Abortion policies at the bedside: incorporating an ethical framework in the analysis and development of abortion legislation.

About 6% of women in the world live in countries that ban all abortions, and 34% in countries that only allow abortion to preserve maternal life or health. In the USA, over the last decades-even before Dobbs v. Jackson Women's Health Organization overturned the federal right to abortion-various states have sought to restrict abortion access. Often times, this legislation has been advanced based on legislators' personal moral values. At the bedside, in contrast, provision of abortion care should adhere to the normative principles of medical ethics and reproductive justice, centreing patients and their individual reproductive intentions and desires. Abortion regulations, through their influence on patients and providers, may facilitate or impede such ethical care at the bedside. In this paper, we present a framework to model how abortion legislation should fit into the patient-provider relationship and to clarify the dynamics by which legislation may affect healthcare encounters. Our proposed framework serves as a tool to analyse the ethical impact of abortion regulations. We propose a model for assessing abortion policies based not on legislators' or advocates' individual moral claims, but on the shared, normative framework of clinical medical ethics. Through contrasting case studies, we demonstrate how a robust normative ethical framework can recentre patients and their reproductive needs. Our model is one way to account for-and safeguard-patients' diverse viewpoints and needs in the development of abortion policy, and it can serve to ground narratives for advocacy by healthcare workers and their professional organisations.

Utilizing International Classification of Diseases Codes to Identify Shoulder Dystocia and Neonatal Brachial Plexus Injury.

BACKGROUND: The utilization of International Classification of Diseases, Ninth or Tenth Revision, (ICD-9/10) coding to identify the incidence of disease is frequently performed in medical research. This study attempts to assess the validity of using ICD-9/10 codes to identify patients with shoulder dystocia (SD) with concurrent neonatal brachial plexus palsy (NBPP). METHODS: This retrospective cohort study examined patients evaluated at the University of Michigan Brachial Plexus and Peripheral Nerve Program (UM-BP/PN) from 2004 to 2018. We reported the percentage of patients with reported NBPP ICD-9/10 and SD ICD-9/10 discharged at birth who were later diagnosed with NBPP by a specialty clinic by interdisciplinary faculty and staff utilizing physical evaluations and ancillary testing such as such as electrodiagnostics and imaging. The relationship of reported NBPP ICD-9/10, SD ICD-9/10, extent of NBPP nerve involvement, and NBPP persistence at age two years were examined via chi-square or Fischer exact test. RESULTS: Of the 51 mother-infant dyads with complete birth discharge records evaluated at the UM-BP/PN, 26 (51%) were discharged without an ICD-9/10 code documenting NBPP; of these 26 patients, only four had ICD-9/10 documentation of SD at discharge, which left 22 patients with no ICD-9/10 code documentation of either SD or NBPP (43%). Patients with pan-plexopathy were more likely to be discharged with an NBBP ICD-9/10 code than those infants with upper nerve involvement (77% vs 39%, P < 0.02). CONCLUSION: Use of ICD-9/10 codes for the identification of NBPP appears to undercount the true incidence. This underestimation is more pronounced for milder forms of NBPP.

Diffuse Large B-Cell Lymphoma During Third-Trimester Pregnancy and Lactation.

BACKGROUND: Diffuse large B-cell lymphoma is the most common type of non-Hodgkin's lymphoma affecting pregnancy. These tumors may be aggressive and rapidly growing in pregnancy. Management is based on the balance of risks and benefits to both the pregnant patient and the fetus. CASE: We present a case of diffuse large B-cell lymphoma diagnosed in the third trimester of pregnancy. The patient underwent labor induction at 34 weeks of gestation, started a standard chemotherapy protocol postpartum, and breastfed following a timed lactation protocol. CONCLUSION: Management of lymphoma during pregnancy highlights the need to consider all aspects of proposed oncologic and obstetric care as well as neonatal risks. Considerations highlighted in this case include staging methods, administration of antenatal steroids, timing of delivery, and lactation during chemotherapy.

Assessing Reproductive Decision-making Among HIV-Positive Women in Kumasi, Ghana.

BACKGROUND OR OBJECTIVES: HIV-positive women have higher rates of unmet need for contraception and unintended pregnancy and face unique obstacles in accessing family planning services, such as healthcare-related stigma and disclosing HIV status to partners. This study characterizes factors that influence the reproductive decision-making of women living with HIV and identifies areas for improvement in reproductive counseling in Kumasi. METHODS: In this cross-sectional study, HIV-positive women, ages 18 to 45 years, presenting for care at Komfo Anokye Teaching Hospital between June and August 2017 were interviewed using structured surveys. Information gathered included demographics, method of contraceptive use, initiation of anti-retroviral therapy (ART), knowledge and use of contraception, and future reproductive plans. The primary outcome was current family planning use and future reproductive desire. Univariate analysis was used to characterize the demographics of the study group. Bivariate analysis including Chi-squared test was employed to assess the association between use of family planning between women with an HIV-positive and HIV-negative partner, with significance set at p < 0.05. RESULTS: A total of 88 women were interviewed. The unmet need for contraception was 10%. Among all sexually active women, 26% did not use contraception. Fewer women with HIV-negative or untested partners were using contraception (65% and 67%, respectively), compared to women with HIV-positive partners (93%). Partner preference was the most common reason cited for not using a method of contraceptive (46%). Similar trends were found in future reproductive desires based on age cohorts, partner status, and use of family planning. CONCLUSION AND GLOBAL HEALTH IMPLICATIONS: Significant barriers to family planning use among HIV-positive women remain, especially those with a serodiscordant partner. Most partners were aware of their partner's HIV status. This highlights an important opportunity to include partners in HIV and contraceptive counseling.

Longer Operative Time in Elderly Patients Undergoing Posterior Lumbar Fusion Is Independently Associated With Increased Complication Rate.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To determine the effects of operative time on postoperative complications in patients age 65 and older undergoing posterior lumbar fusion. METHODS: All patients age 65 and older undergoing posterior lumbar fusion were identified in the 2012 to 2015 American College of Surgeons National Surgical Quality Improvement Program database. The primary outcome measures were complications occurring up to 30 days postoperatively, including death, any complication, and complication subtypes. The primary independent variable was operative duration. Both bivariate and multivariate analyses utilized logistic regression and analyzed operative duration as a continuous variable. Statistical significance was considered P < .05. RESULTS: A total of 4947 patients age 65 and older undergoing posterior lumbar fusion were identified. The mean operative time was 3.3 hours (SD 1.7). The overall complication rate was 13.4% (n = 665). In multivariate analysis, each incremental hour of operative time was associated with increased risk of postoperative thromboembolism (odds ratio [OR] = 1.23; 95% confidence interval [CI] = 1.10-1.37), transfusion (OR= 1.25; 95% CI = 1.18-1.32), urinary tract infection (OR = 1.21; 95% CI = 1.10-1.32), and total postoperative complications (OR = 1.22; 95% CI = 1.16-1.27). CONCLUSION: For patients age 65 and older undergoing posterior lumbar fusion, longer operative time is associated with greater risk for thromboembolism, transfusion, intubation, kidney injury, urinary tract infection, surgical site infection, and overall postoperative complications. This data highlights several specific complications that are influenced by operative time in older patients, and further supports the need for future protocols that seek to safely minimize operative time for posterior lumbar fusion.

Medical Malpractice Claims Following Incidental Durotomy Due to Spinal Surgery.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: Analyze medical malpractice verdicts and settlements associated with incidental durotomy. SUMMARY OF BACKGROUND DATA: Incidental durotomy is a common complication of spine surgery. Although most intraoperative dural tears are repaired without sequelae, persistent Cerebrospinal Fluid leak, infection, or neurological injury can yield adverse outcomes. The medicolegal implications of incidental durotomy are poorly understood. METHODS: Three separate, large legal databases were queried for cases involving incidental durotomy. Case, plaintiff, procedure, and outcome characteristics were analyzed. RESULTS: In total, 48 dural tear-related medical malpractice cases were analyzed. Most cases (56.3%) resulted in a ruling in favor of the defendant physician. Most cases alleged neurological deficits (86.7%). A large majority of cases without neurological sequelae had an outcome in favor of the defendant (83.3%). For cases involving a payment, the average amount was $2,757,298 in 2016 adjusted dollars. Additional surgery was required in 56.3% of cases, a delay in diagnosis/treatment of durotomy was present in 43.8%, and alleged improper durotomy repair was present in 22.9%. A favorable outcome for the plaintiff was more likely in cases with versus without alleged delay in diagnosis/treatment (61.9% vs. 29.6%, P = 0.025) and improper durotomy repair technique (72.7% vs. 35.1%, P = 0.040). Repeat surgery was not associated with favorable outcome for the plaintiff (42.8% cases with reoperation vs. 38.1% without, P = 0.486). CONCLUSION: This analysis of durotomy-associated closed malpractice claims after spine surgery is the largest yet conducted. Durotomy cannot always be considered an entirely benign event, and these findings have several direct implications for clinicians: late-presenting or dehiscent durotomy may be associated with adverse outcomes and subsequent risk of litigation, timely reoperation in the event of durotomy-related complications may not increase surgeon liability, and spine surgeons should be prepared to defend their choice of durotomy repair technique, should dehiscence occur. LEVEL OF EVIDENCE: 3.