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Ethics and organ transplantation
Editorial
Photolibrary
Twins or triplets?
For the NICE guideline see http://www.nice.org.uk/CG129
It would be an unusual woman who, when told she was expecting twins, did not experience some trepidation, maybe even fear, along with joy. Multiple pregnancies are regarded with suspicion in some cultures, signs of good or evil in others, and are widely celebrated sometimes. For all women, though, they entail higher risks to both mother and babies, with increased risk of low birthweight, prematurity, congenital malformation, and stillbirth. Multiple pregnancies are increasing in incidence in many countries because of rising maternal age and assisted reproduction. It is timely, therefore, for the UK National Institute for Health and Clinical Excellence (NICE) to release its first guidance for the antenatal care of twin and triplet pregnancies. A key recommendation is that women who are pregnant with twins or triplets should receive specialist care from a multidisciplinary team of named obstetricians, midwives, and ultrasonographers, all of whom must have experience of managing such pregnancies. This core team should refer women based on their individual needs to a perinatal mental health professional, a women’s health physiotherapist, an infant feeding specialist,
and a dietitian. Referral for a consultant’s opinion at a tertiary-level fetal medicine centre is recommended in the guideline for all monochorionic monoamniotic twin or triplet pregnancies, many other triplet pregnancies, and any pregnancy complicated by discordant fetal growth, fetal anomaly, discordant fetal death, or feto-fetal transfusion syndrome. An early scan to determine gestational age and chorionicity, schedules of specialist antenatal appointments, and guidance for fetal complications, preterm birth, and timing of birth are included in the NICE document. Additionally, there is an appropriate emphasis on emotional wellbeing and the need for regular assessment of mental health, both before and after the births. Obstetricians, midwives, and representatives from associations for multiple births have all welcomed the NICE guidance. Implementation of the recommendations and long-term monitoring of their outcomes, for mothers and their babies, are now needed. As multiple pregnancies become more common, their clinical care needs to be exemplary. ■ The Lancet
Science Photo Library
Ethics and organ transplantation
See Series pages 1414, 1419, and 1428 See Comment page 1357
For more on the organ donation plans in Wales see http:// www.bbc.co.uk/news/ukwales-15154159 For the Nuffield Council on Bioethics report see http://www.nuffieldbioethics. org/sites/default/files/Donation_ full_report.pdf
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Around the world, countries are trying to encourage more people to donate their organs after death to help those desperately in need of transplants. Wales, for example, is poised to become the first country in the UK to introduce an opt-out system, where consent after death is assumed unless families object. Such systems already exist in Spain and Belgium. Meanwhile, a new report by the UK Nuffield Council on Bioethics suggests that the National Health Service tests the idea of paying for the funerals of organ donors as an incentive for donation. And Germany has announced that it wants to make it possible for its citizens to declare their willingness to donate their organs, and have this information stored on electronic health cards. In The Lancet today, we are publishing a Series of three papers to add to the debate about ethical, policy, and clinical issues surrounding organ transplantation. The first paper in the Series calls on governments to develop self-sufficiency in organ transplantation, which will help to end transplant tourism and organ trafficking. The authors outline the legal and medical components that countries should include in their transplant programmes
to achieve this goal. The next papers in the Series focus on clinical care after kidney transplantation—the most common type of transplant globally. Health systems need to provide good care for patients after transplantation not only to avoid organ rejection and failure but also to prevent the other main causes of morbidity and mortality. Premature death after kidney transplantation is more likely to happen from cardiovascular complications, infection, and cancer than from graft failure. The second paper in the Series details the steps to be taken to prevent cardiovascular disease in patients who receive kidneys. Chronic rejection and failure of a kidney graft is still a major problem resulting in return to dialysis, and the final Series paper focuses on monitoring and management of patients to avoid this outcome. The ultimate goal for countries should be ethical systems for organ transplantation that not only encourage and support donation but also provide a high standard of care for patients after transplantation. ■ The Lancet www.thelancet.com Vol 378 October 15, 2011
Photolibrary
Twins or triplets?
For the NICE guideline see http://www.nice.org.uk/CG129
It would be an unusual woman who, when told she was expecting twins, did not experience some trepidation, maybe even fear, along with joy. Multiple pregnancies are regarded with suspicion in some cultures, signs of good or evil in others, and are widely celebrated sometimes. For all women, though, they entail higher risks to both mother and babies, with increased risk of low birthweight, prematurity, congenital malformation, and stillbirth. Multiple pregnancies are increasing in incidence in many countries because of rising maternal age and assisted reproduction. It is timely, therefore, for the UK National Institute for Health and Clinical Excellence (NICE) to release its first guidance for the antenatal care of twin and triplet pregnancies. A key recommendation is that women who are pregnant with twins or triplets should receive specialist care from a multidisciplinary team of named obstetricians, midwives, and ultrasonographers, all of whom must have experience of managing such pregnancies. This core team should refer women based on their individual needs to a perinatal mental health professional, a women’s health physiotherapist, an infant feeding specialist,
and a dietitian. Referral for a consultant’s opinion at a tertiary-level fetal medicine centre is recommended in the guideline for all monochorionic monoamniotic twin or triplet pregnancies, many other triplet pregnancies, and any pregnancy complicated by discordant fetal growth, fetal anomaly, discordant fetal death, or feto-fetal transfusion syndrome. An early scan to determine gestational age and chorionicity, schedules of specialist antenatal appointments, and guidance for fetal complications, preterm birth, and timing of birth are included in the NICE document. Additionally, there is an appropriate emphasis on emotional wellbeing and the need for regular assessment of mental health, both before and after the births. Obstetricians, midwives, and representatives from associations for multiple births have all welcomed the NICE guidance. Implementation of the recommendations and long-term monitoring of their outcomes, for mothers and their babies, are now needed. As multiple pregnancies become more common, their clinical care needs to be exemplary. ■ The Lancet
Science Photo Library
Ethics and organ transplantation
See Series pages 1414, 1419, and 1428 See Comment page 1357
For more on the organ donation plans in Wales see http:// www.bbc.co.uk/news/ukwales-15154159 For the Nuffield Council on Bioethics report see http://www.nuffieldbioethics. org/sites/default/files/Donation_ full_report.pdf
1356
Around the world, countries are trying to encourage more people to donate their organs after death to help those desperately in need of transplants. Wales, for example, is poised to become the first country in the UK to introduce an opt-out system, where consent after death is assumed unless families object. Such systems already exist in Spain and Belgium. Meanwhile, a new report by the UK Nuffield Council on Bioethics suggests that the National Health Service tests the idea of paying for the funerals of organ donors as an incentive for donation. And Germany has announced that it wants to make it possible for its citizens to declare their willingness to donate their organs, and have this information stored on electronic health cards. In The Lancet today, we are publishing a Series of three papers to add to the debate about ethical, policy, and clinical issues surrounding organ transplantation. The first paper in the Series calls on governments to develop self-sufficiency in organ transplantation, which will help to end transplant tourism and organ trafficking. The authors outline the legal and medical components that countries should include in their transplant programmes
to achieve this goal. The next papers in the Series focus on clinical care after kidney transplantation—the most common type of transplant globally. Health systems need to provide good care for patients after transplantation not only to avoid organ rejection and failure but also to prevent the other main causes of morbidity and mortality. Premature death after kidney transplantation is more likely to happen from cardiovascular complications, infection, and cancer than from graft failure. The second paper in the Series details the steps to be taken to prevent cardiovascular disease in patients who receive kidneys. Chronic rejection and failure of a kidney graft is still a major problem resulting in return to dialysis, and the final Series paper focuses on monitoring and management of patients to avoid this outcome. The ultimate goal for countries should be ethical systems for organ transplantation that not only encourage and support donation but also provide a high standard of care for patients after transplantation. ■ The Lancet www.thelancet.com Vol 378 October 15, 2011