OBSTET-L Mensagens pela Julho, 1998: Re: Discusion de un caso clinico

Re: Discusion de un caso clinico

From: Guttenberg Primo

berg@usa.net

Mon, 13 Jul 1998 23:42:14 -0300

<<? Is anyone offering C-S for vag condyloma on the basis of the risk to the baby?>> If I'm not mistaken, the CDC, in their 1993 STD Treatment Guidelines, specifically recommends AGAINST this.

The risk of infecting the child, when the mother has visible condylomata, has been estimated to 1/1000. Shah K et al. Rarity of cesarean delivery in cases of juvenile-onset respiratory papillomatosis. Obstet Gynecol 1986;68:795-9 Sectioning 1000 otherwise healthy mothers to save one child from laryngeal papillomatosis would be criminal.

-- Mats Bergstrom, MD Ob Gyn South Hospital

I have always believed that our society would be much better off with an entirely different system for deciding medical malpractice cases. Just about anything would be better than what we have now. Juries are being asked to absorb 8 or 10 years of medical training in a few days, and render opinions about scientific evidence, when we live in a country that pretty much shuns scientific thought from grade school forward. In the end, juries go "on a hunch", and we end up with ridiculous decisions (and awards). Clearly, there are no data to support performing cesarean sections for patients with genital condyloma, unless the actual condyloma themselves create the rare soft-tissue dystocia making vaginal delivery impossible. If we started doing c/sections for condyloma, when would we start doing them for HPV alone? I am sure that if one of us did a c/section tomorrow for genital condyloma, and the patient developed atony and underwent a cesarean hysterectomy, the lawyers would come after us for doing an "unecessary procedure". Truly, you can't win with the system we have. I think practicing high quality medicine, doing right by your patients, documenting everything, and talking with our patients is still the best way to ward off the legal vultures. Ashley Hill D. Ashley Hill, M.D. Orlando, FL dahmd@gate.net ---------------------------------------------------------------------------- ---- ----------------------------------------------------------------------------

---------------------------------------------------------------------------- vide tb... http://www.fensende.com/users/swnymph/Midwife/wartsuit.html

>Citation/Title >859 F.Supp.22, Randall V. U.S., (D.D.C. 1994) >RANDALL v. UNITED STATES >Civ. A. No. 91-2919-OG >United States District Court >District of Columbia >Aug 2, 1994 > "Patient brough medical malpractice action against military hospital. > The District Court, Gasch, Senior District Judge, held that : (1) patient >had not established that there was a national standard of care, as to whether >Caesarean section should be performed upon evidence that patient had genital >warts attrituble to human papilloma virus (HPV), precluding claim that >physicians had been negligent in not performing Caesarean section so as to >avoid infant's exposure to warts; (2) physicians had not obtained informed >consent of patient to vaginal delivery, as they had not warned her of the >dangers inherent in that delivery in presence of genital warts and given her >option of selecting vaginal or Caesarean delivery; and (3) damages could >include allowance for operations on infants required to remove respiratory >warts every two months, until child reaches age 14." > >.."In order to establish causality aspect of medical malpractice claim, it >is not necessary for expert to testify he was personally certain that patient >would not have sustained injury but for physician's negligence; it is >sufficient for expert to state opinion, based on reasonable degree of medical >certainty, that physician's negligence was more likely than anything else to >cause, or be a cause, of victim's injuries." > >.."Patient claiming that her infant daughter contracted juvenile laryngeal >papillomatosis (JPL) due to passage down birth canal which contained >undiagnosed genital warts did not establish there was national obstetrical >standard of care requiring Caesarean section delivery under those >circumstances, so as to avoid exposure to warts; some experts testified that >Caesarean delivery would be offered only if there were HPV lesions >obstructing birth canal, or when there existed risk of increased bleeding or >infection..." > >.."For purposes of determining whether patient had given informed consent to >undergo a vaginal delivery, as opposed to a Caesarean section, physicians had >duty to disclose to her, based upon pap smear and colposcopy examination >conducted approximately six and three months prior to delivery, that she had >genital warts arising from infection with HPV, and should have counseled her >regarding rish to respiratory system of child from passing through birth >canal versus risks attendant to Caesarean delivery. > >.."was entitled to damages in amount of $500,000."

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