What do medical students experience as moral problems during their obstetric and gynaecology clerkship?

This article reports on moral problems that were raised by medical students as the basis for an ethical case-conference in an obstetrics and gynaecology clerkship. After introducing the issue of teaching clinical ethics, the method of our case-conference is explained. Next, the variety of topics and related moral problems are presented. The article continues with a discussion of three distinct and challenging aspects that characterise obstetrics and gynaecology as a domain for teaching clinical ethics. The conclusion puts forward three significant points our review raises.

[Lichen sclerosus]. / Lichen sclerosus.

Lichen sclerosus is a chronic disorder of skin and mucosa which affects patients of all age groups, particularly women, but also men. It is most commonly seen on the female genital skin, but it also occurs on extragenital areas. Most patients complain of itching and, less frequently, a burning sensation, dyspareunia, dysuria and painful defecation are reported. The cause of lichen sclerosus is largely unknown. However, it has been suggested that a genetic predisposition to inflammatory disorders, an immunological constitution, hormonal influences and local factors might play a role. Anogenital lichen sclerosus is associated with an increased incidence of malignancies, especially vulvular squamous-cell carcinomas. The life-time risk of developing this carcinoma is about 5%. Extragenital lichen sclerosus and lichen sclerosus in children do not seem to be correlated with malignancy. Potent local corticosteroids form the mainstay of treatment for lichen sclerosus. The condition is characterised by remissions and exacerbations. Long-term follow-up is required for the early diagnosis of malignant changes.

Presymptomatic DNA testing and prophylactic surgery in families with a BRCA1 or BRCA2 mutation.

BACKGROUND: Germline mutations in the BRCA1 and BRCA2 genes highly predispose to breast and ovarian cancer. In families with BRCA1 or BRCA2 mutations, identification of mutation carriers is clinically relevant in view of the options for surveillance and prevention. METHODS: We assessed presymptomatic DNA testing and prophylactic surgery in 53 consecutive families presenting to the Rotterdam Family Cancer Clinic with a known BRCA1 or BRCA2 mutation. We identified predictors for DNA testing and prophylactic surgery with univariate and multivariate analysis. FINDINGS: 682 unaffected individuals with a 50% risk (275 women and 271 men) or with a 25% risk (136 women) for carrying a mutation were identified and offered a DNA test. Presymptomatic DNA testing was requested by 48% (198 of 411) of women and 22% (59 of 271) of men (odds ratio for difference between sexes 3.21 [95% CI 2.27-4.51]; p<0.001). In women, DNA testing was significantly more frequent at young age, in the presence of children, and at high pre-test genetic risk for a mutation. Of the unaffected women with an identified mutation who were eligible for prophylactic surgery, 51% (35 of 68) opted for bilateral mastectomy and 64% (29 of 45) for oophorectomy. Parenthood was a predictor for prophylactic mastectomy but not for prophylactic oophorectomy. Age was significantly associated with prophylactic oophorectomy, but not with prophylactic mastectomy, although there was a tendency towards mastectomy at younger ages. INTERPRETATION: In a clinical setting, we show a high demand for BRCA1 and BRCA2 testing by unaffected women at risk, and of prophylactic surgery by unaffected women with the mutation. Young women with children especially opt for DNA testing and prophylactic mastectomy.

Massive solitary metastasis of hepatocellular carcinoma in the ovary two years after liver transplantation.

Case report of a 47-year-old woman with a mass in the lower abdomen, was referred to us by the surgeon, two years after orthotopic liver transplantation for hepatocellular carcinoma (HCC). Serum alpha-fetoprotein (AFP), which was elevated at the time of initial diagnosis, was in the normal range. Frozen section examination during exploratory laparotomy showed appearances consistent with metastatic HCC in the ovary. This was confirmed at the final pathological examination. Definitive pathological conclusions were based on the findings of tumor cells arranged in trabecular and papillary aggregates, and the presence of bile-pigment, along with the patients history. This is the sixth case of metastatic HCC in the ovary being described in literature and the first case in which this metastasis was not accompanied by elevated AFP.

[The bikini incision: nice, but not without painful complications]. / De bikinisnede: mooi, maar niet zonder pijnlijke complicaties.

The low transverse abdominal incision, described by Pfannenstiel, is, mostly because of its decent scar, the incision of choice for most gynaecological operations. Making this incision, the ilioinguinal nerve and the iliohypogastric nerve can be involved. In many cases this causes a lasting numbness in the region around the scar. Some patients have a lasting, radiating, invalidating pain, which can be relieved surgically.