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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, February 28, 2015

Edwards et al. Expanded carrier screening in reproductive medicine—points to consider

Why should you read about this topic?

Where does expanded carrier screening fit in the lives of your patients, pregnant or planning to be pregnant?

What were the authors trying to do?

Demonstrate an approach for providers and laboratories offering expanded carrier screening to their patients

Who participated and in what setting?

The Perinatal Quality Foundation, the American College of Medical Genetics and Genomics, the American College of Obstetricians and Gynecologists, the Society for Maternal-Fetal Medicine,  and the National Society of Genetic Counselors

What was the study design?

Consensus statement

What is the most interesting image in the paper?

Table 1

What does the study contribute for your practice?

A framework for selection of a panel for panethnic expanded carrier screening


Saturday, February 21, 2015

Staer-Jensen et al.  Postpartum recovery of levator hiatus and bladder neck mobility in relation to pregnancy

Why should you read about this topic?

As I wrote in July, 2013, “You’re familiar with the end-result: pelvic organ prolapse and incontinence.  Now we need to know more about how it develops.”

What were the authors trying to do?

Describe postpartum changes in pelvic floor morphology in primiparous women

Who participated and in what setting?

Nulliparous pregnant women (N=300) at Akershus University Hospital between 2010 to 2012

What was the study design?

Prospective longitudinal observational

What were the main outcome measures?

Levator hiatus area at rest by transperineal 3D and 4D ultrasound

What were the results?

In the vaginal delivery group, significant decrease in was seen in all measurements during the postpartum period, especially for the levator hiatus during Valsalva; however, all measurements remained increased one year postpartum compared with second trimester measurements.  At one year postpartum, only the levator hiatus during contraction was different between delivery groups.

What is the most interesting image in the paper?

Figure 2

What were the study strengths and weaknesses?

Strengths: careful estimation of inter-observer agreement; longitudinal study.   Weaknesses: over 40% lost to follow-up

What does the study contribute for your practice?

There is remarkable recovery of pelvic organ support within 6 months after vaginal delivery, but differences compared with cesarean delivery remain one year later.


Thursday, February 05, 2015

Amber Truehart, MD
Amber Truehart, MD
Family Planning Fellow
University of Chicago, Chicago, IL

In college as I daily juggled remembering my oral contraceptive pills, classes, and extracurricular activities, I often daydreamed about an “ideal” contraceptive method. I envisioned this perfect method being implanted somewhere in my body. I would not have to remember anything on a daily, monthly, or even yearly basis. It would have few side effects and be reversible just by removal. Little did I know contraceptive methods very close to my “ideal” did exist and were about to be pushed into the spotlight.

The push came in the form of the contraceptive CHOICE project in St. Louis. This study showed, among other things, that when financial barriers are removed and the most effective options are promoted, the majority of women choose long-acting reversible contraception (LARC), are satisfied with this method and continue it.1,2 This continuation has even been shown to decrease rates of unintended pregnancy and abortion.3 Long-acting reversible contraception (LARC), including intrauterine devices and the subdermal implant, began to transform the world of family planning: LARC devices have few contraindications;4 The American College of Obstetricians and Gynecologists (ACOG) recommends LARC methods as first-line options for both adolescents and nulliparous women;5 furthermore, ACOG reports that postpartum and postabortal insertion is safe and effective.6 So where do, you ask, is this LARC love fest going?

The article by McNicholas et al, published in the March 2015 issue of Obstetrics & Gynecology,7 is where LARC is going. In this study, women willing to continue using their implant or 52 mg levonorgestrel IUD (LNG-IUD) beyond the FDA-approved duration (3 years and 5 years respectively) were followed prospectively. The goal of the study is to quantify the number of unintended pregnancies in these women using LARC for a prolonged time period. Preliminary findings presented only one pregnancy in 197.7 women-years of prolonged IUD use and zero pregnancies in 229.4 women-years of prolonged implant use. This low failure rate suggests that the implant and the LNG-IUD are highly effective for at least an additional year.

LARC just got even better. Prolonged LARC use offers women longer pregnancy prevention with one device and improves cost-effectiveness. In an age when the Supreme Court allows corporate exemptions from federally mandated contraception care, prolonged LARC use may become increasingly important. Many women’s devices are reaching the FDA-approved expiration yet they may not have access to or be able to afford a new one.  While we are fixing the bigger issues around contraception access, prolonged LARC use offers a potential short term solution.

As LARC methods get better (and better) it is important as ob-gyns that we make sure that all our patients have access to them. Recognizing that women should be making these decisions with those they trust--not politicians and employers--we must use our collective voice to protect women’s contraceptive choices; it is in maintaining a broad array of choices, after all, where our patients will discover their “ideal” contraceptive method.

References

  1. Peipert JF, Zhao Q, Allsworth JE, et al. Continuation and satisfaction of reversible contraception. Obstet Gynecol 2011;117(5):1105-13.
  2. O-Neil-Callahan M, Peipert JF, Zhao Q,et al. Twenty-four-month continuation of reversible contraception. Obstet Gynecol 2013;122:1083-91.
  3. Peipert JF, Madden T, Allsworth JE, Secura GM. Preventing unintended pregnancies by providing no-cost contraception. Obstet Gynecol 2012;120:1291–7.
  4. Centers for Disease Control and Prevention, U.S. medical eligibility criteria for contraceptive use, 2010. MMWR. 2010;59(RR-4):1-86. Accessed at http://www.cdc.gov/reproductivehealth/unintendedpregnancy/usmec.htm. Retrieved January 22, 2015.
  5. American College of Obstetricians and Gynecologists. Adolescents and long-acting reversible contraception: implants and intrauterine devices. Committee Opinion No. 539. Obstet Gynecol, 2012:120:983-8.
  6. American College of Obstetricians and Gynecologists. Long-Acting Reversible Contraception: implants and intrauterine devices. Practice Bulletin No. 121. Obstet Gynecol, 2011:118:184-196.
  7. McNicholas C, Maddipati R, Zhao Q, et al. Use of the Etonogestrel Implant and Levonorgestrel Intrauterine Device Beyond the U.S. Food and Drug Administration–Approved Duration. Obstet Gynecol 2015; [Epub ahead of print].

Saturday, January 24, 2015

Mor et al. Alpha-fetoprotein as a tool to distinguish amniotic fluid from urine, vaginal discharge, and semen

Why should you read about this topic?

It’s not always easy to detect PROM

What were the authors trying to do?

Show that AFP can be used to distinguish amniotic fluid from semen, urine, and vaginal discharge in perineal pads

Who participated and in what setting?

Pregnant women (N=79) > 34 weeks at Maimonides Medical Center and men (N=17) undergoing infertility evaluation in 2014

What was the study design?

Prospective cohort

What were the main outcome measures?

AFP concentrations in body fluids

What were the results?

AFP concentrations were much higher in amniotic fluid than in urine, semen, or vaginal discharge.  AFP concentrations extracted from sanitary pads instilled with the same body fluids showed similar relative concentrations.  Amniotic fluid can be distinguished from vaginal discharge with a high level of sensitivity and specificity by measuring AFP concentrations in sanitary pads.

What is the most interesting image in the paper?

Figure 2

What were the study strengths and weaknesses?

Strengths:  the analyte is inexpensive to measure. Weaknesses: most testing was done with artificial, contrived specimens.

What does the study contribute for your practice?

AFP concentrations may be helpful in distinguishing amniotic fluid from other body fluids


Saturday, January 17, 2015

Gordon et al. Sleep position, fetal growth restriction, and late pregnancy stillbirth: The Sydney Stillbirth Study

Why should you read about this topic?

Every year well over 2 million babies are stillborn

What were the authors trying to do?

Identify potentially modifiable risk factors for late pregnancy stillbirth

Who participated and in what setting?

Pregnant women (cases, N=103; controls, N=192) >32 weeks in maternity hospitals in Sydney between 2006 and 2011.

What was the study design?

Population-based case-control interview and questionnaires

What were the main outcome measures?

Stillbirth

What were the results?

Potentially modifiable factors associated with stillbirth included supine sleeping (aOR 6.26), suspected fetal growth restriction (aOR 5.5), not be in paid work (aOR 2.9), and no education beyond high school (aOR 1.9). The population attributable risk for reported supine sleeping was 9.9%.

What is the most interesting image in the paper?

Table 3

What were the study strengths and weaknesses?

Strengths: a priori specified exposures; contemporaneous controls; population based. Weaknesses: recall bias

What does the study contribute for your practice?

“Back to sleep” may be best for infants but not necessarily expectant moms

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.