Skip Navigation LinksHome > Blogs > blO+G
blO+G
Current events in Obstetrics & Gynecology, updates on new web site features and links to other web sites of interest to ObGyns.
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.


Saturday, August 30, 2014

Graham et al. Diagnostic accuracy of fetal heart rate monitoring in the identification of neonatal encephalopathy

Why should you read about this topic?

What obstetrician does not think about neonatal encephalopathy and its consequences?

What were the authors trying to do?

Estimate the diagnostic accuracy of electronic fetal heart rate monitoring immediately prior to delivery for neonatal encephalopathy

Who participated and in what setting?

Neonates (N=39) treated with whole-body hypothermia for neonatal encephalopathy matched with controls (N=78) born in the Johns Hopkins system between 2007 and 2013

What was the study design?

Retrospective case control study of the last hour of electronic fetal heart rate monitoring

What were the main outcome measures?

Neonatal encephalopathy treated with whole body hypothermia; the primary exposure was worst category tracing in the hour prior to delivery

What were the results?

There was no significant difference between groups for tracing category.  Multivariable logistic regression showed that cases had a decrease in frequency of early decelerations, and an increase in total deceleration area 30 and 60 minutes prior to delivery.  Sensitivity and specificity were poor for all associations.

What is the most interesting image in the paper?

Table 6

What were the study strengths and weaknesses?

Strengths:  systematic, comprehensive approach to interpretation of fetal heart tracings; well-defined cases.  Weaknesses: suboptimal inter-observer agreement for tracing characteristics

What does the study contribute for your practice?

Current methods of interpreting fetal heart tracings in the hour prior to delivery are not helpful for predicting neonatal encephalopathy


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.
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.