ABSTRACT
Certain useful pharmaceutical agents carry a high risk of embryopathy. The US Food and Drug Administration (FDA), in cooperation with drug manufacturers, has established pregnancy prevention programs (PPPs) to reduce the incidence of birth defects for thalidomide (STEPS [System for Thalidomide Education and Prescribing Safety]) and isotretinoin (iPLEDGE) but not for other teratogenic drugs in clinical use. These programs are complex and raise important concerns regarding privacy, the clinician-patient relationship, and convenience of medical care. Furthermore, pregnancies continued to occur in isotretinoin-exposed females during the first full year of the iPLEDGE program. We review the design and application of STEPS and iPLEDGE and consider the ethical issues raised by the introduction of these programs. The goal is to eliminate birth defects caused by teratogenic agents, without making procedures so onerous that they result in restricted access to useful agents. Confidentiality must be maintained, and the rights of disadvantaged populations and individuals with special religious concerns must be protected. Informed consent must be complete and include all risks of treatment, including risks of contraceptive methods. All teratogenic agents should be covered by PPPs, which then must be no more burdensome than requirements that have existed for many years for other controlled substances.
Subject(s)
Abnormalities, Drug-Induced/prevention & control , Contraception/ethics , Dermatologic Agents/adverse effects , Drug and Narcotic Control/organization & administration , Mandatory Testing/ethics , Teratogens , Abnormalities, Drug-Induced/epidemiology , Female , Humans , Male , Mandatory Testing/legislation & jurisprudence , Patient Education as Topic/ethics , Patient Rights , Pregnancy , Pregnancy Tests/ethicsABSTRACT
The main focus of this review is the management of active and latent tuberculosis in pregnancy in industrialized countries. The review is geared towards the healthcare professional taking care of the obstetric patient. The epidemiology of active and latent tuberculosis in the USA and recommendations for the screening of tuberculosis in pregnancy are considered. The history of treatment methodology and its relationship to the current treatment of active and latent tuberculosis in pregnancy is reviewed, and finally, a discussion of the best time to treat latent tuberculosis in a pregnant patient is undertaken, along with thoughts on future changes and advances in this field.
Subject(s)
Pregnancy Complications, Infectious/drug therapy , Tuberculosis/diagnosis , Tuberculosis/therapy , Adult , Animals , Drug Resistance, Multiple, Bacterial , Female , Humans , Mass Screening , Pregnancy , Pregnancy Complications, Infectious/epidemiology , Pregnancy Complications, Infectious/microbiology , Tuberculosis/epidemiology , Tuberculosis/microbiology , United States/epidemiologyABSTRACT
Preeclampsia is a common complication of pregnancy and often manifests in severe cases with neurological symptoms. We present the first documented case of preeclampsia associated with third nerve palsy. A 19-year-old primigravida presented at 31 2/7 weeks' gestation with preeclampsia. In addition to classic preeclampsia symptoms, the patient had atypical visual disturbances. Exhaustive neurological and ophthalmological examinations revealed a third nerve palsy with no etiology other than preeclampsia. Deteriorating renal function necessitated preterm delivery. She ultimately underwent a cesarean section. Two months postpartum, the patient has shown complete spontaneous resolution of third nerve palsy. In this case of severe preeclampsia manifested by third nerve palsy, we hypothesize that the mechanism is attributed to vasospasm of the vessels supplying the oculomotor nerve.
Subject(s)
Oculomotor Nerve Diseases/etiology , Pre-Eclampsia/diagnosis , Adult , Diagnosis, Differential , Female , Gravidity , Humans , Infant, Newborn , Male , Pre-Eclampsia/complications , Pre-Eclampsia/pathology , Pregnancy , Pregnancy Trimester, Third , Severity of Illness IndexABSTRACT
OBJECTIVE: To compare clinical and cost-effectiveness of treating recurrent preterm labor (RPTL) with oral nifedipine versus continuous subcutaneous terbutaline infusion (SQT). STUDY DESIGN: Women with singleton gestations prescribed nifedipine for tocolysis following first diagnosis of preterm labor were identified. Women hospitalized with RPTL at <34 weeks were matched by gestational age (GA) after resuming nifedipine (NIF group) with women prescribed SQT (SQT group) after stabilization. Healthcare utilization costs were modeled and compared. RESULTS: This study analyzed 142 matched pairs. GA at RPTL (matched variable) was 30.4+/-2.6 weeks. GA at delivery was earlier in the NIF group versus the SQT group (35.7+/-3.1 weeks versus 36.6+/-2.1 weeks, p=0.004). Overall, infants from the NIF group had lower birth weights and higher nursery days than infants from the SQT group. Healthcare utilization costs were greater in the NIF group versus the SQT group (37,040+/-47,518 US dollars versus 26,546+/-25,386 US dollars, p=0.014). CONCLUSION: Treating RPTL with SQT versus oral nifedipine resulted in a later GA at delivery, improved neonatal outcome, and increased cost-effectiveness.
Subject(s)
Nifedipine/therapeutic use , Obstetric Labor, Premature/economics , Obstetric Labor, Premature/prevention & control , Pregnancy Outcome , Terbutaline/therapeutic use , Tocolysis/economics , Tocolytic Agents/therapeutic use , Administration, Oral , Adult , Case-Control Studies , Cost-Benefit Analysis , Costs and Cost Analysis , Female , Humans , Infusion Pumps, Implantable , Nifedipine/administration & dosage , Pregnancy , Recurrence , Retrospective Studies , Terbutaline/administration & dosage , Tocolysis/methods , Tocolytic Agents/administration & dosageABSTRACT
OBJECTIVE: The study was undertaken to determine factors influencing a medical student's decision to choose obstetrics and gynecology (OB/GYN) versus another specialty. STUDY DESIGN: Medical school graduates from 1991 to 2001 were surveyed about factors influencing their specialty choice. Data were analyzed with chi(2), logistic regression, and odds ratio where appropriate. RESULTS: Of 1128 surveys, 562 (50%) were returned; 37% of respondents were women and 63% were men; and 73 (13%) chose OB/GYN. Statistically significant positive influences included student sex, second-year rotations, OB/GYN staff, continuity of patient care, primary care opportunities, surgical opportunities, healthy patient population, female patients, lifestyle, and financial opportunities. CONCLUSION: Perceived lifestyle, primary care opportunities, and malpractice concerns did not influence the choice to enter the field of OB/GYN. Also, the perception of patient's desire for female physicians had no apparent influence, either positive or negative, in the decision process.
Subject(s)
Career Choice , Gynecology , Obstetrics , Students, Medical , Female , Humans , Internship and Residency , Life Style , Male , Perception , Sex Distribution , Surveys and QuestionnairesABSTRACT
Currently, most cases of active tuberculosis in the United States are a result of activation of latent tuberculosis infection. In this article, the history of the epidemiology of tuberculosis and latent tuberculosis infection is reviewed. Previous and current recommendations for screening and treatment for latent tuberculosis during pregnancy and the postpartum period are discussed. A review of the literature regarding postpartum and antepartum treatment is included. Finally, the question of whether antepartum or postpartum treatment is the most beneficial is discussed.
