FETAL PAIN

30 Years of Life-Saving Science

8 weeks

Unborn and Newborn PainCirca 1978

General belief – Unborn and Newborn did not “Feel” pain

No analgesia for newborn circumcisionNo anesthesia for newborn or neonatal surgeryMain method of surgical anesthesia:

Adhesive Tape

Fetal PainAnd Abortion:The Medical

Evidence By:

Vincent J. Collins, MDSteven R. Zielinski, MD

Thomas J. Marzen, Esq. AMERICANS

UNITED FOR LIFELegal Defense Fund

Law and Medicine Series

1984

Pain: an unpleasant sensory

and emotional experience associated with actual or potential tissue damage

or described in terms of such damage.

Animal Pain – Perception and AlleviationKitchell, R.L., Erickson, H.H., eds.Bethesda, MD.:American Physiological Soc., 1983

Essential Elements

Structure

Function

Aversive Response toA Noxious Stimulus

Nociceptors

Brain Structures

Nerve Pathways

STRUCTURE:WHAT YOU NEED:

Nociceptors Look like small bushes or the frayed end of a rope

Respond to pressure, heat,or cold

Nerve Pathways

Nerves gather into TRACTS That enter Dorsal Hornof the Spinal Cord and go up

Brain Structures

THALAMUS

Central processing center for sensory information

FUNCTION

ELECTRICAL ACTIVITY

Present at 40 days

A recognizable EEG at 19-20 weeks

NEUROTRANSMITTERS

HORMONES

Substance P, Glutamate, CGRP, VIP

Cortisol, Norepinephrine

AVERSIVE RESPONSE TO A NOXIOUS STIMULUS

Full body aversive responses to painful stimuli can be easily witnessed on ultrasound at 13-1/2 weeks gestation…

–Collins, Marzen & Zielinski, 1984

From 16 weeks gestation, the typical change in brain circulation is seen in the fetal brain in response to a painful stimulus.

Wladimiroff JW et. al. Obstet Gynecol 1987;69:705-9

Hormonal stress responses to painful stimuli as early as 16 weeks gestational age, possibly sooner.

NOT JUST PRESENCE, BUT CHANGE

Cardiovascular responses such as increases in blood pressure and heart rate, abnormal heart rhythms, or poor cardiac output.

Anesthesia blunts these responses

EXCUSESCan't speak, can't feel pain.

ReflexNo myelin - no pain.

No Cortex

Minimal or incomplete response

No memory

Decorticate and Decerebrate Rigidity

Stressed-out, or in (utero)? http://www.med.upenn.edu/ins/Journal%20Club/08-09/Fall%202008/Tallie%20Z.%20Baram/tins02.pdf

Abstract…recent evidence that stressful stimuli have a significant impact on neonatal (rat)

and prenatal (human) hippocampal function and integrity…

Early-life stress could constitute a ‘double-edged sword’: mild stress might promote hippocampal-dependent cognitive function, whereas severe stress might impair neuronal function and survival, both immediately and in the long-term. Importantly, these CRH-mediated processes could be targets of preventive and interventional strategies.

RELIGION

DARWIN

FETALPAIN

At 20 weeks, the fetal brain has the full complement of neurons present in adulthood.

Lagercrantz H et. al. Lakartidningen 1991;88:1880-85

By 19-20 weeks, the earliest electroencephalogram(EEG) recordings are possible.

Flower MJ. J Med Philos 1985;10:237-251

From 20 weeks and beyond, the fetus is fully capable of experiencing pain. Expert testimony from Dr. Robert White,

pediatric neurosurgeon, before U.S. Congress, June 15, 1995

CONSCIOUSNESS

A simple definition of consciousness is sensory awareness of the body, the self, and the world.

REMEMBRANCE

Dr. Vincent Collins

Thomas J. Marzen, Esq.

http://www.anaesthetist.com/icu/pain/Findex.htm#pain3.htm

Probably the most significant discovery ever in the field of pain has been the gene c-fos.

The cellular analogue of a viral oncogene, this rather special gene and its cellular product, the protein called Fos seem crucial to the profound central nervous system changes that occur when an animal (or man) feels pain.

Central nervous system c-fos expression correlates extremely well with painful stimulation. Generically, Fos is one of the inducible transcription factors (ITFs) that controls mammalian gene expression.

We now have a molecular marker for pain! Even more important, we know that because c-fos is a proto-oncogene - that is, it can promote vast intracellular changes including cellular restructuring and proliferation

- it is almost certainly involved in the long-term neurological consequences of noxious stimulation.

FOS has been found in the fetal bones at least as early as the 16th week of gestation.