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Effects of hypothyroidism on fetal development
EDITORIAL coMued fan p. I
LETTER TO THE EDITOR EFFECTS OF HYPOTHYROIDISM ON FETAL DEVELOPMENT To the Editor: I would like to make reference to the March/April 200 1 issue of ACOG Clinical Review (vol. 6, no. 2). On page 4, there was reference to articles from the New EngLand Journal of Medicine, relating maternal thyroid deficiency with fetal development (Haddow JE, Palomaki GE, Allan WC, et al. Maternal thyroid de& ciency during pregnancy and subsequent neuropsychological development of the child. NEng~JMed 1999; 342:549-55; Utiger RD. Maternal hypothyroidism and fetal development [editorial]. NEngiJMed 1999; 341:601-2). The synopsis by the Editor makes reference to ACOG Technical Bul.kin No. 181 from June 1993. That bulletin does not address fetal effects from maternal hypothyroidism. However, what was not referenced was ACOG Committee Opinion No. 241 from September 2000. That opinion clearly negates the relevance of the findings from the New England/ournal of Medicine article by Haddow et al. Essentially, the Haddow article was an observational study and, hence, lacks some credibility. I believe it would be worth pointing out ACOG committee Opinion No. 241 to the membership to clarify the interpretation of Haddow’s study. Thank you very much. Vincent A. Pellegrini, MD Women’s Clinic, Ltd. West Reading, Pennsylvania
In reply: Dr. Pellegrini is correct that ACOG Technical Bulletin No. 181, June 1993, entitled Thyroid Diseases in Pregnancy, does not address the issue of hypothyroidism on fetal development, as this effect was not recognized or suspected at the time that bulletin was written. ACOG Technical B~~eti~ No. 181 does address the po12
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tential for hypothyroidism in the infant of a hypothyroid mother. What the Editor wanted to call to the reader’s attention was the review of the diagnosis of thyroid disease in pregnant women that is outlined and explained in that bulletin. ACOG Committee Opinion No. 241, September 2000, from the Obstetric Practice Committee, entitled Screening for Hypothyroidism, had not been approved or published when the March/April 200 1 issue of A COG Ciinical Review was written, so the Committee Opinion could not be referenced. The reader should be aware that each issue of the Review is prepared 4-6 months before it is circulated in order to meet deadlines. ACOG Committee Opinion No. 241 does address the effects of hypothyroidism on fetal development, and does point out the limitations of Haddow et al’s observational study. Furthermore, it is stated that even though the data are consistent with the possibiiity of suboptimal brain development, screening in the first trimester may be too late to obviate a deficiency. Thus, it is premature to call for universal screening for hypothyroidism in pregnancy. Ralph W. Hale, MD Editor
ERRATUM Thanks to Dr. Rudi Ansbacher who recognized that on page 3 of the May/June 2001 issue of ACOG ~~inicaiReview (vol. 6, no. 3), in the synopsis of the article by El-Refaey et al (The misoprostol third stage of labour study: A randomised controlled comparison between orally administered misoprostol and standard management. Br J Ubstet Gynaecol 2000;107:1104-lo), the dosage of misoprostol was stated as 500 mg. The correct dosage should have been 500 pg. Thanks Rudi.
September/October
2001
Testimony that impugns performance that falls within the standard of care, or testimony supporting obviously substandard practice is not acceptable. ACOG’s Code of Professional Ethics charges the ob/gyn who provides expert testimony with the duty to testify truthfully and not about matters in which he or she is not knowledgeable.2 Using these statements as guidelines, review the proposed expert’s curriculum vita. Are the expert’s medical education and practical experience indicative of the requisite knowledge? If not, point out any possible deficiencies to your attorney. Assist your legal counsel by obtaining resource materials that can identify the standard of care current at the time of the alleged malpractice incident. Evidence heard is evidence considered by the jury, despite the judge giving instructions to the jurors to disregard certain statements. One of the duties of defense counsel is to challenge the basis of unfavorable expert evidence/testimony. Attorneys accomplish this by presenting arguments to the judge to persuade him or her to deny admission, thereby preventing the evidence from being heard by the jurors. Your attorney will also be promoting the introduction of favorable evidence/testimony offered by defense experts and defending any plaintiff motions to exclude that evidence.
AD~~SS~B~l~~ OF EXPERT TESTIMONY To understand what information can be useful in this evidentiary process, a review of the background sources that have provided guidance to courts in the area of the admissibility of expert testimony may be helpful. Generally, judges have maintained broad discretionary powers over what testimony is admissible. Therefore, your input at this initial discretionary decisionmaking stage could be a critical tool in your defense strategy. Evidentiaty standards vary depending on whether the judge presides over a federal court or a state court, which is the venue for most medical malpractice cases. For many years, the F?ye standard of general acceptabi~~~ was the benchmark against 02001
by the Amwcan College 01 Obstetricians and Gynecologists Published by Ehewer Science Inc. 10654566Zl0\&6W
LETTER TO THE EDITOR EFFECTS OF HYPOTHYROIDISM ON FETAL DEVELOPMENT To the Editor: I would like to make reference to the March/April 200 1 issue of ACOG Clinical Review (vol. 6, no. 2). On page 4, there was reference to articles from the New EngLand Journal of Medicine, relating maternal thyroid deficiency with fetal development (Haddow JE, Palomaki GE, Allan WC, et al. Maternal thyroid de& ciency during pregnancy and subsequent neuropsychological development of the child. NEng~JMed 1999; 342:549-55; Utiger RD. Maternal hypothyroidism and fetal development [editorial]. NEngiJMed 1999; 341:601-2). The synopsis by the Editor makes reference to ACOG Technical Bul.kin No. 181 from June 1993. That bulletin does not address fetal effects from maternal hypothyroidism. However, what was not referenced was ACOG Committee Opinion No. 241 from September 2000. That opinion clearly negates the relevance of the findings from the New England/ournal of Medicine article by Haddow et al. Essentially, the Haddow article was an observational study and, hence, lacks some credibility. I believe it would be worth pointing out ACOG committee Opinion No. 241 to the membership to clarify the interpretation of Haddow’s study. Thank you very much. Vincent A. Pellegrini, MD Women’s Clinic, Ltd. West Reading, Pennsylvania
In reply: Dr. Pellegrini is correct that ACOG Technical Bulletin No. 181, June 1993, entitled Thyroid Diseases in Pregnancy, does not address the issue of hypothyroidism on fetal development, as this effect was not recognized or suspected at the time that bulletin was written. ACOG Technical B~~eti~ No. 181 does address the po12
l
ACOG CLINICAL REVIEW
l
tential for hypothyroidism in the infant of a hypothyroid mother. What the Editor wanted to call to the reader’s attention was the review of the diagnosis of thyroid disease in pregnant women that is outlined and explained in that bulletin. ACOG Committee Opinion No. 241, September 2000, from the Obstetric Practice Committee, entitled Screening for Hypothyroidism, had not been approved or published when the March/April 200 1 issue of A COG Ciinical Review was written, so the Committee Opinion could not be referenced. The reader should be aware that each issue of the Review is prepared 4-6 months before it is circulated in order to meet deadlines. ACOG Committee Opinion No. 241 does address the effects of hypothyroidism on fetal development, and does point out the limitations of Haddow et al’s observational study. Furthermore, it is stated that even though the data are consistent with the possibiiity of suboptimal brain development, screening in the first trimester may be too late to obviate a deficiency. Thus, it is premature to call for universal screening for hypothyroidism in pregnancy. Ralph W. Hale, MD Editor
ERRATUM Thanks to Dr. Rudi Ansbacher who recognized that on page 3 of the May/June 2001 issue of ACOG ~~inicaiReview (vol. 6, no. 3), in the synopsis of the article by El-Refaey et al (The misoprostol third stage of labour study: A randomised controlled comparison between orally administered misoprostol and standard management. Br J Ubstet Gynaecol 2000;107:1104-lo), the dosage of misoprostol was stated as 500 mg. The correct dosage should have been 500 pg. Thanks Rudi.
September/October
2001
Testimony that impugns performance that falls within the standard of care, or testimony supporting obviously substandard practice is not acceptable. ACOG’s Code of Professional Ethics charges the ob/gyn who provides expert testimony with the duty to testify truthfully and not about matters in which he or she is not knowledgeable.2 Using these statements as guidelines, review the proposed expert’s curriculum vita. Are the expert’s medical education and practical experience indicative of the requisite knowledge? If not, point out any possible deficiencies to your attorney. Assist your legal counsel by obtaining resource materials that can identify the standard of care current at the time of the alleged malpractice incident. Evidence heard is evidence considered by the jury, despite the judge giving instructions to the jurors to disregard certain statements. One of the duties of defense counsel is to challenge the basis of unfavorable expert evidence/testimony. Attorneys accomplish this by presenting arguments to the judge to persuade him or her to deny admission, thereby preventing the evidence from being heard by the jurors. Your attorney will also be promoting the introduction of favorable evidence/testimony offered by defense experts and defending any plaintiff motions to exclude that evidence.
AD~~SS~B~l~~ OF EXPERT TESTIMONY To understand what information can be useful in this evidentiary process, a review of the background sources that have provided guidance to courts in the area of the admissibility of expert testimony may be helpful. Generally, judges have maintained broad discretionary powers over what testimony is admissible. Therefore, your input at this initial discretionary decisionmaking stage could be a critical tool in your defense strategy. Evidentiaty standards vary depending on whether the judge presides over a federal court or a state court, which is the venue for most medical malpractice cases. For many years, the F?ye standard of general acceptabi~~~ was the benchmark against 02001
by the Amwcan College 01 Obstetricians and Gynecologists Published by Ehewer Science Inc. 10654566Zl0\&6W