For Physicians. By Physicians.™
For Physicians. By Physicians.™
Faculty: Natasha Schimmoeller MD
Moderator: Karla Loken, DO
Free for ObGFirst members & ObG Resident CORE™ Members
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ObG GrandRounds Live is a monthly, virtual Grand Rounds experience jointly provided by Postgraduate Institute for Medicine and the ObG Project
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high-quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:
Natasha Schimmoeller, MD has nothing to disclose
The PIM and ObGProject planners and others have nothing to disclose
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Postgraduate Institute for Medicine designates this live activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Urinary tract infections (UTIs) are one of the most common infections in pregnancy, occurring in about 8% of all pregnancies and range from asymptomatic bacteriuria to acute pyelonephritis. They are associated with adverse pregnancy outcomes such as preterm birth and low birth weight, therefore the timely identification and treatment of these is essential. Anatomic changes during pregnancy increase the risk for UTIs, such as ureteral dilation, the mechanical compression of ureters by the uterus causing urinary stasis, contributing to bacteria colonization and ascending infection. E coli remains the most common identified pathogen. Given the high rates of antibiotic resistance to this organism, the selection of first line therapy must avoid antibiotics such as amoxicillin and ampicillin. Treatment of symptomatic bacteriuria decreases the risk of pyelonephritis, which can cause significant maternal complications such as DIC and ARDS, as well as fetal complications such as preterm birth. Patients with hemoglobinopathy have higher rates of cystitis and asymptomatic bacteriuria.
Asymptomatic Bacteriuria (ASB)
Note: Low risk for anaphylaxis, cephalosporin treatment is appropriate | High risk for anaphylaxis should be treated with alternative regimen
Acute Cystitis
Pyelonephritis
Note: Remain suspicious even if only some of the above is present (e.g., fever and UTI)
ACOG Clinical Consensus 4: Urinary Tract Infections in Pregnant Individuals
Effective on June 27, 2023, the Pregnant Workers Fairness Act (PWFA) is a new law that requires covered employers to provide “reasonable accommodations” to a worker’s known limitations related to pregnancy, childbirth, or related medical conditions, unless the accommodation will cause the employer an “undue hardship”. Covered employers are private and public sector employers with at least 15 employees, Congress, federal agencies, employment agencies, and labor organizations. The law is limited to accommodations only. Other laws cover discrimination against workers on the basis of pregnancy, childbirth, or related medical conditions. It also does not replace other state or federal law that protect pregnant workers.
Reasonable accommodations could include but are not limited to
The employer and worker must discuss the accommodation before the worker is required to accept it. The employer cannot deny a job or other employment opportunities to a qualified worker based on the need for a reasonable accommodation.
Employers are required to provide reasonable accommodations unless they would cause an undue hardship on the employer’s operations. Therefore, an employer must demonstrate significant difficulty or expense before denying the accommodation.
The Equal Employment Opportunity Commission (EEOC) will be charged with investigations under this act.
ACOG Committee Opinion 733: Employment Considerations During Pregnancy and the Postpartum Period
The ISPD consensus statement addresses screening using NIPT for the detection of chromosomal conditions in singleton pregnancies. NIPT for the three most common aneuploidies can be used as either a first line screening test for all pregnant individuals or as a follow up screen for those at high risk by serum analyte screening. A baseline sonogram to document viability, gestational dating, and to evaluate the number of fetuses should be performed prior to screening.
NIPT for screening for fetal aneuploidy screening
Faculty: Andrei Rebarber, MD
Moderator: Brian Hines, MD
Free for ObGFirst members & ObG Resident CORE™ Members
Please login here to register
Not an ObGFirst member?
Subscribe Now! Click here for a free month trial ($9 monthly subscription post-trial – cancellable at any time)
ObG GrandRounds Live is a monthly, virtual Grand Rounds experience jointly provided by Postgraduate Institute for Medicine and the ObG Project
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high-quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:
Andrei Rebarber, MD has nothing to disclose
The PIM and ObGProject planners and others have nothing to disclose
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Postgraduate Institute for Medicine designates this live activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
Preimplantation genetic testing (PGT) for monogenic disorders (M) is a form of preimplantation genetic diagnosis. It is an adjunct to assisted reproductive technology (ART) using in vitro fertilization (IVF) to evaluate embryos by genetic testing, preventing the inheritance of serious disorders in the majority of cases. Because of the wider use of prenatal and preconception genetic carrier screening, more disorders are being identified by PGT-M.
What is Preimplantation Genetic Testing?
PGT-M
Indications
Female sexual dysfunction is relatively prevalent. Approximately 43% of American women report sexual problems. However, women are unlikely to report sexual dysfunction with providers unless asked. Dysfunction includes various conditions which report personal distress in one or more of the following areas: desire, arousal, orgasm, or pain.
Female Sexual Interest/Arousal Disorder
Female Orgasmic Disorder
Genito-pelvic Pain/Penetration Disorder
Substance/Medication-Induced Sexual Dysfunction
Other Specified or Unspecified Sexual Dysfunction
Screening
Diagnosis
Psychologic Interventions
Estrogen Therapy
Transdermal Testosterone
Sildenafil Citrate
Filbanserin
Bupropion
Dilation
Physical Therapy
Medications
Lubricants
Female Sexual Dysfunction | ACOG
Psychiatry Online | DSM Library (subscription required)
Diabetes and sexual dysfunction: current perspectives | NCBI
Psychotropic medications on sexual health | NCBI
An advisory panel was selected to review current literature regarding nonhormone therapy based on levels of evidence. In the treatment of vasomotor symptoms in women within ten years of menopause and who are not candidates for or who decline hormone therapy, evidence-based nonhormone options such as behavioral therapies, medications such as SSRIs or gabapentin, and weight loss should be discussed and considered.
NOT Recommended
The 2023 Nonhormone Therapy Position Statement of The North American Menopause Society
SUMMARY: Listeria infection is primarily a foodborne illness resulting from consumption of food contaminated with Listeria monocytogenes. Maternal infection may present as a non-specific, flu-like illness. Fetal and neonatal infections risk severe consequences.
Tap Below to See CDC Page
Asymptomatic
Exposed, Mildly Symptomatic but Afebrile
Exposed, Febrile with Symptoms Consistent with Listeriosis
Management of Pregnant Women with Presumptive Exposure to Listera monocytogenes
CDC: People at Risk – Pregnant Women and Newborns | Listeria
CDC: Prevent Listeria | Listeria
CDC: Information for Health Professionals and Laboratories | Listeria
CDC: Listeria Outbreaks | Listeria
Faculty: Tracy Shevell, MD
Moderator: Brian Hines, MD
Free for ObGFirst members & ObG Resident CORE™ Members
Please login here to register
Not an ObGFirst member?
Subscribe Now! Click here for a free month trial ($9 monthly subscription post-trial – cancellable at any time)
ObG GrandRounds Live is a monthly, virtual Grand Rounds experience jointly provided by Postgraduate Institute for Medicine and the ObG Project
Postgraduate Institute for Medicine (PIM) requires faculty, planners, and others in control of educational content to disclose all their financial relationships with ineligible companies. All identified conflicts of interest (COI) are thoroughly vetted and mitigated according to PIM policy. PIM is committed to providing its learners with high-quality accredited continuing education activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of an ineligible company.
The faculty reported the following relevant financial relationships with ineligible entities related to the educational content of this CE activity:
Tracy Shevell, MD has nothing to disclose
The PIM and ObGProject planners and others have nothing to disclose
In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.
Postgraduate Institute for Medicine designates this live activity for a maximum of 1 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications. The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
As part of the patient-physician relationship, consent for treatment is given. Physicians explain the risks, benefits, and limitations of treatment Nowhere in that consent is a guaranteed good outcome given. It is not possible.
Prior to November 2022, Oregon juries in medical malpractice cases were instructed “Physicians are not negligent merely because their efforts were unsuccessful. A physician does not guarantee a good result by undertaking to perform a service.” This instruction evolved from a series of cases where it was established that a physician does not guarantee a cure. Despite that lack of guarantee, a patient could still sue a physician for medical malpractice, alleging a bad outcome due to the physician’s failure to follow a particular standard of care that caused injury to a patient.
In November 2022, the appellate court of Oregon in Martineau v. Willamette Medical Center ruled that this instruction should no longer be part of the uniform civil jury instruction. The court found issue with the instruction as it obscures the fact that the correct focus is on application of
the standard of care. In addition, the meaning of “result” has a broader meaning than “cure”. Therefore, the statement that “[a] physician does not guarantee a good result by undertaking
to perform a service” is incorrect when stated—as it is in the instruction—as a universal principle.
Let’s turn to the underlying medical facts. Mr. Martineau sought care in the emergency room for chest pain and other complaints. One physician examined him and ordered a chest X-ray that the radiology physician read. The ordering physician however reviewed the X-ray and electrocardiogram of a different patient. He concluded that that the patient did not have an urgent cardiovascular problem or need further testing immediately. To the contrary, Mr. Martineau did have an urgent cardiovascular problem and died the next day.
The plaintiff personal representative of Mr. Martineau filed a lawsuit for wrongful death or, in the alternative, the loss of chance of recovery followed, alleging medical malpractice by the ordering physician, emergency room group, and the radiology physicians. The jury returned a verdict in favor of the defendants.
The appellate judges found two problems with the instruction. First, it takes away from the focus on the standard of care which is the issue to be decided because the guarantee of a good “result” is incorrect as a universal principle. Second, any benefit that it would add to a jury’s understanding of the law was significantly outweighed its potential to confuse a jury. In summary, the statement is likely to mislead a jury and should not have been given by the court.
Next, the appellate court considered where the error was harmless or detrimental. The plaintiff’s theory was that defendants negligently failed to recognize the urgency of the decedent’s condition when he came to the emergency room. If they had, they would have determined he needed a CT scan and performed emergency surgery to save his life.
In summary, the risk of giving the jury the instructions that a good result was not promised might cause the jury to reason that the defendants’ duty did not require them to order a CT scan because the CT scan was the “good result”. The CT scan was the primary focus of the plaintiff’s case.
In its decision, the appellate court deemed the error was not harmless because the instruction was misleading. The jury could have reasoned that even though the radiology defendants’ and the ER defendants’ did not meet the standard of care, the defendants nevertheless were not negligent because a good result was not promised. The difference between a result and care are exemplified in this case. The defendant physicians were obligated to evaluate the deceased patient in accord with a standard of care that included testing and a CT scan.
The AMA vehemently opposes the striking down of this jury instruction regarding the nonguaranteed of a good result. “Medical negligence liability [should] remain based on legal fault, and not medical results.” If the decision were to stand, it opens the door for juries to succumb to their sympathies about the plaintiff and injuries rather than to focus on the legal standard of care.” Recently, the appellate court decision was submitted for review by the Supreme Court of Oregon. The AMA and Oregon Medical Association have submitted an amicus brief asking for the appellate decision to be reversed.
Resources
Juries must be instructed that bad outcomes aren’t always negligence
The Anatomy of a Malpractice Lawsuit
The Medical Malpractice Deposition: A Review for Radiologist-Defendants
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This educational activity may contain discussion of published and/or investigational uses of agents that are not indicated by the FDA. The planners of this activity do not recommend the use of any agent outside of the labeled indications.
The opinions expressed in the educational activity are those of the faculty and do not necessarily represent the views of the planners. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.
Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information
presented in this activity is not meant to serve as a guideline for patient management. Any procedures, medications, or other courses of diagnosis or treatment discussed or suggested in this activity should not be used by clinicians without evaluation of their patient’s conditions and possible contraindications and/or dangers in use, review of any applicable manufacturer’s product information, and comparison with recommendations of other authorities.
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