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2nd part of the case 2

comment on the blog with their group, their conclusions and reflections on the pdf. of babies called Baby Doe generically and the article by Dr. M. Parra on invasive procedures.

Invasive Procedures in Prenatal Diagnosis (Dr. M. Parra)

Screening for chromosomal abnormalities in pregnancy can be made by ultrasound findings (nuchal translucency, absent nasal bone, tricuspid regurgitation, altered ductus venosus, etc.) Associated with measurement of serum chorionic gonadotropin and pregnancy-associated placental protein.
The problem with these non-invasive methods is the false positive rate ranging between 3 and
5% due to the implication that it is possible to predict trisomy and finally an infant born normal.

The accurate diagnosis of fetal karyotype is only possible through any invasive procedure
(taking a sample of amniotic fluid, placental tissue or fetal blood), which positively eliminates the uncertainty of false positive, however implies a risk reproductive loss of around 1%.

For this reason, it is important to note that the use of these methods require invasive proper advice, which respects the autonomy of patients and delivered a thorough information on the benefits and disadvantages of the procedure.

On the other hand, we might ask whether the benefits delivered invasive methods outweigh the possible harm to the embryo in a country like Chile, where abortion is not allowed, and these benefits are limited only to a more informed mother and timely management of complications (eg esophageal atresia.)

"The prevalence of invasive procedures in our
study was 0.45%, much lower than reported in countries where abortion is
legalized
which are higher than 5%, depending on the type of aneuploidy screening used "

A striking difference noted in this study, which concluded that due to good counseling. On the other hand, as you told us an obstetrician at the Hospital San Borja Arriarán, when offered such procedures to patients, not interested.

BABY DOE Case Analysis

Click here to read the case

To give a logical order to help us draw conclusions, we will develop the case from his record. We invite you to read this analysis and also enrich the discussion with their contributions.

Background case:

polypathies Child: Down syndrome, tracheo-esophageal fistula and esophageal atresia.

Possible ways forward:

- Operation gastro-respiratory malformations with 90% probability of success.

- not allow operation with a fatal outcome for the newborn

parental choice:

- not allow operation

Counseling:

- A reference by the obstetrician Walter Owens

type approach in counseling:

- -type persuasive rather than informative

first point to reflect on how medical advice provided in this case the obstetrician Owens. It would have been ethically appropriate provide parents with all available information, the solutions with their advantages and disadvantages, so that in this way they take an informed decision and not to accommodate possible influences of others.

believe at this point the possibility of parental choice, because when there was no case law regarding such situations.

reaction medical settings:

- Rejection of parental decision

Action

type responsible to a decision that clearly showed the least controversial.

Consequences:

- Hearing before Judge John Baker

- Cited Owens to declare that it maintains its position

- state was quoted BABY DOE's father who disagreed with the position of Owens

hearing Features:

- No records

- No guardian ad litem for BABY DOE

The fact that there are no records or guardian ad litem (click here for its meaning) for Baby Doe gives to think of a process rather than wanting the welfare of children, seeks action self-defense to avoid legal consequences or image to the hospital. Also, the fact that no coach is a sign of lack of awareness of life that develops in utero, and are not considered the best interests of children.

judge's decision and consequences:

- Parents have right to make a decision on whether the child is trying

No legislation, decision set for the law but ethically reprehensible .

- Appeals by the district attorney in both instances. Both failed.

- Last appeal to the U.S. Federal Supreme Court. The case does not reach Washington DC before the child's death at 6 days old.

child's birth date:

- April 9, 1982

implications of your case:

- April 30 of that year the Department of Human Services Health banned discrimination against the disabled in future cases.

- DHHS rules that is illegal and discriminatory suspend food or medical support of patients born with disabilities.

- In 1984, the law is passed "The Baby Doe Rules" which he condemns as abuse and neglect, rather than discrimination, failure of medical treatment given to a child, whatever their status, except in cases exceptional.

Due to media attention and further reflection on this case immediately after the death of Baby Doe, begin to develop policies and laws that protect the life of the disabled. This, unfortunately is late, at least a precedent on the responsibility of the state to protect human life in line with all international human rights treaties.

Finally, using the concepts of law, "The Baby Doe Rules" emphasize that in this case there was a neglect and abuse of this form to a human life, which was abruptly abbreviated due mainly to weak legislation and having as additional factors, poor medical advice, a possible negligence regarding the best interests of the child and that includes all these factors, poor bioethical discussion on cases of this type and its management.

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Case 3 Case 4

Patient 32, married, multiparous 3 vaginal deliveries, control goes to gynecological because he contacted from the office at your Pap.
, the patient is concerned and when interviewed by the midwife, it invites you to have a NIE cervicopatía I associated with HPV.
The patient does not understand what it is and asks for an explanation in simple terms.

Do I have cancer?, If I have no chance now Do I have cancer? What chance? "The PAP is false positive? What about false negatives?
What to do? How did this happen to me?

I would answer in a tone that allows you to calm down ... The PAP came
altered, found an injury that needs to be observed from time to time and is caused by a virus called human papilloma virus, which was probably infected via sexual transmission. The spread of this virus is very common in the lives of men and women, independent of socio-economic strata and is related to the number of sexual partners, this means that the higher number of sexual partners, the more likely it is to have an infection by this virus.

QUESTION 1:
• How will you inform. the patient of the above?
• How do you communicate that acquired the virus? • Does
ud. obligation to do so?, in what cases would be required?
No, do not have cancer but there is a slight chance that the injury from becoming cervical cancer, so it should be monitored by taking regular PAP. It may happen that the injury is gone, this is called a transient infection.

QUESTION 2:
• A patient with an STD is more likely to have another.
• Is this an STD?
Yes, it is a sexually transmitted infection, although cases have been described by fomites transmission, this has not yet been proven in a hundred percent. Keep in mind how common is this infection in a person's life and that many of these infections are transient type, this not to stigmatize those affected by HIV patients.

QUESTION 3: The patient wants you. I explained to the husband, who has accompanied her and is in the waiting room. What does that tell you.? Your request
understanding that this situation rests with the couple, not just the patient. Well we avoid misunderstandings and misconceptions about the condition and the cause of infection of the patient.

QUESTION 4: The patient tells him that this does not happen to their daughters, want them vaccinated. She asks: Is there a vaccine to protect them, dr.?
What tells you.?
Yes, there is a vaccine that protects against the papilloma virus types that cause cervical cancer. The cost of this vaccine is quite high and not covered by FONASA, ie the user must pay 100% of the cost of it.

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Case 5: Assisted Reproduction

Ana (30) and Miguel (34) are a couple began his study of infertility after three years of trying without success. They came to two centers of reproductive medicine and the university hospital.

been told in all the same. Have the diagnosis Infertility of unknown cause.

All tests so far have been normal. In the last consultation poses the possibility of an in vitro Fertilization (IVF) and in the center prevents multiple pregnancy and ovarian hyperstimulation syndrome, through the freezing of spare embryos from a single induction procedure ovulation. It has also this procedure, the addition of being cheaper than the subsequent induction of ovulation.

They crave parenting, but had not raised the possibility of frozen embryos.

· ASK No. 1
Review biological aspects of the clinical situation and point raised which are the points where it is still not clear. Try to answer as you know or you manage to check with your teacher.

Our first question is whether is it conducted a comprehensive study to conclude that infertility is the cause "unknown"?. We assume that if you are going to try in vitro fertilization studies are available of semen in man indemnity ovulation and tubo-peritoneal in women. However, there are studies that could not have been done, such as diagnostic laparoscopy , to rule out endometriosis, immune Study: antibodies, thrombophilia study.

probably took all the necessary examinations, and who visited 3 sites with no results, so in-vitro fertilization seems to be his last chance. The advantage of this is performed only once is, and avoid repeated ovarian hyperstimulation treatments, resulting in eggs that are fertilized and then frozen, ready to deploy, so that in case of failure of the method, we have other reserve embryos implanted. Thus avoiding multiple pregnancies (which are risky for both mother and fetuses).

· ASK N º 2
addition to the dilemmas arising from the freezing of embryos:
What other situations (legal, social, economic, family) should face a couples seeking Assisted Reproductive Technology (ART)?

Legal: Chile does not have a law and treatment embryos has not been specified what to do with those embryos in pronucleus surplus status, those who will never be claimed by their parents. At issue is whether these embryos can be donated to other couples, but even so, would embryos "Surplus."

On the other hand, there is some consensus on these methods enable married couples and couples in relationship, but also might have disputes against single women and lesbians.

Social : It makes sense to think that there might be a selfish attitude on the part of couples who spend so much time and money on getting pregnant by these methods, there so many children that need to be adopted and loved in a home. However, nobody can impose it, and it is equally valid to want to conceive a child of a partner product.

Economics: These techniques are expensive, so it produces a bias in the population that has the ability to pay and those without, the latter who are the majority and therefore violates the principle of justice. We also have to consider that technology can fail.

Family: in this area is very important that the wishes of conceiving a son go hand in hand with responsible parents, by what would be a dilemma between providing these methods on demand versus "requirements" necessary to access them.

· ASK No. 3
What is the ethical reflection on these techniques?

ethical problems that arise from these techniques have multiple edges, so you have to look at the issue holistically, that is, from the implications regarding the use of embryos, the problems associated with children born by these techniques.

Frozen Embryo : The main problem with assisted reproduction techniques is the use of preimplantation embryos, the freezing of surplus embryos and the fate that will be given. Some questions that arise are:

· Will they make the parental project of their parents?

· Will be donated to other infertile couples, in what has been called the "prenatal adoption"?

· Will they be destroyed or will die?

· Will they be used for research purposes or for obtaining stem cells, in the interests of Medicine regenerative?

To address these questions, first, try to define what is status of the embryo and their respective rights, and Therefore, respect and protection it deserves. In this regard there are different positions:

a) The embryo as a potential person with the same rights as any

b) That the training of the person is an ongoing process, therefore makes a distinction between an embryo before implantation and one already in place.

c) that arise in certain stages of development: for instance, to eighth week of gestation, at which time completed the process of organogenesis.

Determine when the embryo deserves to be called person is not less because it depends on how a country legislate respect, open doors or not stem cell research, which is subject of a broad debate.

On the other hand, has been in recent times improvements in techniques for freezing oocytes (which was not feasible) that will store these eggs for later use, so it could be a possible solution to the problem of "spare" embryos that are current techniques.

Rather than make a stand, we believe it is imperative to legislate on the subject, so they have clear rules and procedures both the technical side, as the embryos that allow the practice of fertility techniques no irregularities of any kind (eg the manipulation of the embryo and its use as a means of investigation.)

Internet Searching on the subject, we find a bill written by Senator Mariano Ruiz Esquide about assisted reproductive techniques. We very much like the initiative (to read click here )

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ABORTION

female patient of 15 years, emergency consultation at the maternity clinic. Is carried by their parents who report accuses her daughter go because strong abdominal cramping pain in lower abdomen of two days duration, associated with genital bleeding. History of dysmenorrhea grade II to III, from menarche. Vital signs, BP 120/80, pulse 110 x min, FR 16 x min, T ° 37.5 ° C.

care In the box, out of sight of their parents, the patient reported that he had no periods since the summer holidays date on which they had sex with her boyfriend. Not been controlled by fear of their parents.

On examination the pregnant uterus is found approximately 2 ° month of pregnancy. The speculoscopy a gaping neck, by which POC out smelly, and regular blood in quantity.

· Question No. 1

or What is (the) assessment (s) more likely (s ) of the patient?

According to medical history and physical and gynecological examination of this patient are some diagnostics that we can easily dismiss such as a threatened abortion as this is defined as metrorrhagia with or without lower abdominal pain and cramping the speculoscopy is possible to observe a cervix with the OCI (internal os) closed, it is not the case of the patient with a dilated OIC, however it is not an inevitable abortion as this has no expulsion of POC as the patient if expulsion of POC may relate to incomplete abortion. could also suspicious of another diagnosis that is septic abortion, which has several diagnostic criteria such as: abortion, fever> 38 ° C , bad smelling discharge, pelvic pain, painful cervical mobilization of the patient above abortion, fever of 37.5 ° C, smelly, pelvic pain, so we could actually say that studying with evolving septic abortion. For the final diagnosis we must be mindful of the epidemiology of Chile that most abortions are septic abortions, but may find other causes such as pregnancy with IUD in situ and long-RPM, This coupled with the fear felt by the patient to face his parents and tell them about his condition. Therefore we can say the patient had an abortion, incomplete, and septic development.

Once the patient is only asked the doctor who treats you that do not communicate the diagnosis to their parents. However they do require additional examinations and gynecologic ultrasound, for which should be hospitalized.

· Question 2

or What should the doctor do, What you see values \u200b\u200band principles that are in conflict?

The doctor before taking this decision that may be of great importance both as a medical-legal family, should reflect on the values \u200b\u200band principles at stake in this situation. First is the principle of autonomy , since the patient has specifically asked the doctor to be kept secret, but on the other side is opposed to the principle of beneficence , because if the patient is hospitalized properly treated can have serious health consequences, including septic shock and death. As we know medical confidentiality is a fundamental part of the doctor-patient relationship must always be respected, with some exceptions and one of them is that the patient can not make their own decisions, and that is because it is not competent to do so or not old enough to be accountable for its actions and decisions, in this case the patient may be fully aware of their actions and be capable of discernment, but it is legally a minor and medical decisions should be made by their legal representatives, in this case their parents. As we believe that physicians should talk to the patient, alone, explain what their health status, complications if not treated properly and timely and also talk about the medico-legal problems that can cause an abortion in our country, so that the patient can decide on their own to tell their parents, unless this situation believe that the doctor should inform parents of the child's diagnosis has come to, possible treatments, consequences and get their informed consent to hospitalize a patient and perform the necessary tests to confirm their status and treatment. Although as a group believe that if the doctor manages to establish a good relationship with the patient and manage to have adequate confidence, she will probably decide to tell your parents what happened and for that the doctor can help enough to face this situation.

· Question No. 3

or What would you say are the physician's obligations to ...?

a) With What rights do parents have? The physician has an obligation to inform parents the medical condition his daughter, possible treatment options and the risks involved with each procedure you perform. Since we believe that parents have the right to know "why" of the hospitalization of her daughter and we do not invent another appropriate diagnosis because parents with minor children are also part of the doctor-patient is more, they form a triad (Doctor-parent-patient) the physician must respect.

b) With patient What are your rights? The obligation the doctor treating the patient, not just the biomedical, but include it on the biopsychosocial model of modern medicine, which involves dealing effectively with much its medical expertise and professionalism, doing everything in their power to achieve health of the patient. But do not forget the psychological and social support is included in the emotional, empathy, education, social support.

c) With Duties of society "to an abortion doctor? In our country abortion is illegal, so the doctor should not allow or perform an abortion. In patients that you explicitly request that they do one, he must educate them about the abortion law and with great empathy solve doubts and fears that the patient may have about your pregnancy, to achieve greater acceptance of it. Given the situation described in a case the physician should report the situation, because if it does it could mean a penalty against him.

· Question No. 4

Discuss with your teacher this case and ask if you have a situation of confidentiality that is opposed to other principles. What have you done?

Commenting on this case with a teacher tells us that as the patient is a minor, the physician's duty is to give information to parents the diagnosis of her daughter, but that effort must first speak with the patient and adequately explain the situation and talk to her fears and concerns so that she can make the decision alone to tell their parents of their pregnancy and subsequent abortion, we note that in most cases the patient agrees to talk to their parents, but with the help of a doctor.

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CLINICAL CASE No. 2

A pregnant woman aged 37, enrolled in a pregnancy of 13 weeks is taken to the emergency room during the night. Her husband is on the way home from work, very upset, crying because the ultrasound was performed in birth control, told him he had a high risk of having a child with Down syndrome. The patient did not request that he have no special consideration during the scan and asked for his consent to be relayed.

attending the clinic to have a new ultrasound machine, with a group of highly qualified doctors and constantly improvement in a reference center university maternal-fetal medicine.

QUESTION No. 1

Do you know that is "risk of aneuploidy?

If first say that aneuploidy is a change in the number of chromosomes of an individual. For example:

Trisomy 21-Down Syndrome Trisomy 18-

Edwards Syndrome Trisomy 13-

Patau Syndrome

And the risk of aneuploidy is the probability that a woman (or couple) to have a child some alteration in the number of chromosomes.

What are the markers of aneuploidy?

markers of aneuploidy, as its name implies, are instruments through which we can define the risk of aneuploidy and classically have been divided into two: biochemical markers and ultrasound.

biochemical markers: alpha-fetoprotein (decreased in trisomy 21), estriol, B-HCG (increased in trisomy 21) and PAPP-A (pregnancy-associated protein).

ultrasonographic markers, which are determined by "normal variants" that are frequent in children with aneuploidy. Among them we can name the nuchal translucency, ductus venosus, nasal bone, short femur, mild hydronephrosis, echogenic bowel, among other cardiac malformation.

What risks does this patient? Do you know how to define the number of false positives in this situation?

real risk of this patient to have a child with aneuploidy is called Risk Adjusted and corresponds to the baseline risk (age + background) along with the risk of the markers (biochemical and USG).

- Baseline risk: If we consider the patient's age (37 years) and gestational age of pregnancy (13 weeks) could say as Snijder table that has a probability of 1 in 152 of having a child with aneuploidy. On the background we have more data to know whether this patient had a previous child with Down syndrome or other chromosomal abnormality.

- by markers Risk: There have been no biochemical markers, ultrasound only, which do not know what or how many abnormalities were detected by the sonographer. But for example if the translucency was abnormal, with a value of 4 mm, the chance for aneuploidy is 21%, However if the value is 7 mm, the probability is 64%.

therefore not possible to predict the risk of this patient with the background information provided in the clinical case.

False positives: in nuchal translucency is 5%, while the nasal bone hypoplasia is 1.8%. However, the patient should know that the mere presence of ultrasonographic markers not sure that the fetus and unborn child has Down Syndrome, since it is known that the percentage of healthy children had increased nuchal translucency is high, eg

between 3.5 to 4.4 mm - 86% of healthy children Between 4.5 to 5.4 mm

- 77% of healthy children between 5.5 to 6.4 mm

- 67% of healthy children

Mayor of 6.5 mm - 31% of healthy children

QUESTION No. 2

What medical, legal, ethical, experiential, do you think there are associated with the case presented?

- Medical problems: First, it presents the medical problem, unknown to readers of this case in which there is no indication the cause of admissions to the emergency of the mother that night, this may or may not be connected with the news received in the office during control prenatal. However, we believe that this story could actually have altered the psychological environment of the woman, causing great stress, which is shown to be a major risk factor in ascending bacterial infection, which is a risk factor in turn abortion and premature delivery, which may be the reason for the visit to the emergency. This hypothesis needs time to develop, but in the case report does not specify the time between the control in the office and consultation with the urgency of this woman, so our idea may be valid.

- Legal issues: If a result of medical problems that occurred in this woman and that motivated to go to emergency, the fetus is damaged or dies, we believe that the couple could even bring a lawsuit against the consultant medical staff to alter their psychological state and as a result have caused an abortion in a pregnancy that was studying at that time so normal.

- Ethical issues: two main problems occur in this situation. The first is that it does this "measuring or testing" the fetus during the ultrasound without the knowledge or consent of the mother, which disregard the principle of autonomy and second place is given to know this high risk your child has Down syndrome when she did not authorize to be informed and that he knew that he was making this measurement. It follows read in a case that the mother did not receive information in a good way, this may be because it was not explained clearly enough risk means nor what were the chances that this diagnosis is not accurate , leaving a great anxiety and distress in the mother.

- existential problems: There are clearly problems in daily life brings the unexpected information received by the wife, since we can assume the sadness, anger and anxiety that left her knowing this elevated risk for Down syndrome your child.

QUESTION No. 3

Discuss the case with your teacher. Has this ever happened? What did the patient and what did he (council) for his patient?

Al This case discuss with our teacher tells us that in his experience most mothers with a pregnancy at high risk of aneuploidy unrepentant to know the risk, but nevertheless involves a big emotional and anguish for what needs to be very assertive to handle this type of information adequately explaining to the mother and father what the results mean, it's just a probability, but nonetheless if they want there are other diagnostic methods to confirm a certain condition, but most couples choose not to have them, and continue as normal pregnancy.

QUESTION No. 4

What other tests can be derived from this situation clinic? What are the risks? What would you advise?

In this clinical situation can be derived as well as tests to establish more accurate the risk of aneuploidy or confirmatory testing of these pathologies. Among the former are the biochemical markers and ultrasonographic mentioned in question number 1 and confirmatory tests in the genetic study we are using the following techniques:

- chorionic villus sampling (CVS)

- Amniocentesis

- Cordocentesis

The

which are unsafe and are therefore reserved risk groups only. Among the complications of these techniques include: loss of amniotic fluid, infection, bleeding and fetal loss, which reaches 1% at cordocentesis.

Therefore as a clinical case the patient is at high risk of aneuploidy by the medical team would be a candidate for office these confirmatory tests, however we advise you to be held only if she would like some evidence first place a non-invasive as obtaining biochemical markers (B-HCG, PAPP-A, estriol and A-FP) and a second step these other invasive tests performed. Obviously, before explaining the utility, advantages and complications of these techniques, and that knowing the diagnosis of Down syndrome in a prenatal stage, no further change in therapeutic behavior, unless the fetus is a complication that is necessary timely repair and esophageal atresia, whereupon the medical team must be prepared.

QUESTION No. 5

Comment or investigate the following concepts:

iatrogenic verbal The verbal iatrogenic happens when you say you should not say

1. When false as a result of ignorance, ignorance not knowing, not being aware of what is not known.

2. When it is not appropriate.

3. In the absence of the necessary empathy.

4. When you do not know how to use a metaphorical language understandable to the patient.

5. When there is sufficient time for communication doctor / patient may develop and ensure understanding by the patient.

right to be informed is the right that everyone a person to has to know, in cu lquier to moment, what is h to d ce with a person to cough them. In the area of medicine is that the patient has a right to know their diagnosis, what it is and evolution, if not treated. If you choose to be treated, you must know what are the treatment options and side effects they might cause.

right not to know: is restricting the patient to know their diagnosis, evolution and / or prognosis as long as it has expressed previously. Occurs in exceptional situations such as: patients with terminal cancer.

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I was once John Flint ...

Fortunately, divine grace of Our Lady of Mercy, patron and Perpetua Mayor of the City of Baza, I had the privilege to 6 September 2008 to embody the figure of John Flint, better known by the inhabitants of Baza and Guadix as Cascamorras

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Magic Seeds of Fortune

pumpkin seeds various healing properties. As a result they are associated with prosperity. If one is good physically and mentally, has a balance that is sustained over time, have the energy to produce concrete goals, focus, work and find solutions.

advantage for the magical properties of these seeds, we will perform a spell whose purpose is to facilitate the arrival of fast money.

will place in a small wicker basket, a handful of rice, beans and lentils.

then will a ticket for a high intensity ("money attracts money") and currency (the most valuable that you can drop) inside the basket.
top of the ticket, we will extend a handful of sunflower seeds (peeled) and a handful of pumpkin seeds (with or without shell).

Leave it all so immovable in a quiet place until the next new moon, night (just the first night of high) in which we get the ticket and the currency basket and place it in our purse or wallet.

The always take with us to have prosperity in life nuetra. If you had to spend that money, you will have to make the whole ritual again.

You can start the spell on any night of the waxing moon, especially on Friday or Sunday and repeat as many times as you please whenever there is a real need.

shall observe the basket to do other things magical and rice, beans, lentils and sunflower seeds, pumpkin seeds will be collected in a yellow handkerchief (also can be gold) and both sides esparciréis portal your house when you go out into the street the next day. If for any reason not been able to do so, we come near to gardens, and leave on Mother Earth. Later, and keep the handkerchief, folded four times, including your underwear.

I hope you find it useful. God will open the roads and guide us in them!