High-risk pregnancies in obstetrics today

Managing high-risk pregnancies in obstetrics today

By Dr Harini Narayan

Every year, across the world 287,000 women die in pregnancy and childbirth along with at least 2.6 million stillbirths, of which about 50% are intrapartum deaths. Among 133 million babies born alive each year, 2.8 million die in the first week of life. The latest MBRRACE reports of the UK show a maternal mortality rate of 10 per 100,000 women giving birth (December 2014) and an extended perinatal mortality rate of 6.0 per 1,000 total births, comprising 4.2 stillbirths per 1,000 total births and 1.8 neonatal deaths per 1,000 live births (June 2015).

While there have been significant clinical and technical advances in the care of high-risk pregnancies in the last few decades in economically advantaged countries, the complexity of patients has also changed quite dramatically. The challenges are numerous and varied with rising rates of obesity, diabetes, a host of co-morbidities, older mothers, immigration patterns, and social deprivation. Increasing numbers of women who were once unable to become pregnant or were advised not to due to underlying health problems are now able to have children. High-risk pregnancies form a significant and increasing proportion of any pregnant population. Improved outcomes also mean that patient expectations are at an all-time high.

Several generations of Confidential Enquiries into Maternal and Perinatal Mortality in the UK have focused on improvements needed in intrapartum care. The most recent MBRRACE report (2014) has, for the first time, highlighted the vital role of high standard pre-conceptual and antenatal care for women with underlying co-morbidities. Three quarters of all women who died had coexisting medical complications. Pre-existing medical or mental health problems were the main contributors to both direct and indirect causes of maternal death. Timely recognition and diagnosis of a high-risk condition complicating pregnancy, the involvement of appropriate senior staff from multiple disciplines, and prompt treatment or action can make the difference between life and death.

Most high-risk pregnancies belong to one or more of three categories:

1. Where there is a pre-existent medical/mental condition that could have a serious impact on the maternal/fetal outcome of any pregnancy and where specific management plans with multi-speciality input are essential.
2. Where the pregnancy itself could cause worsening of a pre-existent medical/mental disorder which had hitherto remained stable or in remission.
3. Where complications experienced during a previous pregnancy/ies are likely to recur or those that develop de novo in the present pregnancy could adversely affect maternal/fetal outcomes.

There is often much misunderstanding about the label “high-risk pregnancy” amongst health care professionals as well as in pregnant women and their families. It can result in patient anxiety to unwarranted, unnecessary, and sometimes potentially risky interventions undertaken without valid obstetric indications. It often leads to community midwives disengaging almost entirely from the ongoing routine antenatal care with the mistaken impression that their own input is unnecessary. This denies the normality that exists even in the most complex of pregnancies.

F.W. Peabody, a US physician (1881-1927), stated “The treatment of a disease may be entirely impersonal; the care of a patient must be entirely personal.” The corollary is equally true. Once deemed ‘high risk,’ there is often unnecessary duplication of appointments, sometimes within the same week or even the same day between the hospital antenatal clinics and primary care, creating significant disruption and inconvenience for patients. A lack of coordinated and integrated care planning in a patchy service wastes valuable resources. All maternity units are working under serious financial and manpower constraints in an increasingly litigious environment. There is more pressure than ever on the NHS to ensure every penny is spent in the most effective way for patients to improve standards of care while reducing costs. Every antenatal appointment needs a valid purpose, every investigation must be clinically justifiable, and every intervention must be medically indicated.

Challenging the status quo is bound to be difficult. The day-to day reality is that in most maternity units the antenatal care for women with high-risk pregnancy is of variable quality, often laced with conflicting advice. Trainees often find themselves in the dilemma of managing such patients depending on the consultant’s antenatal clinic in which they work. Individualized care pathways grounded in best practice, national guidelines, and centred on the woman with a specific high-risk condition are uncommon. Such care pathways should be designed to enable integrated and seamless care across primary, secondary, and, if indicated, in tertiary settings. Transforming structural and organisational norms is at the core of delivering a truly patient-centred service that starts from pre-pregnancy and continues to post-childbirth.

The crucial role of pre-pregnancy assessment and counselling services for women with pre-existing high-risk conditions is one that is often overlooked by commissioners and providers, quite apart from the woman herself. Does the obstetrician’s role end when the patient is discharged from the hospital? What about ‘after-sales customer care’? Does this extend to discussions about the most appropriate contraception suitable to her underlying medical condition? What about further multidisciplinary disease management and optimisation of health before the next pregnancy ‘just happens’? 

An informed patient who actively participates in the management of her pregnancy is one to be cherished. The keystone for this lies in providing clear and comprehensive information, thus starting the process of shared decision-making throughout pregnancy.

Dr. Harini Narayan has worked in the NHS for more than three decades, 21 years of which have been as Consultant Obstetrician and Gynaecologist and Lead Obstetrician. She is Lead Obstetrician at the Great Western Hospitals Foundation Trust in Swindon, UK (1997-to date), heading maternal medicine, high risk obstetrics and clinical risk management. She is also a preceptor/supervisor for the RCOG ATSMs in Maternal Medicine, Advanced antenatal and labour ward practice and Honorary Consultant in Feto-Maternal Medicine in Oxford. She is the author of Compendium for the Antenatal Care of High-Risk Pregnancies.

Woman sues Marshall Obstetrics & Gynecology for HIPAA violations

Woman sues Marshall Obstetrics & Gynecology for HIPAA violations

July 19, 2013 9:10 AM
By KYLA ASBURY

HUNTINGTON – A woman is suing Marshall Obstetrics & Gynecology for violating the Health Insurance Portability and Accountability Act and causing her damages.

Marshall Obstetrics & Gynecology is doing business as Marshall University-Joan C. Edwards School of Medicine.

Jane Doe was also named as a defendant in the suit.

During the summer and fall of 2012, Savannah Murphy was pregnant and receiving medical treatment and monitoring from two physicians of the defendants, according to a complaint filed June 28 in Cabell Circuit Court.

Murphy claims during her pregnancy, she was going through a divorce from her husband, Jonathan Broce.

Broce had Doe, who was a relative and/or friend, provide him with protected health information during the divorce, according to the suit.

Murphy claims the defendants violated HIPAA and were negligent in allowing her protected health information to be disseminated to Broce without the authority to do so.

The defendants breached Murphy’s confidentiality by allowing Doe, an agent, servant and/or employee, to access and disseminate her protected health information without authority and in violation of HIPAA, according to the suit.

Murphy claims the defendants’ actions caused her damages.

As a direct and proximate result of the defendants’ actions, Murphy’s protected health information was compromised, resulting in an invasion of privacy, according to the suit.

Murphy is seeking damages against the defendants for negligently disseminating the plaintiff’s protected health information. She is being represented by Robert B. Kuenzel and Eric R. Bias of Kuenzel & Associates PLLC.

The case has been assigned to Circuit Judge F. Jane Hustead.

Cabell Circuit Court case number: 13-C-450

When cancer isn't cancer at all

Overtested Americans: When cancer isn't cancer at all

By Jacque Wilson and Amanda Enayati

The patient slammed his fist on the table in Dr. Otis Brawley's office.

"Dammit, I'm American," Brawley remembers him saying. "You can't tell me I have prostate cancer and that we're just going to 'watch it.'"

Brawley is the chief medical officer for the American Cancer Society, a world-renowned cancer expert and practicing oncologist. If you're going to get someone's opinion on a cancer diagnosis or course of treatment, he's a good choice. And in this case, he was recommending no treatment.

It's a scenario that may happen more as science reveals cancer's secrets, the biggest one being that what we now call cancer maybe shouldn't be called cancer at all.

"The word 'cancer' often invokes the specter of an inexorably lethal process," a working group for the National Cancer Institute wrote in a recent recommendation. "However, cancers are heterogeneous and can follow multiple paths, not all of which progress to metastases and death."

Basically, cancer is scary, but some kinds may be more boogeyman-in-the-closet scary than serial killer scary.

To understand fully, you have to look at the history of cancer diagnosis, Brawley says. In the 1850s, a group of German pathologists did some of the first biopsies on people who had clearly died of cancer. They took samples of their tumors and decided what breast cancer looks like, what lung cancer looks like, etc.

Today, Brawley says, there is a patient who has a lesion that's approximately 5 millimeters in diameter -- smaller than a pea. There's a doctor taking a biopsy of that lesion and a pathologist who's analyzing the sample using 21st-century technology. The problem, Brawley says, is that they're still comparing the samples to the cancer definition that was created more than 150 years ago.

"He's going, 'This looks just like what those Germans said is breast cancer,' " Brawley said of the pathologist. "But it's 5 millimeters in size. What killed the woman 160 years ago had spread all throughout her body."

We all harbor abnormalities, says H. Gilbert Welch, Dartmouth professor of medicine and author of the book "Overdiagnosed: Making People Sick in the Pursuit of Health." And new technology is increasingly able to find these abnormalities. When we do, our inclination is to act, even when the remedy turns out to be far more harmful than the disease would have been, had it run its course.

There is a growing consensus, backed by mounting scientific evidence, that Americans tend to be overtested, overdiagnosed and overtreated across a variety of conditions. Some experts estimate that unnecessary interventions account for 10% to 30% of U.S. health care spending.

Part of the problem is our medical culture, Welch says. The physician may be engaging in what is known as "defensive medicine," which entails ordering tests to guard against malpractice suits, should something go awry. There may also be perverse economic incentives at play -- that is, in a fee-for-service system, doctors are compensated for the quantity of tests and procedures they order.

But a recent study of physicians with the U.S. Department of Veterans Affairs found that salaried physicians who received no income from an increased volume of services and who had limited liability concerns ordered as many heart stress tests deemed "unnecessary" as doctors in more traditional settings.

The researchers theorized that the doctors had "an exaggerated perception of benefit" of the tests. In an editor's note on the study, Dr. Deborah Grady observed that while the study sample was small, "neverthless, it suggests that the culture of overdoing is ingrained."

Simply put, physicians are trained to think that the way you take care of people is to "find stuff and to take care of that stuff," Welch says.

Patients aren't exactly helping the issue, either. Energized by public awareness cancer campaigns, many patients have been empowered to find cancer early through screening and to intervene as soon as possible, Welch observes.

"To raise awareness and to get people to participate in screening, we have to whip up fear; we must introduce a bit of 'dis-ease' into the population," he said. "In a way, we have to make them feel as if the world may be a more dangerous place and that they ought to be worried about their future."

Brawley's patient, the one he refused to treat, eventually found another doctor who would treat his prostate cancer. "Patients will doctor-shop until they get what they want," Brawley said.

It's an issue many people have difficulty wrapping their heads around: Some patients who are diagnosed with cancer do not need to be treated, because that cancer is never going to bother them. The problem is that we don't know who those people are.

"There is a lot of work and research in this area in trying to better characterize which tumors will matter," Welch said.

The National Cancer Institute working group made several recommendations for the medical community in addressing cancer overdiagnosis and overtreatment. One was a change in the terminology doctors use to talk about cancer, especially when the cells they've found may not be dangerous.

"Use of the term 'cancer' should be reserved for describing lesions with a reasonable likelihood of lethal progression if left untreated," they wrote.

They also noted that the public should be made aware that overdiagnosis is common in cancer screening.

Doctors know that approximately 10% of localized lung cancer tumors and 20% to 30% of localized breast cancer tumors that are found through screening would never cause harm, Brawley says. "That tumor would just stay there: never grow, never spread." The rate is even higher for prostate cancer at 60%.

But isn't screening used to catch some aggressive cancers in people that we would otherwise see too late to treat?

Some overdiagnosis is acceptable, Brawley says. "We cure and treat some people who don't need to be treated. And in return, we save some lives." But screening has its own dangers.

Whenever you test a population, you will have some false positives. For example, if a woman is told that her mammogram is abnormal, that diagnosis might be straightened out days or weeks later, and she might find out that she does not have cancer. The diagnosis will create anxiety and lead to additional unnecessary testing.

Good health is more than absence of physical abnormality; it's also a state of mind, experts say.

"In my experience, it's not the diagnosis of cancer which really kills people," said Ezekiel Emanuel, a former oncologist, vice provost for global initiatives and chairman of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. "It's the uncertainty."

The National Cancer Institute group recommended reducing the frequency of some screening examinations, focusing that screening on high-risk groups (e.g. screening smokers for lung cancer) and raising the requirements that would lead to a biopsy or other follow up care.

"We've been taught that cancer is a terrible thing and the way to deal with it always is to find it early and cut it out," Brawley said. "We're starting to realize that that is not true in all cases."

Weird facts about Sex and Childbirth

5 questions you'd never think to ask about childbirth

By Robert Martin

The evolutionary background of human reproduction can shed much-needed light on some of life's most intimate mysteries.

In my book, I trace our reproductive lifeline back to its earliest roots, revealing the hard science -- and the primate origins -- behind sex cells, mating behavior, gestation and the way we care for our young.

My main aim is to deal with issues that are of practical importance in everyday life. In that light, here are some of the questions that I tackle.

1. Why are a man's testes located outside the body?

In most mammals, including all primates, the testes descend from their initial position next to the kidneys into a pouch-like scrotum outside the body cavity.

Descent of the testes has been explained in various ways.

The most widely accepted explanation is that descent of testes is connected with the raised body temperature that is typical of mammals. It has often been baldly stated that sperm production cannot take place at body temperature. We know, for instance, that infertility results if a man's testes remain in the body cavity. Yet sperm production clearly can take place inside the body, because some mammals -- such as dolphins, rhinoceroses and elephants -- produce sperm with testes that do not descend.

Instead, it seems that a lower temperature is better for sperm storage. Mammals with undescended testes have various special adaptations to store sperm at sites where the temperature is lower.

2. How many sperm are needed to ensure fertilization?

The short answer is that only one sperm is needed to fertilize an egg. Indeed, it is disastrous if an egg is fertilized by more than one sperm as only one set of paternal chromosomes should be provided.

There are special mechanisms to prevent more than one sperm from fertilizing an egg. Yet the average human ejaculate contains a quarter of a billion (250 million) sperm.

Why so many? Several surveys have shown that men who have ejaculates containing fewer than 60 million sperm tend to have fertility problems. Moreover, fertility improves as sperm counts increase from 60 million to about 200 million sperm. But any further increase seems to have no effect on fertility.

We do know that the large number of sperm initially ejaculated is whittled down and that only a few hundred end up close to the egg. Part of that reduction in numbers clearly serves to remove unsuitable sperm. For instance, deformed sperm are filtered out by the mucus in the neck of the womb (cervix), and it seems likely that further filtering occurs in the oviduct (a tube allowing for the passage of eggs from an ovary). So large numbers of sperm are presumably needed to ensure that one high-quality sperm reaches the target.

3. Is it true that human sperm counts are declining?

Since 1974, various surveys have indicated that human sperm counts have been reduced by about half in several industrialized populations over the past 60 years or so.

But that conclusion has been challenged for various reasons, notably because some studies found no evidence for a decline in sperm counts. It has turned out that this is because there are marked differences in occurrence and timing between regions. It was also suggested that reductions in sperm numbers were an artifact arising from changes in counting methods.

However, the same methods have been used to assess sperm counts in farm animals such as cattle, sheep and pigs, and no decline in numbers has occurred. Human sperm counts have not yet declined to levels where fertility is severely threatened, and decreases may be leveling off.

More worryingly at this point, declining sperm counts are accompanied by a marked rise in abnormalities of the male reproductive system -- undescended testes and abnormal development of the penis -- in tandem with higher rates of testicular and prostate cancer. The evidence suggests an environmental effect of some kind that is only affecting humans. Several factors have been implicated, but prominent candidates are environmental toxins that mimic the action of steroid hormones.

4. Is there a distinct fertile window in a woman's cycle?

The "egg-timer" model of the human menstrual cycle, with ovulation and conception regularly occurring close to midcycle, has formed the basis for medical thinking and intervention since the 1930s. This model needs radical revision.

The notion of regular midcycle ovulation is itself just a statistical abstraction. Menstrual cycles show considerable variation both in length, routinely ranging between three and five weeks, and in timing of ovulation relative to menstruation.

More important, however, several lines of evidence lead to the revolutionary conclusion that sperm are stored in the human womb, probably in crypts in the cervix. This means that intercourse leading to conception can occur up to 10 days or more before ovulation takes place.

This raises major problems for the "rhythm method" of contraception, which relies on the accepted wisdom that sperm and eggs have strictly limited maximum life-spans, surviving for only two days and one day, respectively. In practice, the rhythm method (even with refinements) is very unreliable.

Worse yet, deliberate avoidance of intercourse around the time of ovulation can be confidently expected to increase the risk of fertilization with a time-worn sperm or egg and hence the probability of fetal abnormality. Various studies have indicated that this is, indeed, what happens.

5. Why is human birth such a long and painful process?

Human birth is a challenging process usually lasting several hours, rather than just an hour or two as in monkeys and apes. This is because our newborns are unusually large -- twice as big as babies of great apes -- and have particularly large brains.

During birth, the human baby rotates in a complex manner, with the result that its head normally ends up facing toward the mother's back rather than to the front, as in other primates. Measurement reveals that the size of the newborn's head is pushed to the limit. Biological dimensions generally fit a standard bell curve, which statisticians call a normal distribution. But the curves are truncated at the upper end for the newborn's head and at the lower end the size of the pelvic canal.

In a process called "genetic pruning," natural selection has acted against over-large heads and small pelvic canals. The fit is still so tight that the human brain also has to grow an unusual amount after birth. In other primates, the newborn's brain is about half its adult size, but in humans it is only a quarter of adult size.

So, despite the large size of human newborns and their brains, additional rapid brain growth after birth is needed.

Union to meet midwives amid obstetrics closure

The Nursing and Midwifery Federation will today meet midwives at the Millicent Hospital to discuss their futures.

Country Health SA last week announced plans to close obstetric services at the hospital because of a lack of doctors with obstetric and anaesthetic skills and a drop in births.

The decision has caused a community backlash, with the local mayor saying it goes against assurances that the service would remain intact.

The federation's Rob Bonner says he wants to meet Country Health SA before it finalises the plan.

"We would hope that Country Health SA will listen to our members, will listen to the local community and local government and revisit this kneejerk decision it's announced last week," he said.

He says about six midwives at the hospital stand to lose their jobs.

"Those midwives now are being asked ... to make decisions about where they see their personal and professional futures," he said.

"At least one midwife has already moved her employment to Mount Gambier so she can remain actively practising in the area.

"Others are considering whether they want to do the same."

Study shows US women get too many Pap tests

Study shows US women get too many Pap tests
A new study from America's Centers for Disease Control and Prevention (CDC) reveals that many American women are getting too many unnecessary Pap tests, the screening for cervical cancer.

A study published August 18 in the American Journal of Obstetrics and Gynecology found that many doctors are recommending annual Pap tests, even though guidelines in both the US and UK suggest that women over 30 years old and at average risk for cervical cancer wait at least three years between negative tests.

Researchers noted that over-screening adds up to extra costs, more hassle for women (arranging child care and/or taking time off work for doctor's appointments), and an increased risk of unnecessary treatment for false-positive test results, with no benefit to women in detecting more cancers.

Mark H. Einstein, MD, a gynecologic oncologist in New York City told WebMD News that "there is quite a bit of over-screening in women in the US, which ultimately leads to over-management and over-treatment."

Also the researchers stated that about 51 percent of doctors in their study ordered a recommended co-test for the human papilloma virus (HPV), which is a common cause of cervical cancer, in addition to a Pap test.

"If only half are using the co-test, there is a lack of understanding about the guidelines," says study researcher Katherine Roland, a behavioral scientist at the CDC in a statement. "Women should discuss with their provider whether they are eligible for extended intervals between testing or not based on the type of test that is ordered and their results."

The new findings appear in the American Journal of Obstetrics & Gynecology

Pharmacist Reveals 5 Trade Secrets You Don't Get 'Over-The-Counter'

Pharmacist Reveals 5 Trade Secrets You Don't Get 'Over-The-Counter'

By Alan Okpechi

Behind the glass at your national chain pharmacy exists a world of long periods of boredom punctuated by extremely busy periods of stress, angry and illogical patients in Xanax withdrawal, and screaming babies with fevers. The typicalpharmacist has grown accustomed to a mostly sedentary life of sitting in chairs and occasionally helping patients with problems of the insurance variety.

While we may think our job is to make time go by as quickly as possible, there are constantly issues that go unresolved and leave patients without medication. Placing too much trust in your local pharmacy can also be dangerous for your health and, though rare, errors are made that can compromise your health.

There are, however, simple steps that patients can take to ensure everything is done correctly every time you fill a prescription. Whether it's the pharmacy's fault or not, there are also ways to resolve insurance denials with little effort.

1. Do not trust the expiration date on your prescription bottle.

Unless you are given the exact bottle delivered to us by the manufacturer, you may as well be guessing as to when your medication actually expires. While expired medication may not be worrisome, the effectiveness of your medication decreases with each passing day that the tablet or capsule is expired. With hundreds of bottles of medication being delivered to pharmacies every week, it is easy to overlook the expiration date of medication.

Safety is our first priority for patients, but some things do slip through the cracks. If you have a condition which requires a precise medication and strength, ask the pharmacist to show you the bottle from which the medication originated. Self-verifying the expiration date only takes a few seconds, and gives you the confirmation that you need to trust the effectiveness of your prescription.

2. Do not pay full price for an insurance denial.

If an expensive medication is denied by your health insurance company, ask your pharmacist to perform aprior authorization while you wait. Waiting in the pharmacy is crucial for this process to be successful. A prior authorization is simply a form that is sent to your insurance company and doctor's office that can force your insurance company to pay for your medication. This process usually takes up to 10 days depending on the pharmacy. However, I have personally pushed this process to be completed in under 10 minutes. Make sure that your doctor or his/her staff is prepared to answer the call from your insurance company. Once your doctor or staff says the magic words, "medically necessary," you are on your way to paying your regular co-pay for your medication.

The alternative is waiting 10 days for a rejection from your insurance company for a prior authorization that may or may not have been done in a correct and timely manner. Some pharmacist may try to brush off this request, but the fact is we are legally required to assist you in getting your medication. Anything else can be considered unprofessional, irresponsible, and possibly grounds for malpractice. Do not get pushed around by anyone when it comes to your health.

3. All generics are not created equal.

Insurance companies push generics due to their low cost, but every person reacts differently to medication. There are some medications for conditions like epilepsy and thyroid issues that, for some patients, work differently than their brand-named counterparts. Even the same generic medication made by different manufactures can have a different effect on the same person. While the chemical structure of the medication may be the same, the way it is synthesized and concentrated differs from company to company.

Small differences between medications can make all the difference for a patient. If one generic does not work for you, ask for a different malefactor. If no generics work, you always have the option (under federal law) to substitute for the brand name version. Many patients experience a change in their health when a generic becomes available for their medication, but are unaware that they do not have to take the generic medication.

4. Ask for a loaner when needed.

If you for some reason run out of medication (that is a non-controlled medication such as Xanax or Hydrocodone) your pharmacist has the option to give you up to a three-day loaner supply to hold you over until your doctor is contacted for a refill. This loaner supply also goes for when you are out of town and forgot to pack your medication -- if you do have a refill somewhere in the United States -- though you may have to pay for the three-day supply in this circumstance. Many pharmacist do not extend the offer because they fear taking a loss for the pharmacy, but simply asking is often all a patient needs to do.

5. Take advantage of transfer gift cards!

We will give you a gift card for a transfer in almost any situation. If you are in a large national chain pharmacy, at least. When gift cards were popular for transfer prescriptions in 2005, there were many restrictions placed as to how they were to be given out. These restrictions no longer exist since we have been notified not to argue with customers in this situation. Instead of a pharmacy district manager personally replying to complaints on transfer gift cards, most pharmacies simply give them out. There may be nice pharmacy staff who will give you a gift card automatically, but most hope you don't ask. Ask for the card: Issuing $30 gift cards brings returns to the pharmacy that exceed their cost. The pharmacy makes a fortune from insurance companies, you shouldn't feel guilty or timid for taking advantage of a program created for the patient.