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De Bie FR, Tate T, Antiel RM. Maternal-fetal surgery as part of pediatric palliative care. Semin Fetal Neonatal Med 2023; 28:101440. [PMID: 37173213 DOI: 10.1016/j.siny.2023.101440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Maternal-fetal surgical interventions have become a more common part of prenatal care. This third option, beside termination or post-natal interventions, complicates prenatal decision-making: while interventions may be lifesaving, survivors may face a life with disability. Pediatric palliative care (PPC) is more than end of life or hospice care, it aims at helping patients with complex medical conditions live well. In this paper, we briefly discuss maternal-fetal surgery, challenges regarding counseling and benefit-risk evaluation, argue that PPC should be a routine part of prenatal consultation, discuss the pivotal role of the maternal-fetal surgeon in the PCC-team, and finally discuss some of the ethical considerations of maternal-fetal surgery. We illustrate this with a case example of an infant diagnosed with congenital diaphragmatic hernia (CDH).
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Affiliation(s)
- Felix R De Bie
- Department of General Surgery, KU Leuven University Hospital, Leuven, Belgium
| | - Tyler Tate
- Department of Pediatrics, Oregon Health and Science University, Portland, OR, USA
| | - Ryan M Antiel
- Division of Pediatric Surgery, Department of Surgery, Duke University School of Medicine, Durham, NC, USA.
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2
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Madrigal VN, Feltman DM, Leuthner SR, Kirsch R, Hamilton R, Dokken D, Needle J, Boss R, Lelkes E, Carter B, Macias E, Bhombal S. Bioethics for Neonatal Cardiac Care. Pediatrics 2022; 150:189885. [PMID: 36317974 DOI: 10.1542/peds.2022-056415n] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2022] [Indexed: 02/25/2023] Open
Abstract
BACKGROUND Clinicians caring for neonates with congenital heart disease encounter challenges with ethical implications in daily practice and must have some basic fluency in ethical principles and practical applications. METHODS Good ethical practice begins with a thorough understanding of the details and narrative of each individual case, examination via classic principles of bioethics, and further framing of that translation into practice. RESULTS We explore some of these issues and expand awareness through the lens of a case presentation beginning with fetal considerations through end-of-life discussions. CONCLUSIONS We include specific sections that bring attention to shared decision-making, research ethics, and outcomes reporting. We review empirical evidence and highlight recommendations.
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Affiliation(s)
- Vanessa N Madrigal
- Department of Pediatrics, Division of Critical Care Medicine and Pediatric Ethics Program, Children's National Hospital, George Washington University, Washington, District of Columbia
| | - Dalia M Feltman
- NorthShore University HealthSystem Evanston Hospital, University of Chicago, Pritzker School of Medicine, Chicago, Illinois
| | - Steven R Leuthner
- Departments of Pediatrics and Bioethics, Division of Neonatology, Children's Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Roxanne Kirsch
- Department of Critical Care, Division Cardiac Critical Care Medicine; Department of Bioethics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Rekha Hamilton
- Mednax Inc. Cook Children's Medical Center, Fort Worth, Texas
| | - Deborah Dokken
- Family Leader and Staff Member, Institute for Patient and Family-Centered Care, Bethesda, Maryland
| | - Jennifer Needle
- Department of Pediatrics and the Center for Bioethics, University of Minnesota, Minneapolis, Minnesota
| | - Renee Boss
- Department of Pediatrics, Johns Hopkins School of Medicine and Berman Institute of Bioethics, Baltimore, Maryland
| | - Efrat Lelkes
- Department of Pediatrics, Divisions of Critical Care Medicine and Palliative Medicine, Bioethics, University of California San Francisco, San Francisco, California
| | - Brian Carter
- Departments of Humanities and Pediatrics, Division of Neonatology and Bioethics Center, Children's Mercy Hospital, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Eduardo Macias
- Department of Pediatrics, Division of Pediatric Cardiology. University Hospital, University of Texas, San Antonio, Texas
| | - Shazia Bhombal
- Department of Pediatrics, Lucile Packard Children's Hospital. Stanford, Palo Alto, California
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3
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The key role of the pediatric radiologist in developing a multidisciplinary fetal center. Pediatr Radiol 2020; 50:1801-1809. [PMID: 33252750 DOI: 10.1007/s00247-020-04702-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/10/2020] [Accepted: 05/05/2020] [Indexed: 12/25/2022]
Abstract
With the demand for fetal imaging and fetal care programs on the rise, the authors of this manuscript review the components of building a successful fetal imaging center. Creating an environment that engages a multidisciplinary team, utilizing a central coordinator to review clinical and psychosocial aspects of each patient, and ensuring ongoing research and quality control are essential components to the success of growing a program.
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Edwards LA, Justino H, Morris SA, Rychik J, Feudtner C, Lantos JD. Controversy About a High-Risk and Innovative Fetal Cardiac Intervention. Pediatrics 2018; 142:peds.2017-3595. [PMID: 30097527 DOI: 10.1542/peds.2017-3595] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/03/2017] [Indexed: 11/24/2022] Open
Abstract
A 20-week-old fetus was diagnosed with critical pulmonary valve stenosis. Given the ultrasound findings, the outcome was difficult to predict. The fetal cardiologists discussed the possibility of a pulmonary valvuloplasty (an experimental procedure) with the parents, wherein the fetal right ventricle would be punctured with a long 18G needle, and through it, a wire advanced across the pulmonary valve, allowing for balloon dilation of the valve. The experimental procedure had been performed at a handful of centers. There were some reports of success. The parents sought an opinion at one of the referral centers that had tried the procedure. The doctors there recommended against it. The doctors at the original center were unsure whether they should try the procedure. The parents wanted it. In this ethics rounds, doctors and the parents discuss the arguments for and against a high-risk, innovative in utero procedure.
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Affiliation(s)
- Lindsay Atherton Edwards
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Henri Justino
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Shaine A Morris
- Lillie Frank Abercrombie Section of Pediatric Cardiology, Department of Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | - Jack Rychik
- Fetal Heart Program at The Cardiac Center and
| | - Chris Feudtner
- Department of Medical Ethics, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and
| | - John D Lantos
- Children's Mercy Hospital Bioethics Center, Kansas City, Missouri
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5
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Fry JT, Frader JE. "We want to do everything": how parents represent their experiences with maternal-fetal surgery online. J Perinatol 2018; 38:226-232. [PMID: 29317765 DOI: 10.1038/s41372-017-0040-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 12/04/2017] [Accepted: 12/12/2017] [Indexed: 01/05/2023]
Abstract
OBJECTIVE There is little available evidence on how patients make decisions regarding maternal-fetal surgery. We studied online patient narratives for insight on how pregnant women and their partners consider such decisions. STUDY DESIGN We used Google search strings and a purposive snowball method to locate patient blogs. We analyzed blog entries using qualitative methods to identify author details, medical information, and common themes. RESULTS We located 32 blogs of patients who describe maternal-fetal surgery consultation. Twenty-eight (88%) underwent fetal interventions. Most (91%) explicitly described consultation with maternal-fetal surgery teams; 83% of those depicted making decisions prior to formal consultation. Few expressed regret for decisions made (6%). CONCLUSIONS AND RELEVANCE Patients openly share experiences with maternal-fetal surgery online. Women portray their decisions as made outside of formal medical processes and overwhelmingly feel these decisions were "right". As the field of maternal-fetal surgery expands, prospective evaluation of patient decision-making is needed.
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Affiliation(s)
- Jessica T Fry
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Joel E Frader
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Palliative Care, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Antiel RM, Flake AW, Collura CA, Johnson MP, Rintoul NE, Lantos JD, Curlin FA, Tilburt JC, Brown SD, Feudtner C. Weighing the Social and Ethical Considerations of Maternal-Fetal Surgery. Pediatrics 2017; 140:peds.2017-0608. [PMID: 29101225 DOI: 10.1542/peds.2017-0608] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2017] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The ethics of maternal-fetal surgery involves weighing the importance of potential benefits, risks, and other consequences involving the pregnant woman, fetus, and other family members. We assessed clinicians' ratings of the importance of 9 considerations relevant to maternal-fetal surgery. METHODS This study was a discrete choice experiment contained within a 2015 national mail-based survey of 1200 neonatologists, pediatric surgeons, and maternal-fetal medicine physicians, with latent class analysis subsequently used to identify groups of physicians with similar ratings. RESULTS Of 1176 eligible participants, 660 (56%) completed the discrete choice experiment. The highest-ranked consideration was of neonatal benefits, which was followed by consideration of the risk of maternal complications. By using latent class analysis, we identified 4 attitudinal groups with similar patterns of prioritization: "fetocentric" (n = 232), risk-sensitive (n = 197), maternal autonomy (n = 167), and family impact and social support (n = 64). Neonatologists were more likely to be in the fetocentric group, whereas surgeons were more likely to be in the risk-sensitive group, and maternal-fetal medicine physicians made up the largest percentage of the family impact and social support group. CONCLUSIONS Physicians vary in how they weigh the importance of social and ethical considerations regarding maternal-fetal surgery. Understanding these differences may help prevent or mitigate disagreements or tensions that may arise in the management of these patients.
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Affiliation(s)
- Ryan M Antiel
- Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Biomedical Ethics Program.,Department of General Surgery, Mayo Clinic, Rochester, Minnesota
| | - Alan W Flake
- Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Mark P Johnson
- Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Natalie E Rintoul
- Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - John D Lantos
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri
| | - Farr A Curlin
- Trent Center for Bioethics, Humanities, and History of Medicine, Duke University, Durham, North Carolina; and
| | - Jon C Tilburt
- Biomedical Ethics Program.,General Internal Medicine, and
| | - Stephen D Brown
- Department of Radiology, Boston Children's Hospital, Boston, Massachusetts
| | - Chris Feudtner
- Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania;
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Antiel RM, Collura CA, Flake AW, Johnson MP, Rintoul NE, Lantos JD, Curlin FA, Tilburt JC, Brown SD, Feudtner C. Physician views regarding the benefits and burdens of prenatal surgery for myelomeningocele. J Perinatol 2017; 37:994-998. [PMID: 28617430 DOI: 10.1038/jp.2017.75] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Accepted: 04/07/2017] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Examine how pediatric and obstetrical subspecialists view benefits and burdens of prenatal myelomeningocele (MMC) closure. STUDY DESIGN Mail survey of 1200 neonatologists, pediatric surgeons and maternal-fetal medicine specialists (MFMs). RESULTS Of 1176 eligible physicians, 670 (57%) responded. Most respondents disagreed (68%, 11% strongly) that open fetal surgery places an unacceptable burden on women and their families. Most agreed (65%, 10% strongly) that denying the benefits of open maternal-fetal surgery is unfair to the future child. Most (94%) would recommend prenatal fetoscopic over open or postnatal MMC closure for a hypothetical fetoscopic technique that had similar shunt rates (40%) but decreased maternal morbidity. When the hypothetical shunt rate for fetoscopy was increased to 60%, physicians were split (49% fetoscopy versus 45% open). Views about burdens and fairness correlated with the likelihood of recommending postnatal or fetoscopic over open closure. CONCLUSION Individual and specialty-specific values may influence recommendations about prenatal surgery.
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Affiliation(s)
- R M Antiel
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Department of General Surgery, Mayo Clinic, Rochester, MN, USA
| | - C A Collura
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of Neonatal Medicine, Mayo Clinic, Rochester, MN, USA
| | - A W Flake
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M P Johnson
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - N E Rintoul
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - J D Lantos
- Department of Pediatrics, Children's Mercy Hospital, Kansas City, MO, USA
| | - F A Curlin
- Trent Center for Bioethics, Humanities, and History of Medicine, Duke University, Durham, NC, USA
| | - J C Tilburt
- Biomedical Ethics Program, Mayo Clinic, Rochester, MN, USA.,Division of General Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - S D Brown
- Department of Radiology, Boston Children's Hospital, Boston, MA, USA
| | - C Feudtner
- University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA
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8
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Kett JC, Wolfe E, Vernon MM, Woodrum D, Diekema D. The multidisciplinary fetal center: clinical expertise is only part of the experience. Acta Paediatr 2017; 106:930-934. [PMID: 28258594 DOI: 10.1111/apa.13812] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 01/20/2017] [Accepted: 02/28/2017] [Indexed: 11/27/2022]
Abstract
AIM Multidisciplinary foetal centres have recently emerged in partnership with children's hospitals throughout the United States. The aim of this investigation was to describe the patient experience of pregnant women who were referred to our foetal centres for the evaluation of foetal congenital anomalies. METHODS A qualitative interview study of women referred to our foetal centres was conducted using semi-structured telephone interviews. The data were coded and analysed using thematic networks analysis. RESULTS Six themes were identified (i) foetal centre evaluations had a far-reaching impact on participants' lives, (ii) participants appreciated both expertise and support from providers, (iii) participants recognised the need to cope with uncertainty, (iv) participants sought additional support from multiple arenas, (v) participants specifically looked to the Internet for both information and support and (vi) participants had pre-established views about pregnancy termination. CONCLUSION Multidisciplinary foetal centres can provide a unified source of clinical expertise to women who are carrying a foetus with a suspected or identified congenital anomaly. Despite this diagnostic acumen, uncertainty is pervasive and patients seek support and additional information from a variety of other sources. This investigation is an important initial step in the evaluation of this emerging model of care.
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Affiliation(s)
| | | | | | - David Woodrum
- Seattle Children's Hospital; Seattle WA USA
- University of Washington; Seattle WA USA
| | - Douglas Diekema
- Seattle Children's Hospital; Seattle WA USA
- University of Washington; Seattle WA USA
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Abstract
This article explores some of the complex ethical challenges that exist in the field of fetal diagnosis and treatment, especially surrounding maternal-fetal surgery. The rise of these new treatments force us to reconsider who or what is the fetus, what are our obligations to the fetus, and what are the limits to those obligations. In addition, we will consider provider and professional biases, disability issues, and how maternal-fetal surgery has, for a select group of women, changed the very experience of motherhood.
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Affiliation(s)
- Ryan M Antiel
- Department of Medical Ethics and Health Policy, Perelman School of Medicine at the University of Pennsylvania, 423 Guardian Dr, FL 14 Market St, Suite 320, Philadelphia, PA 19104.
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10
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Brown SD, Donelan K, Martins Y, Sayeed SA, Mitchell C, Buchmiller TL, Burmeister K, Ecker JL. Does professional orientation predict ethical sensitivities? Attitudes of paediatric and obstetric specialists toward fetuses, pregnant women and pregnancy termination. JOURNAL OF MEDICAL ETHICS 2014; 40:117-122. [PMID: 23572566 DOI: 10.1136/medethics-2012-101126] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND To determine (1) whether fetal care paediatric (FCP) and maternal-fetal medicine (MFM) specialists harbour differing attitudes about pregnancy termination for congenital fetal conditions, their perceived responsibilities to pregnant women and fetuses, and the fetus as a patient and (2) whether self-perceived primary responsibilities to fetuses and women and views about the fetus as a patient are associated with attitudes about clinical care. METHODS Mail survey of 434 MFM and FCP specialists (response rates 60.9% and 54.2%, respectively). RESULTS MFMs were more likely than FCPs to disagree with these statements (all p values<0.005): (1) 'the presence of a fetal abnormality is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-78.4% vs 63.5%); (2) 'the effects that a child born with disabilities might have on marital and family relationships is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-80.5% vs 70.2%); and (3) 'the cost of healthcare for the future child is not an appropriate reason for a couple to consider pregnancy termination' (MFM : FCP-73.5% vs 55.9%). 65% MFMs versus 47% FCPs disagreed that their professional responsibility is to focus primarily on fetal well-being (p<0.01). Specialists did not differ regarding the fetus as a separate patient. Responses about self-perceived responsibility to focus on fetal well-being were associated with clinical practice attitudes. CONCLUSIONS Independent of demographic and sociopolitical characteristics, FCPs and MFMs possess divergent ethical sensitivities regarding pregnancy termination, pregnant women and fetuses, which may influence clinical care.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital and Harvard Medical School, , Boston, Massachusetts, USA
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11
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Brown SD, Donelan K, Martins Y, Burmeister K, Buchmiller TL, Sayeed SA, Mitchell C, Ecker JL. Differing attitudes toward fetal care by pediatric and maternal-fetal medicine specialists. Pediatrics 2012; 130:e1534-40. [PMID: 23129074 DOI: 10.1542/peds.2012-1352] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The expansion of pediatric-based fetal care raises questions regarding pediatric specialists' involvement in pregnancies when maternal conditions may affect pediatric outcomes. For several such conditions, we compared pediatric and obstetric specialists' attitudes regarding whether and when pediatrics consultation should be offered and their views about seeking court authorization to override maternal refusal of physician recommendations. METHODS We used a mail survey of 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) (response rate: MFM, 60.9%; FCP, 54.2%). RESULTS FCPs were more likely than MFMs to indicate that pediatric counseling should occur before decisions regarding continuing or interrupting pregnancies complicated by maternal alcohol abuse (FCP versus MFM: 63% vs 36%), cocaine abuse (FCP versus MFM: 60% vs 32%), use of seizure medications (FCP versus MFM: 62% vs 33%), and diabetes (FCP versus MFM: 56% vs 27%) (all P < .001). For all conditions, MFMs were more than twice as likely as FCPs to think that no pediatric specialist consultation was ever necessary. FCPs were more likely to agree that seeking court interventions was appropriate for maternal refusal to enter a program to discontinue cocaine use (FCP versus MFM: 72% vs 33%), refusal of azidothymidine to prevent perinatal HIV transmission (80% vs 41%), and refusal of percutaneous transfusion for fetal anemia (62% vs 28%) (all P < .001). CONCLUSIONS Pediatric and obstetric specialists differ considerably regarding pediatric specialists' role in prenatal care for maternal conditions, and regarding whether to seek judicial intervention for maternal refusal of recommended treatment.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Boston Children's Hospital, Boston, MA 02115, USA.
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12
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Titus MJ, Moodley J. Advances in fetal genetic diagnosis and therapy: ethical issues and appropriate technology in cost-restrained countries. Best Pract Res Clin Obstet Gynaecol 2012; 26:531-40. [PMID: 22853883 DOI: 10.1016/j.bpobgyn.2012.06.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2012] [Revised: 05/14/2012] [Accepted: 06/04/2012] [Indexed: 11/25/2022]
Abstract
The advent of ultrasound in the 1970s heralded a milestone that could give real-time information about fetal abnormalities, and thereby improve diagnostic accuracy. This knowledge could not be used effectively to benefit the fetus for which it was intended. The 1980s saw science catching up with diagnostic advances, and fetal abnormalities could realistically be treated with an expectation of satisfactory outcomes. As a result, parents could have realistic expectations of having healthy children. Prenatal diagnosis is the first step towards this realisation, as diagnosis can be followed by intrauterine treatment. Scientists have realised that, if an abnormality can be corrected prenatally, prognosis can be improved significantly, as the initial problem does not necessarily threaten the fetus; therefore, if the prenatal condition can be dealt with early, then the downstream repercussions can be eliminated. In this chapter, we address ethical issues in prenatal diagnosis and fetal therapy.
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Affiliation(s)
- Mokete J Titus
- Department of Obstetrics and Gynaecology, Pietermaritzburg Metropolitan Hospitals Complex, Grey's Hospital, KwaZulu-Natal, South Africa
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13
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Brown SD, Ecker JL, Ward JR, Halpern EF, Sayeed SA, Buchmiller TL, Mitchell C, Donelan K. Prenatally diagnosed fetal conditions in the age of fetal care: does who counsels matter? Am J Obstet Gynecol 2012; 206:409.e1-11. [PMID: 22340943 DOI: 10.1016/j.ajog.2012.01.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 12/21/2011] [Accepted: 01/19/2012] [Indexed: 10/14/2022]
Abstract
OBJECTIVE We sought to characterize practices and attitudes of maternal-fetal medicine (MFM) and fetal care pediatric (FCP) specialists regarding fetal abnormalities. STUDY DESIGN This was a self-administered survey of 434 MFMs and FCPs (response rate: MFM 60.9%; FCP 54.2%). RESULTS For Down syndrome (DS), congenital diaphragmatic hernia (CDH), spina bifida: MFMs were more likely than FCPs to support termination (DS 52% vs 35%, P < .001; CDH 49% vs 36%, P < .001; spina bifida 54% vs 35%, P < .001), and consider offering termination options as highly important (DS 90% vs 70%, P < .001; CDH 88% vs 69%, P < .001; spina bifida 88% vs 70%, P < .001). For DS only, MFMs were less likely than FCPs to think that pediatric specialist consultation should be offered prior to a decision regarding termination (54% vs 75%, P < .001). MFMs reported report higher termination rates among patients only for DS (DS 51% vs 21%, P < .001). CONCLUSION MFM and FCP specialists' counseling attitudes differ for fetal abnormalities.
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Abstract
The past 2 decades have yielded profound advances in the fields of prenatal diagnosis and fetal intervention. Although fetal interventions are driven by a beneficence-based motivation to improve fetal and neonatal outcomes, advancement in fetal therapies raises ethical issues surrounding maternal autonomy and decision-making, concepts of innovation versus research, and organizational aspects within institutions in the development of fetal care centers. To safeguard the interests of both the pregnant woman and the fetus, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics make recommendations regarding informed consent, the role of research subject advocates and other independent advocates, the availability of support services, the multidisciplinary nature of fetal intervention teams, the oversight of centers, and the need to accumulate maternal and fetal outcome data.
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15
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Gawlikowska-Sroka A, Miklaszewska D, Dzieciolowska-Baran E, Kamienska E, Sroczynski T, Poziomkowska-Gesicka I. Changes of laryngeal parameters during intrauterine life. Eur J Med Res 2010; 15 Suppl 2:41-5. [PMID: 21147618 PMCID: PMC4360329 DOI: 10.1186/2047-783x-15-s2-41] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective Increased care of fetal and neonatal airways has led to advances in neonatal medicine. The early diagnosis and treatment of respiratory diseases require a detailed knowledge of fetal airway anatomy and development. The aim of this study was to determine the anatomical development of the thyroid and cricoid cartilages and their structural variability during fetal life. Materials and methods The study was performed on the thyroid and cricoid cartilages of 55 human fetal larynges of both sexes, between the ages of 13 and 27 weeks of intrauterine life. Numerous measurements of the thyroid and cricoid cartilages were performed. Results Correlations between the obtained results were calculated in relation to the crown-rump (C-R) length of human fetuses and to sex. The structural variability of the thyroid and cricoid cartilages of human male and female fetuses in subsequent weeks of intrauterine life was observed. In both genders a correlation between laryngeal size and fetal crown-rump length, regardless of sex, was found. The thyroid cartilage presents a sexual dimorphism. Conclusions The results of this study can be useful in the analysis of prenatal examinations, and in planning the treatment of airway emergencies.
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Brown SD. The intersection of ethics and communication in prenatal imaging: challenges for the pediatric radiologist. Pediatr Radiol 2010; 40:514-7. [PMID: 20225115 DOI: 10.1007/s00247-009-1516-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pediatric radiologists who practice prenatal imaging are often at the front lines of communication with pregnant patients and their partners. The communication process is particularly complex when a fetal abnormality is diagnosed. Regardless of whether the information is completely new and unexpected, or the patient is referred for tertiary imaging and counseling, few pediatric radiologists are trained specifically in the communication skills necessary to provide optimal care to the prospective parents. This paper reviews current literature regarding communication with patients about unexpected or difficult information, and illustrates key clinical and ethical features that make conversations with pregnant patients particularly challenging in the setting of fetal abnormalities.
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Affiliation(s)
- Stephen D Brown
- Department of Radiology, Children's Hospital Boston and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA.
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17
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Butwick A, Aleshi P, Yamout I. Obstetric hemorrhage during an EXIT procedure for severe fetal airway obstruction. Can J Anaesth 2009; 56:437-42. [PMID: 19396506 DOI: 10.1007/s12630-009-9092-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2008] [Revised: 03/03/2009] [Accepted: 03/05/2009] [Indexed: 12/19/2022] Open
Abstract
PURPOSE To report a case of massive obstetric hemorrhage occurring during Cesarean delivery for an ex utero intrapartum treatment (EXIT) procedure. Methods to optimize the anesthetic, obstetric, and perinatal management are discussed. CLINICAL FEATURES A healthy parturient underwent an urgent EXIT procedure at 32 weeks gestation for a giant fetal neck mass. During the intraoperative period, severe intraoperative hemorrhage occurred from the site of the uterine incision. No evidence of placental bleeding, premature placental separation, or inadequate uterine relaxation was observed during the perioperative period. Placement of a uterine stapling device was unsuccessful in achieving adequate surgical hemostasis. Initial attempts with laryngoscopy and rigid bronchoscopy to secure the fetal airway on placental support were unsuccessful, and early termination of placental support was deemed necessary due to the severity of maternal blood loss. After full delivery of the neonate and termination of placental support, neonatal ventilation with bag-mask ventilation was achieved and successful endotracheal intubation occurred during repeat bronchoscopy. CONCLUSIONS The risk of obstetric hemorrhage due to uterine relaxation and inadequate surgical hemostasis in patients undergoing EXIT procedures is poorly reported. To reduce adverse maternal and neonatal outcomes, the premature termination of placental support during EXIT procedures may be required in the setting of severe obstetric hemorrhage.
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Affiliation(s)
- Alexander Butwick
- Department of Anesthesia (MC:5640), Stanford University School of Medicine, 300 Pasteur Drive, Stanford, CA, 94305, USA.
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