In this issue, a case of aesthetic treatment during pregnancy.
The case presented is a study of aesthetic treatment interventions during pregnancy and the ethics and safety of these interventions.
The results may provide hints for interventions for pregnant women.
Case 1)
A 27-year-old woman
She regularly consults with a specialist about aesthetic procedures such as botulinum toxin type A (BTX-A) and filler injections.
She has a job that requires her to appear on TV.
Her appearance is very important to her, but she is now 30 weeks pregnant and last received BTX-A injections a few weeks before becoming pregnant.
She is now 30 weeks pregnant and last received BTX-A injections a few weeks before becoming pregnant.
Her doctor advised her against this treatment during her pregnancy because the effects on the fetus have not been fully studied.
She was disappointed with the answer and burst into tears.
She confidently checked the results of a large study and claimed that it stated that there was no significant fetal risk from BTX-A.
Consider case #1.
BTX-A is likely not to cross the placenta due to its large molecular weight, and is not expected to be present in the body circulation after an appropriate intramuscular or intradermal injection.
However, there have been 15 cases of botulism reported in pregnant patients that have not been associated with birth defects, neonatal loss, or congenital botulism.
In two cases of maternal botulism, infant serum was collected and no botulinum toxin was detected.These data were obtained from a retrospective review of inadvertent or intentional exposures, and a case report/review of a series of BTX-A injections in early pregnancy revealed two miscarriages.
In these two cases, the women were experiencing miscarriages, and it is not clear whether they are related to botulism.
Even if the physician prioritizes the woman's autonomous decision, ethically, the well-being of the fetus should be the priority.
Isn't there data to support this? One might object that this data is not solid enough to be used as a guideline, and therefore the possibility of a low risk cannot be ignored.
Therefore, refusing to perform the procedure because of the lack of high quality data and the potential for fetal risk is an appropriate ethical choice when the physician recognizes the lack of evidence.
However, the uncertain communication should be done in a way that does not compromise the patient's autonomy, and the physician should not try to impose his or her values on the patient.
Therefore, it is ethically acceptable to suggest alternative procedures that the doctor may consider safer.However, most alternative aesthetic interventions are not as effective as BTX-A due to insufficient data.
Case 2.
The woman is currently 27 weeks pregnant.
She has been suffering from spider veins (e.g. varicose veins) in her legs for some time.
She has visited a dermatologist and requested sclerotherapy treatment, even though she knows that these problems may improve spontaneously after childbirth.
The doctor refuses this treatment and advises that it is best to wait until the pressure on the pelvic veins during pregnancy is released after childbirth to receive the most effective treatment.She also informed the patient that some sclerosing solutions may pass through the placenta, which disappointed her because she believes there is no risk to the fetus at this stage of pregnancy.
She is adamant about sclerotherapy, which can solve her leg problems.
Consider case #2.
Varicose veins, fine webs, and spider veins that develop during pregnancy may improve postpartum, suggesting that we need to wait at least 6~12 months after pregnancy for treatment.
According to the German Society of Venereology, sclerotherapy is contraindicated in early pregnancy and after 36 weeks.
However, in a study comparing 45 patients treated with sclerotherapy using sodium tetradecyl sulfate with 56 patients treated conservatively, there was no difference in pregnancy outcomes between the two groups.
Patient autonomy is fulfilled when treatment is given according to the patient's requirements.Although the fetus is viable and there are risks associated with sclerotherapy, there are no absolute contraindications to sclerotherapy in late pregnancy.
Nonetheless, there will be insufficient data on the safety of the sclerosing agents used to be used during pregnancy.
And if no alternative treatment options are suggested, patient dissatisfaction may occur if treatment is refused.Some conservative measures are recommended by the literature.
It is ethically acceptable to offer safer alternative treatments, such as the long-pulsed Nd:YAG 1064- nm laser, but such laser treatments are not as effective as sclerotherapy for deep reticular veins.
Kroumpouzos G, Bercovitch L. Ethics of esthetic procedures in pregnancy. Int J Womens Dermatol. 2018;4(4):194-197. published 2018 Nov 19. doi:10.1016 /j.ijwd.2018.10.003
Conclusion
These two cases make me wonder if the fetus should be prioritized over the woman herself. These two examples illustrate the dilemma of whether to put the fetus before the woman, and to respect the woman's own wishes.
What should be the priority?
And is the intervention safe to perform?
It can be said that there are more aesthetic treatment interventions during pregnancy that we can be willing to do as further data is gathered.
This case reminded us that more than just treatment techniques are required, as the wrong focus in patient care can result in a loss of patient trust and ethics.
