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Ultrasound rationale debated
ited increase in risk of connective tissue disease. Most of this increased incidence has no predictable pattern. There are questions about this study because it relies on self-reported data with all of their built-in biases. On the other hand, we can expect that women with problems will be more motivated to respond to a questionnaire on implants than those with no problems; thus the data will most likely be biased in the direction of less reassuring findings. When these reports of problems are absent, it gives the physician and patient some reassurance that the hazard is less than might be anticipated.
Systemic lupus Erythematosus Johnson AE, Gordon C, Hobbs FDR, Bacon PA. Undiagnosed systemic lupus erythematows in the community. Lancet 1996;347: 367-9.
Synopsis: Systematic lupus erythematosus (SLE) has many manifestations. The authors used a screening questionnaire in an attempt to diagnose unrecognized cases in the female community. They determined, based on their results, that there are many undiagnosed cases in the community. Only 54 of 100,000 women were diagnosed with SLE, whereas a prevalence of 200 women SLE per 100,000 was found using the questionnaire. l
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Commentary: Any physician who cares for women should be aware of the wide range of symptoms that are produced by SLE. Whenever a physician sees a patient with the appearance of multisystem disease without a readily apparent etiology, SLE should be suspected. The authors in this study of 1,153 women found much higher prevalence of the disease than was currently diagnosed. Similar results have been reported by others. Because early diagnosis is the key to prevention of serious complications, screening with an antinuclear antibody test and a high index of suspicion should be part of the evaluation of the women in our practice.
ULTRASOUND RATIONALE DEBATED To the Editor: I have enjoyed receiving ACOG Clinical Review and find that in volume 1, issue 2, “Advocacy for Routine Obstetric Ultrasound’ was eloquently written. However, the authors should have been more broad-minded to match their eloquent writing style. If one follows the reasoning that they give for routine obstetric ultrasound, namely to advocate the autonomy of pregnant women regarding routine obstetric procedures, then one must concede that the same argument could be made for many other procedures. A common example with similar arguments might be that of genetic counseling. Genetic counseling presents potentially life-threatening and serious consequences to patients, and all obstetricians know that most genetically abnormal babies are born to mothers in the low-risk category, ie, those under age 35. Despite this, I think no one, with the exception of perhaps Mark Evans at Wayne State University in Detroit, is arguing for routine genetic counseling on the basis of pregnant-woman autonomy.
genetic amniocentesis with low-risk women is a common practice among physicians at The New York Hospital-Cornell Medical Center. In short, medicine is not competent to decide for the pregnant woman how to balance the potential harm and cost from genetic amniocentesis versus the potential benefit of the information gained. Clinically, the optimum way to resolve this matter is through the informed consent process. However, in today’s environment of cost containment, sometimes at the expense of fiduciary obligations of physicians to their patients,3 the argument for routinely offering quality ultrasound is stronger than the argument for routinely offering genetic amniocentesis because of the relatively lower costs and risks of the former.2 Frank A. The New Cornell New
Laurence B. McCullough, PhD Baylor College of Medicine Houston, Texas William J. Ledger, MD New York HospitalCornell Medical Center New York, New York
Jeffrey Stieve, MD Portage Physician Group Hancock, Michigan
Authors’ Response: We thank Dr. Stieve for his thoughtful comments concerning our article, “Advocacy for Routine Obstetric Ultrasound.“1 He is correct to state that it follows logically from our argument that genetic counseling and amniocentesis ought to be offered to every pregnant woman. Indeed, we have argued exactly this position elsewhere2 and the practice of discussing
1. Chervenak FA, McCullough LB, Ledger WJ. Advocacy for routine obstetric ultrasound: an essential obligation in contemporary obstetric care. ACOG Clin Rev 1996;1(2):1-4. 2. Druzin ML, Chervenak FA, McCullough LB, et al. Should all pregnant patients be offered prenatal diagnosis regardless of age? Obstet Gynecol 1993;8 1: 615-8. 3. Chervenak FA, McCullough LB. The threat of the new managed practice of medicine to patients’ autonomy. J Clin Ethics 1995;6:320-3.
llllllllsllllllllluliullllllllnllllllllll~ 1085-6862(199605/06)1:3;1-E
16
l
ACOG
CLINICAL
REVIEW
l
May/June
1996
Chervenak, MD York HospitalMedical Center York, New York
RI 51065~862(96)~12-X
1
01996 by the AmericanCollegeof ObstetrlclansandGynecologists PubWisd bv ilsevw ScienceInc. 1085-6862196/$15.00
Systemic lupus Erythematosus Johnson AE, Gordon C, Hobbs FDR, Bacon PA. Undiagnosed systemic lupus erythematows in the community. Lancet 1996;347: 367-9.
Synopsis: Systematic lupus erythematosus (SLE) has many manifestations. The authors used a screening questionnaire in an attempt to diagnose unrecognized cases in the female community. They determined, based on their results, that there are many undiagnosed cases in the community. Only 54 of 100,000 women were diagnosed with SLE, whereas a prevalence of 200 women SLE per 100,000 was found using the questionnaire. l
l
l
Commentary: Any physician who cares for women should be aware of the wide range of symptoms that are produced by SLE. Whenever a physician sees a patient with the appearance of multisystem disease without a readily apparent etiology, SLE should be suspected. The authors in this study of 1,153 women found much higher prevalence of the disease than was currently diagnosed. Similar results have been reported by others. Because early diagnosis is the key to prevention of serious complications, screening with an antinuclear antibody test and a high index of suspicion should be part of the evaluation of the women in our practice.
ULTRASOUND RATIONALE DEBATED To the Editor: I have enjoyed receiving ACOG Clinical Review and find that in volume 1, issue 2, “Advocacy for Routine Obstetric Ultrasound’ was eloquently written. However, the authors should have been more broad-minded to match their eloquent writing style. If one follows the reasoning that they give for routine obstetric ultrasound, namely to advocate the autonomy of pregnant women regarding routine obstetric procedures, then one must concede that the same argument could be made for many other procedures. A common example with similar arguments might be that of genetic counseling. Genetic counseling presents potentially life-threatening and serious consequences to patients, and all obstetricians know that most genetically abnormal babies are born to mothers in the low-risk category, ie, those under age 35. Despite this, I think no one, with the exception of perhaps Mark Evans at Wayne State University in Detroit, is arguing for routine genetic counseling on the basis of pregnant-woman autonomy.
genetic amniocentesis with low-risk women is a common practice among physicians at The New York Hospital-Cornell Medical Center. In short, medicine is not competent to decide for the pregnant woman how to balance the potential harm and cost from genetic amniocentesis versus the potential benefit of the information gained. Clinically, the optimum way to resolve this matter is through the informed consent process. However, in today’s environment of cost containment, sometimes at the expense of fiduciary obligations of physicians to their patients,3 the argument for routinely offering quality ultrasound is stronger than the argument for routinely offering genetic amniocentesis because of the relatively lower costs and risks of the former.2 Frank A. The New Cornell New
Laurence B. McCullough, PhD Baylor College of Medicine Houston, Texas William J. Ledger, MD New York HospitalCornell Medical Center New York, New York
Jeffrey Stieve, MD Portage Physician Group Hancock, Michigan
Authors’ Response: We thank Dr. Stieve for his thoughtful comments concerning our article, “Advocacy for Routine Obstetric Ultrasound.“1 He is correct to state that it follows logically from our argument that genetic counseling and amniocentesis ought to be offered to every pregnant woman. Indeed, we have argued exactly this position elsewhere2 and the practice of discussing
1. Chervenak FA, McCullough LB, Ledger WJ. Advocacy for routine obstetric ultrasound: an essential obligation in contemporary obstetric care. ACOG Clin Rev 1996;1(2):1-4. 2. Druzin ML, Chervenak FA, McCullough LB, et al. Should all pregnant patients be offered prenatal diagnosis regardless of age? Obstet Gynecol 1993;8 1: 615-8. 3. Chervenak FA, McCullough LB. The threat of the new managed practice of medicine to patients’ autonomy. J Clin Ethics 1995;6:320-3.
llllllllsllllllllluliullllllllnllllllllll~ 1085-6862(199605/06)1:3;1-E
16
l
ACOG
CLINICAL
REVIEW
l
May/June
1996
Chervenak, MD York HospitalMedical Center York, New York
RI 51065~862(96)~12-X
1
01996 by the AmericanCollegeof ObstetrlclansandGynecologists PubWisd bv ilsevw ScienceInc. 1085-6862196/$15.00