August 2005 CCC Corner > Hot Topics

• Obstetrics
• Gynecology
• Child Health
• Chronic Disease and Illness

Hot Topics

Obstetrics

Trial of Labor After Cesarean: Evidence based guidelines

The American Academy of Family Physicians Commission on Clinical Policies and Research convened a panel to systematically review the available evidence on trial of labor after cesarean (TOLAC) using the Agency for Healthcare Research and Quality "Evidence Report on Vaginal Birth After Cesarean (VBAC)." The panel’s objective was to provide an evidence-based clinical practice guideline for pregnant women and their families, maternity care professionals, facilities, and policy makers who care about trial of labor and maternity care for a woman with one previous cesarean. The recommendations are as follows:

Recommendation 1: Women with 1 previous cesarean delivery with a low transverse incision are candidates for and should be offered a trial of labor (TOL). (Level A)

Recommendation 2: Patients desiring TOLAC should be counseled that their chance for a successful vaginal birth after cesarean (VBAC) is influenced by the following: (Level B)

Positive factors (increased likelihood of successful VBAC)

Maternal age <40 years

Previous vaginal delivery (particularly previous successful VBAC)

Favorable cervical factors

Presence of spontaneous labor

Non-recurrent indication that was present for previous cesarean delivery (CD)

Negative factors (decreased likelihood of successful VBAC)

Increased number of previous CDs

Gestational age >40 weeks

Birthweight >4,000 g

Induction or augmentation of labor

Recommendation 3: Prostaglandins should not be used for cervical ripening or induction, as their use is associated with higher rates of uterine rupture and decreased rates of successful vaginal delivery. (Level B)

Recommendation 4: TOLAC should not be restricted only to facilities with available surgical teams present throughout labor, because there is no evidence that these additional resources result in improved outcomes. (Level C) At the same time, it is clinically appropriate that a management plan for uterine rupture and other potential emergencies requiring rapid cesarean section should be documented for each woman undergoing TOLAC. (Level C)

Recommendation 5: Maternity care professionals need to explore all the issues that may affect a woman’s decision, including issues such as recovery time and safety. (Level C) No evidence-based recommendation can be made regarding the best way to present the risks and benefits of TOLAC to patients.

Borgmeyer C; American Academy of Family Physicians. Guideline showcases AAFP's commitment to evidence-based, patient-centered care - Trial of Labor After Cesarean (TOLAC), Formerly Trial of Labor Versus Elective Repeat Cesarean Section for the Woman With a Previous Cesarean Section. Annals of Family Medicine 3:378-380 (2005)

http://www.annfammed.org/cgi/data/3/4/378/DC1/1

or

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16046579&dopt=Abstract

OB/GYN CCC Editorial comment:

This document is helpful as it more strictly applies the available scientific literature, rather than including the effects of tort liability. The Indian Health system has had extensive discussions about emergency vaginal delivery in rural settings. As symptomatic uterine rupture is a relatively rare event, it is highly recommended that each center offering vaginal delivery have periodic drills on various other emergency delivery scenarios to assure that the whole labor and delivery system is capable of a timely response.

Other Resources

Vaginal Birth After Cesarean (VBAC), AHRQ, Evidence Report/Technology Assessment: Number71
http://www.ahrq.gov/clinic/epcsums/vbacsum.htm

VBAC: Is There Such a Thing as Low Risk?

Emergency Delivery Simulations: How to Develop Teamwork

Leeman L, Leeman R. Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability. J Fam Pract. 2002 Feb;51(2):129-34.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=11978210&dopt=Abstract

Leeman, L, Leman, R. A Native American Community with a 7% Cesarean Delivery Rate: Does Case Mix, Ethnicity, or Labor Management Explain the Low Rate? Annals of Family Medicine 1:36-43 (2003) http://www.annfammed.org/cgi/content/full/1/1/36

Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 54. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;104:203–12.

ACOG non-members

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15229039&query_hl=5

ACOG Members

http://www.acog.org/publications/educational_bulletins/pb054.cfm

Other Obstetric Hot Topics

Time of birth and risk of neonatal death: 12-16% increase in mortality at night

Conclusion: Identifying the causal factors and reducing the increased burden of mortality for infants born at night should be a major priority for perinatal medicine. Level of Evidence: III.

* After adjusting for the adequacy of prenatal care, complications of pregnancy, gender, and birthweight, mortality for infants born during early night and those born during late night increased by 12% and 16%, respectively, compared with mortality for infants born during the day.

* There was an increase in mortality for both VLBW infants and non-VLBW infants born during early and late night.

* Mortality was significantly elevated for singletons born during early and late night. For multiples, mortality was elevated only for infants born during early night.

* During early night there was a significant increase in the mortality of infants delivered vaginally but not in the mortality of infants delivered by cesarean. During late night, the situation was reversed: there was a marked increase in the mortality of infants delivered by cesarean but only a weak increase among infants delivered vaginally.

* After adjusting for differences in risk across time, there was no significant elevation in mortality for infants born in primary care hospitals. In hospitals with intermediate intensive care, infants born during early or late night had elevated mortality. In hospitals providing community and regional intensive care, mortality was elevated only for infants born during late night.

Gould JB, Qin C, Chavez G. 2005. Time of birth and the risk of neonatal death. Obstetrics & Gynecology 106(2):352-358. http://www.greenjournal.org/cgi/content/abstract/106/2/352 or

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055587&dopt=Abstract

OB/GYN CCC Editorial comment:

There have been several studies of European births during the 1990s reported increased mortality for infants born at night, yet no reports have been published about neonatal mortality by hour of birth in the United States. The article describes a study to determine whether the time of birth influenced the risk of neonatal death for infants born in California. This study provides Level III evidence that infants born at night have a 12-16% increase in mortality and it needs be confirmed with larger prospective trials before major health care shifts are considered.

In the meantime, considering the implications of the evidence to date, facilities in the Indian Health system should carefully investigate their local data and consider reevaluating their diurnal staffing patterns.

Parietal peritoneum closure during cesarean delivery decreases adhesions

Conclusion: Parietal peritoneal closure at primary cesarean delivery was associated with significantly fewer dense and filmy adhesions. The practice of nonclosure of the parietal peritoneum at cesarean delivery should be questioned. Level of Evidence: II-2.
Lyell DJ et al Peritoneal closure at primary cesarean delivery and adhesions. Obstet Gynecol. 2005 Aug;106(2):275-80.,

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055575&dopt=Abstract

Aerobic training increases exercise capacity, overcoming negative effects of pregnancy

Conclusion: Aerobic training in overweight pregnant women substantially increases submaximal exercise capacity, overcoming the otherwise negative effects of pregnancy in this regard. Additional studies are required to evaluate its effect on major clinical outcomes. LEVEL OF EVIDENCE: I. Santos IA, et al Aerobic Exercise and Submaximal Functional Capacity in Overweight Pregnant Women: A Randomized Trial. Obstet Gynecol. 2005 Aug;106(2):243-249
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055571&dopt=Abstract

Prepregnancy obesity: Increasing excess risk of fetal death with advancing gestation

Conclusion: Prepregnancy obesity was associated with an increasing excess risk of fetal death with advancing gestation, and placental dysfunction may be a possible contributing factor. Level of Evidence: II-2. Nohr EA et al Prepregnancy Obesity and Fetal Death: A Study Within the Danish National Birth Cohort. Obstet Gynecol. 2005 Aug;106(2):250-259.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055572&dopt=Abstract

Interpregnancy intervals < 12 months > 59 months associated adverse perinatal outcomes

Conclusion: In Latin America, interpregnancy intervals shorter than 12 months and longer than 59 months are independently associated with increased risk of adverse perinatal outcomes. These data suggest that spacing pregnancies appropriately could prevent perinatal deaths and other adverse perinatal outcomes in the developing world. Level of Evidence: II-2.

Conde-Agudelo A et al Effect of the Interpregnancy Interval on Perinatal Outcomes in Latin America. Obstet Gynecol. 2005 Aug;106(2):359-366.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055588&dopt=Abstract

Study finds that screening asymptomatic, low-risk pregnant women for hepatitis C virus is not cost effective

http://www.ahrq.gov/research/jul05/0705RA16.htm

Simple blood test may predict deadly pregnancy complications

CONCLUSION: Our results indicate that HLA-G levels in plasma from women who subsequently develop PE are lower than control patients, as early as the first trimester. This suggests that determination of circulating HLA-G protein concentration may be useful as an early predictor for the development of PE. Yie SM, Taylor RN, Librach C. Low plasma HLA-G protein concentrations in early gestation indicate the development of preeclampsia later in pregnancy. Am J Obstet Gynecol. 2005 Jul;193(1):204-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16021080&query_hl=3

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Gynecology

Ovarian conservation benefits survival in women when undergoing hysterectomy

Conclusion: Ovarian conservation until at least age 65 benefits long-term survival for women at average risk of ovarian cancer when undergoing hysterectomy for benign disease. Level III
Parker WH et al Ovarian Conservation at the Time of Hysterectomy for Benign Disease. Obstet Gynecol. 2005 Aug;106(2):219-226.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055568&dopt=Abstract

Editorial- Olive DL. Et al Dogma, skepsis, and the analytic method: the role of prophylactic oophorectomy at the time of hysterectomy. Obstet Gynecol. 2005 Aug;106(2):214-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055566&dopt=Abstract

Hysterectomy Associated With Earlier Onset of Menopause

CONCLUSIONS: Hysterectomy is associated with an earlier onset of menopause. Hysterectomy with unilateral oophorectomy is associated with an even earlier onset of the menopause in this study. Farquhar CM, et al The association of hysterectomy and menopause: a prospective cohort study. BJOG. 2005 Jul;112(7):956-62.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15957999&query_hl=25

One in ten adult women perceives urinary incontinence to be barrier to exercise

Conclusion: Urinary incontinence is perceived as a barrier to exercise, particularly by women with more severe leakage. Level of Evidence: II-3. Nygaard I, et al Is Urinary Incontinence a Barrier to Exercise in Women? Obstet Gynecol. 2005 Aug;106(2):307-314.

http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055580&dopt=Abstract

Reclosure of the disrupted laparotomy wound is safe and successful in over 80%

Conclusion: Reclosure of disrupted laparotomy wounds was successful in over 80% of patients. Failed reclosure resulted in no life-threatening complications. Reclosure of disrupted laparotomy wounds is safe and decreases healing times.

Wechter ME, et al Reclosure of the Disrupted Laparotomy Wound: A Systematic Review. Obstet Gynecol. 2005 Aug;106(2):376-383.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055590&dopt=Abstract

Cervical cytology screening and evaluation - Clinical Expert Series

In this article, I will explain how I have incorporated some of the new guidelines into my practice, how the use of the human papillomavirus DNA (HPV-DNA) test can help us manage patients, and how I approach minimally abnormal cytology and biopsy (CIN1).

Noller KL. Cervical cytology screening and evaluation. Obstet Gynecol. 2005 Aug;106(2):391-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=16055593&dopt=Abstract

Diagnosis and Management of Uncomplicated Urinary Tract Infections

http://www.aafp.org/afp/20050801/451.html

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Child Health

AAP Releases Report on Excessive Sleepiness in Adolescents

Inadequate sleep has become a widespread problem for adolescents. Physicians have an important role in identifying adolescent patients at risk for inadequate sleep and in providing counseling and support to help manage sleep-related symptoms.

Common causes of sleepiness in adolescents include normal changes that occur during the transition into adolescence (e.g., varying sleep/wake times, relaxed parental control of bedtimes, changing school start times). Many adolescents also have part-time jobs that cut into their sleep time. Studies have shown that the biological system that regulates circadian rhythms may change during adolescence, creating a later timing of sleep. Because of these changes, adolescents get less sleep than they did as children. Insomnia, narcolepsy, idiopathic hypersomnia, restless legs syndrome, and numerous medications are also common causes of inadequate sleep in adolescents.

Lack of sleep can affect adolescents' cognitive function, concentration and attention, alertness, and ability to perform in school. Studies have shown that many adolescents who have sleep disorders also have symptoms of attention-deficit/hyperactivity disorder. Adolescents with clinical mood disorders, especially severe depression, report higher incidences of sleep disturbance. Sleepiness is also the leading cause of motor vehicle crashes among drivers 16 to 29 years of age.

The AAP concludes that physicians should recognize the significant problem of sleepiness among their adolescent patients. Physicians need to ask questions about sleep patterns, how much sleep their adolescent patients are getting, and if they are having any sleep-related symptoms. A sleep history should focus on the following points:

• Bedtime problems
• Excessive daytime sleepiness
• Awakenings during the night
• Regularity and duration of sleep
• Sleep-disordered breathing (e.g., loud snoring)

AAP recommends educating adolescent patients about their sleep needs and the detrimental effects of sleep loss on performance and health.

Based on a meta-analysis, June 2005 issue of Pediatrics. http://www.aafp.org/afp/20050715/practice.html

High-Grade Cervical Lesions Progress in Adolescents at Similar Rate as in Adults
CONCLUSION: Adolescents with LSIL and HSIL cytology are at significant risk for progression to high-grade cervical abnormalities. The rate of development of high-grade cervical abnormalities in adolescents is similar to adults. Adolescents with cytologic abnormalities mandate close follow-up. LEVEL OF EVIDENCE: II-3.
Wright JD, et al Cervical dysplasia in adolescents. Obstet Gynecol. 2005 Jul;106(1):115-20.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15994625&dopt=Abstract

Reducing the Risk of SIDS Through Community Partnerships: Editorial

http://www.aafp.org/afp/20050715/editorials.html

Fetal Alcohol Spectrum Disorders

http://www.aafp.org/afp/20050715/279.html

Rural hospitals appear to deliver care similar to non-rural hospitals for many common pediatric conditions

http://www.ahrq.gov/research/jun05/0605RA16.htm#head16

Nurses can take steps to prevent pediatric medication errors associated with dosing and administration

http://www.ahrq.gov/research/jun05/0605RA17.htm#head17

Foreign Body Ingestion in Children (also see Patient Education)

http://www.aafp.org/afp/20050715/287.html

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Chronic disease and Illness

Guidelines for Improving Vaccination Rates Among High-Risk Adults, CDC

The Task Force on Community Preventive Services of the Centers for Disease Control and Prevention (CDC) has issued an evidence-based review of interventions to improve influenza, pneumococcal polysaccharide, and hepatitis B vaccination coverage among high-risk adults younger than 65 years. The recommendations were based on a systematic review. Morbidity and Mortality Weekly Report April 1, 2005 http://www.cdc.gov/mmwr/PDF/rr/rr5405.pdf

Bariatric Surgery Resolves Comorbid Conditions

Preventive measures carry the highest hope for managing obesity at the lowest cost. Meanwhile, this review shows that bariatric surgery is far more effective in treating obesity than diet, exercise, or pharmacologic management. Because of the high rate of morbidity and increased mortality associated with epidemic levels of obesity, a cost-benefit analysis is likely to favor surgical intervention. For those who are not candidates for bariatric surgery, recommendations for conventional weight loss goals are 10 percent of body weight. Patients should be told that a 10-kg (22-lb) weight loss results in multiple health benefits, including decreased angina, lower blood pressure, and lower lipid and blood sugar levels. The results, however, will not be nearly as dramatic as those cited here.

CONCLUSIONS: Effective weight loss was achieved in morbidly obese patients after undergoing bariatric surgery. A substantial majority of patients with diabetes, hyperlipidemia, hypertension, and obstructive sleep apnea experienced complete resolution or improvement.
Buchwald H, et al Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004 Oct 13;292(14):1724-37.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15479938&query_hl=8

Tobacco Cessation: Kicking the Habit in Alaska

Part 5 of a 5-Part Series - July 15, 2005 State of Alaska: Section of Epidemiology

http://www.epi.alaska.gov/bulletins/docs/rr2005_01.pdf

Existing coronary heart disease is undiagnosed in half of women who have a first heart attack

http://www.ahrq.gov/research/jun05/0605RA10.htm#head10

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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.