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.     

Bioethics for clinicians: 12. Ethical dilemmas that arise in the care of pregnant women: rethinking "maternal-fetal conflicts".

When a pregnant woman makes a decision or acts in a manner that may be detrimental to the health and well-being of her fetus, her physician may be faced with an ethical dilemma. Is the physician''s primary duty to respect the woman''s autonomy, or to promote behaviour that may be in the best interest of the fetus? The controversial concept of "fetal rights" or the "fetus as a patient" contributes to the notion that the pregnant woman and her fetus are potential adversaries. However, Canadian law has upheld women''s right to life, liberty and security of the person and has not recognized fetal rights. If a woman is competent and refuses medical advice, her decision must be respected even if the physician believes that her fetus will suffer as a result. Coercion of the woman is not permissible no matter what appears to be in the best interest of the fetus.     

The failure of DNA forensic testing: a case study of the 2009 Australian bushfire disaster

Different constructions of the fetus lie at the centre of reproductive, abortion and disability politics. Recent developments mean that, within the same hospital, a fetus may be perceived in contrasting and potentially conflicting ways. It is also argued that the status given to the fetus is directly relevant to the status given to pregnant women. During group discussions facilitated by an ethicist, health-care staff highlighted various perceptions of the fetus which included: person; patient; 'nobody'; commodity. Perhaps not surprisingly in view of the current legal situation, staff tended to claim that it is usually the pregnant woman who decides how her fetus will be constructed, and the practitioner who responds to this. However, various ways in which practitioners might influence women's perceptions of their fetus are highlighted, as are some ways in which the perceptions of staff might be influenced. This paper illustrates how sensitive health-care staff will need to be if they are indeed to respond to, rather than shape, women's constructions of their fetus.     

Ethical issues in recommending and offering fetal therapy

Fetal therapy should be offered and recommended for a viable fetus when these criteria are met: invasive therapy is reliably judged to have a high probability of being life-saving or of preventing serious and irreversible disease, injury, or disability for the fetus and for the child it can become; such therapy is reliably judged to involve low mortality risk and low or manageable risk of serious disease, injury, or disability to the viable fetus and the child it can become; and the mortality risk and the risk of disease, injury, or disability to the pregnant women is reliably judged to be low or manageable. When one or more of these criteria are not satisfied, intervention is experimental and can only be offered, not recommended, on the basis of benefit to future patients and the autonomy of the pregnant woman.     

Immunological Responses in Pregnancy and Survival of Fetal Homograft

Immunological responses were studied in pregnant women and controls using as tests phytohaemagglutinin-induced lymphocyte transformation and the tuberculin reaction. Significantly reduced responses were found to both tests in the pregnant women. These results suggest that a reduction in T-cell activity during pregnancy may help protect the fetus from rejection by its mother''s immunological mechanisms.     

Fetal and maternal body temperatures measured by radiotelemetry in near-term sheep during thermal stress.

Using implanted radiotelemeters, we have measured amniotic temperature and fetal lamb and pregnant ewe body temperatures continuously over the last 34 days of gestation and during conditions of thermal stress. Body temperature of the fetus was approximately 0.6 degrees C higher than that of the mother, and the fetomaternal temperature difference remained constant over the last 25 days of gestation, until the immediate prepartum period, when it rose. During exposure to mild heat stress (35 degrees C dry-bulb temperature, 24 degrees C wet-bulb temperature), ewe and fetal body temperatures rose, but fetal temperature rose at a slower rate. Thus the fetomaternal temperature gradient fell significantly in the initial exposure period. In an environment of 4 degrees C, body temperature of the pregnant ewes fell, but the fetomaternal gradient did not change significantly. During maternal fever, heat loss from the fetus was compromised; body temperature of the fetus rose more than that of the mother, and the fetomaternal temperature gradient rose significantly. We suggest that mild heat or cold exposure in pregnant animals constitutes little risk of fetal thermal stress. During maternal fever, however, the fetus may be at risk of thermal injury.     

Women’s sexual strategies in pregnancy

Humans exhibit an unusual pattern of sexual behavior compared to other mammalian females. Women's extended sexuality has been hypothesized to be related to a variety of possible benefits, especially non-genetic reproductive benefits, such as securing male investment via reinforced pairbonds or paternity confusion. But sexual behavior also comes at a cost, particularly for pregnant women, in terms of energetic costs, potential disease, and possible harm to the fetus. We hypothesize, therefore, that sexual behavior in pregnant women should reflect adaptive strategies and that pregnant women will be particularly strategic about their sexual behavior in order to maximize potential benefits while minimizing potential costs. One hundred twelve pregnant women completed a survey of their partners' qualities and their sexual desires toward their primary partners and men other than their primary partners. Results showed that women's perceptions of relationship threat positively predicted sexual desire for primary partners, while their perceptions of their partner's investing qualities negatively predicted sexual desire for extra-pair mates. These qualities, as well as cues to partner's genetic quality and gestation age, also interacted in ways that suggest that pregnant women's sexual desires are sensitive to cues of future investment and relationship stability.     

Transverse lie with prolapsed arm in a female red‐howler monkey (Alouatta guariba clamitans – Cabrera, 1940)

This study focuses on a case of a red‐howler monkey (Alouatta guariba clamitans) which was found with a fetus in a transverse lie position with a prolapsed arm. The topic of this research is well justified as there are no data on this condition involving this type of non‐human primate in literature. In this study, a red‐howler monkey was observed by locals pulling at her pelvic region for 3 days near a farm. On the third day, the monkey was found lying on the ground at which point she offered no resistance when approached. The environmental police took the monkey to receive medical attention. During the physical examination, it was quickly observed that the monkey was pregnant; the right forelimb of the fetus was exposed from the vulva. An ultrasound revealed a non‐viable fetus, and due to the severe weakness of the mother, we opted for euthanasia. During the necropsy, not only was the fetus found macerated but it was also in a transverse lie position with a prolapsed arm and presented no external or internal injuries consistent with trauma.     

The hit and miss of ISS and TRISS. Yorkshire Trauma Audit Group.

OBJECTIVE--To measure interobserver variation in recording injury from case notes and its effect on calculating injury severity scores (ISS) from identical data and predicting probabilities of survival by using the combined trauma and injury severity score (TRISS). DESIGN--Observer variation study using injury severity scoring and subsequent calculation of probability of survival based on combined trauma and injury severity scores. SUBJECTS--16 patients with a range of injury severity scores, and 15 observers. RESULTS--There was a wide variation in recorded injury severity scores, the probability of two observers agreeing on the score being 0.28 (28%). The probability of any two observers agreeing over which severity band the patient should be in was 0.5 (50%). Observer variation was independent of the training and type of observer. Survival probability (calculated by combined trauma and injury severity scoring methodology from individual observers'' scores) varied by over 0.2 in six of the 16 patients and by over 0.5 in three. CONCLUSIONS--There is wide observer variation in injury severity scoring, which highlights a potential fallibility in its use for trauma audit. The use of combined trauma and injury severity scoring for individual prediction of survival is potentially inaccurate except at the extremes of probabilities. The use of the 0.5 survival line on a combined trauma and injury severity score "pre-chart" is statistically and clinically inappropriate.     

Trauma services requirements in a district general hospital serving a rural area.

OBJECTIVE--To assess the demands made on a regional trauma centre by a district trauma unit. DESIGN--Two part study. (1) Prospective analysis of one month''s workload. (2) Retrospective analysis of one year''s workload by using a computer based records system. Comparison of two sets of results. SETTING--Accident unit in Gwynedd Hospital, Bangor. PATIENTS--(1) All patients who attended the accident unit in August 1988. (2) All patients who attended the accident unit in the calendar year April 1988-April 1989. MAIN OUTCOME MEASURE--Workload of a district trauma unit. RESULTS--In August 1988 there were 2325 attendances; 2302 of these were analysed. In all, 1904 attendances were for trauma; 213 patients were admitted to the trauma ward and 103 required an operation that entailed incision. Patients who attended the unit had a mean (range) injury severity score of 2-13 (0-25). Only two patients had injuries that a district general hospital would not be expected to cope with (injury severity score greater than 20). In the year April 1988-April 1989, 21,007 patients attended the unit. In all, 17,958 attendances were for orthopaedic injuries or injuries caused by an accident; 1966 patients were admitted to the unit. CONCLUSIONS--Most trauma is musculoskeletal and relatively minor according to the injury severity score. All but a few injuries can be managed in district general hospitals. In their recent report the Royal College of Surgeons has overestimated the requirements that a British district general hospital would have of a regional trauma centre.     

Does anaemia increase the risks to the fetus caused by smoking in pregnancy?

A significantly greater rise in carboxyhaemoglobin concentration in response to smoking a single cigarette was shown in pregnant (3-9% increase) as opposed to non-pregnant (2-1% increase) women. This was more pronounced when anaemia was present (5-0% increase) and appeared to be inversely related to the haemoglobin concentration. We suggest that the risks to the fetus may be particularly increased when anaemia complicates pregnancy in women who smoke cigarettes.     

Correlates of agonistic and competitive interactions in pregnant baboons

Maternal condition during pregnancy is known to influence fetal viability. Recently, primatologists have suggested that certain characteristics of the fetus may influence maternal condition as well. For example, among captive pigtailed macaques (Macaca nemestrina) mothers of female infants may be at greater risk of injury during their pregnancies than mothers of male infants. Analysis of the rates of aggression, submission, competition, and wounding among free-ranging pregnant baboons (Papio cynocephalus) in Amboseli National Park generally fail to support these findings, but several other factors such as maternal dominance rank, environmental conditions during pregnancy, maternal parity, and fetal age correlate with aggression, submission, competition, and injuries sustained by pregnant female baboons.     

Pregnancy and Urinary Calculi

The possibility of upper urinary tract calculus disease is at least as great in pregnant as in nonpregnant women, and such disease if present carries greater risks during pregnancy. The well-being and even the life of both mother and fetus may depend on prompt diagnosis, the right kind of management and effective treatment. With adequate precaution, such essential procedures as urography and emergency surgical intervention can be carried out during pregnancy at little greater hazard than ordinarily attends them.     

Fetal and maternal contributions to risk of pre-eclampsia: population based study

Objective: To use familial patterns of recurrence of pre-eclampsia to investigate whether paternal genes expressed in the fetus contribute to the mother’s risk of pre-eclampsia and whether mother’s susceptibility to pre-eclampsia is related to maternal inheritance by mitochondrial DNA. Design: Linked data on pregnancies of different women who had children with the same father, and subsequently linked data on pregnancies of half sisters who either had same mother and different fathers or had same father and different mothers. Setting: Population based data from the Medical Birth Registry of Norway covering all births since 1967 (about 1.7 million) and the Norwegian Central Population Register. Main outcome measures: Relative risk of pre-eclampsia after a previous pre-eclamptic pregnancy in the family. Relative risks approximated by odds ratios. Results: If a woman becomes pregnant by a man who has already fathered a pre-eclamptic pregnancy in a different woman her risk of developing pre-eclampsia is 1.8 (95% confidence interval 1.2 to 2.6). If the woman has a half sister who had pre-eclampsia and with whom she shares the same mother but different fathers the risk of pre-eclampsia is 1.6 (0.9 to2.6). If the two sisters have the same father but different mothers the risk is 1.8 (1.01 to 2.9). Conclusions: Both the mother and the fetus contribute to the risk of pre-eclampsia, the contribution of the fetus being affected by paternal genes. Mitochondrial genes, which are transmitted by mothers, do not seem to contribute to the risk.

Key messages

• Paternal genes in the fetus may contribute substantially to a pregnant woman’s risk of pre-eclampsia
• The role of the fetus may be as important as that of the mother
• Purely maternal inheritance (specifically by mitochondrial DNA) is probably not involved in pre-eclampsia
• Search for specific genes that predispose for pre-eclampsia should include the fetus as well as the mother

     

The recovery process in the fetal rabbit myocardium following mechanical trauma]

Healing processes of the myocardium after an injury during the intrauterine period were studied. After the mechanical trauma of the heart the rabbit fetus is kept in the maternal organism and is born in due course. It was found that the healing of the injured part of the cardiac muscle occurred shortly and was due to the high proliferative activity of the cells. Morphological structure of the tissue appearing at the site of injury is very similar to that of the muscle tissue. However, further studies are necessary for final decision.     

Conflicting perceptions of the fetus: person, patient, 'nobody', commodity?

Different constructions of the fetus lie at the centre of reproductive, abortion and disability politics. Recent developments mean that, within the same hospital, a fetus may be perceived in contrasting and potentially conflicting ways. It is also argued that the status given to the fetus is directly relevant to the status given to pregnant women. During group discussions facilitated by an ethicist, health-care staff highlighted various perceptions of the fetus which included: person; patient; 'nobody'; commodity. Perhaps not surprisingly in view of the current legal situation, staff tended to claim that it is usually the pregnant women who decides how her fetus will be constructed, and the practitioner who responds to this. However, various ways in which practitioners might influence women's perceptions of their fetus are highlighted, as are some ways in which the perceptions of staff might be influenced. This paper illustrates how sensitive health-care staff will need to be if they are indeed to respond to, rather than shape, women's constructions of their fetus.     

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.     

Medical sonography: reproductive effects and risks

While it is clear that the levels and types of medical sonography that have been used in the past have no measurable risks, it would be inaccurate to label the modality of ultrasound as totally safe regardless of exposure. Most agents have reproductive risks and even teratogenic risks if the exposure is raised sufficiently. Thus the prudent use of sonography means that clinicians and designers of equipment have to maintain exposures far below the risks that have been demonstrated in animal studies and from the knowledge obtained about the physical changes that can be produced in humans as the absorbed dose is elevated. The reproductive risks were evaluated using five criteria: 1) human epidemiology, 2) secular trend data, 3) animal experiments, 4) dose response relationships, and 5) biologic plausibility. The analysis reveals that the human epidemiology does not indicate that diagnostic ultrasound presents a measurable risk to the developing embryo or fetus. Animal studies also indicate that diagnostic levels of ultrasound are safe and do not elevate the fetal temperature into the region where deleterious embryonic and fetal effects will occur. Because higher exposures of ultrasound can elevate the temperature of the embryo, the use of diagnostic procedures and the design of sonographic equipment should take into consideration the hyperthermic potential of higher exposures of ultrasound and the hypothetical additional risk of performing sonography on pregnant patients who are febrile. It would appear that if the embryonic temperature never exceeds 39 degrees C, then there is no measurable risk. We suggest that sonography (the field) and sonogram (the procedure) are the most appropriate and least anxiety provoking terms.     

Diagnostic irradiation of women during the reproductive period.

The date of onset of the last menstrual period should be given on radiographic requisitions for all women of reproductive age. Every effort should be made to avoid unnecessary irradiation of any woman who might be pregnant. Radiation damage in the first 2 weeks of pregnancy, however, should be "all or none", resulting in either a miscarriage or a normal child. Diagnostic radiology procedures are not indications for therapeutic abortion. Ultrasound has now replaced ionizing radiation in most examinations of the fetus and placenta. Pelvimetry should be done only when the decision to do a cesarean section hinges on precise knowledge of measurements of the bony pelvis. On the rare occasion when a radiograph of the fetus is necessary the woman should be prone for the examination. All such examinations are best ordered after consultation with a radiologist. Radiography of distant areas with the beam directed away from the woman''s abdomen can be done without concern at any stage of pregnancy.     

Quantitative Proteomic Analysis of Serum from Pregnant Women Carrying a Fetus with Conotruncal Heart Defect Using Isobaric Tags for Relative and Absolute Quantitation (iTRAQ) Labeling

Objective

To identify differentially expressed proteins from serum of pregnant women carrying a conotruncal heart defects (CTD) fetus, using proteomic analysis.

Methods

The study was conducted using a nested case-control design. The 5473 maternal serum samples were collected at 14–18 weeks of gestation. The serum from 9 pregnant women carrying a CTD fetus, 10 with another CHD (ACHD) fetus, and 11 with a normal fetus were selected from the above samples, and analyzed by using isobaric tags for relative and absolute quantitation (iTRAQ) coupled with two-dimensional liquid chromatography-tandem mass spectrometry(2D LC-MS/MS). The differentially expressed proteins identified by iTRAQ were further validated with Western blot.

Results

A total of 105 unique proteins present in the three groups were identified, and relative expression data were obtained for 92 of them with high confidence by employing the iTRAQ-based experiments. The downregulation of gelsolin in maternal serum of fetus with CTD was further verified by Western blot.

Conclusions

The identification of differentially expressed protein gelsolin in the serum of the pregnant women carrying a CTD fetus by using proteomic technology may be able to serve as a foundation to further explore the biomarker for detection of CTD fetus from the maternal serum.