Clinical Insights/Professional Update

December 1, 2003



 

NEWS WATCH

CLINICAL INSIGHTS

Jump to:Choose article section... Prophylactic measures for shoulder dystocia don't work Cervical cerclage doesn't prevent preterm delivery Sex gets better after hysterectomy What do abnormal mammography results

Do lower-dose OCs contribute to lower bone density?

As more and more women use oral contraceptives containing lower amounts of estrogen and progestin, some experts have wondered whether the resulting decreased concentrations of circulating sex steroids might be contributing to lower bone density in reproductive-aged women.

To help provide the answer, Seattle researchers measured bone density at the spine, hip, and whole body of 245 women between the ages of 18 and 39. They found that absolute bone density at 36 months and the rate of bone mineral density change over 3 years did not differ significantly between those using OCs and those not using hormonal contraception.

It is still unknown, however, whether the effects of OCs differ for women in their 20s who are still on the bone-building climb when compared to older premenopausal women who have reached the bone-building peak and are starting their descent.

Reed SD, Scholes D, LaCroix AZ, et al. Longitudinal changes in bone density in relation to oral contraceptive use. Contraception. 2003;68:177-182.

Prophylactic measures for shoulder dystocia don't work

Prophylactic use of the McRoberts maneuver and suprapubic pressure does not hasten delivery in pregnant women at risk for shoulder dystocia and places women at about three times the risk of delivering via cesarean section, according to a recent randomized, controlled trial.

The study involved 128 vaginal deliveries of women at risk for shoulder dystocia with estimated fetal weights in excess of 3,800 g. Half the women underwent the McRoberts maneuver and suprapubic pressure before delivery of the fetal head, while the other half underwent the maneuvers only if they were necessary after delivery of the head.

Head-to-body delivery times, rates of admission of infants to special care nurseries, and the number of birth injuries did not differ significantly between the two groups; however, the risk of delivering via C/S was significantly higher for the group receiving the measures prophylactically (34%) versus the group receiving therapeutic intervention (12%). The only apparent advantage to performing the procedures prophylactically was avoidance of an overt diagnosis of shoulder dystocia in some patients.

Beall MH, Spong CY, Ross MG. A randomized controlled trial of prophylactic maneuvers to reduce head-to-body delivery time in patients at risk for shoulder dystocia. Obstet Gynecol. 2003;102:31-35.

Cervical cerclage doesn't prevent preterm delivery

Despite its use in clinical practice, no conclusive evidence exists to prove that inserting a cervical stitch prophylactically in women at low-to-medium risk of preterm birth or second-trimester pregnancy loss reduces the risk of either, according to a meta-analysis of randomized clinical trials.

When researchers reviewed six trials involving 2,175 women, the pooled results failed to show a statistically significant decrease in early pregnancy loss, total pregnancy loss, or in preterm delivery rates. Only one trial, the largest, revealed a reduction in births less than 33 weeks' gestation, from 17% to 13%, when a cervical suture was used.

Given this and the fact that cervical cerclage is consistently linked to increased risks of maternal infection and pyrexia, the authors concluded that there's no scientific support for cervical cerclage in women at low or medium risk of second-trimester miscarriage or extreme preterm labor. They conceded, however, that the procedure might have merit for women at high risk of second-trimester miscarriage because of at least two previous second-trimester pregnancy losses or progressive shortening of the cervix as revealed by ultrasound.

Drakeley AJ, Roberts D, Alfirevic Z. Cervical cerclage for prevention of preterm delivery: meta-analysis of randomized trials. Obstet Gynecol. 2003;102:621-627.

Sex gets better after hysterectomy

While many of your patients may find this hard to believe, sexual pleasure and well-being improve after hysterectomy, according to 413 women in the Netherlands who underwent the procedure.

Researchers surveyed women who received vaginal hysterectomy, subtotal abdominal hysterectomy, or total abdominal hysterectomy for benign disease other than symptomatic prolapse of the uterus and endometriosis.

According to the women's reports, the quality and quantity of sexual activity after surgery did not differ significantly from before surgery in any of the groups, and general satisfaction about sexuality improved after all techniques.

Compared with women who underwent vaginal hysterectomy, those who received total or subtotal abdominal procedures had only a slight increase in persisting problems with lubrication, arousal, or genital sensation. New sexual problems developed in 23% of the women receiving vaginal hysterectomy, 24% of the women receiving subtotal abdominal hysterectomy, and in 19% of the total abdominal hysterectomy group. By 6 months after surgery, one or more bothersome sexual problems affected 43%, 41%, and 39% of the vaginal, subtotal abdominal, and total abdominal groups, respectively.

Roovers JP, van der Bom JG, van der Vaart CH, et al. Hysterectomy and sexual well-being: Prospective observational study of vaginal hysterectomy, subtotal abdominal hysterectomy, and total abdominal hysterectomy. BMJ. 2003;327:774-778.

What do abnormal mammography results really mean?

In an attempt to help clinicians interpret screening mammograms and guide them on a practical diagnostic course, researchers reviewed relevant studies published in the last 17 years.

They found that a result of "suspicious abnormality" or "highly suggestive of malignancy" on a screening exam is associated with a high likelihood of breast cancer (likelihood ratios 125 and 2,200, respectively). They concluded that such women should undergo core-needle biopsy or needle localization with surgical biopsy.

On the other hand, they found that women who receive a "probably benign finding" result on screening mammography are at low risk of breast cancer (likelihood ratio 1.2) and may be followed with two additional mammographies at 6-month intervals.

Women who receive a "need additional imaging evaluation" result on screening mammography are at intermediate risk of breast cancer (likelihood ratio 7). Clinicians should make every attempt to determine the significance of these lesions through clinical evaluation and radiologic methods before sampling tissue to minimize the number of unnecessary biopsies performed.

The researchers also concluded that either fine-needle aspiration (FNA) biopsy or ultrasonography should be the first diagnostic step for a palpable breast abnormality, that FNA biopsy is useful for characterizing a solid mass, and that diagnostic mammography is useless for determining whether or not a palpable breast mass should be biopsied.

Kerlikowske K, Smith-Bindman R, Ljung BM, et al. Evaluation of abnormal mammography results and palpable breast abnormalities. Ann Intern Med. 2003;139:274-284.

PROFESSIONAL UPDATE

AMA, ACOG challenge GAO report on liability crisis

Earlier this year, the US General Accounting Office released a report saying that rising medical liability rates were affecting access to health care on a local scale—not a widespread basis. Basing its findings on a review of five states with reported malpractice-related problems (Florida, Mississippi, Nevada, Pennsylvania, and West Virginia), and four states without reported problems (California, Colorado, Minnesota, and Montana), the GAO "found that while local problems exist, reports of physicians retiring early, discontinuing services, or moving out of state couldn't be substantiated or didn't have a big effect on access to care," reported American Medical News (9/22–29/03).

Since the release of the report, "Medical Malpractice: Implications of Rising Premiums on Access to Health Care," it has faced criticism by the American Medical Association and the American College of Obstetricians and Gynecologists. The AMA questioned the report's finding, noting that the data used were outdated and that the scope of the review was too limited to give an adequate picture of overall trends.

ACOG noted, for example, that the GAO only focused on how many ob/gyns have closed their practices, rather than also looking at how many ob/gyns have dropped or reduced certain areas of their practice, including obstetrics, gynecologic surgery, or caring for high-risk patients—a key element in determining access to ob/gyns.

According to a statement from the medical organization, "ACOG finds this report to be a dangerously superficial analysis of access problems to ob/gyn care, one that completely misses the patient care crisis in obstetrics and gynecology. It does the US Congress and the American people a disservice by ignoring significant problems pregnant women and women in need of ob/gyn care are facing."

A cost-effective, pharmacologic way to treat recurrent preterm labor

Continuous subcutaneous terbutaline is a more cost-effective pharmacologic way of treating recurrent preterm labor than prescribed oral tocolytics, according to a study in Managed Care (July 2003). The study's researchers found that the cost for a singleton pregnancy with recurrent preterm labor was higher among women prescribed oral tocolytics than those who received a continuous, low-dose infusion of terbutaline.

The study involved two groups of women—one group was treated with oral tocolytics and the other with continuous subcutaneous terbutaline. To determine the cost-effectiveness of each treatment, the researchers created a conservative model in which the costs per day for antepartum hospital days, outpatient nursing services, and newborn care were standardized. Not considered in the cost of care were physician charges and lifetime medical expenses.

Regardless of which treatment the women received, the researchers found that nursery costs were the largest expense. For women who received subcutaneous terbutaline, the second largest expense was the cost of outpatient nursing services related to drug administration. For women who received oral tocolytics, the second largest expense was the cost of maternal antepartum hospital days.

The researchers estimate that $4.6 million was spent on overall care for women prescribed subcutaneous terbutaline, whereas more than $6.1 million was spent for women prescribed oral tocolytics. Moreover, they found that overall costs averaged $5,286 less per pregnancy for those treated with subcutaneous terbutaline vs. those given oral tocolytics.

 

Clinical Insights/Professional Update. Contemporary Ob/Gyn Dec. 1, 2003;48:12-16.