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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, October 18, 2014

Cantu et al. Predicting fetal acidemia using umbilical venous cord gas parameters

Why should you read about this topic?

Cord blood gas when you really need it—sometimes all you have is a venous sample.  This article can help with interpretation

What were the authors trying to do?

Assess the value of venous cord blood gases for predicting arterial cord blood gases and fetal acidemia

Who participated and in what setting?

All singleton newborns (N=11,455) with paired arterial and venous cord blood gas samples born at UAB between 2006 and 2012

What was the study design?

Retrospective cohort study

What were the main outcome measures?

Fetal acidemia defined as arterial cord pH<7.0 or arterial cord base deficit>12 mmol/L

What were the results?

Venous cord blood pH and base deficit were highly predictive of acidemia.  Cutoffs for a 5% probability of acidemia were a venous cord blood pH of 7.17 and a venous cord base deficit of 8.2 mmol/L.

What is the most interesting image in the paper?

Figure 2

What were the study strengths and weaknesses?

Strengths: large number of arterial-venous pairs; stringent criteria for validating sampling. Weaknesses: large proportion of missing data; thresholds not validated in an independent sample

What does the study contribute for your practice?

When you don’t have an arterial cord blood gas, a venous sample is the next best thing for estimating fetal acidemia


Wednesday, October 08, 2014
Luu Ireland, MD
Luu Ireland, MD, MPH
Fellow in the Division of Family Planning
Department of Obstetrics and Gynecology
David Geffen School of Medicine at the University of California, Los Angeles
 
Abnormal uterine bleeding is a common gynecologic problem with widespread implications. Women with heavy menstrual bleeding report health-related quality of life scores that are in the 25th percentile for similar aged women.1
Approximately 30% of women will seek medical care for heavy menstrual bleeding at some point during their lives.2 These women are 1.45 times more likely to utilize health care services.3 They are also 72% as likely to be employed compared to their normal flow counterparts.4 The resulting economic impact is profound, with the direct and indirect cost of abnormal uterine bleeding estimated at $13 billion each year.1
 
So what is a physician to do? Surgical management, particularly hysterectomy, has high satisfaction rates. However, this major surgery is accompanied with significant cost and operative risk. For women seeking to retain their fertility, definitive management is not an option. Furthermore, with the rise in obesity and chronic disease, such as diabetes and hypertension, many women with heavy menstrual bleeding will be suboptimal surgical candidates.
 
For many of these reasons, endometrial ablation has risen in popularity as a minimally invasive way to treat abnormal uterine bleeding. However, a new study in the November 2014 issue of Obstetrics & Gynecology reminds us that endometrial ablation is not without risk. Wishall and colleagues5 conducted a retrospective study of 270 women who underwent endometrial ablation to treat abnormal uterine bleeding. Twenty-three percent reported new onset or worsening pelvic pain following the procedure and 19% went on to undergo hysterectomy. The investigators identified history of dysmenorrhea and tubal ligation as significant risk factors for new or worsening pain following ablation (OR 1.74, 95% CI 1.06-2.87 and OR 2.06, 95% CI 1.14-3.70, respectively).
 
As surgeons, however, we often underestimate the power of a simple office-based alternative to treat abnormal uterine bleeding: the levonorgestrel intrauterine device (LNG-IUD). The LNG-IUD works quickly and effectively, with 86% reduction in blood loss at 3 months, 97% reduction in blood loss at 12 months, and rates of amenorrhea ranging from 20% to 80%.2 A meta-analysis by Kaunitz et al comparing LNG-IUD to endometrial ablation for the treatment of heavy menstrual bleeding demonstrated similar therapeutic benefits with ablation having higher rates of anesthetic and surgical complications.6 A 2009 Cochrane review also showed comparable treatment success between the two modalities.7 Furthermore, Blumenthal et al. demonstrated the LNG-IUD as the most cost-effective first line therapy in women with abnormal uterine bleeding with a cost-savings of over $2000 per woman over a 5-year period compared to surgical management or oral hormonal therapy.8
 
The LNG-IUD has many other benefits over endometrial ablation. In women who are at high risk for endometrial hyperplasia or malignancy, the LNG-IUD both allows for endometrial sampling and also confers a protective benefit. In women with a history of endometriosis, the LNG-IUD is an effective treatment for dysmenorrhea and chronic pelvic pain.2 Furthermore, the LNG-IUD may be used safely in women with a prior tubal ligation.
 
As more women gain health insurance through the Affordable Care Act, the number of women seeking care for abnormal uterine bleeding is sure to increase. The LNG-IUD presents a safe, easy, cost-effective treatment for abnormal uterine bleeding.

References
  1. Liu Z, Doan QV, Blumenthal P, Dubois RW. A systematic review evaluating health-related quality of life, work impairment, and health-care costs and utilization in abnormal uterine bleeding. Value Health 2007;10:183-94.
  2. Noncontraceptive uses of hormonal contraceptives. Practice Bulletin No. 110. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;115:206–18.
  3. Cote I, Jacobs P, Cumming DC. Use of health services associated with increased menstrual loss in the United States. Am J Obstet Gynecol 2003;188:343-8.
  4. Palep-Singh M, Prentice A. Epidemiology of abnormal uterine bleeding. Best Pract Res Clin Obstet Gynaecol 2007;21:887-90.
  5. Wishall KM, Price J, Pereira N, Butts SM, Della Badia CR. Postablation risk factors for pain and subsequent hysterectomy. Obstet Gynecol 2014;124:904–10.
  6. Kaunitz AM, Meredith S, Inki P, Kubba A, Sanchez-Ramos L. Levonorgestrel-releasing intrauterine system and endometrial ablation in heavy menstrual bleeding: a systematic review and meta-analysis. Obstet Gynecol 2009;113:1104-16.
  7. Marjoribanks J, Lethaby A, Farquhar C. Surgery versus medical therapy for heavy menstrual bleeding. Cochrane Database Syst Rev 2006(2):CD003855.
  8. Blumenthal PD, Trussell J, Singh RH, Guo A, Borenstein J, Dubois RW, et al. Cost-effectiveness of treatments for dysfunctional uterine bleeding in women who need contraception. Contraception 2006;74:249-58.

Saturday, September 27, 2014

Kho et al. Intracorporeal electromechanical tissue morcellation: a critical review and recommendations for clinical practice.

Why should you read about this topic?

As I wrote last month, alternatives to conventional intra-abdominal power morcellation need to be explored.

What were the authors trying to do?

Summarize the risks of adverse outcomes arising from the use of intracorporeal power morcellation and provide recommendations for clinical practice

What was the study design?

Current commentary

What were the conclusions?

When possible, use alternatives such as mini-laparotomy, vaginal morcellation, or morcellation within a bag.  Make sure the patient is fully informed of the risks of and alternatives to power morcellation to enable her to make the best choice for her.  Before using power morcellation, screen for and exclude women with malignancies.

What is the most interesting image in the paper?

Video

What does the study contribute for your practice?

Until more data are available, use intracorporeal power morcellation as a last resort and make sure the patient is fully informed of risks


Saturday, September 20, 2014

Huh et al. Relevance of random biopsy at the transformation zone when colposcopy is negative

Why should you read about this topic?

To understand the value and limitations of colposcopy for detecting high-grade lesions

What were the authors trying to do?

Determine the prevalence of high-grade CIN at biopsy of women with negative colposcopy

Who participated and in what setting?

Women (N=2,839) > 25 years of age undergoing routine cervical screening who had ASC-US or worse cytology or high-risk HPV at 61 clinical centers across the US between May 2008 and August 2009.  Also included were a randomized subset of women with negative cytology and negative results of high-risk HPV.

What was the study design?

Secondary analysis of the ATHENA trial

What were the main outcome measures?

CIN 2 or 3

What were the results?

An undirected biopsy diagnosed 20.9% of the total number of cases of CIN2 or worse, and 18.9% of CIN3 or worse.  The diagnostic yield was higher in the presence of HPV 16/18 genotype.  However, over 95% of women with no colposcopic lesion had CIN 1 or less on biopsy.

What is the most interesting image in the paper?

Figure 2

What were the study strengths and weaknesses?

Strengths: central pathology review; large number of participants.  Weaknesses: biopsies not truly “random”

What does the study contribute for your practice?

No lesions on colposcopy?  Take a single biopsy.


Saturday, September 13, 2014

Andersen et al. Exposure to selective serotonin reuptake inhibitors in early pregnancy and the risk of miscarriage

Why should you read about this topic?

SSRIs are commonly used, often during pregnancy.  Vigilance for adverse outcomes associated with their use is essential.

What were the authors trying to do?

Determine whether the use of SSRIs during the first trimester is associated with miscarriage.

Who participated and in what setting?

All pregnancies (N=1,279,840) recorded in the National Birth Registry and National Hospital Register in Denmark between 1997 and 2010

What was the study design?

Retrospective population-based cohort study

What were the main outcome measures?

Miscarriage (unintended pregnancy loss prior to 20 weeks)

What were the results?

Women exposed to SSRIs during the first 35 days of pregnancy had a 27% increased rate of miscarriage.  Women discontinuing SSRIs 3-12 months prior to pregnancy also had an increased rate of miscarriage (24%).

What is the most interesting image in the paper?

Figure 2

What were the study strengths and weaknesses?

Strengths: huge, complete population-based study sample. Weaknesses:  atypically low rate (1.8%) of use of SSRIs during pregnancy and before pregnancy

What does the study contribute for your practice?

Treatment with SSRIs should not be discontinued during pregnancy due to fear of miscarriage.

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.