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Spotlight on obstetrics
SPOTLlGHT QN OBSTETRICS Ralph W. Hale, MD Editor
ACOG CLINICAL REVIEW Ralph W. Hale, MD Editor
.
Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Pediatrics 2000;105:789-93. Synopsis:
Gerald B. H&man, MD Luella Klein, MD Stanley Zinberg, MD Associate Editors .
Decreased Incidence of UTI Associated With Circumcision in the First Year of life
.
Journals Surveyed Include: Acta Obstetricia et Gynecologica Scandinavica l American Journal of Obstetrics and Gynecology . Annals of Internal Medicine l Australian and New Zealand Journal of Obstetrics and Gynaecology BMJ . British Journal of Obstetrics and Gynaecology Canadian Medical Association Journal l Cancer l European Journal of Obstetrics, Gynecology,
These authors conducted a retrospective study of 14,893 male infants delivered in 1996. Of these, 9668 (64.9%) underwent circumcision. Their objective was to determine the effect of circumcision of the newborn on subsequent urinary tract infections (UTIs) during year one of life. They found 154 UTIs in this cohort of male infants of which 132 (86%) occurred in those who were uncircumcised. They concluded that newborn circumcision resulted in a 9.1-fold decrease in the incidence of UTIs during the first year of life. . . .
an~~$!$$i~~~ii$y Commentary:
International Uro necology Journal JAMA . Journ aYof Ultrasound in Medicine . Lancet l Military Medicine . New England Journal of Medicine l Obstetrics and Gynecology l Pediatrics .
.
.
rhc
Co yright Q 2000 by Amencan College ofobstetricians an Gynecolo istr. Pubbrhcd by Elsevier Science Inc. ACOG B ClznrcnPRrvrrw 1s &cd bnnonrbly by Elsevier Science Inc.. 655 Avrnue of rbc Ameru.s, New York, NY 10010. Subscriprion prices pa year: For cutomers in the Unirrd Scares: Instnutionai rare: $205 00, pcrsonll rate: $106.00. For‘ustomersinEuropcand rbeCIS, lnsrirutional ncc: NLG 403.00, personal rare: NLG 208.00. For cusmmcrs m Japan: lnst,turional rate: JPY 25,300.00, personai rare: JPY 13,100.OO. Prices include port c and arc rubjecr to change wirhour norice. For additmn 2 mformarion, contacr Elscwer Science Customer Sup on Dcpanmenr, P.O. Box 945, NnvYork, NY 10010, K-7. (212) 633-3730 Toll free. (for customers in North Amena): I-888-4ESINF0, Fax: (212) 633.3680, E-til: [email protected]. Address advcnising mqumes co Phlrmaceurical Medm Inc., 30 Easr 33rd St., NW York, NY 10016. Application to mail al eriodnls osta races15pending m New York, NY. an B al addition max in c&es. Postmaster: Send addresschanges j $7 10 ACOG C&co Rmm, Elsevier Science Inc., 655 Avenue ofrhe Americas,NewYork, NY 10010-5107. No res onsibihry isvsumed bythcpublishcror rhc AmericanCal e e of Obrtetricianr and Gynccologms for any mjury and/or% amage to persons or property 15 a matter of prcducrs lizbdiry, negkgencc or other,&, or from any use or aperarmn ofany methods, producrr, insrrucrions, or ideas conramed m rhc materill heran. Becaw of rapid advances in the mcdid sc~cnces,inh “dent verification of dngnoses and drug dosagesrhoul r bc made. Discussmns, VICWS,and recommendations as IO medal procedures, choice of drugs, and drug das es arc rhe rcrponslbiliry ofrhe aurhors. The appearance of P% vrrrxsmg m publiatians of rhe Amrrun College of Obstetncmns and Gynrcologiscs (and/or m exhlbns ar meerings of rhe College) does nor conxicucc a guaranree or endorscment of the u&y or value of such product or of the cllims made for it,% y its manufacturer. The fax char a prodUCI, SENICC, or cornpan is advcrnsed m a public-aim or exhibired at a meeung o F rhe College shall not bc referred to by rhe manufacturer in advernsmg.
2 . i\C;OG
CLlNlCAL
REVIEW
.
Newborn circumcision has become a topic of much discussion and debate in the last 10 years. The use of anesthesia has been recommended in a number of reports including articles abstracted in previous issues of ACOG Clinical Review. A number of groups have attacked circumcision as a needless procedure without medical indication. One correspondent who contacted this editor when ACOG released its report on female genital mutilation asked when we would release a similar report on male genital mutilation (AKA circumcision). The American Academy of Pediatrics, in response to the debate and question, has published a report on circumcision. This detailed report discusses the controversy and gives recommendations. For the interested reader the report can be found in the Circumcision Policy Statement, American Academy of Pediatrics, Task Force on Circumcision. Pediatrics 1999;103:686-93. The present article, however, offers a different perspective. They have shown a medical indication for cir-
NovembcriDecernbrr
2000
cumcision, that is, prevention of UTIs. They have also made a calculation of potential cost savings. Not included in the comparison is the cost of the procedure in the 90% who have no problem; thus, the cost comparison has no real value. Likewise, until follow-up of years has shown significant subsequent problems in male infants with UTIs in the first year, no conclusion can be substantiated. Circumcision has many ramifications other than the prevention of UTIs. Religious and social issues also play a role in the parents’ decision about circumcision. Most likely, the debate will take generations to come to a conclusion, if it ever does. Therefore, as the AAP has stated, it is a decision best left to the parents and their physicians after presentation of the current available information.
Appendicitis in Pregnancy Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy: New information that contradicts long-held clinical beliefs. Am J Obstet Gynecoi 2000;182: 1027-9. Synopsis:
In a retrospective review of 66,993 deliveries from 1986 to 1995, the authors found 45 cases of histologically proved appendicitis and 22 cases that were unproved after pathologic examination. The cases occurred in all three trimesters and right lower quadrant pain was the most common presenting complaint in all trimesters. The mean white blood cell count was 16.4 X lO’/L for patients with proved appendicitis, compared with 14.0 X 10 /L for those with normal histologic findings. Perforation occurred in eight cases. They conclude that right lower quadrant pain is the most common symptom and that fever and leukocytosis are not clear indicators. They further concluded that preterm labor may be a problem but preterm delivery is rare. . . . Commentary:
Based on 45 cases, it is difficult to make any generalized conclusion, especially when a retrospective chart review is the basis for the study. It is of interest that right lower quadrant pain was the best diagnostic tool and that regardless of trimester the pain occurred in the right lower quadrant. Appendicitis in pregnancy is not
‘CZOOOby
theA~ner’can COlkQe 01 Dbstelrlc,ans
and G;necoloyirti PublIShed bv Elsevler Scl~llce inc 1085.6862,00’$6 OC
rare but neither is it common. In this series the occurrence was I in I493 pregnancies. The only message from this report is to consider appendicitis if pain persists in the right lower quadrant.
Maternal Mortality in the UK De Swiet M. Maternal mortality: Confidential enquiries into maternal deaths in the United Kingdom. Am J Obstet Gynecol 2000;182:760-6.
Synopsis: The author of this report reviewed the Confidential Enquiries Into Maternal Deaths in the United Kingdom, a regular audit of maternal mortality. The rate of maternal mortality in 1952-1954 was 70 per 100,000 and fell to 11 per 100,000 in 1994-1996. The largest drop occurred after the 1968 legalization of abortion. Before that time abortion was the leading cause of maternal death. In 1994-1996 there were only three deaths related to abortion, The leading causes of maternal death in 1994-l 996 were thrombosis and hypertension. Other less common causes were hemorrhage, amniotic fluid embolism, pregnancy loss, and sepsis. They identified substandard care as a significant contributor in 1952-1954 (406 cases) but this factor had been reduced in 1994-1996 (76 cases). Cases of substandard care were most often due to failure to refer, failure of consultants to respond, lack of a clear policy for severe preeclampsia, and lack of recognition of a problem outside the area of expertise. In 1994 -1996, substandard care was common in deaths due to hemorrhage and ectopic pregnancy (65%). The author concluded that audits of maternal mortality are effective in reducing rates and identifying the causes. . . . Commentary: This report is different from those usually reviewed by the editor. It is not a research report but an invited lectureship. The author, Dr. Michael de Swiet, was the Joseph Price Orator at the most recent American Gynecological and Obstetrical Society Meeting (Carlsbad, California, September 16-18, 1999). This lecture was chosen for review because it addressed an important topic, maternal mortality, and the author shows the benefits of maternal mortality reviews. Unfortunately, in many parts of the United
States this type of review is no longer actually pursued. There are many reasons. However, until maternal mortality is recognized to be an ongoing problem and actions are taken at all levels to investigate why, we will never lower our rate to the 3 per 100,000 that most experts consider to be the lowest possible rate.
VBAC: An Australian Study Appleton B, Targett C, Rasmussen M, Readman E, Sale F, Permael M, and the VBAC Study Group. Vaginal birth afrer cesarean section: An Australian multicentre study. Aust N Z J Obstet Gynaecd 2000;40:87-91.
Synopsis: This report is a retrospective analysis of vaginal birth after cesarean section. It is a report from the Australian vaginal birth after cesarean (VBAC) study group and was performed at 11 major obstetric hospitals from July 1992 to June 1997. There were 234,0 15 deliveries in the cohort and 21,452 (9.2%) had had one or more prior cesarean deliveries. In this subgroup 5419 (25.33%) had a vaginal delivery. They found 62 cases of significant rupture with a perinatal mortality rate of 25% and serious maternal complications in 25%. The final estimate, based on this study, was a uterine rupture associated with VBAC in 0.3%, with 0.05% experiencing a perinatal death and 0.05% needing a hysterectomy. . . . Commentary: VBAC has received a lot of emphasis in the past few years. Two main factors appear to have been the strong motivator for this emphasis. First was the recognition that repeat cesarean delivery was a major component of the increasing rate of cesarean delivery in the United States. By 1995, this rate had reached about one in four deliveries. The second important factor was an increasing preference by patients who had had a previous cesarean delivery to have a vaginal delivery with a subsequent pregnancy. This article is one of many now being published that investigate the complications associated with VBAC. Because many of these articles are from single institutions, the possibility of selection bias is ever present. In this study there were 11 centers. Unfortunately, the data are only retrospective so there is still the possibility of misinterpretation; however, they
have restricted their review to very specific concerns and, thus, avoided an attempt to be all inclusive with limited data. Their incidence of VBAC attempt is lower than that reported in the United States so this also affects their data. A major question is whether the selected patients represented an optimal group. Would higher rates with fewer preselected patients result in greater or lesser percentages of complications? We will not know but the rate of uterine rupture with significant sequelae, even though low, still should alert the obstetrician and the patient that a VBAC is not the same as a labor and vaginal delivery with an unscarred uterus. ACOG Practice Bulletin Number 5, Vaginal Birth Afier Previous Cesarean Delivety, July 1999, is a comprehensive review of this issue. It includes clinical considerations and counseling, as well as an algorithm for the care of a patient requesting VBAC.
Twin Birth Outcomes and Prenatal Care in the United States Kogan MD, Alexander GR, Kotelchuck M, MacDorman MF, Buekens P, Martin JA, et al. Trends in twin birth outcomes and prenatal care utilization in the United States, 1981-1992 JAMA2000;283:335-41.
Synopsis: This study was undertaken to determine if aggressive management of twin births would affect the outcome. The information was obtained from the data on birth and death records between 198 1 and 1997 maintained by the National Center for Health Statistics. The preterm birth rate for twins increased from 40.9% in 1981 to 55.0% in 1997. Low birth weight infants increased from 5 1% to 54%. The preterm small for gestational age (SGA) infants increased from 11.9% to 14.1% and the percentage of term SGA infants decreased from 30.7% to 20.5%. When intensive prenatal care use was factored into the study the preterm birth rate increased from 35.1% to 55.8%, whereas those women with less intensive prenatal care had an increase from 50.6% to 59.2%. However, those with the more intensive care had a lower infant mortality rate. . . .
Commentary: This article from the Maternal and Child Health Bureau of the Health Resources and Services Administration is an attempt to document changes in care of twin pregnancies by evaluating the outcomes over an extended period of years. The unexplained finding is that preterm birth is more frequent in the last part of the study than earlier. The inference that intensive prenatal care may be a contributing factor is unfortunate. These authors have relied on birth records that may or may not be accurate. There was no ability to review the actual labor records. To substantiate any claim of validity, the actual hospital record must be reviewed for accuracy of the data on the birth record. A major concern with this study is that obstetric care has changed dramatically over this 16-year period; thus, comparisons are meaningless. Earlier intervention in problem cases is frequently used to improve outcome as opposed to 20 years ago when “watchful waiting” was advocated. Likewise, those with intensive prenatal care were more likely to have problems that would encourage earlier intervention. This article is an example of those studies that present an analysis of statistics but in reality have no practical importance because the underlying data on which the statistics are based are unreliable.
Maternal Age and Fetal Loss Andersen AMN, Wohlfahrt J, Christens I’, Olsen J, Melbye M. Maternal age and fetal loss: Population based register linkage study. BMJ 2000;320:1708-12.
Synopsis: This investigation was conducted in Denmark. The country has a unique system in which all citizens are registered and a national database is compiled. Using these data, the authors reviewed 643,272 women with 1,22 1,546 pregnancies to determine the association between maternal age and fetal death as defined by spontaneous abortion, ectopic pregnancy, and stillbirth. They found that 13.5% of pregnancies ended in a fetal death. At age 42, more than 50% were lost. Compared with a rate of 8.9% in women aged 20 to 24, spontaneous abortion in those ages 45 or more was 74.7%. They concluded that fetal loss is high in women in their late 30s or older.
. . . Commentary: Because of the large number and the validity of the database, these results are significant. The association of advancing age and fetal loss has been shown to increase proportionately. This study confirms similar reports and the anecdotal experience of many ob/gyns. This is an epidemiological study so no attempt was made to correlate the findings with current practice. However, the authors urge everyone involved in prepregnancy counseling to caution their patients about prolonged delays in child bearing. As more women plan to continue their careers and delay pregnancy after marriage, they need to be made aware of this potential problem.
Predictors of Severe Preeclampsia Stamilio DM, Sehdev HM, Morgan MA, Propert K, Macones GA. Can antenatal clinical and biochemical markers predict the development ofsevere preeclampsia? Am J Obstet Gynecol 2000;182:589-94.
Synopsis: This retrospective cohort analysis was undertaken in an attempt to determine clinical or biochemical factors that could be helpful in predicting preeclampsia. The second trimester studies included the “triple screen” as well as clinical data. There were 49 patients with severe preeclampsia in the study group. After analysis, the only factors that remained significant were nulliparity, history of preeclampsia, elevated screening mean arterial pressure and low unconjugated estriol concentration. The predictive value for these variables had a 76% sensitivity and a 46% specificity. . . . Commentary: Preeclampsia is a disease of pregnancy that continues to defy investigations into its etiology. As a result we are left with attempts to determine when and if it will occur. This report is another attempt to determine factors that may be predictive of development of the disease. They were only moderately successful as noted by the 76% sensitivity and only 46% specificity. Neither of these would be reassuring predictive valves and could be misleading if the obstetrician attempted to rely on the tests upon which they are based.
Both nulliparity and past history of preeclampsia have long been known to be risk factors. Concentrations of human chorionic gonadotrophin, a-fetoprotein, estriol, and other biochemical markers have added little to this study or our knowledge. Until we ultimately discover the etiology or etiologies, we are still treating symptoms and relying on early recognition to prevent serious consequences.
Birth Weight and Parental Smoking Haug K, Irgens LM, Skjaerven R, Markestad T, Baste V, Schreuder P. Maternal smoking and birthweight: Effect modification of period, maternal age and paternal smoking. Acta ObstetGynecolStand 2000;79:485-9.
Synopsis: This study was undertaken to determine the effect of maternal smoking on birth weight. By use of a questionnaire, the authors surveyed a random sample of 34,799 women in Norway who gave birth between 1970 and 1991. They found the overall mean birth weight between smokers and nonsmokers to be 197 g. The difference increased with maternal age and was 232 g for those 35 years ofage or older. They concluded that the negative effect on birth weight was significant and increased with age. They also found that when both parents smoked, birth weight was also lower. . . . Commentary: This retrospective study addressed one aspect of smoking during pregnancy that was easily identifiable. For a country such as Norway where there is a central data bank, this was a restricted investigation that could have been much more informative. That smoking decreases birth weight has been found in many studies over the years so nothing new has been added. What is missing is whether the lower birth weight had any effect on the infant. ACOG Educational Bulletin Number 240, Smoking and Women? Health, September 1997, gives a complete review. This document and the supporting references refer to the increased perinatal mortality associated with maternal smoking during pregnancy. This article does not address the issue and thus, misses an opportunity to further clarify the adverse impact of smoking on the pregnancy.
ACOG CLINICAL REVIEW Ralph W. Hale, MD Editor
.
Schoen EJ, Colby CJ, Ray GT. Newborn circumcision decreases incidence and costs of urinary tract infections during the first year of life. Pediatrics 2000;105:789-93. Synopsis:
Gerald B. H&man, MD Luella Klein, MD Stanley Zinberg, MD Associate Editors .
Decreased Incidence of UTI Associated With Circumcision in the First Year of life
.
Journals Surveyed Include: Acta Obstetricia et Gynecologica Scandinavica l American Journal of Obstetrics and Gynecology . Annals of Internal Medicine l Australian and New Zealand Journal of Obstetrics and Gynaecology BMJ . British Journal of Obstetrics and Gynaecology Canadian Medical Association Journal l Cancer l European Journal of Obstetrics, Gynecology,
These authors conducted a retrospective study of 14,893 male infants delivered in 1996. Of these, 9668 (64.9%) underwent circumcision. Their objective was to determine the effect of circumcision of the newborn on subsequent urinary tract infections (UTIs) during year one of life. They found 154 UTIs in this cohort of male infants of which 132 (86%) occurred in those who were uncircumcised. They concluded that newborn circumcision resulted in a 9.1-fold decrease in the incidence of UTIs during the first year of life. . . .
an~~$!$$i~~~ii$y Commentary:
International Uro necology Journal JAMA . Journ aYof Ultrasound in Medicine . Lancet l Military Medicine . New England Journal of Medicine l Obstetrics and Gynecology l Pediatrics .
.
.
rhc
Co yright Q 2000 by Amencan College ofobstetricians an Gynecolo istr. Pubbrhcd by Elsevier Science Inc. ACOG B ClznrcnPRrvrrw 1s &cd bnnonrbly by Elsevier Science Inc.. 655 Avrnue of rbc Ameru.s, New York, NY 10010. Subscriprion prices pa year: For cutomers in the Unirrd Scares: Instnutionai rare: $205 00, pcrsonll rate: $106.00. For‘ustomersinEuropcand rbeCIS, lnsrirutional ncc: NLG 403.00, personal rare: NLG 208.00. For cusmmcrs m Japan: lnst,turional rate: JPY 25,300.00, personai rare: JPY 13,100.OO. Prices include port c and arc rubjecr to change wirhour norice. For additmn 2 mformarion, contacr Elscwer Science Customer Sup on Dcpanmenr, P.O. Box 945, NnvYork, NY 10010, K-7. (212) 633-3730 Toll free. (for customers in North Amena): I-888-4ESINF0, Fax: (212) 633.3680, E-til: [email protected]. Address advcnising mqumes co Phlrmaceurical Medm Inc., 30 Easr 33rd St., NW York, NY 10016. Application to mail al eriodnls osta races15pending m New York, NY. an B al addition max in c&es. Postmaster: Send addresschanges j $7 10 ACOG C&co Rmm, Elsevier Science Inc., 655 Avenue ofrhe Americas,NewYork, NY 10010-5107. No res onsibihry isvsumed bythcpublishcror rhc AmericanCal e e of Obrtetricianr and Gynccologms for any mjury and/or% amage to persons or property 15 a matter of prcducrs lizbdiry, negkgencc or other,&, or from any use or aperarmn ofany methods, producrr, insrrucrions, or ideas conramed m rhc materill heran. Becaw of rapid advances in the mcdid sc~cnces,inh “dent verification of dngnoses and drug dosagesrhoul r bc made. Discussmns, VICWS,and recommendations as IO medal procedures, choice of drugs, and drug das es arc rhe rcrponslbiliry ofrhe aurhors. The appearance of P% vrrrxsmg m publiatians of rhe Amrrun College of Obstetncmns and Gynrcologiscs (and/or m exhlbns ar meerings of rhe College) does nor conxicucc a guaranree or endorscment of the u&y or value of such product or of the cllims made for it,% y its manufacturer. The fax char a prodUCI, SENICC, or cornpan is advcrnsed m a public-aim or exhibired at a meeung o F rhe College shall not bc referred to by rhe manufacturer in advernsmg.
2 . i\C;OG
CLlNlCAL
REVIEW
.
Newborn circumcision has become a topic of much discussion and debate in the last 10 years. The use of anesthesia has been recommended in a number of reports including articles abstracted in previous issues of ACOG Clinical Review. A number of groups have attacked circumcision as a needless procedure without medical indication. One correspondent who contacted this editor when ACOG released its report on female genital mutilation asked when we would release a similar report on male genital mutilation (AKA circumcision). The American Academy of Pediatrics, in response to the debate and question, has published a report on circumcision. This detailed report discusses the controversy and gives recommendations. For the interested reader the report can be found in the Circumcision Policy Statement, American Academy of Pediatrics, Task Force on Circumcision. Pediatrics 1999;103:686-93. The present article, however, offers a different perspective. They have shown a medical indication for cir-
NovembcriDecernbrr
2000
cumcision, that is, prevention of UTIs. They have also made a calculation of potential cost savings. Not included in the comparison is the cost of the procedure in the 90% who have no problem; thus, the cost comparison has no real value. Likewise, until follow-up of years has shown significant subsequent problems in male infants with UTIs in the first year, no conclusion can be substantiated. Circumcision has many ramifications other than the prevention of UTIs. Religious and social issues also play a role in the parents’ decision about circumcision. Most likely, the debate will take generations to come to a conclusion, if it ever does. Therefore, as the AAP has stated, it is a decision best left to the parents and their physicians after presentation of the current available information.
Appendicitis in Pregnancy Mourad J, Elliott JP, Erickson L, Lisboa L. Appendicitis in pregnancy: New information that contradicts long-held clinical beliefs. Am J Obstet Gynecoi 2000;182: 1027-9. Synopsis:
In a retrospective review of 66,993 deliveries from 1986 to 1995, the authors found 45 cases of histologically proved appendicitis and 22 cases that were unproved after pathologic examination. The cases occurred in all three trimesters and right lower quadrant pain was the most common presenting complaint in all trimesters. The mean white blood cell count was 16.4 X lO’/L for patients with proved appendicitis, compared with 14.0 X 10 /L for those with normal histologic findings. Perforation occurred in eight cases. They conclude that right lower quadrant pain is the most common symptom and that fever and leukocytosis are not clear indicators. They further concluded that preterm labor may be a problem but preterm delivery is rare. . . . Commentary:
Based on 45 cases, it is difficult to make any generalized conclusion, especially when a retrospective chart review is the basis for the study. It is of interest that right lower quadrant pain was the best diagnostic tool and that regardless of trimester the pain occurred in the right lower quadrant. Appendicitis in pregnancy is not
‘CZOOOby
theA~ner’can COlkQe 01 Dbstelrlc,ans
and G;necoloyirti PublIShed bv Elsevler Scl~llce inc 1085.6862,00’$6 OC
rare but neither is it common. In this series the occurrence was I in I493 pregnancies. The only message from this report is to consider appendicitis if pain persists in the right lower quadrant.
Maternal Mortality in the UK De Swiet M. Maternal mortality: Confidential enquiries into maternal deaths in the United Kingdom. Am J Obstet Gynecol 2000;182:760-6.
Synopsis: The author of this report reviewed the Confidential Enquiries Into Maternal Deaths in the United Kingdom, a regular audit of maternal mortality. The rate of maternal mortality in 1952-1954 was 70 per 100,000 and fell to 11 per 100,000 in 1994-1996. The largest drop occurred after the 1968 legalization of abortion. Before that time abortion was the leading cause of maternal death. In 1994-1996 there were only three deaths related to abortion, The leading causes of maternal death in 1994-l 996 were thrombosis and hypertension. Other less common causes were hemorrhage, amniotic fluid embolism, pregnancy loss, and sepsis. They identified substandard care as a significant contributor in 1952-1954 (406 cases) but this factor had been reduced in 1994-1996 (76 cases). Cases of substandard care were most often due to failure to refer, failure of consultants to respond, lack of a clear policy for severe preeclampsia, and lack of recognition of a problem outside the area of expertise. In 1994 -1996, substandard care was common in deaths due to hemorrhage and ectopic pregnancy (65%). The author concluded that audits of maternal mortality are effective in reducing rates and identifying the causes. . . . Commentary: This report is different from those usually reviewed by the editor. It is not a research report but an invited lectureship. The author, Dr. Michael de Swiet, was the Joseph Price Orator at the most recent American Gynecological and Obstetrical Society Meeting (Carlsbad, California, September 16-18, 1999). This lecture was chosen for review because it addressed an important topic, maternal mortality, and the author shows the benefits of maternal mortality reviews. Unfortunately, in many parts of the United
States this type of review is no longer actually pursued. There are many reasons. However, until maternal mortality is recognized to be an ongoing problem and actions are taken at all levels to investigate why, we will never lower our rate to the 3 per 100,000 that most experts consider to be the lowest possible rate.
VBAC: An Australian Study Appleton B, Targett C, Rasmussen M, Readman E, Sale F, Permael M, and the VBAC Study Group. Vaginal birth afrer cesarean section: An Australian multicentre study. Aust N Z J Obstet Gynaecd 2000;40:87-91.
Synopsis: This report is a retrospective analysis of vaginal birth after cesarean section. It is a report from the Australian vaginal birth after cesarean (VBAC) study group and was performed at 11 major obstetric hospitals from July 1992 to June 1997. There were 234,0 15 deliveries in the cohort and 21,452 (9.2%) had had one or more prior cesarean deliveries. In this subgroup 5419 (25.33%) had a vaginal delivery. They found 62 cases of significant rupture with a perinatal mortality rate of 25% and serious maternal complications in 25%. The final estimate, based on this study, was a uterine rupture associated with VBAC in 0.3%, with 0.05% experiencing a perinatal death and 0.05% needing a hysterectomy. . . . Commentary: VBAC has received a lot of emphasis in the past few years. Two main factors appear to have been the strong motivator for this emphasis. First was the recognition that repeat cesarean delivery was a major component of the increasing rate of cesarean delivery in the United States. By 1995, this rate had reached about one in four deliveries. The second important factor was an increasing preference by patients who had had a previous cesarean delivery to have a vaginal delivery with a subsequent pregnancy. This article is one of many now being published that investigate the complications associated with VBAC. Because many of these articles are from single institutions, the possibility of selection bias is ever present. In this study there were 11 centers. Unfortunately, the data are only retrospective so there is still the possibility of misinterpretation; however, they
have restricted their review to very specific concerns and, thus, avoided an attempt to be all inclusive with limited data. Their incidence of VBAC attempt is lower than that reported in the United States so this also affects their data. A major question is whether the selected patients represented an optimal group. Would higher rates with fewer preselected patients result in greater or lesser percentages of complications? We will not know but the rate of uterine rupture with significant sequelae, even though low, still should alert the obstetrician and the patient that a VBAC is not the same as a labor and vaginal delivery with an unscarred uterus. ACOG Practice Bulletin Number 5, Vaginal Birth Afier Previous Cesarean Delivety, July 1999, is a comprehensive review of this issue. It includes clinical considerations and counseling, as well as an algorithm for the care of a patient requesting VBAC.
Twin Birth Outcomes and Prenatal Care in the United States Kogan MD, Alexander GR, Kotelchuck M, MacDorman MF, Buekens P, Martin JA, et al. Trends in twin birth outcomes and prenatal care utilization in the United States, 1981-1992 JAMA2000;283:335-41.
Synopsis: This study was undertaken to determine if aggressive management of twin births would affect the outcome. The information was obtained from the data on birth and death records between 198 1 and 1997 maintained by the National Center for Health Statistics. The preterm birth rate for twins increased from 40.9% in 1981 to 55.0% in 1997. Low birth weight infants increased from 5 1% to 54%. The preterm small for gestational age (SGA) infants increased from 11.9% to 14.1% and the percentage of term SGA infants decreased from 30.7% to 20.5%. When intensive prenatal care use was factored into the study the preterm birth rate increased from 35.1% to 55.8%, whereas those women with less intensive prenatal care had an increase from 50.6% to 59.2%. However, those with the more intensive care had a lower infant mortality rate. . . .
Commentary: This article from the Maternal and Child Health Bureau of the Health Resources and Services Administration is an attempt to document changes in care of twin pregnancies by evaluating the outcomes over an extended period of years. The unexplained finding is that preterm birth is more frequent in the last part of the study than earlier. The inference that intensive prenatal care may be a contributing factor is unfortunate. These authors have relied on birth records that may or may not be accurate. There was no ability to review the actual labor records. To substantiate any claim of validity, the actual hospital record must be reviewed for accuracy of the data on the birth record. A major concern with this study is that obstetric care has changed dramatically over this 16-year period; thus, comparisons are meaningless. Earlier intervention in problem cases is frequently used to improve outcome as opposed to 20 years ago when “watchful waiting” was advocated. Likewise, those with intensive prenatal care were more likely to have problems that would encourage earlier intervention. This article is an example of those studies that present an analysis of statistics but in reality have no practical importance because the underlying data on which the statistics are based are unreliable.
Maternal Age and Fetal Loss Andersen AMN, Wohlfahrt J, Christens I’, Olsen J, Melbye M. Maternal age and fetal loss: Population based register linkage study. BMJ 2000;320:1708-12.
Synopsis: This investigation was conducted in Denmark. The country has a unique system in which all citizens are registered and a national database is compiled. Using these data, the authors reviewed 643,272 women with 1,22 1,546 pregnancies to determine the association between maternal age and fetal death as defined by spontaneous abortion, ectopic pregnancy, and stillbirth. They found that 13.5% of pregnancies ended in a fetal death. At age 42, more than 50% were lost. Compared with a rate of 8.9% in women aged 20 to 24, spontaneous abortion in those ages 45 or more was 74.7%. They concluded that fetal loss is high in women in their late 30s or older.
. . . Commentary: Because of the large number and the validity of the database, these results are significant. The association of advancing age and fetal loss has been shown to increase proportionately. This study confirms similar reports and the anecdotal experience of many ob/gyns. This is an epidemiological study so no attempt was made to correlate the findings with current practice. However, the authors urge everyone involved in prepregnancy counseling to caution their patients about prolonged delays in child bearing. As more women plan to continue their careers and delay pregnancy after marriage, they need to be made aware of this potential problem.
Predictors of Severe Preeclampsia Stamilio DM, Sehdev HM, Morgan MA, Propert K, Macones GA. Can antenatal clinical and biochemical markers predict the development ofsevere preeclampsia? Am J Obstet Gynecol 2000;182:589-94.
Synopsis: This retrospective cohort analysis was undertaken in an attempt to determine clinical or biochemical factors that could be helpful in predicting preeclampsia. The second trimester studies included the “triple screen” as well as clinical data. There were 49 patients with severe preeclampsia in the study group. After analysis, the only factors that remained significant were nulliparity, history of preeclampsia, elevated screening mean arterial pressure and low unconjugated estriol concentration. The predictive value for these variables had a 76% sensitivity and a 46% specificity. . . . Commentary: Preeclampsia is a disease of pregnancy that continues to defy investigations into its etiology. As a result we are left with attempts to determine when and if it will occur. This report is another attempt to determine factors that may be predictive of development of the disease. They were only moderately successful as noted by the 76% sensitivity and only 46% specificity. Neither of these would be reassuring predictive valves and could be misleading if the obstetrician attempted to rely on the tests upon which they are based.
Both nulliparity and past history of preeclampsia have long been known to be risk factors. Concentrations of human chorionic gonadotrophin, a-fetoprotein, estriol, and other biochemical markers have added little to this study or our knowledge. Until we ultimately discover the etiology or etiologies, we are still treating symptoms and relying on early recognition to prevent serious consequences.
Birth Weight and Parental Smoking Haug K, Irgens LM, Skjaerven R, Markestad T, Baste V, Schreuder P. Maternal smoking and birthweight: Effect modification of period, maternal age and paternal smoking. Acta ObstetGynecolStand 2000;79:485-9.
Synopsis: This study was undertaken to determine the effect of maternal smoking on birth weight. By use of a questionnaire, the authors surveyed a random sample of 34,799 women in Norway who gave birth between 1970 and 1991. They found the overall mean birth weight between smokers and nonsmokers to be 197 g. The difference increased with maternal age and was 232 g for those 35 years ofage or older. They concluded that the negative effect on birth weight was significant and increased with age. They also found that when both parents smoked, birth weight was also lower. . . . Commentary: This retrospective study addressed one aspect of smoking during pregnancy that was easily identifiable. For a country such as Norway where there is a central data bank, this was a restricted investigation that could have been much more informative. That smoking decreases birth weight has been found in many studies over the years so nothing new has been added. What is missing is whether the lower birth weight had any effect on the infant. ACOG Educational Bulletin Number 240, Smoking and Women? Health, September 1997, gives a complete review. This document and the supporting references refer to the increased perinatal mortality associated with maternal smoking during pregnancy. This article does not address the issue and thus, misses an opportunity to further clarify the adverse impact of smoking on the pregnancy.