The importance of professional responsibility and fetal viability in the management of abortion.

In June 2022, the Dobbs v. Jackson Women's Health Organization Supreme Court decision ended the constitutional right to the professional practice of abortion throughout the United States. The removal of the constitutional right to abortion has significantly altered the practice of obstetricians and gynecologists across the US. It potentially increases risks to pregnant patients, leads to profound changes in how physicians can provide care, especially in states with strict bans or gestational limits to abortion, and has introduced personal challenges, including moral distress and injury as well as legal risks for patients and clinicians alike. The professional responsibility model is based on the ethical concept of medicine as a profession and has been influential in shaping medical ethics in the field of obstetrics and gynecology. It provides the framework for the importance of ethical and professional conduct in obstetrics and gynecology. Viability marks a stage where the fetus is a patient with a claim to access to medical care. By allowing unrestricted abortions past this stage without adequate justifications, such as those concerning the life and health of the pregnant individual, or in instances of serious fetal anomalies, the states may not be upholding the equitable ethical consideration owed to the fetus as a patient. Using the professional responsibility model, we emphasize the need for nuanced, evidence-based policies that allow abortion management prior to viability without restrictions and allow abortion after viability to protect the pregnant patient's life and health, as well as permitting abortion for serious fetal anomalies.

Effectiveness and adverse effects of vaginal misoprostol as a single agent for second trimester pregnancy termination: the impact of fetal viability.

PURPOSE: To compare the effectiveness of vaginal misoprostol for second-trimester termination between pregnancies with a dead fetus in utero and those with a live fetus and to identify factors associated with the success rate. METHODS: Singleton pregnancies with live fetuses and dead fetuses, between 14 and 28 weeks of gestation, with an unfavorable cervix, were recruited to have pregnancy termination with intravaginal misoprostol 400 mcg every 6 h. RESULTS: Misoprostol was highly effective for termination, with a low failure rate of 6.3%. The effectiveness was significantly higher in pregnancies with a dead fetus (log-rank test; p: 0.008), with a median delivery time of 11.2 vs. 16.7 h. Fetal viability, fetal weight or gestational age, and an initial Bishop score were significantly associated with the total amount of misoprostol dosage used for induction. Fetal viability and gestational age/fetal weight were still independent factors after adjustment for other co-factors on multivariate analysis. CONCLUSION: Vaginal misoprostol is highly effective for second-trimester termination, with significantly higher effectiveness in pregnancies with a dead fetus. Also, the effectiveness is significantly associated with birth weight/gestational age, and initial Bishop score.

The (mis)use of fetal viability as the determinant of non-criminal abortion in the Netherlands and England and Wales.

Time plays a fundamental role in abortion regulation. In this article, we compare the regulatory frameworks in England and Wales and the Netherlands as examples of the centrality accorded to viability in the determination of the parameters of non-criminal abortion, demonstrating that the use of viability as a threshold renders the law uncertain. We assess the role played by the concept of viability, analysing its impact upon the continued criminalization of abortion and categorization of abortion as a medical matter, rather than a reproductive choice. We conclude that viability is misconceived in its application to abortion and that neonatal viability (relating to treatment of the premature infant) and fetal viability (related to the capacity to survive birth) must be distinguished to better reflect the social context within which the law and practice of abortion operate. We show how viability thresholds endanger pregnant people.

Orphans cannot be after-birth aborted: a response to Bobier.

I offer a response to an objection to my account of the moral difference between fetuses and newborns, an account that seeks to address an analogy between abortion and infanticide, which is based on the apparent equality of moral value of fetuses and newborns.

Estrogen receptor 1 appears essential for fetal viability in a murine model of premature birth.

PROBLEM: Protective effects for adult neurological disorders have been attributed to sex hormones. Using a murine model of prematurity, we evaluated the role of estrogen signaling in the process of perinatal brain injury following exposure to intrauterine inflammation. METHOD OF STUDY: Intrauterine lipopolysaccharide (LPS) was used to invoke preterm labor and fetal neuroinflammation. Fetal brains were analyzed for changes in Esr1, Esr2 and Cyp19. Dams heterozygous for the Esr1 knockout allele were also given intrauterine LPS to compare delivery and offspring viability to wild type controls. RESULTS: The upregulation in inflammatory cytokines was accompanied by an increase in Esr1 and Esr2 transcripts, though protein levels declined. Cyp19 did not differ by mRNA or protein abundance. Offspring from Esr1 mutants were larger, had a longer gestation and significantly greater mortality. CONCLUSIONS: Estrogen signaling is altered in the fetal brains of preterm offspring exposed to neuroinflammatory injury. The reduction of Esr1 and Esr2 proteins with LPS suggests that these proteins are degraded. It is possible that transcriptional upregulation of Esr1 and Esr2 occurs to compensate for the loss of these proteins. Alternatively, the translation of Esr1 and Esr2 mRNAs may be disrupted with LPS while a feedback mechanism upregulates transcription. Intact Esr1 signaling is also associated with early preterm delivery following exposure to intrauterine LPS. A loss of one Esr1 allele delays this process, but appears to do so at the cost of fetal viability. These results suggest estrogen signaling plays opposing roles between maternal and fetal responses to preterm birth.

Limite de viabilidade de prematuros extremos atendidos em um hospital universitário / Limit of viability of extremely preterm infants treated at a university hospital / Límite de viabilidad de prematuros extremos atendidos en un hospital universitario

Objetivo: descrever o perfil de recém-nascidos com prematuridade extrema e identificar fatores associados a mortalidade segundo idade gestacional e o limite de viabilidade destes. Método: estudo observacional retrospectivo, com abordagem quantitativa, realizado em um hospital universitário do estado de Minas Gerais, desenvolvido de agosto de 2021 a janeiro de 2022. A amostra foi composta por 39 prontuários de prematuros extremos nascidos vivos. Foi realizada a análise descritiva das variáveis quantitativas usando medidas como média, desvio-padrão e valores mínimo e máximo. As variáveis categóricas foram descritas a partir de suas distribuições de frequência absoluta e percentual. Resultados: a maioria das gestantes são mulheres adultos-jovens, realizaram pré-natal e parto cesárea. Dos prematuros prevalece sexo masculino, idade gestacional de 25 semanas, evoluíram para óbito a maioria destes com idade gestacional de 23 e 24 semanas. Conclusão: o limite de viabilidade nesse serviço situa-se em uma idade gestacional igual ou maior que 25 semanas.

Objective: to describe the profile of newborns with extreme prematurity and to identify factors associated with mortality according to gestational age and their limit of viability. Method: a retrospective observational study, with a quantitative approach, carried out in a university hospital in the state of Minas Gerais, developed from August 2021 to January 2022. The sample consisted of 39 records of live-born extreme preterm infants. Descriptive analysis of quantitative variables was performed using measures such as mean, standard deviation and minimum and maximum values. Categorical variables were described from their absolute and percentage frequency distributions. Results: most pregnant women are young-adult women, who underwent prenatal care and cesarean delivery. Of the preterm infants, the male sex prevails, with a gestational age of 25 weeks, most of whom died at a gestational age of 23 and 24 weeks. Conclusion: the limit of viability in this service is at a gestational age equal to or greater than 25 weeks.

Objetivo: describir el perfil de los recién nacidos con prematuridad extrema e identificar los factores asociados a la mortalidad según la edad gestacional y su límite de viabilidad. Método: estudio observacional retrospectivo, con abordaje cuantitativo, realizado en un hospital universitario del estado de Minas Gerais, desarrollado entre agosto de 2021 y enero de 2022. La muestra estuvo compuesta por 39 prontuarios de prematuros extremos nacidos vivos. El análisis descriptivo de las variables cuantitativas se realizó utilizando medidas como la media, la desviación estándar y los valores mínimo y máximo. Las variables categóricas se describieron a partir de sus distribuciones de frecuencia absoluta y porcentual. Resultados: la mayoría de las gestantes son mujeres adultas jóvenes, que realizaron control prenatal y parto por cesárea. De los prematuros prevalece el sexo masculino, con una edad gestacional de 25 semanas, la mayoría de los cuales fallecieron a las 23 y 24 semanas de edad gestacional. Conclusión: el límite de viabilidad en este servicio es a una edad gestacional igual o mayor a 25 semanas.

Trends in Active Treatment of Live-born Neonates Between 22 Weeks 0 Days and 25 Weeks 6 Days by Gestational Age and Maternal Race and Ethnicity in the US, 2014 to 2020.

Importance: Birth in the periviable period between 22 weeks 0 days and 25 weeks 6 days' gestation is a major source of neonatal morbidity and mortality, and the decision to initiate active life-saving treatment is challenging. Objective: To assess whether the frequency of active treatment among live-born neonates in the periviable period has changed over time and whether active treatment differed by gestational age at birth and race and ethnicity. Design, Setting, and Participants: Serial cross-sectional descriptive study using National Center for Health Statistics natality data from 2014 to 2020 for 61 908 singleton live births without clinical anomalies between 22 weeks 0 days and 25 weeks 6 days in the US. Exposures: Year of delivery, gestational age at birth, and race and ethnicity of the pregnant individual, stratified as non-Hispanic Asian/Pacific Islander, non-Hispanic Black, Hispanic/Latina, and non-Hispanic White. Main Outcomes and Measures: Active treatment, determined by whether there was an attempt to treat the neonate and defined as a composite of surfactant therapy, immediate assisted ventilation at birth, assisted ventilation more than 6 hours in duration, and/or antibiotic therapy. Frequencies, mean annual percent change (APC), and adjusted risk ratios (aRRs) were estimated. Results: Of 26 986 716 live births, 61 908 (0.2%) were periviable live births included in this study: 5% were Asian/Pacific Islander, 37% Black, 24% Hispanic, and 34% White; and 14% were born at 22 weeks, 21% at 23 weeks, 30% at 24 weeks, and 34% at 25 weeks. Fifty-two percent of neonates received active treatment. From 2014 to 2020, the overall frequency (mean APC per year) of active treatment increased significantly (3.9% [95% CI, 3.0% to 4.9%]), as well as among all racial and ethnic subgroups (Asian/Pacific Islander: 3.4% [95% CI, 0.8% to 6.0%]); Black: 4.7% [95% CI, 3.4% to 5.9%]; Hispanic: 4.7% [95% CI, 3.4% to 5.9%]; and White: 3.1% [95% CI, 1.1% to 4.4%]) and among each gestational age range (22 weeks: 14.4% [95% CI, 11.1% to 17.7%] and 25 weeks: 2.9% [95% CI, 1.5% to 4.2%]). Compared with neonates born to White individuals (57.0%), neonates born to Asian/Pacific Islander (46.2%; risk difference [RD], -10.81 [95% CI, -12.75 to -8.88]; aRR, 0.82 [95% CI, [0.79-0.86]), Black (51.6%; RD, -5.42 [95% CI, -6.36 to -4.50]; aRR, 0.90 [95% CI, 0.89 to 0.92]), and Hispanic (48.0%; RD, -9.03 [95% CI, -10.07 to -7.99]; aRR, 0.83 [95% CI, 0.81 to 0.85]) individuals were significantly less likely to receive active treatment. Conclusions and Relevance: From 2014 to 2020 in the US, the frequency of active treatment among neonates born alive between 22 weeks 0 days and 25 weeks 6 days significantly increased, and there were differences in rates of active treatment by race and ethnicity.

Proteome-defined changes in cellular pathways for decidua and trophoblast tissues associated with location and viability of early-stage pregnancy.

BACKGROUND: In early pregnancy, differentiating between a normal intrauterine pregnancy (IUP) and abnormal gestations including early pregnancy loss (EPL) or ectopic pregnancy (EP) is a major clinical challenge when ultrasound is not yet diagnostic. Clinical treatments for these outcomes are drastically different making early, accurate diagnosis imperative. Hence, a greater understanding of the biological mechanisms involved in these early pregnancy complications could lead to new molecular diagnostics. METHODS: Trophoblast and endometrial tissue was collected from consenting women having an IUP (n = 4), EPL (n = 4), or EP (n = 2). Samples were analyzed by LC-MS/MS followed by a label-free proteomics analysis in an exploratory study. For each tissue type, pairwise comparisons of different pregnancy outcomes (EPL vs. IUP and EP vs. IUP) were performed, and protein changes having a fold change ≥ 3 and a Student's t-test p-value ≤ 0.05 were defined as significant. Pathway and network classification tools were used to group significantly changing proteins based on their functional similarities. RESULTS: A total of 4792 and 4757 proteins were identified in decidua and trophoblast proteomes. For decidua, 125 protein levels (2.6% of the proteome) were significantly different between EP and IUP, whereas EPL and IUP decidua were more similar with only 68 (1.4%) differences. For trophoblasts, there were 66 (1.4%) differences between EPL and IUP. However, the largest group of 344 differences (7.2%) was observed between EP and IUP trophoblasts. In both tissues, proteins associated with ECM remodeling, cell adhesion and metabolic pathways showed decreases in EP specimens compared with IUP and EPL. In trophoblasts, EP showed elevation of inflammatory and immune response pathways. CONCLUSIONS: Overall, differences between an EP and IUP are greater than the changes observed when comparing ongoing IUP and nonviable intrauterine pregnancies (EPL) in both decidua and trophoblast proteomes. Furthermore, differences between EP and IUP were much higher in the trophoblast than in the decidua. This observation is true for the total number of protein changes as well as the extent of changes in upstream regulators and related pathways. This suggests that biomarkers and mechanisms of trophoblast function may be the best predictors of early pregnancy location and viability.

Delivery management of a complete hydatidiform mole and co-existing viable fetus: A meta-analysis and systematic review.

OBJECTIVE: A twin pregnancy with a complete hydatidiform mole and co-existing viable fetus (CHMCF) is an exceedingly rare obstetric complication with few data related to perinatal treatment. This study determined the optimal timing of pregnancy termination and mode of delivery in women with CHMCF and a viable fetus. METHODS: The articles published involving CHMCF and a viable fetus from 1967 to 31 December 2020 in the PubMed and EMBASE databases were systematically reviewed. Observational cohort studies with three or more cases identified and data on delivery management were selected. The articles were analyzed independently for full text and the data were integrated. The timing of pregnancy termination and mode of delivery were calculated using Review Manager 5.4.1. RESULTS: There were 192 reports involving CHMCF; 209 cases had a viable fetus. According to the inclusion criteria, there were 6 case series, including 72 cases that were eligible for the analysis. The average rate of live births was 34.4%. The average duration of pregnancy was 34 weeks, ranging from 25 to 41 weeks. From 2000-2017 the live birth rate was increased year-after-year. Specifically, the live birth rate was16.7% in 2000, 33.3% in 2012, and 50% in 2017. Fifty-two cases (72.2%) had cesarean sections and 20 cases (27.8%) had vaginal deliveries. The incidence of gestational trophoblastic neoplasia was not significantly different between the two modes of delivery. CONCLUSIONS: Ideally, a twin pregnancy with a complete hydatidiform mole co-existing with a viable fetus is managed by an obstetrician, pediatrician, and oncologist. Appropriate timing of pregnancy termination and mode of delivery are related to the pregnancy outcome.

Case report and literature review of management of preterm prelabour rupture of membranes before fetal viability.

Preterm prelabour rupture of membranes (PPROM) complicates up to 3% of pregnancy and is responsible for one third of preterm deliveries. PPROM at extremely preterm gestations (<24 weeks) affects 0.4% of pregnancies and is associated with low neonatal survival rates, high rate of neonatal complications in survivors, and carries major risk of maternal morbidity and mortality. We present a rare case of pregnancy complicated by PPROM at 14 weeks which resulted in a term delivery and a good neonatal outcome.

Why appeals to the moral significance of birth are saddled with a dilemma.

In 'Dilemma for Appeals to the Moral Significance of Birth', we argued that a dilemma is faced by those who believe that birth is the event at which infanticide is ruled out. Those who reject the moral permissibility of infanticide by appeal to the moral significance of birth must either accept the moral permissibility of a late-term abortion for a non-therapeutic reason or not. If they accept it, they need to account for the strong intuition that her decision is wrong as well as deny the underlying normative principle that killing a viable fetus requires good reason, and not wanting to care for the child when the child could be easily placed for adoption is not a good enough reason to abort. If they reject the moral permissibility of the late-term abortion, they need to explain why her decision is wrong. Doing so, however, will undermine their own project of denying infanticide by appeal to birth. Walter Veit argues that the dilemma relies too much on intuition and does not live up to biological continuity. We explain why his criticisms are unconvincing.

Does birth matter?

This paper is a response to a recent paper by Bobier and Omelianchuk in which they argue that the critics of Giubilini and Minerva's defence of infanticide fail to adequately justify a moral difference at birth. They argue that such arguments would lead to an intuitively less plausible position: that late-term abortions are permissible, thus creating a dilemma for those who seek to argue that birth matters. I argue that the only way to resolve this dilemma, is to bite the naturalist bullet and accept that the intuitively plausible idea that birth constitutes a morally relevant event is simply mistaken and biologically misinformed.

Histerectomia radical após parto cesáreo por adenocarcinoma de colo uterino: relato de caso / Radical hysterectomy after c-section in cervical adenocarcinoma: a case report

Mundialmente, o câncer de colo uterino ocupa o quarto lugar das neoplasias em mulheres, porém, nos países em desenvolvimento, as taxas de incidência superam de forma impactante os casos de países desenvolvidos. Apesar de ser um evento incomum durante a gestação, é cada vez mais observado, o que talvez possa ser atribuído às gestações programadas em idades mais avançadas. O caso descrito refere-se a uma paciente de 32 anos de idade, diagnosticada no terceiro trimestre da gestação com adenocarcinoma de origem endocervical com estadiamento anatomopatológico final (FIGO 2018) 1B2. Ela foi submetida à abordagem cirúrgica como tratamento inicial. Foi adotada como conduta a resolução da gestação, com boa vitalidade fetal, ao final da 34ª semana, após corticoterapia para maturação pulmonar fetal. Foi realizado parto cesariano seguido de histerectomia radical tipo C1 na classificação de Querleu e Morrow associado a linfadenectomia pélvica, no mesmo ato operatório.(AU)

Worldwide, cervical cancer ranks fourth in female cancers, but when assessing data from developing countries, incidence rates are significantly higher than in developed countries. Although it is an uncommon event during pregnancy, it is increasingly observed, which may perhaps be justified due to pregnancies postponed at older ages. The case described relates to a 32-year-old woman diagnosed in the third trimester of pregnancy with endocervical adenocarcinoma, whose final anatomopathological staging (FIGO 2018) was IB2. The same was submitted to the surgical approach as an initial treatment. It was adopted as a conduct, the resolution of pregnancy, with good fetal viability, at the end of the 34th week, after corticosteroid therapy for fetal lung maturation. The patient underwent cesarean section followed by radical type C1 hysterectomy in the classification of Querleu and Morrow associated with pelvic lymphadenectomy in the same surgery.(AU)