Re: Discusion de un caso clinico
From: Ricardo Savaris (savaris@orion.ufrgs.br)
Thu, 09 Jul 1998 00:54:27 -0300
Guttenberg Primo wrote:
> Complementando ainda....
>
> <<? 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."
>
> So vale o que esta escrito...
Ótima intervenção, Guttemberg,
Alguns anos atrás, houve um grande debate sobre essa questão com a lista
em inglês e eles me convenceram de que eu não deveria fazer cesárea por
causa de HPV, a não ser que houvesse obstrução do canal.
Eu já vi pacientes morrerem em cesárea eletiva, fazendo CIVD, mas nunca
vi um caso de epiglotite por HPV.
--
Ricardo Savaris, MD, MSc, TEGO
Porto Alegre - Brasil
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