Although neither cyclo- have an electrocardiogram and an echocar- that their child may inherit the same condi- prior to conception the patient should be sporine nor tacrolimus has been reported to diogram17 order cytotec with american express treatment lice. If the maternal diagnosis is known dur- vaccinated against infuenza buy discount cytotec 100 mcg symptoms miscarriage, pneumococ- be teratogenic or mutagenic purchase cytotec 100mcg on line symptoms rotator cuff tear, both have been angiography (to exclude allograft coronary ing the pregnancy, antenatal ultrasound may cus, hepatitis B and tetanus17. Women who associated with low birth weight, intrauterine artery disease), right heart catheterization and be used to look for the typical changes of refux are not rubella immune should receive the growth retardation and small size for gesta- cardiac biopsies, but these tests may not be nephropathy in the fetus29. Prenatal testing ued during the pregnancy to avoid graft rejec- as an immunosuppressive agent following It is not uncommon for recipients of both may be available for certain conditions1. Studies in pregnant rats have Reports indicate that sirolimus is associated rine and no drug-related problems have been offspring of treated rats and rabbits showing shown that whilst sirolimus is not teratogenic, with altered sex hormone levels (low testos- noted in their babies35. A case was described wherein a 30-year- sirolimus-associated infertility in a young male azathioprine, the consensus opinion for tacro- matic hernias38,39. Sperm quality improved limus is that breastfeeding is not absolutely A number of case reports presently describe healthy normal baby at term having taken following the withdrawal of sirolimus and the contraindicated, but babies should be closely congenital abnormalities following human sirolimus throughout the pregnancy41. Two maternal deaths occurred when recommended during pregnancy and should motility, although sperm count and morphol- Milk concentrations range from 5 to 25% of immunosuppression was discontinued during be discontinued at least 6 weeks before con- ogy are not completely restored to normal44. In cardiac transplant recipients, ception is attempted, during which time effec- The true incidence and prevalence of male are found in breast milk following a 10mg there is a high risk of acute rejection in preg- tive contraception should be used. Nei- ever, small studies have shown no evidence as a biopsy usually involves X-ray screening malformations, notably involving development ther azathioprine nor calcineurin inhibitors of harm in the babies of azathioprine-treated which is contraindicated in pregnancy. It is a major cause Table 1 Characteristics of pregnancy among transplant recipients during pregnancy and of their infants, function during a pregnancy. The increased glomerular fltration rate eclampsia and resulting increases in the risk Characteristic Kidney Liver and kidney Heart Lung which occurs in pregnancy usually results in of fetal growth restriction, placental abruption No. Hypertension is common in the solid organ Diabetes during pregnancy (%) 3–12 0–13 2 4 21 For patients with liver transplants, any dete- transplant recipient even before pregnancy, Rejection episodes (%) 2–12 0–11 6 22 31 rioration in liver chemistry during the preg- and particularly if the patient is receiving a Pre-eclampsia (%) 29–31 13–33 33 10 13 nancy requires aggressive evaluation. Graft loss within 2 years (%) 4–14 3–9 17 0 23 no contraindication to liver biopsy, if required, The incidence rates of both hypertension and to look for evidence of rejection1. Pre-eclampsia develops in 15–37% of Reproduced with permission from McKay and Josephson8 from graft rejection and exacerbation of under- renal transplant recipients58 and is reportedly lying liver disease such as hepatitis C1. Lower rates have been reported underlying renal impairment, reduce maternal Other beta blockers are safe in pregnancy and given to treat an acute rejection episode and is in liver, heart and lung recipients53. It is essential hydralazine has been extensively used in preg- hypertension and a 10% rate of pre-eclampsia 62 that these are reviewed ideally before concep- nancy with few adverse events reported. A recent study reported Hypertension is a common medical disorder ally be maintained at less than 140/90mmHg associated with small-for-gestational age a 2. However, in cases of severe edema the ent in patients with diabetic nephropathy The overall risk of infection during pregnancy transplantation year when levels of immuno- risk–beneft ratio of diuretic therapy should be affecting a transplanted kidney, especially if varies according to the organ transplanted. Low-dose prophylactic aspirin helps prevent A patient whose diabetes is normally treated Bacterial infections laxis is also advised in cases where the donor pre-eclampsia75. Few studies, however, have with oral hypoglycemic agents may require and recipient are both seropositive and the specifcally examined the purported beneft in insulin during pregnancy. Aciclovir is not known to weeks in the high-risk patient if there are no Approximately 1–2% of patients on the renal that all renal transplant recipients should be be harmful in pregnancy, but its manufactur- contraindications58. If asymptom- when the potential benefts outweigh any nancy is often a consideration for this category atic bacteriuria is present, a course of antibiot- risks47. The presence of Prophylactic antibiotics are recommended for rological, hearing, visual or dental abnormali- One meta-analysis shows that the risk of anti-Ro and anti-La antibodies increases the organ recipients requiring invasive procedures ties. It occurs erythropoietin, the relative increase in plasma The combination of hepatitis B vaccination in up to 20% of renal transplant recipients can occur in solid organ transplant recipients58. In addition, how- Hepatitis C Hepatitis C is now more com- secretion of erythropoietin by native kidneys, vaginal delivery, and cesarean delivery reduces ever, anemia may occur due to bone marrow mon than hepatitis B in renal transplant transplanted kidneys or the liver. Should exposure also may have anemia related to chronic renal Pregnant transplant recipients known to have viral load, can be increased as a consequence occur, prophylactic intervention with intrave- impairment. Venesection can be considered following organ transplantation is currently 87 poietin during the pregnancy if graft function if the hematocrit rises signifcantly. As no means of pre- humans have described central nervous sys- ratio should involve close liaison between hepatolo- venting vertical transmission exists, preg- tem defects and limb abnormalities in new- gists, obstetricians and transplant physicians. These should be reviewed prior to Solid organ transplantation restores fertility 1998;31:766–73 pregnancy with a view to stopping those that to many women with end-stage organ disease 5. Calcium supple- and undoubtedly offers the best chance of a 2004;36:1999–2000 ments and alfacalcidol are safe in pregnancy successful pregnancy to women of childbear- 6. In order to make an informed deci- Successful pregnancies after human renal tions are seen in 77% of renal transplant phosphate binders are also safe in pregnancy, sion, it is essential that women of childbear- transplantation. N Engl J Med 1963;269:341–3 recipients92, due either to impaired transplant but newer agents such as lanthanum carbonate ing age are counseled regarding contraception 7. Bisphosphonates, which time to protect graft function and minimize 1978;132:340–1 patient is mild and asymptomatic, but few are used in the treatment and prevention of risks to the fetus. Pregnancy in recipi- published data describe the outcome of preg- osteoporosis, are known to cross the placenta, fed where necessary, and concurrent medical ents of solid organs – effects on mother and nancy58. Menstrual problems among Drugs considered safe in pregnancy Drugs not recommended for use in pregnancy ratory Physician, Glenfeld Hospital, Leicester, kidney transplant recipients. Reprod- Women’s Health Committee of the American Other drugs Lanthanum carbonate, sevelamer uction with women with end-stage renal dis- Society of Transplantation. Outcome of pregnancy in women with con- Transplantation 2006; 1:636 Gynecol 1991;34:100–11 and Lung Transplantation: twenty-third off- genital heart disease: a literature review. Pregnancy and renal cial adult lung and heart-lung transplantation Coll Cardiol 2007;49:2303–11 tility after renal transplantation: achievement transplantation. Fertility and contraceptive issues after utero exposure to mycophenalate mofetil; Siroliumus-associated infertility: case report sion in renal disease in pregnancy. Confdential Enquiries into Maternal Deaths in Pregnancy and Lactation; a Reference Guide to plant couple resulting from in-vitro fertilisa- Systemic lupus erythematosus. Worldwide, cervical cancer remains the Stage 1a1 disease (invades the major cause of cancer death in women, espe- 3 cervical stroma to less than 3 mm cially in the developing world. Small volume stage 1b1 cervical cancer (lesions confned to the cervix more than stage 1a2 but not greater than 2cm) For women in the reproductive age group, treatment options are either radical hysterec- tomy and bilateral pelvic lymphadenectomy or radical trachelectomy followed by laparoscopic pelvic lymphadenectomy11. However, after radical trachelec- Figure 2 Diagram showing the part of cervix Vagina tomy, the following problems may arise and where a cone biopsy is performed patients should be counseled beforehand that Figure 3 Diagram showing extent of tissue extra postoperative vigilance will be necessary: removal during radical trachelectomy for stage 1a2 1. Careful delivered prematurely due to the presence of Canada reported 3800 new cases in 200412; preoperative counseling (as in radical hyster- an incompetent cervix. On the other hand, if patients succeed a cure, so that the overall 5-year survival is The risk of lymph node metastases at this Daniel Dargent as a modifcation of the radical in conceiving, they should be warned about about 75%. This decision should not be Another issue that has recently come to the Fallopian tube Uterus taken lightly as the long-term implications of fore is the possibility of ovarian conservation such an action remain to be determined. Immunohistochemistry stud- 25% of endometrial cancer patients will have ies should be performed on the specimen to coexistent ovarian cancer (either metastatic or Vagina determine the hormone receptor status, as primary disease). Under these circumstances, progestin sensitivity or uptake is associated it is vital to discuss ovarian conservation with the patient before her surgery or conservative with good prognostic outcome.

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Drumstick: lobular projection from nucleus of polymorphonuclear leucocytes in females order cheap cytotec line medicine quetiapine. The usefulness of endophenotypes as a simpler path to the genetics of psychiatric disorders has been questioned order cytotec in india symptoms xanax treats. Epistasis: 2 or more loci show a multiplicative interaction where the final result is greater than the sum of the effects of individual loci order 200mcg cytotec with visa 714x treatment. This phenomenon may be important in interpreting genetic studies of families containing members with schizophrenia. Expressivity: variability in clinical manifestation of a genetic trait (see penetrance), e. Family studies: These can be of the family history variety where a history is taken from the proband, who may not be very knowledgeable, or the family study variety where all available relatives are directly interviewed. F body: fluorescent body exhibited by males during interphase; consists of the Y-chromosome. First-degree relatives: parents, siblings, children, all having 50% of the index person’s genes; second- degree relatives are grandparents, grandchildren, aunts and uncles, all sharing an average of one-quarter of the index person’s genes. Genetic heterogeneity: this may be allelic when there are different alleles at the same locus, or nonallelic when there are defects at different loci. Some people affected by a disease or syndrome will have inherited the disease gene but will not have inherited the marker that is linked to it in the other family members. The notion of one gene for one protein is an oversimplification, many of them being capable of producing multiple proteins. The human genome contains about 25,000-30,000 (double that of the fruit fly) that are able to make at least a quarter of a million proteins! One long-term follow-up of schizophrenic patients failed to find a history of the disorder in first- or second-degree relatives in 60% of cases. Early studies of schizophrenia supported this phenomenon, but more recent reports have been more equivocal. Hox (homeotic) genes: first discovered in flies but known to exist in humans, mutation in these genes cause conversion of one part of the body into another. Hypervariable probes: those probes recognising several different alleles; therefore more likely to be highly informative since variation between individuals is high. Imprinting: the foetus is able to tell the difference between maternally- and paternally-derived chromosomes; deletion of part of paternal 15q gives rise to the Prader Willi syndrome, whereas deletion of a similar region of the same chromosome from the mother causes Angelman syndrome. Informative family: one containing many affected members, the disorder running through one side (father or mother of proband) of the family only. Also, as the population becomes more genetically homogeneous the apparent heritability of a trait decreases. Using autoradiographic methods, it is possible to quantitatively study gene expression in individual neurones. Isochromosomes: rarely, the centromere (often of the X chromosome) divides horizontally instead of longitudinally leaving a chromosome consisting of either 2 long arms or 2 short arms. Karyotyping: chromosomes can only be viewed with clarity during cell division; phytohaemagglutinin is used to stimulate cell division in vitro, then colchicine is used to arrest cell division in metaphase; hypotonic saline is then used to swell the cell so as to separate the chromosomes from one another; stains, such as Giemsa, demonstrate the banding properties (light and dark bands that are characteristic of each 885 chromosome ); a photograph is taken, from which the chromosomes are cut and arranged in homologous pairs. The term karyotype analysis simply refers to the visualisation of chromosome number and gross structure. Linkage analysis: tests if observed co-occurrence of a disorder and a marker for a genetic locus within a given pedigree are compatible with that locus contributing to disease susceptibility. One can attempt to trace a gene from a protein or a protein from a gene, or look at candidate genes. However, for loci closely situated to one another, recombination is rare, and associations tend to persist for many generations. Mosaicism (in Down’s syndrome): occurs when non-disjunction takes place during any cell division after fertilisation; there are normal and trisomic cells in the same person; the effects on cognitive development are very variable. Liability must pass a certain threshold: population incidence represents the threshold for the general population. Familial incidence is the threshold for relatives of patients with multifactorial disorder. Notation for gene locations: this is a shorthand way of describing the position of a gene in the genome. Xq27-28 means that the gene is on the X chromosome, on the long arm (p, short arm, from French for 885 Each band is assigned a number. The astute observer will have noticed that the example given is that of the fragile site in the fragile X syndrome. A + or – sign before a symbol refer to the addition or absence of whole chromosomes (e. Pairwise concordance: the proportion of pairs of twins concordant for a particular trait. To be more exact: number of twin pairs in which both twins are affected by a condition divided by the total number of twins. Partial trisomy: a translocation occurs where a part of a chromosome becomes attached to a different one. If parents are phenotypically normal carriers of translocations are at risk for having a partial trisomy for the first mentioned chromosome, i. In other words, the proportion of heterozygotes who express (see expressivity) the gene in any degree (some authors see penetrance as an all or none phenomenon, and expressivity as a more variable phenomenon); penetrance is a product of the modifying influence of other genes and the environment; some cases of tuberous sclerosis, for example, have only sparse facial papules because of low penetrance. Pericentric inversion: swapping of chromosomal material from one arm of a single chromosome with the other arm of the same chromosome. When people have 1 copy of a certain allele and share the same phenotype as do people with 2 copies of the same allele the allele is dominant for that trait. A recessive allele would need to occur twice in the same person (2 copies) to be expressed in the phenotype. Co-dominance refers to the situation where the person has 1 copy of the allele and a phenotype that is somewhere between (intermediate) those with 0 and 2 copies of the allele. Philadelphia chromosome: acquired chromosomal abnormality involving a deleted chromosome 22, its long arm being translocated to another autosome, usually chromosome 9; associated with chronic myeloid leukaemia. Pleiotropism (pleiotropic genes): a gene with more than one effect on the phenotype; several genes may contribute to one disorder, and a single gene may contribute to several disorders; many psychiatric disorders may be polygenic, the summation of a number of genes, each of small effect. Polygenes (polygenic): a character that is determined by more than one gene; many genes of small effect acting in concert to produce a phenotype, e. These have demonstrated downregulation of key oligodendrocyte and myelination genes (incl. Polymorphic markers: markers recognising fragments of variable size; at least 2 alleles should be present in the population to be useful. Positional cloning: a set of techniques by means of which disease genes are identified through their position in the genome rather than through their function. Presumed obligate carriers: non-affected relatives the gene or genes for a disorder, such as the mother of a patient with schizophrenia who, although not psychotic herself, has a parent or sibling with schizophrenia. Proband: a sampled individual with a condition or trait; propositus if male, proposita if female.

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The protective effect of a mood stabilizer is required before using an antidepressant and as soon as the depressive episode resolves order cheap cytotec line treatment for piles, the antidepressant is usually withdrawn 100 mcg cytotec with amex medicine 013. Prognosis 961 After accounting for some confounding factors like brain disease 100mcg cytotec mastercard treatment 34690 diagnosis, evidence suggests that 34-50% of elderly manic patient will die on long term follow up as against 20% of elderly patients with unipolar depression. Also, 32% will suffer significant cognitive decline, as measured by a score of less than 24 on Mini-Mental State Examination. This suggests that mania has a poorer prognosis and represents a more severe disruption of the central nervous system function. Summary and recommendations of a report of a working party of the Royal College of Physicians. Anxiety Disorders Oliaku Eneh Definition The psychological symptoms of anxiety comprise of fear, worry, nervousness, tension, apprehension, irritability, difficulty concentrating and insomnia. The physical symptoms include increased heart rate resulting in palpitations, breathlessness, light headedness and dizziness, nausea, tremor, dry mouth, sweating, abdominal discomfort that may progress to diarrhoea and frequent micturition. Patients may have a tendency to alleviate their symptoms by abusing alcohol and prescribed medications, especially benzodiazepines. Most psychiatric disorders in the elderly have co-morbid anxiety and many elderly people get very anxious about the multiple health conditions they are faced with, resulting in the under-recognition and under-treatment of primary anxiety disorders. Epidemiology The prevalence of most anxiety disorders falls with age and is higher in women than in men. This gender difference is less pronounced in the elderly and the majority of cases are longstanding with onset in young adulthood and middle age. Overall prevalence in the elderly ranges from 5-10%, the highest rates are found in the community with phobic disorders presenting the most while panic disorders present the least. Aetiology As with other psychiatric disorders, many factors come to play in the development of anxiety disorders in the elderly. Physical illness- there is an association between anxiety disorders and increased mortality and physical morbidity from cardiovascular, respiratory and gastrointestinal complaints. This is further confounded by the physical symptoms of anxiety with some important physical disorders presenting with anxiety symptoms and vice versa. In the majority of elderly people, the investigations and treatment of physical illness is frightening and may provoke anxiety disorder in vulnerable individuals. Psychosocial stressors- evidence shows that anxiety is associated with low socioeconomic status. Adverse life events especially if they are threatening in nature are known to precipitate anxiety. In addition, individuals may also develop late life vulnerability to anxiety when faced with challenges if they were previously exposed to early adverse experience such as parental loss. In contrast to late life depression, phobic disorders in the elderly are not associated with the lack of confiding relationships; rather it is believed that in some cases the presence of close relationships may maintain phobic avoidance (Lindesay, 1996) because in a bid to protect and support the patient, families and other home based services invariably encourage the housebound approach and may thereby worsen the situation. Drug induced- A variety of drugs have been implicated in the onset of anxiety symptoms. They include: - Thyroxine - Antidepressants - Anticholinergics - Sympathomimetics 963 - Steroids - Alcohol - Caffeine In addition, withdrawal symptoms from psychotropic medications can also precipitate anxiety symptoms (Rodda ea, 2008). Co-morbidity with other psychiatric illness- - High levels of anxiety are often found in elderly patients in the early stages of dementia. Recent studies revealed that different genes showed evidence for association with specific types of anxiety disorders, such as panic disorder, social phobias or generalised anxiety disorder (Academy of Finland, 2008). Specific anxiety disorders and their clinical features Phobic disorder Phobia occurs commonly in the elderly with increasing frailty and prevalence ranges from 0. These disorders provoke clinically significant levels of distress and disability due to high levels of anxiety. They are usually heralded by a traumatic event usually of a physical nature and may have had a public manifestation. However, in spite of the complete resolution of the physical event, the psychological impairment persists. There are 3 main types of phobia: Agoraphobia- prevalence in the elderly is estimated to range from 1. These individuals may be rendered housebound because many are terrified by the thought of collapsing and being left helpless in public. It can occur with or without panic attacks but always causes anxiety symptoms during the situation. This fear may spiral out of control if there is no obvious escape route and embarrassment is perceived. Consequently the individual learns to avoid these situations and this avoidance in turn reinforces the fear. Fear can also occur merely in anticipation of the anxiety-provoking situation and symptoms are not better explained by another mental or physical disorder. Specific phobias- fear is experienced only in the presence of a particular object or situation. Onset is usually in childhood and prevalence in the elderly is estimated to range from 3. Anxiety is restricted to the presence of the specific phobic object or situation, all other diagnostic criteria are similar to those of social phobia. Panic disorder Panic attacks and panic disorder are rare and symptomatically less severe in the elderly, estimates of prevalence ranges from 0. However, the prominent physical symptoms of panic disorder may result in patients being referred instead to cardiologists, neurologists and gastroenterologists. In one study of cardiology patients with chest pain and no coronary disease, one third of those aged 65 and over met the criteria for panic disorder. Several attacks occur within a period of one month and symptoms are not better explained by another psychiatric or physical disorder. Panic attacks are often co-morbid with other psychiatric disorders, particularly depression, and it may be severe enough to mask depressive features. In addition the condition should not meet the criteria for other anxiety disorders, psychiatric or physical disorders. Onset in old age is rare, the majority starting before the age of 25 and usually running a chronic fluctuating course into old age especially if left untreated. Obsessional symptoms may appear at any age following head injury or cerebral tumour. The individual recognizes them as originating from his own mind but is unable to resist them despite repeated attempts at doing so. Compulsion is the irresistible urge to perform an act repeatedly despite the futility of that action. Insight is usually fully intact and the patients usually regard these symptoms as unreasonable and are distressed by them so much so that their functioning is impaired to a greater or lesser degree. Obsessions and or compulsions should last at least two weeks and not arise as a result of another mental disorder. The experience of the event is sometimes regarded as “near death” for the individual and might actually have involved the death of another person.

But there is no need to consider this complication at length here because we are concerned only with health as a prerequisite for a minimally satisfying life purchase cytotec 100 mcg line symptoms nausea fatigue. While this may be regarded as an unsatisfactory criterion in that in some cultures debilitating conditions may be the norm purchase discount cytotec online symptoms torn meniscus, Purdy suggests that this objection can be circumvented by saying that parents ought to try to provide for their children health that is normal for that culture order cheap cytotec line symptoms 4dp5dt, even though it may be inadequate if judged by some outside standard. She states that such a position would still justify eVorts to avoid the birth of children at risk for Huntington’s disease and other serious genetic diseases in all societies (Purdy, 1996: p. If the couple at risk of bearing a severely handicapped child make the decision to go ahead, then who precisely will bear the cost of care and of medical treatment if the risks attendant upon handicap materialize? The ‘welfare’ mother may decide to go ahead and have a child, but the consequent costs of bringing the child into the world are likely to fall upon the State in such a situation – housing, medical treatment and the fact that the woman may be unable to enter the workforce, at least for some time, due to child-care commitments. While some ‘harms’ and some ‘costs’ may be identiWed, does this lead us inexorably to the conclusion that persons should be held to be under a duty not to reproduce? Some may think that conception and birth where there is a risk of those harms/costs arising may be undesirable, but does this ever really equate with imposing a duty not to reproduce, and in particular, backing that duty up through some recognition of legal liability? First, he suggests that few of those conditions would make the life of a child so horrible that its interests would have been better served had that child never been born. Secondly, Robertson argues that because a woman’s reproductive interest is generally very strong, there would need to be compelling criteria to override it, and factors such as saving money would not generally be adequate. She suggests that there are other ways in which reproduc- tive desires may be satisWed, including adoption and the use of new reproduc- tive technologies. She comments that other arguments for having children, such as wanting the genetic line to be continued, are not particularly rational when it brings a sinister legacy of illness and death. She also states that while a desire to bear children who physically resemble oneself is understandable although basically narcissistic, its fulWlment cannot be guaranteed even by normal reproduction. It could be argued, however, that some of those persons whose opportunity to conceive naturally was, prima facie, limited by a duty not to reproduce, could still conceive through the use of artiWcial reproduc- tive technologies. One alternative is to say to such a couple, ‘You will be penalized if you reproduce naturally and the ‘‘harm’’ in the form of the disability materializes. However, you do have the option of pre-implantation genetic diagnosis, and this oVers you an alterna- tive; therefore we are not limiting your reproductive choices, your pro- creative liberty, to any great extent at all. Before we go down this road we need to address serious and fundamental questions, not simply about an individual’s choice, but also about society’s attitude to the disabled members of our community. Furthermore, the recognition of a duty not to reproduce may be regarded as unacceptable because it may mean that a person will in eVect be virtually forced to discover their genetic status should they want to reproduce. This may itself have other consequences with regards to the use of that genetic information – for example, with regards to insurance and employment prospects in years to come. It is worth noting that the Council of Europe (1996), in the Convention for the Protection of Human Rights and Dignity of the Human Being with Regard to the Application of Biology and Medicine, provides that: Everyone is entitled to know any information collected about his or her health. Say that there are certain, perhaps very limited, situations in which individuals may be wrong in seeking to reproduce – so wrong that they should actually be held to be under a duty. If the bodily intrusion associated with compulsory contraception is relatively minor, it may be that compelled contraception in rare cases could be justiWed, though such policies would be highly controversial. Some would argue that the a moral duty may be recognizable, but as Robertson has noted, that ‘does not mean that those duties should have legal standing’ (Robertson, 1994: p. To hold a woman or a couple liable for their decision to have a child, despite what are substantial warnings regarding the risks of such a course of action, might also constitute a breach of the European Convention on Human Rights – for example, of Article 12, the right to marry and found a family. There are fundamental questions regarding the privacy of the individual in relation to their home and family life under Article 8 which would arise in such a situation. It should also be noted that the Council of Europe Convention on Human Rights and Biomedicine provides in Article 11 that ‘Any form of non-discrimination against a person on grounds of his or her genetic heritage is prohibited’. We need of course to bear this in mind, particularly in view of the fact that those provisions of the European Convention of Human Rights are now justiciable in the English courts since the Human Rights Act 1988 came into force in October 2000. Secondly, would this be a duty involving state sanctions, enforceable, for example, through the criminal law or will it be limited to civil liability, perhaps in the form of an action brought by the child consequent upon birth? How do you inform people that they are under such a legal duty, and that if they reproduce without Wnding out their genetic status, there may be legal consequences? Do we have to put up notices in railway stations, general medical practitioners’ surgeries and night clubs warning people that if they conceive unwittingly, some form of legal liability may result? After all, with the pace of technological developments such as gene therapy, the serious degenerative late-onset disorder may be curable by the time that infant reaches adulthood. It is also the case that the practical diYculties of recognizing such a duty may also collide with another set of legal principles, namely, membership of the European Union. Cases such as that of Blood send out a powerful message – European regulation is changing the face of health care today, and single jurisdiction regulation may indeed be inadequate in health care law. McHale Repaying the state An alternative is to say to the individual/couple: ‘Yes, you may reproduce in a ‘‘risky’’ situation, but if the ‘‘harm’’ does arise and, as a consequence, the state incurs costs, then you will be liable to pay that cost’. This solution, however, can be seen as undesirable, in that at the very least it is discriminatory between those with Wnancial resources and those without. Secondly, an action could be brought by the child, for example, claiming that the parents’ actions resulted in their birth in a disadvantaged or disabled condition. The Congenital Disabili- ties Civil Liability Act 1976 provides that an action may be brought by a child born with a disability as a result of an occurrence which aVects either of its parents in their ability to have a normal healthy child, or an occurrence which aVects the mother during pregnancy and either mother and child during birth. While there is the possibility that fathers may be sued under the Congenital Disabilities Civil Liability Act 1976, the mother is excluded from liability with the exception of the situation where she has been involved in a road traYc accident. Questions as to what constitutes reasonable parental conduct, what good suing a parent does the disabled child, may apply with equal force to both parent. The real issue in the case was, however, the claim by Mary McKay that the doctor owed her a duty of care when she was in utero, which involved advising her mother as to the desirability of having an abortion, which advice the mother said she would have accepted. First, if the duty of care to the fetus involved imposing a duty on the doctor – albeit indirectly – to prevent the child’s birth, the child would have a cause of action against her mother if she refused to have an abortion. Secondly, the Law Commission in their Report on Injuries to Unborn Children (1974), which had rejected the wrongful life claim, had been of the view that such a claim would impose intolerable burdens on the medical profession, because of subconscious pressure to advise abortion in doubtful cases through fear of action for damages. He was of the view that provided that the defendants gave a balanced explanation of risks involved in alleged pregnancy, including risk of injury to the fetus, the doctor could not be expected to do more. Finally, the Court of Appeal held that section 4(5) of the Congenital Disabilities (Civil Liability) Act 1976 excluded liability in wrongful life claims, a point on which all the members of the Court of Appeal in this case agreed. Section 4(5) of the 1975 Act provides that the Act applies to all births after its passing, and in respect of any such birth, it replaces any law in force before its passage whereby a person could be held liable to a child in respect of disabilities with which it might be born. The policy arguments against their acceptance, as outlined in relation to the judgments of the Court of Appeal in this case, have been echoed by academic commentators (Lee, 1989; Fortin, 1987). For example, Mason and McCall Smith have suggested that ‘we favour abandoning the principle of ‘‘wrongful life’’ in favour of diminished life; we can then look not at a comparison, whether it be between the neonate’s current existence and non-existence or with normality, but rather at the actual suVering that has been caused’ (Mason and McCall Smith, 1999: p. They comment further that, ‘This carries the practical advan- tage that the courts can understand and accommodate this form of damage, which allows for a distinction to be made between the serious and slight defect’ (Mason and McCall Smith, 1999: p. Presumably in this situation the couple would not be liable, but here an action may then be brought against the clinician, precisely the type of action rejected in McKay. The diYculties that arise in the context of the competent adult are magniWed still further when we consider mentally incompetent persons and the teenage pregnancy.