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walkitoutOnce upon a time (according to women who were having babies forty years ago) there was this idea circulating that the placenta completely blocked all the nasties from getting from mama to fetus and therefore smokin' and drinkin' and pretty much any kind of (prescription) drug was A-OK because after all it Couldn't Get to The Baby.
Yeah, we know _that_ didn't turn out to be true.
Still, even after we realized that all kinds of stuff made it through the placenta, there was still this whacky idea out there that the amniotic sac was somehow "sterile", which is part of what enabled the medical community to claim they needed to shave and "sterilize" the mother to prevent her from giving some Nasty Disease to the baby. (a) Did not turn out to be possible to sterilize the mother (even with a c-section delivery) and (b) attempts to do so interfered with normal colonization of the infant with comparatively benign stuff, with the result that when they inevitably were colonized, it was with much nsatier stuff.
Which isn't necessarily relevant to this particular rant.
We've known (well, _I_'ve known and I must have read it somewhere) for a while that infection that had crossed into the womb in the course of a pregnancy dramatically increased the odds of preterm birth (and not the relatively uneventful kind of preemie -- no, the in the NICU for a month or more kind of preemie with all kinds of follow-on problems). For reasons best known to the medical community, this was believed to be fairly unusual (even in cases of pre-term birth).
http://health.usnews.com/articles/health/healthday/2008/08/26/preterm-births-linked-to-infection-of-amniotic.html
They're rethinking that now, too.
And what do they think is a reasonable next step? Hey, let's just do screening amnio on every pregnant woman at 20 weeks to see if she's got an infection.
What could go wrong with _that_, after all?
Well, there is the fact that, even with good technique, but especially with sloppy technique, there's a risk of _introducing_ an infection that way. Dunno how many would be reduced in practice to detected, but that'd be something to worry about.
Then there's the question of exactly what would you _do_ if you detected an infection at 20 weeks? Abort? _That's_ gonna go over really well. Treat? Presumably with antibiotics, but delivered how? And who knows what kind of effects that could have. If group B strep is anything to go by, you'd just wind up with increased resistance and nastier bugs in the remaining group of infected uteri -- and that group might only not be smaller, it might have gotten bigger (see issue above of introducing an infection).
I'd bring up what they used to do to "sterilize" or "clean" the uterus post c-section and sometimes post vaginal birth (just pull it out after the baby and scrub it up good. Yeah. That'll only help.). But that would be gross.
Altho it would be relevant. (And goes a long ways to explaining why prolapsed uteri are so common in women who had babies during a certain time period. No, Virginia, those are _not_ complications of "vaginal birth". Those are complications of having a really evil birth attendant do bad, bad things to your body.)
*sigh*
Around this point with T., I quit reading about pregnancy and birth. But I've actually not been reading that much this time around. And this particular item came from my daily news skim -- not from any pointed googling.
ETA: Just to avoid looking like a complete idiot: a lot of the infections were not bacterial, but rather fungal therefore obviously antibiotics would be a complete non-starter as an idea. The good aspect of the screening amnio is that, presumably, you'd have a cultured (ETA2: er, sequenced; they used PCR because a lot of these little guys don't survive attempts to culture) version of whatever the bug in question was so you'd have a good idea what might reasonably counter it. OTOH, are there any "safe" antifungals for during pregnancy? And what, precisely, would be a safe and effective delivery mechanism (because ya gotta wonder if oral or even IV would get through the placenta in appropriate amounts)? And if you went back into the sac directly, how are you planning on testing this for safety and efficacy before you start treating pregnant women this way?
Does this strike anyone else as ethically really dodgy?
ETA3: and apparently _one_ organism found via PCR appears to be New to Us. Hey! The Womb, the Final Frontier.
Yeah, we know _that_ didn't turn out to be true.
Still, even after we realized that all kinds of stuff made it through the placenta, there was still this whacky idea out there that the amniotic sac was somehow "sterile", which is part of what enabled the medical community to claim they needed to shave and "sterilize" the mother to prevent her from giving some Nasty Disease to the baby. (a) Did not turn out to be possible to sterilize the mother (even with a c-section delivery) and (b) attempts to do so interfered with normal colonization of the infant with comparatively benign stuff, with the result that when they inevitably were colonized, it was with much nsatier stuff.
Which isn't necessarily relevant to this particular rant.
We've known (well, _I_'ve known and I must have read it somewhere) for a while that infection that had crossed into the womb in the course of a pregnancy dramatically increased the odds of preterm birth (and not the relatively uneventful kind of preemie -- no, the in the NICU for a month or more kind of preemie with all kinds of follow-on problems). For reasons best known to the medical community, this was believed to be fairly unusual (even in cases of pre-term birth).
http://health.usnews.com/articles/health/healthday/2008/08/26/preterm-births-linked-to-infection-of-amniotic.html
They're rethinking that now, too.
And what do they think is a reasonable next step? Hey, let's just do screening amnio on every pregnant woman at 20 weeks to see if she's got an infection.
What could go wrong with _that_, after all?
Well, there is the fact that, even with good technique, but especially with sloppy technique, there's a risk of _introducing_ an infection that way. Dunno how many would be reduced in practice to detected, but that'd be something to worry about.
Then there's the question of exactly what would you _do_ if you detected an infection at 20 weeks? Abort? _That's_ gonna go over really well. Treat? Presumably with antibiotics, but delivered how? And who knows what kind of effects that could have. If group B strep is anything to go by, you'd just wind up with increased resistance and nastier bugs in the remaining group of infected uteri -- and that group might only not be smaller, it might have gotten bigger (see issue above of introducing an infection).
I'd bring up what they used to do to "sterilize" or "clean" the uterus post c-section and sometimes post vaginal birth (just pull it out after the baby and scrub it up good. Yeah. That'll only help.). But that would be gross.
Altho it would be relevant. (And goes a long ways to explaining why prolapsed uteri are so common in women who had babies during a certain time period. No, Virginia, those are _not_ complications of "vaginal birth". Those are complications of having a really evil birth attendant do bad, bad things to your body.)
*sigh*
Around this point with T., I quit reading about pregnancy and birth. But I've actually not been reading that much this time around. And this particular item came from my daily news skim -- not from any pointed googling.
ETA: Just to avoid looking like a complete idiot: a lot of the infections were not bacterial, but rather fungal therefore obviously antibiotics would be a complete non-starter as an idea. The good aspect of the screening amnio is that, presumably, you'd have a cultured (ETA2: er, sequenced; they used PCR because a lot of these little guys don't survive attempts to culture) version of whatever the bug in question was so you'd have a good idea what might reasonably counter it. OTOH, are there any "safe" antifungals for during pregnancy? And what, precisely, would be a safe and effective delivery mechanism (because ya gotta wonder if oral or even IV would get through the placenta in appropriate amounts)? And if you went back into the sac directly, how are you planning on testing this for safety and efficacy before you start treating pregnant women this way?
Does this strike anyone else as ethically really dodgy?
ETA3: and apparently _one_ organism found via PCR appears to be New to Us. Hey! The Womb, the Final Frontier.
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no subject
Date: 2008-08-26 06:35 pm (UTC)no subject
Date: 2008-08-26 06:44 pm (UTC)I'll further add that I'm in no way opposed to treating the mother for illnesses she has.
http://www.telegraph.co.uk/news/uknews/2626033/Testing-women-for-infections-could-prevent-1000-premature-births-a-year.html
This guy (NOT one of the study authors) went _straight_ to antibiotics will prevent preterm birth (never mind that if there is fungal overgrowth, don't you think antibiotics may well have played a part in _causing_ this problem in the _first_ place?).
*sigh* OTOH, he's claiming there is other research saying antibiotics deployed correctly help with preterm birth. *shrug*
maybe, maybe not
Date: 2008-08-26 06:51 pm (UTC)http://www.emedicine.com/MED/topic3245.htm
The current approach seems to be, if you _know_ the mother is infected, go ahead and treat; if you think she might be infected, "prophylactic" antibiotics may help or may not but the effect is neither larger nor consistent. The current study appears to be designed to ferret out if maybe we need more certainty about the nature of the infection so the best treatment can be devised.
So, yay, better research good. But still not optimistic. At all.
This is way crappy secondary coverage, but here:
http://www.marchofdimes.com/aboutus/10651_10794.asp
Treating _between pregnancies_ with antibiotics to try to knock down an infection that may or may not have been present and caused a previous preterm birth resulted in slightly more preterm the next birth and lower birth weight (both indicators of possible infection). Given the presence of fungi in the PCR study, that actually makes a lot of sense, and makes the just give her a bunch of antibiotics theory really, really not good.
Re: maybe, maybe not
Date: 2008-08-26 07:15 pm (UTC)I had recurrent bacteria in the urine (too much to be considered at all normal, too low to be considered a full-blown infection most of the time) during the pregnancy with my twins. It did turn into a kidney infection and land me in the hospital at one point. I am virtually certain the antibiotics for *that* episode were a Really Good Idea, but far less certain that the other courses of antibiotics for the bacteremia or whatever it's called were. I do know my doctor went and consulted a urologist about the matter, rather than just winging it (one of the reasons I liked that doctor -- he also admitted to me that the urologist was not sure either what the best course of action was).
Re: maybe, maybe not
Date: 2008-08-26 10:23 pm (UTC)I have heard gingivitis/gum infections as a possible preterm labor problem; I don't know that I'd ever heard a mechanism one way or the other.
I always appreciate it when doctors are willing to go collect other opinions. When R. went to visit my family in the Netherlands with me shortly before we got married, my cousins were concerned at the time that J.'s leg might need to be amputated. I was absolutely struck by how non-rushed the decision making process was. It involved a variety of doctors who all got together and _had a meeting_ (at least that's how A. described it to me) to weigh the tradeoffs (J. at the time was in his early 80s, IIRC, and this was a circulatory issue related to his diabetes). The decision was that an amputation was not yet called for, which was a huge relief all around although because the process was drawn out, I didn't hear for months afterward.
Sometimes I think about that process (the Groningen protocol article brought it to mind most recently) and think, if that's the way the medicine was practiced here consistently, most of my problems with medicine would disappear.