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Spotlight on obstetrics
ment time and date and enter this information into the patient’s chart. Tracking of the consultant’s report will be initiated after the referral visit takes place. Tracking should also be done for visits of patients who are referred from an outside office to the physician’s office. If the referred patient does not keep her appointment, a letter should be sent to the referring physician notifying him or her. This notification should be documented in the patient’s chart. Laboratory Reports and Imaging Studies Making sure that all tests ordered are completed is of the utmost importance. The system should be reviewed daily by a designated staff person (with a back-up in case of that employee’s absence). Established protocol for this process should be strictly followed. The tracking system should indicate the patient’s name, which tests have been ordered (such as laboratory work or imaging studies), and the date by which the test(s) must be completed. Also document the following information: Y Date test was actually completed. Y Date results were reviewed by the physician. Y Date the patient was notified of the test results. According to ACOG’s “Ethics in Obstetrics and Gynecology,” information ordinarily may not be revealed to anyone other than the patient without the patient’s express consent. Y Whether any further follow-up is needed (which, in turn, should also be tracked). No tracking system will be completely fail-safe. Patients should be consistently reminded that not receiving test results does not imply that the results are normal. Patients should be encouraged to call the office if they do not receive test results within a specified time. All “essential” diagnostic tests ordered (either within or outside the office) must be tracked to assure completion. Each physician should determine what tests are “essential,” such as any test ordered during an acute or critical problem; any test to monitor medication with known adverse effects (eg, diuretics or other prescribed medications); and any test in which subsequent follow-up is essen©2002 by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1085-6862/02/$6.00
tial (and the risk for not following up is high), for example, biopsies, repeat Papanicolaou tests, mammograms, or x-rays or other tests to rule out malignancies. Other clinical findings that should be tracked include skin lesions, rectal bleeding, breast lumps, and chest pain. Review of Incoming Reports All laboratory work, imaging studies, test reports, consultations, and other pertinent documents must be seen by the practitioner before being filed in the medical chart. The person responsible for filing the document should be trained NOT to file reports unless they have been initialed and reviewed by the ordering practitioner and/or supervisory physician. With a comprehensive tracking system in place, physicians will be more likely to ensure that their patients are followed up as necessary to help prevent cases of delayed diagnoses or failure to provide medically necessary treatment. Collaboration between the physicians and patients will also help prevent these potential errors from occurring. The bottom line is caring, compassion, and communication to be understood as an essential component of competence. The physician must have a genuine interest in the patient beyond disease. We have this higher obligation to the patient.
SPOTLIGHT ON OBSTETRICS Morton A. Stenchever, MD Editor
External Cephalic Version Leads to Frequent Obstetric Intervention Chan LYS, Leung TY, Fok WY, Chan LW, Lau TK. High incidence of obstetric interventions after successful external cephalic version. BJOG 2002;109:627–31.
Synopsis: The authors of this casecontrol study from Hong Kong investigated 279 consecutive singleton deliveries at term over a 6-year period in women who had undergone a successful external cephalic version. These deliveries were compared with a con-
trol group of 28,447 singleton term deliveries during the same 6-year period. The risks of instrumental delivery and of emergency cesarean delivery were higher in the external cephalic version group than in the control group (14.3% versus 12.8%, and 23.3% versus 9.4%, respectively). The higher risk for cesarean was due to an increase in all of the major indications for cesarean including fetal distress, failure to progress in labor, and failed induction, whereas the higher incidence of instrumental delivery was due mainly to an increase in prolonged second stage. The labor induction rate was higher in the external cephalic version group (24% versus 13.4%), as was the use of epidural anesthesia (20.4% versus 12.4%). The higher induction rate was primarily due to post-term abnormal cardiotocography and antepartum hemorrhage of unknown origin. Level II-3. ● ● ●
Commentary: Breech presentation is not normal and external cephalic version is not a cure-all. Therefore it is not surprising that the incidence of problems and complications would be higher in the external cephalic version group than in the general population. Nevertheless, as most women who were successfully converted delivered vaginally and did well, the procedure had demonstrated benefits over the alternative, elective cesarean delivery. However, an important question remains to be answered: whether the cumulative risk of version, the complications of the type of delivery that follows version, and the anxiety experienced by patients and doctor alike outweigh the risk of elective cesarean for all breeches.
Breast Cancer and Breast-Feeding Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: Collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50,302 women with breast cancer and 96,973 women without the disease. Lancet 2002;360:187–95.
Synopsis: The authors analyzed individual data from 47 epidemiologic studies performed in 30 countries that addressed breast-feeding patterns and
November 2002
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other aspects of childbearing in 50,302 women with breast cancer and 96,973 controls. Women with breast cancer had, on average, fewer births compared with controls (2.2 versus 2.6 births) and fewer parous women with cancer than parous controls had ever breast-fed their infants (71% versus 79%). The average total lifetime duration of breast-feeding was shorter (9.8 versus 15.6 months). Relative risk (RR) of breast cancer decreased by 4.3% for every 12 months of breast-feeding in addition to a decrease of 7% for each birth. The size of the decline in RR did not differ significantly in women from developed or developing nations, nor did it vary significantly by age, menopausal status, ethnic origin, number of births a women had, a woman’s age at the birth of her first child, or any of nine other personal characteristics that the authors examined. The authors estimated that breast-feeding could account for as much as two thirds of the estimated reduction in breast cancer incidence. Level II-3.
primigravidae who have an elective cesarean section for breech presentation? BJOG 2002;109:624 – 6.
Synopsis: The authors of this Irish study compared subsequent risk of cesarean delivery in 194 women who had had an elective cesarean delivery for breech presentation as primigravidae with 121 women who had undergone an elective cesarean delivery as primigravidae, but with a cephalic presentation. Nineteen (9.8%) of the women with previous breech presentation had a breech presentation in the next delivery compared with two (1.7%) of the control women. Despite the increased risk of breech presentation, the overall cesarean rate in the next pregnancy was 43.8% in women with previous breech presentation compared with 61.2% in women with previous cephalic presentation. Of women allowed to labor after elective cesarean, 84% of the women with previous breech presentation delivered vaginally compared with 68% of women with a previous cephalic presentation. Level II-1.
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Commentary: As early as the 1920s, studies indicated that women who breast-fed were less likely to have breast cancer. The current huge review of 47 epidemiologic studies made two points clear: Each birth had an independent effect of reducing the RR of breast cancer by 7% per birth, and breast-feeding offered additional protection that increased with the length of time that breast-feeding occurred. Physicians can share this important information with their patients who are contemplating breastfeeding. In developed countries today, large families are not as feasible socially or economically as they once were, and therefore the protection that would be afforded by multiple births is decreased. However, breast-feeding is socially acceptable and economically advantageous in developed countries, and protection against breast cancer is an additional benefit of this activity.
Outcome of Next Delivery After Elective Cesarean Delivery Coughlan C, Kearney R, Turner MJ. What are the implications for the next delivery in
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Commentary: The authors have furnished interesting data with respect to the risk of repeat cesarean in women who underwent elective cesarean delivery because of breech presentation. There did appear to be differences between these women and women who underwent cesarean delivery for other reasons, with a cephalic presentation. The rate of vaginal delivery success was even more impressive when one notes that the incidence of breech presentation in the subsequent delivery was higher in the breech group than in the cephalic group. Increased incidence of breech presentation in the subsequent pregnancy was probably related to the causes of breech presentation in the first pregnancy in this group of women, but the good news appeared to be that their ability to deliver vaginally was good in a subsequent pregnancy that involved a cephalic presentation. The higher cesarean rate with subsequent pregnancies in women who underwent elective cesarean as primigravidae probably reflected the mixed indications for cesarean, not factors that related directly to the cause of the breech presentation.
November 2002
Pfannenstiel Versus Maylard Incision for Cesarean Delivery Giacalone PL, Daures JP, Vignal J, Herisson C, Hedon B, Laffargue F. Pfannenstiel versus Maylard incision for cesarean delivery: A randomized controlled trial. Obstet Gynecol 2002;99:745–50.
Synopsis: The authors performed a randomized double-masked study that compared two incision techniques, the Pfannenstiel and the Maylard (muscle cutting) for elective and emergency cesarean delivery. They evaluated surgical characteristics, complications, postoperative pain using a visual analogue scale, the amount of analgesic ordered, and related quality of life at 1 and 3 months as determined by self-administered patient questionnaires. They also studied abdominal wall muscle recovery and strength. They found no differences between the two groups and concluded that transecting the rectus muscle was no more deleterious than performing a Pfannenstiel incision. Level I. ● ● ●
Commentary: Proponents of the Pfannenstiel incision and the musclecutting incision have disagreed over time about the respective benefits of each technique. These authors found no difference in healing or muscle strength, at least in the short term, ie, 3 months. This information is worthwhile, as circumstances may indicate one type of incision is more appropriate for a specific patient. Many training programs routinely use one or the other technique. It probably would behoove programs to teach both.
Blunt Versus Sharp Expansion of the Uterine Incision at Cesarean Delivery Magann EF, Chauhan SP, Bufkin L, Field K, Roberts WE, Martin JN Jr. Intra-operative haemorrhage by blunt versus sharp expansion of the uterine incision at caesarean delivery: A randomised clinical trial. BJOG 2002;109:448 –52.
Synopsis: The authors studied 470 women whose uterine incision at the time of cesarean delivery was sharply expanded by scissors and 475 women ©2002 by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1085-6862/02/$6.00
whose uterine incision was bluntly expanded. The women were randomly assigned to their respective category. Blood loss was estimated by evaluating the amount of blood collected in the suction apparatus, the plastic steridrapes, and lap pad and sponges. Blood loss was also assessed by comparing the immediate preoperative hematocrit with a second hematocrit obtained 48 hours after the operative procedure. The women undergoing sharp incision had an estimated blood loss of 886 versus 843 mL in the blunt group (P⫽.001), a change in mean hematocrit of 6.1% versus 5.5% (P⫽.003), and an incidence of postpartum hemorrhage of 13.0% versus 9.0%. Blood transfusion was necessary in 2.0% of the sharp incision patients and in 0.4% of the blunt incision patients. The authors concluded that sharp incision of the uterus significantly increased intraoperative blood loss and the need for subsequent transfusion. Level I. ● ● ●
Commentary: There has long been a controversy about how best to open the uterus at the time of cesarean delivery. At most institutions there are proponents of both the sharp and blunt approaches. Those who favor the sharp approach believe that the incision of the uterus can be better controlled using this technique. Those who favor the blunt approach believe that it is quicker and associated with less hemorrhage. According to the findings of this study, it would appear that the proponents of the blunt technique are correct. The authors have demonstrated that it is always wise periodically to evaluate procedures that we consider routine and correct.
Intrauterine Death Is Associated With Thrombophilia Many A, Elad R, Yaron Y, Eldor A, Lessing JB, Kupferminc MJ. Third-trimester unexplained intrauterine death is associated with inherited thrombophilia. Obstet Gynecol 2002;99:684 –7.
Synopsis: The authors studied 40 women with unexplained intrauterine third-trimester fetal death and 80 matched controls delivered during the ©2002 by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1085-6862/02/$6.00
study period which extended from 1997 to 1999. They evaluated patients for mutations of factor V Leiden, prothrombin gene, methylenetetrahydrofolate reductase, and for deficiencies of protein S, protein C, and antithrombin III. They also tested patients and found them to be negative for anticardiolipin antibodies. They discovered a frequency of inherited thrombophilias of 42.5% in the study group compared with 15% in the control group, odds ratio 2.8 (95% confidence interval 1.5, 5.3; P⫽.001). The incidence of prothrombin mutation and protein S deficiency was significantly higher in the study group. The incidence of factor V Leiden was higher but did not reach statistical significance in this group. Level II-2. ● ● ●
Commentary: The authors found an intrauterine fetal death rate in the third trimester of 0.36% (66 of 18,503 deliveries). When known causes of fetal deaths were excluded, 40 patients remained in their study. The finding of a high incidence of inherited thrombophilia is supported by the work of others. The authors suggested that a work-up for thrombophilia should be added to the evaluation of a patient who has an unexplained intrauterine fetal death and this reviewer believes that this is the important take-home message from this study. Whenever there is an unexplained intrauterine death, the patient should be thoroughly evaluated to determine if conditions exist that might be repetitive. Furthermore, if a condition could be identified as the probable cause of death, it might be possible to take steps to prevent it in future pregnancies. Our responsibility as obstetricians does not end with the delivery of an infant. If an unfortunate outcome occurs, it is important that we determine, whenever possible, why it occurred. The information in this study added an additional dimension to our work-up of such an event.
Comprehensive Stillbirth Assessment Michalski ST, Porter J, Pauli RM. Costs and consequences of comprehensive stillbirth as-
sessment. Am J Obstet Gynecol 2002;186: 1027–34.
Synopsis: The authors studied retrospectively 1477 stillbirth pregnancies referred to the Wisconsin Stillbirth Service Program between 1983 and 2000 for which there were complete data of comprehensive assessment. The authors found new information relevant to recurrent risk estimation, prenatal diagnosis recommendation, and preconceptual, prenatal, perinatal, or neonatal treatment in 51% of stillborn infants studied. The real cost per assessment was $1450. Information pertaining to the risk of recurrence was obtained from 40.1% of the stillborn infants studied, indicating a need for prenatal diagnosis in 21.4%, preconceptual management in 9.1%, prenatal management in 7.4%, neonatal management in 3.7%, and perinatal management in 2.0%. Level III. ● ● ●
Commentary: As the authors pointed out, even with the gradual decline in the number of stillbirths that has been seen in the last several decades, intrauterine death in the third trimester still occurs in between one in 115– 125 births. They demonstrated that for a relatively modest cost, comprehensive evaluation yielded a great deal of information that could be helpful in counseling couples about future pregnancies and the management of those pregnancies. A stillbirth is a tragedy for the couple involved and extremely upsetting to the caregiver. However, not learning from this experience, and thereby running the risk of suffering a repetition, would be a greater tragedy. The findings of this study should stimulate obstetricians to order a careful assessment of every stillbirth.
Neonatal Outcomes After Topical Use of Corticosteroid in Pregnancy Mygind H, Thulstrup AM, Pedersen L, Larsen H. Risk of intrauterine growth retardation, malformations and other birth outcomes in children after topical use of corticosteroid in pregnancy. Acta Obstet Gynecol Scand 2002;81:234 –9.
Synopsis: The authors performed a population-based follow-up study evaluating the risk of fetal growth re-
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striction (FGR), congenital malformations, and other birth outcomes among children of women exposed to topical corticosteroids during pregnancy or just before pregnancy. In a population in one county in Denmark, which represented 9% of the Danish population, 363 women were found to be exposed to topical corticosteroids during pregnancy and were compared with 9263 who were not exposed to these medications. No statistically significant differences existed with respect to congenital malformations, preterm birth, or low birth weight (LBW) among the offspring of women receiving topically administered weak to medium strong corticosteroids or strong to very strong corticosteroids. Level II-2.
that, at least in the 34 women and 25 infants involved, no HIV infection was transmitted; suggesting that this means was reasonably safe for HIVpositive men to have children. When the authors compared the treatment efficacy with that of control couples, they found no statistically significant differences. Level II-3. ● ● ●
Commentary: These authors furnished worthwhile information for the counseling of HIV serodiscordant couples who hope to have children. Although the method is costly, the safety that intracytoplasmic sperm injection apparently offers more than compensates for the financial burden.
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Commentary: There has been controversy over whether corticosteroids administered during pregnancy increase the risk of congenital malformation or LBW. More recent studies have cast doubt on the likelihood of this risk. In the current study, the authors demonstrated that the topical use of even strong corticosteroid agents did not increase the risk of FGR or congenital malformations, even when used in the first trimester. This information is useful for physicians counseling patients who have been exposed either through intentional use of corticosteroids or because they did not know that they were pregnant at the time of use. As the study was population-based and retrospective, the dosage and length of time of exposure to corticosteroids were not known. Nevertheless, this was a large study and the results were reassuring.
IVF With HIV-Positive Men Sauer MV, Chang PL. Establishing a clinical program for human immunodeficiency virus 1-seropositive men to father seronegative children by means of in vitro fertilization with intracytoplasmic sperm injection. Am J Obstet Gynecol 2002;186:627–33.
Synopsis: In this study, the authors assessed the safety of using in vitro fertilization with intracytoplasmic sperm injection to assist human immunodeficiency virus (HIV)-positive men to father children. They demonstrated 6
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Risk of Prenatal Death Associated With Labor After Previous Cesarean Delivery Smith GCS, Pell JP, Cameron AD, Dobbie R. Risk of prenatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002; 287:2684 –90.
Synopsis: The authors presented the results of a population-based retrospective cohort study of data from the linked Scottish Morbidity Record and Stillbirth and Neonatal Death Enquiry carried out on births in Scotland between 1992 and 1997. A total of 303,238 singleton births between 37 and 43 weeks’ gestation were studied. Four groups were studied: women who had a trial of labor after a previous cesarean delivery; women who had a planned repeat cesarean delivery; and multiparous and nulliparous women at term without a history of previous cesarean who were delivered spontaneously. The overall rate of delivery-related perinatal death in the previous cesarean delivery group was 12.9 per 10,000 women. This rate was 11 times greater than the risk associated with women who had repeat cesarean delivery, and more than twice the risk for spontaneously delivering women with no history of cesarean delivery. In the trial of labor group the risk of uterine rupture was 4.5 per 10,000 women, which was eight times greater than the risk of uterine rupture in spontaneously delivering women
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without a history of cesarean. Level II-2. ● ● ●
Commentary: The authors correctly stated that the absolute risk of perinatal death related to trial of labor after a previous cesarean was low. However, the rate of perinatal death was considerably higher than in the planned cesarean group and most of these deaths were related to rupture of the uterus. The study was large and therefore of significant power to define the actual risk. The information generated should be part of the counseling process for women who must decide whether or not to have a trial of labor after a previous cesarean delivery. The economics of the situation are understandable, but it is clear that women who select vaginal birth after cesarean delivery assume a somewhat increased risk to themselves and their infant.
SPOTLIGHT ON GYNECOLOGY Morton A. Stenchever, MD Editor
Treatment Strategies for Pelvic Inflammatory Disease Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al, for the PID Evaluation and Clinical Health (PEACH) Study Investigators. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: Results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002; 186:929 –37.
Synopsis: The authors enrolled 831 women in multiple centers who had mild-to-moderate pelvic inflammatory disease (PID) and randomized them to a treatment protocol on an inpatient or outpatient basis in order to determine if outpatient treatment of PID was as effective as inpatient therapy. Inpatient treatment consisted of intravenous cefoxitin and doxycycline, and outpatient treatment consisted of a single intramuscular injection of cefoxitin and oral doxycycline. Short-term clinical and microbiological improvement was ©2002 by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1085-6862/02/$6.00
tial (and the risk for not following up is high), for example, biopsies, repeat Papanicolaou tests, mammograms, or x-rays or other tests to rule out malignancies. Other clinical findings that should be tracked include skin lesions, rectal bleeding, breast lumps, and chest pain. Review of Incoming Reports All laboratory work, imaging studies, test reports, consultations, and other pertinent documents must be seen by the practitioner before being filed in the medical chart. The person responsible for filing the document should be trained NOT to file reports unless they have been initialed and reviewed by the ordering practitioner and/or supervisory physician. With a comprehensive tracking system in place, physicians will be more likely to ensure that their patients are followed up as necessary to help prevent cases of delayed diagnoses or failure to provide medically necessary treatment. Collaboration between the physicians and patients will also help prevent these potential errors from occurring. The bottom line is caring, compassion, and communication to be understood as an essential component of competence. The physician must have a genuine interest in the patient beyond disease. We have this higher obligation to the patient.
SPOTLIGHT ON OBSTETRICS Morton A. Stenchever, MD Editor
External Cephalic Version Leads to Frequent Obstetric Intervention Chan LYS, Leung TY, Fok WY, Chan LW, Lau TK. High incidence of obstetric interventions after successful external cephalic version. BJOG 2002;109:627–31.
Synopsis: The authors of this casecontrol study from Hong Kong investigated 279 consecutive singleton deliveries at term over a 6-year period in women who had undergone a successful external cephalic version. These deliveries were compared with a con-
trol group of 28,447 singleton term deliveries during the same 6-year period. The risks of instrumental delivery and of emergency cesarean delivery were higher in the external cephalic version group than in the control group (14.3% versus 12.8%, and 23.3% versus 9.4%, respectively). The higher risk for cesarean was due to an increase in all of the major indications for cesarean including fetal distress, failure to progress in labor, and failed induction, whereas the higher incidence of instrumental delivery was due mainly to an increase in prolonged second stage. The labor induction rate was higher in the external cephalic version group (24% versus 13.4%), as was the use of epidural anesthesia (20.4% versus 12.4%). The higher induction rate was primarily due to post-term abnormal cardiotocography and antepartum hemorrhage of unknown origin. Level II-3. ● ● ●
Commentary: Breech presentation is not normal and external cephalic version is not a cure-all. Therefore it is not surprising that the incidence of problems and complications would be higher in the external cephalic version group than in the general population. Nevertheless, as most women who were successfully converted delivered vaginally and did well, the procedure had demonstrated benefits over the alternative, elective cesarean delivery. However, an important question remains to be answered: whether the cumulative risk of version, the complications of the type of delivery that follows version, and the anxiety experienced by patients and doctor alike outweigh the risk of elective cesarean for all breeches.
Breast Cancer and Breast-Feeding Collaborative Group on Hormonal Factors in Breast Cancer. Breast cancer and breastfeeding: Collaborative reanalysis of individual data from 47 epidemiological studies in 30 countries, including 50,302 women with breast cancer and 96,973 women without the disease. Lancet 2002;360:187–95.
Synopsis: The authors analyzed individual data from 47 epidemiologic studies performed in 30 countries that addressed breast-feeding patterns and
November 2002
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other aspects of childbearing in 50,302 women with breast cancer and 96,973 controls. Women with breast cancer had, on average, fewer births compared with controls (2.2 versus 2.6 births) and fewer parous women with cancer than parous controls had ever breast-fed their infants (71% versus 79%). The average total lifetime duration of breast-feeding was shorter (9.8 versus 15.6 months). Relative risk (RR) of breast cancer decreased by 4.3% for every 12 months of breast-feeding in addition to a decrease of 7% for each birth. The size of the decline in RR did not differ significantly in women from developed or developing nations, nor did it vary significantly by age, menopausal status, ethnic origin, number of births a women had, a woman’s age at the birth of her first child, or any of nine other personal characteristics that the authors examined. The authors estimated that breast-feeding could account for as much as two thirds of the estimated reduction in breast cancer incidence. Level II-3.
primigravidae who have an elective cesarean section for breech presentation? BJOG 2002;109:624 – 6.
Synopsis: The authors of this Irish study compared subsequent risk of cesarean delivery in 194 women who had had an elective cesarean delivery for breech presentation as primigravidae with 121 women who had undergone an elective cesarean delivery as primigravidae, but with a cephalic presentation. Nineteen (9.8%) of the women with previous breech presentation had a breech presentation in the next delivery compared with two (1.7%) of the control women. Despite the increased risk of breech presentation, the overall cesarean rate in the next pregnancy was 43.8% in women with previous breech presentation compared with 61.2% in women with previous cephalic presentation. Of women allowed to labor after elective cesarean, 84% of the women with previous breech presentation delivered vaginally compared with 68% of women with a previous cephalic presentation. Level II-1.
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Commentary: As early as the 1920s, studies indicated that women who breast-fed were less likely to have breast cancer. The current huge review of 47 epidemiologic studies made two points clear: Each birth had an independent effect of reducing the RR of breast cancer by 7% per birth, and breast-feeding offered additional protection that increased with the length of time that breast-feeding occurred. Physicians can share this important information with their patients who are contemplating breastfeeding. In developed countries today, large families are not as feasible socially or economically as they once were, and therefore the protection that would be afforded by multiple births is decreased. However, breast-feeding is socially acceptable and economically advantageous in developed countries, and protection against breast cancer is an additional benefit of this activity.
Outcome of Next Delivery After Elective Cesarean Delivery Coughlan C, Kearney R, Turner MJ. What are the implications for the next delivery in
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Commentary: The authors have furnished interesting data with respect to the risk of repeat cesarean in women who underwent elective cesarean delivery because of breech presentation. There did appear to be differences between these women and women who underwent cesarean delivery for other reasons, with a cephalic presentation. The rate of vaginal delivery success was even more impressive when one notes that the incidence of breech presentation in the subsequent delivery was higher in the breech group than in the cephalic group. Increased incidence of breech presentation in the subsequent pregnancy was probably related to the causes of breech presentation in the first pregnancy in this group of women, but the good news appeared to be that their ability to deliver vaginally was good in a subsequent pregnancy that involved a cephalic presentation. The higher cesarean rate with subsequent pregnancies in women who underwent elective cesarean as primigravidae probably reflected the mixed indications for cesarean, not factors that related directly to the cause of the breech presentation.
November 2002
Pfannenstiel Versus Maylard Incision for Cesarean Delivery Giacalone PL, Daures JP, Vignal J, Herisson C, Hedon B, Laffargue F. Pfannenstiel versus Maylard incision for cesarean delivery: A randomized controlled trial. Obstet Gynecol 2002;99:745–50.
Synopsis: The authors performed a randomized double-masked study that compared two incision techniques, the Pfannenstiel and the Maylard (muscle cutting) for elective and emergency cesarean delivery. They evaluated surgical characteristics, complications, postoperative pain using a visual analogue scale, the amount of analgesic ordered, and related quality of life at 1 and 3 months as determined by self-administered patient questionnaires. They also studied abdominal wall muscle recovery and strength. They found no differences between the two groups and concluded that transecting the rectus muscle was no more deleterious than performing a Pfannenstiel incision. Level I. ● ● ●
Commentary: Proponents of the Pfannenstiel incision and the musclecutting incision have disagreed over time about the respective benefits of each technique. These authors found no difference in healing or muscle strength, at least in the short term, ie, 3 months. This information is worthwhile, as circumstances may indicate one type of incision is more appropriate for a specific patient. Many training programs routinely use one or the other technique. It probably would behoove programs to teach both.
Blunt Versus Sharp Expansion of the Uterine Incision at Cesarean Delivery Magann EF, Chauhan SP, Bufkin L, Field K, Roberts WE, Martin JN Jr. Intra-operative haemorrhage by blunt versus sharp expansion of the uterine incision at caesarean delivery: A randomised clinical trial. BJOG 2002;109:448 –52.
Synopsis: The authors studied 470 women whose uterine incision at the time of cesarean delivery was sharply expanded by scissors and 475 women ©2002 by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1085-6862/02/$6.00
whose uterine incision was bluntly expanded. The women were randomly assigned to their respective category. Blood loss was estimated by evaluating the amount of blood collected in the suction apparatus, the plastic steridrapes, and lap pad and sponges. Blood loss was also assessed by comparing the immediate preoperative hematocrit with a second hematocrit obtained 48 hours after the operative procedure. The women undergoing sharp incision had an estimated blood loss of 886 versus 843 mL in the blunt group (P⫽.001), a change in mean hematocrit of 6.1% versus 5.5% (P⫽.003), and an incidence of postpartum hemorrhage of 13.0% versus 9.0%. Blood transfusion was necessary in 2.0% of the sharp incision patients and in 0.4% of the blunt incision patients. The authors concluded that sharp incision of the uterus significantly increased intraoperative blood loss and the need for subsequent transfusion. Level I. ● ● ●
Commentary: There has long been a controversy about how best to open the uterus at the time of cesarean delivery. At most institutions there are proponents of both the sharp and blunt approaches. Those who favor the sharp approach believe that the incision of the uterus can be better controlled using this technique. Those who favor the blunt approach believe that it is quicker and associated with less hemorrhage. According to the findings of this study, it would appear that the proponents of the blunt technique are correct. The authors have demonstrated that it is always wise periodically to evaluate procedures that we consider routine and correct.
Intrauterine Death Is Associated With Thrombophilia Many A, Elad R, Yaron Y, Eldor A, Lessing JB, Kupferminc MJ. Third-trimester unexplained intrauterine death is associated with inherited thrombophilia. Obstet Gynecol 2002;99:684 –7.
Synopsis: The authors studied 40 women with unexplained intrauterine third-trimester fetal death and 80 matched controls delivered during the ©2002 by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1085-6862/02/$6.00
study period which extended from 1997 to 1999. They evaluated patients for mutations of factor V Leiden, prothrombin gene, methylenetetrahydrofolate reductase, and for deficiencies of protein S, protein C, and antithrombin III. They also tested patients and found them to be negative for anticardiolipin antibodies. They discovered a frequency of inherited thrombophilias of 42.5% in the study group compared with 15% in the control group, odds ratio 2.8 (95% confidence interval 1.5, 5.3; P⫽.001). The incidence of prothrombin mutation and protein S deficiency was significantly higher in the study group. The incidence of factor V Leiden was higher but did not reach statistical significance in this group. Level II-2. ● ● ●
Commentary: The authors found an intrauterine fetal death rate in the third trimester of 0.36% (66 of 18,503 deliveries). When known causes of fetal deaths were excluded, 40 patients remained in their study. The finding of a high incidence of inherited thrombophilia is supported by the work of others. The authors suggested that a work-up for thrombophilia should be added to the evaluation of a patient who has an unexplained intrauterine fetal death and this reviewer believes that this is the important take-home message from this study. Whenever there is an unexplained intrauterine death, the patient should be thoroughly evaluated to determine if conditions exist that might be repetitive. Furthermore, if a condition could be identified as the probable cause of death, it might be possible to take steps to prevent it in future pregnancies. Our responsibility as obstetricians does not end with the delivery of an infant. If an unfortunate outcome occurs, it is important that we determine, whenever possible, why it occurred. The information in this study added an additional dimension to our work-up of such an event.
Comprehensive Stillbirth Assessment Michalski ST, Porter J, Pauli RM. Costs and consequences of comprehensive stillbirth as-
sessment. Am J Obstet Gynecol 2002;186: 1027–34.
Synopsis: The authors studied retrospectively 1477 stillbirth pregnancies referred to the Wisconsin Stillbirth Service Program between 1983 and 2000 for which there were complete data of comprehensive assessment. The authors found new information relevant to recurrent risk estimation, prenatal diagnosis recommendation, and preconceptual, prenatal, perinatal, or neonatal treatment in 51% of stillborn infants studied. The real cost per assessment was $1450. Information pertaining to the risk of recurrence was obtained from 40.1% of the stillborn infants studied, indicating a need for prenatal diagnosis in 21.4%, preconceptual management in 9.1%, prenatal management in 7.4%, neonatal management in 3.7%, and perinatal management in 2.0%. Level III. ● ● ●
Commentary: As the authors pointed out, even with the gradual decline in the number of stillbirths that has been seen in the last several decades, intrauterine death in the third trimester still occurs in between one in 115– 125 births. They demonstrated that for a relatively modest cost, comprehensive evaluation yielded a great deal of information that could be helpful in counseling couples about future pregnancies and the management of those pregnancies. A stillbirth is a tragedy for the couple involved and extremely upsetting to the caregiver. However, not learning from this experience, and thereby running the risk of suffering a repetition, would be a greater tragedy. The findings of this study should stimulate obstetricians to order a careful assessment of every stillbirth.
Neonatal Outcomes After Topical Use of Corticosteroid in Pregnancy Mygind H, Thulstrup AM, Pedersen L, Larsen H. Risk of intrauterine growth retardation, malformations and other birth outcomes in children after topical use of corticosteroid in pregnancy. Acta Obstet Gynecol Scand 2002;81:234 –9.
Synopsis: The authors performed a population-based follow-up study evaluating the risk of fetal growth re-
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striction (FGR), congenital malformations, and other birth outcomes among children of women exposed to topical corticosteroids during pregnancy or just before pregnancy. In a population in one county in Denmark, which represented 9% of the Danish population, 363 women were found to be exposed to topical corticosteroids during pregnancy and were compared with 9263 who were not exposed to these medications. No statistically significant differences existed with respect to congenital malformations, preterm birth, or low birth weight (LBW) among the offspring of women receiving topically administered weak to medium strong corticosteroids or strong to very strong corticosteroids. Level II-2.
that, at least in the 34 women and 25 infants involved, no HIV infection was transmitted; suggesting that this means was reasonably safe for HIVpositive men to have children. When the authors compared the treatment efficacy with that of control couples, they found no statistically significant differences. Level II-3. ● ● ●
Commentary: These authors furnished worthwhile information for the counseling of HIV serodiscordant couples who hope to have children. Although the method is costly, the safety that intracytoplasmic sperm injection apparently offers more than compensates for the financial burden.
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Commentary: There has been controversy over whether corticosteroids administered during pregnancy increase the risk of congenital malformation or LBW. More recent studies have cast doubt on the likelihood of this risk. In the current study, the authors demonstrated that the topical use of even strong corticosteroid agents did not increase the risk of FGR or congenital malformations, even when used in the first trimester. This information is useful for physicians counseling patients who have been exposed either through intentional use of corticosteroids or because they did not know that they were pregnant at the time of use. As the study was population-based and retrospective, the dosage and length of time of exposure to corticosteroids were not known. Nevertheless, this was a large study and the results were reassuring.
IVF With HIV-Positive Men Sauer MV, Chang PL. Establishing a clinical program for human immunodeficiency virus 1-seropositive men to father seronegative children by means of in vitro fertilization with intracytoplasmic sperm injection. Am J Obstet Gynecol 2002;186:627–33.
Synopsis: In this study, the authors assessed the safety of using in vitro fertilization with intracytoplasmic sperm injection to assist human immunodeficiency virus (HIV)-positive men to father children. They demonstrated 6
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Risk of Prenatal Death Associated With Labor After Previous Cesarean Delivery Smith GCS, Pell JP, Cameron AD, Dobbie R. Risk of prenatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002; 287:2684 –90.
Synopsis: The authors presented the results of a population-based retrospective cohort study of data from the linked Scottish Morbidity Record and Stillbirth and Neonatal Death Enquiry carried out on births in Scotland between 1992 and 1997. A total of 303,238 singleton births between 37 and 43 weeks’ gestation were studied. Four groups were studied: women who had a trial of labor after a previous cesarean delivery; women who had a planned repeat cesarean delivery; and multiparous and nulliparous women at term without a history of previous cesarean who were delivered spontaneously. The overall rate of delivery-related perinatal death in the previous cesarean delivery group was 12.9 per 10,000 women. This rate was 11 times greater than the risk associated with women who had repeat cesarean delivery, and more than twice the risk for spontaneously delivering women with no history of cesarean delivery. In the trial of labor group the risk of uterine rupture was 4.5 per 10,000 women, which was eight times greater than the risk of uterine rupture in spontaneously delivering women
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without a history of cesarean. Level II-2. ● ● ●
Commentary: The authors correctly stated that the absolute risk of perinatal death related to trial of labor after a previous cesarean was low. However, the rate of perinatal death was considerably higher than in the planned cesarean group and most of these deaths were related to rupture of the uterus. The study was large and therefore of significant power to define the actual risk. The information generated should be part of the counseling process for women who must decide whether or not to have a trial of labor after a previous cesarean delivery. The economics of the situation are understandable, but it is clear that women who select vaginal birth after cesarean delivery assume a somewhat increased risk to themselves and their infant.
SPOTLIGHT ON GYNECOLOGY Morton A. Stenchever, MD Editor
Treatment Strategies for Pelvic Inflammatory Disease Ness RB, Soper DE, Holley RL, Peipert J, Randall H, Sweet RL, et al, for the PID Evaluation and Clinical Health (PEACH) Study Investigators. Effectiveness of inpatient and outpatient treatment strategies for women with pelvic inflammatory disease: Results from the Pelvic Inflammatory Disease Evaluation and Clinical Health (PEACH) Randomized Trial. Am J Obstet Gynecol 2002; 186:929 –37.
Synopsis: The authors enrolled 831 women in multiple centers who had mild-to-moderate pelvic inflammatory disease (PID) and randomized them to a treatment protocol on an inpatient or outpatient basis in order to determine if outpatient treatment of PID was as effective as inpatient therapy. Inpatient treatment consisted of intravenous cefoxitin and doxycycline, and outpatient treatment consisted of a single intramuscular injection of cefoxitin and oral doxycycline. Short-term clinical and microbiological improvement was ©2002 by the American College of Obstetricians and Gynecologists Published by Elsevier Science Inc. 1085-6862/02/$6.00