June 2005 CCC Corner > Hot Topics

Hot Topics:

• Obstetrics
• Gynecology
• Child Health
• Chronic Disease and Illness

Obstetrics

Slight delay in umbilical cord clamping better for preterm infants
Cochrane for Clinicians: Putting Evidence into Practice
Clinical Question
What is the optimal time to clamp the umbilical cord for infants born at less than 37 weeks' gestation?
Evidence-Based Answer
In preterm infants, clamping the umbilical cord between 30 seconds and two minutes after delivery is associated with lower rates of blood transfusion and intraventricular hemorrhage.
REVIEWERS' CONCLUSIONS: Delaying cord clamping by 30 to 120 seconds, rather than early clamping, seems to be associated with less need for transfusion and less intraventricular haemorrhage. There are no clear differences in other outcomes.
Rabe H, et al. Early versus delayed umbilical cord clamping in preterm infants. Cochrane Database Syst Rev 2004;(3):CD003248 http://www.aafp.org/afp/20050601/cochrane.html
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15495045&query_hl=6

Public versus Private Umbilical Cord Blood Banking: Editorial Green Journal
An individual's chance of using the blood is low.
The possibility of a child's needing hematopoietic stem cell transplantation is low. Best estimates suggest the risk is 1 in 2,700,and the risk advanced by private companies, which one might expect to present the "best case" for cord blood need, is 1 in 1,400 Indeed, the literature reports few cases of an individual's receiving back his or her own banked cord blood, and industry publications, which one might expect would be eager to promote such cases, cite no more. Further, of reported cases, some involve families whose histories suggested the potential need for stem cell therapy before delivery and collection.
Public setting best at this time
In sum, our arguments are not about the potential of umbilical cord stem cells, but are about the setting and system where that potential is best realized. We argue for public umbilical cord blood banking as a matter of good public health and economic sense. We foresee a day in which most patients will volunteer their cord blood to such banks. Those who do so will value real public benefits against the, sometimes, exaggerated claims of individual benefit advanced by private cord blood banks. We prefer, as a matter of public health and policy, to rely on public institutions to manage such a valuable resource as umbilical cord blood and trust that the integrity of these institutions and their obligation to the public will insure the future safety and availability of banked samples.

Although we offer this vision, we cannot predict the future. Some private banks suggest that, in the future, stem cells and cord blood may be used to treat a host of other diseases, such as diabetes or Alzheimer's, in which specific cell lines are depleted or dysfunctional. For now, however, such potentials are, at best, hypothetical and, at worst, exaggerated claims designed to attract business. Time may prove that umbilical cord stem cells have compelling benefits to the individual, but for now the available evidence argues for the promotion of public rather than private cord blood banking.
Ecker JL, Greene MF. The case against private umbilical cord blood banking. Obstet Gynecol. 2005 Jun;105(6):1282-4.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932817&dopt=Abstract

Pregnancy-Related Changes in Physical Activity, Fitness, and Strength
CONCLUSION: Relative to pre-pregnancy performance, fitness and strength declined in the early postpartum period but improved by 27 wk postpartum.
Treuth MS, Butte NF, Puyau M. Pregnancy-related changes in physical activity, fitness, and strength. Med Sci Sports Exerc. 2005 May;37(5):832-7.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15870638&query_hl=10

Women with hypoglycemia during OGTT have lower incidence of GDM and neonatal BW
CONCLUSION: The incidence of reactive hypoglycemia during the 100-g oral glucose tolerance test in our population is 6.3%. Women who experience hypoglycemia during the test have a significantly lower incidence of gestational diabetes and neonatal birth weights. LEVEL OF EVIDENCE: III Weissman A, et al Hypoglycemia During the 100-g Oral Glucose Tolerance Test: Incidence and Perinatal Significance. Obstet Gynecol. 2005 Jun;105(6):1424-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932839&dopt=Abstract

Does the presence of a funnel increase the risk in a patient with a short cervix?
CONCLUSION: The disruption of the internal os, as documented by funneling, is a significant risk factor for adverse perinatal outcome (ie, preterm labor, chorioamnionitis, abruption, rupture of the membranes, and serious neonatal morbidity and mortality). Cervical funneling is best measured as a categorical variable (present or absent).
Rust OA, et al Does the presence of a funnel increase the risk of adverse perinatal outcome in a patient with a short cervix? Am J Obstet Gynecol. 2005 Apr;192(4):1060-6.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15846180&query_hl=5

Use of Prescription Drugs During Pregnancy
almost one half of the women in this study received medications that have no evidence of safety during pregnancy or for which evidence shows a risk to the fetus in animals or humans. They add that these results indicate the need to develop and implement systems that eliminate the exposure of pregnant women to these medications. CONCLUSION: Our finding that almost one half of all pregnant women received prescription drugs from categories C, D, or X of the United States Food and Drug Administration risk classification system highlights the importance of the need to understand the effects of these medications on the developing fetus and on the pregnant woman Andrade SE, et al. Prescription drug use in pregnancy. Am J Obstet Gynecol August 2004;191:398-407.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15343213&query_hl=4

Emergence of Doulas as Childbirth Paraprofessionals
Fourteen randomized trials have demonstrated that continuous caregiver support during childbirth can lead to shorter labors and decrease the need for intervention. Our survey findings suggest that a number of challenges . . . present significant obstacles to the further growth of doulas as childbirth paraprofessionals in the United States. Additional research is needed to better understand the unique role and contributions of doulas/labor assistants to maternity care teams in the 21st century. Lantz PM, Low LK, Varkey S, et al. 2005. Doulas as childbirth paraprofessionals: Results from a national survey. Women's Health Issues 15(3):109-116.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15894196&query_hl=1

Routine Use of Episiotomy in Uncomplicated Births Offers No Benefits to Women
AHRQ released a new evidence report that shows routine use of episiotomy for uncomplicated vaginal births does not provide immediate or longer term benefits for the mother. Episiotomy is the surgical cutting of the perineum-the skin between the vaginal opening and the anus-and is a common procedure used in an estimated one-third of vaginal deliveries to hasten birth or prevent tearing of the skin during delivery. The routine episiotomy, common in many practice settings, did not achieve any of the goals it is commonly believed to achieve. The topic was nominated by the American College of Obstetricians and Gynecologists, which intends to translate the findings into clinical practice guidelines for OB/GYNs. http://www.ahrq.gov/clinic/epcsums/epissum.htm

IV bolus of 1,000 mL, lateral positioning, and oxygen administration at 10 L/min via nonrebreather face mask significantly increase fetal oxygen saturation during labor.
CONCLUSION: An intravenous fluid bolus of 1,000 mL, lateral positioning, and O(2) administration at 10 L/min via nonrebreather face mask are effective in increasing FSpO(2) during labor. LEVEL OF EVIDENCE: II-2.
Simpson KR, James DC. Efficacy of intrauterine resuscitation techniques in improving fetal oxygen status during labor. Obstet Gynecol. 2005 Jun;105(6):1362-8
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932830&dopt=Abstract

A systematic literature review indicated that laser ablation produced better survival for at least 1 twin and lower long-term neurodevelopment morbidity in survivors.
CONCLUSION: In a systematic review of observational and randomized controlled studies, laser photocoagulation of chorionic plate vessels at the intertwin membrane seems to be more effective than serial amnioreduction in the treatment of twin-twin transfusion syndrome with less associated perinatal morbidity and mortality. However, septostomy and selective feticide have not been robustly evaluated. Fox C, Kilby MD, Khan KS.Contemporary treatments for twin-twin transfusion syndrome. stet Gynecol. 2005 Jun;105(6):1469-77.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932845&dopt=Abstract

Management of Pregnancy Beyond 40 Weeks' Gestation (also see Patient Education)
http://www.aafp.org/afp/20050515/1935.html

Back to top

Gynecology

More effective than povidone iodine in vaginal hysterectomy: Chlorhexidine gluconate
CONCLUSION: Chlorhexidine gluconate was more effective than povidone iodine in decreasing the bacterial colony counts that were found in the operative field for vaginal hysterectomy.

Although bacterial contamination may have a greater level of reduction in the chlorhexidine group, this does not guarantee a difference in postoperative infection. Among the 50 patients enrolled in this study, none of them were noted to have a postoperative infection. The authors also commented that if they were to structure the study to look at postoperative infections, they would have to enroll 814 patients in each arm to achieve a 50% reduction. Similar but larger studies may be helpful to assess whether chlorhexidine prep should become the standard prep for vaginal hysterectomies.
Culligan PJ et al A randomized trial that compared povidone iodine and chlorhexidine as antiseptics for vaginal hysterectomy. Am J Obstet Gynecol. 2005 Feb;192(2):422-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15695981&query_hl=17

Transdermal contraceptive promising for reducing bleeding and delaying menses
CONCLUSION: Compared with cyclic use, extended use of the norelgestromin/ethinyl E2 transdermal patch delayed menses and resulted in fewer bleeding days. This regimen may represent a useful alternative for women who prefer fewer episodes of withdrawal bleeding. LEVEL OF EVIDENCE: I. Stewart FH, et al Extended Use of Transdermal Norelgestromin/Ethinyl Estradiol: A Randomized Trial. Obstet Gynecol. 2005 Jun;105(6):1389-1396
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932834&dopt=Abstract

Collagen Injections May Be a Reasonable Option for Treating Female Stress Incontinence
CONCLUSIONS: One year after intervention, the success rate of collagen injection as a treatment for stress urinary incontinence was about 19% lower than that after surgery. This has to be tempered by the similar changes in quality of life and satisfaction in both groups and that the number and severity of complications were much greater after surgery than after collagen injection. The results of this study indicate that collagen injections might be a worthwhile alternative to surgery for the treatment of stress urinary incontinence
Corcos J et al Multicenter randomized clinical trial comparing surgery and collagen injections for treatment of female stress urinary incontinence. Urology. 2005 May;65(5):898-904
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15882720&query_hl=11

Menorrhagia and Screening for von Willebrand Disease
Although von Willebrand disease may be more prevalent in women with menorrhagia than in the general population, it is difficult to identify the proportion of menorrhagia cases attributable to this disease. In addition, there are too few data to confirm the degree of enhanced morbidity or surgical risk in women who have menorrhagia with von Willebrand disease. Routine screening for von Willebrand disease in women with menorrhagia therefore is not supported sufficiently by current evidence. Further data are needed.
James A, Matchar DB, Myers ER. Testing for von Willebrand disease in women with menorrhagia: a systematic review. Obstet Gynecol. 2004 Aug;104(2):381-8.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15292016&query_hl=1

Sexual functioning / quality-of-life outcomes similar in RCT of supracervical hysterectomy
CONCLUSION: Supracervical and total abdominal hysterectomy result in similar sexual functioning and health-related quality of life during 2 years of follow-up. This information can help guide physicians as they discuss surgical options with their patients. LEVEL OF EVIDENCE: I
Kuppermann M et al Sexual Functioning After Total Compared With Supracervical Hysterectomy: A Randomized Trial. Obstet Gynecol. 2005 Jun;105(6):1309-1318.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932822&dopt=Abstract

Uterine Fibroid Embolization - Patient Education
“Known medically as uterine artery embolization, this approach to the treatment of fibroids blocks the arteries that supply blood to the fibroids causing them to shrink. It is a minimally-invasive procedure, which means it requires only a tiny nick in the skin, and is performed while the patient is conscious but sedated /drowsy and feeling no pain....” From Society of Interventional Radiology
http://www.sirweb.org/patPub/uterineTreatments.shtml#uf

Recurrent vulvar itching. Green Journal “In the Trenches”
This month's "In the Trenches" uses a practical question-based case series to assess the evaluation and management of a woman with vulvar itching thought to be due to recurrent vulvovaginitis. Boardman LA, Botte J, Kennedy CM. Recurrent vulvar itching. Obstet Gynecol. 2005 Jun;105(6):1451-5.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932843&dopt=Abstract

Back to top

Child Health

Risk of Autism: Parent, Pregnancy, and Birth Factors Found Possible Associations
Pregnancy factors, parental psychiatric history, and preterm delivery may be associated with the risk of autism. Some of the specific factors that the study found to be associated with the risk of autism included: breech presentation at birth, delivery before 35 weeks, a parent who had a diagnosis of schizophrenia-like psychosis before the date that autism was diagnosed in the child, and low birth weight at delivery. The study also found many of these factors were independently associated with autism. For example, there was an association between adverse pregnancy events and autism, regardless of whether one of the parents had a diagnosed psychiatric illness.
http://www.cdc.gov/od/oc/media/pressrel/r050516.htm

Screening for Idiopathic Scoliosis in Adolescents: Recommendation Statement, USPSTF
The USPSTF recommends against the routine screening of asymptomatic adolescents for idiopathic scoliosis. D recommendation. http://www.aafp.org/afp/20050515/us.html

Back to top

Chronic disease and Illness

Women with pregnancy-induced hypertension: Increased risk of metabolic syndrome later
CONCLUSION: In white women in their mid-30s, the prevalence of the metabolic syndrome is 3- to 5-fold increased in those with a history of PIH in their first pregnancy. This emphasizes the importance of long-term follow-up assessment for cardiovascular risk factors in these women. LEVEL OF EVIDENCE: II-2. Forest JC, et al Early occurrence of metabolic syndrome after hypertension in pregnancy. Obstet Gynecol. 2005 Jun;105(6):1373-80.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db=pubmed&list_uids=15932832&dopt=Abstract

Improving Adherence to Treatment for Hypertension
Cochrane for Clinicians: Putting Evidence into Practice
Clinical Scenario
M.L. is a 58-year-old man with poorly controlled hypertension; he has been prescribed 100 mg of metoprolol twice daily. He says he is so tired when he gets home at night that he usually goes to bed without taking the second dose of his medication.
Clinical Question
What methods are effective at improving adherence to treatment in patients with hypertension?
The most effective strategy to improve patient compliance with antihypertensive medication is to simplify the dosing regimen. There is more limited evidence to support a variety of motivational strategies. Patient education alone is ineffective.
The practice recommendations: http://www.cochrane.org/cochrane/revabstr/AB004804.htm
http://www.aafp.org/afp/20050601/cochrane.html

American Cancer Society Releases Annual Guidelines for the Early Detection of Cancer
Recommendations
BREAST CANCER SCREENING
Breast cancer screening should begin when women are 20 years of age and should consist of clinical breast examinations, counseling to raise awareness of symptoms, and regular mammography after the age of 39. Clinical breast examinations should take place every three years in women 20 through 39 years of age and annually in women 40 years and older. Women at average risk should begin annual mammography at the age of 40 and should continue the practice as long as they are in good health and would be candidates for breast cancer treatment. The ACS no longer recommends monthly breast self-examinations, but instead recommends that women be informed of the potential limitations, risks, and benefits associated with self-examination. The new guidelines emphasize the physician's role in raising and reinforcing awareness of breast cancer, early detection, and the importance of timely reporting of any symptoms.

CERVICAL CANCER SCREENING
Cervical cancer screening should begin three years after the onset of vaginal intercourse but no later than 21 years of age. Screening should be performed annually until the age of 30 with conventional cervical cytology smears, or every two years until the age of 30 with liquid-based cytology. Women older than 30 years who have had three consecutive normal or negative cytology results may reduce the frequency of screening to every two to three years. Women 70 years and older with an intact cervix may cease cervical cancer screening if they have had three or more consecutive normal or negative cytology results within the 10-year period before the age of 70.

Women with a history of cervical cancer or in utero exposure to diethylstilbestrol should continue annual screening after age 30. Women who are immunocompromised (i.e., organ transplant patients, those receiving chemotherapy, those with human immunodeficiency virus infection) should be tested twice in the first year after diagnosis and annually thereafter as long as they are in good health and would benefit from early detection and treatment.

Cervical cancer screening is not indicated for women who have had a total hysterectomy for benign gynecologic disease. Women with subtotal hysterectomy should follow the recommendations for women at average risk.

COLORECTAL CANCER SCREENING
Adults at average risk of developing colorectal cancer should begin screening at 50 years of age using one of five options: (1) annual fecal occult blood test or fecal immunochemical test, (2) flexible sigmoidoscopy every five years, (3) annual fecal occult blood test or fecal immunochemical test plus flexible sigmoidoscopy every five years, (4) colonoscopy every 10 years, or (5) double-contrast barium enema every five years.

More intensive surveillance is recommended for patients with a history of adenomatous polyps, a history of curative-intent resection of colorectal cancer, a family history of colorectal cancer or colorectal adenomas diagnosed in a first-degree relative before the age of 60, a history of inflammatory bowel disease of significant duration, or family history of genetic testing indicating one of two hereditary syndromes.

ENDOMETRIAL CANCER SCREENING
Endometrial cancer screening is not recommended for women at average or somewhat increased risk. However, the ACS recommends that women in these categories be informed of the risks and symptoms of endometrial cancer at the onset of menopause. Women at very high risk of endometrial cancer (i.e., those with known hereditary nonpolyposis colon cancer-associated genetic mutation carrier status, substantial likelihood of being a mutation carrier, or absence of genetic testing results in families with suspected autosomal dominant predisposition to colon cancer) should consider annual screening beginning at 35 years of age.

LUNG CANCER SCREENING
Testing for early lung cancer detection is not recommended for asymptomatic persons who are at risk. The ACS maintains that patients at risk for lung cancer because of significant exposure to tobacco smoke or occupational exposures may discuss with their physicians the benefits and risks of testing and may decide to undergo testing on an individual basis. Ideally, testing should be done only in experienced centers that are linked to multidisciplinary subspecialty groups. Patients who currently smoke should be informed that the immediate preventive health priority is the elimination of tobacco use.
The American Cancer Society (ACS) has released its annual recommendations for the early detection of cancer. The report was published in the January/February 2005 issue of CA: A Cancer Journal for Clinicians http://caonline.amcancersoc.org/cgi/content/full/55/1/31
http://www.aafp.org/afp/20050601/practice.html

Cognitive Therapy May Be Effective for Moderate to Severe Major Depression
CONCLUSION: Cognitive therapy can be as effective as medications for the initial treatment of moderate to severe major depression, but this degree of effectiveness may depend on a high level of therapist experience or expertise.
DeRubeis RJ, et al Cognitive therapy vs medications in the treatment of moderate to severe depression. Arch Gen Psychiatry. 2005 Apr;62(4):409-16.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15809408&query_hl=16

Untreated Depression Common in Minority Women With Cancer
CONCLUSION: Findings indicate that depressive disorder among ethnic minority, low-income women with breast or gynecologic cancer is prevalent and is correlated with pain, anxiety, and health-related quality of life. Because these women are unlikely to receive depression treatment or supportive counseling, there is a need for routine screening, evaluation, and treatment in this population.
Ell K, et al Depression, correlates of depression, and receipt of depression care among low-income women with breast or gynecologic cancer. J Clin Oncol. 2005 May 1;23(13):3052-60.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15860863&query_hl=12

High cholesterol levels in elderly linked to lower dementia risk
CONCLUSIONS: High cholesterol in late life was associated with decreased dementia risk, which is in contrast to previous studies suggesting high cholesterol in mid-life is a risk factor for later dementia. The conflicting results may be explained by the timing of the cholesterol measurements in relationship to age and the clinical onset of dementia.
Mielke MM, et al High total cholesterol levels in late life associated with a reduced risk of dementia. Neurology. 2005 May 24;64(10):1689-95
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15911792&query_hl=8

Back to top

OB/GYN

Dr. Neil Murphy is the Obstetrics and Gynecology Chief Clinical Consultant (OB/GYN C.C.C.). Dr. Murphy is very interested in establishing a dialogue and/or networking with anyone involved in women's health or maternal child health, especially as it applies to Native or indigenous peoples around the world. Please don't hesitate to contact him by e-mail or phone at 907-729-3154.