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Historical perspective on septic abortion

Dear Dr. Zelop:

The article “Sepsis and Septic Shock in Pregnancy” in the June 2018 issue was informative. I thought you would be interested, at least for historical perspective, in the experience at Los Angeles County-USC Medical Center in the 1950-1960 era. At that time septic abortion was by far the most common and severe form of pregnancy infection, especially with complications of generalized sepsis, septicemia, endotoxin shock, renal shutdown (acute cortical necrosis) and vascular collapse.

Until our protocols were developed, at least one fatality per month occurred at that facility. Most of the techniques were employed as described in the contemporary article, including diagnosis-usually very easy-then vascular support, very aggressive antibiotics, antitoxin and steroids, removal of infected tissue (early) and “peritoneal dialysis.”

Enclosed herein is a 1963 paper from the Green Journal from LA County-USC Medical Center by the late and great Gail Anderson, first full-time chief of OBGYN at LA County-USC Medical Center and me, on a special subset caused by clostridium welchii organism. Early removal of infected tissue by hysterectomy, peritoneal dialysis, antitoxin along with antibiotics all were necessary to lower the incidence of morbidity and mortality.

Another paper referenced in this article described the more “usual” septic abortion (E. coli, etc). Of course, since Roe v Wade these medical problems are much reduced, although principles of diagnosis, treatment, etc. described in your article are very beneficial.

The clash between “right to choose” and “right to life” has powerful arguments on both sides. Perhaps more effective, cheaper and safer contraception will help solve the medical, economic, and moral dilemmas on both sides.

 Sincerely yours,

Marshall Kadner, MD

Dear Dr. Kadner:

Thank you for sharing your historical perspective with our readership regarding septic abortion. I would like to take this opportunity to acknowledge the significant clinical contributions to women’s health care made by providers like you who work so diligently in the trenches.

Best regards,

Carolyn

On obstetrics and the Hippocratic Oath

Dr. Lance Lang, the Chief Medical Officer of Covered California (a California health care exchange), has said “time’s up” regarding cesarean delivery rates. By 2019, hospitals whose rates do not meet the ACA Exchange’s average cesarean rate will be kicked out of their network. But the ethical question for physicians and society alike is, is this even moral? 

I have been an ob/gyn for most of four decades and my approach to obstetrics has not changed. Some years, my cesarean delivery rate was very low, and in others I was an “outlier” on the high side. 

Women must be treated as individuals. Although the industrial revolution increased quality and decreased costs in manufacturing, I do not believe that we can or should apply those principles to our patients. Women are not widgets.

In the Oath of Maimonides, we are called upon to vow and say, “May the love for my art actuate me at all time; may neither avarice nor miserliness …engage my mind.”  Yet government regulators, insurance companies, the Leap Frog organization, Dr. Ezekiel Emanuel and Dr. Lang appear to have lost their memory of this oath. In Ancient Greece, Hippocrates said, “Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient.” In 1964, Louis Lasagna, the Academic Dean of the School of Medicine at Tufts University, created the modern version of the Hippocratic Oath that most schools use today. In it, we swear to “apply, for the benefit of the sick, all measures which are required ... ” - to the benefit of the sick, not to the benefit of government, the federal budget, an ACO or the Covered California ACA Exchange.

Dr. Charles Lockwood’s discussion on the “industrialization of medicine”¹ and Dr. Allan Jacobs’s “Is There a Happy Medium?”² articulate how physicians have lost their ability and autonomy to individualize care in their patients’ best interests.

I will always defend best practices as well as the rights of women to have full and truly unbiased informed consent. I will not compromise either my primary responsibility to my individual patients nor my commitment to adhere to the oaths of Maimonides and Hippocrates, and I would advocate that every physician try to understand that perspective when analyzing data on physicians who appear to be outliers.

I recognize the goals of the government and insurance companies, but as someone who had zero NTSV (Nulliparous, Term, Singleton, Vertex ) cesareans for many quarters, I would caution administrators about over-analyzing low-volume physicians like me or hospitals whose demographics differ from the “average.” The statistical swings caused by several patients in any one quarter are truly meaningless. For many years, my cesarean rate was one of the lowest at Cedars-Sinai Medical Center and as noted above, I have not changed my practice style or my patient demographics; other years I was an “outlier” on the high side.

Clearly the informed consent of a 42-year-old who had in vitro fertilization, has a floating vertex presentation with a low Bishop score, and an estimated fetal weight of 4000 g at 40 6/7 weeks must include the risks of primary cesarean but also the risks of a long labor that ends up in a cesarean, the occasional risk of shoulder dystocia or third- or fourth-degree extension. Not having had a shoulder dystocia or third/fourth degree in over a decade clearly justifies my rationale.

Approximately 20 years ago I was “politely” criticized by our then-department chairman for doing serial scalp testing (with good pHs) in the second stage of labor on a primipara. FHTs had deep severe variables with a stable baseline and moderate variability. Once safely deliverable, I placed low forceps and shortened the second stage-cord gases were normal: 7.21/7.23. His argument was that even though I was following the “book,” 1% of the time scalp testing will be falsely negative (saying normal pH when in fact there was acidosis) and that the institution would prefer to have us do a cesarean to avoid litigation. In today’s climate, hospital leadership would prefer the vaginal delivery, lowering their insurance company and government-monitored NTSV cesarean rate. Have women changed in 20 years? Why, then, has the practice of obstetrics?

Brilliant economists like Peter Orzag and Jonathan Gruber recognized that only with consolidation as well as salaried physicians and nurse extenders working under strict centrally planned protocols could costs be contained. Yet these men are not at our patients’ bedsides at 3:00 AM delivering babies. Another lead architect of the ACA, Dr. Ezekial Emanuel, also has advocated making societal trade-offs favoring budget savings over individual health, especially concerning people over the age of 75 or those with a small chance of success from costly therapy. Health economists like him accept more stillbirths, babies with hypoxic ischemic encephalopathy, cerebral palsy or Erb’s palsy as long as it lowers governmental expenditures. Do the parents of these children get a vote? 

In my opinion, the overwhelming majority of practicing physicians, like me, feel more aligned with the oaths of Hippocrates and Maimonides. We believe that we have a moral, ethical and medical responsibility to the individual patient and not to an ACO or government bean counter.

I would suggest an overarching theme: Choice. Doesn’t our country, doesn’t our Constitution give us freedom to make our own intelligent decisions?  Are we not given the right to make reasonable choices different from what others would? Are we not free to make reasonable decisions even if government or their surrogates prefer that we don’t?

Don’t doctors have the right to make different decisions based on reasonable data and their own interpretation of medical literature?

Does one size fit all? Imagine if there were only size 8 jeans in America. Some women couldn’t even fit in them and some would be swimming in them. So why does Washington or Covered California tell us there is only one way to practice obstetrics?

REFERENCES

• Lockwood CJ. Industrialization of medicine: coming soon to a practice like yours. Contemporary OB/GYN, July 1, 2011:10. Available at: http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/modernmedicine/modern-medicine-now/industrialization-medicine-coming-soon-pr?page=full. Accessed Aug 17, 2015.
• Jacobs A. Is There a Happy Medium? Contemporary OB/GYN, July 2011:28