Heidi Anne Duerr, MPH

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Despite the widespread use of oxytocin as a prophylactic for obstetric hemorrhage, there is no clear recommendation as to the optimal dose. To provide insight into this issue, researchers conducted a double-masked randomized trial comparing two higher dose regimens with a standard dose regimen. Their results were published in a recent issue of Obstetrics & Gynecology.

Dr. Alan T.N. Tita, associate professor in the department of obstetrics and gynecology at University of Alabama at Birmingham, Birmingham, Alabama, and colleagues randomized 1,798 women with viable pregnancies undergoing vaginal delivery at 24 weeks of gestation or more to receive oxytocin at doses of 80 units (N=658), 40 units (N=481), or 10 units (N=659).

In comparison with the participants who received 10 units, Tita et al. found that higher doses did not result in a significant decrease in the unadjusted risk of the primary outcome (i.e., a composite of any treatment of uterine atony or hemorrhage) nor a decrease in the treatment of uterine atony or obstetric hemorrhage with any uterotonics. The researchers found a relative risk of 6% for both of the higher doses as compared to 7% for the 10 unit dose. However, Tita and colleagues noted that, when compared with 10 units of oxytocin, 80 units significantly decreased the need for treatment with additional oxytocin. They did not find the same association with 40 units of oxytocin. In addition, fewer women in the group who received 80 units had a 6% or greater decline in hematocrit as compared with the group who received 10 units; a similar association was not found with the group who received 40 units. Higher doses were not associated with higher incidences of such adverse effects as hypotension or fluid overload.

Although higher doses of oxytocin appear to be more effective than lower-dose regimens in preventing postpartum hemorrhage after cesarean delivery, the researchers believe their findings do not show that this is the case for women with vaginal deliveries.  However, Tita et al. found some benefits associated with the 80 unit dose.

“Overall, higher doses of prophylactic oxytocin (80 units or 40 units), as compared with the standard dose of 10 units of oxytocin when administered in 500 mL of crystalloid over the course of 1 hour after vaginal delivery, did not significantly reduce the incidence of the primary composite outcome of uterine atony or hemorrhage requiring any treatment,” Tita and colleagues explained.  “However, 80 units of oxytocin reduced the frequency of two prespecified secondary outcomes: hemorrhage requiring treatment after the first postpartum hour and a decline in hematocrit more than 6% units. There was a significant dose-response trend in these outcomes (reducing incidence with increasing dose of prophylactic oxytocin).”

Preeclampsia Increases the Risk of Postpartum Hemorrhage


 Tita AT, Szychowski JM, Rouse DJ, et al. Higher-dose oxytocin and hemorrhage after vaginal delivery: a randomized controlled trial. 

Articles

Study Provides Dosing Insight for Oxytocin in Preventing Obstetric Hemorrhage

Methods used during closing after a cesarean section affect intra-abdominal adhesions, according to a new study published in 

American Journal of Obstetrics & Gynecology

Dr. Deirdre J. Lyell, associate professor  of obstetrics and gynecology - maternal fetal medicine at Stanford School of Medicine, Stanford University, Stanford, California, and colleagues performed a secondary analysis of a prospective cohort study of women (N=173) who underwent first repeat cesarean delivery.  Lyell et al. used records to assess previous surgical techniques. Severity and location of adhesions, which were noted by surgeons immediately following the surgery, were used in the analysis.

In comparison with visceral peritoneum, Lyell and colleagues found that rectus muscle closure was associated with fewer combined filmy and dense adhesions. Specifically, they found such in 27.5% of cases with rectus muscle closure as compared to 46% in visceral peritoneum. Moreover, rectus muscle closure was associated with fewer dense adhesions overall in comparison with visceral peritoneum (17.5% and 46%, respectively). Meanwhile, increased dense fascia-to-omentum adhesions were associated with visceral peritoneum closure.

Based on these findings, rectus muscle closure appeared to have greater benefits than visceral peritoneum closure, the authors concluded. “Closure of the rectus muscles at cesarean delivery may reduce adhesions, and visceral peritoneum closure may increase them,” Lyell and colleagues explained. They added, “Surgical techniques at cesarean delivery should be assessed independently, because they may have opposite effects on adhesion formation.”


 Lyell DJ, Caughey AB, Hu E, et al. Rectus muscle and visceral peritoneum closure at cesarean delivery and intraabdominal adhesions. 

Methods used during closing after a cesarean section affect intra-abdominal adhesions, according to a new study published in American Journal of Obstetrics & Gynecology.

Rectus Muscle Closure at Cesarean Is Associated With Fewer Adhesions

Laparoscopy has been shown to be a safe and effective option for many diverse pelvic organ diseases, but how does the procedure fare during pregnancy? Due to the absence of large, comparative studies in pregnancy, there has been no definitive answer to this question. Now, researchers from Korea have found that laparoscopic surgeries can be safely used in women who are pregnant. Their results have been published in 

The Australian and New Zealand Journal of Obstetrics and Gynaecology.

Dr. Yu-Jin Koo, from the department of obstetrics and gynecology at Cheil General Hospital and Women’s Healthcare Center, Kwandong University College of Medicine, Seoul, and colleagues conducted a retrospective study of pregnant women (N=262) who underwent laparotomy or laparoscopic surgery for adnexal masses. Women in the laparoscopic surgery group (N=88) received general endotracheal anesthesia and were placed in the modified dorsolithotomy position during surgery. In contrast, women in the laparotomy group (N=174) received general or regional anesthesia; the surgeon’s preference dictated the anesthesia used. Although there were no significant differences in baseline characteristics such as mean age, body mass index, parity, history of assisted reproductive techniques, bilaterality of masses, or preoperative serum CA-125 level, Koo et al. found that patients in the laparotomy group had significantly larger mean mass size while those in the laparoscopy group had a significantly earlier mean gestational age at surgery and a significantly higher rate of undergoing emergency surgery.

Overall, Koo and colleagues found shorter operative times and shorter hospital stays in the laparoscopic group as compared to that of the patients in laparotomy group. In terms of obstetrical outcomes, Koo et al. did not find any significant difference between the groups for mean gestational age, mean birth weight, mean Apgar score, or the rates of preterm delivery, low birth weight, or miscarriage. However, the researchers found that preterm labor occurred more frequently in the laparotomy group as compared to the laparoscopy group (odds ratio= 5.85).

“The results obtained during our 10 years of experience indicate that laparoscopic surgery during pregnancy may have better surgical and similar obstetric outcomes, primarily shorter operative times and shorter lengths of hospital stay compared with those of laparotomy,” Koo and colleagues explained. 
 


 Koo YJ, Kim HJ, Lim KT, et al. Laparotomy versus laparoscopy for the treatment of adnexal masses during pregnancy. 

Laparoscopy has been shown to be a safe and effective option for many diverse pelvic organ diseases, but how does the procedure fare during pregnancy? Due to the absence of large, comparative studies in pregnancy, there has been no definitive answer to this question. Now, researchers from Korea have found that laparoscopic surgeries can be safely used in women who are pregnant. Their results have been published in The Australian and New Zealand Journal of Obstetrics and Gynaecology.

Laparoscopy for Adnexal Masses Is Safe and Effective During Pregnancy

Human papillomavirus vaccines provide still some benefit to women who have undergone treatment for HPV-related diseases, according to a new study published in the 

Dr. Elmar A. Joura, associate professor in the department of gynaecology and obstetrics at the Medical University of Vienna, Comprehensive Cancer Center, in Vienna, Austria, and colleagues conducted a retrospective analysis of data from two international, double blind, placebo-controlled, randomized efficacy trials of quadrivalent HPV vaccine. Joura and colleagues were trying to determine if the administration of quadrivalent HPV vaccine, when compared with placebo, reduced the incidence of subsequent HPV-related disease among women who had undergone surgery for cervical disease or who were diagnosed with vulvar or vaginal disease (i.e., genital warts, vulvar intraepithelial neoplasia, or vaginal intraepithelial neoplasia).  Participants were women (N=17,622) between 15 years old and 26 years old who had a history of less than 4 sexual partners, no previous abnormal results on a cervical smear test, and were not pregnant. Women were randomly assigned to receive intramuscular injections of quadrivalent HPV vaccine or placebo at day 1, month 2, and month 6.

Joura et al. found that women in the placebo group were more likely to undergo cervical surgery for disease due to any HPV type as compared to their counterparts in the vaccine group (N=763 versus N=587, respectively).  Moreover, participants in the placebo group also had higher incidence of any HPV-related disease. Joura and colleagues found a significantly reduced risk of 46.2% of any subsequent HPV-related disease after cervical surgery, irrespective of causal HPV type, associated with the vaccine. They further noted a significant reduced risk of any subsequent cervical disease for cervical intraepithelial neoplasia grade I or worse and any subsequent high grade cervical disease. For participants who received the vaccine, the researchers also found reduced incidence of genital warts and a significantly reduced risk of any subsequent disease related to vaccine HPV type.

“Our study confirms that vaccination does not reduce progression to disease in women who are infected with HPV at the time of vaccination,” the authors wrote, “but women who were treated for disease in the context of these studies were at risk for developing subsequent disease, and vaccination offered substantial benefit.”

Joura et al. added, “Our results of the subgroup analysis demonstrate that vaccination with the quadrivalent HPV vaccine was associated with reduced incidence of subsequent cervical, vulvar, and vaginal intraepithelial neoplasia and genital warts in women who had been diagnosed and treated for cervical and vulvar or vaginal disease.”

Good-bye Annual Exams: New Cervical Cancer Screening Guidelines Focus on Patient's Age 

Genital Herpes Vaccine Not Ready for Prime Time


 Joura EA, Garland SM, Paavonen J, et al. Effect of the human papillomavirus (HPV) quadrivalent vaccine in a subgroup of women with cervical and vulvar disease: retrospective pooled analysis of trial data. 

Human papillomavirus vaccines provide still some benefit to women who have undergone treatment for HPV-related diseases, according to a new study published in the British Medical Journal.

Author | Heidi Anne Duerr, MPH

Articles

Study Provides Dosing Insight for Oxytocin in Preventing Obstetric Hemorrhage

Rectus Muscle Closure at Cesarean Is Associated With Fewer Adhesions

Laparoscopy for Adnexal Masses Is Safe and Effective During Pregnancy

HPV Vaccine Beneficial for Women with Previous Cervical and Vulvar Disease