14 - Maternal-fetal conflict

Summary

Case example

Thirty-seven-year-old Mrs. Grant is twenty-four weeks pregnant. She has been visiting her obstetrician, Dr. Perez, regularly for prenatal care. Her routine sixteen-week fetal ultrasound study revealed fetal anomalies that are consistent with trisomy 21, also known as Down syndrome. At that time, Mr. and Mrs. Grant refused amniocentesis (removal of fluid from the amniotic sac surrounding the fetus, for genetic testing). This testing would have confirmed or ruled out the suspected trisomy 21, but the Grants decided against it because they did not want to terminate the pregnancy, explaining that they would “go along with God's plan.” Children with trisomy 21 have cognitive impairments of varying degrees, and they are at increased risk for cardiac anomalies and other physical impairments.

In her eighteenth week of pregnancy, Mrs. Grant developed polyhydramnios (excess accumulation of amniotic fluid), possibly as a result of the fetus's genetic condition or of Mrs. Grant's diabetes. After monitoring this condition for several weeks, Dr. Perez prescribed indomethacin, an oral medication that can decrease amniotic fluid volume. At her 24-week prenatal visit today, however, her amniotic fluid index (an ultrasonographic measure of amniotic fluid volume) was 36, well above the normal range of 10–22 for this gestational age. She is experiencing multiple symptoms, including shortness of breath when she is lying down, difficulty urinating, swelling of her legs and vulva, and abdominal pain. At her visit one week ago, Dr. Perez performed an amniocentesis to drain excess amniotic fluid, but that resulted in only a slight, temporary improvement in Mrs. Grant's symptoms. Dr. Perez recommends another amniocentesis to drain amniotic fluid, but Mr. and Mrs. Grant respond with a request that Dr. Perez induce labor now. They state that they understand that delivery at this stage of pregnancy will result in a very premature infant who may not survive, but they do not want to prolong Mrs. Grant's considerable pain and suffering or put her health at greater risk as a result of her condition. How should Dr. Perez respond?

What's special about health care for pregnant women?

Health care for pregnant women is distinctive in at least one morally significant way. With the rare exception of treatment for conjoined twins, it is the only type of health care that has a direct effect on two human beings, the pregnant woman and the fetus she carries.