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Volume 4, No. 7, July 2006
Hot Topics
Obstetrics | Gynecology | Child Health | Chronic Disease and Illness
Obstetrics
The return of the vaginal breech delivery
ABSTRACT: In light of recent studies that further clarify the long-term risks of vaginal breech delivery, the American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient’s informed consent should be documented.
OB/GYN CCC Editorial comment:
This is a significant shift in opinion based on the increasing literature supporting the return to vaginal breech delivery in those centers with providers who can display current competence and in which the facility has hospital-specific protocol guidelines. Oxytocin induction or augmentation was not offered. Here are some of the criteria used in the studies analyzed:
-gestational age greater than 37 weeks
-frank or complete breech presentation
-no fetal anomalies on ultrasound examination
-adequate maternal pelvis
-estimated fetal weight between 2,500 g and 4,000 g.
-fetal head flexion
-adequate amniotic fluid volume, defined as a 3-cm vertical pocket
-normal labor progress
ACOG issued the following recommendations
- The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery.
- Obstetricians should offer and perform external cephalic version whenever possible.
- Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.
- In those instances in which breech vaginal deliveries are pursued, great caution should be exercised, and detailed patient informed consent should be documented.
- Before embarking on a plan for a vaginal breech delivery, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned.
- There are no recent data to support the recommendation of cesarean delivery to patients whose second twin is in a nonvertex presentation, although a large multicenter randomized controlled trial is in progress (http://www.utoronto.ca/ miru/tbs).
Mode of term singleton breech delivery. ACOG Committee Opinion No. 340. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:235–7.
Nalbuphine Injection (Nubain) Linked to Risk for Fetal Adverse Events
The FDA approved safety labeling revisions for nalbuphine injection (Nubain, made by Endo Pharmaceuticals, Inc) to warn of the risk for serious fetal and neonatal adverse events associated with its use during labor and delivery.
The placental transfer of nalbuphine is high, rapid, and variable, with a maternal to fetal ratio ranging from 1:0.37 to 1:6. Fetal and neonatal adverse events have included reports of fetal bradycardia, respiratory depression at birth, apnea, cyanosis, and hypotonia. Some of these events have been life-threatening.
Although maternal administration of naloxone during labor has normalized these effects in some cases, severe prolonged fetal bradycardia has occurred, and in some cases, resulted in permanent neurologic damage. Nalbuphine has also been linked to reports of sinusoidal fetal heart pattern.
The FDA advises that nalbuphine be used during labor and delivery only if clearly indicated and the potential benefit outweighs the risk to the infant. Newborns exposed to maternal nalbuphine should be monitored for respiratory depression, apnea, bradycardia, and arrhythmias.
Nalbuphine injection is indicated for the relief of moderate to severe pain.
http://www.medscape.com/viewarticle/518110
OB/GYN CCC Editorial comment:
Severe fetal bradycardia has been reported following nalbuphine use in labor/delivery. Fetal bradycardia may occur when administered earlier in pregnancy (not documented). Use only if clearly needed, with monitoring to detect and manage possible adverse fetal effects. Naloxone has been reported to reverse bradycardia. Newborn should be monitored for respiratory depression or bradycardia following nalbuphine use in labor.
UpToDate
Multiple prior cesarean deliveries are not associated with uterine rupture in VBAC
CONCLUSION: A history of multiple cesarean deliveries is not associated with an increased rate of uterine rupture in women attempting vaginal birth compared with those with a single prior operation. Maternal morbidity is increased with trial of labor after multiple cesarean deliveries, compared with elective repeat cesarean delivery, but the absolute risk for complications is small. Vaginal birth after multiple cesarean deliveries should remain an option for eligible women. LEVEL OF EVIDENCE: II-2.
Landon MB et al Risk of Uterine Rupture With a Trial of Labor in Women With Multiple and Single Prior Cesarean Delivery.
OB/GYN CCC Editorial comment:
The VBAC pendulum is posed to swing back
Landon et al joins a growing literature that shows there is not a consistent trend to limit VBAC to those patients with only 1 previous cesarean delivery as reported in a 2004 ACOG Practice Bulletin. Macones GA, et al published 2 large studies that support Landon et al, above. In retrospect the ACOG Practice Bulletin was essentially based on one study, Caughey AB, et al 1999.
References:
Macones GA, et al Obstetric outcomes in women with two prior cesarean deliveries: is vaginal birth after cesarean delivery a viable option? Am J Obstet Gynecol. 2005 Apr;192(4):1223-8; discussion 1228-9.
Macones GA, et al Maternal complications with vaginal birth after cesarean delivery: a multicenter study. Am J Obstet Gynecol. 2005 Nov;193(5):1656-62.
Caughey AB, et al Rate of uterine rupture during a trial of labor in women with one or two prior cesarean deliveries. Am J Obstet Gynecol. 1999 Oct;181(4):872-6.
Vaginal birth after previous cesarean delivery. ACOG Practice Bulletin No. 54. American College of Obstetricians and Gynecologists. Obstet Gynecol 2004;104:203–12.
Avoiding post-term pregnancy improves perinatal mortality
Conclusions. Although high-risk pregnancies were not allowed to come post-term, postmaturity per se is a moderate risk state compromising fetal well-being with regard to meconium passage and acid-base status at birth. We conclude that simple antenatal monitoring beyond 42 weeks reduces perinatal mortality but is inefficient in reducing meconium-stained liquor seen with increasing gestation.
Hovi M et al Obstetric outcome in post-term pregnancies: time for reappraisal in clinical management. Acta Obstet Gynecol Scand. 2006;85(7):805-9
OB/GYN CCC Editorial comment:
Hovi et al confirm prior studies that show that avoiding post-term pregnancy improves perinatal mortality. I recommend meticulous attention to accurate dating and, if necessary, cervical ripening at 41 weeks to avoid post-term pregnancy. Though there is not an indication for an early ultrasound for a ‘fetal survey’, per se, there is an indication for an early ultrasound to avoid post-term pregnancy, if there is any question about the gestational dating.
Resources
Post-term Pregnancy and Induction of Labor
Perinatology Corner Module: Great resource or free CME / CEUs
http://www.ihs.gov/MedicalPrograms/MCH/M/DP61.cfm#top
Is it standard of care to obtain a 2nd ultrasound on low risk patients for a fetal survey?
http://www.ihs.gov/MedicalPrograms/MCH/M/documents/USPreg42105.doc
Adverse neonatal outcomes were not increased after 30 minute decision to incision times
CONCLUSION: Approximately one third of primary cesarean deliveries performed for emergency indications are commenced more than 30 minutes after the decision to operate, and the majority were for nonreassuring heart rate tracings. In these cases, adverse neonatal outcomes were not increased. LEVEL OF EVIDENCE: II-2.
Bloom SL, et al Decision-to-Incision Times and Maternal and Infant Outcomes. Obstet Gynecol. 2006 Jul;108(1):6-11.
Multiple cesarean deliveries are associated with increasing rate of maternal complications
CONCLUSION: Multiple cesarean deliveries are associated with more difficult surgery and increased blood loss compared with a second planned cesarean delivery. The risk of major complications increases with cesarean delivery number. LEVEL OF EVIDENCE: II-2.
Nisenblat V, et al Maternal complications associated with multiple cesarean deliveries. Obstet Gynecol. 2006 Jul;108(1):21-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=16816051&dopt=Abstract
SSRI Use in Pregnancy Increases Persistent pulmonary hypertension of the newborn
CONCLUSIONS: Pregnancy is not "protective" with respect to risk of relapse of major depression. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation.
Cohen LS, Altschuler LL, Harlow BL, Nonacs R, Newport DJ, Viguera AC, et al. Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment. JAMA 2006;295:499-507.
Editorial comment:
Decisions about the use of antidepressant medication ideally should be made before conception. In practice, however, many women continue taking SSRIs for weeks before finding that they are pregnant. This study showed that, regarding the risk of PPHN, the decision of whether to continue SSRI therapy may safely be delayed until 20 weeks' gestation. At that point, physicians and patients must weigh potential risks to the developing fetus against the risk of recurrent depression. Results from a prospective study1 involving 201 women who were pregnant and had a history of major depressive disorder showed that those who discontinued antidepressants during pregnancy were five times more likely to experience a relapse than those who continued to take their medication. Although there may not be a completely safe choice regarding SSRI use in pregnancy, physicians should make sure that this choice is an informed one
http://www.aafp.org/afp/20060615/tips/10.html
How to Increase Rates of Influenza Vaccination During Pregnancy
Conclusions: Provider education with simple chart prompts seems an effective way to increase rates of physician discussion of influenza vaccination with pregnant women. The increased rates seen in this study across various practice settings also suggest that inclusion of influenza vaccination on standardized prenatal care flowsheets may achieve similar goals with less individualized effort and should be considered.
Wallis DH et al Increasing Rates of Influenza Vaccination During Pregnancy: A Multisite Interventional Study J Am Board Fam Med 2006;19 345-349
http://www.jabfm.org/cgi/content/abstract/19/4/345?etoc
Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes, AHRQ
Evidence Report/Technology Assessment Number 119 Perinatal Depression: Prevalence, Screening Accuracy, and Screening Outcomes Prepared for: Agency for Healthcare Research and Quality.
http://www.ahrq.gov/downloads/pub/evidence/pdf/peridepr/peridep.pdf
Findings of the Alaska Maternal-Infant Mortality Review 1992-2001
http://www.epi.alaska.gov/bulletins/docs/rr2006_03.pdf
Gynecology
CDC’s Advisory Committee Recommends Human Papillomavirus Virus Vaccination
CDC’s Advisory Committee Recommends Human Papillomavirus Virus Vaccination Vaccine considered highly effective in preventing infections that are the cause of most cervical cancers.
The Advisory Committee on Immunization Practices (ACIP) voted Thursday to recommend that a newly licensed vaccine designed to protect against human papillomavirus virus (HPV) be routinely given to girls when they are 11-12 years old. The ACIP recommendation also allows for vaccination of girls beginning at nine years old as well as vaccination of girls and women 13-26 years old. HPV is the leading cause of cervical cancer in women.
According to the ACIP’s recommendation, three doses of the new vaccine should be routinely given to girls when they are 11 or 12 years old. The advisory committee, however, noted that the vaccination series can be started as early as nine years old at the discretion of the physician or health care provider. The recommendation also includes girls and women 13-26 years old because they will benefit from getting the vaccine. The vaccine should be administered before onset of sexual activity (i.e., before women are exposed to the viruses), but females who are sexually active should still be vaccinated.
“This vaccine represents an important medical breakthrough,” said Dr. Anne Schuchat, director of CDC’s National Center for Immunization and Respiratory Diseases. “As a result, these vaccine recommendations address a major health problem for women and represent a significant advance in women’s health. It has been tested in thousands of women around the world and has been found to be safe and effective in providing protection against the two types of HPV that cause most cervical cancers.”
Gardasil®, manufactured by Merck, is the first vaccine developed to prevent cervical cancer, precancerous genital lesions and genital warts due to HPV -- `HPV causes genital warts in men and women. The vaccine is highly effective against four types of the HPV virus, including two that cause about 70 percent of cervical cancer. Those who have not acquired HPV would get the full benefits of the vaccine. On average, there are 9,710 new cases and 3,700 deaths from cervical cancer in the United States each year.
HPV is the most common sexually transmitted infection in the United States, More than 20 million men and women in the United States are currently infected with HPV and there are 6.2 million new infections each year. HPV is most common in young women and men who are in their late teens and early 20s. By age 50, at least 80 percent of women will have acquired HPV infection.
“Although an effective vaccine is a major advance in the prevention of genital HPV and cervical cancer, it will not replace other prevention strategies, such as cervical cancer screening for women or protective sexual behaviors,” said Dr. Schuchat “Women should continue to get pap tests as a safeguard against cervical cancer.”
The ACIP, consisting of 15 members appointed by the Secretary of the Department of Health and Human Services (HHS), advises the director of CDC and Secretary of HHS on control of vaccine-preventable disease and vaccine usage. Recommendations of the ACIP become CDC policy when they are accepted by the director of CDC and are published in CDC’s Morbidity and Mortality Weekly Report (MMWR). There are no federal laws requiring the immunization of children. All school and daycare entry laws are state laws and vary from state to state.
http://www.cdc.gov/od/oc/media/pressrel/r060629.htm
HPV and HPV Vaccine - Information for Healthcare Providers
http://www.cdc.gov/std/HPV/STDFact-HPV-vaccine-hcp.htm
HPV Vaccine Questions and Answers
http://www.cdc.gov/std/hpv/STDFact-HPV-vaccine.htm
OB/GYN CCC Editorial comment:
ACIPs recommendations: Some of the final steps before roll out of this HPV vaccine
Each Indian Health, Tribal, and Urban facility should be making active plans now on how best to implement this vaccine for their clientele. In general most states will make the quadravalent vaccine available to our AI/AN patients at no cost in January 2007. There are many major issues to anticipate while we maintain a highly effective screening program in the meantime.
Here are just a few:
-how to implement as a cancer vaccine while addressing the sexually transmitted infection issues head on
-how to address ‘catch up’ vaccination for those patients over the age of 19 years who will not qualify for Vaccines For Children coverage
-how to monitor the quadravalent vaccine effectiveness (patients may be infected with more than one HPV sub-type), and possible adverse vaccine reactions.
Water-Based Speculum Lubricant Does Not Affect Pap Screening
The authors conclude that water-based lubricant does not affect specimen quality in Pap screening or in the diagnosis of vaginal infections. This confirms other reports. Further studies are needed to determine whether water-based lubricants can reduce the discomfort of pelvic examinations, but the authors state that if pain can be decreased safely, new practices should be instituted.
Hathaway JK, et al. Is liquid-based Pap testing affected by water-based lubricant? Obstet Gynecol January 2006;107:66-70.
and
Speculum lubrication does not affect cervical cytology
Conclusion: Speculum gel lubrication does not affect cervical cytology during the traditional Papanicolaou smear, nor does it provide significant alteration of patient discomfort.
Gilson M et al Does Gel Affect Cytology or Comfort in the Screening Papanicolaou Smear? J Am Board Fam Med 2006;19 340-344
http://www.jabfm.org/cgi/content/abstract/19/4/340?etoc
Three Questions Distinguish Urge From Stress Incontinence
CONCLUSIONS: The 3IQ questionnaire is a simple, quick, and noninvasive test with acceptable accuracy for classifying urge and stress incontinence and may be appropriate for use in primary care settings. Similar studies are needed in other populations. We also need a clinical trial comparing the outcomes of treatments based on the 3IQ and the extended evaluation.
1.) During the last 3 months, have you leaked urine (even a small amount)?
2.) When performing physical activity; When an urge occurred and could not reach the toilet quickly enough; Without physical activity or sense of urgency?
3.) When urine leakage occurs most often and provides a list of four circumstances. The subjects are asked to try to pick one that most often applies.
The answer to this last question determines the type of incontinence: most often with physical activity indicates a diagnosis of stress incontinence; most often with a sense of urgency indicates urge incontinence; without physical activity or urgency suggests another cause; and about equally with physical activity and urgency indicated mixed type (a combination of stress and urge incontinence).
Brown JS et al The sensitivity and specificity of a simple test to distinguish between urge and stress urinary incontinence. Ann Intern Med. 2006 May 16;144(10):715-23
Burch colposuspension combined with uterine prolapse repair reduces incontinence
CONCLUSIONS: In women without stress incontinence who are undergoing abdominal sacrocolpopexy for prolapse, Burch colposuspension significantly reduced postoperative symptoms of stress incontinence without increasing other lower urinary tract symptoms.
Brubaker L, et al Abdominal sacrocolpopexy with Burch colposuspension to reduce urinary stress incontinence. N Engl J Med. 2006 Apr 13;354(15):1557-66.
Monsel's paste and fulguration with ball electrode equally effective for hemostasis after LEEP
Results: Six patients (2 Monsel's and 4 fulguration) required an alternate method of hemostasis. Patient demographics, postprocedural discharge, and recurrent dysplasia were comparable between the 2 groups. Visual analog scale scores and hemostasis time were significantly higher in the fulguration group. Estimated blood loss, although higher in the fulguration group, was not significant between groups.
Conclusion: Monsel's paste and fulguration with ball electrode appear be equally effective as hemostatic agents after loop electrosurgical excision procedure.
Lipscomb GH et al A trial that compares Monsel's paste with ball electrode for hemostasis after loop electrosurgical excision procedure Am J Obstet Gynecol. 2006 Jun;194(6):1591-4; discussion 1595.
Child Health
Boyfriends, girlfriends, and Adolescents’ risk of sexual involvement
We have found that having had a boyfriend or girlfriend by seventh grade is both a predictor of having sex in the ninth grade and a marker of prior risks for sex.
* Males who reported a girlfriend by seventh grade were more likely than those who had not to be sexually active in ninth grade.
* Females who reported a same-age boyfriend in seventh grade were more likely than those reporting no boyfriend in seventh grade to be sexually active in ninth grade, and those reporting an older boyfriend in seventh grade were more likely than those reporting a same-age boyfriend to be sexually active in ninth grade.
* For males, sixth-grade peer norms favoring sex, Hispanic ethnicity, and eighth-grade situations that could lead to sex predicted ninth-grade reports of sexual activity.
* For females, menarche in sixth grade was associated with ninth-grade reports of sexual activity, as were peer norms favoring sex and situations that could lead to sex in eighth grade.
Helping girls to handle the social changes related to early pubertal development, deemphasizing social activities that may pave the way for risky behavior and encouraging parental supervision may help reduce early involvement with a boyfriend or girlfriend.
Marin BV, Kirby DB, Hudes ES, et al. 2006. Boyfriends, girlfriends and teenagers' risk of sexual involvement. Perspectives on Sexual and Reproductive Health 38(2):76-83. Abstract available at http://www.guttmacher.org/pubs/journals/3806606.pdf
OB/GYN CCC Editorial comment:
Lori de Ravello, National IHS STD Program, offers a focus on adolescent sexual behavior this month in the STD Corner below. Lori highlights 5 articles from the June 2006 Perspectives on Sexual and Reproductive Health on findings and strategies in adolescent reproductive health.
In addition Sulak et al below reports a successful sex education program in an academic center
Sulak PJ, Herbelin SJ, Fix DDA, et al. 2006. Impact of an adolescent sex education program that was implemented by an academic medical center. American Journal of Obstetrics and Gynecology 195(1):78-84.
New Guidelines for Pediatric and Neonatal Emergency Cardiovascular Care
The following are the major neonatal resuscitation changes in the 2005 guidelines:
* Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air.
* Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth.
* A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn.
* An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation.
* The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered.
* It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes:
* When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines.
* In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated.
* In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported.
* Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.
American Heart Association. 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support. Pediatrics. 2006 May;117(5)
2nd International Meeting on Indigenous Child Health
- April 20-22, 2007
- Montreal , Quebec, Canada
- Solutions, not Problems
- Joint meeting of IHS, AAP-CONACH, First Nations and several other stakeholders
- http://www.aap.org/nach/2InternationalMeeting.htm
Chronic Disease and Illness
Driving, Other Erratic Behaviors Reported After Taking Zolpidem (Ambien)
Zolpidem (Ambien), a nonbenzodiazepine, sedative-hypnotic prescribed for the short-term treatment of insomnia, has been associated with increased numbers of impaired driving incidents in Wisconsin during the past several years. Although the label directs patients to take zolpidem only when able to devote a full 8 hours to sleep, and cautions against operating heavy machinery or motor vehicles, the patients involved in these incidents have driven while under the influence of zolpidem. Some of these drivers have expressed their belief that they were "sleep-driving," saying they have no memory of the driving incident.
A 'typical' Ambien driver will demonstrate erratic, unsafe driving, often with wide lane deviations, many crashes or near–head on collisions, or unpredictable, bizarre driving maneuvers according to staff at the Toxicology Section at the Wisconsin State Laboratory of Hygiene (WSLH) in Madison.
Erratic behaviors reported after taking zolpidem are not limited to impaired driving, but have included sleepwalking, eating, drinking alcohol, belligerent outbursts, urinating in inappropriate places, agitation, confusion, dazed appearance, slurred speech, incoordination, and poor balance. Usually patients have no memory of these incidents and are at a loss to explain subsequent events, such as why food is missing from the refrigerator or why alcohol bottles are half empty.
Factors associated with zolpidem-impaired driving include not going to bed immediately after taking the drug, attempting to drive too soon after taking it, high blood levels, or ingestion with other drugs and/or alcohol.
Special concerns that patients should be aware of include memory loss or amnesia. Patients are advised to take Ambien only when they are able to get a full night's sleep (7-8 hours) before they need to be active again. http://www.medscape.com/viewarticle/528415?src=sr
New shingles vaccine is a smart precaution with little downside
The recent US Food and Drug Administration approval of the vaccine Zostavax, to prevent herpes zoster in people 60 and older, represents a major step in the fight against shingles. Here is what a NEJM report from June 2005 concluded
CONCLUSIONS: The zoster vaccine markedly reduced morbidity from herpes zoster and postherpetic neuralgia among older adults.
Oxman MN, et al A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005 Jun 2;352(22):2271-84
Medical Management of Common Urinary Calculi (See also Patient Education)
Nephrolithiasis is a common condition affecting nearly 5 percent of U.S. men and women during their lifetimes. Recurrent calculi can be prevented in most patients by the use of a simplified evaluation, reasonable dietary and fluid recommendations, and directed pharmacologic intervention. Serum studies and 24-hour urine collections are the mainstays of metabolic investigation and usually are warranted in patients with recurrent calculi. Although some stones are the result of inherited conditions, most result from a complex interaction between diet, fluid habits, and genetic predisposition. Calcium-sparing diuretics such as thiazides often are used to treat hypercalciuria. Citrate medications increase levels of this naturally occurring stone inhibitor. Allopurinol can be helpful in patients with hyperuricosuria, and urease inhibitors can help break the cycle of infectious calculi. Aggressive fluid intake and moderated intake of salt, calcium, and meat are recommended for most patients. Am Fam Physician 2006;74:86-94, 99-100
http://www.aafp.org/afp/20060701/86.html
Diagnosis and Treatment of Antiphospholipid Syndrome
Antiphospholipid syndrome is associated with various conditions, including arterial and venous thromboses, autoimmune thrombocytopenia, fetal loss, preeclampsia, intrauterine growth restriction, placental insufficiency, and preterm delivery. The American College of Obstetricians and Gynecologists (ACOG) has developed guidelines for the diagnosis and treatment of this condition. The guidelines were published in the November 2005 issue of Obstetrics & Gynecology.
Diagnosis of antiphospholipid syndrome is based on a combination of clinical history and laboratory testing. Initial diagnosis requires testing for lupus anticoagulant and anticardiolipin antibodies; patients should be diagnosed if lupus anticoagulant is present or if medium to high levels (i.e., greater than 20 binding units) of immunoglobulin G (IgG) or IgM anticardiolipid antibodies are present. Positive test results must be confirmed by a second test after several weeks. Testing for antiphospholipid antibodies should be limited to women with appropriate medical or obstetric histories.
The primary manifestations of antiphospholipid syndrome are pregnancy loss and venous or arterial thromboses. Thus, clinical criteria for laboratory testing are three or more consecutive spontaneous abortions before 10 weeks' gestation; one or more unexplained fetal deaths at 10 weeks' gestation or later; severe preeclampsia or placental insufficiency requiring birth before 34 weeks' gestation; unexplained venous or arterial thrombosis; or small-vessel thrombosis in any tissue or organ with no significant evidence of vessel-wall inflammation.
Treatment of antiphospholipid syndrome during pregnancy reduces the risks of pregnancy loss, preeclampsia, placental insufficiency, preterm birth, and thrombosis. ACOG states that women with antiphospholipid syndrome and no history of thrombosis should receive prophylactic doses of heparin and low-dose aspirin during pregnancy and for six to eight weeks postpartum. For women with recurrent miscarriage, the combination of prophylactic heparin and low-dose aspirin may reduce pregnancy loss and is more effective than low-dose aspirin alone or prednisone. Although ACOG found few data on the effectiveness of treatments for women with severe preeclampsia or uteroplacental insufficiency, prophylactic heparin and aspirin generally are recommended. Initiation of heparin before conception is not supported by evidence.
Women with antiphospholipid syndrome and a history of thrombosis should receive full heparin anticoagulation throughout pregnancy and for six to eight weeks postpartum to minimize the risk of maternal thromboembolism. This can be achieved safely with warfarin (Coumadin) after delivery. The benefit of adding aspirin is unknown. After the postpartum period, patients should be referred to a physician with expertise in treating the syndrome for further anticoagulation therapy.
The effectiveness of corticosteroids and intravenous immune globulin for the treatment of antiphospholipid syndrome is uncertain.
Women with antiphospholipid syndrome who are pregnant should be instructed about the signs and symptoms of preeclampsia and thrombosis and should be examined frequently. Serial ultrasonic assessment should be considered because of the risk for growth restriction. Antepartum testing should be considered after 32 weeks' gestation (or earlier if growth restriction is evident).
Long-term risks of antiphospholipid syndrome include thrombosis and stroke. Patients with antiphospholipid syndrome should be referred to a physician with expertise in treating the syndrome for long-term follow-up.
The use of estrogen-containing oral contraceptives has been shown to increase the risk for thrombosis in women with antiphospholipid syndrome and therefore should be avoided in these women.
http://www.aafp.org/afp/20060701/practice.html
Few Americans with Diabetes Receive Multiple Preventive-Care Services
Preventive-care services such as annual foot and dilated eye examinations and biannual A1C tests can prevent or delay amputation and blindness from diabetes. The Centers for Disease Control and Prevention analyzed data from the Behavioral Risk Factor Surveillance System surveys to determine the percentage of Americans with diabetes who receive these services. The report, "Prevalence of Receiving Multiple Preventive-Care Services Among Adults with Diabetes-United States, 2002-2004," was published in the November 11, 2005, issue of Morbidity and Mortality Weekly Report
The study showed that although the percentage of patients with diabetes who received individual preventive-care services was close to or above national targets (75 percent for foot and eye examinations and 50 percent for A1C tests), less than one half of patients reported receiving all three services. Several factors were associated with a greater likelihood of receiving these services: age 75 years or older, non-Hispanic black race, higher education, diabetes duration of 10 to 19 years, insulin use, diabetes management education, and health insurance coverage. Smoking had a negative association. Possible barriers to receiving these services may include lack of awareness, inadequate health insurance coverage, and the inability to make co-payments or visit specialists. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5444a5.htm
Combined Tetanus, Diphtheria and Pertussis (Tdap) Vaccine Recommended for Adults
Provisional Recommendations for Tdap in Adults (NB: Use in pregnancy to be determined)
The following provisional recommendations for a single dose of Tdap (ADACELTM) apply to adults 19-64 years of age who have not received Tdap previously.
• Routine: Adults should receive a single dose of Tdap to replace a single dose of Td for booster immunization against tetanus, diphtheria, and pertussis if they received the last dose of tetanus toxoid-containing vaccine (e.g., Td) >10 years earlier.
• Shorter interval between Td and Tdap: Tdap may be given at an interval shorter than 10 years since receipt of the last dose of tetanus toxoid-containing vaccine to protect against pertussis. The safety of an interval as short as approximately 2 years between administration of Td and Tdap is supported by a Canadian study of children and adolescents. The dose of Tdap replaces the next scheduled booster dose of Td.
• Prevention of pertussis among infants <12 months of age by vaccinating adult contacts: Adults who have or who anticipate having close contact with an infant <12 months of age (e.g., parents, grandparents <65 years of age, childcare providers, health-care workers) should receive a single dose of Tdap. An interval of 2 years or more since the last dose of tetanus toxoid-containing vaccine is suggested; a shorter interval can be used. Ideally, Tdap should be given at least one month before beginning close contact with the infant. Women should receive a dose of Tdap in the immediate post-partum period if they previously have not received Tdap. Any woman who might become pregnant is encouraged to receive a single dose of Tdap.
• Health-care personnel: Health-care personnel who work in hospitals or ambulatory care settings and have direct patient contact should receive a single dose of Tdap as soon as feasible if they have not previously received Tdap. Priority should be given to vaccination of health-care personnel with direct contact with infants aged <12 months. An interval as short as 2 years from the last dose of Td is recommended for the Tdap dose. Other health-care personnel (i.e., those who do not work in hospitals or ambulatory care settings or who do not have direct patient contact) should receive a single dose of Tdap according to the routine recommendation and interval guidance for use of Tdap among adults. However, these personnel are encouraged to receive the Tdap dose at an interval as short as 2 years following the last Td. Hospitals and ambulatory care facilities should provide Tdap for health-care personnel and use approaches that maximize vaccination rates such as education about the benefits of vaccination, convenient access, and provision of Tdap at no charge.
• Simultaneous administration: Tdap should be administered with other vaccines that are indicated during the same visit when feasible. Each vaccine should be administered using a separate syringe at a different anatomic site.
Special Situations
• Tetanus prophylaxis in wound management: Adults 19-64 years of age who require a tetanus toxoid-containing vaccine as part of wound management should receive Tdap instead of Td if they previously have not received Tdap. If Tdap is not available or was administered previously, Td should be administered.
• Incomplete or unknown vaccination history: Adults who have never received tetanus and diphtheria toxoid-containing vaccine should receive a series of three vaccinations. The preferred schedule is a dose of Tdap, followed by a dose of Td >4 weeks later, and a second dose of Td 6 to 12 months later. Tdap can substitute for Td for any one of the three doses in the series.
• History of pertussis: Adults with a history of pertussis generally should receive Tdap according to routine recommendations.
• Pregnancy : Pregnancy is not a contraindication to Tdap or Td vaccination. Guidance on the use of Tdap during pregnancy is under consideration by ACIP. At this time, pregnant women who received the last tetanus toxoid-containing vaccine <10 years earlier should receive Tdap after delivery, according to routine recommendations for vaccinating adult contacts of infants <12 months of age. Women who received the last tetanus toxoid-containing vaccine >10 years earlier should receive Td during pregnancy in preference to Tdap, and pregnant women who have not received the primary 3-dose vaccination series for tetanus should begin the Td series during pregnancy. If Td is indicated during pregnancy, vaccinating during the second or third trimester is preferred when feasible.
• Adults >65 years of age: Tdap is not licensed for use among adults >65 years of age. Recommendations for use of Tdap among adults >65 years of age will be updated as new data become available. All adults, including adults >65 years of age, should receive a dose of tetanus toxoid- and diphtheria toxoid-containing vaccine every 10 years and as indicated for wound management. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr55e223a1.htm
Management of Hip Fracture: The Primary Care Provider's Role (See Patient Education)
The incidence of hip fracture is expected to increase as the population ages. One in five persons dies in the first year after sustaining a hip fracture, and those who survive past one year may have significant functional limitation. Although surgery is the main treatment for hip fracture, family physicians play a key role as patients' medical consultants. Surgical repair is recommended for stable patients within 24 to 48 hours of hospitalization. Antibiotic prophylaxis is indicated to prevent infection after surgery. Thromboprophylaxis has become the standard of care for management of hip fracture. Effective agents include unfractionated heparin, low-molecular-weight heparin, fondaparinux, and warfarin. Optimal pain control, usually with narcotic analgesics, is essential to ensure patient comfort and to facilitate rehabilitation. Rehabilitation after hip fracture surgery ideally should start on the first postoperative day with progression to ambulation as tolerated. Indwelling urinary catheters should be removed within 24 hours of surgery. Prevention, early recognition, and treatment of contributing factors for delirium also are crucial. Interventions to help prevent future falls, exercise and balance training in ambulatory patients, and the treatment of osteoporosis are important strategies for the secondary prevention of hip fracture. Am Fam Physician 2006;73:2195-200, 2201-2.
http://www.aafp.org/afp/20060615/2195.html
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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.
