Updates

UPDATES Rehospitalization following complicated deliveries A retrospective study of all primiparous women who gave birth to singleton infants in Washington State between 1987 and 1996 showed that rehospitalization within 60 days was 1.8 times more likely when delivery was by cesarean section and 1.3 times more likely with assisted vaginal delivery than in those who delivered spontaneously [JAMA. 2000;283:2411-2416]. Among women who had C/S, the most common reasons for rehospitalization were uterine infections, surgical wound complications, and cardiopulmonary and thromboembolic conditions. Among those who required assisted vaginal deliveries, the most common reasons for rehospitalization were postpartum hemorrhage, surgical wound complications, and pelvic injury. Contraception and coexisting conditions The American College of Obstetricians and Gynecologists has issued contraceptive recommendations for women with coexisting conditions, including fibrocystic breast changes, breast cancer, fibroids, migraines, hypertension, diabetes, and high cholesterol. The recommendations address questions regarding when to prescribe a combination oral contraceptive, a progestin-only OC, an implant, or an injection. Among ACOG's suggestions: You can prescribe the Pill to women with a family history of breast cancer, but be very cautious if you give combination OCs to smokers over age 35. For information, visit the organization's Web site at http://www.acog.org. C/S better for woman with cervical Ca When a pregnant woman has undiagnosed cervical cancer, vaginal delivery increases the risk of recurrence after treatment, a case-control study shows [Obstet Gynecol. 2000;95:832-838]. Among women who were diagnosed within 6 months of delivery, 59% of those who had delivered vaginally had a recurrence, compared with only 14% of those who had delivered via C/S. A possible explanation is that cancer cells disseminate more easily with dilation of the cervix during delivery. Relieving tamoxifen-induced hot flashes Oral clonidine reduces the frequency of hot flashes in women who have breast cancer and are taking tamoxifen, according to a randomized, double-blind, placebo-controlled trial that involved 194 postmenopausal women [Ann Intern Med. 2000; 132:788-793]. The women received either oral clonidine hydrochloride in a dose of 0.1 mg/d for 8 weeks or placebo. The mean reduction in hot flash frequency after 8 weeks of treatment was 38% for the clonidine group versus 24% for the placebo group. When a co-twin dies in utero The live-birth twin of a fetus that died in utero has a 1 in 5 chance of suffering cerebral impairment, an analysis of all twin births in England between 1993 and 1995 indicates [Lancet. 2000;355: 1597-1602]. The authors report that gestational age-specific prevalence of cerebral palsy is much higher when one of the twins dies than for the general twin population, but the pathological mechanism that causes the impairment is unclear. Easy method for ruling out PID In women with pelvic pain, evidence of lower-genital-tract inflammationin the form of white blood cells or pus in vaginal dischargeturns out to be a highly sensitive test for upper-genital-tract infection and pelvic inflammatory disease (PID) as well [Infect Dis Obstet Gynecol. 2000;8: 83-87]. This result comes from an analysis of data for the first 157 patients enrolled in the multi-center PID Evaluation and Clinical Health (PEACH) study. While highly sensitive at about 89%, presence of white blood cells or mucopus had a low specificity (19.4%) in the diagnosis of upper-genital-tract infection and PID. On the other hand, the absence of these clinical signs suggests a woman's pelvic pain is probably not caused by endometritis. Menses exacerbates dystonia In a survey, 42% of premenopausal women with dystonia said the severity of their muscle contractions changed with their menstrual cycle, with the majority of these women (92%) reporting worsening of symptoms just prior to or during menses [Mayo Clin Proc. 2000;75:235-240]. It is unclear whether a definite relationship exists between dystonia and menses, however, because these women also reported a worsening of premenstrual symptoms prior to their periods. Hormone replacement therapy, pregnancy, menopause, and the use of oral contraceptive pills had no effect on dystonia, but stress and fatigue were found to exacerbate the symptoms, while sleep improved them. Strategy to help women quit smoking A brief clinic-based intervention that consists of video viewing, behavioral counseling, clinician advice to quit, and follow-up telephone calls was more successful than advice alone in getting low-income women, aged 15 to 35, to quit smoking [Am J Public Health. 2000;90:786-789]. After 6 months of follow-up, 6.4% of the women who participated in the cessation program were biochemically shown to have abstained from cigarettes for at least 30 days, versus 3.8% of the advice-only group. HPV DNA testing A study of previously unscreened South African women found that human papillomavirus DNA testing is at least as sensitive as cytology and easier to implement, possibly making it a lower-cost approach for primary cervical cancer screening [J Natl Cancer Inst. 2000;92:818-825]. While cytology had a statistically superior specificity (96.8%) than the HPV DNA tests Hybrid Capture I (87.8%) or Hybrid Capture II (81.9), DNA tests may nevertheless be more appropriate for low-resource settings because they are standardized, require only midlevel technicians, facilitate handling of large numbers of samples, and are unaffected by cervical inflammation and cervicovaginitis. Literature News Infertility treatments and multiple pregnancies Estimates based on new data from the CDC and the Society for Assisted Reproductive Technology indicate that the incidence of triplet and higher-order multiple births more than quadrupled from 1980 to 1997 and a large proportion of this increase can be attributed to assisted reproductive technology (ART) and ovulation-inducing drugs [MMWR. 2000; 49:535-538]. Triplet and higher-order births went from 37 to 173.6 per 100,000 live-born infants. Among mothers aged 35 to 39, the increase was even more pronounced, from 48 to 403 per 100,000 infants. The researchers estimate that in 1997, over 43% of the triplet and higher-order births were due to ART, about 40% were due to ovulation-inducing drugs without ART, and the rest were spontaneous. According to a separate study, multiple pregnancy is unacceptably frequent after ovulation induction with gonadotropin and less intensive stimulation can reduce the incidence of high-order pregnancies only to a limited extent [N Engl J Med. 2000; 343:2-7]. The latter strategy has the disadvantage of reducing the overall rate of pregnancy in infertile women seeking treatment. An alternative is to use in vitro fertilization instead of ovarian stimulation and to transfer no more than one or two embryos at a time. "Either way, a radical change in focus for both providers and consumers of infertility services is required," concludes an accompanying editorial in The New England Journal of Medicine. Metformin for PCOS A prospective study supports the use of metformin (Glucophage), an insulin sensitizer, for the treatment of polycystic ovary syndrome (PCOS) [Fertil Steril. 2000;73:1149-1154]. In the trial, 39 women with PCOS and fasting hyperinsulinemia were given 12 weeks of metformin therapy, 500 mg three times per day. The treatment significantly decreased the symptoms of hyperandrogenism and hyperinsulinemia. It also produced significant declines in mean body mass index, waist-hip ratio, hirsutism, and acne, and improved the regularity of the women's menstrual cycles. An editorial in the same issue points out that metformin may increase the number of ovulatory cycles in women with PCOS, especially when combined with clomiphene. This approach has fewer potential serious side effects than treatment with gonadotropin or ovarian surgery, previously the only options for women with PCOS who do not get pregnant after treatment with clomiphene alone. To date, however, no large-scale trials with live birth as the primary end point have been reported. The editorialists conclude that before attempting the use of gonadotropin or ovarian surgery, "metformin should be included in the stepwise approach to ovulation induction in women with PCOS," an approach that starts with weight loss and proceeds to clomiphene as a single agent, an insulin sensitizer as a single agent, and a combination of clomiphene and an insulin sensitizer. The most common adverse effects of metformin include diarrhea, nausea, vomiting, and abdominal bloating. In a few cases, primarily involving patients with renal dysfunction, metformin has resulted in fatal lactic acidosis. Because of this risk, experts recommend not using the drug in women with serum creatinine concentrations greater than 1.4 mg/dL. Early feeding after radical hysterectomy Aggressive bowel stimulation and prompt feeding after radical hysterectomy cause bowel function to return sooner and consequently lead to earlier hospital discharge than traditional postoperative feeding protocols, a prospective trial of 20 patients suggests [Am J Obstet Gynecol. 2000;182:996-998]. The women, who underwent class 3 radical hysterectomy, were given a clear liquid diet and 66% sodium phosphate solution (Fleet Phospho-Soda) on the first postoperative day. Mean time to passage of flatus was 2.6 days and to passage of stool 2.8 days. Mean time to discharge was 3.5 days. There were no incidents of emesis, ileus, or bowel obstruction, but 20% of the women reported nausea. Mean time to discharge in another trial, where patients received the conventional treatment of no postoperative bowel stimulation and slow dietary advancement, was 8.2 days. Survival not improved by radiation for early endometrial Ca In a study of 714 women with stage 1 endometrial cancer who had total abdominal hysterectomy and bilateral salpingo-oophorectomy, 5-year overall actuarial survival rates were 81% for the patients randomized to postoperative radiation and 85% for the control group [Lancet. 2000; 355:1404-1411]. Radiation therapy did reduce local recurrence but increased treatment-related complications25% of the women who underwent this treatment had complications, compared with only 6% of those treated with surgery alone. The median duration of follow-up in the study was 52 months. During this time, 9% of the radiation group died of endometrial cancer-related causes, compared with 6% of the controls. The authors suggest that: (1) adjuvant pelvic irradiation be considered selectively for women with the highest risk of relapse and, (2) those who do not have radiation be followed closely for local recurrences. Hypoxia associated with schizophrenia in the child Obstetrical complications that deprive a baby of oxygen double that person's risk of early-onset schizophrenia, according to an analysis of the records of randomly chosen schizophrenia patients born in Finland in 1955, their non-schizophrenic siblings, and unrelated adults [Am J Psychiatry. 2000;157:801-807]. Birth asphyxia in particular increased the risk, but prenatal infection and fetal growth retardation were not linked to the disease. Early onset was defined as before age 22 for women, 19 for men. No relationship was found between oxygen deprivation and late onset of schizophrenic symptoms. Each birth complication that resulted in hypoxia added to the risk of early-onset schizophrenia and individuals whose births had involved three or more complications were 10 times as likely to develop it as those who had no complications. Since most people who had hypoxia nevertheless did not develop schizophrenia, the authors caution that, oxygen deprivation at birth does not predict that a person will get the disease. Chidem Kurdas. Updates. Contemporary Ob/Gyn 2000;9:130-136.