moral status, there is an ethical and legal case for intervening to prevent serious harm to a future child. We examine the arguments for and against intervention on behalf of the future child, drawing on the example of excessive maternal alcohol intake.     

Peripheral Blood Mononuclear Cell Traffic Plays a Crucial Role in Mother-to-Infant Transmission of Hepatitis B Virus

The role of peripheral blood mononuclear cells (PBMCs) in HBV intrauterine infection is not fully defined. Particularly the origin of PBMCs in HBV-infected neonates remains to be addressed. We carried out a population-based nested case-control study by enrolling 312 HBsAg-positive mothers and their babies. PBMC HBV DNA as well as serum HBsAg and HBV DNA was tested in cohort entry samples. Totally, 45.5% (142/312) of the newborns were found to be infected with HBV in perinatal transmission. 119 mother-infant pairs were identified to be different in the genetic profile of maternal and fetal PBMCs by AS-PCR and hemi-nested PCR. Among them, 57.1% (68/119) of the maternal PBMCs in index cases were positive for HBV DNA while 83.8% (57/68) of the HBV DNA positive maternal PBMCs passed the placental barrier and entered the fetus. Furthermore, maternal PBMC HBV infection was significantly associated with newborn infants HBV infection. PBMC traffic from mother to fetus resulted in a 9.5-fold increased risk of HBV infection in PBMC HBV DNA positive newborn infants. These data indicate that maternal PBMCs infected with HBV contribute to HBV intrauterine infection of newborn infants via PBMC traffic from mother to fetus.     

The effect of maternal and cord-blood vitamin C, vitamin E and lipid peroxide levels on newborn birth weight

Background Newborn birth weight has been shown to significantly correlate with the blood levels of vitamin C. Objective This study was planned to answer the question of why vitamin C levels correlate with birth weight; does such correlation reflect a protective effect of vitamin C on fetal growth, by its antioxidant characteristics or does it correspond to the nutritional status of both the mother and the fetus. We examined the hypothesis that maternal blood levels of vitamin C, but not vitamin E influence newborn birth weight. We determined maternal and newborn blood levels of vitamin C, vitamin E, and lipid peroxides (an index of oxidative insult) and the birth weights of full-term newborns delivered at our hospital. Results Compared with maternal blood levels, newborns have higher levels of vitamin C and lipid peroxides, but lower levels of vitamin E. There was a significant correlation in levels between mothers and their newborns for blood levels of vitamin C (r = 0.82, P < 0.01) and vitamin E (r = 0.61, P < 0.02) but not for lipid peroxides (r = 0.001). This suggests that maternal vitamin C and vitamin E intake can influence fetal vitamin C and vitamin E levels. Linear regression analysis shows a significant positive relationship between newborn birth weight and maternal plasma vitamin C (r = 0.51, P < 0.02). Similarly, there was a modest but significant positive relationship between newborn birth weights and newborn vitamin C levels (r = 0.61, P < 0.05). However, there was no relationship between maternal or fetal vitamin E or lipid peroxides levels and the newborn birth weight. Conclusions This study with a small number of subjects suggests a significant association between newborn birth weight and maternal and newborn plasma vitamin C levels. Lack of relationship between birth weight and vitamin E and lipid peroxides suggest that antioxidant function of vitamin C does not appear to have a major role in the effect of vitamin C on birth weight.     

Transfer and distribution of Niobium-95 in adult,fetal, and newborn rats after injection during pregnancy

Summary Following i.v. injection of Nb-95 into pregnant rats, fetuses and newborns were dissected and measured for radioactivity after several time intervals. At any time only a small quantity of the administered radioactivity was transferred to fetus and newborn and the fetal tissue concentrations were always lower than the maternal ones. The highest ratio (0.6) between fetal and maternal tissue concentrations was found in bone.     

Cellular immunity in newborn infants with hyperbilirubinemia]

In order to identify the possibility of prenatal or perinatal bacterial contact with immunization of the cellular immunity system as underlying cause of the "idiopathic" newborn icterus (without blood group incompatibility) the lymphocyte transformation test with addition of streptolysin O or E. coli antigen was carried out in 68 newborns with a birth weight ranging between 1260 and 4200 g. The sensitization rate identified among the newborns with hyperbilirubinaemia did not differ significantly from those of the control group. Thus an ensured connection between a prenatal streptococcus or E. coli contact and the appearance of an idiopathic newborn hyperbilirubinaemia could not be established.     

A Clinical Classification of the Mechanisms of Perinatal Wastage

A clinical classification of perinatal morbidity and mortality should be based upon the pathophysiological mechanisms which affect the fetus and newborn infant, resulting in this morbidity and mortality. Each mechanism is a distinctive disturbance which may be regarded as the common pathway for expression of insults to the fetus and newborn infant arising from a wide variety of obstetric abnormalities and specific disease entities. The following classification of mechanisms incorporating the whole spectrum of perinatal problems is proposed: (1) developmental abnormality; (2) immaturity and prematurity; (3) chronic fetal insufficiency; (4) acute fetal insufficiency; (5) newborn respiratory failure; (6) blood group incompatibility; (7) infection, and (8) trauma.     

Induced abortion as a risk factor for perinatal complications: a review.

Past and continuing studies of the influence of a prior induced abortion on subsequent perinatal complications are reviewed. Many definitive conclusions are precluded because of design problems in the extant studies and these methodological issues, therefore, form the focus for the current review. The available studies do suggest that abortion by vacuum aspiration is not a risk factor for complications of subsequent pregnancies, labor, delivery, or of newborns. Abortion by dilatation and curettage, however, may increase the risk of subsequent spontaneous abortion, low birth weight, and prematurity but these findings need to be confirmed. The impact of other abortion techniques or perinatal complications has not been studied. The more common design problems in the extant literature include: (1) failure to control for confounding maternal factors; (2) problems in reliability of reporting previous abortion; and (3) nonspecific measurement of abortion techniques. Since approximately three-quarters of all abortions performed annually in the United States are on young never-married women who may eventually wish to bear children, further rigorous research to define the risks of induced abortion is urgently required.     

Effect of porcine reproductive and respiratory syndrome virus infection on the ovary and progesterone levels in third trimester pregnant sows

Porcine reproductive and respiratory syndrome virus (PRRSV) is a common cause of reproductive failure and abortion in swine. The mechanism of abortion is not fully defined, and the effect of the virus on luteal function has not been explored. In this study, we exposed late-term pregnant swine to varied doses of PRRSV strain NADC-8 and evaluated effects on ovarian function by serial determination of plasma progesterone levels and by microscopic evaluation of ovarian pathologic alterations combined with immunohistochemistry and in situ hybridization to detect PRRSV antigen. We identified no specific trend in plasma progesterone level associated with PRRSV infection status and no microscopic ovarian lesions. PRRSV antigen was not demonstrated in ovarian tissues by immunohistochemistry or in situ hybridization at necropsy 21 days postexposure. Based on these findings, it does not appear that either a direct or an indirect effect on luteal function contributes to PRRSV-induced abortion.     

Comparison of cerebrovascular effects of intravenous cocaine injection in fetal, newborn, and adult sheep

Cocaine may cause stroke, intracranial hemorrhage, seizures, and neurobehavioral abnormalities in fetuses, newborns, and adults, and there could be developmental and/or species differences in mechanisms for these cocaine-induced cerebrovascular effects. To evaluate developmental differences in responses to cocaine, we compared the cerebrovascular and metabolic responses to a 2 mg/kg iv cocaine dose in unanesthetized fetal (n = 8, previously reported, direct fetal injection), newborn (n = 6), and adult (n = 12) sheep. We measured cerebral blood flow, mean arterial blood pressure, and arterial and venous O(2) content, and we calculated cerebral O(2) consumption and cerebral vascular resistance at baseline and at 30 s and at 5, 15, and 60 min after cocaine injection. Cerebral blood flow increased 5 min after injection in the fetus and newborn, but not until 15 min in the adult. In the fetus, cocaine caused a transient cerebral vasoconstriction at 30 s; in all three groups, cocaine caused cerebral vasodilation, which was delayed in the adult. Cerebral metabolic O(2) consumption increased 5 min after injection in the fetus and newborn, but not until 15 min after injection in the adult. Arterial O(2) content decreased 5 min after injection in the fetus and 15 min after injection in the adult. We speculate that clinical differences in response to cocaine injection may be explained, in part, by these developmental differences in the cerebrovascular and metabolic responses to cocaine.     

Introduction: new technologies for genetic and newborn screening

Screening newborn infants for inherited disorders has been effective in preventing mental retardation, growth failure, and death from several metabolic disorders for more than two decades. Technical advances have provided more screening tools for both genetic and nongenetic conditions, and in the coming decades these techniques will be used not only to screen newborns but to assess genetic risks in entire populations. The financial, legal, and ethical issues which these activities raise must influence the development of public policies in order to reap the benefits promised. The conference published here was designed to address these issues for health care practitioners, health policy planners, and public health professionals.     

Iron release, superoxide production and binding of autologous IgG to band 3 dimers in newborn and adult erythrocytes exposed to hypoxia and hypoxia-reoxygenation

Iron is released in a desferrioxamine (DFO)-chelatable form when erythrocytes are challenged by an oxidative stress. The release is increased when an accelerated removal of erythrocytes occurs such as in perinatal period, in which iron release is greater in hypoxic than in non-hypoxic newborns. This suggests that an hypoxic environment at birth promotes iron release. To test this possibility, iron release in a model of hypoxia, hypoxia-reoxygenation and normoxia was studied in newborn and adult erythrocytes. In newborn erythrocytes, hypoxia induced a much greater iron release compared to an equal period of normoxia. In adult erythrocytes, hypoxia also induced a greater iron release as compared to normoxia, but it was much lower than that seen with newborn erythrocytes. Methemoglobin (MetHb) formation roughly paralleled iron release. The phenylhydrazine-promoted superoxide anion (O(2)?(-)) production was greater with normoxic but lower with hypoxic erythrocytes from newborns as compared to that from adults. This discrepancy between iron release and O(2)?(-) production may be explained by the shift towards MetHb in hemoglobin autoxidation. Iron diffusion out of the erythrocytes was much higher with hypoxic erythrocytes from newborns as compared to that from adults. Also the binding of autologous IgG to band 3 dimers (AIgGB) is much greater with hypoxic erythrocytes from newborns as compared to that from adults, suggesting that the level of iron release is related to the extent of band 3 clustering and that hypoxia accelerates removal of erythrocytes from bloodstream in in vivo condition.     

Research Ethics: Beyond the Guidelines

There is international recognition of the need for sustainable research ethics committees to provide ethical review of human subjects research in developing countries, but many developing countries do not have such committees (often called 'IRBs'). Theoretical and practical uncertainties encountered by an IRB on the Caribbean island of Grenada offer insight into ethical review of research in developing countries. Theoretical uncertainties include questions about whether means of ensuring confidentiality and obtaining informed consent will be effective in local settings, and whether deviations from Western norms are justifiable. International guidelines are helpful in addressing these concerns, but are subject to interpretation. Guidelines are less helpful in practical areas like selecting members or chairs. They do not address what sort of procedures and paperwork will work in a developing country, or IRBs' relationships to governments that have no mandate for them. Experiences presented here show that IRBs in developing countries can sustainably adhere to international standards. Sustainability requires knowledge, personal commitment, and an official mandate to uphold international standards. Capacity building must therefore focus on educational programs to make developing country leaders knowledgeable about the value of international guidelines to their nations. Such knowledge is needed before people will become motivated to promote, implement, and uphold the guidelines. People in developing countries must help design bridges to help their nations put international standards into practice. The structure of such bridges may, of necessity, vary in different settings.     

Influence of psychosomatic stress in pregnant guinea-pigs on fetal lipid metabolism

After a psychosomatic stress applied to pregnant guinea-pigs, 7 or 1 day before term, plasma cortisol and non-esterified fatty acid levels increased immediately in mother and fetus. Plasma levels of cortisol and non-esterified fatty acids in newborns of mothers stressed 1 day before term were lower than in newborns of control mothers. The prenatal stress changed composition of triacylglycerol and phospholipids in newborn liver by inhibiting the postnatal increase of triacylglycerol and phospholipid stearic acid and by inhibiting the postnatal decrease in phospholipid palmitic, palmitoleic, linolenic and arachidonic acids.     

Ethics committees. Research ethics: beyond the guidelines

There is international recognition of the need for sustainable research ethics committees to provide ethical review of human subjects research in developing countries, but many developing countries do not have such committees (often called 'IRBs'). Theoretical and practical uncertainties encountered by an IRB on the Caribbean island of Grenada offer insight into ethical review of research in developing countries. Theoretical uncertainties include questions about whether means of ensuring confidentiality and obtaining informed consent will be effective in local settings, and whether deviations from Western norms are justifiable. International guidelines are helpful in addressing these concerns, but are subject to interpretation. Guidelines are less helpful in practical areas like selecting members or chairs. They do not address what sort of procedures and paperwork will work in a developing country, or IRBs' relationships to governments that have no mandate for them. Experiences presented here show that IRBs in developing countries can sustainably adhere to international standards. Sustainability requires knowledge, personal commitment, and an official mandate to uphold international standards. Capacity building must therefore focus on educational programs to make developing country leaders knowledgeable about the value of international guidelines to their nations. Such knowledge is needed before people will become motivated to promote, implement, and uphold their guidelines. People in developing countries must help design bridges to help their nations put international standards into practice. The structure of such bridges may, of necessity, very in different settings.