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ACOG annual meeting highlights

Impact of epidural on labor and delivery

A comparison of outcomes before and after the introduction of epidural analgesia (EA) at an Army medical center shows no clinically significant effects on fetal head malpositioning, the length of the first stage of labor, or the risk of operative delivery [Obstet Gynecol. 2000;95:43S, 45S, 71S]. The use of EA did prolong the second stage of labor, however, and was associated with a significant increase in intrapartum maternal hyperthermia.

One of the authors, Dina Schweitzer, MD, from Tripler Medical Center, Honolulu, Hawaii, said this study of nearly 800 nulliparous women did not confirm previous reports that EA increases the likelihood of C/S, an encouraging finding that needs to be taken into consideration when counseling patients about options for labor pain.

Elective C/S to prevent complications?

Cesarean birth should be recommended for women carrying a fetus weighing more than 4,000 g or above the 90th percentile for gestational age, concluded an analysis of the literature by Brent W. Bost, MD, MBA, from St. Elizabeth Hospital, Beaumont, Tex. [Obstet Gynecol. 2000;95:46S]. Tissue injury at delivery leads to stress incontinence (SUI) and pelvic prolapse in 50% of parous women and inadequate rectal sphincter control in 5% to 10%, the study found, and specific risk factors for these complications include macrosomia, prolonged second stage of labor, and extensive episiotomy.

Dr. Bost said studies that downplay the adverse effects of vaginal delivery have not followed the patients long enough. In one large study, however, short-term complications alone suggested that elective C/S should be preferred to attempting labor and vaginal delivery for large babies. The argument becomes even more compelling when long-term complications of pelvic organ prolapse and urinary and SUI are included in the analysis. Acknowledging that this perspective may conflict with efforts to reduce the C/S rate, Dr. Bost concluded: "As physicians we must openly discuss the short-and long-term consequences of vaginal delivery versus elective C/S and let our patients make the choice."

Hysterectomy and sexual response

A comparison of sexual activity among women in a wellness program suggests that those with an intact uterus are more active and orgasmic than those who have had a hysterectomy [Obstet Gynecol. 2000;95:19S].

This study challenges a widely reported finding by Rhodes and colleagues that sexuality improves with hysterectomy. Winnifred B. Cutler, PhD, President of the Athena Institute for Women's Wellness (Chester Springs, Pa.) and one of the authors of the new study contends that the baseline used in reaching that conclusion was distorted. She argues that because sexual activity is depressed in women who are scheduled to undergo hysterectomy within 30 days, comparing that to women studied 2 years later introduces a bias.

Cutler and colleagues found that both vaginal and cervical stimulation contribute to sexual arousal in women and removing the uterus compromises sensitivity at these sites. They also found that woman with fibroid tumors have heightened vaginal sensitivity. "Compared to women who have not had a hysterectomy and those who have fibroids, women who had hysterectomy are not having sex as often, are not having orgasm as often, and when they are having sex, the only place they're feeling it is at the clitoris," Dr. Cutler noted.

Managing preterm labor

According to a large-scale review of the evidence, acute tocolysis with any conventional agent is beneficial in the management of premature labor. Home uterine activity monitoring, on the other hand, was found not to be effective for prolonging pregnancy [Obstet Gynecol. 2000;95:75S, 80S]. The same study found that both fetal fibronectin testing and endovaginal U/S have predictive value: A negative result is useful for identifying lower-risk patients.

This review, which also includes reports on maintenance tocolysis and antibiotics for the treatment of preterm labor, will be made available by the Agency for Healthcare Research and Quality, on the Web site, http://www.ahcpr.gov. "We hope this will be a good resource for practitioners," Katherine E. Hartmann, MD, PhD, a member of the research team at the University of North Carolina Evidence-Based Practice Center, Chapel Hill, N.C., told Contemporary OB/GYN.

Expanding gynecologic office practice

At an ACOG session on the evolving role of gynecology, Craig A. Winkel, MD, MBA, Professor at Georgetown University School of Medicine, Washington, D.C., told the audience that about 85% of the health needs of women can be satisfied by ob-gyns and predicted that the future belongs to full-service women's clinics, providing services from contraception, Pap smears, and PMS stress reduction to menopause management, osteoporosis testing, psychological counseling, and even cosmetic procedures. "Consumerism is driving today's healthcare markets," he said, and gynecologists need to expand their practice to survive in this environment. But his opponent in the debate, Stephen K. Klasko, MD, from Lehigh Valley Hospital, Allentown, Pa., warned that people want to see physicians as professionals with an ethic, and asked, "Do we really want to be removing patients' unwanted hair?" Some activities should be beyond bounds for ob-gyns, he argued, but agreed with Dr. Winkel on the advantage of one-stop shopping for medical services.

Literature News

Linking mom's risk of death and infant's birthweight

Women who give birth to infants weighing less than 2,500 g are more than seven times as likely to die from cardiovascular disease than women who give birth to infants weighing 3,500 g or more, according to a longitudinal study [BMJ. 2000;320:839-840]. Even those whose babies weigh between 2,500 g and 3,499 g are almost twice as likely to die from cardiovascular disease as mothers of newborns weighing more than 3,500 g.

The authors point out that this association could be due to maternal characteristics, including nutritional and behavioral factors, that influence both infant birthweight and the woman's cardiovascular mortality, or to poor socioeconomic status that affects both variables, or to genetic factors.

Sertraline for PTSD

The antidepressant sertraline (Zoloft) is a safe, well-tolerated, effective treatment for posttraumatic stress disorder (PTSD), according to a placebo-controlled trial [JAMA. 2000;283:1837-1844]. Sertraline, a selective serotonin reuptake inhibitor, is the first drug to receive FDA approval for the treatment of PTSD.

The patients in this trial, of whom more than 70% were women, were randomized to receive placebo or sertraline hydrochloride in flexible daily dosages of 50 to 200 mg/d, following 1 week at 25 mg/d. The treatment group showed significantly greater improvement than the placebo group on most standardized measures of PTSD severity.

 

Chidem Kurdas. updates. Contemporary Ob/Gyn 2000;7:143-144.