Sunday, February 1, 2009

Medicolegal Pitfalls and diabetes in pregnancies

Two main issues present medicolegal pitfalls for the clinician treating patients with diabetes in pregnancy.
1. Congenital malformations
2. Birth injuries


Congenital malformations
The occurrence of a severe, debilitating congenital anomaly in the infant of a mother with diabetes is serious burden for the mother as well as for the family. Clinicians must take necessary actions to prevent congenital malformations. Ideally this should be started preconceptionally.
If the patient is diabetic prior to pregnancy, The patient should be advised to use a reliable method of contraception until she has achieved a preconceptional HbA1C level within the reference range. This counseling should be recorded in the patient's medical record.
Structural defects occur in 3-8% of offspring of diabetic pregnancy, but this rate drops 3- to 4-fold if excellent glycemic control is maintained during the period of embryogenesis.
Birth injuries
Birth injuries include perinatal asphyxia, clavicle or humerus fracture, brachial plexus disruption, or, less commonly, direct cerebral or cervical spine trauma, shoulder dystocia.
Permanent palsy of the arm and hand after a difficult delivery of an obese fetus usually leads to litigation and, in some cases, large judgments. Although current scientific data establishing the foreseeability and preventability of these injuries remain inadequate, defending obviously high-risk cases can be difficult.
The obstetrician managing the patient's third-trimester prenatal care and labor may be judged at fault should an injury occur during delivery if an ultrasound suggests that fetal weight exceeds 10 lb, labor proceeds slowly, or a difficult forceps or vacuum procedure is necessary to deliver the fetal head. Thus, obtaining an ultrasound-based estimation of fetal weight in the last 2-3 weeks prior to delivery and offering cesarean delivery to a patient with an estimated fetal weight of more than 4500 g or a labor course that is protracted such that she is unable to expel the fetal head spontaneously after 2-3 hours of pushing effort are prudent.

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