1. Management of Fetal Anomalies Beyond the Age of Viability
Dr. Sawsan Al-Obaidly
Consultant, Maternal-Fetal Medicine
Obstetrics and Gynecology Department,
Women’s Hospital, HMC

2. Disclosures
None

3. Objectives Spectrum of fetal anomalies
Obstetric impact of fetal anomalies
Hydrocephalus
The concept of Fetus as a patient
Women counselling of severe fetal anomalies
Guidelines for management

4. ? Fetal Anomalies Non-Lethal Lethal
? Subjective: As OEIS, severe hydrocephalus

5. Lethal Anomalies
The word ‘lethal’ is derived from the Latin ‘letalis’ (deadly), and related to a Greek word meaning ‘oblivion,’ referring to the myth that the souls of the dead forgot their lives on Earth after drinking the waters of the River Lethe. Conventionally, ‘lethal’ is used to describe something (e.g. an action or agent) that will cause death
Oxford English Dictionary online. Oxford University Press; oed.com/.

6. lethal condition invariably leads to death, i. e
lethal condition invariably leads to death, i.e., there is no effective treatment that will prevent a condition, disease, or injury from causing death in the near future’
Chervenak F, McCullough LB. Responsibly counselling women about the clinical management of pregnancies complicated by severe fetal anomalies. J Med Ethics 2012;38:397e8.

7. Malformations most frequently described as ‘lethal’ conditions
Potter's syndrome/renal agenesis
Anencephaly/acrania
Thanatophoric dwarfism
Trisomy 13 or 18
Holoprosencephaly
Wilkinson DJC, Thiele P, Watkins A, De Crespigny L. Fatally flawed? A review and ethical analysis of lethal congenital malformations. Br J Obstet Gynaecol 2012;119:1302e7.

8. Severe Fetal Anomalies Beyond The Age of Viability

9. Prenatally diagnosed Trisomy 18 and 13
GA > 24 weeks
GA < 24 weeks
Total 6 8 GA
25-34 weeks
15-17 weeks
Trisomy 18
GA <24 weeks 19 18
25-37 weeks
12-20 weeks
Trisomy 18 and 13 after viability= 25
Trisomy 18 and 13 before viability= 26

10. Prenatal invasive testing in T18,13 patients Indication for referral >24wks
polyhydramnios
SGA
Congenital anomaly

11. 2010-2014 T18 and 13 > 24 weeks N= 25 IUFD
No prenatal invasive testing
Neonatal death

12. Severe Fetal Anomalies Beyond The Age of Viability
Cause & Effect Diagram
ENVIRONMENT
PATIENT
Ultrasound myths
Concept of New screening technologies (eg NIPT) replacing good quality ultrasound
Lack of awareness about prenatal screening
TOP religious beliefs
Patient self guilt
Increased population in reproductive age
Rare genetic disorders
TOP and social stigma
Complex consanguinity
Late patient presentation
Lack of social support
Doctor shopping
Increased number of pregnant expats (f/u in their country)
Pregnancy at advanced maternal age
Severe Fetal Anomalies Beyond The Age of Viability
Lack of obstetric guidelines for fetal anomalies
Lack of auditing
Lack of professional feedback
Lack of US expertise
Lack of standardized fetal screening approach
Policy, Patients, Community, material, system
Lack of early anatomy
Lack of national policy mandating appropriate training for level 2 US
Late referral with fetal anomalies
Restricted feticide
Lack of Government sector appointments
Lack of ultrasound quality assurance
Late detection of fetal anomalies
Strict TOP ethics approval
Lack of early anatomy
Lack of compliance to referral criteria
POLICY
SYSTEM

13. Potential Obstetric Impact of Fetal Anomalies Beyond Viability

14. Ir Med J. 2010 Mar;103(3):88-9. Congenital anomalies: Impact of prenatal diagnosis on mode of delivery. Dempsey MA1, Breathnach FM, Geary M, Fitzpatrick C, Robson M, Malone FD.
Retrospective cohort of 211,163 patients were delivered of infants weighing at least 500g Two comparative cohorts were created, comprising prenatally diagnosed, n= 634 and prenatally undiagnosed lethal congenital anomalies , n=240. The emergency CD rate was significantly lower where anomaly was detected versus undetected (17.5% versus 31%). In the prenatally diagnosed group, 42% of CD were due to a maternal cause while in the prenatally undiagnosed group such maternal reasons for CD were only found in 19% of cases. Non-reassuring fetal testing was the most common cause for emergency CD Conclusion: Advanced knowledge of the condition of the fetus can have a significant impact on the level of intrapartum fetal monitoring required and consequently on mode of delivery of the affected fetus.
Retrospective cohort of 211,163 patients were delivered of infants weighing at least 500g
Two comparative cohorts were created, comprising prenatally diagnosed, n= 634 and prenatally undiagnosed lethal congenital anomalies and were not anticipated by clinical staff, n=240.
The emergency CD rate was significantly lower where anomaly was detected versus undetected (17.5% versus 31%).
Indications for CD also differed between the prenatally diagnosed and the undiagnosed groups. In the prenatally diagnosed group, 42% of CD were due to a maternal cause (eg. diabetes, pre-eclampsia, multiple previous CD, cephalopelvic disproportion), while in the prenatally undiagnosed group such maternal reasons for CD were only found in 19% of cases. Nonreassuring fetal testing, as evidenced by an abnormal fetal heart rate tracing or fetal scalp pH, was the most common cause for emergency CD
Conclusion: advanced knowledge of the condition of the fetus can have a significant impact on the level of intrapartum fetal monitoring required and consequently on mode of delivery of the affected fetus.
Dempsey, M. A., et al. (2010). "Congenital anomalies: Impact of prenatal diagnosis on mode of delivery." Ir Med J 103(3):

15. Largest series of anencephaly beyond viability n=37 cases
Primi= 24% (9/37). GA at diagnosis 21 wks (21-41). IOL 54% (20/37). GA at birth 34wks (25-44).
Vaginal birth 70% (26/37). Primary C-section 8% (3/37). Repeat C-section 22% (8/37).
No differences in achieving vaginal birth in the spontaneous compared to the induced group. One case of shoulder dystocia. No cases of APH, PPH or uterine rupture.
Conclusion: Apart from tendency for post-term pregnancies, the prenatal diagnosis of anencephaly poses no significant increased maternal risk.
Largest series of anencephaly beyond viability
n=37 cases
Primi= 24% (9/37). GA at diagnosis 21 wks (21-41). IOL 54% (20/37). GA at birth 34wks (25-44).
Vaginal birth 70% (26/37). Primary C-section 8% (3/37). Repeat C-section 22% (8/37).
No differences in achieving vaginal birth in the spontaneous compared to the induced group. One case of shoulder dystocia. No cases of APH, PPH or uterine rupture.
Conclusion: Apart from tendency for post-term pregnancies, the prenatal diagnosis of anencephaly poses no significant increased maternal risk .

16. Severe And Lethal Fetal Abdominal Wall Malformations And Its Obstetric Impact Beyond The Age of Viability
Mount Sinai Hospital
9 years period
Case #
Prenatal USG Diagnosis
Karyotype
GA at delivery
Mode of Delivery
indication for C-section
Birth wgt, grams
A/S
External genitalia
Autopsy Findings 1
BSA
46 XX 34
ABD
N/A
1180
0/0
Female
OEIS 2
46 XY 38
2965
Male 3 32 ND
1365
1/0
Ambigous 4
Not done
CS (MA twins)
NRFH of normal twin
1490 5
POC 41 CS
failure of desent of breech
3290
1/1 6 33
2210 7 25
660
6/4/3 8 36
2290
8/9 9 24
780 10 LO 26
breech and cord presentation
910
1/6/6
10 years period
10 cases with severe Abdominal wall defects (Body Stalk anomaly, Pentalogy of Cantrell, OEIS)
Unpublished data. With permission from Dr. Greg Ryan
Unpublished data. With permission from Dr. Greg Ryan

17. Case of Hydrocephalus in Labor
31 years old G5P4. previous vaginal births. Fetus with severe progressive hydrocephalus.
Prenatal multidisciplinary team meeting:
The consensus for:
No fetal monitoring and no cesarean section for fetal indication as the patient wished to not have cesarean section for fetal reason.
Possibility of cephalocentesis to facilitate vaginal birth which is associated with >90% fetal mortality with risk of procedure failure and therefore delivery by C-section.
Discussed elective preterm induction of labor. The neonatal resuscitation was discussed as it will not be provided if the baby was born in poor condition.
Medical and mechanical IOL was attempted at 34 weeks. Documented patient aware accepted the risk of C-section for failure to progress in labor / failed cephalocentesis.
Transferred to L&D with favorable Bishop score for augmentation
Handover by consultant on-call to receiving team in the L&D at day time during week-day.
Prenatal multidisciplinary team meeting:
At 30w+4d obstetric, genetic, neonatology perspectives and patient wishes were all addressed.

18. SITUATION
ACTION
Oxytocin was started progressed to 5cm with no head descent. Good uterine contractions.
Transvaginal Cephalocentesis was attempted failed for 1st time.
And Increased oxytocin drip!
two hours later Patient progressed to 6 cm with high head
Transvaginal cephalocentesis was attempted failed for 2nd time
Increased oxytocin drip!
Three hours later Patient progressed to 8cm with high head, New team have arrived
Transvaginal cephalocentesis was attempted failed for 3rd time
oxytocin drip ongoing
Three hours later Patient still 8cm with high head. Maternal tachycardia
Transvaginal cephalocentesis was attempted failed for 4th time, fresh uterine bleeding noted.
Emergency laparatomy. Uterine rupture. Fresh stillbirth and Cesarean hysterectomy
Completed 12 hours on oxytocin with no head descent and failed cephalocentesis 3 X
Maternal tachycardia, Completed 12 hours on oxytocin with no head descent and failed cephalocentesis 3 X

19. THE ULTIMATE RESULT!!!
Three hours later Patient still 8cm with high head. Maternal tachycardia

20. Hydrocephalus Case Conclusions
Recognised poor head descent however kept going up with oxytocin!
Multiple failed attempts of cephalocentesis
Oxytocin drip for 12 hours in a multiparous
No call for help for TA cephalocentesis.
C-section for obstetric reasons as failure of head descent after multiple failed attempts of cephalocentesis should have been thought of earlier.
This was an example of poor obstetric management in cases with fetal anomalies

21. Isolated fetal hydrocephalus:
1- Variable outcome
2- Associated anomalies may go undetected
Obstetric ethics: A viable at-term fetus with isolated hydrocephalus is a fetal patient, because neither of the two exceptions described above (certainty or near certainty of diagnosis and certainty or near certainty of outcome) apply, given the variable outcomes of isolated hydrocephalus.
There are compelling, beneficence-based ethical reasons for concluding that
continuing existence of fetuses with isolated hydrocephalus is in their interest.
The probability of Mental retardation does not diminish the interests of the fetal patient with isolated hydrocephalus in continuing existence because:
1 it is impossible to predict which fetuses with isolated hydrocephalus will have
mental retardation, and
2 the degree of mental retardation cannot be predicted in advance.
Cephalocentesis for intrapartum management of hydrocephalus:
Cephalocentesis involves the drainage of an enlarged fetal head, secondary to hydrocephalus. It`s a potentially destructive procedure. Perinatal death following cephalocentesis has been reported in over 90% of cases.
Fetal hydrocephalus is caused by obstruction of cerebrospinal flow and is diagnosed by such sonographic signs as dilatation of the atrium or body of the lateral ventricles.
hydrocephalus can be associated with other abnormalities suggestive of poor prognosis, for example, hydranencephaly, microcephaly, encephalocele, alobar holoprosencephaly, or thanatophoric dysplasia with cloverleaf skull.
In the absence of defined anatomical abnormalities, diagnostic imaging is unable to predict the outcome.
There is considerable potential for normal, sometimes superior, intellectual function
for fetuses with even extreme, isolated hydrocephalus.27–30
However, as a group, infants with isolated hydrocephalus experience a greater incidence of mental retardation and early death than the general population. In addition, associated
anomalies may go undetected, and a fetus may be incorrectly diagnosed as having
isolated hydrocephalus.26,31
One thing is clear in obstetric ethics: A viable at-term fetus with isolated hydrocephalus is a fetal patient, because neither of the two exceptions described above (certainty or near certainty of diagnosis and certainty or near certainty of outcome) apply, given the variable outcomes of isolated hydrocephalus
There are compelling, beneficence-based ethical reasons for concluding that
continuing existence of fetuses with isolated hydrocephalus is in their interest.
Beneficence directs the physician to prevent mortality and morbidity for the fetal
patient. Beneficence also directs the physician to undertake interventions that
ameliorate handicapping conditions such as mental retardation. The probability of
mental retardation does not diminish the interests of the fetal patient with isolated
hydrocephalus in continuing existence because:
1 it is impossible to predict which fetuses with isolated hydrocephalus will have
mental retardation, and
2 the degree of mental retardation cannot be predicted in advance.
Chervenak FA et al. Am J Obstet Gynecol 1985
Raimondi AJ et al. Am J Dis Child 1974
McCullough DC et al. J Neurosurg 1982
Chervenak FA et al. Am J Obstet Gynecol 1990

22. The decision to offer cephalocentesis in such cases (alobar holoprosencephaly) is based on our beneficence-based obligation to the pregnant woman to allow her to avoid cesarean delivery, which would be of little benefit to the fetus.
In view of the short- and long-term consequences of cesarean delivery, the physician can therefore justifiably undertake interventions for maternal benefit that risk fetal death.
Because of these reasons, fetal heart rate monitoring is not indicated after cephalocentesis, as cesarean delivery for an abnormal fetal heart tracing would not be appropriate. A classical incision would preclude future trial of labor due to the risk of uterine rupture.
It is important that the patient understand that cephalocentesis is a potentially destructive procedure and that fetal death is possible.1 This can be ethically justified by the fact that although neonatal survival is possible, the neurologic deficits associated with conditions
such as holoprosencephaly are severe and cannot be improved by any known interventions. In the unlikely event that the fetus survives cephalocentesis, it is unlikely that any damage as a result of the procedure would significantly worsen the prognosis. Thus, the beneficence-based
obligations of the physician and the pregnant woman to sustain the life of the fetus or prevent further neurologic injury are minimal, and offering cephalocentesis is appropriate
When hydrocephalus is isolated or associated
with anomalies that are compatible with a good outcome,
the obligations of the physician and the pregnant woman
are different. In such cases, the possible harms of
cephalocentesis cannot be perceived as insignificant compared
with the maternal benefits of avoiding cesarean delivery.
Since it is not certain which fetuses will have good
outcomes, beneficence-based obligations to the fetus stipulate
that cephalocentesis is inappropriate
Chasen, S. T., et al. (2001). "The role of cephalocentesis in modern obstetrics." Am J Obstet Gynecol 185(3):

23. In summary, Cephalocentesis to allow vaginal delivery is indicated in fetal hydrocephalus with associated anomalies that are either incompatible with life or associated with the severest forms of neurologic dysfunction. In these situations, the benefit of avoiding cesarean delivery clearly outweighs the risk of fetal death
or injury associated with cephalocentesis.

24. Ethics and Non-treatment of Severe Hydrocephalus
Ethics and Treatment of Severe Hydrocephalus?
WILKINSON D. Ethical Dilemmas in Postnatal Treatment of Severe Congenital Hydrocephalus. Cambridge Quarterly of Healthcare Ethics. 2016;25(1): doi: /S

25. Background:
28 years old. G4P3 previous vaginal births.
GA= 39 weeks
Prenatally diagnosed large parieto-occipital encephalocele, microcephaly
PMDT no fetal monitoring and no C-section for fetal reasons.
Intrapartum events:
Patient opts for fetal monitoring
Failure of head descent, deflexed head by large mass
Sac drainage was offered but patient declined
C-section was done. Normal Apgar. AN diagnosis was confirmed
Toddler is now 2 years old. Underwent several corrective surgeries. With neurodevelopmental delay and seizures.

26. Maternal-Fetal Conflict
Maternal-Fetal Conflict Dilemma
Maternal-Fetal Conflict

27. The Ethical Concept of The Fetus as a Patient
The fetus cannot meaningfully be said to possess values and beliefs, because of its insufficiently developed central nervous system. Thus, there is no valid basis for saying that a fetus has a perspective on its interests. There can, therefore, be no autonomy-based obligations to any fetus. In other words, we cannot say with confidence that the fetus possesses independent moral status and generates its own rights. Despite this, the obstetrician has a perspective on the fetus’s health-related interests and therefore can have beneficence-based obligations to the fetus, but only when the fetus is a patient.
beneficence-based obligations to the fetus exist when the fetus can later, after birth, achieve independent moral status.
The fetus cannot meaningfully be said to possess values and beliefs, because of its insufficiently developed central nervous system.
Thus, there is no valid basis for saying that a fetus has a perspective on its interests. There can, therefore, be no autonomy-based obligations to any fetus.3 In other words, we cannot say with confidence that the fetus possesses independent moral status and generates its own rights. Despite this, the obstetrician has a perspective on the fetus’s health-related interests and therefore can have beneficence-based obligations to the fetus, but only when the fetus is a patient.
Because of its centrality for the ethical management of pregnancies complicated by
fetal anomalies, the topic of the fetus as a patient requires detailed consideration.
The authors have argued elsewhere that beneficence-based obligations to the fetus
exist when the fetus can later, after birth, achieve independent moral status.
The fetus is a patient when two conditions are met:
1 the fetus is presented to the physician and
2 there exist medical interventions, whether diagnostic or therapeutic, that reliably
can be expected to result in a greater balance of clinical goods over clinical harms
for the fetus in its future. This component of the ethical concept of the fetus as a patient is what makes it unique in medical ethics
The ethical concept of the fetus as a patient appeals both to beneficence, as does the concept of being a patient in general, and also to links to the fetus later becoming a child and, later still, achieving independent moral status.
McCullough LB, Chervenak FA: Ethics in Obstetrics and Gynecology. New York: Oxford University Press, 1994.

28. how physicians counsel women on the clinical management of pregnancies complicated by severe fetal anomalies?
the ethical concept of the fetus as a patient and the professional responsibility model of obstetric ethics.
When there is certainty about the diagnosis and either a very high probability of either death as the outcome of the anomaly or survival with severe and irreversible deficit of cognitive developmental capacity as a result of the anomaly diagnosed, the pregnant woman should be offered the alternatives of aggressive and non-aggressive obstetric management and induced abortion before viability.
It is also ethically permissible to offer feticide followed by termination of pregnancy after viability in such cases. This ethically justified approach will reduce the variation in the actual practices of specialists in maternal-fetal medicine.
Chervenak, F. and L. B. McCullough (2012). "Responsibly counselling women about the clinical management of pregnancies complicated by severe fetal anomalies." J Med Ethics 38(7):

29. Ethics is an essential dimension of fetocide both before and after fetal viability.
The ethical concept of the fetus as a patient guides the obstetrician in reaching ethically
justified balancing of autonomy-based and beneficence-based obligations to the
Pregnant woman and beneficence-based obligations to the fetal patient, when the fetus
is a patient.
For pre-viable pregnancies, respect for the pregnant woman’s autonomy is the decisive ethical concern, including the subset of selective termination for multifetal pregnancies.
For viable pregnancies, it is sometimes consistent with beneficence-based obligations to the fetal patient to perform fetocide.
By contrast, the recent Groningen Protocol for infanticide should not be adopted anywhere by any conscientious physician or healthcare organization.
Chervenak et al, Fetal and Maternal Medicine Review 2007
Non-aggressive obstetric management
Another exception to aggressive obstetric management is non-aggressive obstetric
management. This exception applies when there is
1 a very high probability, but sometimes less than complete certainty, about the
diagnosis and, either
2a a very high probability of death as an outcome of the anomaly diagnosed, or
2b survival with a very high probability of severe and irreversible deficit of cognitive
developmental capacity as a result of the anomaly diagnosed.3,22
When these two criteria apply, a choice between aggressive or non-aggressive
management should be offered.

30. Termination of Pregnancy After Viability Chervenak et al, Fetal and Maternal Medicine Review 2007
TOP acceptable after viability
TOP NOT Acceptable after viability
Concept
Beneficence-based clinical judgment causing death is an acceptable outcome.
Beneficence-based prohibition against terminating the life of a viable fetus
Anomalies
trisomy 13, trisomy 18, renal agenesis, thanatophoric dysplasia, alobar holoprosencephaly and
hydranencephaly
Down syndrome, spina bifida, isolated hydrocephalus,
diaphragmatic hernia, achondroplasia, and most cardiac anomalies
Justification
because, with these anomalies, either death is already a certain or a near certain outcome or the certain or near certain absence of cognitive developmental capacity is tantamount to death
Although these anomalies involve incremental risks of mental and physical morbidity and mortality, they do not justify third trimester abortion. Under no rigorous clinical evaluation can these conditions be regarded as tantamount to death or absence of cognitive developmental capacity.
FETOCIDE AFTER VIABILITY
After viability, aggressive management is the ethical standard of care. By
aggressive management, we mean optimizing perinatal outcome by utilizing effective
antepartum and intrapartum diagnostic and therapeutic modalities. In addition,
there are three other management options, termination of pregnancy, non-aggressive
management, and cephalocentesis. We emphasize that these options are ethically
challenging and best avoided through early diagnosis
Termination of pregnancy after viability
One important exception is termination of pregnancy after fetal viability. This
exception applies when there is
1 certainty of diagnosis, and either
2a certainty of death as an outcome of the anomaly diagnosed, or
2b in some cases of short-term survival, certainty of the absence of cognitive
developmental capacity as an outcome of the anomaly diagnosed.3,18
When these criteria are satisfied, recommending a choice between non-aggressive
management and termination of pregnancy is justified. Anencephaly is a classic
example of a fetal anomaly that satisfies these criteria.18
A strong ethical argument can also be made that anomalies such as trisomy 13,
trisomy 18, renal agenesis, thanatophoric dysplasia, alobar holoprosencephaly and
hydranencephaly should also count as anomalies that could ethically justify third
trimester abortion.19 This is because, with these anomalies, either death is already a
certain or a near certain outcome or the certain or near certain absence of cognitive
developmental capacity is tantamount to death and so in beneficence-based clinical
judgment causing death is an acceptable outcome.
For many anomalies, such as Down syndrome, spina bifida, isolated hydrocephalus,
diaphragmatic hernia, achondroplasia, and most cardiac anomalies, neither death nor
absence of cognitive developmental capacity is a certain or near certain outcome.
Although these anomalies involve incremental risks of mental and physical morbidity
and mortality, they do not justify third trimester abortion. Under no rigorous clinical
evaluation can these conditions be regarded as tantamount to death or absence
of cognitive developmental capacity. For such anomalies, the beneficence-based
prohibition against terminating the life of a viable fetus remains robustly intact. Any
clinical judgment that does not address and defeat this beneficence-based prohibition
is defective on ethical grounds and therefore is inconsistent with the professional
integrity.19,20

31. Wilkinson, D., et al. (2014). "Ethical language and decision-making for prenatally diagnosed lethal malformations." Semin Fetal Neonatal Med 19(5):

32. Beyond the Concept of ‘Lethal Malformations’
1. Diagnosis: what is the diagnosis, and how certain can practitioners be? 2. Neonatal survival: what is the chance of survival past the newborn period if treatments (including intensive life prolonging therapies) are provided? 3. Long-term survival: how long is the child likely to survive if life sustaining treatment is provided? 4. Long-term impairment and illness: if the newborn survives, what long-term health problems and impairments are they likely to experience? What is the range of possible outcomes? 5. Burden of treatment: what treatments would be required to keep the newborn infant alive, and how burdensome would these be for the child and the family?
In this review, we have analysed and criticized the concept of ‘lethal’ congenital malformations. The term is misleading, and potentially leads to miscommunication with families and inconsistent decision-making. None of the malformations frequently described as ‘lethal’ fits with strict definitions of this term. However, even if they are not lethal, the severity of conditions such as anencephaly, renal agenesis, and T13/T18 means that perinatal palliative care, maternal-focused obstetric care, and potentially termination of pregnancy are justified. It may also be appropriate to provide fetal-oriented obstetric care and some life-sustaining treatments for these conditions where this is consistent with a woman's wishes and the child's best interests.
Wilkinson, D., et al. (2014). "Ethical language and decision-making for prenatally diagnosed lethal malformations." Semin Fetal Neonatal Med 19(5):

33. Practical Points To Consider In Cases Of Severe Fetal Malformations
Survival beyond the newborn period has been described in all of the congenital malformations that are often described as being ‘lethal’.
The terms ‘lethal malformation’ or ‘incompatible with life’ should be avoided in counseling.
A palliative approach to management during pregnancy, delivery, and postnatally may be ethically appropriate for fetuses with a very poor prognosis.
An active approach to obstetric and neonatal care may also be appropriate in these conditions to enable parents to experience some time with their child while alive
Wilkinson, D., et al. (2014). "Ethical language and decision-making for prenatally diagnosed lethal malformations." Semin Fetal Neonatal Med 19(5):

35.  حديث ابن مسعود رضي الله عنه المشهور فيه: (إِنَّ أَحَدَكُمْ يُجْمَعُ خَلْقُهُ في بَطْنِ أُمِّهِ أَرْبَعِينَ يَوْمًا ثُمَّ يَكُونُ في ذَلِكَ عَلَقَةً مِثْلَ ذَلِكَ ثُمَّ يَكُونُ في ذَلِكَ مُضْغَةً مِثْلَ ذَلِكَ ثُمَّ يُرْسَلُ الْمَلَكُ فَيَنْفُخُ فِيهِ الرُّوحَ... الحديث) رواه البخاري ومسلم، فالحديث واضح في أن نفخ الروح يكون بعد مئة وعشرين يوماً، ونظراً لهذا الحديث وغيره من الأحاديث والأحكام الشرعية فإن الجنين إذا علق في الرحم لا يجوز إجهاضه مهما كان عمره، لأنه بداية خلق إنسان محترم، ولو تسبب إنسان في إجهاضه فعليه دية قيمتها خمسة من الإبل، وكفارة صيام شهرين متتابعين، وهذا دليل الإثم في إسقاطه، لكن إذا خشي على أمه ضررًا مؤكدًّا جاز إجهاضه قبل مائة وعشرين يومًا من علوقه، وبعد المئة عشرين لا يجوز إسقاطه إلا إذا قرر الأطباء الثقات لأن بقاءه يؤدي إلى موت أمه حتمًا، وبهذا أخذ مجمع الفقه الإسلامي في مكة المكرمة، والله تعالى أعلم.
"فتاوى الشيخ نوح علي سلمان" (فتاوى الأحوال الشخصية/ فتوى رقم/64)

36. Ethics Committee Obstetrician Maternal-Fetal Medicine Neonatologist
Medical director
Ethicist
Anesthetist
Obstetric nurse
+∕-
Before viability. Precisely before 19 weeks

37. What does an obstetrician/ neonatologist need to know?
Is the condition severe (Yes/No)
Is the diagnosis confirmed (Yes/No)
fetal monitoring (Yes/No)
C-section for fetal reasons (Yes/No)
Palliative neonatal care (Yes/No)
Full neonatal support (Yes/No)
After 24 weeks

38. Guideline of Severe Fetal Anomalies

42. Summary and Conclusions
Fetal anomalies beyond viability may be an obstetric challenge.
Early detection, early anatomy screening policy and good quality ultrasound may optimize the pregnancy outcome.
Multidisciplinary input
TOP option where possible
Maternal-focused obstetric care and perinatal palliative care when appropriate
Whenever appropriate, fetal-oriented obstetric care and some life-sustaining treatments for these conditions where this is consistent with a woman's wishes and the child's best interests.
Further research on this subject based on our local data
Non-aggressive obstetric management
Another exception to aggressive obstetric management is non-aggressive obstetric
management. This exception applies when there is
1 a very high probability, but sometimes less than complete certainty, about the
diagnosis and, either
2a a very high probability of death as an outcome of the anomaly diagnosed, or
2b survival with a very high probability of severe and irreversible deficit of cognitive
developmental capacity as a result of the anomaly diagnosed.3,22
When these two criteria apply, a choice between aggressive or non-aggressive
management should be offered

44. Thank You qatarfetus@gmail.com