Volume 5, No. 6, June/July 2007
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
Placental problems with previous caesarean delivery: Abruptio, previa
Research shows a link between the development of placenta praevia and placental abruption during the subsequent pregnancies of women who previously had a caesarean delivery.
CONCLUSION: Caesarean delivery for first live birth is associated with a 47% increased risk of placenta praevia and 40% increased risk of placental abruption in second pregnancy with a singleton.
Yang Q, et al Association of caesarean delivery for first birth with placenta praevia and placental abruption in second pregnancy. BJOG. 2007 May;114(5):609-13.
Late Pregnancy Bleeding (ALSO serialization)
Effective management of vaginal bleeding in late pregnancy requires recognition of potentially serious conditions, including placenta previa, placental abruption, and vasa previa. Placenta previa is commonly diagnosed on routine ultrasonography before 20 weeks' gestation, but in nearly 90 percent of patients it ultimately resolves. Women who have asymptomatic previa can continue normal activities, with repeat ultrasonographic evaluation at 28 weeks. Persistent previa in the third trimester mandates pelvic rest and hospitalization if significant bleeding occurs. Placental abruption is the most common cause of serious vaginal bleeding, occurring in 1 percent of pregnancies. Management of abruption may require rapid operative delivery to prevent neonatal morbidity and mortality. Vasa previa is rare but can result in fetal exsanguination with rupture of membranes. Significant vaginal bleeding from any cause is managed with rapid assessment of maternal and fetal status, fluid resuscitation, replacement of blood products when necessary, and an appropriately timed delivery. Am Fam Physician 2007;75:1199-206.
http://www.aafp.org/afp/20070415/1199.html
Admission for nephrolithiasis during pregnancy: 80% risk of preterm delivery
CONCLUSION: Although the incidence of nephrolithiasis requiring hospital admission during pregnancy is relatively low, these women have an increased risk of preterm delivery. This has potential implications for counseling of pregnant women with kidney stones requiring hospital admission. Additionally, it may prompt definitive treatment of small, asymptomatic stones in women during reproductive years. LEVEL OF EVIDENCE: II
Swartz
MA, et al Admission for nephrolithiasis in pregnancy and risk of adverse
birth outcomes. Obstet Gynecol. 2007 May;109(5):1099-104. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17470589&dopt=Abstract
Postpartum Depression Screening: Recommendations for Practice
Conclusions: Postpartum depression screening improves recognition of the disorder, but improvement in clinical outcomes requires enhanced care that ensures adequate treatment and follow-up.
Gjerdingen DK,Yawn BP Postpartum Depression Screening: Importance, Methods, Barriers, and
Recommendations for Practice J Am Board Fam Med 2007;20 280-288
http://www.jabfm.org/cgi/content/abstract/20/3/280?etoc
Fetal or infant death is a traumatic event for parents: Measures to assist grieving parents
CONCLUSION: Although care after perinatal death often adheres to published guidelines, substantial room for improvement is apparent. Parents with perinatal losses report few choices during labor and delivery and inadequate communication about burial options and autopsy results. Hospitals, nurses, and doctors should increase parental choice about timing and location of delivery and postpartum care, encourage parental contact with the deceased infant, and facilitate provision of photos and memorabilia.
Gold
KJ, et al Hospital Care for Parents After Perinatal Death. Obstet Gynecol.
2007 May;109(5):1156-1166. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17470598&dopt=Abstract
Iron Deficiency Anemia Screening Recommended Pregnant Women: Rating B
The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women. Rating: B Recommendation
The U.S. Preventive Services Task Force (USPSTF) concludes that evidence is insufficient to recommend for or against routine screening for iron deficiency anemia in asymptomatic children aged 6 to 12 months. Rating: I Recommendation
Screening and Supplementation for Iron Deficiency Anemia, U.S. Preventive Services Task Force
Release Date: May 2006 http://www.ahrq.gov/clinic/uspstf/uspsiron.htm
http://www.medscape.com/viewarticle/555899
The route of delivery of twins is determined by presentation and operator skill
A trial of labor and vaginal delivery are usually indicated in vertex-vertex twins. For vertex-nonvertex twins, vaginal birth is preferred, with the second twin being delivered by breech extraction, unless it is significantly larger than the first. Cesarean delivery is indicated if the first twin is nonvertex and for all cases of monoamniotic or potentially viable conjoined twins. There is a limited role for trial of labor after cesarean delivery in twin gestations. In my opinion, combined vaginal-cesarean birth is the riskiest method for mother and infants and should be avoided if possible.
Cruikshank
DP. Intrapartum management of twin gestations. Obstet Gynecol. 2007 May;109(5):1167-76. http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17470599&dopt=Abstract
Treating Asthma and Co morbid Allergic Rhinitis in Pregnancy
This article presents the specific recommendations from the most recent APWG report and from other systematic reviews about which asthma and allergic rhinitis drugs should be preferred during pregnancy. Of the corticosteroids, budesonide has the most data and is listed as Pregnancy Category B (no evidence of risk in humans). Other inhaled and intranasal corticosteroids have less data and are listed as Pregnancy Category C but may be continued during pregnancy if the patient's asthma was well controlled with the medication before pregnancy. Family physicians should help their patients control allergic rhinitis and asthma during pregnancy, encouraging adherence to needed medications.
Yawn B, Knudtson M Treating Asthma and Comorbid Allergic Rhinitis in Pregnancy J Am Board Fam Med 2007;20 289-298 http://www.jabfm.org/cgi/content/abstract/20/3/289?etoc
Insufficient evidence to show that the addition of rectal misoprostol is superior
CONCLUSIONS: There is insufficient evidence to show that the addition of rectal misoprostol is superior to the combination of oxytocin and ergometrine alone for the treatment of primary PPH.
Mousa HA, Alfirevic Z. Treatment for primary postpartum hemorrhage Cochrane Database Syst Rev. 2007 Jan 24;(1):CD003249
New Guidelines Recommend Universal Prenatal Screening for Down Syndrome (CME)
http://www.medscape.com/viewarticle/550256?src=0_nl_cme_8
Gynecology
Discharge 24 Hours After Vaginal Hysterectomy Safe, Acceptable
CONCLUSIONS: Vaginal hysterectomy performed as a 24-hour day case procedure appears to be as safe as traditional inpatient management, with a high rate of early discharge and a low rate of readmission. This may have additional advantages for the woman and healthcare provider alike.
Penketh R, et al prospective observational study of the safety and acceptability of vaginal hysterectomy performed in a 24-hour day case surgery setting. BJOG. 2007 Apr;114(4):430-6
Laparoscopic and methotrexate in a fixed multiple dose regimen most effective for ectopic
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
Extended Oral Contraceptives Decrease Premenstrual Symptoms
Conclusion: The use of a 168-day extended regimen of drosperinone in combination with ethinyl estradiol decreased premenstrual symptoms compared with a standard 21/7 regimen. This was particularly true for women who had more premenstrual symptoms during the 21/7 regimen.
Coffee AL, et al. Oral contraceptives and premenstrual symptoms: comparison of a 21/7 and extended regimen. Am J Obstet Gynecol November 2006;195:1311-9. http://www.aafp.org/afp/20070415/tips/4.html
Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections
In the United States, gonorrhea is the second most commonly reported notifiable disease, with 339,593 cases documented in 2005. Since 1993, fluoroquinolones (i.e., ciprofloxacin, ofloxacin, or levofloxacin) have been used frequently in the treatment of gonorrhea because of their high efficacy, ready availability, and convenience as a single-dose, oral therapy. However, prevalence of fluoroquinolone resistance in Neisseria gonorrhoeae has been increasing and is becoming widespread in the United States, necessitating changes in treatment regimens.
Beginning in 2000, fluoroquinolones were no longer recommended for gonorrhea treatment in persons who acquired their infections in Asia or the Pacific Islands (including Hawaii); in 2002, this recommendation was extended to California. In 2004, CDC recommended that fluoroquinolones not be used in the United States to treat gonorrhea in men who have sex with men (MSM). This report, based on data from the Gonococcal Isolate Surveillance Project (GISP), summarizes data on fluoroquinolone-resistant N. gonorrhoeae (QRNG) in heterosexual males and in MSM throughout the United States. This report also updates CDC's Sexually Transmitted Diseases Treatment Guidelines, 2006 regarding the treatment of infections caused by N. gonorrhoeae. On the basis of the most recent evidence, CDC no longer recommends the use of fluoroquinolones for the treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease (PID). Consequently, only one class of drugs, the cephalosporins, is still recommended and available for the treatment of gonorrhea.
Update to CDC's Sexually Transmitted Diseases Treatment Guidelines, 2006: Fluoroquinolones No Longer Recommended for Treatment of Gonococcal Infections. MMWR Morb Mortal Wkly Rep. 2007 Apr 13;56(14):332-336.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm
Interventions to Reduce Haemorrhage During Myomectomy for Fibroids
(ACOG Cochrane Update)
AUTHORS’ CONCLUSIONS: There is limited evidence from a few RCTs that misoprostol, vasopressin, bupivacaine plus epinephrine, tourniquet, and mesna may reduce bleeding during myomectomy. There is no evidence that oxytocin and morcellation have an effect on intraoperative blood loss. There is need for adequately powered RCTs to shed more light on the effectiveness, safety, and costs of different interventions in reducing blood loss during myomectomy.
Kongnyuy EJ, Wiysonge CS. Interventions to reduce hemorrhage during myomectomy for fibroids. Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD005355. DOI: 10.1002/14651858.CD005355
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd
=retrieve&db=pubmed&list_uids=17470606
Laxative improves recovery of gastrointestinal function after fast-track hysterectomy
RESULTS: Time to first postoperative defecation was a median of 45 hours in the laxative group and a median of 69 hours in the placebo group (P < .0001). There were no significant differences between groups in pain scores, postoperative nausea and vomiting and the use of morphine or antiemetics. Postoperative hospitalization was a median of 1 day in the laxative group and of 2 days in the placebo group (P = .41).
CONCLUSION: Laxative improves recovery of gastrointestinal function after fast-track hysterectomy but has no significant effect on pain and postoperative nausea and vomiting.
Hansen CT, et al Effect of laxatives on gastrointestinal functional recovery in fast-track hysterectomy: a double-blind, placebo-controlled randomized study Am J Obstet Gynecol. 2007 Apr;196(4):311.e1-7
Insufficient evidence for nerve interruption in the management of dysmenorrhoea
AUTHORS' CONCLUSIONS: There is insufficient evidence to recommend the use of nerve interruption in the management of dysmenorrhoea, regardless of cause. Future methodologically sound and sufficiently powered RCTs should be undertaken.
Proctor ML, et al Surgical interruption of pelvic nerve pathways in dysmenorrhea: a systematic review of effectiveness Cochrane Database Syst Rev. 2005 Oct 19;(4):CD001896
A mild treatment strategy for in-vitro fertilization: a randomized non-inferiority trial
INTERPRETATION: Over 1 year of treatment, cumulative rates of term live births and patients' discomfort are much the same for mild ovarian stimulation with single embryos transferred and for standard stimulation with two embryos transferred. However, a mild IVF treatment protocol can substantially reduce multiple pregnancy rates and overall costs.
Heijnen EM, et al A mild treatment strategy for in-vitro fertilization: a randomized non-inferiority trial Lancet. 2007 Mar 3;369(9563):743-9.
Child Health
Forty percent of 3-month-olds watch TV, DVDs, or videos
CONCLUSIONS: Parents should be urged to make educated choices about their children's media exposure. Parental hopes for the educational potential of television can be supported by encouraging those parents who are already allowing screen time to watch with their children.
Zimmerman FJ, et al Television and DVD/Video Viewing in Children Younger Than 2 Years. Arch Pediatr Adolesc Med. 2007 May;161(5):473-9
Guidelines for School-Based STD Screening in Indian Country
I’m pleased to announce that our office has just released “Guidelines for School-Based STD Screening in Indian Country”. A PDF of the document or hard copies are available, so please let me know if you would like one. Also, the link will be up on our website soon, url below.
Thanks so much to everyone who helped to put these together. We look forward to your feedback. Also, please let us know if you need our technical assistance to implement school-based STD screening in your area. Lori
Table of Contents Page
1 Introduction
2 Getting Started
3 Forming a Team
4 Making a Plan
5 Making the Pitch
6 Making it Happen
7 Making it Stick
Tel: 505-248-4202 or lori.deravello@ihs.gov
http://www.ihs.gov/medicalprograms/epi/index.cfm
Urinary symptoms in adolescent females: STI or UTI?
RESULTS: In the full sample, prevalence of UTI and STI were 17% and 33%, respectively. Neither urinary symptoms nor UTI was significantly associated with STI. Further analyses are reported for the 154 (51%) with urinary symptoms: Positive urine leukocytes, more than one partner in the last three months and history of STI predicted STI. Urinalysis results identified four groups: (1) Normal urinalysis-67% had no infection; (2) Positive nitrites or protein-55% had UTI; (3) Positive leukocytes or blood-62% had STI; and (4) Both nitrites/protein and leukocytes/blood positive-28% had STI and 65% had UTI. Those without a documented UTI were more likely to have trichomoniasis than those with a UTI, and 65% of those with sterile pyuria had STI, mainly trichomoniasis or gonorrhea.
CONCLUSIONS: Adolescent females with urinary symptoms should be tested for both UTI and STIs. Urinalysis results may be helpful to direct initial therapy.
Huppert JS, Biro F, Lan D, Mortensen JE, Reed J, Slap GB. Urinary symptoms in adolescent females: STI or UTI? J Adolesc Health. 2007 May;40(5):418-24. Epub 2007 Mar 9.
http://www.jahonline.org/article/PIIS1054139X06006112/abstract
Sexually transmitted infections in preadolescent children
Pediatric nurse practitioners may be called on to conduct an assessment for sexual abuse of a young child. Depending on the type of sexual contact, a decision may have to be made to obtain cultures for sexually transmitted infections (STIs). Recognizing the symptoms of STIs in preadolescent children, along with having knowledge of the modes of transmission, diagnostics, and treatment, are part of the clinical decision. The impact of STI in preadolescent children has physical and emotional consequences for the child and family, along with legal consequences for an accused perpetrator. Knowledge about types of sexual contact that necessitate STI cultures, incubation periods, and symptomatology is essential. Accurate techniques and appropriate selection of culture materials are necessary. Proper positioning of the child for obtaining cultures can decrease the potential for discomfort during the examination. Gonorrhea, Chlamydia trachomatis, herpes simplex virus, human papillomavirus virus, syphilis, Trichomonas vaginalis, hepatitis B, and HIV are reviewed.
Lewin LC.Sexually transmitted infections in preadolescent children. J Pediatr Health Care. 2007 May-Jun;21(3):153-61.
Adjustments in opthalmia neonatorum (ON): Gonorrhea in pregnancy
Redbook- For routine prophylaxis of infants immediately after birth, a 1% solution of silver nitrate, or 1% tetracycline or 0.5% erythromycin ophthalmic ointment, OU with subsequent irrigation. Prophylaxis delay for up to 1 hour for bonding. Term Infants born to GC infected mom 125mg IV or IM ceftriaxone. The 1993 Pediatrics article (below) suggests that for women receiving PN care: Silver nitrate eye prophylaxis caused no sustained deleterious effects and even provided some benefit to infants born to women without Neisseria gonorrhoeae. However, the effect was modest and against microorganisms of low virulence. The results suggest that parental choice of a prophylaxis agent including no prophylaxis is reasonable for women receiving prenatal care and who are screened for sexually transmitted diseases during pregnancy (cited online April 25, 2007)
Of interest is the WHO Bulletin 2000 – Iodine cost effective and clinically effective in developing countries for prophylaxis of ON
Redbook article
http://pediatrics.aappublications.org/cgi/content/abstract/92/6/755
Chronic Disease and Illness
Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass Surgery
Gastric bypass surgery, by definition, changes the absorption capabilities of the stomach and small intestine. The use of oral medications in patients post gastric bypass may need to be adjusted by medical providers to account for this absorption change. The following case exemplifies this dilemma in a pregnant patient status post gastric bypass surgery with a complicated urinary tract infection.
Magee SR et al Malabsorption of Oral Antibiotics in Pregnancy after Gastric Bypass Surgery J Am Board Fam Med 2007;20 310-313
http://www.jabfm.org/cgi/content/abstract/20/3/310?etoc
Sleeping Poorly ... and Maybe Depressed: Co morbidity in Formal Sleep Studies
In this survey of 100 patients referred to our sleep center, we found that a very high proportion (53%) of them had also been diagnosed with depression. This is consistent with other estimates of co morbidity between depression, insomnia, and obstructive sleep apnea. 6 This high concordance serves as a reminder that when primary care physicians diagnose depression, they should question their patient closely about sleep complaints, especially obstructive breathing patterns and insomnia.
When patients present, as they frequently do, with hypersomnolence, fatigue, irritability, low energy, or diminished cognitive function, the provider's antennae likely will be raised to diagnose and treat depression. These findings serve as a small reminder that they need to be aware that common primary sleep pathologies such as obstructive sleep apnea or insomnia may also account for these symptoms.
Sorscher AJ Sleeping Poorly ... and Maybe Depressed: Co morbidity in Patients Referred for Formal Sleep Studies J Am Board Fam Med 2007;20 320-321
http://www.jabfm.org/cgi/content/full/20/3/320?etoc
Barriers to Smoking Cessation Services in Underserved Communities
Conclusion: "Safety net" providers encounter barriers to providing smoking cessation services that are similar to barriers faced by clinicians serving more affluent and non-minority populations, but also encounter additional barriers that apply most particularly to the underserved.
Blumenthal DS Barriers to the Provision of Smoking Cessation Services Reported by
Clinicians in Underserved Communities J Am Board Fam Med 2007;20 272-279
http://www.jabfm.org/cgi/content/abstract/20/3/272?etoc
Management of Hypertriglyceridemia (see Patient Education)
Hypertriglyceridemia is associated with an increased risk of cardiovascular events and acute pancreatitis. Along with lowering low-density lipoprotein cholesterol levels and raising high-density lipoprotein cholesterol levels, lowering triglyceride levels in high-risk patients (e.g., those with cardiovascular disease or diabetes) has been associated with decreased cardiovascular morbidity and mortality. Although the management of mixed dyslipidemia is controversial, treatment should focus primarily on lowering low-density lipoprotein cholesterol levels. Secondary goals should include lowering non-high-density lipoprotein cholesterol levels (calculated by subtracting high-density lipoprotein cholesterol from total cholesterol). If serum triglyceride levels are high, lowering these levels can be effective at reaching non-high-density lipoprotein cholesterol goals. Initially, patients with hypertriglyceridemia should be counseled about therapeutic lifestyle changes (e.g., healthy diet, regular exercise, tobacco-use cessation). Patients also should be screened for metabolic syndrome and other acquired or secondary causes. Patients with borderline-high serum triglyceride levels (i.e., 150 to 199 mg per dL [1.70 to 2.25 mmol per L]) and high serum triglyceride levels (i.e., 200 to 499 mg per dL [2.26 to 5.64 mmol per L]) require an overall cardiac risk assessment. Treatment of very high triglyceride levels (i.e., 500 mg per dL [5.65 mmol per L] or higher) is aimed at reducing the risk of acute pancreatitis. Statins, fibrates, niacin, and fish oil (alone or in various combinations) are effective when pharmacotherapy is indicated. Am Fam Physician 2007;75:1365-1371, 1372.
http://www.aafp.org/afp/20070501/1365.html
AHA Guidelines for CVD Prevention in Women Focus on Lifetime Risk Factors (CME)
http://www.medscape.com/viewarticle/552777?src=sr
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.
