Faculty Bibliography

The authors utilize stakeholder theory to provide a new analysis of the professional liability crisis, by identifying the major stakeholders in our current system of professional liability, their respective obligations and self-interests, and how these interests are advanced and constrained by the current system. This stakeholder analysis reveals a core ethical obligation of all stakeholders: the preservation of the integrity of our current judicial system. The adverse impact of the pursuit of stakeholder self-interests, rather than fulfillment of their core, shared ethical obligation, on achievement of the goals of the current system, the deterrence of unsafe practice and compensation of injured patients, is then identified. The authors argue that approaches to reform of professional liability in obstetrics be based upon the common obligation of the stakeholders to fulfill the goals of the system, because attempts to align the myriad self-interests of the stakeholders will be futile

Eighty-nine percent of American College of Obstetricians and Gynecologists fellows responding to the 2006 Professional Liability Survey indicated that they had been sued during their careers. Thirty-seven percent had at least one claim from residency, and there were an average of 2.6 claims per obstetrician. Sixty-two percent of these claims were from obstetrics as opposed to gynecology. The articles in this issue discuss various areas of perinatal medicine from the medical and legal perspectives, emphasizing those issues in maternal-fetal medicine that are the most frequent subjects of medical malpractice litigation

More than any other innovation, ultrasound has revolutionized the practice of obstetrics and gynecology in one generation. Unfortunately, there are medical legal risks of which all practitioners should be aware. This article discusses the general aspects of a medical negligence case as they relate to the performance of the obstetric ultrasound examination, summarizes the recommendations of the American College of Obstetricians and Gynecologists and the American Institute of Ultrasound in Medicine regarding the performance of these examinations, outlines potential areas of negligence, and discusses ways to avoid them

This article will focus upon the general aspects of a medical negligence case as they relate to the performance of the obstetric ultrasound examination, summarize the recommendations of both the American College of Obstetrics and Gynecology (ACOG) and the American Institute of Ultrasound in Medicine (AIUM). These organizations have published recommendations regarding guidelines, instrumentation and safety, documentation, indications, examination content, and quality control. The practice bulletin indicates that proof of a clear advantage over 2-dimensional imaging has not yet been demonstrated. ACOG also recommends that practitioners should have a method of storing images, and equipment should be serviced on a regular basis. The US Food and Drug Administration has arbitrarily limited energy exposure from ultra-sonography to 94mW/cm2. The AIUM has published the following »prudent use« statement, endorsed by ACOG. The AIUM advocates the responsible use of diagnostic ultrasound. The AIUM strongly discourages the non-medical use of ultrasound for psychosocial or entertainment purposes. The use of either two-dimensional or three dimensional ultrasound only to view the fetus, obtain a picture of the fetus or determine the fetal gender without a medical indication is inappropriate and contrary to responsible medical practice

PIP: A growing number of US women are delaying childbirth until their late 30s. Pregnant women 35 years old face various risks including genetic disorders, prenatal medical and obstetric complications, intrapartum complications, and perinatal and neonatal morbidity and mortality. With each passing year, the risk of chromosomal abnormality such as Down's syndrome increases. Physicians perform chorionic villus sampling (CVS) between 9-11 weeks gestation and amniocentesis between 16-18 weeks to detect chromosomal abnormalities. CVS carries the higher risk of spontaneous abortion (1-2%). 35-year old pregnant women are more likely to suffer from hypertension and gestational diabetes than younger women. Yet their incidence remains at an acceptable level. Older pregnant women tend to also be at risk of several antepartum obstetric complications such as gestational bleeding, abruptio placentae, and placenta previa. The likelihood of cesarean section and dysfunctional labor is greater among 35-year old pregnant women. Between 1974 and 1978, older mothers were 4 times more likely to die than young mothers, but by 1982 the overall maternal mortality rate fell by 50%. The main causes of death among older mothers were hemorrhage, embolism, and hypertensive conditions. Positive effects of advanced maternal age were less worry about and better adjustment to pregnancy, cautiousness, and more likely to consult their physicians. Advanced maternal age tends not to effect neonatal outcome other than chromosomal anomalies. Physicians should not allow the pregnancy of 35-year old mothers to go beyond 42 weeks' gestation. Despite the minimal increased risks, 35-year old women should not allow their advanced age to be an absolute barrier to reproductive decisions. Obstetricians should conduct thorough and appropriate antepartum testing and surveillance, however

We examined the exactness of the timing of the 1-hour glucose sample following a 50-g oral glucose challenge as a critical variable in interpretation of the test. Heparin locks were placed in 45 pregnant patients between 25 and 28 weeks' gestation, and 5 patients between 30 and 33 weeks' gestation. Venous samples were taken at intervals of 50, 60, and 70 minutes from completion of the ingestion of a 50-g oral glucose load. We found all of the nine possible patterns of blood glucose values that can derive from three sequential values. There was no consistent relationship between these 60 +/- 10 minute values. Two of the patients had a 60-minute value greater than 140 mg/dL, but a 50- or 70-minute value that was less than 140 mg/dL. Four of the patients had a 50- or 70-minute value that was greater than 140 mg/dL, but a 60-minute value that was less than 140 mg/mL. The range of results in this study reflects a continuum of values that change rapidly over time and in patterns that are not predictable. We conclude that accurate timing is important to avoid erroneous interpretation of the 1-hour glucose screen

PIP: A review of 13 cases of second trimester termination at 20-24 weeks by dilation and evacuation after insertion of laminaria in women with critical illness is presented. The patients ranged in age from 17-41, parity from 0-5, and diagnoses covered a wide range, including hematologic, respiratory, vascular, gastrointestinal, cardiac systems, malignancies, autoimmune disorders and infections, as well as several with multiple problems, including intravenous drug use. Most were the result of late diagnosis or late presentation. Procedures were performed according to a standard protocol by 1 physician, from 1983- 1987, using iv meperidine and diazepam sedation and paracervical block, 12 after laminaria insertion. Amniotomy and evacuation with large ovum forceps were followed by oxytocin and sharp curettage. There were no complications in this series. The dilation and curettage method is preferable in such cases because the timing of the procedure can be planned for maximal use of facilities and staff, the patient is spared by unattended delivery, the length of the abortion process is minimal, and incidence of infection and retained placenta is lower. Need for lengthy analgesia and fluid monitoring is reduced, an advantage for many critically ill women. This approach is best done by a physician with specific experience, in a setting capable of managing severe complications

Currently in the United States there is widespread agreement that obstetric ultrasonography should be performed when indicated, based on a beneficence-based calculus. However, there is considerable uncertainty that routine ultrasonography is similarly indicated for every pregnant woman. We argue that the standard of care demands that prenatal informed consent for sonogram be accepted as an indication for the prudent use of obstetric ultrasonography performed by qualified personnel. Prenatal informed consent for sonogram, a primarily autonomy-based indication, should be given the same weight in clinical judgment and practice as the beneficence-based indications listed by the National Institutes of Health consensus panel