News from ACOG 2015

May 6, 2015

Research looks at ACOG's 39-week initiative, whether a diagnosis of GBS in 1 pregnancy increases likelihood in future pregnancies, and more data on open versus in-bag morcellation.

Stillbirths and ACOG’s 39-week initiative

 A single-institution study presented at the American College of Obstetricians and Gynecologists (ACOG) 63rd Annual Clinical and Scientific Meeting is casting new light on the group’s “39-week” rule for pregnancy.  In their population, the researchers said, the rate of stillbirth has increased since implementation of guidelines for eliminating non-medically indicated deliveries before 39 weeks’ gestation.

More: Why are women having nonindicated early deliveries?

The findings, from the Hurley Medical Center/Michigan State University, are from a retrospective chart review of 6561 deliveries with stillbirth from March 4, 2012 to July 31, 2014 at or beyond 20 weeks’ gestation or birthweight ≥350 g when the gestational age was unknown.  Of the deliveries, 2846 occurred before (Group 1) and 3715 occurred after the ACOG guidelines were implemented.

In November 2013, ACOG and the Society for Maternal-Fetal Medicine recommended replacing the use of “term,” which previously indicated gestation between 37 weeks and 42 weeks, with four separate gestational age designations. Since then, “full term” has been defined as 39 weeks through 40 weeks and 6 days. The change reflected a growing body of research findings showing that key developmental processes occur between 37 weeks and 39 weeks and that birth at or after 39 weeks is associated with the healthiest outcomes for babies.

In the case of the Michigan cohort, the rate of stillbirth increased from 0.35 to 1.35 per 1000 births after implementation of the guidelines, with 16 intrauterine fetal demises in Group 1 versus 29 cases in Group 2. The researchers said that their data, albeit in a small sample in a single institution, suggested a “disturbing trend that needs further evaluation, especially in medical centers caring for a high-risk pool of patients for whom all medical indications are not covered by the lists of approved indications.”

Satti MA, Raju R, Abhari S, et al. The effect of the 39-week initiative on intrauterine demise. Abstract 254.

NEXT: Does GBS in 1 pregnancy mean GBS in all pregnancies?

 

Once GBS always GBS in pregnancy?

A systematic review and meta-analysis presented at the American College of Obstetricians and Gynecologists (ACOG) 63rd Annual Clinical and Scientific Meeting adds credence to previous reports suggesting that Group B Streptococcus (GBS) in pregnancy predisposes women to the condition in subsequent gestations.

Conducted by researchers from Kelsey-Seybold Clinic in Houston, Texas, the analysis looked at 5 cohort studies that included 1150 women in a subsequent pregnancy. Prevalence of recurrent GBS was 44.5% (512/1150) and GBS in an index pregnancy was associated with a higher rate of recurrent colonization in a later gestation (3 studies: 50.2% versus 14.1%, pooled fixed-effects odds ratio [OR] 6.05, 95% confidence interval [CI] 4.84-7.55 P<.01). Heavy colonization (>80 colony-forming units) in women with GBS was associated with increased risk of recurrence (4 studies: 52.0% versus 45.1%, pooled fixed effects OR 1.54, 95% CI 1.02-2.31; P=.04) A pregnancy interval <12 months, body mass index ≥30, primiparity in a subsequent pregnancy, race, and ethnicity had no effect on the outcome in subgroup analysis.

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Colonization with GBS in pregnancy, the researchers concluded, is associated with a high rate of recurrence in a subsequent gestation and even more likely in women who are considered to be highly colonized.

Turrentine MA, Colicchia L, Hirsch E, et al. Risk of recurrence of Group B Streptococcus in subsequent pregnancies. Abstract 303

NEXT: What does the recent data say about morcellation?

 

More data on in-bag versus open morcellation

In the wake of ongoing controversy about morcellation during laparoscopy, researchers from Brigham & Women’s Hospital presented new data at the American College of Obstetricians and Gynecologists (ACOG) 63rd Annual Clinical and Scientific Meeting that suggest an in-bag procedure may be a safer option for contained tissue extraction. The findings were based on outcomes in patients at 4 hospitals with an average age of 43.16 years.

Included in the analysis were 76 women undergoing laparoscopic or robotic hysterectomy or myomectomy (42 hysterectomy, 34 myomectomy). After surgical dissection, specimens to be extracted were placed into a containment bag with blue dye. The bag was insufflated intracorporeally, punctured to enable access for visualtion and electromechanical morcellation and tissue extraction was performed. The containment system’s integrity was evaluated visually for leakage of dye or tears in the bag.

Of the women, 33 had a history of abdominal surgery and average body mass index was 26.47 ±5.93. In all cases, a laparoscopic or robotic multiport technique was used. Average morcellation time was 30.2 minutes.

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No bag tears occurred during morcellation but there was one tear before morcellation. In 7 cases, spillage of dye or tissue was noted but the bags were intact except for the intended puncture site. Only one intraoperative complication (estimated blood loss 3600 mL and conversion to open radical hysterectomy) was observed. Median blood loss was 50 mL and the most common pathologic finding was benign leiomyoma.

According to Dr. James Greenberg, “contained tissue extraction using electromechanical morcellation and intracorporeally insufflated bags may provide a safe alternative to uncontained morcellation by decreasing the spread of tissue in the peritoneal cavity while allowing for the traditional benefits of laparoscopy. The method used in our study is not the final answer but we are pleased with this important first step in validating this techniques potential safety.”

Goggins ER, Greenberg JA, Cohen SL, et al. Efficacy of tissue extraction for minimizing tissue dissemination during laparoscopic hysterectomy and myomectomy. Abstract 66