Acrobat
MS Word
PowerPoint
Volume 6, No. 5, May 2008
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Pregnant Women Who are Obese Linked with Greater Health Care Services Use
Obesity during pregnancy is associated with greater use of health care services and longer hospital stays. The primary reasons for the increased utilization of these services were increases in Caesarean section and obesity-related high risk conditions. Caesarean delivery rates were 45.2 percent for extremely obese women, compared to 21.3 percent for normal weight women.
Given the health and economic costs, the importance of preventing obesity in women of child-bearing age in order to enhance health during pregnancy and throughout the course of life still remains a vital public health concern.
CONCLUSIONS: Obesity during pregnancy is associated with increased use of health care services
Chu SY et al Association between obesity during pregnancy and increased use of health care. N Engl J Med. 2008 Apr 3;358(14):1444-53. http://www.ncbi.nlm.nih.gov/pubmed/18385496
New Evidence Report on Management and Postpartum Follow-Up of Gestational Diabetes Mellitus
A new AHRQ evidence report finds there are no substantial differences in maternal or neonatal outcomes associated with the use of glyburide or insulin analogues, as opposed to the use of insulin in women with gestational diabetes. The report also finds that further studies are needed to inform the development of evidence-based guidelines for elective induction or cesarean delivery in women with diabetes. Select to review an abstract of the report . A print copy is available by sending an e-mail to ahrqpubs@ahrq.hhs.gov.
Therapeutic Management, Delivery, and Postpartum Risk Assessment and Screening in Gestational Diabetes http://www.ahrq.gov/clinic/tp/gestdiabtp.htm
High caffeine consumption during pregnancy may increase the risk of miscarriage
The results from our prospective cohort study supported previous findings that high caffeine consumption during pregnancy may increase the risk of miscarriage. Caffeine is among the most frequently ingested pharmacologically active substances in the world. Caffeine can readily cross the placental barrier to the fetus and has been reported to increase the risk of miscarriage. However, the effect of caffeine on the risk of miscarriage remains controversial because of methodological limitations in past studies. The objective of the present population-based prospective study was to examine the effect of maternal caffeine intake during pregnancy on the risk of miscarriage, taking into account a number of potential confounders, especially the impact of nausea and vomiting during pregnancy.
The authors found that
* Overall, 172 women (16.18%) miscarried.
* Whereas 264 women (25%) reported no caffeine consumption during pregnancy, 635 women (60%) reported 0-200 mg of caffeine consumption per day, and 164 women (15%) reported 200 mg or more of caffeine consumption per day.
* Compared with non-users, women who consumed 0-200 mg of caffeine per day had an increased risk of miscarriage (15% vs. 12%), and the corresponding risk was much greater (25%) among women who consumed 200 mg or more per day.
* After adjusting for potential confounders, including maternal age, race, education, household income, marital status, previous miscarriage, smoking, alcohol consumption, Jacuzzi use, MF exposure, and nausea and vomiting, the hazard ratio of miscarriage was 1.42 and 2.23 for daily caffeine consumption of 0-200 mg and 200 mg or more, respectively.
* Caffeine's affect on the risk of miscarriage remained strong among women without a history of miscarriage, whereas the association no longer existed among women with such a history.
The authors conclude that "it may be prudent to stop or reduce caffeine intake during pregnancy."
Weng X, Odouli R, Li D. 2008. Maternal caffeine consumption during pregnancy and the risk of miscarriage: a prospective cohort study. American Journal of Obstetrics and Gynecology 198(3):279.e1-278.e8 http://www.ncbi.nlm.nih.gov/pubmed/18221932
Grief subsequent to an early miscarriage
The paucity of clear information as to the incidence, characteristics, and duration of grief following miscarriage suggests that practitioners can offer only suggestive guidelines as to what constitutes an adaptive or typical reaction to miscarriage.
The author found that
* The affective and behavioral reactions that typically occur following miscarriage seem similar to the affective and behavioral reactions that typically occur following other types of significant loss. At the same time, grief following miscarriage seems somewhat distinct from grief that typically occurs following other losses in the preponderant emphasis on times ahead rather than on remembered times.
* With regard to the percentage of individuals who experience a grief reaction following miscarriage, no clear guidelines can be formulated.
The available literature does suggest that grief reactions are common and that the grief is similar in intensity to grief following other types of losses. In addition, like grief following other types of losses, grief after miscarriage seems to abate in intensity by about 6 months following the miscarriage.
* Gender differences in relation to grief following miscarriage are evident, with men seeming to experience less intense and enduring grief than women.
* Although many variables have been studied to determine their role as moderators of the intensity and duration of grief following miscarriage, few clear conclusions can be drawn.
The authors conclude that "the similarity in the results of studies examining the duration and intensity of grief following miscarriage and the duration and intensity of grief following other types of losses supports using the general literature on grief to help guide patient expectations."
Brier N. 2008. Grief following miscarriage: A comprehensive review of the literature. Journal of Women's Health ahead of print. http://www.liebertonline.com/doi/abs/10.1089/jwh.2007.0505 or http://www.ncbi.nlm.nih.gov/pubmed/18345996
Stillbirth: Good differential Dx plus an uncommon presentation of a common disease
Gibbs RS, Roberts DJ Case records of the Massachusetts General Hospital. Case 27-2007. A 30-year-old pregnant woman with intrauterine fetal death. N Engl J Med. 2007 Aug 30;357(9):918-25
http://www.ncbi.nlm.nih.gov/pubmed/17761596
Gynecology
Non-surgical treatment of urinary incontinence and prevention of urinary and fecal incontinence
A recent AHRQ sponsored review of published evidence on the non-surgical treatment of urinary incontinence in women included the following estimates of efficacy, based on a review of the available randomized controlled trials:
Background: Urinary incontinence in women is a common problem that adversely affects quality of life.
Conclusions: Moderate levels of evidence suggest that pelvic floor muscle training and bladder training resolved urinary incontinence in women. Anticholinergic drugs resolved urinary incontinence, with similar effects from oxybutynin or tolterodine. Duloxetine improved but did not resolve urinary incontinence. The effects of electrostimulation, medical devices, injectable bulking agents, and local estrogen therapy were inconsistent.
Specific estimates of efficacy from available randomized controlled trials included that pelvic floor muscle training would resolve 490 cases of stress incontinence per 1000 cases treated.
This article was accompanied by an NIH “state of the science” statement addressing prevention of urinary and fecal incontinence. Conclusions included that “routine episiotomy is the most easily preventable risk factor for fecal incontinence” and that pelvic floor muscle training may prevent or reduce incontinence in older women and lifestyle changes, such as weight loss and exercise, may prevent both urinary and fecal incontinence.
Shamliyan TA, Kane RL, Wyman J, Wilt TJ. Systematic review: randomized, controlled trials of nonsurgical treatments for urinary incontinence in women. Ann Intern Med. 2008 Mar 18;148(6):459-73.
http://www.ncbi.nlm.nih.gov/pubmed/18268288 or http://www.annals.org/cgi/content/full/0000605-200803180-00211v1
Landefeld CS , Bowers BJ , Feld AD , Hartmann KE , Hoffman E , Ingber MJ , King JT Jr , McDougal WS , Nelson H , Orav EJ , Pignone M , Richardson LH , Rohrbaugh RM , Siebens HC , Trock BJ . National Institutes of Health state-of-the-science conference statement: prevention of fecal and urinary incontinence in adults. Ann Intern Med. 2008 Mar 18;148(6):449-58.
http://www.ncbi.nlm.nih.gov/pubmed/18268289 or http://www.annals.org/cgi/content/full/0000605-200803180-00210v1
Ultrasonography differentiated between benign and malignant: Improved outcomes
BACKGROUND: The diagnostic accuracy of ultrasonography for differentiating between benign and malignant adnexal masses is proportional to the expertise of the operator. However, we do not know whether improved diagnostic accuracy will affect the management of these tumours. We assessed the effect of the quality of gynaecological ultrasonography on the management of patients with suspected ovarian cancer in a randomised controlled trial.
INTERPRETATION: Improved quality of ultrasonography has a measurable effect on the management of patients with suspected ovarian cancer in a tertiary gynaecology cancer centre, and results in a significant decrease in the number of major staging procedures and a shorter inpatient hospital stay.
Yazbek J et al Effect of quality of gynaecological ultrasonography on management of patients with suspected ovarian cancer: a randomised controlled trial. Lancet Oncol. 2008 Feb;9(2):124-31. http://www.ncbi.nlm.nih.gov/pubmed/18207461
Saffron effective in the treatment of premenstrual syndrome: a double-blind, RCT
CONCLUSION: The results of this study indicate the efficacy of C. sativus L. in the treatment of PMS. However, a tolerable adverse effects profile of saffron may well confirm the application of saffron as an alternative treatment for PMS. These results deserved further investigations.
Agha-Hosseini M, et al Crocus sativus L. (saffron) in the treatment of premenstrual syndrome: a double-blind, randomised and placebo-controlled trial.
BJOG. 2008 Mar;115(4):515-9. http://www.ncbi.nlm.nih.gov/pubmed/18271889
Biofeedback Reduces Psychological Burden in Older Women With Urge UI
In older women with urge urinary incontinence (UI), biofeedback (BFB) therapy significantly improved psychological burden, especially in those with a history of depression.
CONCLUSION: In older women with urge UI, BFB significantly improves psychological burden, especially in those with a history of depression, in whom psychological burden is linked to change in perception of control. Psychological factors are relevant outcome measures for UI, and these data suggest that focusing on UI frequency alone may have underestimated BFB's efficacy and additional therapeutic benefits.
Tadic SD et al Effect of biofeedback on psychological burden and symptoms in older women with urge urinary incontinence. J Am Geriatr Soc. 2007 Dec;55(12):2010-5. Epub 2007 Nov 20.
http://www.ncbi.nlm.nih.gov/pubmed/18028340
Child Health
Preemies Face Risks As They Grow Up
CONTEXT: Preterm birth is a major cause of infant morbidity and mortality. Less is known about long-term health among persons born preterm. OBJECTIVE: To determine the long-term effects of preterm birth on survival, reproduction, and next-generation preterm birth.
CONCLUSION: In persons born in Norway in 1967-1988, preterm birth was associated with diminished long-term survival and reproduction.
Swamy GK et al Association of preterm birth with long-term survival, reproduction, and next-generation preterm birth. JAMA. 2008 Mar 26;299(12):1429-36.
http://www.ncbi.nlm.nih.gov/pubmed/18364485
Cognitive and Neuromotor Impairments Seen at 5 Years in Children Born Preterm
Follow-up of a large cohort of children born before 33 weeks' gestation shows that, despite improvements in treatment and survival, many of these children have cognitive and neuromotor impairment and require specialized care by 5 years of age
INTERPRETATION: In children who are born very preterm, cognitive and neuromotor impairments at 5 years of age increase with decreasing gestational age. Many of these children need a high level of specialised care. Prevention of the learning disabilities associated with cognitive deficiencies in this group is an important goal for modern perinatal care for children who are born very preterm and for their families.
Larroque B et al Neurodevelopmental disabilities and special care of 5-year-old children born before 33 weeks of gestation (the EPIPAGE study): a longitudinal cohort study. Lancet. 2008 Mar 8;371(9615):813-20. http://www.ncbi.nlm.nih.gov/pubmed/18328928
Is Short-term Therapy Effective for Treating Latent TB in Children?
Results: Final analysis included 926 patients with a mean age of 8.7 years. Overall, 850 participants (91.8 percent) had excellent or moderate compliance rates, although significantly lower compliance rates occurred in patients receiving the nine-month isoniazid regimen compared with the other groups. No patient in any group progressed to active TB during the study or follow-up period, and no serious drug-related adverse events were reported. Six percent of patients receiving the long-term regimen had transient liver enzyme elevations compared with 1.2 percent in the short-term treatment groups, and 6.5 percent of patients receiving the long-term regimen developed nausea and epigastric pain compared with 0.7 percent in the short-term treatment groups. In addition, 2 percent of patients in the short-term treatment groups developed photosensitivity reactions or transient maculopapular rashes. Treatment discontinuation was not required in any patient.
Conclusion: The authors conclude that a three- to four-month course of isoniazid/rifampin combination therapy is well tolerated in children and is as effective as the traditional nine-month course of isoniazid monotherapy. In addition, the shorter treatment courses are associated with higher compliance rates.
Spyridis NP, et al. The effectiveness of a 9-month regimen of isoniazid alone versus 3- and 4-month regimens of isoniazid plus rifampin for treatment of latent tuberculosis infection in children: results of an 11-year randomized study. Clin Infect Dis. 2007;45:715-722.
http://www.ncbi.nlm.nih.gov/pubmed/17712755
Chronic Disease and Illness
FDA Approves Alternative Dosing Schedule for Combined Hepatitis Vaccine
In April 2007, the U.S. Food and Drug Administration (FDA) approved an alternative schedule for the combined hepatitis A and hepatitis B vaccine Twinrix (GlaxoSmithKline). The vaccine was first licensed in 2001 for vaccination of persons 18 years and older with a schedule of three doses administered at zero, one, and six months. An alternative four-dose schedule can now be used, with doses administered at zero, seven, and 21 to 30 days, and at 12 months.
Studies showed that the first three doses of the four-dose schedule provide equivalent protection to the first two doses in the three-dose series, as well as to a single dose of monovalent hepatitis A vaccine and to two doses of monovalent hepatitis B vaccine. The FDA suggests that the four-dose schedule may be useful if vaccination with the combination vaccine has been initiated but potential exposure (e.g., through travel) is expected before the second dose is due, according to the standard three-dose schedule. Additional information is available from the manufacturer's package insert and GlaxoSmithKline Vaccines (telephone, 800-366-8900).
Morbidity and Mortality Weekly Report, October 12, 2007
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5640a5.htm
Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes: The SANDS randomized trial
CONCLUSIONS: Reducing LDL-C and SBP to lower targets resulted in regression of carotid IMT and greater decrease in left ventricular mass in individuals with type 2 diabetes. Clinical events were lower than expected and did not differ significantly between groups. Further follow-up is needed to determine whether these improvements will result in lower long-term CVD event rates and costs and favorable risk-benefit outcomes
Howard BV et al Effect of lower targets for blood pressure and LDL cholesterol on atherosclerosis in diabetes: the SANDS randomized trial.
JAMA. 2008 Apr 9;299(14):1678-89 . http://www.ncbi.nlm.nih.gov/pubmed/18398080
All drugs containing PHENYLPROPANOLAMINE are being recalled
The Food and Drug Administration (FDA) is taking steps to remove phenylpropanolamine (PPA) from all drug products and has requested that all drug companies discontinue marketing products containing PPA. In addition, FDA has issued a public health advisory concerning phenylpropanolamine. This drug is an ingredient that was used in many over-the-counter (OTC) and prescription cough and cold medications as a decongestant and in OTC weight loss products.
All drugs containing PHENYLPROPANOLAMINE are being recalled. STOP TAKING anything containing this ingredient. It has been linked to increased hemorrhagic stroke (bleeding in brain) among women ages 18-49 in the three days after starting use of medication. Problems were not found in men, but the FDA recommended that everyone (even children) seek alternative medicine. http://www.fda.gov/cder/drug/infopage/ppa/
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.
