August 2005 CCC Corner > Hot
Topics
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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