The oral cavity is one of the many systems that is perfectly designed while a fetus develops in a mother’s womb

The first event that takes place inside the mother’s womb is the union of sperm and egg to form into a single cell which later takes the shape of an embryo by rapid division and development. This embryological development occurs in three stages.

In the first of these stages (2-5 weeks), the fertilized egg (zygote) proliferates by dividing and planting itself to the womb wall (implantation). During the advance of the zygote towards the womb, some biochemical signals are sent in order to make the mother sense this situation. Via these signals, the mother’s body is prepared to supply the necessary nutrients to this cellular mass. When these biochemical signals reach the ovaries, various hormones are secreted and the ovulation that occurs during monthly periods is ceased.

During the second stage (5-6 weeks), major activities are started inside the cellular mass, which is now in the form of an embryo. The developmental process of organ and system generation from cells begins.

And during the third stage (from the 8^th week until birth), the embryo has become a fetus, and its facial and bodily structures have begun to be immaculately shaped (Figure-1).

How do organs develop?

Tissues and organs of the embryo, which morphologically starts to look like a human, develop from three layers, which are called the ectoderm, mesoderm, and endoderm. While the baby continues to come to life inside the mother’s womb, the cranial and facial regions, along with oral cavity, start to form via the development of cells in the area called the neural crest. This development is the result of perfectly corresponding functions in between the epithelium and outer mesenchyme, which results in the facial skeleton and formation of teeth.

Jaw and facial development occur during the 4-12 weeks in the womb. By the end of the 10^th week, the face can be seen with an ultrasonographic examination.

The nose forms at this point. Mid and lateral nose projections develop. A forehead projection called the “frontonasal protrusion” forms in between the two sided mid nose projections. These projections initially develop towards the lower direction because of the volume of the tongue. Later, after the palate has begun to form, and with the growth of the lower jaw and the downward extension of the tongue, like an open-close bridge, the lower and upper jaw join at the midline by rising upward. This union takes place from front to back, like closing a zipper, stage by stage.

This way, the oral cavity and the surrounding structures (tongue, teeth, etc.) that will enable speech and taste are knit, loop by loop, inside the mother’s womb. (Figure 1-2)

Due to the complexity of this process, if there happens to be any failure in the merging, some anomalies can form, such as split lips or palates. These splits are anomalies present at birth. Such lip or palate splits may arise during this phase of the pregnancy because of various negative factors: they can stem from inter-family marriages, diseases that the mother experiences during the first three months of the pregnancy (especially measles or toxoplasmosis), exposure to radiation, alcohol consumption during pregnancy, or various drugs the mother uses. These anomalies need to be corrected by plastic surgeons, upper respiratory tract specialists, and orthodontists.

Despite these anomalies, most of the time, babies are born with their oral cavities in perfect working order – which is extraordinary given the complexity of the process.

Reference

Oral R. J, Goldman H.M. Thoma’s oral Pathology.The CV Mosby Comp. St. Louis.

Figure-1: Ultrasonographic image of the facial region of a fetus in the mothers womb.

Figure-2: Upper jaw bone

How is uterus to be placed in the frontier abdomen?

In order for a baby to survive, a suitable space in which it will be fed and protected is necessary. Therefore, the uterus is in the best location as it is, and its equivalent cannot be maintained in the belly. Let us consider that births would really happen through the belly. If the uterus, where a baby develops in 40 weeks, were placed in the belly, then a set of problems would appear. The opening of the uterus would be turned toward the abdomen wall, and thus there would be no strong bonds to tie it up with the surrounding area. In this case we cannot place the intestines, mesenteric blood vessels, aorta, and the net of nerves in connection to them in any way. If the uterus were in the belly, it would unavoidably pressurize the stomach, liver, spleen, and other internal organs, as the mass inside a pregnant woman grew. This could obviously pose a lethal threat for both the mother and the baby.

How would the birth process begin?

If the uterus were anywhere else than its present position, it would contradict the physiology of birth. The fetus assumes three different positions along the developmental process: as it begins to be formed the head is up and the feet are down. At the sixth month, the baby assumes a horizontal position. When the birth draws near, feet and the hips are positioned on top and the head is turned downward, closer to the opening of the uterus. As the head gets closer to the opening, mechanical pressure increases. Thus, signals for the birth are sent to the brain so that the relevant hormone aid is sent in response. With the effect of the hormones, the uterus begins to contract in order to dispose of the being inside. As the opening of the uterus enlarges, the contractions increase. With its mechanical help, the sacro-coccigeal joint makes a 2-cm stretch to give way and with the support of the pubis bone in front, the birth is realized. If human birth was to occur through the belly, then how would the process—including the brain, pituitary gland, and adrenal glands—be triggered with mechanical pressure without the help of gravitation? If the uterus is placed inside the belly vertically, then a tube or similar opening is needed for a way out from between the legs. Even if there is mechanical pressure and the hormones to facilitate birth are secreted, then what way will the baby move? How can birth be realized through the soft-walled belly without any mechanical support at all? If human birth were possible through the belly without any support from the bones, the duration of birth would be much greater. In addition, as the size of the baby increased, a high positive pressure would be needed in order to balance the effect of gravity. However, the more a belly grows, the weaker its muscles become. If birth would ever be possible through the belly, then the mother would have to deliver her baby by lying prone in order to prevent the soft tissue to be torn. In addition certain flora (beneficial microorganisms) need to be placed to the birth channel in order to prevent relevant complications. Should the genital organ be transferred to the navel? For the best protection against complications, the baby’s head need to be in horizontal position as if it were swimming. The effect of gravitation applies different pressures on the baby’s head while the mother stands, sits, and lies in a supine position. In this case, by which force would the head be directed toward the opening in the frontal abdomen wall to start the birth process? The three different positions of a fetus along its development will never be possible in a uterus located in the belly. Then the fetus would dangle like a tree leaf under the effect of gravitation.

The easiness of normal physiological birth

A form of birth through the belly, a cesarean delivery is only realized in the face of certain anomalies. Although some women assume cesarean as a painless form of birth, findings adds to the cons of cesarean. Accordingly, rate of allergic asthma in cesarean-born children is found six times higher in comparison to others. It is thought that during normal birth, the baby receives some of the microorganisms on the mother’s genital organ and the immune system forms antidote against them, which provides protection against asthma.

Strapping up the uterus?

As the baby develops in a period which lasts more than nine months, the uterus gradually grows. In the mean time, it is necessary to fix the uterus with sound bonds so that it becomes resistible to shakes. Counting in both sides, 14 pieces of bonds fixes the uterus to the bones (ilium, ischium, pubis, sacrum) around the hips. Were the uterus to be in the belly, how could we find such sound structure to support the bonds?

To conclude, God Almighty could have created our body in a different form, and He would have shaped our anatomy accordingly, which would then provide the best means for an ideal birth. Thus, it is nonsensical to seek errors in our present biological makeup in order to dishearten the faithful in their belief. Leaving aside such speculations, one cannot help but admire the perfect arrangement in human anatomy when considered from the perspective of wisdom.

Arslan Mayda is a medical doctor at Sifa Hospital, Izmir, Turkey.

The problem of pulmonary tuberculosis in pregnancy has attracted the attention of doctors for many years and it is still a current issue. Modern researchers and physicians divide tuberculosis into several independent problems which have difficult solutions. On the one hand, there is the influence of tuberculosis on the course of pregnancy and child delivery as well as on the health of a mother and her child. On the other hand, there is the influence of pregnancy and childbirth, the puerperal period and lactation on the course and progress of tuberculosis.

Research on how pregnancy influences the course of tuberculosis has been carried out for many years. Even in the oldest available documents we can find instructions for “personal precautions” and preventative measures against tuberculosis, as well as thoughts about pregnancy and tuberculosis. In 1400 BC the Law of Manu from ancient India prohibited marriages to girls from families with tuberculosis. In different world religions, including Islam and Christianity, there are special restrictions concerning people who suffer from this illness.

In ancient times Hippocrates and Galen taught that pregnancy has a positive influence on the function of lungs. But the Islamic doctors, Arabian as well as Spanish, of the Cordoba Caliphate considered that the blessed process of pregnancy must not be complicated by pulmonary diseases.

With time European medical science changed its point of view. From the second part of the 17th century until the beginning of the 19th century doctors considered that pregnancy had a bad effect on the course of tuberculosis, but then the situation, for some reason, changed. Doctors began to think that pregnancy had a good influence on lung diseases. They even started to advise girls who were susceptible to tuberculosis to marry. Time passed and doctors began to change their opinion on tuberculosis in pregnancy and the extremes in views became less obvious. This happened due to the introduction of an artificial pneumothorax into the treatment of tuberculosis.

Since then the third period in the understanding of the relationship between pregnancy and tuberculosis has begun. The opinion about the course of tuberculosis in pregnant women has changed due to the successful therapy of tuberculosis with the help of the artificial pneumothorax.

During the gestation period, all the organs and tissues of the entire organism experience an increased load, as they are trying to satisfy both their own needs and that of the developing fetus. These morphological and functional changes do not lead to any pathological state in the mother if she is healthy and her course of pregnancy is normal. If the woman’s organism has been weakened by a chronic immunodeficiency due to poor environmental conditions or if she has a tuberculosis process in her organism, then functional changes and tissue dystrophies can develop in her nervous system which will lead to metabolic disorders. Changes in ergasia caused by pregnancy and connected with changes in higher nervous activity, as well as with endocrine reorganization, can influence the development and the course of the tubercular process.

Before penicillin was discovered, pregnancy usually led to the progression of the disease and in many cases even ended fatally. Nowadays due to the use of effective antituberculous medicines the attitude towards possible pregnancy of women who have active tuberculosis has considerably changed.

Tuberculosis in a pregnant woman usually starts in an acute form; at this stage infiltrative forms of the disease with necrogenic and bacterioexcretion prevail, often combined with exudative pleurisy, trachea, larynx and bronchi lesions.

Frequent consecutive pregnancies have a negative effect on the state of women who suffer from tuberculosis; they weaken the organism and can cause the recrudescence of the tuberculosis process. This is very typical of many families in poor Asian and African countries. More than half of all pregnant women suffering from an active form of tuberculosis experience a progressive iron deficiency anemia during the first three months of pregnancy and in the second trimester of pregnancy this can be observed in almost all patients. Malaria is also widespread in Asian and African countries that are situated to the south of Sahara and are the second reason for iron deficiency anemia.

According to modern views, one of the reasons for the recrudescence of the tubercular process during pregnancy is an irregular or non-systematic treatment of this illness or the absence of any treatment at all. The recrudescence of the process observed in those suffering from destructive pulmonary tuberculosis is caused by the severity of the illness itself when new conditions for the organism occur. In this case, pregnancy begins against the background of an advanced chronic immune deficiency. At the same time, due to the feto-placental complex operation, functional changes in the nervous, respiratory, cardiovascular and urinary systems, as well as hormonal changes, in the organism of a pregnant woman take place.

Moreover, the development of the fetal skeleton requires calcium which is absorbed not only via the blood of the mother, but also from the healed niduses of tuberculosis and as a result, the progression of a specific process can appear.

The reactivation of the tubercular process happens due to a decrease in the responsiveness of the organism and because of an increase in the activity of the reproductive hormones and the loosening of the connective tissues which are physiologically involved in pregnancy. The amount of plasma and extra vascular fluid increases. Due to these changes, a swelling and loosening in the inactive tubercular niduses with the mycobacteria of tuberculosis can appear. And loosening, in its turn, enables a lymphohematogenous spread of mycobacteria.

In addition to these, the delivery of a child leads to a speedy reorganization of all the functions of the organism; lactation and nursing in their turn are combined with an increased loss daily of nutritious matters and a large amount of protein and fats. In case of destructive pulmonary tuberculosis, due to the fact that the diaphragm descends (resulting in the abdominal decompression ceasing to have a therapeutic action of pneumoperitoneum) bronchogenic dissemination appears in the unaffected parts of the lungs.

A specific active process can be observed in women belonging to the high-risk group in connection with tuberculosis. The high-risk group combines women who have recently suffered from tuberculosis (less than one year after treatment), those who have just been operated on for a tuberculosis connected illness (less than one year), women with tuberculosis of different localizations younger than 20 years (for Asia and Africa) and those older than 35 years (for Europe and the USA), those with widespread forms of the tubercular process withstanding its stage, women who have had contact with people discharging bacteria or people suffering from tuberculosis but not discharging bacteria, and also those who have coexisting illnesses (diabetes, chronic nonspecific pulmonary illnesses, problems with kidneys, stomach and duodenum ulcer), and also women who use alcohol, narcotics, those who smoke and lead asocial ways of life. In these cases, the women must be properly examined during the gestation period, including X-rays.

Treatment of tuberculosis during pregnancy

All other conditions being equal, the timely detection of active tuberculosis during pregnancy allows doctors to provide a full course of treatment, allowing the woman to recover and give birth to a healthy child. Untreated active tuberculosis of the mother is much more dangerous for the fetus than anti-tuberculosis chemotherapy.

Special attention must be paid to healthy women who are in contact with bacillary patients. Quite often these women might undergo active tuberculosis for the first time during pregnancy or after the delivery itself.

In the pre-penicillin era the recrudescence of the tubercular process during pregnancy and after the delivery proceeded in an acute form with frank infiltrative changes, a necrogenic process, bloody expectoration and very often a generalization of the process. Nowadays, the clinical outlook for complications and the recrudescence of tuberculosis against the background of pregnancy is less gloomy. It more resembles the toxicosis of pregnancy or respiratory diseases.

While examining a patient, special attention must be paid to chest problems like moist or dry coughs, bloody expectoration, pain in the chest and shortness of breath. If the patient coughs with expectoration for 2 weeks then she must be examined for mycobacteria with the usage of a microscopic technique.

Another syndrome, which is also very important, is a complex of intoxication symptoms (weakness, hidrosis, anorexia, weight loss, long-lasting low grade fever and hyperirritability) which need to be detected to discover the reason for their development. While examining the anamnesis of a pregnant woman it is necessary to learn if she has ever suffered from tuberculosis before, if she has had any possible contacts with infected people, whether there are cases of tuberculosis or concomitant diseases in her family as all of these can be very useful for the verification of tuberculosis.

When active pulmonary tuberculosis is suspected an X-ray examination is necessary. When the chest is in frontal projection, the X-ray exposure of the fetus is 10 times lower than that of its mother (with compulsory use of a protective apron). Examination of the cough expectoration for the presence of tubercular mycobacteria is one of the easiest, most effective and informative diagnostic methods.

Chemotherapy, which destroys the tubercle bacillus that spread in the organism, plays a leading role in the variety of methods for tuberculosis treatment. By reducing the population of bacteria, chemotherapy supports the healing process, the dispersion of inflammatory changes, the closing of caverns, the encapsulation of the remaining loci as well as preventing the development of sclerosis. When the patient suffers from tuberculosis, the healing processes are very slow; the first stage of the recovery process of mycobacteria ceases and only after some months, in the case of a successful treatment of tuberculosis, does the healing process finish.

The necessary treatment of pregnant women who suffer from tuberculosis must start as soon as the diagnosis has been made. Chemotherapy implies taking antibacterial medicines (isoniaside, rifampicin, pyrazinamide, ethambutol, ethionamide and etc.) in different combinations. The choice of this or that combination depends on the stage of the disease as well as on any undesirable reactions to the medicines prescribed.

The treatment of tuberculosis (if there are indications) continues during the entire pregnancy and lactation period. In particular, patients with tuberculosis that has been diagnosed during the pregnancy are in need of treatment. When there is a systematic treatment, up to the moment of delivery and in the puerperal period, positive clinicoradiologic dynamics can be observed regarding the specific inflammation (stoppage of bacterioexcretion, closing of caverns, dispersion of loci, infiltration and exudate). Patients who reject treatment during the process of pregnancy suffer from an advancement of the illness.

Transplacental infection of the fetus with tuberculosis almost never occurs, but the baby can be infected from the mother in the puerperal period. There is also a possibility of contamination during delivery, but this is a rare occurrence.. God truly protects the innocent!

Permission to breast feed must be given by a joint resolution of an obstetrician, a pediatrician, and a specialist of tuberculosis taking into account the state of a woman and the form and the stage of the tubercular process. Overall precautionary measures must be taken (a nonbacterial mask of 5-6 layers covering the nose and the mouth, a kerchief covering the head and thoroughly washed hands).

A bacteriological study of the breast milk of women who suffer from tuberculosis shows that typical mycobacteria rarely vegetates (no more than 0.33%). Human milk has the ability to suppress the development of the mycobacteria of tuberculosis. This must be connected with the rich spectrum of ferments, immunoglobulins, cellular elements, macro-phages, the complement system, interferon and other factors of nonspecific protection which human milk contains.

The contraindications for nursing are as follows: tuberculosis of the lactiferous gland, an acute form of tuberculosis, active pulmonary tuberculosis with bacterioexcretion, active tuberculosis of any organs detected at the end of the pregnancy or after the delivery, and recrudescence of tuberculosis during the pregnancy. Children born to such mothers are immediately isolated after their birth and bottle fed, they are vaccinated and stay in the hospital for 6 weeks if possible (the minimum period for compulsory postvaccinal isolation).

Thus the tubercular process in the lungs, especially an active one, will have a negative influence on pregnancy and delivery. Babies born to such mothers belong to a high-risk group as far as the possibility of neonatal pathology and antenatal death of the fetus are regarded. Women with pulmonary tuberculosis must undergo regular consultations with both an obstetrician-gynecologist and a phthisiologist from the very early stages of their pregnancy. They must also receive special treatment until all the signs of active tuberculosis have been eliminated.

A wanted child brings happiness to a family; it is a gift from God. And, of course, every woman who wants to give birth wants to bring up a healthy and beautiful child. Unfortunately, the health index of the modern generation of women at child-bearing age is not very high (there are many chronic diseases, spiritual poverty, with a high vulnerability to different infections due to a variety of reasons). Due to this reason, medical interference in what is a natural process has become more frequent recently. Statistics show that more than 92% of women use different drugs at different stages of pregnancy. The question is to what extent this medication is safe for the future baby. This is a fundamentally important matter to investigate because a pregnant woman taking any chemicals is in essence applying a kind of experiment on her as well as the baby’s health which can have a variety of different consequences.

The problem of medical effects on the development of a fetus has recently become very acute. This is because there are many different medications that are common and easily available nowadays, and they are very often taken without a doctor’s prescription. Unfortunately, the consequences of this fact are not pleasant. Prenatal development is one of the most important and difficult stages in a person’s life. Just in 9 months an ovicell (an egg cell) and a sperm cell form an extremely complex living organism that consists of millions and billions of cells! Moreover, all these cells are combined into tissues, organs and systems that are always interacting. The fetus has a fascinating rate of growth to become a structure with an ever-increasing complexity. In addition, all these processes do not happen chaotically but in a strict order. This order is supplied by two factors: the first is a sound genetic program. It is obtained by the fetus from its parents and the decoding of the genome vividly denotes the existence of Divine Power. The second factor is the state of a maternal organism which supplies everything necessary for the realization of the genetic program and protects the fetus from the negative influence of the environment. In this way the failure of one of the mentioned factors can lead to different deviations and to the disturbance of the development, including the formation of congenital malformations of the fetus and even prenatal death.

The history of medicine shows that medications can be the most harmful etiological factor in relation to the fetus. Today, there are many examples proving this fact. One of the best-known is the thalidomide tragedy which happened in Europe in the 1950-60s. As a result of taking a poorly studied medicine (a light tranquilizer) the children of hundreds (!) of women were born with serious physical defects. Unfortunately, the list of drugs that causes fetal malformation is not short. Nowadays doctors are aware of syndromes caused by hydantoin, warfarin, aminopterin, and many other medications. Each of these has a specific effect on the fetus (mostly leading to serious abnormalities) when taken by a pregnant woman. In the past, people believed that such children were marked by Satan. But nowadays we say that it is the unpredictable effect of the medicine on the realization of the Creator’s program. Medical interference can lead to a disruption in the rate of development and affect the order of differentiation in the tissues and organs of fetus. Moreover, drugs can interrupt the blood circulation in the placenta, change the metabolic process between the fetus and the mother, causing a retardation of intrauterine growth or premature labor, or they can be the reason for a falloff in the health of the child in the first years of life.

The influence of drugs on the fetus depends on different factors, such as the term of gestation at which the drug is administered, the dosage, and the length of time that the medicine is taken, as well as the ways that the drug is excreted, the health of the mother and her inherited sensitivity to medicine, and, of course, the properties of the medicine itself. There are many drugs whose influence on the fetus have not yet been examined, as such research is very difficult, expensive, or in many cases simply impossible. If we understand this, we can see that the outlook for scientific interference in God’s creation of human beings is not good.

You may wonder why the wide-spread usage of medication by pregnant women throughout the whole world has not lead to a continuous increase in congenital malformations if it is really this dangerous. Thanks to a happy concourse of circumstances, this process has not become too wide-spread, as there are many factors that allow the fetus to “escape” medical danger. For example, there may be an inherited insensitivity on the part of the fetus to the influence of different medications, the placenta has its own inherent protective function, the medication may be taken in a small dosage, the developmental stage of the fetus may be at a “non-critical” period, plus many other factors. Doubtless, although this has not been proven, is the fact that the mother has a sincere faith in God and believes in God’s protection of her and her child, which has a positive influence on the development of the fetus.

The initial clustering of embryonic cells and the formation of all the fetus’ organs and systems occur in the first trimester of pregnancy. It is particularly in this period that the fetus is very sensitive to the influence of different factors, including different drugs.

It is quite common that the results of the use of some teratogens¹ by pregnant women, which can have fatal effects, can simply go unnoticed in some cases, resulting in the death of the fetus during the first two weeks of development. In this case, the woman does not even know that she is pregnant. Such cases are not rare (according to some researchers, up to 70% of all pregnancies finish in the early death of the fetus).

What should a pregnant woman do if she is ill or feeling unwell? How can she effectively help herself and minimize the risk of any medications on her baby at the same time? It is never a good idea to self-medicate if you are pregnant, particularly in the case of little-known or untested medications. In any case, it is better to consult an experienced doctor or pharmacist. If for some reason this is impossible, please read the prospectus which is to be found with the medicine carefully. Which dangers the medicine can cause are probably mentioned on the prospectus, and it may be written that the drug should not be used if pregnant. If a drug has been used while being unaware of pregnancy (for example, during the first 2 weeks) then immediately consult a specialist about any possible negative effects there might be for the fetus as soon as you found out that your are pregnant. Going to see your doctor early will allow you the necessary time to avoid any dangers and allow you to arrive at a decision about this pregnancy. If the medicine has been prescribed by a doctor then be sure to ask about possible unwanted side effects for the fetus. Don’t hesitate to ask such questions. If it seems to you that your doctor’s attitude to this question is not serious enough (unfortunately, this happens quite often) then consult a competent specialist (a geneticist or a clinical pharmacist).

If you are just planning your pregnancy, then try to predict all the negative factors beforehand. If you have some chronic diseases which may become acute during the pregnancy, or if you have an allergic predisposition or high sensitivity to acute respiratory diseases, then you should consult a doctor. Preventive methods which have been worked out especially for you minimize the risk of the illness and the risk of using drugs that are potentially harmful to the fetus.

During early stages of ontogenesis the fetus has almost no adaptation mechanisms or specific reactions in its response to the influence of pathogenic agents. Only with time will the fetus’ main organs and systems become mature and the functions of the placenta fully form the morphological and functional backgrounds of the response characteristics peculiar to a new-born baby. We usually say that everything happens according to God’s Will but He has created us for a full, vivid, and creative life. And He wants us to understand and be attentive to the miracle that happens during pregnancy.

Note

1. Agents such as drugs, chemicals and infections that can cause birth defects when a mother is exposed to them during pregnancy.

Nephrology is the study of the kidneys, the essential organ of excretion, and elements related to it. If due observation and research are thoroughly carried out on every part of the human metropolis, when the integrated hierarchical mechanisms are analyzed, it can be seen that numerous events are constantly taking place; these can open new doors to various sciences and offer us new horizons of reflection on the Divine Wisdom. In this way, these events are an interpretation of the saying “If all the seas were to be made up of ink, and all the trees were pens, they would still not be able to write down the knowledge of God,” which points to the existence of an Omnipotent Being with infinite knowledge.

One of these constant activities in our body is the excretion system which works like a well-regulated clock. In the body of a healthy adult, the bladder, after an accumulation of urine that has been filtered through the kidneys, resembles a balloon that has been inflated. The bladder enlarges according with the amount of urine that has been filtered by the kidneys. The autonomous nervous system has a significant role in the wonderful functioning of this urine storage mechanism. If we assume that an average adult urinates 5-6 times a day, we can say that the average time adults spend for urination is about 5 minutes daily. The autonomous system of a baby however, is not properly developed and has a very limited capacity of urine storage. Therefore, the bladder of a baby is frequently emptied. As for newborn babies, the number of times that they empty their bladder can be as much as 20-25 times a day. In this way, both the urine that comes from the kidneys flows to the bladder freely, and the urination channels are automatically cleaned.

In order to allow the urine flowing from the kidneys to the bladder to pass freely through the small tubes that measure between 3-7 mm (the urethra) the inner pressure in the bladder needs to be kept at low levels. This is realized in the body of a baby by the frequent emptying of the bladder, until the autonomous nervous system has properly developed. After the sixth month, the autonomous nervous system develops, the urine storing capacity of the bladder increases, and the number of urination times decreases. As the child grows, the ability to store urine and to excrete it at the proper time and place is completed in a gradual process. Being only one of the hundreds of wonders in the human metropolis, this balance is maintained as a clear reflection of Divine Mercy.

Cooperation in the urinary tract

There is a fascinating cooperation between the departments of this metropolis. The urine that is excreted by the kidneys does an excellent job of cleaning all along the urinary tract, like a river cleaning the stones over which it passes. This cleaning includes not only any microorganisms, but also any gravel which might form in the urination channels. Research has proved that when bacteria are injected into the bladders of healthy people no infection is developed in the urinary tract, since the pressure of their urine excretion drives the bacteria away. The protection of the kidneys by both the expansion of the flexible bladder wall and the decrease in the pressure inside the bladder is a good example of the cooperation between the kidneys and the bladder. If the pressure was not able to be decreased by such flexibility, the kidneys could not function under the resulting high pressure. The smooth functioning of the kidneys is maintained through urine excretion in suitable amounts and at a suitable pressure. Taking all this for granted, one usually comes to realize what a blessing the excretion system is only when there is a problem.

The urination of a baby in the womb

The placenta has the duty of being the main regulator of the feeding and excretion systems of a fetus. The kidneys of a fetus also play significant roles. For instance, they balance acidity through liquid electrolytes, carry out the functions of hormone production, and growth. From the fourth month on, the fetus begins to produce urine and the bladder is filled and emptied every 30-60 minutes. The urine inside the bladder is emptied into the amniotic fluid which surrounds the fetus like a protective pad. The duty of the amniotic fluid includes protecting the fetus against the changes in the mother’s body temperature, providing space for normal development, providing suitable conditions for food and oxygen supply, and protecting the baby against any possible blows that the mother’s belly might be exposed to. The amniotic fluid in which a baby is placed is a liquid similar to urine, and it is produced for the comfort of this new guest to our world.

The formation of urine

The blood, which is charged with transmitting nutrients and oxygen even to the remotest parts of the body, brings the toxic disposal our body has produced due to various causes on its way back to the kidneys. The blood, which bears the responsibility of maintaining the health of metropolis of the body, is continuously filtered when it reaches the kidneys. In the kidneys, the waste material is so delicately separated that it as if the kidneys know “which substance is needed in what amounts,” without meticulous calculation and infinite knowledge. Artificial kidneys supported by latest technology (like modern devices of dialysis) are never a substitute for a real kidney. A healthy kidney, which is made to serve under the veil of causes created by the Owner of infinite knowledge and power, does its duty with divine guidance. It sends what is to be disposed of to the bladder in the form of urine.

The substances urine contains are used when diagnosing illnesses, for they possess different qualities. The color, smell, and density of the urine and the substances it contains give us various clues about the health of that person. Deviations in the sensitive balance established in the excretion system are considered to be a sign of something gone wrong in the human metropolis. In other words, a urine analysis is an important indication of health, for many factors, such as our lifestyle, our eating habits, disease, and the medicines we use can effect changes on the consistency and composition of the urine (figure 1-3). The urine of a healthy person is yellow and clear. This color is derived from the urochrome pigment along with urobilin and uroerythrin. Colorless urine can be seen if there has been recent fluid consumption, or the use of diuretics, or disorders such as different types of diabetes (diabetes mellitus, diabetes insipitus, etc). The color of urine can fluctuate between yellow and clear within the day (for example, 1-2 hours after a meal it can be clear, whereas it can turn to dark orange due when one has been making heavy effort). Beetroot, artificial colorings and some drugs can turn the urine red. When the complaints of a patient are taken together with a medical examination and lab analyses, urine samples which are colored red-brown, blue-grey, milky-white or which are cloudy may all be symptoms of disease.

As we learn new things about urine we will hopefully attain a deeper comprehension of the infinite divine blessings that have been bestowed upon us, offering thanks to our Creator from new perspectives. 

There are many reasons why a developing baby may have congenital problems (Moore, 1989, p.lO8). Exposure to infections and certain drugs (most commonly, alcohol), chromosomal abnormalities and inherited congenital conditions have all been shown to disrupt normal fetal development. In this article we will concentrate on the diagnosis of chromosomal and genetic disorders during pregnancy.

PNT procedures and their interpretation can be extremely intimidating for parents. It is therefore important that tests are done only after a full explanation of the procedures involved and their possible consequences. The aim of PNT is to inform and prepare parents for the birth of an affected infant, so that they can choose between the possible courses of action (Aksoy, 1996). The possibilities will include: (1) in utero treatment; (2) delivery at a special centre for immediate postnatal treatment; and 3) termination of an affected fetus, i.e. abortion.

Over the years, professional standards and laws have evolved which influence the clinical application of PNT and help to tackle many of the complex ethical issues involved. There is little doubt that relatively non-invasive techniques whose primary purpose is to diagnose treatable disorders and then treat them, before or after birth, would be warmly welcomed by all, especially the parents. The fact is, however, that in practice PNT is generally being used to diagnose abnormality and then terminate the life of the unborn babies. The reality is that prenatal diagnosis rarely leads to fetal therapy

In what follows, we will try to explain the range of prenatal tests available and indications for their appropriate use. We will consider some of the technological advances on the horizon in this field of medicine, as well as some of the ethical dilemmas that arise.

Prenatal Diagnostic Tests

Prenatal diagnostic tests can be divided into two types, invasive and non-invasive. Non-invasive tests simply involve a blood sample taken from the pregnant woman or an ultrasound scan. Invasive tests on the other hand are more complicated and involve obtaining a sample of cells or tissue from the developing foetus, either by amniocentesis or chorionic villus biopsy. The samples obtained by invasive tests can be used, specifically to assess the fetal chromosome pattern, to determine if the fetus has a particular genetic mutation, or for a whole range of biochemical assays.

Maternal Blood Sampling. Between 15 and 19 weeks of pregnancy, the pregnant woman attending ante-natal clinic will be offered a blood test. The blood sample will be analysed to assess the level of three proteins, b human chorionic gonadotropin (b HCG), oestriol and a -fetoprotein (a FR). The three levels in combination with the mother’s age can be used to estimate the risk of the baby being affected by a chromosomal problem, especially Down’s syndrome (Wald and Cuckle, 1992, pS63). If the test result indicates a high level of risk, the mother will be offered further tests to assess the status of her baby.

Ultrasound Scan. Ultrasound uses high frequency waves to form a picture as the waves are reflected back by tissues of different density. The developing fetus grows in a liquid filled sac (amnion). As fluid shows black on the scan, this provides a good contrast with the fetal parts allowing high resolution images. Early in the first trimester an ultrasound scan can be used assess the viability of a fetus and to estimate its stage of development. Most women will be offered a formal high resolution scan at between 16 and 19 weeks (Sutton, 1990, pp.20- 1). The images from the scan will be the first time the expectant mothers see the baby. For many, this is a happy event; for the others it could be a very sad event if the scan indicates an abnormality.

Amniocentesis. In this test, done between 15 and 20 weeks of pregnancy (Cohen, 1990, pp.19- 20), a very fine needle is passed through the abdomen under ultrasound guidance, avoiding the fetus, and a sample of amniotic fluid containing fetal cells is withdrawn. The sample is cultured to grow more cells so that the chromosome pattern of the cells can be examined or DNA extracted for genetic analysis. This process can take three weeks, a period of considerable anxiety for the parents. There is also a small risk of miscarriage occurring after an amniocentesis.

Chorionic Villus Sampling. In this test, done in the same way as than amniocentesis but five weeks earlier, a sample of tissue is taken from the developing placental tissue. Both chromosomal and genetic analysis can be performed on this tissue, and the results are available quicker and at an earlier stage of the pregnancy than with amniocentesis. However, there is a higher miscarriage rate following chorionic villus sampling than amniocentesis (Boss, 1994).

Fetal Blood Sampling. Occasionally, when there is concern that a pregnant woman has been exposed to an infection early in her pregnancy, a sample of blood will be taken from the umbilical cord with a very fine needle under ultrasound guidance. This sample is used to assess if the fetus has become infected and at high risk of development problems following the maternal exposure.

New Advances

Advances in prenatal diagnosis have followed rapidly from technological improvements in ultrasound equipment, refinement and experience of current techniques, and the development of new tests. The aim of research in this area is to provide the earliest possible accurate information about the health of the developing baby, and to do so in the way safest for the expectant mothers and their babies. If the information is reassuring, the couple can enjoy the remainder of the pregnancy in the knowledge that everything will progress normally. However, if the result are unfavourable and an abnormality is diagnosed, earlier decisions about potential treatment or termination are possible and so may be less traumatic for those involved.

Fluorescent in situ Hybridisation (FISH). FISH is a technique which uses a specific DNA sequence as a probe to recognise its complementary sequence on a chromosome. The probe has a fluorescent tag attached which lights up when it is attached to the recognised chromosome segment. Recently FISH has been applied to analysis of amniocentesis samples to assess if an extra chromosome 21 is present or not in the cells. Because the amniocentesis cells do not require culturing for this technique the test results can potentially be available sooner than following standard amniocentesis.

Fetal Blood Cells in the Maternal Circulation. At about 6 weeks fetal blood cells can be found in a blood sample taken from a pregnant woman. These cells exists in very small numbers. Recent work has extracted and purified these cells to allow assessment of the fetal chromosome pattern and to determine if the fetus has a specific genetic mutation. Although this technique is very new it has the potential to make the currently used invasive techniques obsolete and will allow very early diagnosis.

Preimplantation Diagnosis. This procedure involves the use of technology developed with in vitro fertilisation (IVF). An oocyte is removed from the woman and brought into contact with spermatozoa from her partner under controlled conditions. One of the spermatozoa effects fertilisation to form a zygote. Following three stages of cell division (this eight-cell stage is termed, the blastocyst), one cell can be removed and used for analysis (Aksoy, 1997a). The DNA sequence of this cell can be determined to identify the presence or absence of a gene mutation that has caused illness in one of the parents. If the cell does not contain the mutation, the blastocyst can be implanted in the womans uterus (womb) to develop into a fetus which is unaffected by the condition that has affected other family members.

Human Genome Project. The aim of the Human Genome Project is to have identified the entire human DNA sequence (genome) by 2005. The extra information generated about specific genes and their association with specific disorders has the potential to expand dramatically the number of genetic tests available to couples with a family history of a genetic condition.

Ethical Issues

It is important to understand the purpose of prenatal diagnosis. It is done to provide parents with information about the health and development of their baby, not to provide them with a reason to have a termination of pregnancy. There are 180,000 terminations performed each year in the United Kingdom, of these 5000 are because of fetal abnormalities diagnosed by prenatal tests. Abortion is a serious problem itself in all regions of the world, developed and developing, and we discussed it in an earlier issue of this magazine (Aksoy 1997b). When prenatal tests reveal that a baby has health problems, parents face a number of difficult questions. Is any treatment available? What are the baby’s chances of survival? What would be the baby’s quality of life if he or she did survive? Some illnesses can be treated during pregnancy and after delivery. One of the main aims of fetal medicine is to develop therapies to treat fetuses and improve the survival. However, some conditions are fatal despite all treatment. In these circumstances couples sometimes take the extremely difficult decision to have a termination of pregnancy

For religious, moral or other reasons many couples opt not to have any tests performed during pregnancy. They feel that even if the results of any test indicated that their baby was affected by a serious condition they should and would continue with the pregnancy. It is important in each situation that the parents’ decisions are respected and supported. The parents need to be given appropriate guidance and counselling rather than be met with disapproval.

In some countries prenatal testing has been extensively used to determine the sex of the baby at an early stage, with the intention of ensuring that only male babies are born (Kusum, 1993). In the United Kingdom, as in many other places, prenatal diagnosis to determine fetal sex is deemed morally unacceptable. It is important that new advances in medicine are paralleled by an informed ethical debate. Prenatal tests should reflect what is appropriate within a society rather than just allowing what is technically feasible. A number of regulatory groups have been formed, including the Human Fertilisation and Embryology Authority (HFEA), to monitor and regulate new advances in this area.

In sum: prenatal diagnosis is a rapidly expanding area of medicine. New techniques are constantly being developed which are aimed at allowing earlier diagnosis, less invasive methods and, ultimately, treatment. It is important that developments are monitored and regulated to ensure that the techniques available are applied within an ethical framework.

REFERENCES

Aksoy, S. (1996) ‘Prenatal Testing: An Ethical Perspective’, The New Journal of Medicine, 13:2, pp.12-14.

Aksoy, S. (1997) ‘Moral Controversies on Preimplantation Genetic Testing’, paper presented at UNESCO Asian Bioetlncs Conference, Kobc-Japan, November 1997.

Aksoy, S. (1997), ‘Abortion: Mercy or Murder?’, The Fountain, 2:17 pp.32-5.

Atkins, A.F.J. and Hey, EN. (1991) ‘The Northern Regional Fetal Abnormality Survey’, in Drife, jO. and Donnai, D.(cds) Antenatal Diagnosis of Fetal Abnormalities, Springer-Verlag Ltd., London.

Boss, J.A. (1994) ‘First Trimester Prenatal Diagnosis: Earlier is not Necessarily Better’, JME, 20 pp.l46-5l. )

Cohen, L.G. (1990 Before Theýr Týme at Risk, American Association on Mental Retardation, Washington DC.

Kusum (1993) ‘The Use of Pre-natal Diagnostic Techniques for Sex Selection: The Indian Scene’, Bioethics, 7: 2/3 pp,149-65.

Moore, K.L. (1989) Before We Are Born: Basic Embryology and Birth Defects, WB. Saunders Comp., Philadelphia.

Sutton, A. (1990) Prenatal Diagnosis: Confronting the Ethical Issues, The Linacre Centre, London.

Wald, NJ. and Cuckle, H.S. (1992) ‘Biochemical Screening’, in Brock, D.J.H., Rodeck, C.H. and Ferguson-Smith, MA.(eds) Prenatal Diagnosis and Screening, Churchill Livingstone, Edinburgh.

Two principal kinds of indications have been defined for ‘termination of pregnancy’. The first, called ‘medical indications’, are: 1) That continuance of the pregnancy would put the life of the pregnant woman at risk, or put her physical or mental health or that of any existing children, at greater risk than if the pregnancy were terminated; 2) There is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously disabled.

The second kind of indications, the so-called ‘social indications’, are more complex and vary between cultures and epochs. Examples are: pregnancies resulting from extra-marital relations, from rape or incest, unwanted or unplanned pregnancies, pregnancies at too young or too old an age, expecting a baby of the ‘wrong’ sex – the information being provided by recent medical technology. We may note that it is primarily ‘social reasons’ of this sort that lead parents to seek abortion. The actual termination of pregnancies has been carried out either by health professionals or by some unqualified person, sometimes even by the pregnant woman herself.

Abortion has always been discussed by doctors, philosophers, lawyers and theologians from different perspectives. Here I shall go over some of these arguments, and try to come to a conclusion about the ethics of abortion. Actually, as Dunstan observes (1978, p.7S), we shall be considering the ethics of a practice already very widespread, and likely to become more so, in all regions of the world, developed and developing. At least fifty million abortions are carried out annually world-wide, and, for example in France and Japan, half of all pregnancies end in abortion (E.B., 1982, vol.2, plO69). One and half million abortions are performed in USA each year, one-third of them on teenagers between 12 and 17 years old (Poots & Diggory, 1983, p.287). Therefore, it is rather difficult to discuss the moral acceptability of something which has already been so widely accepted. A 1991 Harris poll showed 81% of adults in England in favour of a woman’s right to choose’ to have an abortion in the first three months of pregnancy (Cole, 1992, p.2) Mason (p.113) states that: ‘The significant feature is not so much the total number of abortions but, rather, the steady escalation in numbers over the years. The figures indicate that there must be an increasing public acceptance of abortion as a natural way of life’. Dunstan (1974, p.87) commenting on this fact writes: ‘Abortion is now being more widely legalized and practised because that is what people want – an indication for medical intervention for the destruction of life unknown in our ethics before’.

Writers on the abortion issue have concentrated most on two matters: first, the ‘rights’ of the fetus and the mother, in particularly the property right of the woman on her body; second, the question of the ‘personhood’ of the prenate (i.e. the unborn child). Judith Jarvis Thomson is one of the pioneers among writers who approach the issue from the perspective of the ‘rights’ of the fetus and the mother. She has no difficulty recognizing the ‘personhood’ of the fetus. She says every person has a right to life, so the fetus has a right to life. However, she believes that the mother has a right to decide what shall happen in and to her body (Dunstan, 1974, p.203).

The ‘personhood’ or legal, moral status of the prenate is a very involved legal, philosophical question which I have addressed elsewhere (see Aksoy, 1996).

People who have defined views on the issue generally take one of three positions: 1) abortion is always wrong and must never be performed at any time for any reason; 2) abortion may be carried out at any time for any reason; and 3) abortion should only be allowed up to a certain stage of pregnancy, after which it should not be allowed except under certain special conditions.

The people in the first group are not very many. They follow the Roman Catholic teaching. which maintains:

‘We cannot be absolutely certain when animation takes place, or when the conceptus or the fetus is a human person; but it may well be precisely at the moment of conception. This being so, it would be seriously wrong to destroy the fertilized ovum even then, because one might be killing a human person’ (Mahoney, 1984, p.69). According to this strict line, abortion is impermissible even when the mother’s life is in danger or the pregnancy is the result of an indecent event, like rape or incest.

The second position is held by those who advance the ‘personhood’ argument. Harris (1990) is one of those writers who suggest that: ‘A person is a creature capable of valuing its own existence. And non-persons or potential persons cannot be wronged in this way because death does not deprive them of anything they can value. If they cannot wish to live, they cannot have that wish frustrated by being killed.’

The third position which may be defined as ‘moderate’ maintains that abortion should not be allowed after a certain stage of pregnancy and only if particular circumstances justify it. For instance, it is a very common view that abortion should be permitted in order to save the mother’s life. Some people believe that abortion is also morally permissible when pregnancy is the result of rape or incest, and when a severe fetal abnormality has been diagnosed. There are also writers who suggest that termination of pregnancy should be permissible if the potential mother is too young.

One exceptional circumstance which justifies abortion, on this view, is the diagnosis of severe abnormalities in the fetus. The argument is that it is wrong to bring avoidable suffering into the world and we are morally obliged to terminate the life of severely handicapped fetuses. One writer has explained that it is a misconception to regard this justification as ‘on behalf of’ the fetus (Mason, p.106). In reality the suffering being avoided is being avoided on behalf of the mother and other potential carers. We need to be clear about whether the termination due to disability is being considered in the supposed interest of the unborn child – that it is ‘better’ for that child not to live at all then to live with a foreseeable handicap – or in the ‘interest’ of those who would have the care and burden of that child’s life, including its suffering and pain (Dunstan, 1974, p.84). Williams (1987, p.297) is explicit that abortion on such grounds relates to the welfare of the parents, whose life may be blighted by having to rear a grossly defective child, with perhaps in the background such secondary considerations as costs to the public purse.

For all the debate, the suggestions and counter-suggestions and alternatives, it seems likely that abortion will remain the dilemma it has been for centuries. However, we must bear in mind the fundamental fact that abortion is termination of the life of a living creature. We must approach ending the life of a prenate as cautiously and sensitively as we would ending the life of any other living creature, and we should not end the life of any living being unnecessarily and without very good reason. On the question of the ‘personhood of the prenate, we can be sure only that we will never be sure about it, unless we discover some sort of ‘Turnasol Paper’ like indicator to decide the matter. As the moral status of the prenate is not something material, we need to refer to the authority of metaphysical and transcendental knowledge, and the religions are among these sources. As I have tried to show elsewhere (Aksoy, 1966), not only all religions but also many philosophers from Aristotle onwards have declared that a human being consists of body and soul. In the religious perspective, the earthly existence of a person ends when the soul departs the body. At the other end of this ‘silent journey’ (Aksoy, 1995), the human person begins when the soul joins the body. We do not know very much about the when and how of the soul’s departure, but there are clear statements in the Qur’an about the time and the process of ensoulment. There is also some information related to this in the Talmud, and some detailed explanation in Aquinas’s works.

All the scientific (anatomical and physiological) and metaphysical (religious and spiritual) arguments tell us that, if there is a time between conception and birth at which the prenate ‘enters humanity’, ‘becomes a person’, ‘becomes morally important’ or however we call it, it is most likely to be at some time in the eighth week (Aksoy, n.d.). In sum: even at the very beginning of its existence we owe respect to the unborn, but after eight weeks time to terminate its life should be defined as morally unacceptable.

It may be asked, if the prenate ‘becomes a real person’ after eight weeks, then how do we regard embryos? Donceel (1984, p. 15) suggests that, ‘Although a prehuman embryo cannot demand from us the absolute respect which we owe to the human person, it deserves a very great consideration, because it is a living being, endowed with a human finality, on its way to homonization. Therefore it seems to me that only very serious reasons should allow us to terminate its existence.’ Apparently, it is one thing to say that an entity lacks the dignity of being a person in the strict sense of ‘person’, and another thing to say that it does not have any value. The embryo may, in this respect, be regarded as similar to a human corpse. At the moment in question neither of them are existing human persons. The embryo will be one, as the dead body once was. And we owe respect to both. If we mutilate and disgrace a human corpse it is something immoral and shameful, even though not illegal. Similarly, if we destroy or terminate the life of an embryo, it is not an attack on an individual human being but still inhumane and undignified. However, sometimes it might be necessary to undertake an undignified and inhumane action to undo the signs of another ‘more’ undignified and inhumane action, like rape.

The way Dunstan has expressed the dilemma of abortion (1974, p. 85-6) gives a most helpful direction to our moral thinking on it; ‘We should pass from the question, what harm are we doing to the fetus by destroying it, to the question, what harm are we doing to ourselves, to humanity, when we do so?”

References

• AKSOY, S. (1995) ‘The Silent Journey’, The Fountain, 2 (12), PP. 42-4.
• (1996) ‘What makes a person?’, The Fountain, 14, (n.d.) ‘When does a human individual begin to be? A philosophical, embryological and theological perspective’. (Unpublished paper)
• COLE, L. (1992) My Baby, My Body, My Choice, Lloyd Cole Books,Maidenhead.
• DONCEEL, J.F. (1984) ‘A liberal Catholic’s view’ in Joel Feinberg (ed.)
• The Problem of Abortion, Wodsworth, Belmont CA.
• DUNSTAN, G.R. (1974) The Artifice of Ethics, SCM Press Ltd, London.
• E.B. (1982) Encyclopedia Britannica, 15th edn, Chicago, vol.2, p.1069.
• HARRIS, 1. (1990) ‘Wrongful birth’ in David R. Bromham, Maureen E.
• Dalton & Jennifer C. Jackson (eds) Philosophical Ethics in Reproductive Medicine, Manchester University Press.
• MAHONEY, J. (1984) Bio-ethics and Belief Sheed & Ward Ltd. London.
• MASON, J.K.. (1990) Medicolegal Aspects of Reproduction and Parenthood, Dartmounth, Hants.
• POTTS, M. & DIGGORY, P. (1983) Textbook of Contraceptive Practice, Cambridge University Press, New York.
• PRICE, D.P. (1988) ‘Selective reduction and feticide: the parameters of abortion’, Criminal Law Review, PP. 199-210.
• REISER, S.J., DYKE A.J. & CURRAN, W.J. (1977) (eds) Ethics in Medicine: Historical Perspective and Current Concerns, MIT Press, Cambridge Mass.
• WILLIAMS, G. (1987) Textbook of Criminal Law, Stevens, London.