ETHICAL ISSUES IN ABNORMAL PREGNANCIESEthical Considerations in Early Induction of LaborEthics in treating Ectopic PregnancyMaternal-fetal Conflict

Ethical Considerationsin Early Induction of LaborReporter: ABRIGO, Veronica RosaAcop, Karla MarieResearchers:Antonio Abello, Maria Rose Aceron, Karla Marie Acop, Andre Acosta

Labor inductionLabor is induced to cause a pregnant woman's cervix to open (dilate) and thin out (efface) to prepare for the vaginal birth of her baby. Use of medicines or with surgical methods

What are the risks of inducing labor?Induction itself carries serious risks to both mother and infantLonger and stronger contractionsmay lead to a more painful laborincreases the chance that pain medication will be used, with the possibility of risks related to the pain medicationinterrupt blood flow and oxygen to the fetusDecrease in heart rate

Poor positioning of the fetusIncrease the risk of cesarean if induction failsPostpartum hemorrhage Emotional distress

With all of these risk factors, what would be a good and morally upright reason for inducing labor? Induction should be avoided if possible.

Did you kick me out of my warm, cozy home early?

EARLY INDUCTION OF LABORearly induction for fetuses with anomalies incompatible with life"This procedure induces a woman into labor after her unborn child reaches viability around 23 to 26 weeks in cases when the child is known to have a condition that makes death inevitable soon after even a full-term birth.

IndicationsTimingAt least 1 to 2 weeks past the due dateMother's healthPre-eclampsiaGestational diabetesPregnancy itselfProblems in the sac that holds the baby Early breaking of the membrane that holds the sac without the start of laborabnormal fetal heart ratethe placenta is pulling away from the wall of the uterus (abruption)death of the baby before birthUniversity of Michigan Health Systems

Whats at stake?Why women consider?They are overwhelmed by emotional and mental stress. They are convinced that going to full term will not improve the child's chances of survival. In cases of renal agenesis, fetal death could result in release of toxins dangerous to the mother.

Whats at stake?ObjectionsEarly induction is only permissible when the physical life of the mother is gravely endangered a very rare situation. Prenatal diagnosis can be wrong, and a healthy child could die as a result. The procedure presents increased risk to the mother of conditions including incompetent cervix, impaired mental health and breast cancer. Prematurity reduces the chances of survival for a child already diagnosed as unable to survive.

What is right?Early induction is doneOperations, treatments, and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child.Directive 47 (Ethical and Religious Directives)

Early induction is doneFor a proportionate reason, labor may be induced after the fetus is viable.proportionateFrom the teaching of St. Alphonsus Ligouri, who used the term for situations in which some grave risk would be incurred if an action were not taken to avoid it.

Ethical issues Specific Ends of Early Induction of Labor

complete avoidance of direct abortion

preservation of the lives of both mother and child to the extent possible under the circumstances

NCBC STATEMENT ON EARLY INDUCTION OF LABOR March 11, 2004

Principle of Double EffectActions that might result in the death of a child are morally permitted ONLY IF ALL of the following conditions are met:

treatment is directly therapeutic in response to a serious pathology of the mother or child

the good effect of curing the disease is intended and the bad effect foreseen but unintended

the death of the child is not the means by which the good effect is achieved

the good of curing the disease is proportionate to the risk of the bad effect.

Fulfillment of all four conditions precludes any act that directly hastens the death of a child.

ExampleChorioamnionitisPreeclampsiaH.E.L.L.P. syndrome.

--it directly cures a pathology by evacuating the infected membranes in the case of chorioamnionitis, or the diseased placenta in the other cases, and cannot be safely postponed.

AnencephalyDefect in the closure of the neural tube during fetal development resulting in the absence of a major portion of brain, skull and scalp.Remaining brain tissue often exposedUsually without a forebrain and cerebrum (thinking parts)University of Michigan Health Systems

AnencephalyUsually blind, deaf, unconscious, and unable to feel pain Lack of a functioning cerebrum permanently rules out the possibility of ever gaining consciousness Reflex actions such as breathing and responses to sound or touch may occurUniversity of Michigan Health Systems

AnencephalyCause is unknown Mother's diet and vitamin intake may play a role, but is not the sole factorAddition of folic acid to the diet of women of childbearing age may significantly reduce the incidence of neural tube defectsUniversity of Michigan Health Systems

AnencephalyNo cure Treatment is mainly supportivePrognosis is extremely poor If the infant is not stillborn, then he or she will usually die within a few hours or days after birthUniversity of Michigan Health SystemsEarly induction for fetuses with anomalies incompatible with life (EIFWAIL)

Issue at handAnencephaly was regarded as a special case from other lethal birth defects because of the presumed lack of mental function. Women for Faith and Family Organization

Sister Jean deBlois, CSJ1993, then-senior associate for clinical ethics at The Catholic Health AssociationAnencephaly as a case where the pregnancy may be terminated at any time although there is no life-threatening maternal pathology she cited the increased physical risks during labor and delivery, the emotional trauma suffered by a couple upon diagnosis of anencephaly, and the lack of mental development in the baby as justification for "inducing labor to end the pregnancy".

Acknowledged that "there is NO life-threatening maternal pathology"

Sister Jean deBlois, CSJPrinciples of proportionality and "double effectThe resulting fetal death is indirect" and thus NOT an abortion.

Human life involves more than simply biologic life. Infants with anencephaly lack "psychological, social, and creative capacities and can never acquire the quality of viability, properly understood".

Once the diagnosis is made, there seems to be no purpose in maintaining the pregnancy".

If that is soCatholic hospitals would then be ethically allowed to perform early induction delivery -- an acknowledged abortion procedure used for terminating babies with birth defects -- as a kind of termination of life support rather than abortion.

What is right"Moral Principles Concerning Infants with Anencephaly - statement by US bishops in 1996It is clear that before 'viability' it is never permitted to terminate the gestation of an anencephalic child as the means of avoiding psychological or physical risks to the mother. Nor is such termination permitted after 'viability' if early delivery endangers the child's life due to complications of prematurity.

What is rightTerminating her pregnancy cannot be a treatment to a pathology she does not have. Only if the complications of the pregnancy result in a life-threatening pathology of the mother, may the treatment of this pathology be permitted even at a risk to the child, and then only if the child's death is not a means to treating the mother".--Bishops Doctrinal Committee"Moral Principles Concerning Infants with Anencephaly

Change of heartA Primer for Health Care Ethics - by Father Kevin ORourke, 2000. The application of the principle of double effect does not seem to justify the early delivery of anencephalic infants. (Reversal of opinion: A Primer for Health Care Ethics-Essays for a Pluralistic Society. co-authored with Father Patrick Norris, OP and Sister deBlois.

Another blow"Early Delivery of a Fetus with Anencephaly - article by Father Norman Ford, 2003.Theorized that waiting until 33 weeks (almost two months before term) to induce delivery of anencephalic infants meets ethical standards. Pre-maturity is considered as delivery before 37 weeks.Cause of death would then be anencephaly instead of pre-maturity since most normal babies survive when delivered at that stage Deaths of anencephalic infants are anticipated.Motivated by "a compassionate desire to alleviate the mother's distress and minimize potential health risks for the mother" "by this stage the mother's duty of reasonable care for her fetus would have been satisfied".

When it rains, it poursTwo October 2003 articles -- one in the Catholic Anchor, Anchorage's archdiocesan newspaper, and one in the National Catholic Register Reported early induction deliveries of infants with other "anomalies incompatible with life" in Catholic hospitals as early as 24 weeks into pregnancy, which is the commonly accepted limit of viability even with treatment. The ethicists involved defend the early inductions as consistent with Directive number 49 of the US Bishops' Ethical and Religious Directives for Catholic Health Care Services (ERD), which says: "For a proportionate reason, labor may be induced after the fetus is viable".

When it rains, it poursDr. Maria Wallington, director of ethics at Providence Alaska Medical Center."The ERDs talk about proportioned good and then they don't talk about how you decide that".In a later article in the January 23, 2004 edition of the Anchorage Daily News, Dr. Wallington continued to defend the early inductions: "The practice relieves suffering, Wallington said. Imagine how hard it would be for a pregnant woman to face constant questions about a baby she knows will die."

ProportionalityDefinitionDebunk

Risks of Early Induction of LaborNot uncommon practice and can even be life-saving for the mother or babyInducing delivery two to four months early is a situation that would certainly not be contemplated for a healthy baby and a healthy mother. The process itself carries serious risks to both mother and infant. May 2003 editorial in the American Family Physician journal states, even elective induction delivery near- or post-term "is not without potential risks, including iatrogenic prematurity, uterine hyperstimulation, nonreassuring fetal heart rate tracing, and greater likelihood of operative delivery, shoulder dystocia, and postpartum hemorrhage".

Other risksAbnormal fetal heart rate from contractions that are too strong or frequent, or from a squeezing (compression) of the umbilical cordSeparation of the placenta from the uterus (abruption) if contractions are too strongProlapsed umbilical cord (the umbilical cord falls into the birth canal ahead of the baby's head or other parts of the baby's body) or infection as a result of amniotomyDamage to the uterus Cesarean delivery if induction of labor does not work.Infection from the breaking of the bag of waters with amniotomy.

Choose LIFE Despite the advances in prenatal diagnostics, prenatal testing is still not 100% accurate and there exists a risk of misdiagnosis that can and often does result in the loss of a less impaired or even healthy baby by early termination of pregnancy.Even when induction is considered necessary in medically emergent situations, such as severe pre-eclampsia, every effort is made to give the baby as much time in the womb as possible to lessen the usual risks of prematurity.

ParentsDiagnosis of a lethal or other serious anomaly in an infant is a distressing moment, whether this occurs before or after birth. There is a normal grieving process as the parents face the reality of the loss of the "perfect" baby they had imagined and must eventually prepare for the death of that child. In utero, there is a natural tendency to want to "get it over with" rather than endure well-meaning comments from strangers and imagine a sadly different labor and delivery weeks or months in advance.

ParentsThe natural grief of losing a child cannot be avoided. Will waiting an additional two to four months before the pregnancy is terminated decrease maternal distress? We have not found cited studies supporting the contention that early induction can be psychologically beneficial.

ParentsWhich would be more distressing?Knowing that your child will die.Living the rest of your life knowing that you had a hand in killing your own baby.

What we learnedBioethics is an unforgiving area of medicine.Lives can be unnecessarily and unjustly lost because of a redefinition of terms or a subjective interpretation of principles.As in the argument on when life startsIssues once considered settled can then become open to even radical change with unexpected consequences.

What we are facingPresumed lack of mental function is a lethal pathology that can override the obligation to provide for the basic needs of a person. Unborn baby with anencephaly (presumed to lack mental function and with a lethal pathology), similar override of the obligation to provide for the basic needs of the babybyjustifying abortion. Thus, pregnancy itself can then be viewed as a form of 'life support" that can be ethically withdrawn at some stage where, as Father Ford states, "the mother's duty of reasonable care for her fetus would have been satisfied".

The answer?Pregnancy is NOT a form of life support.God given giftSpecially given to women to take a part in the wonder of creationWomen are not machinesMachines cannot feel and nurture and love

What we are facingArguments about the perceived burdens of continuing an unborn life that may be short. PsychologicalMentalFinancial

The answer?A person's life is to be valued at all stages and conditions until natural death. preclude attempts to justify causing or even hastening death by early induction of labor.

ConclusionElective early induction delivery of babies with anencephaly or other lethal defects is unfortunately motivated by a misplaced compassion that not only deprives the baby of his or her natural lifespan, but also deprives the mother of the chance to truly bond withand nurture her afflicted child until death intervenes.

ConclusionWe should set a standard of integrity by offering grieving families continuing support and encouragement rather than a premature termination of pregnancy. Become much-needed and powerful witness to the value of all human life, regardless of age or condition.

There is no if-clause to our parenthood: I will love you if you are perfect. The first thing a parent can do is love his or her child. In some cases, it's the only thing we can do, and so we love them all the harder. - Carrying to Term Pages

We didnt put any pictures of anencephalic babies in the report. We all know how babies with the condition look like.

Rather we would like you to see them as part of families, as the human beings that they are.

ECTOPIC PREGNANCY

Topic OutlineIntroductionAnatomyNormal implantationEctopic pregnancySites of ectopic pregnancyCurrent Medical ProceduresMoral ConsiderationsConclusion

Female Reproductive System

Ectopic Pregnancyleading cause of pregnancy-related death during the first trimester in the United States9% of all pregnancy-related deathsthe woman's future ability to reproduce may be adversely affected

Ectopic Pregnancyfrom the Greek word ektopos, meaning out of placeimplantation of a fertilized egg in a location outside of the uterine cavitygrows and draws its blood supply from the site of abnormal implantationcreates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal developmentlead to massive hemorrhage, infertility, or death

Common Sites of Ectopic Pregnancy

Normal course of an egg down through the fallopian tube and into the wall of the uterus.

In Ectopic pregnancy the embryo is implanted in the fallopian tube before it reaches the uterus.

The embryo grows causing the fallopian tube to bulge.

As the embryo grows larger, the fallopian tube ruptures and hemorrhages.

Current Procedures for Managing Ectopic Pregnancy

Medical InterventionMethotrexate an antimetabolite chemotherapeutic agentbinds to the enzyme dihydrofolate reductaseinterferes with DNA synthesis and disrupts cell multiplication destroys the placental (trophoblast) cells/tissue

Medical InterventionMethotrexate option when the pregnancy is located on the cervix, ovary, or in the interstitial or the cornual portion of the tubeSurgical treatment in these cases is often associated with increased risk of hemorrhageresulting in hysterectomy or oophorectomy good subsequent reproductive outcomesrisk of tubal injury is reduced

Surgical MethodsLaparotomy surgical procedure involving an incision through the abdominal wall to gain access into the abdominal cavityalso known as coeliotomy

Laparoscopy surgical procedure in which a small incision is made, usually in the navel, through which a viewing tube (laparoscope) is inserted

Types of SurgerySalpingectomysurgical removal of a Fallopian tube

Salpingostomy surgical incision into a fallopian tube

Fimbrial Expression Proceduresome ampullary pregnancies can be teased out and expressed through the fimbrial end (milking of the tube) by using digital expression, suction, or aqua-dissection

Surgical Intervention

Moral Considerations for Managing Ectopic Pregnancy

all actions must be analyzed according toIntention (motive) of the acting subjectMeans (the circumstances and consequences)End (the (moral) object itself of his act)If any of these three are immoral, the act itself is immoral.

Principle of Totalityholds that we may sacrifice even a basic bodily function or organ to preserve the whole of the bodily life provided there is no less invasive way of achieving this goal.

Principle of Double Effectaction to produce both a desired good effect and at the same time allow for certain evil consequences

Four Conditionsfor Considering the Principle of Double Effect1. The moral object may not be evil in itself; the moral act must itself be good or morally indifferent.2. The good and evil effect must proceed at least equally directly from the act (the immediate effect must not be solely evil and the good effect should not physically result from the evil effect).3. The agent may not intend or approve the evil effect.4. There must be a proportionate grave reason in order to allow the evil effect.

Evangelium Vitae (The Gospel of Life)The evil of direct or induced abortion, for whatever reason, is a moral absolute.

Procured abortion, according to John Paul II is the deliberate and direct killing, by whatever means it is carried out, of a human being in the initial phase of his or her existence, extending from conception to birth and this direct and voluntary killing of an innocent human being is always gravely immoral.

Evangelium Vitae (The Gospel of Life)The killing of innocent human creatures (an ectopic), even if carried out to help others (e.g., the mother), constitutes an absolutely unacceptable act.

Therefore, any attempt to directly remove the living fetus, even if it is deemed nonviable, as is eventually the case currently with tubal pregnancies, has always been recognized by Catholic moral teaching as gravely immoral and essentially similar to abortion.

SalpingectomyIn extrauterine pregnancy the affected part of the mother (e.g., cervix, ovary, or fallopian tube) may be removed, even though fetal death is foreseen, provided that (a) the affected part is presumed already to be so damaged and dangerously affected as to warrant its removal, and that (b) the operation is not just a separation of the embryo or fetus from its site within the part (which would be a direct abortion from a uterine appendage) and that (c) the operation cannot be postponed without notably increasing the danger to the mother.

SalpingectomyIn the case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion. Operations, treatments and medications that have as their direct purpose the cure of a proportionately serious pathological condition of a pregnant woman (i.e., a salpingectomy) are permitted when they cannot be safely postponed until the unborn child is viable, even if they will result in the death of the unborn child It is not permissible, however, to initiate or to recommend treatments that have as their purpose or direct effect the removal, destruction, or interference with the implantation of a fertilized ovum

SalpingostomyFimbrial Expression ProcedureMethotrexatedirectly attack an innocent human lifeintrinsically immoral and never can be justified violate the Sixth Commandment "means" used to accomplish the "end" are not the same

Reporter: Joanabeth Aguirre

Before you were conceived I wanted you Before you were born I loved you Before you were here an hour I would die for you This is the miracle of Mother's Love. -- Maureen Hawkins

Roe vs. Wade (1973)controversial United States Supreme Court case that resulted in a landmark decision regarding abortiondecision overturned all state and federal laws outlawing or restricting abortion

central holding of Roe v. Wade was that abortions are permissible for any reason a woman chooses, up until the "point at which the fetus becomes viable, that is, potentially able to live outside the mother's womb, albeit with artificial aidcourt accepted the conventional medical wisdom that a fetus becomes viable at the start of the last third of a pregnancy, the third trimester, sometime between the 24th and 28th week

because the point of viability varies, the court ruled, it could only be determined case by case and by the woman's own doctor

Doe vs. Dalton (1973)US Supreme Court supported abortion rights after the point of fetal viability in order to preserve womens lives and continuing healthconcept of health, as defined by the Supreme Court in Doe v. Bolton, includes all medical, psychological, social, familial and economic factors that may potentially encourage a decision to obtain an abortion

R. vs. Morgentaler (1988)the court ruled that the Criminal Code violated womens rights because forcing a woman, by threat of criminal sanction, to carry a fetus to term unless she meets certain criteria unrelated to her own priorities and aspirations, is a profound interference with a womans body and thus a violation of security of the person

Maternal-fetal conflict occurs when a pregnant womans interests, as she defines them, conflict with the interests of her fetus, as defined by the womans physician.A conflict of this nature may occur when a pregnant woman decides not to comply with recommendations that her physician considers to be in the best interest of the fetus.

Some ethicists believe human life begins when the female egg is fertilized by the male sperm, forming one cell.Others believe that life begins from the 14th day after conception, when nidation of the embryo has occurred and the primitive streak is present.There are others that believe life begins at the moment of birth and that the fetus does not have an independent moral status while in utero.

Fertilization, at which point fetus receives genetic blueprint from parents.Implantation, embryonic attachment to uterine wall.At birth28 days after birth.

Life begins upon the creation of a genetically unique individual- fertilization.Most popular public stance.Scientists- process of 12-24 hours.Twinning argumentAbility of zygote to split into 2 or more zygotes.Genetic uniqueness not prerequisite.

Beginning of life at gastrulationEstablishing all three germ layers.Third week of gestation.Results in development of separate individuals, unique personalities and souls.Human individual vs. human person.

I will prescribe regimens for the good of my patients according to my ability and my judgment and never do harm to anyone...To please no one will I prescribe a deadly drug nor give advice which may cause his death.Nor will I give a woman a pessary to procure abortion...In every house where I come I will enter only for the good of my patients, keeping myself far from all intentional ill-doing

The United KingdomOfficial view: embryonic view (Gilbert, 2006).British Abortion Act of 1967The United StatesNo official view on beginning of life.Unborn Victims of Violence Act of 2004.Argument for/against embryonic stem cell research

Male fetus- animated with a soul 40 days after conception.Female fetus- 80 days after conception.Fetus condemned if died without being baptized

1701- Pope Clement and the Feast of the Immaculate Conception.1854- Pope Pius IXMary was without sin at the moment of conception.

Life begins at conception

If the fetus is considered to have the full rights of a person, then it should be treated as a separate entity from the mother. Thus, the pregnant woman and the fetus should be treated as two individual patients.The medical model for the biological maternal- fetal relationship has shifted emphasis from unity to duality, and the fetal organism is considered a distinct patient.

CONFLICT: fetal dependence on motherFetal diagnosis and therapy optimize fetal outcome, however any procedure performed must include the involvement of the pregnant woman.

The concept of a persons autonomy is their right to choose how to live their own life. The right to be free from unwanted bodily invasions and to control ones own life.The pregnant woman should be allowed the freedom to decide upon alternative courses of therapeutic action based on her values and beliefs.

The principle of beneficence requires an individual to act in such a way as to reliably produce more good than harm in the lives of others.With respect to maternal-fetal relationships, the physician should assess objectively the various therapeutic options that may exist. The physician should implement those that will most likely offer the patient and fetus greater benefit over risk.

Others argue that the fetus acquires moral status as it advances in gestation

Society perceives moral differences between an early abortion and termination of full term fetus

This suggests that moral status of the fetus does increase with gestation

Human life begins long before conception What we really want to know is whether the living human fetus should be recognized as a bearer of the same range of fundamental moral rights that you and I have, among them the right not to be killed without very good reason.

Human life begins long before conception(Scientific claim)Distinct person emerges at conception(Moral claim)To call something a person is to already assert that it is a bearer of the strongest moral rightsfundamental rights comparable to yours and mine, among them the right not to be killed except for the most compelling of moral reasons

Recognizing a person as a person if he has certain characteristicsA conceptus, however, has none of these characteristics. What is amazing is that such radically different beings emerge from such beginnings.

Personhood at birthPersonhood at conception

whether we should recognize the fetus as a person now (full range of fundamental moral rights attaches to the fetus ) or whether we should recognize the fetus as a potential personas a person-not-yet (remains an open question what moral duties we might have toward the fetus ).Doubt of the personhood of fetus(if there is any possibility that the fetus is a person, we have a duty to act as if it were a person -- a duty to avoid acting recklessly )

Abortion in cases of rape or incest must be ruled out If fetuses are to be recognized as full-fledged persons, then justice requires that those who abort them for reasons less than self-defense must be recognized as full-fledged murderers and treated as such.

If the fetus is a person who has precisely the same moral status as the woman, the state must, as a matter of fairness to the fetus, do nothing that would involve it in giving the woman an unfair advantage over the fetus. And, again, this means that the state should not permit the use of technologically advanced institutions or the use of technologically advanced practitioners which give the woman an unfair advantage in this battle for life between moral equals.

CASES OF MATERNAL-FETAL CONFLICTReporter: Albert Alcaraz

Religious refusal of blood products during pregnancy and deliveryRefusal of diagnostic testing blood drawsRefusal of delivery options like C-sectionsDrug / alcohol use / abuse during pregnancyTreatment of cancer during pregnancy

Angela Carder the 27-year-old woman was hospitalized at the 25th week of gestation with metastatic terminal sarcomashe agreed to a medical plan which consisted of palliative therapy, attempting to extend her life to the 28th week of gestationit was thought that if the baby was delivered at 28 weeks of gestation, there would be reasonable expectation for survival

Angelas condition deteriorated and she required intubation and sedation she was judged to be terminally ill and near deathhospital administration became concerned about the well-being of the fetus and despite the opposition of her attending physicians and family, obtained a court order authorizing a forced cesarean sectionjudge ruled in favour of the cesarean section

Angela unexpectedly regained consciousness and was informed about the judges order. although she expressed her disapproval with the decision, a cesarean section was performedseveral hours following the operation, the baby died and two days later, so did the mother

case was reviewed by the Appeals Court, District of Columbia, which was critical of the trial judges decisionjudge had based his decision on balancing the rights of the mother against the interests of the state in the life and well-being of the fetushe reached his decision by assessing that the States interest in protecting the fetus outweighed whatever rights or interests the dying woman had

A 29 year old woman in labor, progressing very slowly, breech presentation, large baby. The patient was told this information and that a c section would need to be performed. The patient refused the c-section explaining that she and her family wanted a natural birth. A psych evaluation to look at capacity was done while the patient was in advanced labor. CPS was also contacted and they informed the team that they would follow the case but were unable to intervene until the child was born.

Position 1: The Pregnant Woman's Autonomy Has Priority.- consistent with other health care practicesPosition 2: Beneficence Toward the Fetus has Priority.- arguably, beneficence toward the patient, or at least nonmaleficence, always overrides respect for autonomy, just as moral obligations are greatest toward those who are most in need.

Position 3: Beneficence Toward Both Patients Trumps Respect for the Pregnant Woman's Autonomy.- Coercive intervention is permissible in cases of well documented complete placenta previa

Acting on a refusal of treatment would amount to acting on unreliable clinical judgmentThis justifies the physician's resisting the patient's exercising a positive right - Since fulfilling the positive right contradicts the most highly reliable clinical judgment, dooms the beneficence-based interests of the fetus, and virtually dooms the beneficence-based interests of the pregnant woman.

Background.Malaria is one of the world's most serious health problems. It causes about 1 million deaths every year, and most of these deaths are in children. Several different parasites can cause malaria; the most serious is Plasmodium falciparum. One of the most serious consequences of infection is that this parasite can multiply in the placenta of a pregnant woman. This placental malaria is very harmful to the mother and to the fetus; it leads to low birth weight and is estimated to be responsible for the deaths every year of about 200,000 babies within their first year of life. A woman who is pregnant for the first time is most likely to suffer from placental malaria, and to have her placenta become highly infected and extremely inflamed. If she later becomes pregnant again, she will be protected to some extent by antibodies she has developed against the parasite.Another problem that is common in tropical countries and also causes many deaths during pregnancy is preeclampsiahigh blood pressure (hypertension) and protein loss in the urine. This is also a condition that is most common in first-time mothers. The causes of preeclampsia are not clear, but many factors are probably involved. Among the theories that have been proposed are that inflammation in the placenta might play a part, and that there may be a conflict between the needs of the mother and those of the fetus.

Why Was This Study Done?The researchers wanted to see whether placental malaria might be a factor in the development of preeclampsia. This association has been suggested before, but there has been no clear evidence.What Did the Researchers Do and Find?Working with pregnant women in Tanzania, they found that, overall, women with placental malaria were no more likely than other women to develop hypertension. However, for those women who were aged 1820 and pregnant for the first time, having placental malaria was associated with hypertension. The researchers also measured levels of a substance called sVEGFR1 (also called sFlt1), which is known to increase before and during preeclampsia and is thus considered to be a biomarker for the condition. sVEGFR1 levels were high in first-time mothers with either placental malaria or hypertension, or both, but levels were not raised in other mothers with these conditions. A related substance, VEGF, which is known to be involved with the process that causes inflammation, was high in first-time mothers with placental malaria, but not in those who had preeclampsia alone.What Do These Findings Mean?The researchers believe that their findings support the view that, in younger first-time mothers only, placental malaria can cause preeclampsia and that this results from a conflict between the mother and her fetus. Action to reduce the chance of such women getting malaria would have the additional benefit of lowering their chance of developing preeclampsia. The findings have also led the researchers to propose possible mechanisms as to how placental malaria leads to preeclampsia. They have made suggestions regarding the further research that is now needed.

Source: http://dx.doi.org/10.1371/journal.pmed.0030446

A medical condition where hypertension arises in pregnancy (pregnancy-induced hypertension) in association with significant amounts of protein in the urine.While blood pressure elevation is the most visible sign of the disease, it involves generalized damage to the maternal endothelium and kidneys and liver.It may develop from 20 weeks gestation (it is considered early onset before 32 weeks, which is associated with increased morbidity) and its progress differs among patients; most cases are diagnosed pre-term.Apart from abortion, Caesarean section, or induction of labor, and therefore delivery of the placenta, there is no known cure. It may also occur up to six weeks post-partum. It is the most common of the dangerous pregnancy complications; it may affect both the mother and the fetus.

Cancer is the second most common cause of death among women during the reproductive years, complicating approximately 1/1000 pregnancies.The most common cancers that occur during pregnancy are cervical, breast, melanoma, thyroid, leukemia, lymphoma and colorectal (Sorosky et al., 1997). In part, the recent increase in cancer-complicated pregnancies may be due to the increased frequency of delayed childbearing.

A diagnosis of cancer during pregnancy causes significant conflict for both the physician and the patient when attempting to optimize maternal theraoy and fetal well being.

Cancer patients have an increased tendency to undergo febrile illnesses due to infections and/or as a result of the tumor itselfHuman studies do support the hypothesis that maternal fever in early pregnancy may be associated with neural tube defects and microphthalmia. Children's long-term cognitive outcome could also be affected by maternal malnutrition, which may be linked to malignancy

All chemotherapeutic agents are potentially teratogenic and mutagenic because they act on rapidly dividing cells. The potential exists for fetal malformations, intrauterine growth restriction, spontaneous abortion, stillbirth or premature delivery when a woman is exposed to chemotherapeutic agents prior to, or during, pregnancy.Possible outcomes depend on the particular treatment, its timing and duration, and the ability of the drug to cross the placenta.

The risk for birth defects to occur is greatest when the fetus is exposed to chemotherapy during the first trimester of pregnancy. This is because the firstFirst trimester organogenesis, period of rapid cell growth Since chemotherapeutic drugs interfere with cell growth and division, the fetus is most vulnerable during this period of time.Exposure to chemotherapeutic drugs during the first trimester may also increase the risk for miscarriage.Therefore, whenever possible, chemotherapy is avoided during the first trimester of pregnancy.

The risk for birth defects is less when chemotherapy is administered in the second or third trimester.With a few exceptions (such as the brain and the reproductive system), most fetal organ system development is completed by the beginning of the second trimester. However, exposure to chemotherapeutic drugs in the second and third trimester has been associated with a greater risk for premature birth, low birth weight, and a temporary reduction in some of the babys blood cells.

Source: http://www.motherisk.org/women/commonDetail.jsp?content_id=231

Hence in cancer treatment, physician must consider the gestational age of the pregnancy, the stage of the cancer, and the emotional, religious, social and moral concerns of the individual prospective parents.

Vast majority of pregnant women are willing to assume significant risks for the welfare of their fetuses. Problems arise when potencially beneficial advice is rejected.The role of the physician is to be an informed educator and counselor, weighing the risks and benefits to both patients, and consider the social and cultural context in which these decisions are made.

The use of judicial authority to implement treatment regimens to protect the fetus violates the pregnant womans autonomy and must be avoided

SourcesNational Institute for Neurological Disorders and StrokeWomen for Faith and FamilyVoices Online Edition Vol. XIX No. 2, Pentecost 2004http://www.anencephaly.net/http://www.ewtn.com/library/PROLIFE/bcdanen1.htmhttp://www.geocities.com/tabris02/index.htmlhttp://www.anencephalie-info.org/e/pictures.phphttp://www.lifeissues.net/writers/val/val_24prematureinduction.htmlhttp://www.lifeissues.net/writers/szy/szy_01prenatalethics.htmlhttp://www.ncbcenter.org/04-03-11-EarlyInduction.asphttp://www.wf-f.org/04-2-PrematureInduction.htmlhttp://www.che.org/ethics/topics.php?id=161http://www.aafp.org/afp/990800ap/477.html

How much more will the mother suffer knowing that she had a hand in killing her own child?Definition of termsIatrogenic prematurity - doctor decided to deliver baby even when prematureUterine hyperstimulation - six or more contractions in 10 minutes, on two consecutive 10 minute windows,or tetanic contractions lasting more than two minutesand that are accompanied by non-reassuring changes in the fetal heartNon reassuring fetal heart rate tracing - wala ako mahanap something wrong with the heart rate cgro.. Bwahahaha!Shoulder dystocia

Ie - start of lifeReasons???Ectopic pregnancy currently is the leading cause of pregnancy-related death during the first trimester in the United States, accounting for 9% of all pregnancy-related deaths. In addition to the immediate morbidity caused by ectopic pregnancy, the woman's future ability to reproduce may be adversely affected as well.

Ectopic pregnancy is derived from the Greek word ektopos, meaning out of place, and it refers to the implantation of a fertilized egg in a location outside of the uterine cavity, including the fallopian tubes, cervix, ovary, cornual region of the uterus, and the abdominal cavity. This abnormally implanted gestation grows and draws its blood supply from the site of abnormal implantation. As the gestation enlarges, it creates the potential for organ rupture because only the uterine cavity is designed to expand and accommodate fetal development. Ectopic pregnancy can lead to massive hemorrhage, infertility, or death.

Most ectopic pregnancies are located in the fallopian tube. The most common site is the ampullary portion of the tube, where over 80% occur. The next most common sites are the isthmic segment of the tube (12%), the fimbria (5%), and the cornual and interstitial region of the tube (2%). Nontubal sites of ectopic pregnancy are a rare occurrence, with abdominal pregnancies accounting for 1.4% of ectopic pregnancies and ovarian and cervical sites accounting for 0.2% each.Any growing pregnancy requires a large nutrient source (blood supply)and develops many communications with the mother's (pregnantwoman's) vascular system (blood vessels). The uterus is uniquelydesigned to accommodate this development, so that when a pregnancybegins to grow in other surrounding structures the vascularcommunication may be inadequate.The mostfeared complication of an ectopic pregnancy is internal bleeding, causingpelvic and abdominal pain, shock, and even death. Therefore, bleeding inan ectopic pregnancy may require immediate surgical attention. Bleedingresults from the rupture of the fallopian tube, or from blood leaking fromthe end of the tube as the growing placenta erodes into the veins andarteries located inside the tubal wall. Blood coming from the tube can bevery irritating to other tissues and organs in the pelvis and abdomen, andresult in significant pain. The pelvic blood can lead to scar tissueformation and problems with becoming pregnant in the future. The scartissue can also increase the risk of future ectopic pregnancies.Furthermore, as the pregnancy grows in size the uterus dramaticallychanges shape and size. Surrounding structures are usually not able tochange as readily so they are often damaged or "ruptured" by a containedgrowing ectopic pregnancy. When the ectopic pregnancy outgrows thelimits of the space enclosing it, there can be life threatening bleeding.Methotrexate is an antimetabolite chemotherapeutic agent that binds to the enzyme dihydrofolate reductase, which is involved in the synthesis of purine nucleotides. This interferes with DNA synthesis and disrupts cell multiplication. Its effectiveness destroying the placental trophoblastic tissue has been well established.Treatment with methotrexate is an especially attractive option when the pregnancy is located on the cervix, ovary, or in the interstitial or the cornual portion of the tube. Surgical treatment in these cases is often associated with increased risk of hemorrhage, often resulting in hysterectomy or oophorectomy. Successful medical treatment using methotrexate has been reported in the literature with good subsequent reproductive outcomes. By avoiding surgery, the risk of tubal injury is reduced.

A tubal or ectopic pregnancy can be removed in several ways. If the fallopian tube is ruptured (A), the tube is tied off on both sides, and the embryo removed. If the tube is intact, the embryo can be pulled out the end of the tube (C), or tube can be cut open and the contents removed (D). The presence of an ectopic pregnancy may result from a tubal disorder or cause the fallopian tube to be pathological. In all cases, all actions must be analyzed according to intention, means, and end. If any of these three are immoral, the act itself is immoral. With this in mind, however,one must acknowledge the existence of moral absolutes, namely that there are certainspecific kinds of behavior that are always wrong to choose, because choosing theminvolves a disorder of the will, that is, a moral evil,33 and thus good intentions andcircumstances are not in themselves always sufficient.There are two principles that are commonly applied to ectopic pregnancy situations.The first is the principle of totality, which holds that we may sacrifice even a basicbodily function or organ to preserve the whole of the bodily life provided there is no lessinvasive way of achieving this goal.34 Thus, it might be morally permissible to removethe mothers fallopian tube or a portion of it, which is causing harm to her life, to protectthe totality of her bodily life. (removal of a pathological part to preserve the life of the person)But in certain circumstances, it might be acceptable for anaction to produce both a desired good effect and at the same time allow for certain evilconsequences in what is called the principle of double effect. There is a vital differencebetween a directly willed effect and an indirectly willed effect.In the Principle of Double Effect, the only moral action in an ectopic pregnancy, where a woman's life is directly threatened, is the removal of the tube containing the human embryo. The death of the human embryo is unintended although foreseen. Put another way, if there were a way to save both lives, which, of course, are of equal value, one would be obliged morally to do so. At this time, this is not possible. This directive clearly authorizes as morallylicit the use of partial salpingectomy or total salpingectomy in order to safeguard themothers life when there is grave danger of hemorrhaging from the fallopian-tubepregnancy. But it also clearly excludes use of a salpingostomy. At the time this directivewas written, the management of tubal pregnancies by methotrexate was not known.Opening the tube and "suctioning out the human embryo" or administering methotrexate either via mouth or laparoscopy. Both of these procedures directly attack an innocent human life and are intrinsically immoral and never can be justified. In fact, they violate the Fifth Commandment, which under all circumstances prohibits a direct attack on innocent human life. There are absolutely no exceptions to the 5th Commandment as described. While removing the tube containing the human embryo results in the death of a human being as does suctioning out the human embryo or administration of methotrexate, one cannot ethically conclude that all the actions have the same intended end result. The reason for this is that the "means" used to accomplish the "end" are not the same. Refusal to make this distinction results in a Machiavellian approach employing any "means" to the "end" including the direct assault on the human being intended to result in his death. While it is acknowledged that removal of the tube containing the human embryo may result in sterility, it is not morally justified to directly attack human life by suctioning out the human embryo or administering methotrexate even though fertility is preserved.