Hypoplastic left heart syndrome: to treat or not to treat.

OBJECTIVE: To review our experience in managing infants with hypoplastic left heart syndrome (HLHS) and to establish a consistent approach in counseling families based on our experience and on review of medical literature. METHODS: Infants were divided into three group periods based on significant changes in the approach to treatment. After a diagnosis of HLHS was made, a multidisciplinary team met the family to discuss different management options: compassionate care, active treatment by heart transplantation, or Norwood staged surgery. RESULTS: Parents of 58 infants (58%) opted for compassionate care, and 41 (42%) opted for active treatment. Seven infants underwent heart transplantation and all remain alive. A total of 27 infants underwent Norwood stage I, and 19 (70%) survived. There was a significant increase in parental choice for active treatment over the three time periods. CONCLUSION: These results indicate that HLHS can no longer be regarded as a uniformly fatal congenital anomaly. However, due to uncertainty about long-term outcome, discussion with parents should be open, and compassionate care should be presented as a management option until long-term data are available.     

Current knowledge of transient hypothyroxinemia of prematurity: to treat or not to treat?

Background: Thyroid hormones (THs) play a critical role in normal maturation of the developing brain in the fetus and infant. Continuing advances in neonatal medicine have contributed to an increased survival of extremely premature infants with neonatal morbidities. In these infants, thyroid system immaturities, as well as morbidity-related thyroid dysfunction, contribute to transient hypothyroxinemia of prematurity (THOP), which is characterized by very low total and free thyroxine and normal or low thyroid-stimulating hormone (TSH) levels.

Review: Undoubtedly, low levels of THs with elevated TSH are associated with poor neurodevelopmental outcome. However, continuing debate exists regarding whether THOP is harmful to the developing brain. Moreover, no clear effects of TH treatment on neurodevelopmental outcome in preterm infants with THOP have been demonstrated. THs could have unpredictable effects if given unnecessarily.

Conclusion: The current recommendation is to treat THOP with TH only if THOP is accompanied with TSH elevation.     

To treat or not to treat: perceptions of the initial American Society for Reproductive Medicine COVID-19 recommendations among women’s health providers

PurposeThe objective of this study was to evaluate the perception of the initial ASRM COVID-19 recommendations for infertility treatment held by women’s health providers within varying subspecialties, as well as their attitudes toward pregnancy and fertility during this time.MethodsAn electronic survey was sent to all women’s healthcare providers, including physicians, mid-level providers and nurses, in all subspecialties of obstetrics and gynaecology (Ob/Gyn) at a large tertiary care university-affiliated hospital.ResultsOf the 278 eligible providers, the survey response rate was 45% (n = 127). Participants represented 8 Ob/Gyn subspecialties and all professional levels. Participants age 18–30 years were significantly more likely to feel that women should have access to infertility treatment despite the burden level of COVID-19 in respective community/states (p = 0.0058). Participants within the subspecialties of general Ob/Gyn, maternal foetal medicine and gynecologic oncology were significantly more likely to disagree that all women should refrain from planned conception during the COVID-19 pandemic, in comparison to those in urogynecology and reproductive endocrinology and infertility (p = 0.0003).ConclusionsConsidering the immediate and unknown long-term impact of the COVID-19 pandemic on fertility care delivery, a better understanding of perceptions regarding infertility management during this time is important. Our study shows overall support for the initial ASRM recommendations, representing a wide spectrum of women’s health providers.     

To mesh or not to mesh

We are in the midst of an increasingly acrimonious discussion regarding the use of mesh in pelvic reconstructive surgery. Modern mesh kits, aggressively marketed by biotech companies, have become widespread. At times, they are used inappropriately, and significant complications such as pain syndromes and erosion are not uncommon. While conventional alternatives such as sacrospinous colpopexy and Burch colposuspension are not without their problems either, the discussion surrounding mesh use has a character never encountered before in urogynaecology. Many colleagues feel that the resolution of this conflict may be found in large randomised controlled trials such as the PROSPECT trial currently being planned in the UK. I feel that such a trial may well do more harm than good, unless certain precautions are taken. In this opinion piece I'll try and explain why.     

Antithyroid drugs: to breast-feed or not to breast-feed

Historically, women taking antithyroid drugs generally have not been permitted to breast-feed. However, recent studies suggest that infants exposed to the small amounts of antithyroid drugs in breast milk experience no change in thyroid function. Propylthiouracil is the drug of choice in this situation, since it does not cross membranes readily, and milk concentrations are therefore quite low. However, methimazole in low dosages might be used if the infant's thyroid status was monitored at frequent intervals.     

To have or not to have a pregnancy

A follow-up study of more than 65,000 healthy women aged 15 to 44 was conducted to assess the association between oral contraceptive use and thromboembolism, stroke, or nonfatal myocardial infarction from 1980 through 1982 at Group Health Cooperative of Puget Sound. A positive association existed between current oral contraceptive use and venous thromboembolism (rate ratio equals 2.8), but there was no positive association between current oral contraceptive use and stroke or myocardial infarction.     

Biomedical technology: to use or not to use?

The past 30 years have seen tremendous advances in biomedical technology that have changed dramatically the practice of medicine in general, of neonatology in particular. All changes have not been for the best, however. The price tag has been especially steep, but there have been adverse effects on the quality of medicine as well. The reasons we rely on high technology, its risks and pitfalls, and our future handling of decisions regarding using or not using biotechnology deserve careful consideration, including financial factors that physicians have been loath traditionally to address. If the medical profession is to avoid becoming enslaved to technology, our future decisions must be better informed, more rational, and based on more scientific facts than they have been in the past. Above all, physicians must avoid becoming mere technicians at the expense of the traditional humanistic approach to patient care.