Case I Part 1: Tracy and Dylan
by Sarah Feltz
1. What is the relationship between lupus and adverse pregnancy events?
1.1. Women with lupus who get pregnant are considered to have a "high risk pregnancy". Aka higher maternal and fetal mortality and morbidity (9).
1.1.1. Outcomes for mothers: disease flares, pre-eclampsia, and other complications
1.1.2. Outcomes for fetus: higher risk of fetal loss, pre-term birth, intra-uterine growth restriction and neonatal lupus syndromes
2. What is the doctor's responsibility to fulfill a patient's desire to become pregnant?
2.1. According to the AMA, a physician is required to complete the process of informed consent, consisting of: a) assessing pt's ability to understand information, tx, and alternatives to make voluntary decision b) presenting relevant information accurately and sensitively to educate patient in making decision c) documenting informed consent conversation (10).
2.2. A physician has a responsibility to patients to support continuity of care for their patients in the case they choose to refuse care and withdraw from a case. The physician must notify the patient in advance and facilitate the transfer of care when appropriate (10).
3. References: 1. Ottesen EW, Howell MD, Singh NN, Seo J, Whitley EM, Singh RN. Severe impairment of male reproductive organ development in a low SMN expressing mouse model of spinal muscular atrophy. Sci Rep. 2016;6:20193. Published 2016 Feb 2. doi:10.1038/srep20193 2. Prior TW, Finanger E. Spinal Muscular Atrophy. 2000 Feb 24 [Updated 2016 Dec 22]. In: Adam MP, Ardinger HH, Pagon RA, et al., editors. GeneReviews® [Internet]. Seattle (WA): University of Washington, Seattle; 1993-2019. Available from: Spinal Muscular Atrophy 3. Carp HJ, Shoenfeld Y. Anti-phospholipid antibodies and infertility. Clin Rev Allergy Immunol. 2007;32(2):159–61. 4. Richard A. Hickman, Caroline Gordon, Causes and management of infertility in systemic lupus erythematosus, Rheumatology, Volume 50, Issue 9, September 2011, Pages 1551–1558, https://doi.org/10.1093/rheumatology/ker105 5. Infertility coverage by state http://www.ncsl.org/research/health/insurance-coverage-for-infertility-laws.aspx 6. 2012 Connecticut General Statutes Title 38a - Insurance Chapter 800c - Health Insurance Section 38a-509 - Mandatory coverage for infertility diagnosis and treatment. Limitations. https://law.justia.com/codes/connecticut/2012/title-38a/chapter-700c/section-38a-509/ 7. AB460 Health care coverage: infertility (California) https://leginfo.legislature.ca.gov/faces/billTextClient.xhtml?bill_id=201320140AB460 8. New California Law Gives LGBT Couples Equal Access to Infertility Insurance https://www.iflg.net/new-california-law-gives-lgbt-couples-equal-access-to-infertility-insurance/ 9. Lateef A, Petri M. Managing lupus patients during pregnancy. Best Pract Res Clin Rheumatol. 2013;27(3):435–447. doi:10.1016/j.berh.2013.07.005 10. https://www.ama-assn.org/delivering-care/ethics/code-medical-ethics-overview
4. What is the significance of same sex marriage on health care policy execution for infertility?
4.1. In CT, it is required by law that health insurance organizations provide coverage for medically necessary expenses in the diagnosis and treatment of infertility, including IVF. Infertility in this case, refers to an otherwise healthy individual who is unable to conceive or produce conception or to sustain a successful pregnancy during a one-year period (5,6)"
4.2. There are many articles detailing the divide between heterosexual and same-sex couples and coverage for infertility treatment.
4.3. So far, California is the first state to pass a bill into law that gives LGBT couples equal access to infertility insurance and offers a non-discrimination statement (7,8).
5. What is the nature of infertility
5.1. In a carrier of SMA?
5.1.1. If both parents are carriers, they have a 25% change of producing an affected child, a 50% chance of producing an asymptomatic carrier, and 15% chance of producing an unaffected child who is not a carrier (1).
5.1.2. There is evidence that low levels of survival motor neuron (SMN), which causes SMA, can lead to severe impairment of male reproductive organ development. However, no overt sex organ phenotype was seen in a mild SMA model (mouse) (2).
5.2. In a lupus patient with positive anticoagulant?
5.2.1. Other was SLE could impact fertility is through menstrual disturbances, cervico-vaginal inflammation, and other secondary infections (e.g. CMV, EBV) (4).