Sexually transmitted diseases and unwanted pregnancies in chronically ill psychiatric patients.
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Adult↗
Biomedical subjects
F A Chervenak
Publications and source records attributed to F A Chervenak.
Clinical implications of respect for autonomy in the psychiatric treatment of pregnant patients with depression.
Major depression, as well as depressive symptoms that do not meet the full diagnostic criteria for a diagnosis of depression, can chronically and variably affect a woman patient's decisions about the management of pregnancy, including the decision about whether to continue a pregnancy. Depression also has potential adverse consequences for the pregnant woman and her pregnancy. However, little attention has been given to the ethical challenges posed by the psychiatric management of depression during pregnancy. The psychiatrist should balance respect for the autonomy of the depressed woman with beneficence-based obligations to the pregnant woman, and also to the fetus, when the fetus is viable. The authors recommend strategies for assessing the decision-making abilities of pregnant patients with depression and for enhancing their autonomy. They suggest that nondirective counseling should generally be used with pregnant patients with depression when the fetus is previable and that directive counseling is ethically justifiable when the fetus is viable.
Abortion, Induced↗
Vascularity of uterine myomas: assessment by color and pulsed Doppler ultrasound.
OBJECTIVE: To evaluate the effects of different clinical and anatomical factors on the vascularity of uterine myomas METHODS: The study group included 195 patients, 153 premenopausal and 42 postmenopausal. Four hundred five myomas, 316 in the first group and 89 in the second, were studied by color Doppler ultrasound. Differences in the visualization of blood flow and resistance index (RI) were analyzed according to several factors, including: menopausal status, phase of menstrual cycle, duration of menopause, size and location of the myomas, and secondary changes within the myomas. RESULTS: The size of myomas was the most important single factor in determining both visualization of blood flow and RI. A higher blood flow visualization rate (BFVR) and a lower RI were found: (1) in the premenopausal compared with the postmenopausal patients (P < 0.05), (2) in the group of larger myomas compared with the group of smaller myomas (P < 0.0001), and (3) in submucosal and subserosal myomas compared with intramural myomas (P < 0.05). Other above-mentioned factors did have some, but not significant, influence on the visualization of blood flow and resistance to blood flow. CONCLUSION: Differences in the vascularity and resistance to blood flow in uterine myomas may limit the clinical use of color Doppler ultrasound.
Case-Control Studies↗
An ethically justified algorithm for offering, recommending, and performing cesarean delivery and its application in managed care practice.
When cesarean delivery is substantively supported and vaginal delivery is not supported in beneficence-based clinical judgment, the physician should offer and recommend only cesarean delivery. When both cesarean and vaginal delivery are substantively supported in beneficence-based clinical judgment, the physician should offer both, discuss any controversy, and make a recommendation. When cesarean delivery is substantively supported and vaginal delivery is more substantively supported in beneficence-based clinical judgment, the physician should offer both and recommend vaginal delivery. If cesarean delivery is not supported and vaginal delivery is substantively supported in beneficence-based clinical judgment, the physician should offer only vaginal delivery. When cesarean delivery is requested and well supported solely in autonomy-based clinical judgment, the physician should repeat the recommendation for vaginal delivery and either perform cesarean delivery or make a referral. Physicians may use this algorithm in negotiating managed care contracts.
Algorithms↗
Cesarean delivery for intrapartum fetal heart rate abnormalities: incorporating survey data into clinical judgment.
OBJECTIVE: To identify the descriptive clinical practice of maternal-fetal medicine specialists when faced with severe intrapartum fetal heart rate (FHR) abnormalities (as determined by continuous electronic fetal monitoring). METHODS: All regular members of the Society of Perinatal Obstetricians (maternal-fetal medicine specialists) were sent a survey questionnaire on the topic of cesarean delivery for intrapartum FHR abnormalities. The time from observation of FHR abnormalities to making the decision to proceed to cesarean delivery was the main outcome measure. Time was allowed for intrauterine resuscitative maneuvers to alleviate the abnormal pattern. Legislative definitions of consensus and strong consensus were applied to the data. Analysis of covariance was performed to determine the effect of physician demographic factors on the times reported. RESULTS: Four hundred thirty-one of 704 (61.2%) questionnaires were returned. Consensus was identified for deciding on cesarean delivery (after intrauterine resuscitation) 1) after 30 minutes for cases of repetitive late and severe variable decelerations, 2) after 10 minutes in cases of fetal bradycardia, and 3) in all scenarios with decreased beat-to-beat variability of the FHR. Consensus was identified for deciding on cesarean delivery in five of eight intrapartum FHR pattern abnormalities. CONCLUSION: The descriptive clinical practice of maternal-fetal medicine specialists demonstrated in this study should be considered in prudential clinical judgment.
Arrhythmias, Cardiac↗
Fetal seizures: further observations.
BACKGROUND: Previous reports of ultrasonographically diagnosed seizure activity in utero have described fetuses with obvious, gross, tonic-clonic movements of trunk and extremities. CASES: Three fetuses with akinesia deformation sequence are described: two with arthrogryposis multiplex congenita and one with Pena-Shokeir syndrome. Each was demonstrated by serial real-time ultrasound examinations to have joint contractures, absent fetal breathing motions, and lack of gross movements other than sonographically evident subtle seizure activity. CONCLUSION: Fetal seizure activity can be subtle when seen in the presence of fetal anomalies that limit joint movement. The prognosis remains poor.
Abnormalities, Multiple↗
The impact of routine obstetric ultrasonographic screening in a low-risk population.
OBJECTIVES: Our goal was to develop a framework for evaluating the current controversy regarding routine obstetric ultrasonography in a population of low-risk pregnancies. STUDY DESIGN: A retrospective chart review was performed for all low-risk pregnancies from a single obstetric practice during 1990 to 1994, to determine the accuracy of screening ultrasonography for fetal anomalies. All patients received a routine ultrasonographic examination at 18 to 20 weeks' gestation. Neonatal records for all patients were evaluated for the presence of both major and minor anomalies. The data were analyzed with attention to the classification of anomalies (all anomalies vs major anomalies, detectable vs nondetectable). RESULTS: A total of 860 fetuses in 854 pregnancies were evaluated. Anomalies were present in 5.35% (46/860); these were major anomalies in 1.16% (10/860) and minor anomalies in 4.19% (36/860). The sensitivity, specificity, and positive and negative predictive values for the diagnosis of all anomalies were 8.7%, 99.9%, 80%, and 95.7%, respectively. However, if only major anomalies detectable by ultrasonography are included, these values become 75%, 100%, 100%, and 99.9%, respectively. There was one false-positive diagnosis not affecting outcome, a small ventriculoseptal cardiac defect. Postnatal ascertainment of anomalies was excellent, as determined by an incidence of ventriculoseptal defects of 1 in 120. CONCLUSION: Distinguishing between major and minor anomalies and between ultrasonographically detectable versus nondetectable anomalies is essential in the evaluation of the diagnostic accuracy of screening ultrasonography. Any comparisons of studies examining the effectiveness of prenatal screening for congenital anomalies with ultrasonography should use the same outcome: major anomalies identifiable by ultrasonography.
Congenital Abnormalities↗
Ethically justified guidelines for defining sexual boundaries between obstetrician-gynecologists and their patients.
OBJECTIVE: This article proposes ethically justified guidelines that should govern the ethical obligations of obstetrician-gynecologists when they experience sexual feelings toward patients. STUDY DESIGN: We reviewed literature on physician-patient sexual contact and related that literature to ethical principles. RESULTS: Existing guidelines that prohibit sexual contact between physicians and patients are based on an ethical argument that such relationships violate the ethical principles of respect for both autonomy and beneficence. This argument is incomplete because patients can provide valid consent for sexual relationships with their own obstetrician-gynecologists. CONCLUSION: We propose a virtues-based ethical argument that is independent of informed consent for governing sexual relationships between obstetrician-gynecologists and their patients. In the context of the physician-patient relationship the professional virtues of self-effacement and self-sacrifice obligate the obstetrician-gynecologist to set aside and never act on feelings of sexual attractiveness toward patients.
Ethics, Medical↗
Ethically justified clinically comprehensive guidelines for the management of the depressed pregnant patient.
OBJECTIVE: This article proposes ethically justified clinical guidelines for managing depressed patients during pregnancy. STUDY DESIGN: We reviewed literature on depression and its consequences for pregnancy and related that literature to ethical principles. RESULTS: The health effects of depression on the pregnant woman and her fetus cannot be managed without consideration of the chronic and variable impairment of autonomy that may result from the effects of depression on the pregnant woman's decision-making capacity. CONCLUSION: When the fetus is previable, recommendations concerning the disposition and prenatal diagnosis of the pregnancy should be nondirective, whereas strong treatment recommendations are justifiable if the pregnant woman has decided to continue her pregnancy and is severely depressed. After viability, directive counseling for fetal benefit is ethically justified. The guidelines focus on preventive ethics strategies to enhance the decision-making capacity of the depressed pregnant patient.
Beneficence↗
Selective reduction of multifetal pregnancies to twins improves outcome over nonreduced triplet gestations.
OBJECTIVE: Our purpose was to evaluate effects of multifetal pregnancy reduction on pregnancy complications and birth weights of remaining twin fetuses compared with expectantly managed triplets and nonreduced twins. STUDY DESIGN: Medical records of 54 triplet pregnancies, 59 twin pregnancies resulting from multifetal pregnancy reduction, and 88 sets of twins conceived with assisted reproductive techniques and delivered at New York Hospital after 24 weeks were retrospectively reviewed. Birth weights were corrected for gestational age at delivery by use of a formula derived from composite standardized growth curves. Statistical analysis was performed with chi(2) analysis and Student t test. RESULTS: Twins remaining after reduction and nonreduced twins were less likely to have preeclampsia than were triplets (14% and 23% vs 30%) and to be delivered before 36 weeks (39% and 27% vs 72%). They had birth weights that were > 100 gm larger than those of triplets even when corrected for gestational age. Reduced twins were similar to nonreduced twins in all parameters studied. CONCLUSIONS: Multifetal pregnancy reduction results in pregnancy complications, gestational age, and birth weights closer to those of nonreduced twins than to expectantly managed triplets.
Adult↗
Should sex identification be offered as part of the routine ultrasound examination?
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Beneficence↗
Responding to the ethical challenges posed by the business tools of managed care in the practice of obstetrics and gynecology.
We provide a preventive ethics approach that equips obstetrician-gynecologists to respond proactively to the ethical challenges posed by the business tools of managed care. This approach is based on an ethical analysis of medicine as a fiduciary profession. This analysis identifies four virtues: self-effacement, self-sacrifice, compassion, and integrity. We show how these four virtues can be applied proactively in response to conflicts of interest in how physicians are paid and strict control of clinical judgment and practice, the two main business tools of managed care.
Ethics, Medical↗
Advantages of larger volume, less frequent intrauterine red blood cell transfusions for maternal red cell alloimmunization.
Larger volume intravascular transfusions to manage severe maternal red cell alloimmunization in pregnancy may prolong the interval between procedures without increasing maternal, fetal, or neonatal complications. A retrospective cohort study compared the management and outcome of 19 patients with severe red cell alloimmunization managed at two facilities with different intravascular transfusion protocols. The volume of blood transfused, pre- and post-transfusion fetal hematocrit, and interval (days) between intravascular transfusions were compared. The respective maternal, fetal, and neonatal results were compared. The red blood cell volume transfused per procedure and the post- but not pre-transfusion fetal hematocrits were higher at New York Hospital than at Westchester County Medical Center. The interval between transfusions at New York Hospital (25.2 +/- 8.65 days) was longer than at Westchester County Medical Center (13.5 +/- 6.0 days, p < 0.0001). Although larger volume transfusion was occasionally associated with transient fetal bradycardia, all red blood cell transfusions were completed without complication. The adverse outcomes, complication rates, and neonatal outcomes were otherwise similar in both management protocols. It is possible to significantly increase the interval between intravascular transfusions with larger transfusion volumes for the management of severe maternal red cell alloimmunization without undue risk. The overall risk for the fetus and mother may be reduced by performing fewer transfusions and avoiding additional blood product exposures.
Blood Transfusion, Intrauterine↗
Conflicts between physicians and patients in non-elective cesarean delivery: incidence and the adequacy of informed consent.
A study was undertaken in 372 consecutive patients undergoing non-elective cesarean delivery to explore the incidence and nature of conflicts between physician and patient surrounding the decision to undergo non-elective cesarean delivery; to examine the adequacy of informed consent at the time of non-elective cesarean delivery; and to describe the importance of a preventive ethics approach to non-elective cesarean delivery. During a 6-month interval, all patients who underwent non-elective cesarean delivery and their physicians were asked to take part in a survey in the early postpartum period concerning their response to recommendations for cesarean delivery. The survey included demographics as well as questions pertaining to informed consent and the presence and nature of patient-physician conflict. Of the 326 patients who were interviewed, 319 (98%) agreed to the recommendation for non-elective cesarean delivery and 7 patients (2%) initially disagreed. Reasons for disagreeing included: feared surgery (4 of 7), needed husband's approval (1 of 7), and questioned the medical necessity of surgery (2 of 7). In all 7 cases of initial disagreement, cesarean delivery was eventually performed with the patient's consent. The mean age of patients who initially disagreed was younger (24.7 +/- 6) than that of those who agreed (31.0 +/- 4 [p < 0.05]). Conflicts were present in 7 of 113 clinic patients and 0 of 213 private patients (p < 0.05). Of those surveyed, 26 (8.7%) indicated that they did not have adequate input in the decision for non-elective cesarean delivery. Patients with inadequate input expressed significantly more concerns with regard to the effect of surgery on their own health (p < 0.05) as well as its effect on the baby (p < 0.05). Our findings suggest that even though the incidence of physician-patient conflict about non-elective cesarean delivery was quite low, a significant number of patients (1 in 12) may have reservations concerning the informed consent process at the time of non-elective cesarean delivery. Patients with reservations are more likely to have greater concerns with regard to maternal and fetal risks, suggesting that a more detailed risk disclosure prior to the procedure is warranted for all pregnant patients. Perhaps by incorporating the preventive strategies discussed, the adequacy of informed consent and therefore the patient's autonomy could be enhanced, thus diminishing patient reservations and preventing physician-patient conflict in the intrapartum period.
Adult↗
Common ethical dilemmas encountered in the management of HIV-infected women and newborns.
The clinical management of the HIV-infected pregnant woman and newborns involves multifaceted ethical challenges. We have argued that rights-based approaches, based on a civil rights model, are not adequate to clinically address these challenges. We have argued instead for a more nuanced ethical framework that emphasizes the beneficence-based obligations of the physician of the pregnant woman, to the fetal patient, and to the newborn, as well as the beneficence-based obligations of the pregnant woman to the fetal patient and to the newborn. The ethical principle of respect for autonomy shapes the counseling process about termination of pregnancy, contraception, and advance directives.
Adolescent↗
Clinical implications and management strategies when depression occurs during pregnancy.
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Decision Making↗
Sexually transmitted disease prevention services for female chronically mentally ill patients.
Chronically and variably impaired autonomy makes women with chronic mental illness particularly vulnerable to contracting sexually transmitted diseases (STDs) including AIDS. A lack of female controlled protective devices also adds to the vulnerability of these patients. In this context, the authors make recommendations for the design of clinically comprehensive and ethically justified programs to minimize the risk of mentally ill women for STDs. When female chronically mentally ill patients are at risk of STDs, barriers to the exercise of their autonomy must be identified and clinically treated. Preventive clinical interventions can also be usefully augmented by educational strategies and facilitate patients' communication and behavioral skills, particularly in order to enable them to abstain from unwanted sex or to make prospective male partners wear a condom. Outreach efforts to the male partners of female patients and to the homeless mentally ill may also be required. Preventive services could be integrated and coordinated with STD clinics, substance abuse treatment programs and family planning programs.
Acquired Immunodeficiency Syndrome↗
Three ethically justified indications for selective termination in multifetal pregnancy: a practical and comprehensive management strategy.
The authors provide an ethical justification for three indications for performing selective termination of multi-fetal pregnancies. These indications are (1) achieving a pregnancy that results in a live birth or one or more infants with minimal neonatal morbidity and mortality, (2) achieving a pregnancy that results in a live birth of one or more infants without antenatally detected anomalies, and (3) achieving a pregnancy that results in a singleton live birth. This ethical justification is based on two basic approaches to obstetric ethics that emphasize that these indications must be established on the basis of informed consent. The authors underscore the importance of matters of private conscience and demonstrate the consistency of ethical justification with existing public policy in the United States.
Beneficence↗