"Munchausen by proxy syndrome": not only pathological parenting but also problematic doctoring?

Certain social expectations of medicine combine with characteristics of subspecialised technological paediatrics to facilitate the form of child abuse labelled "Munchausen by proxy syndrome". Examining this form of child abuse highlights possible shortcomings of medical practice. The primary medical tasks of diagnosing and curing illness and of preventing suffering are sometimes overridden by other motivations of which doctors may not be fully aware. More open discussion of what motivates health professionals in their work may improve medical practice and lead to a reduced incidence of Munchausen by proxy syndrome.     

Munchausen syndrome by proxy and child's rights

Munchausen syndrome by proxy (MSBP) is an extreme form of child abuse in which perpetrators induce life-threatening conditions in their children. A case of MSBP is described in detail. Difficulties in diagnosis and management in this part of the world are presented. Until now, no national legal guidelines exist in the Kingdom of Saudi Arabia (KSA) to child abuse in general and MSBP in particular. Urgent guidelines, policies, and legal system are required in the KSA.     

Factitious patients with fictitious disorders: a note on Munchausen's syndrome

OBJECTIVE OURS: To review historical aspects and note several contemporary manifestations of the Munchausen syndrome, including "Munchausen by proxy" and "pseudo-Munchausen", to offer our respect to the infamous McIIroy (the quintessential example), as well as to encourage interest and assuage irritation by medical attendants. THEIRS: Impatient to be patients, dying to see doctors, hooked on hospitals, and seeking "ill" gotten gains, they thrive on medical investigations.     

Munchausen syndrome by proxy

Five children (3F:2M), in the age group 1 years to 11 years, with Munchausen syndrome by proxy are reported from the Sultanate of Oman. They were seen over a four years period from 1996-1999. In all these children, the mother came up with history of uncontrolled epilepsy. Carbamazepine was the most common antiepileptic drug used. One of these children remained hospitalized elsewhere for nearly 9 months, as a case of uncontrolled status epilepticus. It took 18 months to 6 years (mean 2.8 years) to establish the diagnosis and the mother was the offender in all. The main lead to diagnosis, was the disparity between history and clinical presentation to hospital. The carbamazepine levels were several times above the upper limit of therapeutic range. Munchausen syndrome by proxy very much exists here, but is possibly less recognized and needs immediate attention to formulate policies to identify and manage these children. It is necessary to create awareness even in the medical community, to recognise this problem. There is an urgent need to develop a child protection council at the national or regional level.     

The investigation of life-threatening child abuse and Munchausen syndrome by proxy.

The use of covert video surveillance in the investigation of suspected life-threatening child abuse and Munchausen syndrome by proxy raises important ethical questions. That the recently reported provision of this facility in North Staffordshire was not presented to a Local Research Ethics Committee (LREC) for approval as a research exercise raises important questions about the ethical review of research and practice. The case made for avoiding such review is first set out and then examined. The three main premisses which form the basis of the view that LREC approval is not required are identified and tested in turn. The conclusion is that there is an undeniable element of research involved in the procedure and that the welfare of all those subjected to the surveillance would be best protected by the submission of the protocol to an independent committee for ethical assessment.     

早产相关因素323例临床分析

目的 分析与人工早产和自然早产有关的危险因素。方法 我院1993年1月～1999年12月间分娩的自然早产274例和人工早产49例,分别与同期分娩的足月对照组323例相比,进行早产的因素分析。结果 孕期母亲未作产前检查、胎膜早破、多胎、产前出血、中重度妊高征、内科合并症等均与早产有关;人工早产者产前检查率最低,剖宫产率最高,并主要与产前出血、中重度妊高征、多胎有关;自然早产者产前检查率低于足月对照组,其主要与胎膜早破、不明原因早产有关。结论 孕期多种因素与早产有关,且自然早产和人工早产具有不同的危险因素。     

A study of twins--in search of an optimal age for delivery

The question regarding the optimal age of delivery in twins remains unanswered. A prospective observational study was carried out in the gynaecology and obstetrics department of RG Kar Medical College and Hospital, Kolkata during 2008-2009 to arrive at a logical conclusion to this question. The objective of this study was to evaluate the optimal timing of delivery in twins and compare the perinatal outcome in these babies by dividing them into 3 groups: 34 weeks to 35 weeks 6 days, 36 weeks to 37 weeks 6 days and >38 weeks. Perinatal outcome was also compared between different modes of delivery. Few maternal complications like pre-eclampsia, anaemia, premature rupture of membrane, preterm labour and antepartum haemorrhage were also evaluated.     

早产危险因素325例分析

目的：分析早产有关的危险因素。方法：选取我院1997年1月至2001年12月分娩的早产325将，将早产分为自然早产269例和人工早产56例，分别与同期足月分娩的330例相比，进行早产的临床因素分析。结果：早产与孕妇无产前检查、胎膜早破、多胎、产前出血、中重度妊高征、内科合并症、胎儿畸形等均有关；人工早产者产前检查率最低，剖宫产率最高，其主要与产前出血、中重度妊高征、多胎有关；自然早产者产前检查率低于足月对照组，其主要与胎膜早破、不明原因早产有关。结论：早产与孕期多种因素有关，自然早产和人工早产具有不同的危险因素，做好产前检查保健工作是预防早产发生的根本。     

Patterns of fractures in accidental and non-accidental injury in children: a comparative study

The incidence and pattern of fractures in children who had been abused were compared with those of fractures sustained by children of similar ages in whom abuse had been excluded. From 1976 to 1982 there were 35 children with fractures resulting from child abuse, and all were aged under 5. Of the 826 children in the control group, seen from January to June 1981, 85% were aged over 5. Abused children were much more likely to have multiple fractures (p less than 0.001) and bruising of the head and neck (p less than 0.001). Fractures of the ribs were common in children who had been abused, and their presence, in the absence of major chest trauma, strongly suggested that abuse was occurring. Injuries to the long bones were invariably spiral or oblique fractures or subperiosteal new bone formation--both "gripping or twisting" injuries. Spiral fracture of the humeral shaft was significantly more common (p less than 0.001) in the group of abused children. Classic metaphyseal chip fractures were uncommon. One child in eight aged under 18 months who sustains a fracture may be a victim of child abuse.     

71例前置胎盘的临床分析

目的探讨前置胎盘类型、产前出血状况与妊娠结局的关系。方法71例前置胎盘按胎盘位置分为边缘型组(23例)、部分型组(18例)和中央型组(30例),分析其临床表现和妊娠结局。结果中央型组初次出血及诊断孕周均小于其他两组(P<0.05),部分型组与边缘型组无显著差异(P>0.05);产前出血发生率、出血次数及大出血例数三者无显著差异(P>0.05);有产前出血者其诊断及分娩时孕周、新生儿体质量均低于无出血者(P<0.01),急诊剖宫产率显著高于无出血者(P<0.01)。结论前置胎盘的妊娠结局不能以类型来预测。产前出血对急诊剖宫产率、新生儿体质量有一定影响。     

早产危险因素261例分析

目的探讨早产发生的危险因素和对围生期的影响。方法对我院261例早产孕妇(早产组)与同期随机抽取的261足月孕妇(对照组)进行回顾性比较,分析早产的危险因素及对围产期的影响。结果高龄与未定期产检是早产的相关危险因素。早产的病因中胎膜早破、子痫前期、产前出血、妊娠合并症均多于对照组,两组差异有统计学意义。早产使剖宫产率、新生儿窒息、低体重儿增加。结论定期产前检查、适龄妊娠、提高围产期保健意识可降低早产的发生,提高围生医学质量。     

On children and proxy consent.

The meaning of valid proxy consent for children has recently been the subject of an important debate between Richard McCormick and Paul Ramsey on the ethics of experimenting with children. Ramsey is willing to agree with McCormick that parental consent for a child to undergo some medical procedure is valid only if parents consider what the child would consent to if he could. But beyond this, Ramsey has a fundamentally different conception of the child from McCormick, and therefore gives a very different interpretation to this standard for valid proxy consent. In Ramsey's view, McCormick's basic mistake is to think of the child as a small adult, thereby overlooking the child's peculiar vulnerabilities and needs. In particular, McCormick fails to attend to the child's needs for "preservation in life and healthful growth". In this paper, the author pursues Ramsey's suggestion that a correct analysis of valid proxy consent for children would replace the "language of consent" with the "language of need". He does this by sketching a theory of parenthood that rests on two central notions: that of primary goods, as found in the writing of John Rawls, and that of autonomy.     

Periodic health examination, 1994 update: 4. Secondary prevention of elder abuse and mistreatment. Canadian Task Force on the Periodic Health Examination.

OBJECTIVE: To provide recommendations for family physicians on the detection, assessment and management of abuse or mistreatment in patients over 65 years of age. OPTIONS: Detection of elder abuse by history and examination or by specific protocols; intervention through mandatory reporting, removing the victim from the situation or acting as an advocate for the patient. OUTCOMES: Termination of abusive situation and prevention of further abuse. EVIDENCE: A MEDLINE search was conducted with the use of medical subject headings "elder abuse" and "epidemiology" for articles published from January 1980 to October 1992 and headings "elder abuse" and "clinical trials" for articles published from January 1980 to February 1994. Standard references and review articles and their bibliographies were scrutinized, and experts were consulted. VALUES: The evidence-based methods and values of the Canadian Task Force on the Periodic Health Examination were used. Since senior citizens are among the most disadvantaged people in Canadian society, prevention of abuse and promotion of their autonomy were the highest values selected. BENEFITS, HARMS AND COSTS: The principal benefits are cessation and prevention of abuse. Potential harms include the loss of a personal residence, the erosion of an established family structure and the loss of autonomy for the victim. RECOMMENDATIONS: There is poor evidence to include case finding for elder abuse in or exclude it from the periodic health examination. However, it is prudent for physicians to be alert for indications of elder abuse and, if such abuse is discovered, to take measures to prevent further abuse.     

The challenge of grandmultiparity in obstetric practice

INTRODUCTION: Traditionally grandmultiparity has been considered to be an obstetric hazard both to the mother and foetus. Compounding factors are low socioeconomic status, poor female literacy and social deprivation. In developed populations with improved and optimal obstetric services, parity per se is no longer considered a significant risk for adverse obstetric and perinatal outcome. OBJECTIVES: To compare the obstetric and perinatal outcome between grandmultiparas and second gravidas with previous one delivery as well as analyse certain socio demographic features in the two groups. METHODOLOGY: Case records from Maternity Hospital, Kathmandu, an inner city tertiary care centre were retrospectively studied. 106 cases of grandmultiparous patients were compared with 110 cases of second gravidas who had previously delivered once which was taken as the control group. Biosocial features as well as obstetric and perinatal outcome were analyzed. RESULTS: Rural residents comprised 60.4% of the grandmultiparous group versus 27.7% of the control group. A predominance of early marriage as well as an older age profile was noted in the grandmultipara. ANC attendance was documented to be much lower among grandmultipara with 26.4% having absolutely no antenatal care. A higher frequency of hypertensive disorders in pregnancy, preterm birth, anaemia, malpresentations, multiple pregnancy and premature rupture of membranes, postpartum haemorrhage and retained placenta was noted in the grandmultipara which also had a slightly higher caesarean delivery rate. The salient adverse perinatal outcome was found to be intrauterine foetal death, preterm birth and neonatal sepsis. CONCLUSION: In our set up, grandmultiparity continues to challenge our obstetric practice with its associated increased likelihood of maternal and perinatal complications. Concerted effort should be directed to reducing high parity in the community through effective family planning initiatives and specialized antepartum and intrapartum supervision of this group should be available.     

Massive pre-placental and subchorionic haematoma

We report an unusual case of massive pre-placental and subchorionic haematoma occurring in a 26-year-old woman who presented with antepartum haemorrhage at 24 weeks gestation. Ultrasonography showed a subchorionic haematoma in the lower posterior uterine wall measuring 5.0 cm in largest diameter. There was also a separate irregular multiloculated structure measuring 4.3 cm in largest diameter on the surface of the placenta, due to a pre-placental haematoma. The subchorionic haematoma diminished in size over time, while the pre-placental haematoma continued to grow, measuring 9.0 cm at 28 weeks, and 9.3 cm at 32 weeks. At 32 weeks, the patient presented with premature rupture of membranes and four days later, an emergency caesarean section was performed when the patient had another episode of severe antepartum haemorrhage. Both mother and child recovered well. The current literature on such haematomas is reviewed.     

Fetal and neonatal mortality: a matter of care? Report of a survey in Cura?ao, Netherlands Antilles

A detailed clinicopathological analysis of 223 consecutive fetal and neonatal deaths was carried out in Cura?ao during 1984 and 1985; this included careful histological examination of 210 infants (94%). The crude death rate was 34.2 per 1000 total births. Malformation was the principal cause of death in 28 cases, antepartum haemorrhage in 19, hypertension in 25, and asphyxia in 35. Death was caused by problems of preterm birth in 68 cases. No specific cause could be found for 34 deaths. Improvement in the quality of obstetric care might substantially reduce both fetal and neonatal death rates.     

Shaken baby syndrome

Shaken baby syndrome is the most common cause of death or serious neurological injury resulting from child abuse. It is specific to infancy, when children have unique anatomic features. Subdural and retinal haemorrhages are markers of shaking injury. An American radiologist, John Caffey, coined the name whiplash shaken infant syndrome in 1974. It was, however, a British neurosurgeon, Guthkelch who first described shaking as the cause of subdural haemorrhage in infants. Impact was later thought to play a major part in the causation of brain damage. Recently improved neuropathology and imaging techniques have established the cause of brain injury as hypoxic ischaemic encephalopathy. Diffusion weighted magnetic resonance imaging is the most sensitive and specific method of confirming a shaking injury. Families of children with subdural haemorrhages should be thoroughly investigated by social welfare agencies.     

Premature labour.

Intravenously administered salbutamol inhibited premature labour for at least 48 hours in 49 of 76 patients (64%), but was more effective (89%) when the cervical dilatation was less than 2 cm, and no apparent cause for the premature labour was evident. Even when premature labour complicated multiple pregnancy, hydramnios, or followed a small antepartum haemorrhage, suppression of labour could often be achieved for at least 48 hours, thus following the administration of betamethasone or the transfer of the patient to a hospital with intensive care facilities for both mother and child. Treatment with betamethasone, in addition to salbutamol, was associated with a less severe form of respiratory distress syndrome, and did not increase the risk of maternal or fetal infection, except in patients with cervical incompetence when 46.2% of such patients were infected.     

早产儿肺透明膜病相关因素的多元回归分析

目的:探讨早产儿肺透明膜病(HMD)发病的相关危险因素。方法:回顾性分析我院2004年1月至2005年12月出生的580例早产儿资料,采用Logistic回归筛选出与HMD相关的因素。结果:(1)HMD发生的相关因素有胎龄、体重、性别、宫内窘迫、出生窒息、胎膜早破及产前是否促肺成熟治疗;(2)早产儿胎龄越小、出生体重越低,HMD发生率越高;宫内窘迫及出生窒息可增加HMD发生;胎膜早破及产前促肺成熟治疗可降低HMD发生;男婴HMD发生率高于女婴。结论:HMD的发生是多因素作用的结果,其主要危险因素有胎龄、出生体重、性别、宫内窘迫、出生窒息,而胎膜早破及产前行促肺成熟治疗对HMD的发生有抑制作用。及时有效地控制危险因素,可以从根本上减少HMD的发生。     

Relapse of idiopathic pulmonary haemorrhage and glomerulonephritis associated with cytomegalovirus (CMV) infection

A 49 year old man who developed idiopathic pulmonary haemorrhage and glomerulonephritis responded initially to immunosuppressive treatment and plasmapheresis. However, he died later from massive pulmonary haemorrhage and necropsy showed cytomegalovirus infection of the lungs. We propose that relapse of pulmonary haemorrhage may be associated with cytomegalovirus infection and that preventive measures against acquiring the virus through blood products should be considered for elective transfusions in view of the relatively good long term prognosis of this syndrome.