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Volume 6, No. 1, January 2008
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Cesarean delivery on request not recommended if desiring several children, ACOG
ABSTRACT: Cesarean delivery on maternal request is defined as a primary cesarean delivery at maternal request in the absence of any medical or obstetric indication. A potential benefit of cesarean delivery on maternal request is a decreased risk of hemorrhage for the mother. Potential risks of cesarean delivery on maternal request include a longer maternal hospital stay, an increased risk of respiratory problems for the baby, and greater complications in subsequent pregnancies, including uterine rupture and placental implantation problems. Cesarean delivery on maternal request should not be performed before gestational age of 39 weeks has been accurately determined unless there is documentation of lung maturity. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. Cesarean delivery on maternal request is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and the need for gravid hysterectomy increase with each cesarean delivery.
Cesarean Delivery on Maternal Request. ACOG Committee Opinion no. 394. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1501-4.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18055756
Other Cesarean Delivery related resources
Placenta previa: Increasing cesareans is associated with adverse maternal outcomes
CONCLUSION: Among women with a placenta previa, an increasing number of prior cesarean deliveries is associated with increasing maternal, but not perinatal, morbidity. LEVEL OF EVIDENCE: II.
Grobman WA et al Pregnancy Outcomes for Women With Placenta Previa in Relation to the Number of Prior Cesarean Deliveries. Obstet Gynecol. 2007 Dec;110(6):1249-1255.
Sense of coherence and symptoms of post-traumatic stress after emergency caesarean
CONCLUSIONS: Symptoms of post-traumatic stress following emergency caesarean delivery are associated both with the new mother's personal coping style and with the circumstances of the event. We recommend that women who belong to groups who more often report a low of coherence or who had imminent asphyxia as an indication for the operation should be offered support and follow-up.
Tham V et al Sense of coherence and symptoms of post-traumatic stress after emergency caesarean. Acta Obstet Gynecol Scand. 2007;86(9):1090-6.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17712650
Other
Late-preterm (34-36 weeks) infants have higher mortality rate than term at one year of age
OBJECTIVE: To assess differences in mortality between late-preterm (34-36 weeks) and term (37-41 weeks) infants.
RESULTS: Significant declines in mortality rates were observed for late-preterm and term infants at all age-at-death categories, except the late-neonatal period. Despite the decline in rates since 1995, infant mortality rates in 2002 were 3 times higher in late-preterm infants than term infants (7.9 versus 2.4 deaths per 1000 live births); early, late, and postneonatal rates were 6, 3, and 2 times higher, respectively. During infancy, late-preterm infants were approximately 4 times more likely than term infants to die of congenital malformations (leading cause), newborn bacterial sepsis, and complications of placenta, cord, and membranes. Early-neonatal cause-specific mortality rates were most disparate, especially deaths caused by atelectasis, maternal complications of pregnancy, and congenital malformations.
CONCLUSIONS: Late-preterm infants have higher mortality rates than term infants throughout infancy. Our findings may be used to guide obstetrical and pediatric decision-making.
Tomashek KM Differences in mortality between late-preterm and term singleton infants in the United States, 1995-2002. J Pediatr. 2007 Nov;151(5):450-6, 456.e1. Epub 2007 Jul 24.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17961684
Spinal analgesia increases the success rate of external cephalic version from 32% to 67%
CONCLUSION: Administration of spinal analgesia significantly increases the success rate of external cephalic version among nulliparous women at term, which allows possible normal vaginal delivery.
Weiniger CF et al External cephalic version for breech presentation with or without spinal analgesia in nulliparous women at term: a randomized controlled trial.
Obstet Gynecol. 2007 Dec;110(6):1343-50
Milk consumption during pregnancy is associated with increased infant size at birth
CONCLUSION: Milk intake in pregnancy was associated with higher birth weight for gestational age, lower risk of SGA, and higher risk of LGA.
Olsen SF et al Milk consumption during pregnancy is associated with increased infant size at birth: prospective cohort study. Am J Clin Nutr. 2007 Oct;86(4):1104-10 .
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17921389
Gynecology
Early feeding within the first 24 hours after major abdominal gynecologic surgery is safe
SELECTION CRITERIA: Randomized controlled trials that compared the effect of early versus delayed initiation of oral intake of food and fluids after major abdominal gynecologic surgery were considered. Early feeding was defined as having oral intake of fluids or food within the first 24 hours after surgery regardless of the presence or absence of the signs that indicate the return of bowel function and delayed feeding was defined after first 24 hours following surgery and only after clinical signs of resolution of postoperative ileus
CONCLUSIONS: Early feeding after major abdominal gynecologic 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 individualised. 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 gynecologic surgery. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD004508. Review.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17943817
Abnormal Uterine Bleeding: A Management Algorithm
Abnormal uterine bleeding is a common problem, and its management can be complex. Because of this complexity, concise guidelines have been difficult to develop. We constructed a concise but comprehensive algorithm for the management of abnormal uterine bleeding between menarche and menopause that was based on a systematic review of the literature as well as the actual management of patients seen in a gynecology clinic. We started by drafting an algorithm that was based on a MEDLINE search for relevant reviews and original research. We compared this algorithm to the actual care provided to a random sample of 100 women with abnormal bleeding who were seen in a university gynecology clinic. Discrepancies between the algorithm and actual care were discussed during audiotaped meetings among the 4 investigators (2 family physicians and 2 gynecologists). The audiotapes were used to revise the algorithm. After 3 iterations of this process (total of 300 patients), we agreed on a final algorithm that generally followed the practices we observed, while maintaining consistency with the evidence. In clinic, the gynecologists categorized the patient's bleeding pattern into 1 of 4 types: irregular bleeding, heavy but regular bleeding (menorrhagia), severe acute bleeding, and abnormal bleeding associated with a contraceptive method. Subsequent management involved both diagnostic and treatment interventions, which often occurred simultaneously. The algorithm in this article is designed to help primary care physicians manage abnormal uterine bleeding using strategies that are consistent with the evidence as well as the actual practice of gynecologists.
Ely JW, et al Abnormal Uterine Bleeding: A Management Algorithm J Am Board Fam Med. 2006;19(6):590-602
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17090792
Addition of HPV to Pap test to screen in mid-30s for cervical cancer reduces in CIN 2 or 3
CONCLUSIONS: The addition of an HPV test to the Pap test to screen women in their mid-30s for cervical cancer reduces the incidence of grade 2 or 3 cervical intraepithelial neoplasia or cancer detected by subsequent screening examinations.
Naucler P, et al Human papillomavirus and Papanicolaou tests to screen for cervical cancer. N Engl J Med. 2007 Oct 18;357(16):1589-97.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17942872
Medical Therapy for Ectopic Pregnancy
Methotrexate for treatment of ectopic tubal pregnancy has become an accepted alternative to surgical options. Methotrexate is a folic acid analog that interferes with DNA synthesis. Protocols using planned multiple doses of methotrexate alternating with citrovorum rescue factor and one protocol using only a single planned dose are both currently used in the treatment of ectopic pregnancy. In remains unclear which protocol is superior. This article reviews the indications, contraindications, and specifics of using methotrexate for this purpose. Also reviewed are predictors of success and management of usual complications associated with methotrexate therapy.
Lipscomb GH. Medical Therapy for Ectopic Pregnancy Semin Reprod Med. 2007;25(2):93-98.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17377896
A cautionary case: Balloon occlusion of internal iliac arteries for abnormal placentation
Massive hemorrhage from abnormal placentation is a leading cause of postpartum maternal death and hysterectomy after cesarean section. The endovascular surgeon and radiologist are increasingly asked to assist in the management of these complex patients with the placement of bilateral internal iliac artery balloon catheters. We report the case of a 27-year-old woman with placenta percreta with preemptive bilateral internal iliac artery balloons who had iliac artery thrombosis and acute limb ischemia develop 7 hours after cesarean hysterectomy. This is the first report of iliac artery thrombosis in this setting. A review of the vascular and obstetrical literature reveals divergent recommendations for the use of this technique in patients with abnormal placentation. No guidance from rigorous prospective evidence is available and thus we offer recommendations for the cautious use of this modality.
Greenberg JI et al Prophylactic balloon occlusion of the internal iliac arteries to treat abnormal placentation: a cautionary case. Am J Obstet Gynecol. 2007 Nov;197(5):470
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=17980178
Child Health
Rapid response team: Implications of findings on mortality rates for children are dramatic
Implementation of an RRT [rapid-response team] in our free-standing, quaternary care academic children's hospital was associated with statistically significant reductions in hospital-wide mortality rates and code rates outside the ICU [intensive care unit] setting.
The authors found that
* A significant decrease in the hospital-wide mortality rate of 18% occurred after RRT implementation. Mean monthly mortality rates preintervention and postintervention were 1.01 and 0.83 deaths per 100 discharges, respectively.
* The rate of codes outside the ICU per 1,000 eligible patient-days decreased by 71.2% after RRT implementation, with preintervention and postintervention rates of 0.52 and 0.15, respectively.
* The rate of codes outside the ICU per 1,000 eligible admissions decreased by 71.7%, with preintervention and postintervention rates of
2.45 and 0.69, respectively.
* The estimated code rate per 1,000 admissions for the postintervention group was 0.28 times that for the preintervention group.
The potential implications of these findings on national mortality rates for children could be dramatic.
Sharek PJ, Parast LM, Leong K, et al. 2007. Effect of a rapid response team on hospital-wide mortality and code rates outside the ICU in a children’s hospital. JAMA, the Journal of the American Medical Association 298(19):2267-2274
http://jama.ama-assn.org/cgi/content/abstract/298/19/2267?etoc
Obesity In Children
What are the effects of lifestyle interventions for the treatment of childhood obesity?
Likely to be beneficial
Multifactorial Interventions. Multifactorial interventions (particularly those that included problem solving) delivered to the family were more effective at reducing body mass index (BMI), decreasing the number of overweight children, or both, than the interventions delivered to children alone.
Unknown effectiveness
Behavioral Interventions Alone. We found insufficient evidence that behavioral interventions alone can effectively promote weight loss in children and adolescents.
Diet Alone. One randomized controlled trial found no significant difference in reduction in overweight between two dietary interventions of higher and lower protein levels.
Physical Activity Alone. We found insufficient evidence that physical activity interventions alone can effectively promote weight loss in children and adolescents.
Definition
Obesity is a chronic condition characterized by an excess of body fat. It is most often defined by the BMI, which is highly correlated with body fat.1 BMI is weight in kilograms divided by height in meters squared (kg per m2). In children and adolescents, BMI varies with age and sex. It typically rises during the first months after birth, falls after the first year, and rises again around the sixth year of life.2 A given BMI value is usually compared against reference charts to obtain a ranking of BMI percentile for age and sex. The BMI percentile indicates the relative position of the child's BMI compared with a historical reference population of children of the same age and sex. Worldwide, there is little agreement on the definition of overweight and obesity among children; however, a BMI above the 85th percentile is generally considered to be at least "at risk for overweight" in the United States and United Kingdom. A BMI above the 95th percentile is variably defined as overweight or obese, but generally indicates a need for intervention.
Prevalence
The prevalence of obesity (generally BMI above the 95th percentile) is steadily increasing among children and adolescents. In the United Kingdom in 2004, it was estimated that 14 percent of boys and 17 percent of girls two to 15 years of age were obese.3 The prevalence of overweight among children and adolescents in the United States increased from 14 percent in 1999 to 2000, to 16 percent in 2003 to 2004, among females and from 14 to 18 percent among males.4
Etiology
Obesity is the result of long-term energy imbalances in which daily energy intake exceeds daily energy expenditure.5 Energy balance is modulated by a myriad of factors, including metabolic rate, appetite, diet, and physical activity.6 Although these factors are influenced by genetic traits in a moderate number of children, the increase in obesity prevalence in the past few decades cannot be explained by changes in the human gene pool, and is more often attributed to environmental changes that promote excessive food intake and discourage physical activity.6,7 The risk of childhood obesity is related to childhood diet and sedentary time. Other risk factors are parental obesity, low parental education, social deprivation, infant feeding patterns, early or more rapid puberty (both a risk factor and an effect of obesity), extreme (both high and low) birth weights, and gestational diabetes.2 Specifically, physical activity levels have decreased over the years and now only 36 percent of children and adolescents in the United States are meeting recommended levels of physical activity.8 Less commonly, obesity may also be induced by medications (e.g., high-dose glucocorticoids), neuroendocrine disorders (e.g., Cushing's syndrome), or inherited disorders (e.g., Down syndrome, Prader-Willi syndrome).2 In this review, we have considered treatment of children for overweight and obesity in a clinical setting (not broader public health settings, such as interventions given to a whole school). We have included interventions given to the children, their parents, or both.
Prognosis
Most obese adolescents will become obese adults. For example, a five-year longitudinal study of obese adolescents, 13 to 19 years of age, found that 86 percent remained obese as young adults.9 Obesity is associated with a higher prevalence of insulin resistance, elevated blood lipid levels, increased blood pressure, and impaired glucose tolerance, which in turn may increase the risk of several chronic diseases in adulthood, including hypertension, dyslipidemia, diabetes, cardiovascular disease, sleep apnea, osteoarthritis, and some cancers.2,10 Perhaps the most significant short-term morbidities for overweight and obese children are psychosocial, and include social marginalization, low self-esteem, and an impaired quality of life.2 Physicians should emphasize improvements in diet, physical activity, and health independent of changes in body weight.
Arterburn DE . Obesity in children. Clin Evid Handbook Dec 2007:110-1.
Clinical Evidence Concise A Publication of BMJ Publishing Group
http://www.aafp.org/afp/20071201/bmj.html
Newborn Screening
ABSTRACT: Newborn screening tests are designed to detect infants with specific conditions whose families also would benefit from early diagnosis and treatment. These conditions include disorders of metabolism, endocrinopathies, hemoglobinopathies, hearing loss, and cystic fibrosis. Each state program must have a system in place for notification, timely follow-up, and evaluation of any infant with a positive screening result. Newborn screening programs have enormous public health benefits and have been effective in identifying newborns that can benefit from early treatment.
Newborn Screening. ACOG Committee Opinion no. 393. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;110:1497-500.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd=ShowDetailView&TermToSearch=18055755
Chronic Disease and Illness
Reconsider use of rosiglitazone
A 2004 meta-anylsis described both drugs have similar effects on glycemic control and body weight. Both drugs appear to have a beneficial effect on serum lipids. In a meta-analysis comparing the effect of thiazolidinediones on cardiovascular risk factors, pioglitazone produced a more favorable lipid profile. The Proactive study measurement of macrovascular events included all cause mortality and non-fatal stroke with combined endpoints. It was noted the study narrowly made statistical significance. Both drugs increased HDL, rosiglitazone increased LDL and had a neutral effect on TG whereas pioglitazone had a neutral effect on LDL and lowered TG. Rosiglitzone was shown in JAMA June and September 2007 meta-analysis to increase macrovascular events. The first study demonstrated increase risk of MI with rosiglitazone and the 2nd study displayed increased risk of MI but not death. No head-to-head trials have been conducted to date. In regards to adverse effects, both drugs may cause fluid retention which may exacerbate or lead to heart failure. Thiazolidinediones are not recommended for patients with NYHA Class 3 & 4 cardiac status. Some clinicians chose to avoid this class of drugs in NYHA Class 2 as well. Edema was more pronounced as a side effect with both drugs; rosiglitazone 4.8% and pioglitazone 4.8% versus placebo 1.3% and 1.2%, respectively. LFT monitoring is recommended for both drugs. Post-marketing experience with rosiglitazone reported some cases of angioedema and urticaria. Rifampin decreased rosiglitazone AUC by 66% and the clinical significance of this is unknown. Look-alike, sound-alike: Avandia and either Coumadin or Prandin; Actos and Actonel noted by the Institute for Safe Medication Practices. Use of rosiglitazone has changed from 2005 to 2007, from 170 to 119 patients, respectively. Use of pioglitazone has increased from 2005 to 2007, from 66 to 128 patients. Clinical trials have shown similar decreases in A1C between pioglitazone 15 and 30mg. Based on safety, pioglitazone has been shown better safety profile than rosiglitazone. Dialogue regarding the Accord trial pointed out the study is still in progress, and results inconclusive with cardiovascular events. Pioglitazone has a significantly lower risk of death. Today, rosiglitazone is not as cost effective as it was back in 2005. The current data describes a potential increase in cardiovascular events associated with rosiglitazone that has not been seen with pioglitazone. Questions: ggivens@anmc.org
Conclusion:
Reconsider use of rosiglitazone. Patients who are taking rosiglitazone 2 or 4 mg can be switched to pioglitazone 15mg and those taking rosiglitazone 8mg can be switched to 45mg of pioglitazone.
Resource:
Charbonnel B. Glitazones in the treatment of diabetes mellitus: clinical outcomes in large scale clinical trials. Fndam Clin Pharmacol. 2007 Nov;21 Suppl 2:19-20.
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=18001315
Therapy Insight: Management of Graves' Disease During Pregnancy
The diagnosis of Graves' disease in pregnancy can be complex because of normal gravid physiologic changes in thyroid hormone metabolism. Mothers with active Graves' disease should be treated with antithyroid drugs, which impact both maternal and fetal thyroid function. Optimally, the lowest possible dose should be used to maintain maternal free thyroxine levels at or just above the upper limit of the normal nonpregnant reference range. Fetal thyroid function depends on the balance between the transplacental passage of thyroid-stimulating maternal antibodies and thyroid-inhibiting antithyroid drugs. Elevated levels of serum maternal anti-TSH-receptor antibodies early in the third trimester are a risk factor for fetal hyperthyroidism and should prompt evaluation of the fetal thyroid by ultrasound, even in women with previously ablated Graves' disease. Maternal antithyroid medication can be modulated to treat fetal hyperthyroidism. Serum TSH and either total or free thyroxine levels should be measured in fetal cord blood at delivery in women with active Graves' disease, and those with a history of (131)I-mediated thyroid ablation or thyroidectomy who have anti-TSH-receptor antibodies. Neonatal thyrotoxicosis can occur in the first few days of life after clearance of maternal antithyroid drug, and can last for several months, until maternal antibodies are also cleared.
Chan GW, Mandel SJ. Therapy Insight: Management of Graves' Disease During Pregnancy Nat Clin Pract Endocrinol Metab. 2007; 3(6):470-478
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17515891
Antithrombotic therapy and pregnancy: consensus report and recommendations
Venous thromboembolism and adverse pregnancy outcomes are potential complications of pregnancy. Numerous studies have evaluated both the risk factors for and the prevention and management of these outcomes in pregnant patients. This consensus group was convened to provide concise recommendations, based on the currently available literature, regarding the use of antithrombotic therapy in pregnant patients at risk for venous thromboembolic events and adverse pregnancy outcomes.
Duhl AJ et al Antithrombotic therapy and pregnancy: consensus report and recommendations for prevention and treatment of venous thromboembolism and adverse pregnancy outcomes.Am J Obstet Gynecol. 2007 Nov;197(5):457
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17980177
Cholesterol <10th population percentile was strongly associated with preterm delivery
CONCLUSIONS: Total serum cholesterol <10th population percentile was strongly associated with preterm delivery among otherwise low-risk white mothers in this pilot study population. Term infants of mothers with low total cholesterol weighed less than control infants among both racial groups
Edison RJ, et al Adverse birth outcome among mothers with low serum cholesterol. Pediatrics. 2007 Oct;120(4):723-33
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17908758
Cisplatin with RT improves long-term progression-free survival in 1B cervical carcinoma
CONCLUSION: Concurrent weekly cisplatin with radiation therapy significantly improves long-term progression-free survival and overall survival when compared with radiation therapy alone. Serious late effects were not increased. The inclusion of hysterectomy has been discontinued on the basis of another trial. Pending further trials, weekly cisplatin with radiation
Stehman FB, et al Radiation therapy with or without weekly cisplatin for bulky stage 1B cervical carcinoma: follow-up of a Gynecologic Oncology Group trial. Am J Obstet Gynecol. 2007 Nov;197(5):503
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&Cmd
=ShowDetailView&TermToSearch=17980189
From Your Colleagues ‹ Previous | Next › Features
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.
