Ethical Considerations in Multiple Pregnancy: Preterm Delivery in the Setting of Discordant Fetal Anomaly.

Planning for the preterm birth of a fetus with known anomalies can raise complex ethical issues. This is particularly true of multiple pregnancies, where the interests of each fetus and of the expectant parent(s) can conflict. In these complex situations, parental wishes and values can also conflict with the recommendations of treating clinicians. In this article, we consider the case of a dichorionic twin pregnancy complicated by the diagnosis of vein of Galen aneurysmal malformation (VGAM) in one of the twins at 28 weeks' gestation. Subsequent deterioration of the affected twin prompted the parents to request preterm delivery to prevent the imminent in-utero demise of the affected twin. However, given the associated risks of prematurity, complying with the parents' request may have disadvantaged the health and wellbeing of the unaffected twin. This article canvases the complex ethical issues raised when parents request preterm delivery of a multiple pregnancy complicated by a fetal anomaly in one twin, and the various ethical tools and frameworks that clinicians can draw on to guide their decision-making in such cases.

The urologist's role in multidisciplinary management of placenta percreta.

OBJECTIVE: To evaluate urological interventions in patients with placental adhesive disorders in our collaborative experience at a tertiary referral centre. PATIENTS AND METHODS: We performed a retrospective analysis of a prospectively collected data set, consisting of all women that presented with placental adhesive disorders at the Royal Women's Hospital from August 2009 to September 2013. Patients who required urological intervention were identified and perioperative details were retrieved. RESULTS: Of the 49 women that presented with placental adhesive disorders, 36 (73.5%) underwent urological interventions. The patients were divided into three groups: planned hysterectomy (37 patients), planned conservative management (five) and undiagnosed placenta percreta (seven). In the planned hysterectomy group, 29 patients underwent preoperative cystoscopy and ureteric catheter placement. In 10 patients (34%), the placenta partially invaded the bladder and/or ureter, requiring urological repair. In the conservative management group, four underwent preoperative cystoscopy and ureteric catheter placement, and one case required closure of a cystotomy. Of the seven patients with undiagnosed percreta, two were noted to have bladder involvement requiring repair at the time of Caesarean hysterectomy. CONCLUSION: Patients with placental adhesive disorders frequently require urological intervention to prevent or repair injury to the urinary tract. These cases are best managed in specialist centres with multidisciplinary expertise including urologists and interventional radiologists.

Pregnancy in a woman with a Fontan circulation: A review.

More women with congenital heart disease survive to childbearing ages, due to improvements in surgical practice and postoperative care. This review discusses pregnancy in women with a single ventricle, describing maternal obstetric and cardiovascular complications and the increased risks of prematurity and adverse neonatal outcomes. Recommendations are made based on current understanding, guidelines and published literature, with recognition that there is much knowledge yet to be gained.

The effect of testosterone on cytokine production in the specific and non-specific immune response.

PROBLEM: Cytokine production of monocytes and lymphocytes differs between males and females. This difference is characterized by a decreased percentage of interleukin (IL)-2-producing lymphocytes and an increased percentage of IL-12, IL-1beta and tumour necrosis factor (TNF)-alpha-producing monocytes in males compared with females. In the present study, we investigated whether testosterone may explain these differences. METHOD OF STUDY: Stimulated whole blood of healthy woman was incubated with different concentrations of testosterone. Intracellular lymphocyte production of IL-2 and interferon (IFN)-gamma, as well as intracellular monocyte production of IL-12, IL-1beta and TNF-alpha were measured using flow cytometry. RESULTS: A significant increased percentage of IL-12- and IL-1beta-producing monocytes was found after incubation with physiological concentrations of testosterone. No effect of testosterone was found on IL-2- and IFN-gamma-producing lymphocytes and TNF-alpha-producing monocytes. CONCLUSIONS: The increased percentage of IL-12- and IL-1beta-producing monocytes in males compared with females in vivo may be induced by testosterone, as the in vitro percentage of IL-12- and IL-1beta-producing monocytes is increased after incubation with physiological concentrations of testosterone.