Fetal Pain Research Articles

The Problem of Fetal Pain and Abortion: Toward an Ethical Consensus for Appropriate Behavior

Debate exists over whether fetuses feel pain, and if so what to do about it. Because they cannot provide self-report, certitude on the question cannot be reached. The essay argues that a presumption of reasonable doubt is adequate to inform moral behavior. It looks at the most recent evidence from fetal anatomical, neurochemical, physiological and behavioral research and concludes that a reasonable doubt exists that fetuses from 20 to 23 weeks do not feel pain. It proposes that where abortion is legal, providers should be legally required both to provide full disclosure of the possibility of fetal pain starting at 20 weeks and to offer pain-relief measures to suppress fetal pain to all women seeking an abortion.

Intrapartum fetal pain management in lethal osteogenesis imperfecta

We were stimulated to review aspects of fetal pain duringthe care of a 25-year-old nulliparous woman who had aroutine 20-week fetal morphology ultrasound showing severemicromelia, multiple fractures, reduced bone mineralizationand a bell shaped chest. Lethal fetal skeletal dysplasia wasdiagnosed, likely osteogenesis type II.

Prelabor uterine rupture and extrusion of fetus with intact amniotic membranes: a case report

Abstract Introduction: The increasing rate of cesarean sections is an important issue globally, especially in developed countries. During the last decade, despite decreasing rates of vaginal delivery attempts after a previous cesarean section, the risk of uterine rupture has remained. Uterine rupture is a significant and catastrophic obstetric complication associated with maternal and fetal morbidity and mortality. We report here a very rare case of prelabor uterine rupture with intact membranes. Case report: A 28-year-old, gravida 3, para 2 Turkish woman was referred to our emergency unit at 34 weeks’ gestation because of the absence of fetal movements and abdominal pain. She had had a vaginal birth in 2007 and a cesarean section in 2009. In the delivery room, the fetal extremities were palpated at the abdominal wall, and an ultrasonography revealed ruptured uterus and fetal death. A midline laparotomy was carried out to open the peritoneal cavity. An intact amniotic sac with fetus was observed in the abdominal cavity, and the uterus was also observed to be ruptured. The male fetus, weighing 2500 g, was dead. The rupture was extending from the left lateral side of cervix to the fundus. The tear was repaired by primarily suturing the uterus in two layers after ligation of the left uterine artery to control hemorrhage. The total estimated blood loss was about 1300 mL. The patient received two units of blood transfusion during the operation. In the 4th postoperative day, the patient was discharged. Conclusion: Complete uterine rupture is a rare but catastrophic event, and if diagnosed late, can result in mortality. Uterine rupture is rare during a trial of vaginal labor in a patient with a history of cesarean section; it is much rarer to occur before any trial of vaginal labor in such a patient. If a patient with a history of cesarean section, especially with an unknown type of incision, presents with complaints of abdominal tenderness or vaginal bleeding in the 3rd trimester, the possibility of complete uterine rupture must be considered.

Fetal Pain Legislation and the Abortion Debate Presidential Address

Fetal Pain Legislation and the Abortion Debate Presidential Address

Ourselves unborn: a history of the fetus in modern America

INTRODUCTION: FETAL STORIES 1. Discovering Fetal Life, 1870s-1920s 2. Interpreting Fetal Bodies, 1930s-1970s 3. Defining Fetal Personhood, 1973-1976 4. Defending Fetal Rights: 1970s-1990s 5. Debating Fetal Pain, 1984-2007 EPILOGUE: FETAL MEANINGS NOTES BIBLIOGRAPHY

Fetal Pain During Prenatal Surgery: The State of the Art

During open fetal surgery under maternal general anesthesia, providing additional analgesia for the fetus is still a matter of debate. In order to collect and analyze scientific literature on this topic, we performed a careful Medline research, matching the following key words: “pain”, “fetus”, “analgesia”, “anesthesia” “surgery”, “brain”, “behavioral states”. We retrieved and analyzed those papers that provided: Conclusion: Clinical evidence shows that the doses of maternal anesthetic may not be sufficient to anesthetize the fetus, that fetal analgesia for fetal surgery is recommended after the middle of the pregnancy. Doses and routes of analgesic drugs, to achieve the best results, deserve further research.

The Legislative Process Is Not Fit for the Abortion Debate

In the wake of Republican gains in November 2010, anti-abortion bills were common and aggressive during the 2011 legislative sessions. (1) State general assemblies passed statutes that include provisions to (a) block abortions after twenty weeks of gestation, (b) require doctors to tell pregnant women that fetuses feel pain at or before twenty weeks of gestation, (c) prevent state or federal health care dollars from reaching clinics and physician groups that provide abortions as part of their services, (2) and (d) require doctors to describe the ultrasound images of the fetus and offer women the option to view the ultrasound and listen to the fetal heartbeat before an abortion. (3) These statutes are troubling for a number of reasons. Many of their provisions violate constitutional principles enunciated by the Supreme Court in Roe v. Wade and Planned Parenthood of Southeastern Pennsylvania v. Casey. (4) For example, the Court has held that states must leave the determination of fetal viability to the medical judgment of physicians rather than defining viability at a specific point in pregnancy (like twenty weeks of gestation). (5) The Court also has insisted that when states mandate disclosures to patients, they may not prescribe information that is nontruthful or misleading. (6) The statements about fetal pain misrepresent medical understanding. (7) As for federal health care funding, states may choose how to allocate their own dollars, but their efforts to interfere with the implementation of federal spending decisions may run afoul of the supremacy clause principle that federal law takes priority over state law. (8) The state statutes also reveal flaws in the argument that divisive moral issues like abortion should be resolved through the political process rather than by courts. Some people, including Supreme Court Justice Antonin Scalia, make this argument on the grounds that our democratic system is premised on majority rule and that elected representatives are more likely than unelected judges to reflect public sentiment. (9) To be sure, majorities cannot override constitutional principles, but champions of the political process believe that the text of the Constitution provides little support for fundamental rights like abortion and that judges who find such rights are relying more on their own preferences than the intentions of the constitutional framers. Justice Ruth Bader Ginsburg and others have argued that deciding public policy through judicial fiat short-circuits a deliberative political process that can allow for a public consensus to evolve over time and through a laboratory of state experimentation in which different states try different approaches. (10) But arguments in favor of the political process neglect the fact that many elected officials are not interested in finding common ground on divisive social issues like abortion. Indeed, candidates and public officials often prefer to exploit such controversies for electoral gain. By running on issues, candidates can attract voters who ordinarily would identify with the opposition. (11) From the late 1960s to the mid-1980s, pro-life individuals were more likely to vote Democratic and pro-choice individuals more likely to vote Republican in presidential elections. (12) By adopting strong antiabortion positions, Republican candidates have been able to attract voters who previously aligned themselves with the Democratic Party. (13) When a political party has found a potent wedge issue, it may conclude that it has more to gain on election day by perpetuating the conflict than by resolving the issue. (14) As a result, policies that could reduce the demand for abortion may fail to gain support. Republicans often oppose funding for contraceptive education or products, and a bill to cut off funding for all of Planned Parenthood's family planning and reproductive health services was passed in Indiana this year. (15) If it survives legal challenge, the legislation may have profound implications for unwanted pregnancies. …

Dor fetal: motivo para preocupação?

IntroductionWith the evolution of Fetal Medicine and the increasing use of invasive techniques, it is mandatory to investigate if fetal pain is really an issue. MethodsA bibliographic search on scientific knowledge of fetal pain, its neuroanatomical and neurophysiological bases, consequences and clinical implications was conducted in Pubmed. ResultsDue to practical and ethical restrictions in using the human fetus in research, most of the evidence in this area is indirectly inferred from animal studies and through observations made in preterm human newborns. Pain perception is assumed from the integrity of neuroanatomic structures and its functionality, as well as from the endocrinal, hemodynamic and behavioral changes associated with pain. This perception is not likely to exist before 29-30 weeks of gestational age. The exposure to noxious stimulus in the perinatal period seems likely to cause to neurological development and behavioral changes, thereby fetal analgesia/anesthesia can mitigate the reaction to stress and thus avoid these deleterious long-term effects. ConclusionsGiven that pain is a subjective experience, its neurobiological understanding is far more complex than the basic knowledge of the anatomical and physiological ways of nociception. Available data derived from main studies in this area do not take into account the intrauterine environment idiossincracies and so can not prove the existence of fetal pain awareness. On the other hand, further investigation is needed to clarify the impact of fetal nociception in postnatal neurodevelopment, as well as the need for fetal analgesia/anesthesia.

Fetal Pain, Abortion, Viability, and the Constitution

In early 2010, the Nebraska state legislature passed a new abortion restricting law asserting a new, compelling state interest in preventing fetal pain. In this article, we review existing constitutional abortion doctrine and note difficulties presented by persistent legal attention to a socially derived viability construct. We then offer a substantive biological, ethical, and legal critique of the new fetal pain rationale.

Fetal pain perception

Author presents a comprehensive overview of the currently available information about fetal pain perception. In this context the article discusses the concept of pain sensation, its evolution during intrauterine life and its physical and biochemical signs. Only the last mentioned phenomena allow deduction with regard to the severity of pain related stress reaction, in the absence of objective yardstick for measuring the intensity of pain felt by the fetus. The discussion also involves pain associated with birthing process and extends to its possible alleviation.

Fetal pain - neurobiological causes and consequences.

The existence of putatively painful situations to the fetus demands a careful evaluation of the issue of fetal pain. Several indirect approaches are used to evaluate the existence of fetal pain. Neurobiological studies showed that from the 30th week on, the anatomical and physiological system for pain transmission is already developed, with the connections from the periphery to the cortex being successively established. Stress responses to a painful stimulation are complex but they can be detected from the 16th week on. There is activation of the hypothalamus-pituitary-adrenal axis, autonomic nervous system and hemodynamic changes in response to nociceptive stimulation. In prematures exposed to pain there are significant increases of adrenaline, noradrenaline and cortisol, hemodynamic changes, motor reflexes and facial reactions. The changes induced by strong nociceptive stimulation of newborns have important postnatal consequences since they affect future reactions to noxious stimuli. Central sensitization and immaturity of the pain inhibitory system are the main neurobiological explanations for the increased pain. Detailed studies of the neurobiological mechanisms of the transmission of painful stimuli along with follow-up studies of the consequences of exposure to pain during the development of the fetus are necessary to fully understand fetal pain.

Fetal pain and intrauterine analgesia/anesthesia – long-term pathologic effects, causes and alleviation of intrauterine pain

The human fetus can suffer several presumably painful interventions perinatally and even before, during its intrauterine life. In the past years, scientific dispute concerning the existence of fetal pain and the need for its relief has expanded, and a heated social, political, religious, moral and philosophical debate has arisen, focusing mainly on the suffering experienced by the fetus during artificial abortion. In our two connected papers, medical scientific knowledge regarding fetal pain in the literature is reviewed. In the first article published in Orvosi Hetilap volume 150, issue 11, we defined pain and the neuroanatomical structures participating in subjective pain perception, as well as the development of these structures. Then, the objective indicators of intrauterine stress response (such as fetal neuroendocrine, cardiovascular, reflex and behavioral reactions) evoked by noxious stimuli were discussed. The present second article gathers the evidence of long-term pathologic effects caused by early-experienced pain and stress in animal models and humans. Finally, the potentially pain-evoking pre- and perinatal interventions are evaluated, as well as the analgetic/anesthetic methods that can be applied to intrauterine fetuses in everyday obstetrical practice.

Fetal pain and intrauterine analgesia/anesthesia: neuroanatomy, ontogenesis and physiology of pain perception

The human fetus can suffer several presumably painful interventions perinatally and even before, during its intrauterine life. In recent years, a scientific dispute has expanded, concerning the existence of fetal pain and the need for its relief, and a heated social, political, religious, moral and philosophical debate has arisen, focusing mainly on the suffering experienced by the fetus during artificial abortion. We review the medical scientific knowledge regarding fetal pain in the literature. The definition of pain and the neuroanatomical structures participating in subjective pain perception, followed by the development of the latter in the course of ontogeny is presented. The objective indicators of intrauterine stress response (such as fetal neuroendocrine, cardiovascular, reflex and behavioral reactions) evoked by noxious stimuli are discussed.

Schwangerschaftsabbruch

Effective January 1st 2010, changes to the German law on pregnancy conflicts will take effect along with the new requirements that consultation also encompass fetal development disturbances and at least 3 days must pass between diagnosis, consultation, and indication. A great variety of problems can arise when dealing with pregnancy termination. Especially significant is that now, 15 years later, the discrete eugenic indication has been discontinued, i.e. severe fetal disturbance is a necessary reqirement for termination but no longer itself sufficient justification. Ending a pregnancy now is justified only when the mother clearly is suffering acutely from the disturbance and when that suffering cannot be sufficiently reduced less aggressively. Problems often occur involving a physician’s right to refuse to participate in terminating, since the right to abort by no means requires performance by a medical doctor. Thanks to prenatal diagnostics more fetal disturbances are being recognized and sooner, so that late abortion with its potential morbidity and mortality can be avoided. In rare situations fetocide allows keeping fetal pain during termination as low as possible and liberates the child from the risk and possibly serious results of premature delivery.

Biased abortion counseling laws and abortion demand

Since the U.S. Supreme Court's 1992 Casey decision many states have enacted biased abortion counseling laws. These laws mandate that abortion providers furnish to women with unwanted pregnancies state-approved medical information about possible side effects from having an abortion that are false. The most egregious falsehoods are that abortion is linked to mental health problems (e.g., suicide, postabortion traumatic stress syndrome, and depression), breast cancer, infertility and fetal pain. This paper investigates whether these four biased abortion falsehoods have an impact on the demand for abortions in the year 2000. The empirical results find that these four biased abortion falsehoods have no significant impact on the abortion demand of pregnant women of childbearing age (15–44 years), adult pregnant women (18–44 years) or pregnant teen minors (15–17 years). The findings remain robust even after controlling for regional differences in antiabortion attitudes.

FETAL PAIN

The concept of fetal pain is becoming more and more relevant since the possibilities for invasive intrauterine treatment are increasing. However, there is much debate as to whether the fetus is mature enough to be able to perceive pain. But what is ‘pain’? One cannot determine whether a fetus feels pain unless one has a conception of what pain is. There is a difference in opinion about what pain reallyisand that is also the difficulty in studies on fetal pain: we cannot simply ask the fetus whether or not it feels pain. We can only give indirect evidence of possible harmful effects of stressful stimuli on the developing fetus. In this review we will first explore the meaning of ‘pain’. We will then discuss fetal anatomic, neurophysiologic and behavioural development and the responses which are thought to be required to experience pain. Finally, we discuss some ethical considerations and suggestions on fetal anaesthesia.

DNA polymorphisms at the BCL11A , HBS1L-MYB , and β- globin loci associate with fetal hemoglobin levels and pain crises in sickle cell disease

Sickle cell disease (SCD) is a debilitating monogenic blood disorder with a highly variable phenotype characterized by severe pain crises, acute clinical events, and early mortality. Interindividual variation in fetal hemoglobin (HbF) expression is a known and potentially heritable modifier of SCD severity. High HbF levels are correlated with reduced morbidity and mortality. Common single nucleotide polymorphisms (SNPs) at the BCL11A and HBS1L-MYB loci have been implicated previously in HbF level variation in nonanemic European populations. We recently demonstrated an association between a BCL11A SNP and HbF levels in one SCD cohort [Uda M, et al. (2008) Proc Natl Acad Sci USA 105:1620-1625]. Here, we genotyped additional BCL11A SNPs, HBS1L-MYB SNPs, and an SNP upstream of (G)gamma-globin (HBG2; the XmnI polymorphism), in two independent SCD cohorts: the African American Cooperative Study of Sickle Cell Disease (CSSCD) and an SCD cohort from Brazil. We studied the effect of these SNPs on HbF levels and on a measure of SCD-related morbidity (pain crisis rate). We strongly replicated the association between these SNPs and HbF level variation (in the CSSCD, P values range from 0.04 to 2 x 10(-42)). Together, common SNPs at the BCL11A, HBS1L-MYB, and beta-globin (HBB) loci account for >20% of the variation in HbF levels in SCD patients. We also have shown that HbF-associated SNPs associate with pain crisis rate in SCD patients. These results provide a clear example of inherited common sequence variants modifying the severity of a monogenic disease.

Fetal Pain: Do We Know Enough to Do the Right Thing?

Raising the possibility of fetal pain continues as a tactic to undermine support for abortion in the US and the UK. This paper examines anatomical and psychological developments in the fetus to assess the possibility of fetal pain. Neurobiological features that develop at 7, 18 and 26 weeks gestation suggest an experience of pain in utero. Pain, however, cannot be inferred from these features because they are not informative about the state of consciousness of the fetus and cannot account for the content of any presumed pain experience. We may be confident the fetus does not experience pain because unique in utero neuroinhibitors and a lack of psychological development maintain unconsciousness and prevent conscious pain experience. Before an infant can experience sensations and emotions, the elements of experience must have their own independent existence in the infant's mind. This is achieved after birth through discoveries made in action and in patterns of adjustment and interaction with a caregiver. Recommendations about anaesthetic practice with the fetus and the newborn or young infant should not focus on pain but on outcomes with obvious, and measurable, importance. In the case of an unwanted pregnancy, the health of the woman should guide anaesthetic practice. In the case of a wanted pregnancy, the survival and long-term health of both the woman and fetus should guide anaesthetic practice. In any case, current evidence does not support efforts to inform women of the potential for fetal pain. Any policy to mitigate fetal pain could expose women to inappropriate intervention, risk and distress.

On the Nature, Assessment, and Treatment of Fetal Pain: Neurobiological Bases, Pragmatic Issues, and Ethical Concerns

Over the past 2 decades, the issue of fetal pain and stress has attracted considerable attention and has become the focus of ongoing debate in light of advances in medical diagnostics and technology that allow invasive prenatal medical intervention(s), and an enhanced understanding of fetal neurophysiology, together with a broadened appreciation for the relationship of brain and consciousness. In this essay, we explore the issue of fetal pain based upon knowledge of both the ontogeny and function of the nervous system and the interaction of brain, mind, and pain. We posit that contemporary understanding of neurological development fortifies appreciation that pain sensation and perception occurs during (later) fetal life and that this pain warrants clinical consideration during the conduct of invasive prenatal procedures. We present differing perspectives on this issue, discuss the relative merits and difficulties of these positions, and ultimately describe the fundamental basis for a consideration of fetal pain and address this consideration with regard to pragmatic and ethical benefits, burdens, and risks. We adopt a neurocentric, yet consilient approach that entails both scientific and philosophical orientations. By attempting to reveal inherent limitations in our contemporary appreciation and approach(es) to fetal pain, we hope to illustrate the need for and posit potential venues toward resolving these limitations and dilemmas.

Smith’s Anesthesia for Infants and Children, 7th Edition.

Mayo Clinic College of Medicine, Rochester, Minnesota. flick.randall@mayo.eduSmith’s Anesthesia for Infants and Children, 7th Edition. By Etsuro K. Motoyama, M.D., Peter J. Davis, M.D. St. Louis, Mosby, 2006. Pages: 1,256. Price: $175.00.What does one write about a textbook that has been a standard in the field of pediatric anesthesiology for nearly five decades? The seventh edition of Smith’s Anesthesia for Infants and Children , edited by Etsuro K. Motoyama and Peter J. Davis, certainly qualifies as that standard—a standard set by Dr. Robert Smith and passed into the caring, capable hands of Drs. Davis and Motoyama with the fifth edition. The task of writing this review prompted me to take from the shelf my first copy of Dr. Smith’s text, a dog-eared volume marked with endless notes, underlinings, and doodlings that stand as evidence of my devotion not only to their text, but also to the field. It is clear from the enduring quality of Smith that Drs. Davis and Motoyama share that devotion. It would be sufficient at this point to conclude this review by simply stating that this text has been and remains a standard in the field and all those having an interest in the anesthetic care of children should own at least one copy, preferably two—one for themselves and one to share with a promising student, resident, or fellow who represents the future of our field.However, the editor has asked that I provide a review of 500–1,000 words that is clear, concise, and entertaining. With his instructions in mind, and a current word count of 260, I will endeavor to supply the reader with three or four hundred additional words about this fine text.With few exceptions, Drs. Davis and Motoyama have combined the efforts of some of the finest clinicians, researchers, and scholars in the field to assemble a comprehensive yet concise and very readable text. Although the general organization of the text is little changed from previous editions, several sections and chapters have been updated and, in some instances, expanded to reflect advances in the field such as fetal surgery, office-based practice, regional anesthesia, pain management, and psychological aspects of pediatric anesthesia practice. Sadly, in response to the epidemic of obesity among children, a significant portion of one chapter is now devoted to bariatric surgery in pediatric patients.Several other chapters and topics have been added. Most notable is the addition of a DVD providing an opportunity for the authors to include video and still images that are enormously helpful in demonstrating such procedural skills as fiberoptic intubation, single-lung ventilation, and regional anesthetic techniques. In some of the slide presentations, I found the transition to be painfully slow, although it may have been a problem with my laptop rather that the disc itself. I especially appreciate the addition of still images of some of the myriad syndromes each of us encounter more or less frequently in our daily practices. It would have been a bit more helpful if the photographs were accompanied by a minimum of text to provide the viewer with a brief overview of the syndrome. Likewise, I found the video presentation of normal and abnormal cardiac anatomy to be of limited value. The pathology specimens are difficult to orient oneself to, and, as I frequently find myself suggesting to residents and students, anatomy is for surgeons; we in anesthesiology are most interested in physiology. With that in mind, I wonder whether the next edition might also include video cartoon depictions of various examples of congenital heart disease illustrating alterations in physiology. I find these to be much more useful in helping learners understand approaches to the treatment of children with complex congenital heart disease. Clearly, the DVD represents a good first attempt at the inevitable transition from the bound text to the digital one.At 700 words, I will close by stating that it is indeed a pleasure to have been given the opportunity to review this text for Anesthesiology. Thanks to the review copy provided by Anesthesiology, I can now retire my old copy of Smith and spend some quality time with the new improved and updated seventh edition.Mayo Clinic College of Medicine, Rochester, Minnesota. flick.randall@mayo.edu