Aspectos bioéticos del aborto terapéutico en niñas y adolescentes menores de 15 años

El objetivo de este trabajo es identificar y discutir los argumentos científicos y bioéticos que justifiquen el aborto terapéutico en niñas y adolescentes menores de 15 años. Para ello se hizo búsqueda bibliográfica no sistemática en fuentes nacionales y extranjeras en las diferentes indexadoras. Se encontró que existe suficiente evidencia de carácter científico que identifica al embarazo no intencional en niñas y adolescentes menores de 15 años como una urgencia médica y de alto riesgo por las diferentes complicaciones severas que se pueden dar y argumentos de carácter bioético en favor del aborto terapéutico. En conclusión, las evidencias científicas y los argumentos bioéticos sustentan suficientemente la atención del aborto terapéutico en niñas y adolescentes menores de 15 años.

The objective of this paper is to identify and discuss the scientific and bioethical arguments that justify therapeutic abortion in girls and adolescents under 15 years of age. For this purpose, a non-systematic bibliographic search was made in national and foreign sources in the different indexers. It was found that there is sufficient scientific evidence that identifies unintended pregnancy in girls and adolescents under 15 years of age as a medical emergency and of high risk due to the different severe complications that can occur and bioethical arguments in favor of therapeutic abortion. In conclusion, scientific evidence and bioethical arguments sufficiently support therapeutic abortion care for girls and adolescents under 15 years of age.

Safety of voluntary interruption of pregnancy (VIP) in two healthcare institutions in Medellín, Colombia, in 2019. Historical cohort / Seguridad de la Interrupción Voluntaria del Embarazo (IVE) en dos Instituciones Prestadoras de Salud en Medellín, Colombia, en 2019. Cohorte histórica.

Objectives: To characterize a cohort of women with voluntary interruption of pregnancy (VIP) and to describe intraoperative complications according to the technique used. Materials and Methods: Descriptive study in a historical cohort of women undergoing VIP in two healthcare institutions in Medellín, Colombia, in 2019. Women with pelvic infection and STIs were excluded. Consecutive sampling was used. Sociodemographic, sexual and reproductive health, clinical characteristics of the pregnancy, legal cause of the VIP, characteristics of the care process and complications of the VIP techniques up to post-procedural day 7 were the measured variables. A descriptive analysis was carried out. Results: Overall, 1,520 women were identified as eligible during the study period. Of them, 46 were intervened in other institutions, leaving 1,474 candidates to enter the study. Of them, 30 were excluded because of pelvic or sexually transmitted infections. Ultimately, 1,444 pregnant women were included in the analysis. Risk to the mother's health was the most frequent legal cause in 94.3% of cases. Ninety-nine percent of women received pre-procedural counseling, and 78.4% agreed to use some form of contraception after VIP. Manual vacuum aspiration (MVA) was used in 95.6% of women and dilation and curettage (D&C) in 4.4%. Complications up to postoperative day 7 occurred in 17.56%, and there were no complications in the MVA group; 80% of women attended the follow-up visit on post-VIP day 7. Conclusions: MVA is a safe procedure which was not associated with complications within the first seven post-VIP days in the studied patients. Prospective studies to assess the safety and cost of the different VIP options are required.

Objetivos: caracterizar una cohorte de mujeres con interrupción voluntaria del embarazo (IVE) y describir las complicaciones intraoperatorias según la técnica aplicada. Materiales y métodos: estudio descriptivo, de cohorte histórica en mujeres intervenidas a IVE en dos Instituciones Prestadoras de Salud-IPS en Medellín, Colombia, en el 2019. Se excluyeron aquellas mujeres con infección pélvica, e ITS. Se realizó un muestreo consecutivo, se evaluaron variables sociodemográficas, de salud sexual y reproductiva, características clínicas del embarazo, causa legal de la IVE, características de la atención y las complicaciones hasta los 7 días posteriores al procedimiento de las técnicas de IVE. Finalmente, se hace análisis descriptivo. Resultados: durante el periodo de estudio hubo 1.520 mujeres elegibles de las cuales 46 fueron intervenidas en otras instituciones por lo que quedaron 1.474 candidatas a ingresar al estudio, de estas se excluyeron 30 por presentar infecciones pélvicas o de transmisión sexual, por lo que, finalmente, se analizaron 1.444 mujeres gestantes. Los riesgos para la salud de la mujer fueron la causa legal más frecuente con un 94,3%. El 99% de las mujeres tenían asesoría previa, y el 78,4% aceptó algún método anticonceptivo post-IVE. El 95,6% de las mujeres fueron intervenidas por la técnica de aspiración manual endouterina (AMEU) y al 4,4% se la practicó la técnica de dilatación y curetaje (D&C). En un 17,56% de las pacientes intervenidas con D&C se presentaron complicaciones hasta el séptimo día posoperatorio, no hubo complicaciones en el grupo sometido a AMEU, el 80% de las mujeres asistieron a control el séptimo día post-IVE. Conclusiones: la AMEU es un procedimiento seguro que no generó complicaciones intraoperatorias en el procedimiento hasta los primeros siete días después de la IVE, en las pacientes estudiadas. Se requieren estudios prospectivos que evalúen la seguridad y costos de las diferentes alternativas de IVE.

Seguridad de la Interrupción Voluntaria del Embarazo (IVE) en dos Instituciones Prestadoras de Salud en Medellín, Colombia, en 2019. Cohorte histórica / Safety of voluntary interruption of pregnancy (VIP) in two healthcare institutions in Medellín, Colombia, in 2019. Historical cohort

RESUMEN Objetivos: caracterizar una cohorte de mujeres con interrupción voluntaria del embarazo (IVE) y describir las complicaciones intraoperatorias según la técnica aplicada. Materiales y métodos: estudio descriptivo, de cohorte histórica en mujeres intervenidas a IVE en dos Instituciones Prestadoras de Salud-IPS en Medellín, Colombia, en el 2019. Se excluyeron aquellas mujeres con infección pélvica, e infecciones de transmisión sexual (ITS). Se realizó un muestreo consecutivo, se evaluaron variables sociodemográficas, de salud sexual y reproductiva, características clínicas del embarazo, causa legal de la IVE, características de la atención y las complicaciones hasta los 7 días posteriores al procedimiento de las técnicas de IVE. Finalmente, se hace análisis descriptivo. Resultados: durante el periodo de estudio hubo 1.520 mujeres elegibles de las cuales 46 fueron intervenidas en otras instituciones por lo que quedaron 1.474 candidatas a ingresar al estudio, de estas se excluyeron 30 por presentar infecciones pélvicas o de transmisión sexual, por lo que, finalmente, se analizaron 1.444 mujeres gestantes. Los riesgos para la salud de la mujer fueron la causa legal más frecuente con un 94,3%. El 99% de las mujeres tenían asesoría previa, y el 78,4% aceptó algún método anticonceptivo post-IVE. El 95,6% de las mujeres fueron intervenidas por la técnica de aspiración manual endouterina (AMEU) y al 4,4% se la practicó la técnica de dilatación y curetaje (D&C). En un 17,56% de las pacientes intervenidas con D&C se presentaron complicaciones hasta el séptimo día posoperatorio, no hubo complicaciones en el grupo sometido a AMEU, el 80% de las mujeres asistieron a control el séptimo día post-IVE. Conclusiones: la AMEU es un procedimiento seguro que no generó complicaciones intraoperatorias en el procedimiento, mientras la D&C se acompañó de complicaciones en una de cada seis pacientes. Se requieren estudios prospectivos que evalúen la seguridad y costos de las diferentes alternativas de IVE.

ABSTRACT Objectives: To characterize a cohort of women with voluntary interruption of pregnancy (VIP) and to describe intraoperative complications according to the technique used. Materials and methods: Descriptive study in a historical cohort of women undergoing VIP in two healthcare institutions in Medellín, Colombia, in 2019. Women with pelvic infection and Sexually Transmitted Infections (STIs) were included. Consecutive sampling was used. Sociodemographic, sexual and reproductive health, clinical characteristics of the pregnancy, legal cause of the VIP, characteristics of the care process and complications of the VIP techniques up to postprocedural day 7 were the measured variables. A descriptive analysis was carried out. Results: Overall, 1,520 women were identified as eligible during the study period. Of them, 46 were intervened in other institutions, leaving 1,474 candidates to enter the study. Of them, 30 were excluded because of pelvic or sexually transmitted infections. Ultimately, 1,444 pregnant women were included in the analysis. Risk to the mother's health was the most frequent legal cause in 94.3% of cases. Ninety-nine percent of women received pre-procedural counseling, and 78.4% agreed to use some form of contraception after VIP. Manual vacuum aspiration (MVA) was used in 95.6% of women and dilation and curettage (D&C) in 4.4%. Complications up to postoperative day 7 occurred in 17.56%, and there were no complications in the MVA group; 80% of women attended the follow-up visit on post-VIP day 7. Conclusions: MVA is a safe procedure which was not associated with intraperatory comoplications. D&C was associated to complications in one of each six patients. Prospective studies to assess the safety and cost of the different VIP options are required.

Interrupción terapéutica del embarazo en casos de fetos anencefálicos y la objeción de conciencia: comparación entre bioética y jurisprudencia / Therapeutic Termination of Pregnancy in Cases of Anencephalic Fetuses and Conscientious Objection: Comparison Between Bioethics and Jurisprudence / Interrupção terapêutica da gravidez em fetos anencéfalos e objeção de consciência: comparação entre bioética e jurisprudência

Resumen: Si bien la interrupción terapéutica del embarazo en los casos de fetos anencefálicos ha sido ampliamente discutida, y se han llegado a conclusiones éticas que la justifican (si no existe contraindicación médica y se obtiene el consentimiento informado de la mujer), es importante reevaluar el tema. Por ello, se deben contrastar los principios bioéticos con sentencias judiciales de fenómenos jurídicos que están surgiendo en el mundo, y que pueden provocar cambios en los derechos sexuales y reproductivos. No obstante, esto no debe implicar un cambio en los argumentos bioéticos. Asimismo, debido al resurgimiento a nivel global de un conservadurismo moral, que propone un planteamiento en torno a la objeción de conciencia, se torna imperativo analizar desde la perspectiva bioética si la misma puede ser invocada en casos de interrupción terapéutica del embarazo. Para ello, se deberían ponderar los principios bioéticos y utilizar una bioética laica, pluralista y basada en ética de mínimos, la cual busque la dignidad de las personas que enfrentan una gestación de fetos anencefálicos. En ese sentido, la objeción de conciencia no debería utilizarse como instrumento para negar la atención a estas personas.

Abstract: Although the therapeutic interruption of pregnancy in cases of anencephalic fetuses has been widely discussed, and ethical conclusions have been reached that justify it (if there is no medical contraindication and the informed consent of the woman is obtained), it is important to reassess the issue. Hence, bioethical principles must be contrasted with judicial rulings on legal phenomena that are emerging in the world, and that can cause changes in sexual and reproductive rights. However, this should not imply a change in the bioethical arguments. Likewise, due to the global resurgence of moral conservatism, which proposes an approach regarding conscientious objection, it becomes imperative to analyze, from a bioethical perspective, if it can be invoked in cases of therapeutic interruption of pregnancy. To do this, bioethical principles should be weighed and a secular, pluralistic bioethics based on minimum ethics should be used, which seeks the dignity of persons facing an anencephalic fetus gestation. In this sense, conscientious objection should not be used as an instrument to deny care to these individuals.

Resumo: Embora a interrupção terapêutica da gravidez nos casos de fetos anencéfalos tenha sido amplamente discutida e tenham chegado a conclusões éticas que a justifiquem (se não houver contraindicação médica e for obtido o consentimento informado da mulher), é importante reavaliar a questão . Por isso, os princípios bioéticos devem ser contrastados com as decisões judiciais sobre fenômenos jurídicos que estão surgindo no mundo e que podem causar mudanças nos direitos sexuais e reprodutivos. No entanto, isso não deve implicar uma mudança nos argumentos bioéticos. Da mesma forma, devido ao ressurgimento global do conservadorismo moral, que propõe uma abordagem em torno da objeção de consciência, torna-se imperativo analisar na perspectiva bioética se ela pode ser invocada nos casos de interrupção terapêutica da gravidez. Para tanto, deve-se pesar os princípios bioéticos e utilizar uma bioética laica, pluralista, pautada na ética mínima, que busque a dignidade das pessoas diante da gestação de feto anencéfalo. Nesse sentido, a objeção de consciência não deve ser utilizada como instrumento para negar atenção a essas pessoas.

Interrupción voluntaria del embarazo en Latinoamérica, superando barreras / Voluntary interruption of the pregnancy in Latin America, overcoming barriers

Resumen Introducción: El embarazo no planeado o no intencional y el aborto son situaciones que afectan la vida de mujeres a nivel mundial, sin distinción de etnia, edad, riqueza, o ubicación geográfica, sin embargo, tiene una mayor posibilidad de presentarse y generar consecuencias negativas en mujeres con ciertas determinantes sociales. Objetivo: Mostrar el estado actual de la interrupción voluntaria del embarazo en países de Latinoamérica y del Caribe con énfasis en el reciente avance de la legislación argentina sucedido durante diciembre del 2020. Metodología: Se realizó una búsqueda no estructurada de información sobre la legislación del aborto en países de Latinoamérica y del Caribe y se hizo una revisión de tema sobre aspectos actuales y relevantes de la interrupción voluntaria del embarazo. Conclusiones: Es necesario que prestadores de servicios de salud y sociedad latinoamericana repasen las lecciones aprendidas de diferentes países sobre las consecuencias negativas para la salud de las mujeres y sus familias debido a las restricciones para acceder al aborto seguro. El mejoramiento de la calidad y las capacidades de los sistemas de salud en los países de bajos y medianos recursos, con mayor inversión e investigación en temas de salud sexual y reproductiva, resultará en la eliminación de barreras e inequidades en la prestación de atención médica a las mujeres, respetando sus derechos y autonomía.

Abstract Introduction: Unplanned or unintended pregnancy and abortion are situations that affect the lives of women worldwide without distinction of ethnicity, age, economic level, or geographical location. However, they have a greater probability of occurring and negative consequences in women with certain social determinants. Objective: Our main objective is to show the current state of the Voluntary Interruption of Pregnancy in Latin American and Caribbean countries with special emphasis on the recent advance of the legislation of Argentina that occurred last December. Methodology: An unstructured search for information about Abortion Legislation in Latin American and Caribbean countries was carried out and a subject revision on current and relevant aspects of Voluntary Interruption of Pregnancy was made. Conclusions: It is necessary that as Health Service providers and as a Latin American Society, we review the lessons learned from different countries about the negative consequences on the health of women and their families due to the restrictions for accessing legal abortions. Improving the quality and capacity of the health system in low- and middle- income countries, in addition to greater investment and research in sexual and reproductive health issues, will derive a removal of barriers and inequity related to the provision of medical attention for women while respecting their rights and autonomy.

[SAFETY OF THE TREATMENT FOR VOLUNTARY PREGNANCY TERMINATION BY GESTATIONAL AGE. MEDELLÍN, COLOMBIA, 2013-2014].

OBJECTIVE: To describe the safety of medical and surgical treatments used in women seeking voluntary pregnancy termination. METHODS: Historical cohort of all pregnant women with up to 26 weeks of gestation who received treatment for voluntary pregnancy termination in a referral institution in Medellín, Colombia, between January 2013 and December 2014.Sampling was consecutive. Measured variables included sociodemographic and obstetric variables, undesired effects, and complications of the voluntary pregnancy termination treatment. A descriptive analysis was carried out. RESULTS: Overall, 87 women were included. The mean age at the time of termination was 24 years (inter-quartile range [IQR] = 12), 69.0% were single, and 73,4% were unemployed. The main reason for termination was the risk to the mother's health in 61,0% of cases, followed by a history of sexual violence in 26.4% and fetal malformations in 12.6%; a total of 70 women (80,4%) had less than 18 weeks of gestation and were treated with misoprostol plus manual vacuum aspiration; 17 (19,6%) had between 18 and 26 weeks of gestation and were treated with misoprostol followed by dilation and curettage. The first group (gestational age <18 weeks) experienced undesired effects such as pain and vomiting; in the second group (> or equal to 18 weeks), 41.0% of the women experienced hemorrhage. CONCLUSIONS: The risk to the mother's health was the main reason for the termination of pregnancy. Termination before 18 weeks was found to be safe, while termination between 18 and 26 weeks using misoprostol and curettage was associated with a high frequency of hemorrhage.

TITULO: SEGURIDAD DEL TRATAMIENTO DE LA INTERRUPCIÓN VOLUNTARIA DEL EMBARAZO SEGÚN EDAD GESTACIONAL EN MEDELLÍN, COLOMBIA, 2013-2014. OBJETIVO: describir la seguridad del tratamiento médico-quirúrgico empleado en mujeres que acuden a interrupción voluntaria del embarazo. METODOS: cohorte histórica. Se incluyeron todas las mujeres embarazadas, hasta con 26 semanas de edad gestacional, a quienes se les dio tratamiento para interrupción voluntaria del embarazo en una institución de referencia en Medellín, Colombia, entre enero de 2013 y diciembre de 2014. Muestreo consecutivo. Se midieron las variables sociodemográficas obstétricas, los efectos no deseados y las complicaciones en el tratamiento de la interrupción voluntaria del embarazo. Se hizo análisis descriptivo. RESULTADOS: se incluyeron 87 mujeres, la mediana de edad de las mujeres al momento de la interrupción fue de 24 años (rango intercuartílico [Rq] = 12), el 69,0 % estaban solteras y el 73,4% desempleadas. La principal causa de interrupción fue el riesgo para la salud de la madre en el 61,0 %, seguido por antecedente de violencia sexual en el 26,4 % y malformaciones fetales en el 12,6 %; un total de 70 mujeres (80,4 %) tenía menos de 18 semanas de gestación y fueron tratadas con misoprostol más aspiración manual endouterina; 17 (19,6%) tenían entre 18 y 26 semanas de gestación, las cuales recibieron misoprostol y legrado. El primer grupo (edad gestacional <18 semanas) no presentó complicaciones, solo efectos no deseados tales como dolor y vómito; el segundo grupo (> o igual a 18 semanas) presentó hemorragia en el 41 % de los casos. CONCLUSIONES: el riesgo para la salud materna constituyó el principal motivo para la interrupción del embarazo. La interrupción del embarazo antes de la semana 18 es segura, entre las semanas 18 a 26, con misoprostol y legrado uterino, se acompañó de una alta frecuencia de hemorragia.

Safety of the treatment for voluntary pregnancy termination by gestational age. Medellín, Colombia, 2013-2014 / Seguridad del tratamiento de la interrupción voluntaria del embarazo según edad gestacional en medellín, colombia, 2013-2014

RESUMEN Objetivo: describir la seguridad del tratamiento médico-quirúrgico empleado en mujeres que acuden a interrupción voluntaria del embarazo. Materiales y métodos: cohorte histórica. Se incluyeron todas las mujeres embarazadas, hasta con 26 semanas de edad gestacional, a quienes se les dio tratamiento para interrupción voluntaria del embarazo en una institución de referencia en Medellín, Colombia, entre enero de 2013 y diciembre de 2014. Muestreo consecutivo. Se midieron las variables sociodemográficas obstétricas, los efectos no deseados y las complicaciones en el tratamiento de la interrupción voluntaria del embarazo. Se hizo análisis descriptivo. Resultados: se incluyeron 87 mujeres, la mediana de edad de las mujeres al momento de la interrupción fue de 24 años (rango intercuartílico [Rq] = 12), el 69,0 % estaban solteras y el 73,4 % desempleadas. La principal causa de interrupción fue el riesgo para la salud de la madre en el 61,0 %, seguido por antecedente de violencia sexual en el 26,4 % y malformaciones fetales en el 12,6 %; un total de 70 mujeres (80,4 %) tenía menos de 18 semanas de gestación y fueron tratadas con misoprostol más aspiración manual endouterina; 17 (19,6 %) tenían entre 18 y 26 semanas de gestación, las cuales recibieron misoprostol y legrado. El primer grupo (edad gestacional <18 semanas) no presentó complicaciones, solo efectos no deseados tales como dolor y vómito; el segundo grupo (> o igual a 18 semanas) presentó hemorragia en el 41 % de los casos. Conclusiones: el riesgo para la salud materna constituyó el principal motivo para la interrupción del embarazo. La interrupción del embarazo antes de la semana 18 es segura, entre las semanas 18 a 26, con misoprostol y legrado uterino, se acompañó de una alta frecuencia de hemorragia.

ABSTRACT Objective: To describe the safety of medical and surgical treatments used in women seeking voluntary pregnancy termination. Materials and Methods: Historical cohort of all pregnant women with up to 26 weeks of gestation who received treatment for voluntary pregnancy termination in a referral institution in Medellín, Colombia, between January 2013 and December 2014. Sampling was consecutive. Measured variables included sociodemographic and obstetric variables, undesired effects, and complications of the voluntary pregnancy termination treatment. A descriptive analysis was carried out. Results: Overall, 87 women were included. The mean age at the time of termination was 24 years (inter-quartile range [IQR] = 12), 69.0 % were single, and 73,4 % were unemployed. The main reason for termination was the risk to the mother's health in 61,0 % of cases, followed by a history of sexual violence in 26.4 % and fetal malformations in 12.6 %; a total of 70 women (80,4 %) had less than 18 weeks of gestation and were treated with misoprostol plus manual vacuum aspiration; 17 (19,6 %) had between 18 and 26 weeks of gestation and were treated with misoprostol followed by dilation and curettage. The first group (gestational age <18 weeks) experienced undesired effects such as pain and vomiting; in the second group (> or equal to 18 weeks), 41.0 % of the women experienced hemorrhage. Conclusions: The risk to the mother's health was the main reason for the termination of pregnancy. Termination before 18 weeks was found to be safe, while termination between 18 and 26 weeks using misoprostol and curettage was associated with a high frequency of hemorrhage.

Vivencia de madres gestantes de niños y niñas con malformaciones incompatibles con la vida / Pregnancy experience associated to fetal abnormality incompatible with life / Experiência das mães grávidas de crianças com má formação genéticas incompatíveis com a vida

Resumen: 14. La creciente precocidad diagnóstica fetal permite conocer anticipadamente la condición de salud de un hijo o hija por nacer. Cuando este diagnóstico arroja un resultado de incompatibilidad con la vida, ello presenta una dificultad emocional y dilemas éticos a la gestante y profesionales de salud que la atienden, así como complejidades al sistema de salud para una atención de calidad. Mediante un estudio cualitativo, se entrevistó a siete matronas/es, una psicóloga y tres mujeres que dieron a luz hijos que fallecieron dada su condición, residentes del Valle de Aconcagua (Región de Valparaíso, Chile). Se recogió su experiencia acerca del proceso de embarazo, parto y puerperio, y su percepción de la respuesta del sistema sanitario. El impacto emocional del diagnóstico es elevado y el periodo de gestación, parto y puerperio transcurre con sentimientos de ambivalencia y como un duelo prolongado y de alto costo psicológico para la mujer. El acompañamiento de los profesionales de salud, particularmente la matronería, presenta complejidades, y si bien hay esfuerzos para una mejor atención, se señalan aspectos claves que deben ser reforzados para facilitar el proceso, incluso en un contexto de legalización probable del aborto terapéutico.

Abstract: 18. Increasing precocity of fetal diagnosis allows parents an early knowledge of the health conditions of their unborn child. When a fetal abnormality incompatible with life is diagnosed, the pregnant woman receives an emotional shock and faces ethical dilemmas, and the health care system must deal with complexities in quality service provision. In a qualitative study at the Aconcagua Valley, seven male and female midwives, a psychologist and three women that gave birth to newborns that died due to their condition, were interviewed. The interviews shed light on the women´s processes at their pregnancy, childbirth and postnatal stages, and on their impression of the healthcare system´s response: the diagnosis has a high emotional impact and the pregnancy evolves with an important psychological cost for the pregnant woman, who faces the situation with ambivalent feelings, and as a prolonged period of mourning. For the health professionals, particularly for midwives assisting these cases, the situation is complex, and even though the professionals strive for improved care, the process should be facilitated by developing key aspects tending towards an integral approach to health provision, even in the context of a probable legalized therapeutic abortion.

Resumo: 22. A crescente prematuridade diagnóstica fetal permite saber de antemão o estado de saúde de um filho ou filha que está para nascer. Quando este diagnóstico gera um resultado de incompatibilidade com a vida, este apresenta uma dificuldade emocional e dilemas éticos para a gestante e profissionais de saúde que a acompanham, bem como complexidades para o sistema de saúde para uma assistência de qualidade. Por meio de um estudo qualitativo, foram entrevistadas sete parteiras/os, um psicólogo e três mulheres que deram à luz crianças que foram à óbito dado a suas condições, residentes do Valle de Aconcagua (região de Valparaíso, Chile). Foram coletadas as experiências sobre o processo de gravidez, o parto, o puerpério e sua percepção da resposta do sistema de saúde. O impacto emocional do diagnóstico é elevado e o período de gravidez, parto e puerpério traz sentimentos de ambivalência e como um duelo prolongado e de alto custo psicológico para a mulher. O acompanhamento de profissionais de saúde, particularmente a figura da parteira, apresenta complexidades e enquanto há esforços para uma melhor atenção, são designados os aspectos chaves para facilitar o processo, mesmo em um contexto de legalização de aborto terapêutico.

Abortion, an increasing public health concern in Ecuador, a 10-year population-based analysis.

OBJECTIVES: To describe the epidemiology of abortion in Ecuador from 2004 to 2014 and compare the prevalence between the public and the private health care systems. METHODS: This is a cross-sectional analysis of the overall mortality and morbidity rate due to abortion in Ecuador, based on public health records and other government databases. RESULTS: From 2004 to 2014, a total of 431,614 spontaneous abortions, miscarriage and other types of abortions were registered in Ecuador. The average annual rate of abortion was 115 per 1,000 live births. The maternal mortality rate was found to be 43 per 100,000 live births. CONCLUSIONS: Abortion is a significant and wide-ranging problem in Ecuador. The study supports the perception that in spite of legal restrictions to abortion in Ecuador, women are still terminating pregnancies when they feel they need to do so. The public health system reported >84% of the national overall prevalence.

A 38-year-old woman with a legal and voluntary interruption of pregnancy due to mental health risk. An unexpected outcome / Mujer de 38 arios con interrupción legal y voluntaria del embarazo por riesgo para la salud mental. Un desenlace inesperado

Abstract Objective: To describe a case of legal and voluntary interruption of pregnancy due to a mental health risk in the mother. However, the foetus survived and the mother decided to care for the child. Methods: Description of the case and a non-systematic review of the relevant literature. Results: A multiparous woman of 38 years with unknown gestational age who requests legal and voluntary interruption of pregnancy. After abortion a male child born of 1050 g was born, intubated and admitted to intensive care. Subsequently, the mother, without the mental problems that led to abortion, gradually assumed the care of the child. Discussion: To address this complex case, several aspects are analysed: first, the change of mind of a woman in her desire to be a mother. Second, the disappearance of mental symptoms in the immediate postpartum. Third, the need to review the clinical, ethical and legal foundations of the legal ruling that allows therapeutic abortion in Colombia.

Resumen Objetivo: Describir un caso clínico de interrupción legal y voluntaria del embarazo por riesgo para la salud mental de la madre con sobrevida del feto y posterior deseo de la madre de cuidar del niño. Métodos: Descripción del caso clínico y revisión no sistemática de la literatura relevante. Resultados: Mujer de 38 arios multigestante, con edad gestacional desconocida, solicitó interrupción legal y voluntaria del embarazo por riesgo para la salud mental por embarazo no deseado. Luego de la interrupción del embarazo, nació un varón de 1.050g de peso, al que se intubó y trasladó a cuidados intensivos. Tras el parto, los síntomas mentales que llevaron a esta mujer al aborto terapéutico desaparecieron, y decidió asumir el cuidado del niño. Discusión: Frente a este complejo caso, se analizan varios aspectos: primero, el cambio de opinión de una mujer sobre su deseo de ser madre; segundo, la desaparición de los síntomas mentales en el posparto inmediato, y tercero, la necesidad de revisar los fundamentos clínicos, éticos y legales de la norma legal que permite el aborto terapéutico en Colombia.

[A 38-year-old Woman with a Legal and Voluntary Interruption of Pregnancy due to Mental Health Risk. An Unexpected Outcome]. / Mujer de 38 años con interrupción legal y voluntaria del embarazo por riesgo para la salud mental. Un desenlace inesperado.

OBJECTIVE: To describe a case of legal and voluntary interruption of pregnancy due to a mental health risk in the mother. However, the foetus survived and the mother decided to care for the child. METHODS: Description of the case and a non-systematic review of the relevant literature. RESULTS: A multiparous woman of 38 years with unknown gestational age who requests legal and voluntary interruption of pregnancy. After abortion a male child born of 1050 grams was born, intubated and admitted to intensive care. Subsequently, the mother, without the mental problems that led to abortion, gradually assumed the care of the child. DISCUSSION: To address this complex case, several aspects are analysed: first, the change of mind of a woman in her desire to be a mother. Second, the disappearance of mental symptoms in the immediate postpartum. Third, the need to review the clinical, ethical and legal foundations of the legal ruling that allows therapeutic abortion in Colombia.

Las interrupciones del embarazo en la práctica obstétrica: recurso terapéutico vs aborto provocado / Discontinuation of pregnancy in obstetric practice: therapeutic resource versus provoked abortion / As interrupções da gravidez na prática obstétrica: recurso terapêutico vs aborto provocado

En el tema del aborto provocado, en general, y del aborto llamado "terapéutico" en particular, se involucran valores importantes para los individuos y para toda la población. Existe mucha confusión respecto de los términos empleados para nominar las distintas acciones que los médicos obstetras deciden realizar en las situaciones clínicas que presentan sus pacientes. Este trabajo pretende precisar cuáles interrupciones de un embarazo corresponden a acciones no solamente lícitas sino obligatorias para un médico, por corresponder a los fines de la medicina, y cuáles son abortos provocados. Para ello se analiza el fin de la profesión médica y a quienes debe el profesional de la salud otorgar siempre sus cuidados. Realiza una reflexión sobre la diferencia entre concepto, criterios y signos para distinguirlos cuando hablamos de viabilidad fetal y de aborto provocado. Desde esa perspectiva, establece el concepto de aborto provocado, buscando sus rasgos necesarios y evitando la confusión con los criterios y signos utilizados para reconocer esa realidad en un caso particular. Finalmente, deduce los criterios y signos de una interrupción de un embarazo en armonía con los valores de la medicina.

The issue of induced abortion, in general, and the called therapeutic abortion in particular, has generated a lot of concern for both the medical profession, as well as for all society. They involve important values for individuals and for the entire population. There is much confusion about the terms used to nominate the various actions that the obstetricians decide to implement in clinical situations that their patients present. This paper aims to clarify which pregnancy interruptions are not only permissible but obligatory actions to a doctor, and correspond to the goals of medicine, and which of them are really induced abortions. To do so, the purpose of the medical profession is analyzed and to whom the health professional should always provide their care. Performs a reflection on the difference between concept, criteria, and signs to distinguish them when talking about fetal viability and induced abortion. From that perspective, establishes the concept of induced abortion, seeking its necessary features and avoiding confusion with the criteria and signs used to recognize this reality in a particular case. Finally, follows which are the criteria and signs of a termination of pregnancy in agreement with the values of medicine.

No tema do aborto provocado, em geral, e do aborto chamado "terapêutico" em particular, se envolvem valores importantes para os individuos e para toda a população. Existe muita confusão a respeito dos termos empregados para nominar as distintas ações que os médicos obstetras decidem realizar nas situações clínicas que apresentam as suas pacientes. Este trabalho pretende precisar quais interrupções de uma gravidez correspondem a ações não somente lícitas senão obrigatórias para um médico, por corresponder aos fins da medicina, e quais são abortos provocados. Para isso se analisa o fim da profissão médica e a quem deve o profissional da saúde outorgar sempre os seus cuidados. Realiza uma reflexão sobre a diferença entre conceito, critérios e sinais para distingui-los quando falamos de viabilidade fetal e de aborto provocado. A partir dessa perspectiva, estabelece o conceito de aborto provocado, buscando seus traços necessários e evitando a confusão com os critérios e sinais utilizados para reconhecer essa realidade num caso particular. Finalmente, deduz os critérios e sinais de uma interrupção de uma gravidez em harmonia com os valores da medicina.

Aproximación ética científica al doble efecto o único bien posible en el aborto terapéutico / Scientific ethical approach to double effect or only possible good in therapeutic abortion / Aproximação ética científica ao duplo efeito ou único bem possível no aborto terapêutico

El estudio muestra como la doctrina o principio del doble efecto (DDE) de una acción con efecto secundario negativo no puede aplicarse a todos los casos de aborto terapéutico (AT). Con el análisis de las causas e indicación de AT se demuestra que solo algunos de estos corresponden a DDE. Cuando no es el feto el que lleva a la madre a tener un embarazo de alto riesgo con amenaza de daño severo o muerte para ella, el caso puede adscribirse a la DDE; cuando es el feto directa o indirectamente el que causa a lleva a ese riesgo materno, el caso no se adscribe a la DDE. Si el feto es la causa de la muerte inminente de la madre, la remoción de la causa, que es la terapia adecuada, coincide con matarlo; entonces la acción buena (salvar a la madre tratándola causalmente) es la misma que la mala (matar al feto), situación que no puede asimilarse sea a la DDE o a la doctrina del mal menor. Más aún, decidir no interrumpir el embarazo produciría la muerte de la madre y el feto. El caso debería adscribirse al principio del único bien posible.

This study shows the inapplicability of the doctrine of double effect (DDE) to all the cases of therapeutic abortion (TA). The causes of the maternal risk define cases that cannot be included in the DDE. When it is not the embryo or fetus that produces the mother pathology the case can be assigned to the DDE. When the embryo or fetus produces directly or indirectly the process that threatens the mother’s life the case cannot be assigned to the DDE. If the fetus is the cause of the imminent mother’s death, the removal of the cause, that is the proper therapy, coincides with killing him or her; then the good action (to save therapeutically the mother) is the same to the bad action (to kill the fetus) and this situation cannot be assimilated either to the DDE or to the doctrine of the lesser evil. Deciding not to kill the fetus will produce the death of the mother and the fetus. So this situation should be ascribed to the principle of the unique possible well.

O estudo mostra como a doutrina ou princípio do duplo efeito (DDE) de uma ação com efeito secundário negativo não pode aplicar-se a todos os casos de aborto terapêutico (AT). Com a análise das causas e indicação de AT se demonstra que só alguns destes correspondem a DDE. Quando não é o feto que leva a mãe a ter uma gravidez de alto risco com ameaça de dano severo ou morte para ela, o caso pode circunscrever-se à DDE; quando é o feto direta ou indiretamente quem causa ou leva a esse risco materno, o caso não se circunscreve a DDE. Se o feto é a causa da morte iminente da mãe, a remoção da causa, que é a terapia adequada, coincide em matá-lo; então a ação boa (salvar a mãe tratando-a causalmente) é a mesma que a má (matar o feto), situação que não pode assimilar-se à DDE ou à doutrina do mal menor. Mais ainda, decidir não interromper a gravidez produziria a morte da mãe e do feto. O caso deveria circunscrever-se ao princípio do único bem possível.

Proyecto de ley sobre despenalización del aborto: análisis ético / Draft law on the decriminalization of abortion: ethical analysis

El proyecto de ley presentado por el gobierno de Chile en Enero del 2015 al Congreso Nacional, que pretende regular "la despenalización de las interrupciones del embarazo en tres causales", ha provocado mucho impacto en la opinión pública y en las agrupaciones médicas, especialmente en las dedicadas a la atención de la mujer embarazada. El proyecto en una primera mirada busca, sin abandonar el respeto a la vida del que está por nacer, quitar el castigo a la mujer y al médico que practica un aborto sólo en tres causales. Se apoya para ello en principios distintos y contradictorios en cada una de ellas. Una segunda mirada revela que el principio de respetar la vida de los pacientes, que funda a la profesión médica desde sus inicios, se reemplaza por la decisión de la mujer para continuar o no cualquier gestación. En efecto, la manera como se estructura el proyecto permite en definitiva, que sea ella la que determine el estatuto de paciente del hijo/hija que gesta y por lo tanto de merecer el cuidado de los profesionales de la salud. Este trabajo revela ese principio oculto, totalmente opuesto al respeto de la vida de todo ser humano sin discriminación.

The project of law presented by the government of Chile, in January 2015, at the National Congress, which seeks to regulate "the decriminalization of pregnancy termination in three causal", has caused much impact on public opinion and in the medical groups, especially in those dedicated to the care of pregnant women. The project at a first glance looks, without abandoning the respect for the life of an unborn child, to remove the punishment on the female and the doctor who performs an abortion only in three grounds. It bases this on various and contradictory principles in each of the three figures. A second look reveals that the principle of respecting the lives of patients, who founded medical profession since its beginnings, is replaced by the women's decision to continue or not any gestation. In effect, the way how is structured allows definitively, that should be the woman the one that determines the patient's statute of her son or daughter, and therefore of deserving the health professional's care of them. This work reveals a hidden principle, totally opposed to the respect the life of every human being without any discrimination.

Análise da experiência de mulheres atendidas em um serviço de referência para vítimas de violência sexual e aborto previsto em lei, Caxias do Sul, Brasil / Analysis of women experience attending in a referral service for victims of sexual violence and abortion provided by law, Caxias do Sul, Brasil

INTRODUÇÃO O atendimento à vítima de violência sexual nos serviços de saúde tem priorizado o atendimento global e interdisciplinar nas diversas áreas para além das urgências médicas. OBJETIVO: Ampliar o conhecimento acerca das experiências emocionais das pacientes atendidas em um serviço de referência em Caxias do Sul, Brasil, para o atendimento de vítimas de violência sexual e mulheres em situação de aborto previsto em lei. MÉTODO: Foram avaliados 23 depoimentos escritos por meio de análise de conteúdo privilegiadas as categorias: motivo do atendimento, atendimento no serviço, relação com a equipe e papel da rede familiar e social. Do total, 14 depoimentos são das mulheres atendidas e nove dos parentes. RESULTADOS: Constataram‐se as potencialidades e destacou‐se a relação favorável das pacientes com a equipe cuidadora; e eventuais fragilidades nos protocolos de atendimento da equipe interdisciplinar responsável pelo serviço. Salientou‐se o contexto em que a paciente ingressa no serviço, ainda sob o impacto da violência e/ou do diagnóstico. CONCLUSÃO: Iniciativas interdisciplinares que estabeleçam mediações em tais situações são estimuladas para a adesão das pacientes aos protocolos de atendimento previstos nessa área.

INTRODUCTION: The service for victims of sexual violence in health services has prioritized the global and interdisciplinary care in several areas beyond medical emergencies. OBJECTIVE: To increase understanding on the emotional experiences of patients attended at a referral center in Caxias do Sul, Brazil for caring to victims of sexual violence and women undergoing abortion provided by law. METHOD: It was analyzed 23 testimonials written by content analysis concentrating on the categories: the reason for seeking treatment, the treatment in the care service, the relationship with the team and the role of family and social network after the event. Of the total, 14 are women and nine are from the family attended. RESULTS: Realize the potential outcomes, highlighting the favorable ratio of patients with the caretaker staff and possible weaknesses in the protocols of the interdisciplinary care team responsible for the service, emphasizing the context in which the patient enters the service still under the impact of violence or diagnosis. CONCLUSION: Interdisciplinary initiatives that establish mediations in such situations are encouraged to adherence of patients to treatment protocols provided in this area.

Aborto terapéutico: ¿realmente existe? / Therapeutic abortion: is there really?

A propósito de la reciente promulgación de la Resolución Ministerial N.º 4862014/Minsa, que aprueba la guía técnica nacional para el aborto terapéutico, se ha generado un gran debate al respecto. Como un aporte a la discusión, se presenta una revisión sobre las definiciones y tipos de aborto, para luego centrarse en el denominado ‘aborto terapéutico’ y explorar las dificultades que existen para definirlo. Finalmente, se presentan algunas observaciones a esta Guía técnica emitida por el Minsa. Se concluye que el término ‘aborto terapéutico’ es anacrónico y contradictorio porque el aborto no es un tratamiento que asegure mejorar la salud de la mujer ni la del niño. El término apropiado debería ser ‘interrupción del embarazo por razones médicas’.

With regard to the recent enactment of the Peruvian Ministerial Resolution N.º 4862014/Minsa, which approves the national technical guide for therapeutic abortion, has generated considerable debate. A review of the definition and type of abortion and the focus on the socalled ‘therapeutic abortion’ is presented. This article explores the difficulties in defining it. Finally, some comments are presented to the Technical Guidance issued by the Minsa. We conclude that the term ‘therapeutic abortion’ is anachronistic and contradictory because abortion is not a treatment ensuring better health of the woman neither for the unborn child. The proper term should be ‘termination of pregnancy for medical reasons’.

The anencephalic fetus abortion and the constitutional issue / O aborto do feto anencefálico e a questão constitucional

Abortion has long occupied the legal discussions in both Brazilian and international law. It is asubject of immense complexity, which in its interdisciplinarity, generates intense discussions among lawyers, doctors, scientists, philosophers and the civil society. In this environment, the question concerning the possibility or not of the termination of the anencephalic pregnancy occupies the halls of the Brazilian Constitutional Court, which has enabled the clash of ideas and the full participation of all stakeholders. Through the trial of ADPF 54, all the peculiarities of this "type of abortion" are being teased out. However, the issue should be constitutionally interpreted by the hermeneutist. In a moment of contemporary constitutionalism that values the fundamental principles of the citizenship, dignity, freedom and health of the mother should be placed in prominence, even making use of instruments of constitutional hermeneutics, as the consistent interpretation and reflection. Thus, the legal treatment of anencephalic pregnancy must face the interruption as a therapeutic guarantor of human dignity for women, and never as abortion.(AU)

Há tempos o aborto vem ocupando as discussões jurídicas, tanto no ordenamento pátrio como internacional. É tema de imensa complexidade, que, por sua interdisciplinaridade, gera intensas discussões entre juristas, médicos, cientistas, filósofos e a própria sociedade civil. Nesse ambiente, a questão referente à possibilidade, ou não, da interrupção da gestação do feto anencefálico vem ocupando os salões da Corte Constitucional Brasileira, que tem possibilitado o embate de ideias e a participação ampla de todos os interessados. Por meio do julgamento da ADPF 54, todas as particularidades dessa "modalidade de aborto" vêm sendo esmiuçadas. Porém, é por meio de uma interpretação constitucional que os hermeneutas devem compreender a questão. Em um momento de constitucionalismo contemporâneo valorizador dos princípios fundamentais do cidadão, a dignidade, a liberdade e a saúde da mãe devem ser colocadas em proeminência, lançando-se mão, inclusive, de instrumentos da hermenêutica constitucional, como a interpretação conforme e a ponderação. Assim, o tratamento jurídico da gravidez anencefálica deve entender a interrupção desta gestação como medida terapêutica garantidora da dignidade humana da mulher, e jamais como aborto.(AU)

El acceso al aborto no punible como cuestión de derechos humanos: persistencia de barreras en jurisdicciones con y sin reglamentación del aborto legal / Access to not punishable abortion as a human right issue: persistance of barriers in jurisdictions with and without legal regulation of abortion

INTRODUCCION: Desde 1921, el Código Penal de la Nación (CPN) de Argentina penaliza el aborto pero establece ciertas excepciones en el artículo 86. Sin embargo, el acceso de las mujeres al aborto no punible (ANP) se encuentra seriamente restringido. La ausencia o precariedad de reglas y políticas públicas para facilitar el ejercicio de las permisiones, los debates irresueltos sobre su alcance, los trámites excesivos en los centros sanitarios y la intervención injustificada del sistema de justicia, son sólo algunos de los obstáculos que deben enfrentar las mujeres al requerir un aborto amparándose en los casos contemplados por el mencionado artículo.OBJETIVOS: Contribuir a la remoción de las barreras de acceso de las mujeres al ANP a partir del estudio de los debates jurídicos y los problemas de implementación institucional de las reglas vigentes en la Ciudad Autónoma de Buenos Aires (CABA).METODOS: Se realizó una indagación exhaustiva de los discursos judiciales sobre aborto y ANP y una revisión de los discursos doctrinarios vigentes en el país y el derecho comparado.RESULTADOS: Se realizó una serie de publicaciones que discuten los mecanismos de regulación y distintos argumentos que fundamentan la legalidad del ANP. La investigación permitió reconstruir el recorrido que las mujeres deben realizar para acceder al aborto legal en dos hospitales de la CABA.CONCLUSIONES: El estudio sirvió para realizar un mapeo de algunas de las opiniones de los profesionales de la salud sobre el ANP y las barreras de oferta que identificaron.

INTRODUCTION: Since 1921, the Argentine Criminal Code (ACC) criminalizes abortion but provides some exceptions in Article 86. However, women’s access to not punishable abortion (NPA) is severely restricted. The absence or weakness of rules and policies to facilitate the exercise of the permissions, the unresolved legal debates about its scope, the excessive requirements in health centers and the unjustified recourse to the justice system are some of the obstacles faced by women requiring abortion invoking cases covered by the article mentioned above.OBJECTIVE: To contribute to the removal of barriers to women’s access to NPA through the study of the legal debates and problems of institutional implementation of the current rules in the Autonomous City of Buenos Aires (ACBA).METHODS: A thorough investigation of judicial discourses on abortion and NPA and a review of current doctrinal discourses in the country and comparative law were made.RESULTS: Several publications have been produced discussing the regulatory mechanisms and arguments that support the legality of NPA. This research describes the different stages required for the access of women to legal abortion in two hospitals of ACBA. CONCLUSIONS: The research was used to perform a mapping of some of the opinions of health professionals about the NPA and the barriers they identified.CONCLUSIONS: The research was used to perform a mapping of some of the opinions of health professional about the NPA and the barriers they identified.

El acceso al aborto no punible como cuestión de derechos humanos: persistencia de barreras en jurisdicciones con y sin reglamentación del aborto legal / Access to not punishable abortion as a human right issue: persistance of barriers in jurisdictions with and without legal regulation of abortion

INTRODUCCION: Desde 1921, el Código Penal de la Nación (CPN) de Argentina penaliza el aborto pero establece ciertas excepciones en el artículo 86. Sin embargo, el acceso de las mujeres al aborto no punible (ANP) se encuentra seriamente restringido. La ausencia o precariedad de reglas y políticas públicas para facilitar el ejercicio de las permisiones, los debates irresueltos sobre su alcance, los trámites excesivos en los centros sanitarios y la intervención injustificada del sistema de justicia, son sólo algunos de los obstáculos que deben enfrentar las mujeres al requerir un aborto amparándose en los casos contemplados por el mencionado artículo.OBJETIVOS: Contribuir a la remoción de las barreras de acceso de las mujeres al ANP a partir del estudio de los debates jurídicos y los problemas de implementación institucional de las reglas vigentes en la Ciudad Autónoma de Buenos Aires (CABA).METODOS: Se realizó una indagación exhaustiva de los discursos judiciales sobre aborto y ANP y una revisión de los discursos doctrinarios vigentes en el país y el derecho comparado.RESULTADOS: Se realizó una serie de publicaciones que discuten los mecanismos de regulación y distintos argumentos que fundamentan la legalidad del ANP. La investigación permitió reconstruir el recorrido que las mujeres deben realizar para acceder al aborto legal en dos hospitales de la CABA.CONCLUSIONES: El estudio sirvió para realizar un mapeo de algunas de las opiniones de los profesionales de la salud sobre el ANP y las barreras de oferta que identificaron.

INTRODUCTION: Since 1921, the Argentine Criminal Code (ACC) criminalizes abortion but provides some exceptions in Article 86. However, womens access to not punishable abortion (NPA) is severely restricted. The absence or weakness of rules and policies to facilitate the exercise of the permissions, the unresolved legal debates about its scope, the excessive requirements in health centers and the unjustified recourse to the justice system are some of the obstacles faced by women requiring abortion invoking cases covered by the article mentioned above.OBJECTIVE: To contribute to the removal of barriers to womens access to NPA through the study of the legal debates and problems of institutional implementation of the current rules in the Autonomous City of Buenos Aires (ACBA).METHODS: A thorough investigation of judicial discourses on abortion and NPA and a review of current doctrinal discourses in the country and comparative law were made.RESULTS: Several publications have been produced discussing the regulatory mechanisms and arguments that support the legality of NPA. This research describes the different stages required for the access of women to legal abortion in two hospitals of ACBA. CONCLUSIONS: The research was used to perform a mapping of some of the opinions of health professionals about the NPA and the barriers they identified.CONCLUSIONS: The research was used to perform a mapping of some of the opinions of health professional about the NPA and the barriers they identified.

O aborto do feto anencefálico e a questão constitucional / The anencephalic fetus abortion and the constitutional issue

Há tempos o aborto vem ocupando as discussões jurídicas, tanto no ordenamento pátrio como internacional. É tema de imensa complexidade, que, por sua interdisciplinaridade, gera intensas discussões entre juristas, médicos, cientistas, filósofos e a própria sociedade civil. Nesse ambiente, a questão referente à possibilidade, ou não, da interrupção da gestação do feto anencefálico vem ocupando os salões da Corte Constitucional Brasileira, que tem possibilitado o embate de ideias e a participação ampla de todos os interessados. Por meio do julgamento da ADPF 54, todas as particularidades dessa "modalidade de aborto" vêm sendo esmiuçadas. Porém, é por meio de uma interpretação constitucional que os hermeneutas devem compreender a questão. Em um momento de constitucionalismo contemporâneo valorizador dos princípios fundamentais do cidadão, a dignidade, a liberdade e a saúde da mãe devem ser colocadas em proeminência, lançando-se mão, inclusive, de instrumentos da hermenêutica constitucional, como a interpretação conforme e a ponderação. Assim, o tratamento jurídico da gravidez anencefálica deve entender a interrupção desta gestação como medida terapêutica garantidora da dignidade humana da mulher, e jamais como aborto.