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Clinical Case Report # 4

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Patient 32, married, multiparous than 3 vaginal deliveries, pelvic control goes to because he approached from the office for their Pap test.

, the patient is concerned and when interviewed by the midwife, it invites you to have a NIE cervicopatía 1 associated with HPV.

The patient does not understand what it is and asks for an explanation in simple terms.

Do I have cancer? If I have now, do I have chance of cancer? What chance? Is it false positive Pap? What about false negatives? What to do? How did this happen to me?

1. How do you inform the patient of the above?

intraepithelial neoplasia 1 (NIE I) is not cancer, but it is a disease that alters the normal barrier of the cervix, which is likely to get cancer, thus being a premalignant condition. The NIE 1 in more than half of the cases (70%) and improved return spontaneously, leaving a percentage of the injury remains stable, and a small percentage progressing to NIE 2 and 3 and possibly to cancer .

The PAP has false positives and negatives. Is estimated to have a sensitivity of 50-60% for the diagnosis of histological atypia, but its specificity is 90-99%. False positives are 16%, and false negatives 20%. This means that the test will not detect all patients with abnormal, but if detected, is very sure that you have an injury.

must have a serial control (clinical and PAP) on a regular basis to control the natural progression of this injury. In general has a good prognosis.

How would report it acquired a virus?

will inform you the truth about how he acquired the virus. What is sexual transmission. This is because the benefits we get with education and awareness are higher than hide this information.

Do you have the obligation to do so? What cases do you have?

the doctor is obliged to inform the way they acquired the virus, since in this particular disease, infection with this pathogen is a major risk factors and etiologies that explain their picture. For this reason, allows us to educate the patient, and to take all appropriate action.

2. A person with an STD is more likely to have another STD. Is this an STD?

A person with an STD, have a higher risk of having another STD depending solely on their risk factors (promiscuity, unsafe sex without protection methods, etc.). In this case we must evaluate the background to suspect in other infections. But the caveat is that this type of infection is highly prevalent in the general population, so given the high prevalence does not to think about other sexually transmitted infections if there are no risk factors.

3. The patient wants to explain to her husband. What did you say?

You must first find a comfortable and sheltered. It should be explained naturally, without falling in intonation or severity alarm. We explained that an infection is highly prevalent in the general population, which corresponds to a sexually transmitted disease course is often asymptomatic, and can generate lesions that have a partner. We partner education. We believe it is important to explain the possible form of timely transmission of the infection.

4. The patient tells you that, so this does not happen to their daughters, you want to vaccinate. Is there a vaccine to protect them?

There is a vaccine that can immunize against the human papilloma virus. It is necessary to investigate the ages of the girls, because to be effective, it has been shown to be applied before the start of sexual life. Anyway, once begun is effective sexual life, but it depends entirely on chance of not having a relationship where you purchased the virus. We advise you to vaccinate their daughters, as has been proven effective for 70 to 95% protection against the most prevalent strains that produce cancer cervical. It is also important to educate people about safe and healthy sexual behavior.

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Case Report No. 1

Patient 28, a lawyer by profession, married, primigravida, studying physiological evolution pregnancy of 36 weeks.

is seen by an obstetrician in a normal control and she reminds him that "there was a pending conversation" on the route of delivery.

In the first weeks of pregnancy she had raised fears for normal childbirth as it has had to deal professionally with some women who had complications or product delivery are not indicated time cesarean section.

She is very confident of the capabilities of your doctor, but the fear of labor is higher and raises him that without access to operate, she changed doctors.

1. What are the perinatal risks of vaginal birth compared with cesarean delivery?
   vaginal delivery, in fact, may have multiple complications, which are different from those presented by cesarean section.
   in natural childbirth for the mother there is the risk of perineal trauma, bleeding from the birth canal, urinary incontinence, fecal incontinence or constipation. May require an episiotomy, risk of anal sphincter injury. Improper handling of the placenta can cause uterine inversion. The fetus, in turn, may suffer craniofacial and intracranial injury.
   instrumental vaginal delivery in these risks are more numerous. With the use of forceps increased the likelihood and severity of vaginal laceration, postpartum and produces greater discomfort can injure the facial nerve of the newborn. Using suction cups, shows the cephalohematoma retinal hemorrhage and subarachnoid hemorrhage and subgaleal.
   
   
2. What are the future risks of a cesarean vs. vaginal delivery? Can the cesarean limit future fertility?
   Caesarean section is a procedure not without risk. The passage through the birth canal helps lung maturation and the removal of secretions from the airway of the fetus, effects that are lost in the caesarean section. It also increases the risk of uterine lacerations, bladder and ureteral injury, injury to the gastrointestinal tract, uterine atony endomyometritis, amniotic, and air embolism, septic pelvic thrombophlebitis and infection of the wound.
   A woman undergoing cesarean section introduces some added risk in their next birth, placenta previa, placenta accreta and uterine laceration probability. Moreover, in the event vaginal birth after cesarean increases the risk of uterine rupture, endometritis, and maternal death, and increased blood transfusion requirement. For these reasons, it is not recommended caesarean section in women who want more children.
   
   
3. Are there any clinical ethical problem here?
   There is. The patient wants to undergo caesarean section despite having no obstetric indication for it, which adds an element to be considered for the doctor when you need to explain the alternatives to the patient.
   In simple terms, the patient wants to change other proceedings for which no indication, due to fears that the former will produce. The decision, then, is being taken without adequate information about risks and benefits of each option, the obstetrician must provide.
   Then there is what the doctor thinks indicated on this at their discretion, experience and available evidence. Although caesarean section without obstetric indication can be done and, in fact, is is possible to assess the situation from a viewpoint based on principles. Autonomy
   . We are facing a competent patient, in full possession of his mental faculties, and now informed, who freely expressed their preference for caesarean section. Thus, accept or decline your request involves no respect or autonomy.
   No malice. Failure to perform caesarean section, there is harm to the patient in the sense of making you feel a pain that does not suffer, plus the ability to also require cesarean section, but as emergency procedure in a first vaginal delivery, but that complicated.
   If, by contrast, is performed, the ability to cause disease is more ambiguous. The available evidence suggests that caesarean section has more complications than vaginal delivery for both mother and fetus, but there are conflicting data. This prevents an unambiguous stance against this issue. Charity
   . Make caesarean section because a good mother, because it suits their desires. Do not do it well as serving a purpose is less clear because it is difficult to ensure that actually cause a good if not performed by the same arguments in the previous section.
   Justice. The procedure in question is not available for all patients. In the public health system, caesarean sections are performed only when obstetric indication for antepartum or you see it, but there is no alternative requested in this case.
   
   Obstetricians who have faced similar cases they try, usually argue in favor of vaginal delivery when there is no indication de cesárea. Si la paciente insiste, respetan sus deseos a menos que exista una contraindicación clara. En el sistema público la libertad de maniobra es menor, pero en casos puntuales se ha recurrido a interpretar laxamente las indicaciones de cesárea para poder incluir a la paciente en cuestión en el grupo de cesáreas electivas.

La paciente es informada de los riesgos, los beneficios del parto vaginal y de la cesárea. Ella justifica su insistencia en operarse, basada en el principio de autonomía.