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Current events in Obstetrics & Gynecology, updates on new web site features and links to other web sites of interest to ObGyns.
Saturday, August 23, 2014

Van Mieghem et al. Prenatal management of monoamniotic twin pregnancies

Why should you read about this topic?

Where is the equipoise between stillbirth risk and preterm delivery consequences for monoamniotic twins?

What were the authors trying to do?

To evaluate antenatal surveillance strategies and derive the optimal time for elective delivery of monoamniotic twin pregnancies

Who participated and in what setting?

Women (N=193) with monoamniotic twin pregnancies (excluding conjoined twins and TRAP sequence pregnancies) at 8 university hospitals in Europe and North America between 2003 and 2012

What was the study design?

Retrospective chart review

What were the main outcome measures?

Fetal death and a composite neonatal morbidity (non-respiratory neonatal complications or death)

What were the results?

Risk of fetal death is greater than the risk of non-respiratory neonatal morbidity at or after 32½ weeks. No difference in outcomes was seen in outpatient vs. inpatient comparisons

What is the most interesting image in the paper?

Figure 2

What were the study strengths and weaknesses?

Strengths:  confirmation of amnionicity by pathology; large number of monoamniotic pregnancies.  Weaknesses: retrospective study; inadequate power to compare inpatient with outpatient management

What does the study contribute for your practice?

Information helpful for counseling patients about risks of adverse outcomes


Saturday, August 16, 2014

Cohen et al. Contained power morcellation within an insufflated isolation bag.

Why should you read about this topic?

Alternatives to conventional intra-abdominal power morcellation need to be explored.

What were the authors trying to do?

Demonstrate the feasibility of intra-abdominal power morcellation using an isolation bag during minimally invasive gynecologic surgery

Who participated and in what setting?

Women (N=73) undergoing hysterectomy or myomectomy requiring morcellation to remove the excised specimen during minimally invasive gynecologic surgery at 4 hospitals in the US.

What was the study design?

Retrospective chart review and some by prospective observation

What were the main outcome measures?

Specimen removal by morcellation

What were the results?

Morcellation within an isolation bag was successful without complications in all cases.

What is the most interesting image in the paper?

The attached video

What were the study strengths and weaknesses?

Strengths:  careful description of the operative procedure.  Weaknesses: retrospective; number of patients too small to demonstrate safety and efficacy of prevention of dissemination

What does the study contribute for your practice?

Principles that will be key for development of safe power morcellation in the future.


Wednesday, August 06, 2014
Sarah Wallett, MD
Family Planning Fellow
University of Michigan
Ann Arbor, MI
 
Oral contraceptives are the most commonly used reversible form of birth control in the United States, with 27.5% of women choosing this method. Another 7.2% of women use some other hormonal contraceptive, including injectable progestin, the contraceptive patch, or the contraceptive ring.1 Serious adverse events with the use of hormonal contraception, mainly the perceived high risk of venous thromboembolism, remain a concern for patients, clinicians, and the public. Recently, concerns regarding the risk of venous thromboembolism with drospirenone-containing combined oral contraceptives, the contraceptive patch, and the contraceptive ring have all received substantial attention in the popular press and media.
  
A new study by Bergendal et al published in the September 2014 issue of Obstetrics & Gynecology adds to the medical literature surrounding this topic.2 In this case-control study, the risk of venous thromboembolism associated with use of hormonal contraception was noted to vary by type of progestin. Risk of venous thromboembolism was also shown to be higher among users of hormonal contraception with thrombophilic mutations, including Factor V Leiden and prothrombin gene mutations.
  
As obstetrician-gynecologists, it is critical for us to stay up-to-date on the medical literature surrounding this important topic in order to provide women with the highest quality patient care. However, it is also vital for us to learn how to effectively communicate the relative risks and benefits of hormonal contraception to our patients. Although the use of hormonal contraception does increase risk of venous thromboembolic disease when compared to risk among non-pregnant nonusers, the risk remains substantially lower than the risk during pregnancy and the postpartum period.3 Placing the risk of venous thromboembolic disease within the appropriate context for our patients and the public, while elucidating the benefits of hormonal contraception—including the prevention of unplanned pregnancies and their medical and social consequences—in the discussion, is an essential part of contraceptive counseling and risk communication.4
  
Ultimately, decisions regarding the use of any hormonal contraceptive method should be left up to an individual woman and her physician, taking into account her personal preferences, any risk factors for venous thromboembolic disease, and the benefits she might experience from its use. Resources to help with this discussion that are easily accessible to patients and clinicians include the ACOG-endorsed U.S. Medical Eligibility Criteria for Contraceptive Use (available both online and downloadable as a mobile app at http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm) and the You Decide Tool Kit developed by the Association of Reproductive Health Professionals (available at http://www.arhp.org/Publications-and-Resources/Clinical-Practice-Tools/You-Decide).5
 
References
  1. Jones J, Mosher WD, Daniels K. Current contraceptive use in the United States, 2006–2010, and changes in patterns of use since 1995. National Health Statistics Reports. 2012; no. 60. Hyattsville, MD: National Center for Health Statistics. 2012. Available at: http://www.cdc.gov/nchs/data/nhsr/nhsr060.pdf. Retrieved July 25, 2014.
  2. Bergendal A, Persson I, Odeberg J, Sundstrom A, Holmstrom M, Schulman S, et al. Association of venous thromboembolism with hormonal contraception and thrombophilic genotypes. Obstet Gynecol 2014;124:600–9.
  3. Risk of venous thromboembolism among users of drospirenone-containing oral contraceptive pills. Committee Opinion No. 540. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;120:1239–42.
  4. Jensen J. Trussell J. Communicating risk: does scientific dabate compromise safety? Contraception 2012;86:327–9.
  5. Understanding and using the U.S. Medical Eligibility Criteria for Contraceptive Use, 2010. Committee Opinion No. 505. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;118:754–60.

Saturday, August 02, 2014

Stamilio and Scifres. Extreme obesity and postcesarean maternal complications

Why should you read about this topic?

Just a quick walk through your waiting room will give you the answer to this question

What were the authors trying to do?

Estimate the association between obesity and maternal complications after cesarean delivery

Who participated and in what setting?

Women (N=585) participating in a randomized controlled trial of supplemental oxygen for postcesarean infectious morbidity between 2008 and 2010

What was the study design?

Secondary analysis

What were the main outcome measures?

Composite variable of wound infection and endometritis

What were the results?

Women with extreme obesity (BMI>45) had an adjusted odds ratio of 2.7 for the composite outcome, and 3.4 for wound infection.  Risks associated with obesity were independent of skin or uterine incision, diabetes, or hypertension.

What is the most interesting image in the paper?

Table 2

What were the study strengths and weaknesses?

Strengths: used outcomes that were a focus of the primary study; pre-specified BMI cutoffs. Weaknesses: 23% had the primary outcome determined by phone contact with the study participant; underpowered for multivariable analysis

What does the study contribute for your practice?

In cases of extreme obesity, be on the lookout for postcesarean wound complications.


Saturday, July 26, 2014

Smith et al. Bipolar radiofrequency compared with thermal balloon ablation in the office: a randomized controlled trial.

Why should you read about this topic?

Randomized controlled trials of commonly used surgical techniques are always welcome, especially those with 5 year follow-up

What were the authors trying to do?

Compare the efficacy at 5-year follow-up of bipolar radiofrequency ablation with thermal balloon ablation of the endometrium in the office for treatment of heavy menstrual bleeding

Who participated and in what setting?

Women (N=81) >25 years old with heavy menstrual bleeding and a normally configured uterine lumen at Birmingham Women’s Hospital in the UK

What was the study design?

Follow-up questionnaire study of a single-masked randomized controlled trial

What were the main outcome measures?

Amenorrhea.  Secondary outcomes included global and disease-specific quality of life questionnaires.

What were the results?

Amenorrhea rates and satisfaction with treatment outcomes scores were not different between groups.  Re-operation rates were not different, either, although the study sample size was too small to detect meaningful differences.  Quality of life measures were not different between groups.

What is the most interesting image in the paper?

Table 2

What were the study strengths and weaknesses?

Strengths:  randomized controlled trial. Weaknesses: postal questionnaire; very small study at a single institution.

What does the study contribute for your practice?

Whether it’s Thermachoice III or NovaSure, the results are the same 5 years later.

About the Author

William C. Dodson, MD
William C. Dodson, MD, is Professor of Obstetrics and Gynecology and Director of the Division of Reproductive Endocrinology and Infertility at Penn State College of Medicine. He completed his fellowship in reproductive endocrinology at Duke University. His research and clinical areas of focus include treatment of infertility, especially ovulation induction. He was previously on the Editorial Board of Obstetrics & Gynecology and has served as the Consultant Web Editor for Obstetrics & Gynecology since 2008.