Un caso de rotura uterina durante el embarazo / A case of uterine rupture during pregnancy

Este artículo presenta un caso poco habitual de ruptura uterina durante la 19ª semana de gestación en el lugar de la cicatriz de una cesárea realizada dos años antes. El feto estaba todavía vivo, pero murió pocos minutos después debido a su inmadurez. Se consiguió preservar el útero, aconsejando vivamente a la mujer el no volver a quedar embarazada, y sugiriendo realizar la ligadura de trompas. En estas páginas se examina la literatura sobre la ruptura uterina, en concreto, la que se produce tras una intervención cesárea, valorando la posibilidad de calcular el riesgo de ruptura a través del estudio ecográfico. A continuación se ofrece el análisis moral del caso desde la perspectiva de la moral católica, preguntándose concretamente por la licitud de la histerectomía en ciertas condiciones. Se recuerda la ilicitud de toda esterilización directa, o sea, de aquellas intervenciones que se proponen impedir la procreación. Al mismo tiempo se explica que algunas operaciones en este ámbito pueden no configurarse como esterilización directa, cuando se llegue a la certeza moral de que el útero, por las condiciones en las que se encuentra, no será capaz de desarrollar un embarazo hasta la viabilidad del feto. En estos casos la intervención no puede decirse antiprocreativa porque el sistema reproductivo de la mujer es incapaz de cumplir su función natural

The article presents a rare case of uterine rupture at the 19th week of gestation, in the presence of a scar after a caesarean section practiced two years earlier. The fetus was pulled out alive, but given the gestational age, died within a few minutes. The uterus was preserved, but the woman was advised to proceed with tubal ligation and, in any case, to absolutely avoid a new pregnancy. The literature on uterine rupture is examined focusing on the problem of uterine rupture resulting after a caesarean section, analyzing the possibility of monitoring the risk of rupture through ultrasound evaluation. Finally, the article conducts a moral analysis of the case in the light of personal bioethics, questioning in particular the acceptability of a hysterectomy under certain conditions. The illegitimacy of direct sterilization is reaffirmed, that is to say, an intervention whose purpose is the impediment of procreation, but it is emphasized that direct sterilization cannot occur when it comes to the moral certainty that that uterus, because of its conditions , cannot carry on a pregnancy until the viability of the fetus. In fact, an intervention that affects a uterus that is objectively incapable of carrying out its natural function cannot be qualified as anti-procreative

[Legitimidad de la histerectomía para resolver el "problema" de la higiene menstrual en adolescentes con discapacidad intelectual].

Menstrual hygiene in adolescents with intellectual disability (ID) represents an extra burden for parents or primary caregivers, especially in developing countries, where social institutions, including the health system, lack the capability to help this group of teenagers and their families; hence, hysterectomy to eliminate menstrual bleeding is considered a morally acceptable resource. Hysterectomy to solve the "problem" of menstrual hygiene reflects obstacles that affect the care provided by the physician to the adolescent with ID: on one hand, the criterion of social value about a "poor quality of life," and on the other, discrimination when only socioeconomic conditions are considered rather than the lack of a social network of support and special education. In Mexico, current medical support for girls and adolescents with ID for the management of menstrual hygiene is unsatisfactory. The practice of hysterectomy with the single purpose of menstrual hygiene is ethically and morally unfair and maleficent.

La higiene menstrual en las adolescentes con discapacidad intelectual (DI) representa una carga extra para los padres o cuidadores primarios, principalmente en países en desarrollo, donde las instituciones sociales, incluyendo el sistema sanitario, no tienen la capacidad suficiente para ayudar a este grupo de adolescentes y sus familias; de ahí que la histerectomía para eliminar el sagrado menstrual sea considerada como un recurso éticamente aceptable. La histerectomía para resolver el "problema" de la higiene menstrual refleja óbices que afectan la atención que el médico otorga a la adolescente con DI: por un lado, el criterio de valía social sobre una "calidad de vida deficiente" y, por otro, la discriminación, al considerar solo las condiciones socioeconómicas y no la falta de una red social de apoyo y de educación especial. En México, la actual asistencia médica a las niñas y adolescentes con DI para el manejo de la higiene menstrual es insatisfactoria. La práctica de la histerectomía por el solo hecho de higiene menstrual resulta ser ética y moralmente injusta y maleficente.

Ethical Controversy About Hysterectomy for a Minor.

One of the most complicated ethical issues that arises in children's hospitals today is the issue of whether it is ever permissible to perform a procedure for a minor that will result in permanent sterilization. In most cases, the answer is no. The availability of good, safe, long-acting contraception allows surgical options to be postponed when the primary goal of such surgical options is to prevent pregnancy. But what if a minor has congenital urogenital anomalies or other medical conditions for which the best treatment is a hysterectomy? In those cases, the primary goal of therapy is not to prevent pregnancy. Instead, sterility is an unfortunate side effect of a medically indicated treatment. Should that side effect preclude the provision of a therapy that is otherwise medically appropriate? We present a case that raises these issues, and asked experts in law, bioethics, community advocacy, and gynecology to respond. They discuss whether the best option is to proceed with the surgery or to cautiously delay making a decision to give the teenager more time to carefully consider all of the options.

Instilling fear makes good business sense: unwarranted hysterectomies in Karnataka.

This paper uses data from two fact-finding exercises in two districts of Karnataka to trace how government and private doctors alike pushed women to undergo hysterectomies. The doctors provided grossly unscientific information to poor Dalit women to instil a fear of "cancer" in their minds to wilfully mislead them to undergo hysterectomies, following which many suffered complications and died. The paper examines a review, made by two separate panels of experts, of women's medical records from private hospitals to illustrate that a large proportion of the hysterectomies performed were medically unwarranted; that private doctors were using highly suspect diagnostic criteria, based on a single ultrasound scan, to perform the hysterectomies and had not sent even a single sample for histopathology; and that the medical records were incomplete, erroneous and, in several instances, manipulated. The paper describes how a combination of patriarchal bias, professional unscrupulousness and pro-private healthcare policies posed a serious threat to the survival and well-being of women in Karnataka.

The Ashley Treatment: Improving Quality of Life or Infringing Dignity and Rights?

The 'Ashley treatment' (growth attenuation, removal of the womb and breasts buds of a severely disabled child) has raised much ethical controversy. This article starts from the observation that this debate suffers from a lack of careful philosophical analysis which is essential for an ethical assessment. I focus on two central arguments in the debate, namely an argument defending the treatment based on quality of life and an argument against the treatment based on dignity and rights. My analysis raises doubts as to whether these arguments, as they stand in the debate, are philosophically robust. I reconstruct what form good arguments for and against the treatment should take and which assumptions are needed to defend the according positions. Concerning quality of life (Section 2), I argue that to make a discussion about quality of life possible, it needs to be clear which particular conception of the good life is employed. This has not been sufficiently clear in the debate. I fill this lacuna. Regarding rights and dignity (section 3), I show that there is a remarkable absence of references to general philosophical theories of rights and dignity in the debate about the Ashley treatment. Consequently, this argument against the treatment is not sufficiently developed. I clarify how such an argument should proceed. Such a detailed analysis of arguments is necessary to clear up some confusions and ambiguities in the debate and to shed light on the dilemma that caretakers of severely disabled children face.

Parental reasoning about growth attenuation therapy: report of a single-case study.

In 2006 a case report was published about a 6-year-old girl, Ashley, who has profound developmental disabilities and was treated with oestrogen patches to limit her final height, along with a hysterectomy and the removal of her breast buds. Ashley's parents claimed that attenuating her growth would make it possible for them to lift and move her more easily, facilitating greater involvement in family activities and making routine care more straightforward. The 'Ashley treatment' provoked public comment and academic debate and remains ethically controversial. As more children are being referred for such treatment, there is an urgent need to clarify how clinicians and ethics committees should respond to such requests. The controversy surrounding the Ashley treatment exists, at least in part, because of gaps in the literature, including a lack of empirical data about the outcomes for children who do and do not receive such treatment. However, we suggest in this paper that there is also merit in examining the parental decision-making process itself, and provide empirical data about the reasoning of one set of parents who ultimately chose part of this treatment for their child. Using the interview data, we illuminate some important points regarding how these parents characterise benefits and harms and their responsibilities as surrogate decision-makers. This analysis could inform decision-making about future requests for growth attenuation and might also have wider relevance to healthcare decision-making for children with profound cognitive impairment.

Bits and pieces: the ethics of uterine morcellation.

Intensive media and policy attention has been focused on the ongoing controversy surrounding uterine morcellation in gynecologic surgery. What has been missing from this impassioned discourse is an objective analysis of the ethical implications of uterine power morcellation in gynecologic surgery. This article discusses competing ethical duties of physicians, industry, the U.S. Food and Drug Administration, and the media to develop a more robust and nuanced understanding of informed consent for the use of morcellation in benign gynecologic surgery. Ultimately, as physicians, we must remain steadfast in our dedication to the use of evolving technologies to better patient health in a safe and ethical manner that is well-studied, informed, and implemented with appropriate training and precautions.

Maternal request for caesarean section: an ethical consideration.

Caesarean section (CS) is a method of delivering a baby through a surgical incision into the abdominal wall. Until recently in the UK, it was preserved as a procedure which was only carried out in certain circumstances. These included if the fetus lay in a breech position or was showing signs of distress leading to a requirement for rapid delivery. CS is perceived as a safe method of delivery due to the recommendation by the National Institute for Health and Care Excellence (NICE) in these situations. As a result, the opportunity for maternal request for CS arose, whereby the mother requests the operation despite no medical indication. There are risks associated with CS, as with all surgery, however, these risks in current and future pregnancies may not be fully understood by the mother. The ethics of exposing mothers to these risks, as well as performing surgery on what is otherwise a healthy patient, become entangled with the demand for patient choice, as well as the increasing financial strain on our healthcare system. The main question to be examined in this essay is whether it is ethical to allow women to choose a CS in the absence of obstetric indication, taking into account the increased risk to the mother and her future offspring in order to potentially decrease the risk to the current baby. Alongside a case report, this analysis will apply Beauchamp and Childress' four principles of biomedical ethics and an exploration of the scientific literature.

Risks for donors in uterus transplantation.

Uterus transplantation (UTx) is an alternative to gestational surrogacy and adoption for patients with absolute uterine infertility. Studies have been conducted in animals, and UTx is now within the reach of clinical application in humans. Procedures in humans have been published, but many medical, ethical, and social problems and risks of UTx require discussion prior to widespread clinical application, from the perspectives of donors, recipients, families, and newborns. In this article, we summarize the burdens and risks of UTx, with a focus on donors who provide the uterus.

[Informing a patient about surgical treatment for pelvic organ prolapse]. / Quelle information délivrer à une patiente avant une chirurgie de prolapsus?

Inform consent is a major objective in the relation patient-physician. Patient's information becomes doubt when it is insufficient. To answer to medical persons asking about patient's information, pretreatment clinical and paraclinical assessment will be discussed. Reflexion delay, surgical alternative therapy and pre-operatory examination will be exposed. Several critical situations, such as associated hysterectomy, patient's comorbidity (tobacco, obesity) or synthetic mesh reinforcement have to be well-known to inform patient about failures and outcomes.

The quality of operative consenting against RCOG advice as standard.

Clinical Governance Advice published by the RCOG states that 'before seeking a women's consent ... you should ensure that she understands the nature of the condition for which treatment is being proposed, its prognosis, likely consequences and risks of receiving no treatment at all'. The importance of obtaining informed consent within obstetrics and gynaecology is highlighted by the litigious nature of our specialty, with CNST data, demonstrating that it makes up 21% of all claims and incur highest cost of any other specialty. We present an audit of the quality of operative consenting for 120 procedures over a 3-month period for five procedures (diagnostic hysteroscopy and laparoscopy, total abdominal hysterectomy, vaginal repair/hysterectomy and lower segment caesarean section) for which we have RCOG advice (Numbers 1, 2, 4, 5, 7, respectively). The quality of consent was also assessed by grade of clinicians. The results identify significant deficiencies when various gynaecological and obstetric procedures are being consented for, and we have discussed various options recommended for improvement.

Ashley revisited: a response to the critics.

The case of Ashley X involved a young girl with profound and permanent developmental disability who underwent growth attenuation using high-dose estrogen, a hysterectomy, and surgical removal of her breast buds. Many individuals and groups have been critical of the decisions made by Ashley's parents, physicians, and the hospital ethics committee that supported the decision. While some of the opposition has been grounded in distorted facts and misunderstandings, others have raised important concerns. The purpose of this paper is to provide a brief review of the case and the issues it raised, then address 25 distinct substantive arguments that have been proposed as reasons that Ashley's treatment might be unethical. We conclude that while some important concerns have been raised, the weight of these concerns is not sufficient to consider the interventions used in Ashley's case to be contrary to her best interests, nor are they sufficient to preclude similar use of these interventions in the future for carefully selected patients who might also benefit from them.