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Sheet:  305 9 923

305 9 923 | Response ID | Status | Title, Author | Responder | [NAME] | Response
 | [NAME] | P | Re:[NAME]: Care at the Crossroads, Incarceration and Pregnancy [NAME], February 27, 2011 | [NAME],  MD MPH  Clinic on The Common | [EMAIL] | There is a recent NIH paper which approves the use of Buprenorphine ( Subutex TM ) as a "maintenance" opioid during pregnancy, and we do exactly that at the Friday Buprenorphine Clinics that I run. It is pretty a simple strategy; switch the addicted patient from an opioid that makes them "high" to one that does not, an opioid substitute that stops cravings at the same time. Buprenorphine meets both criteria. Stability can be achieved, and maintained, and we use urine testing, each visit, to assure compliance. (We are running this program as an outpatient clinic and thus have risk of noncompliance.) Buprenorphine is now available as a generic drug, so is low cost, a much better choice than Methadone. In a prison setting, it should be easy to duplicate this diversionary treatment plan and to enforce compliance. The only remaining question is when/if to detox the patient, ie. slowly detox during pregnancy and deliver drug free, , or continue the Subutex through until and beyond the delivery date. I have not been able to find any peer reviewed literature, that is compelling, on any increased risk of pregnancy complication that is undertaken when a gradual detox plan is adopted. I have two pregnant women in late second trimester who are on a "glide pattern" to be drug free well before delivery. Unless someone convinces me otherwise,I will continue this path and see no reason why a similar plan should not be adopted with an incarcerated patient [NAME] MPH   Conflict of Interest: None declared
 | jama_el;698 | NR | Pregnant In Prison [NAME], et al., March 2, 2011 | [NAME],  MD  Virginia Hsopital Center,  [NAME], MD | [EMAIL] | Preface: this letter is in response to a Clinical Crossroads/Readers Respond piece in JAMA online February 9, 2011.doi: 10.1001/jama.2011.125. Authors and contact info at bottom. No conflict of interest for either author. Pregnant In Prison Sign-out was all a buzz this morning as there was a term laboring patient from the local prison. She was charged with a violent crime and was said to be vicious. Her room was the very last one at the end of the L&D hall. She had 2 armed guards at her door and wasn't allowed any visitors. I remember thinking I sure feel bad for the person that has to labor that patient...wait that's the intern...wait that was me! I started thinking to myself about what the plan would be for delivery (as I did for any other patient) but admittedly I thought about how the fact that she came from prison would affect/change those plans. The fact of the matter was that no matter this patient's creed or crime, she was still a pregnant patient who needed my help...our help to safely bring her child into the world. I remember being very nervous when first entering the patient's room. I had the nurse accompany me. I introduced myself and went over the then current plan for delivery. She introduced herself and admitted to me that as this was to be her first delivery, she was nervous and wasn't sure what to expect. When finished I asked reflexively if the patient had any questions, and to my surprise they were normal questions! How does my baby's heartbeat look on the monitor doctor? When do you think the baby will be born? How soon after the baby is born can I breastfeed? Medical management in the strictest sense should not differ for these women as they are still patients. The still have past medical and surgical histories, they still have allergies, and they still report events like vaginal bleeding, loss of fluid, or contractions. Without sounding too idealistic and philosophical, it should be stressed that aside from their criminal record, these women are pregnant women just the same as women who are not imprisoned. Antepartum management and delivery of these patients should again be no different. Pregnant prisoner may not have the advantage of a one-on-one relationship with a board-certified health care provider, as they often receive prenatal care through an Ob/Gyn or Family Medicine resident-supervised clinic. Traditionally, when labor ensues, pregnant women, who routinely have 24/7 access to a private physician via an answering service, receive reassurance and instructions when to go to the hospital. In the case presented, the patient came close to delivering on-site at the prison while awaiting ambulance transport to the hospital. This scenario would be unlikely to occur with a non-incarcerated patient as most patients have a friend/family member who will drop everything to take that patient to the hospital immediately upon the physician's request. Patients should be monitored and cared for on labor and delivery units with staff trained in...labor and delivery and its complications. With that said, it should be kept in mind, that these women are charged with or have been convicted of breaking the law, and that the hospital staff has every right to his/her safety and security which is why the presence of guards accompanying these patients is appreciated. These women should also be allowed to make choices surrounding their antepartum, intrapartum, and postpartum courses that are within the confines of the law assuming that these choices will be safe for the patient, her child, and the staff needed to guide her through the labor and delivery stages. In terms of pregnant women in prison addicted to narcotics, again their medical management should not differ from those women who are pregnant, addicted to narcotics, and not imprisoned. Suggestions include transitioning a patient to an effective dose of Methadone to avoid the unpleasant and potentially lethal symptoms of narcotic withdrawal, and avoiding the temptation to wean or attempt to discontinue narcotic substitution to minimize newborn withdrawal. In addition to the use of methadone, Buprenorphine, a newer narcotic, may be considered in the armamentarium of agents used to minimize maternal narcotic withdrawal. Ideally, once these women have delivered, given that it is indeed safe for them to have their child in the room, rooming-in should be allowed during the duration of the hospital stay. Upon discharge, some prisons have mother-baby units where women are allowed to nest with their newborns for several weeks after delivery until further plans for the care of the child have been arranged. This would be best disposition for both the new mother and her child; however, in cases in which facilities like these are not available, hospital social workers should aide in helping these patients transition the care of their newborn to either family willing to accept the child, or government protective services, as the patient sees fit. The ultimate goal would be that, once the patient has completed her sentence, she has the choice and/or opportunity to rejoin her child in a residential parenting program much like the one Ms. [NAME] had the opportunity participate in. For the most part, Ms. [NAME]'s chronicle of her labor, delivery, and eventual outcomes was as close to ideal as possible. She had a safe delivery and was eventually reunited with her child in a safe environment for the both of them. The matter that was perhaps not the most ideal was how Ms. A felt during her delivery and afterwards because she was made to deliver and bond with her child in the presence of a prison guard. Improvement in the care for pregnant women, especially during the labor and delivery course has everything to do with reminding healthcare professionals that again, aside from the crimes these patients committed, these women are patients. These women require some level of privacy and have the need to bond with their child just the same. They have the same concerns and questions as many of our other patients do and they hope for an uncomplicated delivery and the birth of a healthy child just the same. [NAME], MD, PGY-1, Washington Hospital Center Ob/Gyn Residency Jon M. Katz, MD, Director, Maternal-Fetal Medicine, Virginia Hospital Center 1635 North George Mason Drive Suite #190 Arlington, VA 22205 [PHONE] [PHONE] (fax) [EMAIL]  Conflict of Interest: None declared
 | jama_el;700 | NR | Pregnant in Prison [NAME], et al., March 2, 2011 | [NAME],  MD  Virginia Hospital Center,  [NAME], [NAME], | [EMAIL] | Preface: this letter is in response to a Clinical Crossroads/Readers Respond piece in JAMA online February 9, 2011.doi: 10.1001/jama.2011.125. Authors and contact info at bottom. No conflict of interest for either author. Please note our previous response was > 500 words, thus this is an edited version (now 561 words).   [NAME], MD, PGY-1, Washington Hospital Center Ob/Gyn Residency Jon M. Katz, MD, Director, Maternal-Fetal Medicine, Virginia Hospital Center 1635 North George Mason Drive Suite #190 Arlington, VA 22205 [PHONE] [PHONE] (fax) [EMAIL]   Medical management should not differ for these women. They still have past medical and surgical histories, they still have allergies, and they still report events like vaginal bleeding, loss of fluid, or contractions. Without sounding too idealistic, it should be stressed that aside from their criminal record, these women are pregnant women just the same as women who are not imprisoned. Antepartum management and delivery of these patients should again be no different. Pregnant prisoner may not have the advantage of a one-on-one relationship with a board-certified health care provider, as they often receive prenatal care through an Ob/Gyn or Family Medicine resident-supervised clinic. Traditionally, when labor ensues, pregnant women, who routinely have 24/7 access to a private physician via an answering service, receive reassurance and instructions when to go to the hospital. In the case presented, the patient came close to delivering on-site at the prison while awaiting ambulance transport to the hospital. This scenario would be unlikely to occur with a non- incarcerated patient as most patients have a friend/family member who will drop everything to take that patient to the hospital immediately upon the physician's request. Patients should be monitored and cared for on labor and delivery units with staff trained in labor and delivery. Hospital staff has every right to his/her safety which is why the presence of guards accompanying these patients is appreciated. These women should also be allowed to make choices in their antepartum, intrapartum, and postpartum courses that are within the confines of the law, assuming that these choices will be safe for the patient, her child, and the staff needed to guide her through the labor and delivery stages.   In terms of pregnant women in prison addicted to narcotics, their medical management should not differ from those women who are pregnant, addicted to narcotics, and not imprisoned. Suggestions include transitioning a patient to an effective dose of Methadone to avoid the unpleasant and potentially lethal symptoms of narcotic withdrawal, and avoiding the temptation to wean or attempt to discontinue narcotic substitution to minimize newborn withdrawal. In addition, Buprenorphine, a newer narcotic, may be considered in the armamentarium of agents used to minimize maternal narcotic withdrawal.   Ideally, once these women have delivered, rooming-in should be allowed. Upon discharge, some prisons have mother-baby units where women nest with their newborns for weeks after delivery until further plans for the care of the child have been arranged. This would be the best disposition for both the new mother and her child; however, in cases in which facilities like these are not available, hospital social workers should aide in helping these patients transition the care of their newborn to either family willing to accept the child, or government protective services. Once the patient has completed her sentence, she would have the choice and/or opportunity to rejoin her child in a residential parenting program much like the one Ms. [NAME] had the opportunity participate in.   For the most part, Ms. [NAME]'s chronicle of her labor, delivery, and eventual outcomes was as close to ideal as possible. She had a safe delivery and was eventually reunited with her child in a safe environment. The matter that was perhaps not the most ideal was how Ms. A felt during her delivery and afterwards because she was made to deliver and bond with her child in the presence of a prison guard.   Conflict of Interest: None declared
 | jama_el;734 | NR | Re:[NAME]: Care at the Crossroads, Incarceration and Pregnancy [NAME], et al., March 28, 2011 | [NAME],  MD, PhD  Rheumatology and rehabilitation department; Faculty of Medicine Cairo University, Cairo Egypt,  Dr [NAME] ;Rheumatology and rehabilitation department;Suez Canal University, Cairo Egypt | [EMAIL] | Dear Editor We read carefully the case of [NAME], first we totally disagree that the case is Unprovoked Venous Thromboembolism, after careful review of the case I can see that the diagnosis was missing in this case although it is obvious in the CT angiographic findings. To our knowledge this is a straight forward case of Huges Stovin syndrome which is a rare autoimmune disorder of unknown cause that is characterized by the combination of multiple pulmonary artery aneurysms and deep vein thrombosis . The syndrome is considered a form of incomplete BehÃ§et's disease. Although the patient has no definite pulmonary aneurysms in the pulmonary artery yet fusiform dilation was evident on CT angiographic findings presented, the dilated main pulmonary artery and also the cuts of the terminal branches of pulmonary arteries are also evident of CT angiography. And if we have other CT cuts we may see what is so called mycotic pulmonary artery aneurysms that typical of pulmonary vasculitis in either BehÃ§et's disease or Huges Stovin syndrome. So for how long to be maintained on anticoagulant therapy is quite important issue to address as the mainstay now treatment for pulmonary vasculitis in BehÃ§et's disease and Huges Stovin syndrome is to give Immune Modulator drugs and anticoagulation should be revised in such case in view of the CT angiographic findings as we presented. I recommended for Ms W to receive Azathioprine 100 mg/day/PO or Cellcept 1000 mg/day. The main issues to discuss here is that for any patient present with DVT and then chest pain pulmonary embolism seems likely, but in view of our previous comments I can see that this is a case of pulmonary thrombi due to underlying pulmonary vasculitis and not due to pulmonary embolism secondary to DVT. Moreover we can consider to stop anticoagulant for her so long no extensive thrombi is present in the pulmonary arterial branches and many patients do well on that lines of treatment. Sp please consider our comments and CT cuts should be reviewed in view of our previous comments.  Conflict of Interest: None declared
 | jama_el;693 | P | [NAME]: Care at the Crossroads, Incarceration and Pregnancy [NAME], et al., February 23, 2011 | [NAME],  MD, MA  University of California, San Francisco Obstetrics & Gynecology, Dept. of Public Health, Jail Health,  [NAME], MD, MPH Fellow, [NAME] Clinical Scholars Program, Departments of Obstetrics and Gynecology and General Internal Medicine, [NAME] of Medicine at University of California, Los Angeles | [EMAIL] | Pregnancy for incarcerated women represents a complex crossroads of care: medical standards, correctional regulation, gender discrimination, criminal and medical management of substance abuse, and the impact of these on birth outcomes. The 8th amendment guarantees the right to health care for incarcerated persons; nonetheless, the variable and often inadequate services have been well documented 1, 2.  For many women, jail intake may be the first time they learn they are pregnant. This moment in pregnancy care highlights the challenges of "choice" in a setting where even mundane choices -- like when to wake up -- are limited. Incarcerated women have a constitutional right to obtain an abortion 2. However, one study found that while 68% of correctional health professionals said women can obtain an abortion, many fewer facilitate access 3.  When a woman chooses to continue a pregnancy, she should receive standard prenatal care, either on-site or via transport to a local hospital. Despite clear protocols from APHA 4 and NCCHC 5, an evaluation found that 38 states had inadequate prenatal services 1. The lack of standard prenatal care further challenges the management of common co-morbidities, like substance abuse. Acute opiate withdrawal during pregnancy increases the risk of miscarriage and stillbirth, and opiate-addicted women are transitioned to methadone or buprenorphine 6. This medical management requires immediate attention and prolonged waits in holding cells may put the pregnancy at risk.  Nowhere is the "crossroads" more apparent than in the practice of shackling in labor. Both ACOG and the NCCHC condemn this medically unsafe practice citing its danger when obstetric emergencies occur; the United Nations also declares it a human rights violation 7. From a security perspective, shackling is unnecessary; 65% of women are incarcerated for non-violent crimes 8. Additionally, labor pains and use of epidural anesthesia make fleeing unlikely. Nonetheless, only 10 states have anti-shackling laws.  Birth outcomes have been shown to be worse than in the general population, indicating that these are high risk pregnancies. However, when compared to disadvantaged controls, incarcerated women had lower rates of stillbirth and low birthweight 9. While the relative stability incarceration may improve immediate outcomes, few studies have reported the long term consequences on families. Most mothers become separated from their babies after delivery, as only 13 states have prison nursery programs. Postpartum separation is disruptive not only for the nuclear family, but also for extended families and communities which assume the responsibility of childcare 10.  Much needs to be done in this country to improve the care of incarcerated pregnant women. The report Mothers Behind Bars provides a comprehensive evaluation of pregnancy care in prisons, with concrete recommendations for change 1. As physicians, we should encourage our state legislatures to put an end to the unsafe and inhumane practice of shackling in labor. Currently, 12 states are hearing bills which pertain to this issue (Table 1). If the US is to improve care for incarcerated, pregnant women, it must see the complex social, economic, and political circumstances which underpin the need to improve pregnancy care.  Table 1 States with Active Anti-Shackling Bills in State Legislature  Arizona HB 2294  California AB 568  Connecticut GA 124  Florida SB 1086, HB 779  Hawai'i HB 131, SB 219  Idaho HB 163  Illinois HB 1958  Iowa SF 101, SF173  New York SB 375  New Jersey Assembly No 3492  Oregon SB 632  Rhode Island SB 165, HB5257   *Courtesy of ACLU Reproductive Freedom Project, February 18, 2011     Abbreviations  ACOG: American College of Obstetricians and Gynecologists APHA: American Public Health Association NCCHC: National Commission on Correctional Health Care  References  The Rebecca Project for Human Rights. Mothers Behind Bars: A state-by-state report card and analysis of federal policies on conditions of confinement for pregnant and parenting women and the effect on their children. 2010 National Women's Law Center. [NAME],L. 2007 Women Don't Check Their Reproductive Rights at the Jailhouse Door Women, Girls and Criminal Justice. Feb/Mar 2007: 21-28. Sufrin CB, [NAME], and [NAME]. Incarcerated Women and Abortion Provision: A Survey of Correctional Health Professionals. Perspectives on Sexual and Reproductive Health 2009 Mar; 41(1): 6-11. Standards for Health Services in Correctional Institutions. American Public Health Association. Washington, DC; 2003:108. National Commission on Correctional Health Care. Women's Health Care in Correctional Settings (2005 Update). Journal of Correctional Health Care. 2005; 11:381-389. [NAME], [NAME], Heil SH, et al. Neonatal Abstinence Syndrome after Methadone or Buprenorphine Exposure. 2010. N Engl J Med. 363: 2320-31. United Nations Human Rights Committee, Eighty-seventh session, July 2006, page 11. US Department of Justice: Bureau of Justice Statistics. [NAME]: Prisoners in 2009.http://bjs.ojp.usdoj.gov/index.cfm?ty=pbdetail&iid=2232 (Accessed February 22, 2011) Knight M & Plugge E. The outcomes of pregnancy among imprisoned women: A systematic review. 2005; 112: 1467-1474. Golden, R. (2005). War on the Family: Mothers in Prison and the Families They Leave Behind. New York: Routledge. Conflict of Interest: None declared
 | jama_el;690 | P | A 25-year-old woman pregnant in jail [NAME], February 21, 2011 | [NAME],  MD  A. Gemelli University Hospital, Rome | [EMAIL] | To the Editor: With regard to Dr Delbanco's discussion,(1) in particular what are the outcomes for the new mother, the child and nuclear family, as a paediatrician I think that the same sanitary assistance given to the population outside prison must be equally guaranteed to prisoners. Children are clearly a separate category, with needs more different from other prison populations. In our experience, the law allows female prisoners to keep their babies with them until the age of 3 years in specific "nest areas" inside female detention centres.(2) Parental contact is fundamental for the child and must be guaranteed inside the prison as a constitutional principle. There should be a balance between the possible damage of separating children from their mothers and the potential harm to children kept in prison. The choice to separate mothers and children is rarely justified; it often took place because of the inadequacy of the detention centre. Although there is poor direct evidence about the long-term effects of separating or keeping mothers with their babies while in prison, the role of the family as an essential element for mental and emotional development of the child is well known. From 0 to 3 years of age the interactive context of children coincides with the maternal figure and the mother's psyche becomes an integral part of the child's mind.(3,4) The mother and baby relationship can promote prisoners' rehabilitation to the community.(5) Children living in prison with their mother represent a vulnerable group with particular healthcare needs and the access to the prison health service may be the first opportunity for an inmate to receive medical care. Moreover, the period in prison could offer opportunities to improve the prisoner's health. We have verified that during their stay in prison the children's health was not damaged (relative to their growth, immunisation status and medical assistance) but on the contrary there was an improvement in their health.(2,6) To improve the condition of these mothers and their relationships with the babies, more attention should be paid to healthcare promotion by providing healthcare educational programmes, with periodic meetings on important themes such as breast-feeding, infant sleeping position, accident prevention, first steps, alcohol and drugs use. Prison may act as a gateway to facilitate the health and general well-being of these babies. A civil society is one that cares for its babies. Finally, I recommend for Ms A simply to be mum. Like all mothers of the world.   [NAME], MD  A. Gemelli University Hospital  Rome  [EMAIL]  1. [NAME] A 25-Year-Old Woman Pregnant in Jail. JAMA 2011  February 9;305,6.[Epub ahead of print]. 2. Ferrara P, Gatto A, Nicoletti A, Emmanuele V, Fasano A, [NAME] care of children living with their mother in prison compared with the general population. Scand J Public Health 2009 May;37(3):265-272.  3. [NAME] mothers’ contact with children, perceived family relationships, and depressive symptoms. J Fam Psychol 2005;19:350-357.  4. [NAME], [NAME], [NAME], Brooks-Gunn J. Early mother-child separation, parenting, and child well-being in Early Head Start families. Attach Hum Dev 2011 Jan;13(1):5-26.  5. Hotelling BA. Perinatal needs of pregnant, incarcerated women. J Perinat Educ 2008;17(2):37-44.  6. [NAME], [NAME], Joestl SS. Intergenerational transmission of attachment for infants raised in a prison nursery. Attach Hum Dev 2010 Jul;12(4):375-393.).  Conflict of Interest: None declared