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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, 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.


Saturday, July 19, 2014

Pergament et al. Single-nucleotide polymorphism-based noninvasive prenatal screening in a high-risk and low-risk cohort

Why should you read about this topic?

Because noninvasive prenatal screening is one of the most rapidly evolving areas of our specialty.  Try to keep up.

What were the authors trying to do?

Measure the performance of a single-nucleotide polymorphism-based noninvasive test for fetal aneuploidy in high-risk and low-risk groups

Who participated and in what setting?

Women (N=1064) with a singleton pregnancy at least 7 weeks gestational age at 36 prenatal care centers

What was the study design?

Retrospective cohort study of cell-free DNA analyzed using a single-nucleotide polymorphism-based algorithm

What were the main outcome measures?

Trisomy 21, 18, 13, or monosomy X, euploid, and male or female

What were the results?

8.1% did not generate a cell-free fetal DNA result (no-calls).  Excluding no-calls, triploidy, sex chromosome abnormalities, and fetal mosaicism, sensitivity was 100% for trisomy 21, 13, and sex, 96% for trisomy 18, and 90% for monosomy X.  Specificity was 100% for trisomies 21 and 13 and 99.9% for trisomy 18 and monosomy X.  Test performance was not different between high-risk and low-risk groups. Fetal sex was correctly identified in all cases (excluding no-calls).

What is the most interesting image in the paper?

Table 2

What were the study strengths and weaknesses?

Strengths: analysis for aneuploidy in no-calls.  Weaknesses: no adjustment for maternal weight

What does the study contribute for your practice?

Another option for non-invasive fetal aneuploidy testing


Wednesday, July 09, 2014
Matthew L. Zerden, MD, MPH
Fellow, Division of Family Planning
Department of Obstetrics and Gynecology
School of Medicine
University of North Carolina
 
As clinicians in the field of contraceptive care, we are consistently attempting to find ways to promote the most effective forms of contraception, which includes intrauterine contraception (IUC). We now have excellent evidence to support the use of IUC in almost all patients at risk of unintended pregnancy; however, concerns regarding painful pelvic exams and insertions have deterred some nulligravid patients from choosing IUC. We also know that social networks (ie, family and friends) in younger populations are very influential in contraceptive decision-making.1,2 Because women who have a negative, painful experience are likely to influence others, we need to make the insertion as painless as possible, focusing on nulligravid women.
 
Efforts to improve IUC insertion in this population have taken many different avenues, including developing more narrow and smaller IUC (Skyla); pharmacologic interventions for all nulligravidas such as pre-procedural misoprostol3 and intrauterine lidocaine4; informational campaigns (Bedsider.org); and even novel approaches such as self-administered vaginal lidocaine.5
 
In their innovative attempt to risk stratify patients who will have a difficult or painful insertion published in the August 2014 issue of Obstetrics & Gynecology, Kaislasuo and colleagues performed a pre-insertion transvaginal ultrasound to evaluate if uterine parameters could predict a challenging insertion.6 Their results confirmed clinical suspicions: women with smaller uteri, smaller cervices, and more flexion had more difficult insertions. Unfortunately, a cut-off value of uterine length could not be determined and, not surprisingly, women with a history of dysmenorrhea had increased pain on insertion.
 
Consistent with the previous attempts and strategies to decrease pain with IUC insertion cited above, Kaislasuo and colleagues were unable to demonstrate that their intervention should be adopted into routine clinical practice. Because the intervention involves an additional, intrusive test, transvaginal ultrasounds should be reserved for clinically indicated scenarios, such as a women with a prior failed insertion.
 
Perhaps what is most useful from this study is that providers should continue to rely on their gestalt, and consider other relevant clinical information that confers a higher likelihood of pain with IUC insertion. Conditions such as a history of dysmenorrhea, pelvic pain, or vulvodynia are more likely to predict a challenging insertion and require more thoughtful care. When providers encounter a woman who has these characteristics, the provider and patient can consider peri-procedural strategies that may ameliorate the pain experienced by the patient, even if these interventions have not been shown to be effective for the average woman. Explaining the potential benefit of misoprostol, non-traditional uses of lidocaine, or a pre-insertion ultrasound may provide the reassurance that will facilitate successful insertion. Anecdotally, having patient buy-in for challenging insertions can be a key step to achieving IUC insertion when others have failed. Specialists who attempt difficult IUC insertions will continue to benefit from research such as the present study by Kaislasuo, and we should continue to search for the elusive intervention that will significantly decrease IUC pain at insertion.
 
 
References
 
  1. Weston MR, Martins SL, Neustadt AB, Gilliam ML. Factors influencing uptake of intrauterine devices among postpartum adolescents: a qualitative study. Am J Obstet Gynecol 2012;206:40-e1.
  2. Gilliam ML, Warden M, Goldstein C, Tapia B. Concerns about contraceptive side effects among young Latinas: a focus-group approach. Contraception 2004;70:299-305.
  3. Swenson C, Turok DK, Ward K, Jacobson JC, Dermish A. Self-administered misoprostol or placebo before intrauterine device insertion in nulliparous women: a randomized controlled trial. Obstet Gynecol 2012;120:341-7.
  4. Mercier RJ, Zerden ML. Intrauterine anesthesia for gynecologic procedures: a systematic review. Obstet Gynecol 2012;120: 669-77.
  5. Rapkin RB, Achilles SL, Boraas C, Cremer M, Schwarz EB, Chen BA. Self-administered lidocaine gel for intrauterine device insertion in nulliparous women: a randomized controlled trial. Obstet Gynecol 2014;123:110S.
  6. Kaislasuo J, Heikinheimo O, Lähteenmäki P, Suhonen S. Predicting painful or difficult intrauterine device insertion in nulligravid women. Obstet Gynecol 2014;124(2).

Saturday, June 28, 2014

Frey, et al. Stillbirth risk among fetuses with ultrasound-detected isolated congenital anomalies

Why should you read about this topic?

There are few things more feared by mothers than stillbirth.

What were the authors trying to do?

Estimate the risk of stillbirth among fetuses found to have a major isolated congenital anomaly on antepartum ultrasound

Who participated and in what setting?

Women (N=65,308) with singleton pregnancies undergoing routine anatomic survey at Wash U between 1990 and 2009, excluding those with chromosomal abnormalities and those with minor anomalies

What was the study design?

Retrospective cohort

What were the main outcome measures?

Stillbirth after 24 weeks gestation

What were the results?

Stillbirth rate was higher in fetuses with a major anomaly (55/1000 compared with 4/1000), and even higher when associated with growth restriction (birthweight<10%ile 127/1000 compared with 18/1000).  Stillbirth rates were similar prior to 32 weeks gestation compared with after 32 weeks.

What is the most interesting image in the paper?

Table 2

What were the study strengths and weaknesses?

Strengths: Large number of observations; acceptable loss-to-followup rate.  Weaknesses: retrospective; single center; perinatal database; long study span with changing technology; growth restriction defined by birthweight rather than EFW

What does the study contribute for your practice?

Stillbirth rate is increased in fetuses with an isolated major anomaly regardless of growth status.   One in every 18 pregnancies complicated by a single major anomaly will result in a fetal death


Saturday, June 21, 2014

Harrison et al. Reducing postoperative pain after tubal ligation with rings or clips: a systematic review and meta-analysis

Why should you read about this topic?

Postoperative pain control is a major driver of patient satisfaction

What were the authors trying to do?

Estimate the efficacy (pain control) of local anesthesia applied to the fallopian tubes during laparoscopic sterilization with rings or clips under general anesthesia.

Who participated and in what setting?

Published reports (N=20) of women (N=1095) participating in randomized, double-masked, placebo-controlled trials of topical or injectable local anesthetic applied to the fallopian tubes to reduce pain at laparoscopic sterilization.

What was the study design?

Systematic review and meta-analysis

What were the main outcome measures?

Pain scores

What were the results?

Postoperative pain decreased with the use of local anesthetic compared with placebo by 11.9-18.6 mm (VAS) and by at least 33% in the first 8 hours, with greater benefit going to those patients receiving sterilization by rings.

What is the most interesting image in the paper?

Figure 2

What were the study strengths and weaknesses?

Strengths: thoughtful, pre-specified subanalyses; results stratified for risk of bias.   Weaknesses: no recent primary studies

What does the study contribute for your practice?

Local anesthetic applied to the fallopian tubes when sterilized with rings or clips by laparoscopy yields lower pain scores in the first 8 postoperative hours.

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.