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Lecture
for 3rd year medical students at the Faculty of Medicine King Fahad
Medical City on November 10, 2013 by Professor Omar Hasan Kasule Sr.
LEARNING OBJECTIVES
·
To
introduce students the medical, legal and moral concerns in the decision-making
process during dilemmas in Neonatology
·
To
understand the role of parents and doctors in the decision-making process in
the commonly encountered dilemmas in Neonatology
KEY WORDS
·
Decision-making
·
Dilemmas
·
Roles
·
Ethical
issues
PROBLEMS
ARISING FROM THE INTRA-UTERINE PERIOD: intra-uterine growth retardation:
·
IUGR can be due to fetal,
placental, or maternal factors.
·
The fetal factors are: congenital
anomalies and congenital infections.
·
Placental insufficiency develops in
the third trimester is caused by: abruptio placenta, placenta previa, placental
thrombosis, placental infarctions, and multiple pregnancy.
·
Maternal causes of IUGR are:
toxemia, HT, maternal malnutrition, narcotic abuse, alcohol intake, and
cigarette smoking.
PROBLEMS
ARISING FROM THE INTRA-UTERINE PERIOD: malformations:
·
Teratology is the study of
abnormalities of embryogenesis.
·
Anomalies may be structural or
may be disorders of metabolism.
·
Chromosomal anomalies are Down’s
syndrome, Turner’s syndrome,
·
Congenital malformations are due
to genetic factors, environmental factors, or an interaction between the two.
·
Environmental factors may be
infections such as rubella, syphilis, and toxoplasma.
·
Irradiation, drugs, and chemicals
cause anomalies.
·
Hormonal deficiencies and
excesses can also cause anomalies.
PROBLEMS
ARISING FROM THE INTRA-UTERINE PERIOD: Neoplams & malnutrition
·
Neoplasms are rare in
neonates. The most common ones are Wilms' tumor, neuroblastoma, and various
types of teratoma.
·
Protein and energy malnutrition in the mother
affects fetal growth. Placental insufficiency decreases fetal growth. It may
cause premature deliverym and fetal
distress,
PROBLEMS
ARISING FROM THE PERINATAL PERIOD
·
Neonatal infections occur during
the peri-natal period and may have long-term sequelae if not treated
vigorously. Maternal infections may be viral (eg rubella), bacterial, or
protozoal (eg toxoplasmosis). The microorganisms cross the placenta and attack
the fetus.
·
Transplacental drugs: The following
types of drugs can cross the placenta and cause adverse effects in the fetus:
analgesics, sedatives, anti-hypertensives, antibiotics, and antithyroids.
Narcotics and alcohol can cross the placenta.
PROBLEMS
ARISING IN THE INTRA PARTUM PERIOD: birth injuries
·
Infants may have birth injuries
due to dystocia or other causes.
·
Bruising, abrasions, and edema
may occur.
·
Fractures or nerve injuries can
occur but are rare.
·
Severe anoxia may cause death or
brain damage.
PROBLEMS
OF THE NEONATAL PERIOD: Pre-maturity
·
Pre-term or premature infants are
born before the 37th week.
·
Small for gestation age newborns
must be distinguished clinically from the premature infants because treatments
are different.
·
Premature infants have
respiratory problems due to deficiency of surfactant and have difficulty
sucking at the breast.
·
Premature infants have more
difficulty maintaining body temperature.
·
Prematurity is associated with
higher mortality and mental retardation among survivors.
PROBLEMS
OF THE NEONATAL PERIOD: infections
·
Infections can be transcervical
or trans-placental.
·
Maternal rubella in the first 8
weeks of pregnancy is found in 50% of cases with congenital anomalies.
·
CMV infection may cause death or
brain damage among survivors.
·
Toxoplasmosis may cause
microcephalus, hydrocephalus, and mental retardation.
·
Infections are bacterial and
cause pneumonia, meningitis, and septicemia
·
Infants with agammaglubulinemia
may die of overwhelming infections.
PROBLEMS
OF THE NEONATAL PERIOD: metabolic disorders: .
·
Tetany can occur due to low serum
calcium, high plasma phosphate, or low plasma magnesium.
·
Metabolic disorders due to
genetic causes are more severe and long-lasting.
·
The common metabolic disorders
are inborn errors of metabolism such as
PKU, galactosemia, cystic fibrosis, SIDS.
·
Phenyketonuria (PKU) is due … and
is detected using the Githrie test. It is easily managed by dietary
modifications.
PROBLEMS
OF THE NEONATAL PERIOD: Respiratory disorders:
·
The Respiratory distress syndrome
is common in the premature infants, infants of diabetic mothers, and infants
delivered by Ceserian section.
·
Pneumothorax and atelectasis
occur and may be fatal
·
Pneumonia may be due to pre-natal
or post-natal infection.
·
Meconium inhalation may block
respiration.
·
Pneumothorax and atelectasis may
occur.
·
Sudden Infant Death Syndrome
(SIDS) usually at night and of unknown cause
PROBLEMS
OF THE NEONATAL PERIOD: Cardiovascular disorders:
·
Neonatal cardiovascular disorders are
congenital either due to chromosomal anomalies, infection (eg rubella), or
developmental anomalies of unknown cause.
·
Congenital cardiovascular disorders
are associated with chromosomal disorders (Down’s or Turner’s syndromes) or
maternal rubella
·
Blood disorders: Erythroblastosis
fetalis is due to incompatibility between an Rh-negative mother and an
Rh-positive infants. Anemia is a neonatal blood disorder.
PROBLEMS
OF THE NEONATAL PERIOD: Gastrointestinal and genitourinary disorders:
·
Vomiting may be due
intestinal obstruction or overfeeding. Infants may have pyloric stenosis or
various forms of intestinal obstruction
·
Physiological jaundice is
normal in newborns. Neonatal jaundice may be physiological or may be due to
septicemia, liver disorders, or bile duct obstruction. Excessive jaundice
causes nerve damage (kernicterus) that leads to deafness and cerebral palsy
·
Kidney and urinary tract disorders: Neonatal
kidney anomalies are usually congenital such as renal agenesis, renal
dysplasia, and polycystic kidney. The bladder or the ureter may be obstructed.
Infections.
PROBLEMS
OF THE NEONATAL PERIOD: neural tube defects
·
The neural tube, the embryonic
structure that develops into the central nervous system, normally closes by the
end of the third week of fetal growth; severe deficits result if it fails to
close.
·
Examples of neural tube defects
include the absence of brain (anencephaly) and a cyst replacing the cerebellum.
The spinal canal or cord may also fail to close up.
PROBLEMS
OF THE NEONATAL PERIOD: neural tube defects: spina bifida
·
Spina bifida is a neural tube
defect that varies in severity.
·
In spina bifida occulta there is
only X-ray evidence of damage to the spinal cord.
·
The meningocele form of the spina
bifida disorder is characterized by a meningeal pouch that visibly projects
through the skin. Spina bifida meningomyelocele is diagnosed when such a pouch
contains elements of the spinal cord or nerve roots.
·
Function of the legs and bladder
and bowel control is often severely impaired in individuals with spina bifida.
Infants with the defect commonly have hydrocephalus as well.
PROBLEMS
OF THE NEONATAL PERIOD: neural tube defects: hydrocephalus
·
Hydrocephalus, the accumulation
of cerebrospinal fluid in the ventricles, or cavities, of the brain, causes
progressive enlargement of the head.
·
The condition usually results
from a congenital malformation that blocks normal drainage of the fluid.
·
A tube called a shunt is required
to drain cerebrospinal fluid from the brain and prevent further expansion of
the skull.
PROBLEMS
OF THE NEONATAL PERIOD: Nervous, endocrine,
musculoskeletal disorders and neoplasms:
·
Nervous system disorders are
usually congenital: anencephaly, microcephaly (retarded brain growth),
hydrocephalus (CSF obstruction), and spina bifida.
·
Infants may convulse due to
traumatic brain injury, infection, or metabolic disorders.
·
Convulsions are due to brain
damage or due to infections or metabolic disorders.
·
Endocrine disorders are
congenital such as hypothyroidism and adrenal hyperplasia
·
Congenital musculoskeletal
disorders include clubfoot (talipes equinovarus), talipes calcaneovulgus, and
dislocation of the hip
·
Tumors, benign and malignant. The
malignant tumors are usually: neuroblastoma, retinoblastoma, and Wilm's tumor
PROBLEMS OF THE NEONATAL PERIOD: Maternal disease:
· Infants of diabetic mothers have large organs (macrosomia), hypoglycemia, and respiratory distress.
· Infants born to mothers addicted to heroin or morphine suffer from withdrawal symptoms. Infants of alcoholic mothers may get the feto-alcohol syndrome which consists of mental retardation, growth retardation, and microcephaly.
· In mild or moderate maternal malnutrition, the infant may not be affected. The infant is affected in severe maternal malnutrition.
· Fetal malnutrition may be caused by placental insufficiency.
FIQH ISSUES FOR THE NEW BORN..1.
·
Adhan and iqamat are required for
the newborn.
·
A name should be chosen as soon
as possible. A problem could arise in cases of indeterminate gender.
·
The ‘aqiiqah ceremony for the
newborn is a social occasion for introducing the baby as a new member of the
community.
·
Uncontrollable bleeding may
complicate circumcision of newborns with hemostatic diseases. Screening
newborns for metabolic & genetic disorders is encouraged since it leads to
discovery of diseases early to enable earlier treatment.
FIQH
ISSUES FOR THE NEW BORN..2
·
Newborn Immunization is
encouraged because it prevents disease.
·
Breast-feeding is mandatory for 2
years according to Qur’anic injunction. Breast-feeding by a wet-nurse is
allowed. Milk banks are discouraged because they may create unregistered foster
relations that invalidate marriage later in life. Payments are made to a
divorced mother for breast-feeding the baby.
·
Nafaqat includes all material
sustenance needed for the infant such as food, clothing, and medical care. The
father is responsible for nafaqat during marriage and also after divorce. The
extended family and the state are responsible for financial maintenance of
single poor mothers.
ETHICAL
DILEMMA 1: Dystocia and interventions:
·
In difficult labor,
contradictions in the purposes and principles of the law can arise because
there are two lives to consider, the mother and the fetus.
·
Early medical and surgical
intervention in the birthing process is generally for the benefit, maslahat, of
the mother but could be detrimental, dharar, to the pre-mature fetus.
·
In some cases like those of
ecclampsia, early delivery is more to the benefit of the mother but delay of
delivery could eventually be harmful to the fetus as well.
·
The principle of necessity,
dharuurat, is invoked in situations of respiratory distress when delivery must
be effected as early as possible to prevent further deterioration in the fetus.
ETHICAL
DILEMMA 2: vaccination
·
According to the purpose of
preserving life, taking an infant for immunization is waajib. Vaccination is usually
against smallpox, chicken pox, measles, and mumps.
·
The risk of vaccination reactions
is small compared to the advantages of the procedure.
ETHICAL
DILEMMA 3: delivery of neural tube defects
·
Before OR at term? Anencephaly,
Spina bifida, Hydrocephalus
·
Vaginal OR Caeserean?
Anencephaly, Spina bifida, Hydrocephalus
·
CPR at birth: provide or
withhold: Anencephaly, Spina bifida, Hydrocephalus
ETHICAL DILEMMA 4: routine neonatal
screening
·
Disease
screened for: PKU? Cystic fibrosis? Sickle cell disease? Muscular dystrophies?
·
Ethical
issues: Informed consent, Benefits vs risks, detection of carriers (worry for
nothing?)
ETHICAL
DILEMMA 5: decisions
·
Parents and doctors disagree
·
Parents disagree with one another
ETHICAL
DILEMMA 6: disclosure of anomaly to parents: case study 1
·
Zulaikha, a 45-year old housewife
and mother of 7 healthy children, went into labor with no worries or anxieties
since she has been through this many times.
·
When the baby was delivered she
wanted to see him immediately but the midwife seemed reluctant and her face
showed that she was worried but she said nothing.
·
The mother was told that the
doctor has been called to look at the baby and that after that she will be able
to see and hold the baby. Zulaikha suspected that something was wrong because
on previous occasions she was able to see and hold the baby immediately.
·
She was told after half an hour
that the baby had difficulty in breathing and was being treated in the
intensive care unit.
·
Q1. What ethical issue (s) can
you identify at this stage?
ETHICAL
DILEMMA 6: disclosure of anomaly to parents: case study 2: Pediatric
examination:
·
Examination by a specialist
physician showed a child with unusual facial features but not much was made of
these because normal new borns have faces distorted by the birthing process.
·
Heart murmurs were heard.
·
The examining pediatrician
requested chromosomal analysis. The results indicated a karyotype of 47,XY,+21.
·
Q2. What do you think is
the problem?
ETHICAL DILEMMA 6: disclosure of
anomaly to parents: case study 3: Encounter with the pediatrician 2
·
It was not until 3 days
after birth hours later that the pediatrician came to talk to Zulaikha.
·
The doctor went straight to
the matter ‘I am sorry Mrs Zulaikha, you have produced an abnormal baby with a
congenital condition of genetic origin. You should not be surprised at this
outcome because mothers of your age have a high risk of having abnormal babies.
·
Someone should have advised
you not to get pregnant this late in your life. We have delivered a couple of
such babies in the past but very few survived early childhood. I only pray that
your also survives for sometime’.
ETHICAL
DILEMMA 6: disclosure of anomaly to parents: case study 4: Encounter with the
pediatrician 2
·
Mrs Zulaikha asked the
pediatrician why she was not informed of the genetic anomaly during pregnancy.
·
The pediatrician answered that
it was the fault of the obstetrician who looked after her in the pre-natal
period.
·
Q3. What is your opinion
about the communication between the pediatrician and Mrs Zulaikha?
·
Q4. Give a reason for and reason against
screening for genetic anomalies during pregnancy
ETHICAL
DILEMMA 6: disclosure of anomaly to parents: case study 5: Encounter with the
baby
·
Zulaikha was shocked but
she retained her calm and asked the doctor that all she needed was to see the
baby. The doctor ordered the nurse to bring the baby.
·
Zulaikha was shocked to see
the baby and refused to touch him. “This is an abnormal baby. This is not my
baby. You have mixed up my baby with someone else’s baby. I actually suspected
this because the midwife would not let me see the baby immediately after
delivery as is the usual practice’.
·
She started crying and
moving off the bed and has to be restrained and calmed down.
·
The baby was taken back to
the newborn nursery.