Thursday, July 29, 2010

Two births that made me happy

Last week two births made me very happy.

I had blogged about one of the mother before. She was a type 1 Diabetic dependent on Insulin for more than 12 years now. I had blogged about my interview with her to-be-husband  in 'Strange Interview' . Also I had posted about the first time she became pregnant in 'Happy News' and about her abortion in 'Sad News'. Now she has delivered a healthy baby. She recently came to me with her husband and the new born and we were all smiling.
Many type 1 Diabetics deliver normal healthy babies but  still it is a difficult task. Perinatal mortality and still birth rates are 4 to 5 times of normal pregnancies. That is why we were smiling.

The other birth was the planned conception and delivery of a  baby for an HIV positive couple.The couple were my patients for last 5 years.They had asked me the possibility of parenting a child before .Initially I did not encourage them because I did not knew how compliant they will be with the treatment.schedule. They were regular in their follow up and very compliant in taking medicines in time. When they asked me again after 3 years of Anti retro viral therapy I was more positive.I directed them to a suitable center for guidance. After a lot of counseling they were ready to accept the risks involved. They did everything as told and the mother delivered by cesarian section a healthy baby recently.

This proved that nothing is impossible for a 'positive' couple.
Read more about HIV and Pregnancy here

15 comments:

Ketan said...

Congratulations!

About the second couple I was thinking wouldn't it have been better had they decided to conceive earlier? Asking this, as that'd have kept the chances of drug resistance low. Of course, it's a good thing that baby turned out fine. :)

So, the baby was prescribed his/her mother's breast milk or some substitute?

Also, are there any specific laws/regulations as to whether HIV/AIDS patients are allowed to conceive or not?

Thanks!

L said...

While having a child is good for the couple, is it in the child's interest to have parents both of whom may not be alive for long?
Of course losing one's parents can happen to anyone...we have so many road accidents, but I don't think I would give birth to a child if I was not reasonably sure that I would be alive and healthy to finish my parenting job.

Ketan said...

L,

Good point there! While, I'd certainly applaud the progress medical science & dedicated medical workers have made, the ethical conundrum on the issue persists for me.

Charakan said...

my logical guess is both mothers will live near normal life with medicines till the adulthood of the child Is it still an ethical problem?

L said...

Doc, I can understand that the diabetic lady can manage her condition and live long enough to bring the child up. No issues there. But is it true that the HIV + lady will have a good chance of a 18/20 more healthy years? Am I being ignorant? I thought the onset of AIDS could happen pretty early in many cases.

Indian Home Maker said...

This is information! I was under the impression that HIV positive parents should not have children! They are a brave couple - my best wishes to them!

Ketan said...

Apart from what L mentions, I'm concerned the chances of transmission despite nevirapine therapy (or even HAART) remain around 5%? Is that ethical/legal? At the time of writing this, have not checked latest statistics. Will verify & get back.

Ketan said...

This (click) review article has more info. In West (with all possible precautions, including Zidovudine, cesarean section, peripartum (around the time of delivery) nevirapine & avoidance of breast-feeding) risk of transmission is 1 to 2%. With breast-feeding it increases to around 25%.

Why I consider this an ethical issue is because is it alright for parents to decide on behalf of their child that it can suffer (with 1-2% probability) from a disease like AIDS purely for their OWN gratification (of furthering the family tree)?

I guess, it would be more humanitarian to adopt a child (if parents are assured of that kind of lifespan).

Charakan said...

L, With continuous optimal life long anti retro viral therapy, a 'positive' person can live a life of near normal life expectancy. HIV infection is now considered as a chronic manageable condition like Diabetes.

Charakan said...

Ketan, thank you for your comments.

Why conceiving the baby was delayed? They asked me about it after about an year of diagnosis,but I was reluctant.At that time the system of care in India was also not mature enough to think about a planned pregnancy in HIV. Anyway the mother always had a high CD 4 count and was never on therapy and the father is having good response to ART without resistance even after 5 years.
In my practice I never advice breast milk and also no one in Kerala is so poor so as not being able to afford formula feeds.Care and delivery of this mother was in a specialized care center and so was not under my care.She was also only giving breast milk substitutes.
The United Nations have several times declared that a 'positive' woman have the right to conceive and become a mother.
About the ethics.
In general Human rights are always about the rights of already born humans and not about yet to be born humans. That is why abortion of healthy fetus is legal in many circumstances.

The right to conceive and become a parent is a human right. If you try to prevent it, it becomes discrimination punishable by law.

The 2% you quoted as the chance of perinatal transmission is mainly for those who came to know they are positive after they become pregnant.In planned pregnancies it is still less.
Current guidelines for MTCTP is here

Charakan said...

IHM,
Yes many including health care workers are unaware of this possibility.

Ketan said...

Thanks, Charakan!

I'm sorry, I could not open the PDF document you had provided the link to, from the PC where I was trying to access it.

Slightly old (so situation might have further improved in the interim), but, American statistics state the following here (click) [from CDC]:

"This reduction is attributed to routine HIV screening of pregnant women, use of antiretroviral (ARV) drugs for treatment and prophylaxis, avoidance of breastfeeding, and use of elective cesarean delivery when appropriate. With these interventions, rates of HIV transmission during pregnancy, labor, or delivery from mothers infected with HIV have been reduced to less than 2%."

But I must admit, after going through 4 sources in all, I could not conclude with confidence if the transmission rate is for those diagnosed with HIV and then subsequently given HAART with planned parenthood, OR those diagnosed with HIV after getting pregnant.

Actually, I was shocked to learn that the mother had not been on ART anytime during her lifespan, and yet had conceived - is it not risky? Was her viral load measured any time during pregnancy, or only CD4+ counts were considered?

With regard to your argument that ethical considerations are not applied to those unborn, I agree to some degree, but not fully. E.g., abortion is legal only till the age of 20 weeks, and obviously the criterion used is viability of the fetus. So a viable fetus is considered to have some human rights. That's why abortion of viable fetus is illegal.

Moreover, making female feticide illegal in India also follows partially from the idea that even female fetus just like the male counterparts have equal right to live.

Also, at many places in medical practice, the right to conceive has an important caveat - that that conception must be in the best interest of the prospective child. It is for this reason that practices that could potentially harm the child (but benefit the mother) are to be strictly avoided, unless and until they would prove life-saving for the mother. Examples of that are avoidance of X-rays/other ionizing radiation and teratogenic drugs.

In your practice you never advise breast-feeding only to HIV+ patients, or in general? Sorry, your statement was ambiguous in that regard.

And of course, I've not even remotely suggested punishing of HIV+ patients who wish to conceive. But then as could be easily recognized, law and ethics do not always coincide. If I am not mistaken it is mandatory for a spouse to reveal if he/she contracts HIV/AIDS, so that the spouse can make of choice of not contracting it herself/himself by abstaining from intercourse or using appropriate barrier contraception. Does the prospective child born in case of HIV+ parent(s) get to exercise such an option? No. That's why I was trying to equate the two.

Also, the caveat that, parents as they were responsible for bringing the child to life without the child's consent, are also responsible for his/her safety/welfare is indicated in the tone of section 317 of IPC (click).

In the current case, I'm afraid I feel the parents acted by placing their less significant interest above the more significant issue of health of the child. Meaning, on the whole 'risk-benefit' ratio of the decision was weighed in the 'risky' side.

Lastly, I've been hearing that HIV/AIDS is a chronically manageable disease since last 4 years, but as I learn more I also understand that being a syndrome, it does not merely cause opportunistic infections, but it is carcinogenic, mutagenic, and elicits autoimmune responses that cause many other maladies, which in my opinion a yet-to-be-born child must not be exposed to (especially without taking child's consent, which anyway is impossible to take).

Charakan said...

Ketan, Let me clear few misunderstandings The mother was on anti retro viral drugs from 2nd trimester and will continue it life long as per recommendation.There was never an indication to start her on ART for her health. Breast feeding I meant only about HIV pos mothers. About ethical issues my views are similar to all International and National regulatory authorities like UN,WHO, CDC, FIGO etc

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