A retrospective study on the prevalence, severity and outcomes of intraventricular haemorrhage in infants with a low birth weight in a quarternary hospital in a low- to middle-income country

Background. Intraventricular haemorrhage (IVH) is a serious complication in infants with a low birth weight (LBW). Objective. To study the prevalence, severity and outcomes of IVH in LBW infants admitted to a neonatal intensive care unit (NICU). Methods. This was a retrospective cohort study of LBW infants admitted to the NICU at a quarternary hospital between January and December 2012. Neonates with recorded cranial ultrasound scans were included and followed up to between 18 and 24 months of age for neurological outcomes. Results. An overall IVH prevalence of 44.3% (95% confidence interval 40 - 50) was observed in the study population (N=210). The prevalence of IVH in infants with a very low birth weight (VLBW) was 67.0%. Multivariable logistic regression showed risk factors for IVH to be VLBW, extreme prematurity, exposure to HIV, outborn delivery and receipt of a blood transfusion. Moderate to severe IVH was more common in VLBW and extremely premature infants. Severe IVH was associated with high mortality. At follow-up, 18.8% of the subjects showed signs of neurodevelopmental delay, while 6.3% were diagnosed with epilepsy. The overall all-cause mortality rate was 15.7% at discharge. Mothers' antenatal clinic attendance and caesarean delivery were protective factors. Conclusion. Improved perinatal care for women in preterm labour, especially in rural areas in South Africa, could lead to better outcomes in infants. A screening schedule could contribute to timeous detection of brain injury in at-risk babies to facilitate appropriate medical management and detection of lesions associated with adverse long-term neurodevelopmental outcomes

Ethical and legal dilemmas around termination of pregnancy for severe fetal anomalies: A review of two African neonates presenting with ventriculomegaly and holoprosencephaly.

Termination of pregnancy (TOP) or feticide for severe fetal anomalies is ethically and morally challenging and maybe considered illegal in countries with restrictive abortion laws. While diagnostic modalities such as fetal ultrasound, magnetic resonance imaging, and genetic screening have improved prenatal diagnosis, these technologies remain scarce in many African countries making diagnosis and counseling regarding TOP difficult. Ethical dilemmas such as women's autonomy rights may conflict with fetus' right to personhood, and doctor's moral obligations to society. In liberal jurisdictions, previable fetuses may not have legal rights of personhood; therefore, appropriate action would be to respect pregnant women's decisions regarding TOP. However, in countries with restrictive abortion laws the fetus maybe imbued with the right of personhood at conception, making TOP illegal and exposing doctors and patients to potential criminal prosecution. Birth of a severely disabled baby with independent legal rights creates further conflicts between parents and clinicians complicating healthcare decision-making. Irrespective of the maternal decision to accept or refuse TOP, the psychological and emotional impact of an impaired fetus or neonate, often lead to moral distress and posttraumatic stress reactions in parents. Doctors have legal and ethical obligations to provide an accurate antenatal diagnosis with full disclosure to enable informed decision making. Failure to provide timely or accurate diagnosis may lead to allegations of negligence with potential liability for "wrongful birth" or "wrongful life" following birth of severely disabled babies. Mismanagement of such cases also causes misuse of scarce healthcare resources in resource-poor countries. This paper describes ethical challenges in clinical management of two neonates born following declined and failed feticide for severe central nervous system anomalies with a critical appraisal of the relevant literature.