CPD questions for volume 15, number 2

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image Surrogate pregnancy: ethical and medico-legal issues in modern obstetrics

With regard to different types of surrogacy,

  1.  the practice of ‘straight surrogacy’ produces a child who has no genetic link to the surrogate mother.

When medical interventions in pregnancy (such as amniocentesis) are recommended,

  1.  a doctor should obtain consent from both the commissioning parents and the surrogate if the baby is the genetic child of the commissioning mother.
  2.  In 2013, professional medical bodies are totally opposed to surrogacy arrangements in the UK.

After delivery,

  1.  the community healthcare visitor should only visit a baby if it resides with the surrogate mother.

If the surrogate mother has a miscarriage,

  1.  the doctor may be asked to provide evidence to support this.

Commissioning parents,

  1.  previously knew the surrogate mother in about 10% of cases.
  2.  are free to consent to medical treatment for the baby while waiting for parental responsibility to be granted, provided that the child resides with them.

With regard to the surrogacy contract,

  1.  it is legally enforceable and therefore the involvement of the Trust’s legal team is unnecessary.

With regard to current legislation surrounding the practice of surrogacy in the UK,

  1.  the introduction of The Human Fertilisation and Embryology Act 1990 makes it likely that there will be more cases of surrogacy in the future.
  2. if the surrogate or a foreign commissioning parent domiciles in the UK, then UK laws apply regardless of where conception occurred.
  3. organisations and agencies involved are legally allowed to operate in the UK, and can charge membership fees provided that they operate on a non-profit basis.
  4. if a surrogate mother feels emotional and unsure about handing over the baby to the intended parents after birth, since she has already accepted payment from the intended parents she is bound by the terms of her contract and must continue with the arrangement.
  5. advertising the availability of surrogate service is illegal in the UK.

Regarding parental responsibility,

  1. the court will grant a parental order if the commissioning couple are either married or cohabitees and both are >16 years old.
  2. a parental order can only be granted to a same sex couple if they have been together for at least 10 years.
  3. the commissioning couple should apply for parental responsibility within 6 months after the birth of the child.

With regard to the surrogate mother,

  1. if she changes her mind about handing over the baby after birth, it is possible that she may be able to retain legal custody of the child if she has a genetic link to the child.
  2. if her husband was unaware that his wife underwent artificial insemination and became pregnant as a surrogate, he is still the legal father of the child.

If a woman has donated an egg,

  1. she is legally considered to be the mother of the child.

The commissioning mother,

  1. will be entitled to normal maternity rights with her employer if she has a genetic link to the child.

image Sickle cell disease and β-thalassaemia major in pregnancy

With regard to pregnancies in women with sickle cell disease in the UK,

  1.  the perinatal mortality rate is about double the overall national rate.
  2.  the maternal mortality rate is about 220 times higher than the overall national rate.

The following complications occur with increased frequency in pregnancies in women with sickle cell disease:

  1.  severe pre-eclampsia.
  2.  placental abruption.
  3.  pyelonephritis.

The following medication should be stopped in a woman with sickle cell disease who is trying to conceive:

  1.  vitamin C.
  2.  hydroxycarbamide.
  3.  desferrioxamine.

With regard to the national antenatal and newborn screening programme for haemoglobinopathies in the UK,

  1.  one in 35 pregnant women carries a haemoglobinopathy.
  2. about 300 babies are born annually with sickle cell disease.
  3. about 200 babies are born annually with β-thalassaemia major.

Treatment of a patient with an acute sickling crisis requiring hospital admission in pregnancy should usually include:

  1. low molecular weight heparin injections.
  2. blood transfusion.
  3. intramuscular injection of pethidine for analgesia.

Complications seen with increased frequency during pregnancy in women with sickle cell trait include:

  1. chest syndrome.
  2. acute pyelonephritis.

In the context of the complications of haemosiderosis, seen in transfusion-dependent young adults with β-thalassaemia,

  1. diabetes is the commonest endocrine complication.
  2. osteoporosis correlates directly with the occurrence of hypogonadotrophic hypogonadism.

The following are among the most significant (i.e. most frequent) complications of pregnancy in women with β-thalassaemia major:

  1. cardiomyopathy.
  2. obstructed labour.

image Role of surgery to optimise outcome of assisted conception treatments

Regarding salpingectomy for the management of hydrosalpinx,

  1.  although the detrimental effect of hydrosalpinx on the outcome of in vitro fertilisation (IVF) is now well documented, the underlying reasons are still not very clear.
  2.  there is very little evidence to suggest that salpingectomy for hydrosalpinx, prior to IVF, improves outcomes.
  3.  a larger treatment effect has been observed (up to 3.5-fold increase in delivery rate) for women with more severe disease.
  4.  patients who refuse primary surgery should not be counselled regarding benefits of interval salpingectomy after a failed IVF treatment cycle.
  5.  there is good evidence to offer salpingectomy for communicating hydrosalpinx only.

With regard to uterine fibroids in women with infertility,

  1.  they are associated with decreased pregnancy rates following IVF treatment.
  2.  most experts recommend removal of cavity-distorting intramural fibroids before IVF, although there is no strong evidence that their removal improves outcomes.

With regard to polyps,

  1.  despite lack of clinical evidence, most clinicians would recommend hysteroscopic removal of endometrial polyps prior to IVF.

Regarding uterine septum and other uterine anomalies,

  1.  a review of non-controlled trials reported a 74% reduction in miscarriage risk following hysteroscopic division (septoplasty) in patients with recurrent miscarriage.
  2. the presence of a septum represents an important hysteroscopically preventable risk factor for lower implantation rates in patients undergoing IVF treatment.
  3. available evidence suggests poor outcomes for women with arcuate uterus; however, there is no agreement whether this anomaly should be treated even in patients with recurrent miscarriage.

Regarding endometriosis,

  1. it affects 20–40% of women who complain of subfertility.
  2. possible reasons for subfertility in women with this conditon include interference with embryo development and implantation.
  3. IVF success is similar if not better in patients with this condition than in those with other aetiologies such as tubal factor infertility (despite reduced responsiveness to ovarian stimulation).
  4. medical treatment, although useful for management of pain symptoms and limiting progression of disease, is very much compatible with fertility.
  5. surgical treatment of the condition aims to remove all areas of endometriosis (optimal debulking) and restore anatomy by the division of adhesions.
  6. the ENDOCAN multicentre RCT showed a two-fold increase in conception rate following laparoscopy and treatment of superficial condition compared with diagnostic laparoscopy alone.
  7. a Cochrane review of three RCTs found that the administration of GnRH agonists for a period of 3–6 months prior to IVF in women increases the odds of clinical pregnancy four-fold.
  8. the evidence for increased spontaneous conception rates following treatment of endometrioma is based on a review of observational uncontrolled trials.
  9. international (ESHRE) guidelines recommend treatment of endometrioma larger than 40 mm prior to IVF.

image The BSUG national database: concept, design, implementation and beyond

It is recommended by the British Society of Urogynaecology (BSUG) that prior to using the database within the Trust one should inform the following:

  1.  the local Caldicott Guardian.
  2.  the clinical director.
  3.  the Trust research and development ethics committee.

The data on the BSUG database is useful for:

  1.  personal development and appraisal.
  2.  clinical governance purposes.
  3.  identifying the training offered to trainees by a given clinician.

With regard to the BSUG database,

  1.  patient identifiable data (PID) are only visible to the patient's clinician.
  2.  the management of the patient identifiable data within the BSUG database has to fulfil the Caldicott Guardian principles.
  3. in patients who are already in the system (having had previous surgery) their identifiable data need to be re-entered for each surgical episode.
  4. a patient’s verbal consent is adequate for use of their personal data on the database.

The following questionnaires form part of the objective measures of outcome in the BSUG database:

  1. ICIQ-VS.
  2. ICIQ-SM.
  3. ICIQ-OAB.
  5. EPAQ.

With regard to the BSUG database,

  1. it is still awaiting recognition by the National Institute for Health and Clinical Excellence (NICE).
  2. tertiary hospitals comprise at least half of the active centres on the database.
  3. BSUG currently allows any consultant or associate specialist/subspecialty trainee who performs anti-incontinence and/or prolapse surgery to gain access to the database.
  4. the majority of the registered centres in the UK actively submit data to the database.
  5. Approximately 150–200 cases are entered onto the BSUG database per week.

image The use of chromosomal microarray in prenatal diagnosis

With regard to the history of prenatal chromosomal testing,

  1.  DNA extracted from chorionic villus sampling was the first method of fetal DNA extraction.
  2.  many laboratories are now only performing quantitative fluorescent polymerase chain reaction (QFPCR) testing for ‘high risk screening results’.

With regard to the timeframe of prenatal chromosome testing,

  1.  QFPCR can be turned around in less than 24 hours.
  2.  cell culture can take up to 3 weeks.

With regard to the differences between G-band karyotyping and chromosomal microarray (CMA),

  1.  conventional karyotyping can look at the fetal chromosome at a resolution of 5–10 Mb.
  2.  CMA has a quicker ‘turnaround time’ than G-band karyotyping as it can be used on uncultured cells.

With regard to CMA limitations,

  1.  triploidy undetected by CMA is likely to be detected by QF-PCR.

With regard to the prenatal detection rates of chromosomal abnormalities,

  1.  the rates by CMA performed for a structural abnormality on ultrasound scans are higher than when performed for other indications (e.g. advanced maternal age, high risk screening result or parental anxiety).

Counselling for CMA should include the following information:

  1.  incidental or unsolicited findings are likely to occur in 10–20% of cases.
  2. variants of unknown significance (VOUS) are likely to occur in 15% of cases.
  3. when performed for abnormal ultrasound scan findings, CMA detects chromosomal abnormalities in 15% more cases then conventional karyotyping.

When counselling for prenatal CMA,

  1. chromosomal differences of unknown significance must be discussed.

With regard to the cost-effectiveness,

  1. CMA has already been shown to be cost-effective in postnatal settings when testing children with idiopathic learning disability.

With regard to the processing of microarrays,

  1. Cot-1 DNA is used to suppress repetitive sequences when processing the microarray.
  2. array platforms in common clinical use have a typical resolution of 10 kb in targeted disease specific regions of the genome and 200 kb in the genome backbone.

With regard to limiting the chromosomal results of unknown significance

  1. a highly targeted CMA test would limit detection of novel microdeletion or microduplication syndromes.
  2. databases of genetic variation will increase the chromosomal variants of unknown significance.

With regard to the international current recommendations for prenatal CMA use,

  1. the American College of Obstetricians and Gynecologists recommend the use of CMA for advanced maternal age.
  2. Canadian recommendations are to use CMA in lieu of karyotyping when the indication is ultrasound scan abnormalities.
  3. Italian recommendations are to use CMA in lieu of karyotyping in all cases.

image Management of menstrual problems in adolescents with learning and physical disabilities

With regard to the management of menstrual problems in women with disabilities, studies have shown that:

  1.  these women have fewer problems with premenstrual syndrome than the general population.
  2.  one particular reason for a parent or caregiver to access paediatric and adolescent gynaecology services is concern over cyclical behavioural changes.

With regard to epilepsy,

  1.  epileptic exacerbations at the time of menstruation are called catamenial seizures.
  2.  Sodium valproate has been linked with hyperprolactinaemia.

With regard to the combined oral contraceptive pill,

  1.  it is contra-indicated in girls with cyanotic congenital heart disease.
  2. using it continuously until breakthrough bleeding occurs and then having 7 pill-free days is not safe.
  3.  a thrombophilia screen is recommended before prescribing it.

With regard to the transdermal combined hormonal contraceptive patch,

  1.  it is safer than the combined oral contraceptive pill.
  2.  there is no need to have a bleed every 21 days when using the transdermal patch.

In girls with learning disabilities and physical disabilities on the progestogen only contraception,

  1. unopposed intramuscular preparation is associated with a lower final bone mineral density.
  2. initial breakthrough bleeding occurs in approximately 50% of those using depot medroxyprogesterone acetate.
  3. a uterine length of approximately 5 cm (adult length) is required for the successful insertion of the levonorgestrel intrauterine system (LNG-IUS).
  4. heavy bleeding is common in those who use Nexplanon® (Merck Sharp & Dohme Limited, Hoddesdon, Herts).
  5. the LNG-IUS causes fewer widespread side effects than the combined oral contraceptive pill.

With regard to menstrual problems in those with learning and physical disabilities;

  1. in most circumstances, medical treatment is successful and therefore the request for permanent surgical procedures is approved only in exceptional circumstances.
  2. surgical options, including endometrial ablation or hysterectomy, should only be used as a last resort in adolescents with seriously distressing symptoms.

With regard to the Mental Capacity Act 2005:

  1. under this Act, doctors have a legal duty to consult a range of people when determining the best interests of a person who lacks capacity.
  2. the Act does not cover children under 16 years old.

With regard to consent to treatment,

  1. the requirement for interventions should be the least restrictive of basic rights and freedom.
  2. under UK law, approval from the magistrate court is necessary before surgery can be carried out.

image Timing of administration of prophylactic antibiotics for caesarean section: a systematic review and meta-analysis

Baaqeel H, Baaqeel R. Timing of administration of prophylactic antibiotics for caesarean section: a systematic review and meta-analysis. BJOG 2012;DOI: http://dx.doi.org/10.1111/1471-0528.12036.

Regarding infectious morbidities after caesarean section:

  1.  the rate is greater than four-fold compared with vaginal delivery.
  2.  women undergoing elective caesarean section are roughly at equal risk.
  3.  the risk of developing infection is modified by the composition of the vaginal microbial flora.
  4.  greater than 50% of the infections are clinically manifest by the fourth postoperative day.
  5.  the term surgical site infection (SSI) refers to infections confined to the skin, subcutaneous tissues, fascia or muscles.

The following are true statements about principles of antibiotic prophylaxis in surgical procedures:

  1.  to reduce the inoculum of microbial contamination to a level that can be handled by the host defenses.
  2.  an ideal agent should be safe, inexpensive, and bacteriostatic.
  3. to maintain therapeutic levels of the agent in serum and tissues at incision and throughout the operation.
  4. a single agent is as effective as multiple agents.

Interventions known to reduce the risk of post caesarean section infectious morbidities include:

  1. showering with 4% chlorhexidine gluconate the night before elective surgery.
  2. shaving pubic hair immediately preoperatively.
  3. exteriorization of the uterus for repair.
  4. avoidance of manual removal of the placenta and fetal membranes.
  5. closure of the skin with staples rather than subcuticular stitch.
  6. preoperative vaginal cleansing with povidone iodine.
  7. closure of the pelvic peritoneum.

With use of prophylactic antibiotics at caesarean section:

  1. the risk of maternal adverse effects (allergic reactions, nausea, vomiting, diarrhoea, skin rashes, thrush) compared to none use, can be as high as 400%.
  2. pre-incision administration is associated with excessive neonatal septic work up.
  3. there is a shift from group B streptococcal (GBS) early neonatal sepsis into none GBS early neonatal sepsis.
  4. fetal exposure to antibiotics is an important risk factor in the development of allergic disease in infancy.