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Volume 6, No. 2, February 2008
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Knowledge of cervical length / fetal fibronectin associated with shorter evaluation and PTB
CONCLUSION: The knowledge of cervical length and fetal fibronectin was associated with reduction in length of evaluation in women with cervical length > or = 30 mm and in incidence of spontaneous preterm birth in all women with preterm labor.
Ness A et al Does knowledge of cervical length and fetal fibronectin affect management of women with threatened preterm labor? A randomized trial. Am J Obstet Gynecol. 2007 Oct;197(4):426.e1-7. http://www.ncbi.nlm.nih.gov/pubmed/17904989
Sublingual misoprostol associated with higher patient satisfaction compared with vaginal
CONCLUSION: Sublingual misoprostol (50 micrograms) is associated with a significantly higher patient satisfaction rate compared with a similar dose of vaginal misoprostol. Sublingual administration offers additional choice to women, in particular those wishing to avoid vaginal administration.
Nassar AH et al A randomised comparison of patient satisfaction with vaginal and sublingual misoprostol for induction of labour at term. BJOG. 2007 Oct;114(10):1215-21.
http://www.ncbi.nlm.nih.gov/pubmed/17877674
Management of shoulder dystocia: trends in incidence and morbidity
RESULTS: There were 514 cases of shoulder dystocia among 79,781 (0.6%) vaginal deliveries with 44 cases of neonatal brachial plexus injury and 36 asphyxiated neonates; two neonates with cerebral palsy died. The McRoberts' maneuver was used increasingly to overcome the obstruction, from 3% during the first 5 years to 91% during the last 5 years. The incidence of shoulder dystocia, brachial plexus injury, and neonatal asphyxia all increased over the study period without change in maternal morbidity frequency. CONCLUSION: The explanation for the increase in shoulder dystocia is unclear but the introduction of the McRoberts' maneuver has not improved outcomes compared with the earlier results. LEVEL OF EVIDENCE: II.
MacKenzie IZ et al Management of shoulder dystocia: trends in incidence and maternal and neonatal morbidity. Obstet Gynecol. 2007 Nov;110(5):1059-68.
http://www.ncbi.nlm.nih.gov/pubmed/17978120
CDC Issues Guidelines for Preconception Care of Women
The Centers for Disease Control and Prevention have published national recommendations for improving preconception health and health care in response to unfavorable aspects of the health status of women and children in the United States. The publication explains that the national recommendations are part of a strategic plan for improving preconception health through the provision of clinical care as well as the promotion of changes in individual behaviors, health policy, and public health strategies. The concept of preconception care has been articulated for well over a decade but has not become part of the routine practice of family medicine. Because all women of reproductive age presenting to the primary care setting are candidates for preconception care, the essential and critical role of family physicians in the provision of preconception care is apparent. As a specialty, we are now challenged to devise ways to effectively translate the concept of preconception care into clinical reality.
Dunlop AL et al National recommendations for preconception care: the essential role of the family physician. J Am Board Fam Med. 2007 Jan-Feb;20(1):81-4.
Full text
http://www.jabfm.org/cgi/content/abstract/20/1/81
PubMed Abstract
http://www.ncbi.nlm.nih.gov/pubmed/17204739
Year end recap
Guidelines Recommend Universal Prenatal Screening for Down Syndrome
The American College of Obstetrics and Gynecology (ACOG) recommends that all pregnant women, regardless of their age, be offered screening for Down syndrome.
"Historically, maternal age 35 years or older at the time of delivery has been used to identify women at highest risk of having a child with Down syndrome, and these women have been offered genetic counseling and amniocentesis or chorionic villus sampling (CVS)," write Ray Bahado-Singh, MD, Deborah Driscoll, MD, and colleagues, of the ACOG Committee on Practice Bulletins — Obstetrics, the ACOG Committee on Genetics, and the Society for Maternal–Fetal Medicine Publications Committee. "Biochemical serum screening for Down syndrome in women younger than 35 years was introduced in 1984, when an association between low maternal serum alpha-fetoprotein (AFP) levels and Down syndrome was reported... The practice of using age cutoffs to determine whether women should be offered screening or invasive diagnostic testing has been challenged."
These guidelines were developed to review and evaluate the best available evidence for the use of ultrasonographic and serum markers for selected aneuploidy screening in pregnancy and to offer practical recommendations for implementing Down syndrome screening in clinical practice.
In recent years, numerous markers and strategies for Down syndrome screening have been developed, as have algorithms combining ultrasound and serum markers in the first- and second trimesters. Various markers have included human chorionic gonadotropin (hCG) and unconjugated estriol used in combination with maternal serum alpha-fetoprotein levels.
Using all 3 markers (triple screen) has a detection rate for Down syndrome of approximately 70%, with a positive screen result in approximately 5% of all pregnancies. Adding inhibin A to the triple test (quadruple screen) improves the detection rate for Down syndrome to approximately 80%.
"Screening with biochemical markers, ultrasonography, or both is being offered increasingly to the entire pregnant population to provide a more accurate estimate of individual Down syndrome risk," the authors write. "Higher sensitivity or detection rates (defined as the percentage of Down syndrome pregnancies identified with a positive test result) at low false-positive rates have led to increased use of screening and a decline in the number of amniocenteses performed."
Another screening procedure is evaluation of nuchal translucency, an early presenting feature of a wide variety of fetal chromosomal, genetic, and structural abnormalities. Guidelines for the systematic measurement of nuchal translucency have been standardized, improving the detection rates for Down syndrome. For screening programs that include nuchal translucency measurement, specific training for a standardized method of measurement and ongoing audits of examination quality are recommended.
An important breakthrough in first-trimester screening for Down syndrome was achieved by expressing the nuchal translucency measurement as a multiple of the median and combining it with free β-hCG and pregnancy-associated plasma protein A (PAPP-A). Maternal serum analytes, PAPP-A, and hCG or free β-hCG are effective for screening in the first trimester, but alpha-fetoprotein levels, unconjugated estriol, and inhibin A are useful only in the second trimester.
Specific guideline recommendations based on good and consistent scientific evidence (level A) are as follows:
- First-trimester screening using both nuchal translucency measurement and biochemical markers is an effective screening test for Down syndrome in the general population. This screening strategy results in a higher detection rate than does the second-trimester maternal serum triple screen and a comparable rate to the quadruple screen, with the same false-positive rates.
- For first-trimester screening, measurement of nuchal translucency alone is less effective than is the combined use of nuchal translucency measurement and biochemical markers.
- Women found to have increased risk for aneuploidy based on first-trimester screening should be offered genetic counseling and the option of chorionic villus sampling or second-trimester amniocentesis.
- Nuchal translucency measurement for Down syndrome risk assessment should be limited to centers and individuals meeting the criteria for specific training, standardization, use of appropriate ultrasound equipment, and ongoing quality assessment.
- Women who elect only first-trimester screening for aneuploidy should be offered neural tube defect screening in the second trimester.
"Regardless of which screening tests you decide to offer your patients, information about the detection and false-positive rates, advantages, disadvantages, and limitations, as well as the risks and benefits of diagnostic procedures, should be available to patients so that they can make informed decisions," the authors conclude. "Patients may decline Down syndrome screening because they would not use the information in deciding whether to have a diagnostic test or because they wish to avoid the chance of a false-positive screening test result. The choice of screening test depends on many factors, including gestational age at first prenatal visit, number of fetuses, previous obstetric history, family history, availability of nuchal translucency measurement, test sensitivity and limitations, risk of invasive diagnostic procedures, desire for early test results, and options for earlier termination."
Screening for fetal chromosomal abnormalities. ACOG Practice Bulletin No. 77. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:217–27.
http://www.ncbi.nlm.nih.gov/pubmed/17197615
Gynecology
Misoprostol in the setting of incomplete abortion series
Misoprostol is as effective as manual vacuum aspiration in SAB of <12 weeks
CONCLUSION: Misoprostol is as effective as manual vacuum aspiration (MVA) at treating incomplete abortion at uterine size of <12 weeks. The acceptability of misoprostol appears higher. Given the many practical advantages of misoprostol over MVA in low-resource settings, misoprostol should be more widely available for treatment of incomplete abortion in the developing world.
Shwekerela B et al Misoprostol for treatment of incomplete abortion at the regional hospital level: results from Tanzania. BJOG. 2007 Nov;114(11):1363-7
http://www.ncbi.nlm.nih.gov/pubmed/17803714
Oral misoprostol is safe and acceptable as MVA for the treatment of incomplete abortion
CONCLUSION: Six hundred micrograms of oral misoprostol is as safe and acceptable as MVA for the treatment of incomplete abortion. Operations research is needed to ascertain the role of misoprostol within postabortion care programmes worldwide.
Dao B et al Is misoprostol a safe, effective and acceptable alternative to manual vacuum aspiration for postabortion care? Results from a randomised trial in Burkina Faso, West Africa. BJOG. 2007 Nov;114(11):1368-75 http://www.ncbi.nlm.nih.gov/pubmed/17803715
Hysterectomy vs LNG-IUS series
Hysterectomy reduces menstrual bleeding, but LNG-IUS effective in quality of life
AUTHORS' CONCLUSIONS: Surgery, especially hysterectomy, reduces menstrual bleeding at one year more than medical treatments but LNG-IUS appears equally effective in improving quality of life. The evidence for longer term comparisons is weak and inconsistent. Oral medication suits a minority of women long term.
Marjoribanks J et al Surgery versus medical therapy for heavy menstrual bleeding.
Cochrane Database Syst Rev. 2006 Apr 19;(2):CD003855
http://www.ncbi.nlm.nih.gov/pubmed/16625593
Hysterectomy improves sexual functioning vs LNG-IUS among women with menorrhagia CONCLUSIONS: Among women with menorrhagia, hysterectomy improves sexual functioning, whereas LNG-IUS does not have such a positive effect.
Halmesmäki K et al The effect of hysterectomy or levonorgestrel-releasing intrauterine system on sexual functioning among women with menorrhagia: a 5-year randomised controlled trial. BJOG. 2007 May;114(5):563-8. http://www.ncbi.nlm.nih.gov/pubmed/17439564
Other
Intracervical balloon placement for saline sonohysterography superior vs intrauterine
CONCLUSION: Intracervical catheter placement results in significantly less pain during an saline infusion sonohysterography and also requires half the saline volume to perform the saline infusion sonohysterogram. Therefore, routine intracervical balloon placement should be considered for saline infusion sonohysterogram. LEVEL OF EVIDENCE: I.
Spieldoch RL et al Optimal catheter placement during sonohysterography: a randomized controlled trial comparing cervical to uterine placement. Obstet Gynecol. 2008 Jan;111(1):15-21.
http://www.ncbi.nlm.nih.gov/pubmed/18165388?dopt=Abstract
PCA, scheduled intravenous, and scheduled subcutaneous: None appears to be superior
CONCLUSION: Given these findings as well as those in previous literature, no specific method of postoperative analgesia appears to be superior.
Bell JG et al Randomized trial comparing 3 methods of postoperative analgesia in gynecology patients: patient-controlled intravenous, scheduled intravenous, and scheduled subcutaneous. Am J Obstet Gynecol. 2007 Nov;197(5):472.e1-7. http://www.ncbi.nlm.nih.gov/pubmed/17980179
Liquid-based cervical cytology neither more sensitive nor more specific vs conventional
CONCLUSION: Liquid-based cervical cytology is neither more sensitive nor more specific for detection of high-grade cervical intraepithelial neoplasia compared with the conventional Pap test.
Liquid Compared With Conventional Cervical Cytology: A Systematic Review and Meta-analysis. Obstet Gynecol. 2008 Jan;111(1):167-177. http://www.ncbi.nlm.nih.gov/pubmed/18165406?dopt=Abstract
Early feeding after abdominal Gyn surgery is safe and reduces length of hospital stay
AUTHORS' CONCLUSIONS: Early feeding after major abdominal gynaecologic surgery is safe however associated with the increased risk of nausea and a reduced length of hospital stay. Whether to adopt the early feeding approach should be individualized. Further studies should focus on the cost-effectiveness, patient's satisfaction, and other physiological changes
Charoenkwan K et al Early versus delayed (traditional) oral fluids and food for reducing complications after major abdominal gynaecologic surgery. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508 http://www.ncbi.nlm.nih.gov/pubmed/17943817
VI-SENSE test superior to traditional individual tests in diagnosis of vaginal infections
RESULTS: The VI-SENSE test was positive in 226 of 249 patients (90.8%) with bacterial vaginosis or trichomoniasis. Nitrazine pH paper revealed elevated pH in 165 (66.5%) and the amine test was positive in 160 (64.3%) patients. The VI-SENSE test was negative in 217 of 267 patients (81.3%) without trichomoniasis or bacterial vaginosis. The VI-SENSE was positive in 85 of 92 women (92%), with mixed vaginal infection including Candida and bacterial vaginosis or trichomoniasis. Amine test, nitrazine pH paper and physician diagnosis relying only on speculum examination were inferior and positive in only 65 (70%), 59 (64%), and 66 (72%) patients, respectively. CONCLUSION: The VI-SENSE test was found to be superior to traditional individual tests in facilitating preliminary diagnosis of vaginal infections.
Geva A et al The VI-SENSE-vaginal discharge self-test to facilitate management of vaginal symptoms. Am J Obstet Gynecol. 2006 Nov;195(5):1351-6
http://www.ncbi.nlm.nih.gov/pubmed/16769019
Laparoscopic surgery is a cost effective treatment for tubal ectopic pregnancy
AUTHORS' CONCLUSIONS: In the surgical treatment of tubal ectopic pregnancy laparoscopic surgery is a cost effective treatment. An alternative nonsurgical treatment option in selected patients is medical treatment with systemic methotrexate. Expectant management can not be adequately evaluated yet.
Hajenius PJ et al Interventions for tubal ectopic pregnancy. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD000324. http://www.ncbi.nlm.nih.gov/pubmed/17253448
2 techniques of postoperative bladder testing after transvaginal surgery: RCT
RESULTS: Sixty subjects were enrolled. The mean time in the perioperative anesthesia care unit for the backfill group was 199.5 minutes vs 226.6 minutes in the spontaneous voiding group (P = .08). Subjects randomized to backfill were more likely to adequately empty their bladders and be discharged home without catheter drainage than subjects in the spontaneous voiding group (61.5% vs 32.1%, respectively, P = .02). Multiple logistic regression further demonstrated that the backfill-assisted technique predicted successful bladder emptying after vaginal surgery (P = .02). CONCLUSION: Women undergoing transvaginal outpatient surgery are more likely to empty their bladder effectively before discharge if they are evaluated with a backfill-assisted voiding trial.
Foster RT Sr, et al A randomized, controlled trial evaluating 2 techniques of postoperative bladder testing after transvaginal surgery. Am J Obstet Gynecol. 2007 Dec;197(6):627.e1-4.
http://www.ncbi.nlm.nih.gov/pubmed/18060956
Abdominal sacrocolpopexy reduces irritative and obstructive symptoms Prophylactic
RESULTS: In all women, the mean irritative score decreased from 19.6 +/- 16.3 (mean +/- SD) to 9.1 +/- 10.6; for obstructive symptoms, from 34.8 +/- 21.0 to 6.3 +/- 10.4 (both P < .001). Preoperative bothersome irritative symptoms resolved in 74.6% (126 of 169) and obstructive symptoms in 85.1% (212 of 249), independent of Burch. Fewer women with Burch had urge incontinence (14.5% vs 26.8%, P = .048) and fulfilled the stress endpoint (25.0% vs 40.1%, P = .012). CONCLUSION: Abdominal sacrocolpopexy (ASC) reduced bothersome irritative and obstructive symptoms. Prophylactic Burch reduced stress and urge incontinence.
Burgio KL et al Bladder symptoms 1 year after abdominal sacrocolpopexy with and without Burch colposuspension in women without preoperative stress incontinence symptoms. Am J Obstet Gynecol. 2007 Dec;197(6):647.e1-6. http://www.ncbi.nlm.nih.gov/pubmed/18060965
Child Health
11th Annual Patty Iron Cloud National Native American Youth Initiative
The Association of American Indian Physicians (AAIP) is now accepting applications for the 11th Annual Patty Iron Cloud National Native American Youth Initiative which will be held in Washington D.C., June 21- 29, 2008. American Indian/Alaska Native (AI/AN) high school students, ages 16- 18, who have an interest in the health careers and/or biomedical research are encouraged to apply. The NNAYI scholarship pays for travel, lodging, and most meals during the program. NNAYI's curriculum is strategically designed to prepare students for admission to college and professional schools, as well as for careers in health and biomedical research.
To accompany the students, AAIP is accepting applications for counselors, age 21 and older, to serve as role models during the nine-day program.
AI/AN college students and health professionals are encouraged to apply.
Feel free to share this information with other interested parties.
Deadline for student application is April 18, 2008 and for counselor application is March 21, 2008. Please visit the NNAYI website:
www.aaip.org/programs/nnayi/nnayi.htm to obtain detail information and to access the on-line application.
Secondhand smoke during infancy linked in dose-response fashion with allergies
Swedish children exposed to secondhand tobacco smoke in infancy had a higher rate of indoor inhalant and food allergies than did children whose parents didn’t smoke. The study found a dose-response relationship between exposure to smoke and allergy, supporting possible causality and indicating that exposure in early infancy to tobacco smoke may be associated with an increased risk of atopic sensitization.
Lannerö E at al Exposure to environmental tobacco smoke and sensitisation in children.Thorax. 2007 Dec 18 http://www.ncbi.nlm.nih.gov/pubmed/18089631
Oral health of Aboriginal children
The Australian Institute of Health and Welfare has released a new report:
Aboriginal and Torres Strait Islander children in Australia are disadvantaged in terms of oral health. This publication provides a summary of Aboriginal and Torres Strait Islander child oral health using information from the Child Dental Health Survey, the Aboriginal and Torres Strait Islander Children and Receipt of Hospital Dental Care Investigation and the Study of Aboriginal and Torres Strait Islander Child Oral Health in Remote Communities. Throughout the states and territories studied, Aboriginal and Torres Strait Islander children had consistently higher levels of dental disease in the deciduous and permanent dentition than their non-Aboriginal and Torres Strait Islander counterparts. Aboriginal and Torres Strait Islander children most affected were those in socially disadvantaged groups and those living in rural / remote areas. Trends in Aboriginal and Torres Strait Islander child caries prevalence indicate that dental disease levels are rising, particularly in the deciduous dentition. Indigenous children aged <5 years had almost one-and-a-half times the rate of hospitalization for dental care as other Australian children, and the rate of Indigenous children receiving hospital dental care rose with increasing geographic remoteness. Less than 5% of remote Indigenous pre-school children reported brushing their teeth on a regular basis and many young remote Indigenous children experienced extensive destruction of their deciduous teeth. Improving the oral health of Aboriginal and Torres Strait Islander children in Australia is an important public health and dental service provision issue.
http://www.aihw.gov.au/mediacentre/2007/mr20071214.cfm
Report http://www.aihw.gov.au/publications/index.cfm/title/10411
ACIP Releases 2008 Child and Adolescent Immunization Schedules
The 2008 recommended immunization schedules for children and adolescents are unveiled in this issue of American Family Physician. There are no significant additions to this year's schedule. Rather, formatting has been simplified and footnotes have been updated for hepatitis B, pneumococcal, meningococcal, and influenza vaccines. Two changes are of note: the expanded age ranges for quadrivalent meningococcal conjugate vaccine (MCV4; Menactra) and for live, attenuated influenza vaccine (LAIV; Flumist).
MCV4 replaces the meningococcal polysaccharide vaccine (Menomune) as the preferred vaccine for children two to 10 years of age with terminal complement deficiencies, anatomic or functional asplenia, or certain other high-risk conditions. In addition, MCV4 is recommended for any previously unimmunized adolescent 11 to 18 years of age.1 Because adolescents present less often to their physicians for well care, any visit should be considered an opportunity to provide MCV4, the quadrivalent human papillomavirus vaccine (Gardasil), and tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine (Tdap; Adacel), as well as a second dose of varicella vaccine.
The approval of LAIV by the Advisory Committee on Immunization Practices (ACIP), as well as the vaccine's recommendation by the U.S. Food and Drug Administration and coverage by the Vaccines for Children Program, can only help to improve influenza immunization rates for young children in the United States. Based on the 2005 National Immunization Survey, only 20.6 percent of children six to 23 months of age were fully immunized for influenza.2 Estimated rates for full immunization in older children (24 to 59 months) ranged from 3.0 to 26.9 percent.3
During the 2006-07 influenza season, 73 children died of the disease.4 However, the morbidity and mortality associated with influenza can be significantly reduced in children. The number needed to vaccinate (NNV) to prevent one hospitalization for younger children (six to 23 months) is 1,031 to 3,050.5 For children 24 to 59 months of age, the NNV is estimated at 4,255 to 6,897.5 Furthermore, one outpatient visit is prevented for every 12 to 42 children immunized, regardless of age.5
In a rare head-to-head, double-blind, randomized controlled vaccine trial involving children six to 59 months of age, LAIV significantly outperformed trivalent inactivated vaccine (TIV).6 Two findings from this study were notable. First, only 491 culture-confirmed cases of influenza were identified in the 7,852 vaccine recipients (infection rate = 6.3 percent), regardless of type. Second, LAIV recipients had a 55 percent decrease in influenza infection compared with TIV recipients (P < .001).
LAIV is a nasal spray vaccine and is refrigerator stable. The following conditions are contraindications or precautions for the use of LAIV in young children:
-concomitant aspirin therapy
-history of recurrent wheezing
-altered immunocompetence
-medical conditions predisposing the patient to influenza complications.
The widespread use of vaccines has profoundly altered children's health. A recent review underscores the declines in the prevalence of vaccine-preventable diseases (more than 92 percent) and deaths (more than 99 percent) in the United States.8 However, compared with the prevaccine prevalence of most vaccine-preventable diseases and their associated mortality rates, contemporary influenza remains an outlier, with extremely high prevalence and moderate mortality. New vaccines and new approaches can help address influenza's challenge, but they require coupling with the efforts of the medical community and within the medical home9 to ensure the health and safety of children. AFP Practice Guidelines http://www.aafp.org/afp/20080101/practice.html
Chronic Disease and Illness
'Awake' during surgery: Examining intraoperative awareness
Estimates show as many as 2 in every 1,000 patients who receive general anesthesia remember events that occurred while they were "under."
Given that over 40 million patients undergo general anesthesia each year in North America, it is not surprising the phenomenon has become the subject of a new Hollywood movie. Dr Beverley A. Orser from the University of Toronto and colleagues use the occasion of the recent release of "Awake"—a film depicting a man who experiences "anesthesia awareness" and is conscious, but physically paralyzed during surgery—to delve deeper into the issue of intraoperative awareness.
Orser and colleagues said most patients who experience intraoperative awareness do not experience pain but have "vague auditory recall or a sense of dreaming and are not distressed by the experience." The authors add, however, that some patients do experience pain, and it is occasionally severe.
In a study involving 11,785 patients who had received general anesthesia, the incidence of awareness was 0.18% in cases in which neuromuscular blockers were used and 0.10% in the absence of such drugs. Of the 19 patients who experienced recall, 7 (36%) reported some degree of pain, ranging from soreness in the throat because of the endotracheal tube, to severe pain at the incision site. Patients may remember these events immediately after surgery, or hours or days later.
"Immense efforts have been made to understand the effects of anesthetics on physiologic processes and to develop strategies and technologies to manage the adverse effects of these drugs," the authors said. "However, certain risks remain, including the possibility of intraoperative awareness."
The authors conclude that intraoperative awareness should be viewed as a recognized complication, with many features similar to those of other adverse intraoperative and perioperative events. They add that anesthesiologists are directing research and patient care efforts toward reducing the incidence and consequences of this adverse event, but they suggest that more large-scale studies of the efficacy of brain-monitoring devices in the prevention of awareness are required.
Orser BA et al Awareness during anesthesia. CMAJ. 2007 Dec 11;
http://www.ncbi.nlm.nih.gov/pubmed/18073268
5-day course of nitrofurantoin is effective fluoroquinolone-sparing treatment of cystitis
CONCLUSION: A 5-day course of nitrofurantoin is equivalent clinically and microbiologically to a 3-day course of trimethoprim-sulfamethoxazole and should be considered an effective fluoroquinolone-sparing alternative for the treatment of acute cystitis in women.
Gupta K et al Short-course nitrofurantoin for the treatment of acute uncomplicated cystitis in women. Arch Intern Med. 2007 Nov 12;167(20):2207-12.
http://www.ncbi.nlm.nih.gov/pubmed/17998493
Cardiovascular disease and pre-eclampsia related. Pre-eclampsia and cancer are not
CONCLUSIONS: A history of pre-eclampsia should be considered when evaluating risk of cardiovascular disease in women. This association might reflect a common cause for pre-eclampsia and cardiovascular disease, or an effect of pre-eclampsia on disease development, or both. No association was found between pre-eclampsia and future cancer.
Bellamy L et al Pre-eclampsia and risk of cardiovascular disease and cancer in later life: systematic review and meta-analysis.BMJ. 2007 Nov 10;335(7627):974. Epub 2007 Nov 1
http://www.ncbi.nlm.nih.gov/pubmed/17975258
Factors Related to Cardiovascular Disease Risk Reduction in Midlife and Older Women
In this study, qualitative methods were used to better understand knowledge and awareness about CVD in women, perceived threat of CVD, barriers to heart-healthy eating and physical activity, and intervention strategies for behavior change. Most women were aware of the modifiable risk factors for CVD. Although they realized they were susceptible, they thought CVD was something they could overcome. Interventions to change behavior should be hands-on, have a goal-setting component, and include opportunities for social interaction. It is especially important to offer interventions as awareness increases and women seek opportunities to build skills to change behavior. http://www.cdc.gov/pcd/issues/2008/jan/06_0156.htm
Herbal and Dietary Supplement-Drug Interactions in Patients with Chronic Illnesses
Herbs, vitamins, and other dietary supplements may augment or antagonize the actions of prescription and nonprescription drugs. St. John's wort is the supplement that has the most documented interactions with drugs. As with many drug-drug interactions, the information for many dietary supplements is deficient and sometimes supported only by case reports. Deleterious effects are most pronounced with anticoagulants, cardiovascular medications, oral hypoglycemics, and antiretrovirals. Case reports have shown a reduction in International Normalized Ratio in patients taking St. John's wort and warfarin. Other studies have shown reduced levels of verapamil, statins, digoxin, and antiretrovirals in patients taking St. John's wort. Physicians should routinely ask patients about their use of dietary supplements when starting or stopping a prescription drug, or if unexpected reactions occur. Am Fam Physician. 2008;77(1):73-78. http://www.aafp.org/afp/20080101/73.html
Heart Rhythm Problems with Haloperidol
A recent FDA alert, along with new labeling, warns health professionals about the possibility of QT prolongation and Torsades de Pointes (TdP) in patients treated with the antipsychotic drug Haldol (haloperidol).
The risk appears to be higher when the drug is administered intravenously or in higher doses than recommended. Injectable haloperidol is approved only for intramuscular administration, but it's sometimes used intravenously to treat severe agitation.
FDA is advising particular caution if the drug is used in patients who have other QT-prolonging conditions, including electrolyte imbalance. Caution should also be used in patients taking drugs known to prolong the QT interval, and in those who have underlying cardiac abnormalities, hypothyroidism or familial long QT syndrome. FDA also recommends ECG monitoring if haloperidol is given intravenously.
Additional Information:
FDA MedWatch Safety Alert. Haloperidol (marketed as Haldol, Haldol decanoate, and Haldol lactate). September 17, 2007. http://www.fda.gov/medwatch/safety/2007/safety07.htm#Haloperidol
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OB/GYN
Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.
