An Ethical Framework for Research in Maternal-Fetal Intervention in the Presence of Maternal Human Immunodeficiency Virus or Hepatitis B and C Infection.

Maternal-fetal interventions continue to be a groundbreaking and rapidly expanding area. In this article, we examine whether it is ethically permissible to conduct investigation into the expansion of inclusion criteria for existing maternal-fetal interventions to include pregnant patients with human immunodeficiency virus (HIV) and hepatitis B or C infection with low or undetectable viral loads. We addressed this ethical question by appealing to ethical principle of respect for the autonomy of the pregnant patient; the patient status of the fetus; the balance of overall benefits and risks of the procedure(s) to pregnant, fetal, and neonatal patients; and to the ethical principle of justice. The ethical framework we have provided supports the conclusion that research on maternal-fetal interventions with pregnant women with HIV and hepatitis B and C infection with low or undetectable viral loads is ethically permissible. To accumulate sufficient numbers, such research should be multicenter.

Management of Labor and Delivery After Fetoscopic Repair of an Open Neural Tube Defect.

OBJECTIVE: To report labor, delivery, and neonatal outcomes in a cohort of women delivering neonates who had undergone fetoscopic neural tube defect repair. METHODS: We conducted a retrospective cohort study from April 2014 to January 2018. All patients met Management of Myelomeningocele Study eligibility criteria. We included patients with completed second-trimester fetoscopic neural tube defect repair (laparotomy, uterine exteriorization, and minimally invasive access through two or three uterine ports) followed by standardized management of labor and delivery at our institution. Outcomes included rates of vaginal delivery, term delivery, and intrapartum cesarean delivery as well as obstetric and neonatal outcomes after oxytocin. Complications of interest included preterm prelabor rupture of membranes, chorioamnionitis, uterine dehiscence or rupture, 5-minute Apgar score less than 7, and neonatal acidosis (umbilical artery pH less than 7.15). RESULTS: Thirty-four patients had fetoscopic repair, followed by 17 vaginal deliveries (50%, 95% CI 32-68%). Median gestational age was 38 1/7 weeks at vaginal delivery (range 26 0/7-40 2/7 weeks of gestation) and 37 1/7 weeks of gestation at cesarean delivery (range 25 5/7-40 5/7 weeks of gestation); 62% of deliveries occurred at term. Eight patients had prelabor cesarean delivery: three nonurgent and five urgent (for nonreassuring fetal heart tracings). Twenty-six patients labored; six were induced and 20 labored spontaneously. Of the latter, five were augmented. Of 26 laboring patients, 17 delivered vaginally and nine underwent urgent cesarean delivery (35%, 95% CI 17-56%; seven nonreassuring fetal heart tracings and two breech). There were no cases of uterine rupture or dehiscence. Most (94%, 95% CI 80-99%) had normal 5-minute Apgar scores; one neonate (3%, 95% CI 0-15%) had acidosis but normal Apgar scores. CONCLUSION: Our data regarding trial of labor, use of low-dose oxytocin, and vaginal delivery after prenatal fetoscopic neural tube defect repair are reassuring. Importantly, fetoscopic repair may permit delivery at advanced gestational ages.