Maternal Morbidity

Ob.Gyn. News

N EONATAL W ITHDRAWAL S YNDROME

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C OURTESY D R . M ARJORIE J EFFCOAT

Periodontal Disease Raises Preterm Risk

Dr. Flamm’s Clinical Pearls Contest

BY ROBERT FINN

San Francisco Bureau

R E N O , N E V. — Maternal morbidity increases significantly with each subsequent cesarean delivery, according to a large prospective cohort study reported by Robert M. Silver, M.D., at the annual meeting of the Society for Maternal-Fetal Medicine. Moreover, morbidity rates show a particularly large increase with the fourth and subsequent cesarean deliveries, according to the study, which was based on data from the Maternal Fetal Medicine Units (MFMU) Network, created by the National Institute of Child Health and Human Development.

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The Rest Of Your Life How physicians can fit exercise into a busy schedule. PAGE 38

Flu Shot Study finds vaccine is safe and effective in second half of pregnancy.

BY ROBERT FINN

San Francisco Bureau

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Medical care All items

3%

2%

2000

2001

2002

2003

Note: Based on Consumer Price Index (CPI) data from the Bureau of Labor Statistics. Source: Centers for Disease Control and Prevention

K EVIN F OLEY, R ESEARCH /S ARAH L. G ALLANT, D ESIGN

5%

4%

The central conclusion of this study is that “the number of intended pregnancies should be factored into consideration of primary elective cesarean delivery or attempted vaginal birth after cesarean,” said Dr. Silver of the University of Utah, Salt Lake City. In addition, the study suggests that physicians should give serious thought to a trial of labor in women who are candidates for a first cesarean delivery and who are planning to have several children. Of the 378,168 births followed prospectively by the 14 tertiary care centers in the MFMU Network, there was a total of 57,068 See Morbidity page 5

17P: Best for Prior Preterm Births Before 34 Weeks

Medical Care Spending Outstrips Inflation

1%

MARCH 15, 2005

Maternal Morbidity Rises Sharply With Repeat Cesareans

VITAL SIGNS

Average Annual % Change in CPI

U N I V E R S A L C I T Y, C A L I F. — Every prepregnancy consultation should include a recommendation for a full periodontal examination, and patients should be monitored throughout pregnancy for signs of periodontal disease, Todd Hartsfield, D.D.S., recommended. Evidence compiled from many studies suggests that maternal periodontal disease may be responsible for 18% of preterm, low-birth-weight deliveries, he said at a meeting of the Obstetrical and Gynecological Assembly of Southern California. Moreover, research suggests that in patients with periodontitis during the second trimester, deep instrumental cleaning, known among dentists as scaling and root planing, may substantially lower the risk of preterm delivery. Many of the studies detailing periodontal risk have appeared in dental journals that obstetricians never see, said Dr. Hartsfield, director of the Dental Clinical and Prevention Support Center of the Inter Tribal Council of Arizona in Phoenix. “I’d like to see more interplay between our professions,” Dr. Hartsfield said during a special lecture at the meeting. “The dentist and dental hy-

gienist should be a part of the health team that is involved in caring for expectant mothers.” He recommended several patient brochures offered by the American Dental Association, including “Women and Gum Disease,” “What is Scaling and Root Planing?” and “Gum Disease: The Warning Signs.” Dr. Hartsfield also suggested joint meetings of local dental and ob.gyn. societies, and sessions in which dentists and dental hygienists could teach ob.gyn. nurses and practitioners to conduct “quick look” oral screenings during each routine prenatal visit. See Periodontal page 4

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Largest increase seen after fourth delivery.

Periodontitis may cause 18% of preterm, low-birth-weight deliveries; treatment in the second trimester may lower that risk.

Los Angeles Bureau

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R E N O , N E V. — T herapy with 1 7
- hyd r ox y p r o g e s t e r o n e caproate to prevent recurrent preterm birth is associated with an overall prolongation of pregnancy, especially in women with a prior spontaneous birth before 34 weeks’ gestation, Catherine Y. Spong, M.D., reported. Weekly injections of 17
-hydroxyprogesterone caproate (17P) was associated with an average pregnancy prolongation of 1.5 weeks in women whose earliest prior preterm birth was

before 34 weeks’ gestation, she said at the annual meeting of the Society for Maternal-Fetal Medicine. Women whose earliest prior preterm birth was between 34 and 37 weeks’ gestation exhibited a trend toward a statistically significant prolongation of gestation, but this did not reach statistical significance, according to Dr. Spong of the National Institute of Child Health and Human Development, Bethesda, Md. The study involved a secondary analysis of a doublemasked, placebo-controlled trial See 17P page 5

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M a r c h 1 5 , 2 0 0 5 • w w w. e o b g y n n e w s . c o m

Repeat Cesareans Increase Risk Morbidity from page 1

cesarean deliveries. Dr. Silver’s study fo- creasing numbers of cesarean deliveries. cused on the 30,132 cesarean deliveries that These included maternal death, deep vewere not accompanied by a trial of labor. nous thrombosis, pulmonary embolus, reMore than 6,000 women who participated operation, endometritis, and wound dein the study were having at least their third hiscence. Dr. Silver pointed out that previous cesarean delivery. And more than 1,800 smaller studies had suggested women were having their that the rate of placenta accfourth or more than fourth The study was reta with placenta previa and cesarean delivery, making carried out at one prior cesarean delivery this by far the largest study was about 25%. The MFMU of its kind. tertiary care study suggests that this rate is Several morbidities incenters, so closer to 10% than 25%. Dr. creased significantly with Silver cautioned that the each subsequent cesarean participants are morbidity rates in the delivery. (See table.) These not representative MFMU study should not be included placenta accreta, seen as an estimate of the placenta previa, hysterectoof the entire true prevalence in the popumy, cystotomy, bowel inpopulaiton. lation at large. jury, ureteral injury, ileus, The study was carried out need for a ventilator postoperatively, and transfusion of at least four in tertiary care centers that are likely to units of blood. Increases were also seen in see an especially large proportion of comICU admissions, operative time, and num- plicated pregnancies and cesarean deliveries, so the women who were included ber of days in the hospital. On the other hand, several morbidities in the study are not representative of the showed no significant increase with in- entire population. ■

Complication Rates Increase With Number of Cesarean Deliveries 1

0.2%

Placenta accreta Placenta accreta in women with placenta previa Hysterectomy

2

0.3%

3

0.6%

4

2.1%

5

2.3%

³6

6.7%

3.3% 11.0% 40.0% 61.0% 67.0% 67.0% 0.6% 0.4% 0.9% 2.4% 3.5% 9.0%

Source: Dr. Silver

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I

t’s time again for our annual Clinical Pearls contest. This year we are awarding a portable DVD player with car kit to nine lucky winners. Bruce L. Flamm, M.D., will select the top nine entries, which will be featured in upcoming columns. So start thinking about those clinical tips that have helped you out over the years but aren’t widely published. We’re looking for items that can be summarized briefly.

Two Ways to Submit Your Entry 1. Drop off your pearls at the OB.GYN. NEWS booth #529 at the annual meeting of the American College of Obstetricians and Gynecologists in San Francisco May 9-11. 2. Send them to Dr. Flamm by Fax: 909-353-5625 E-mail: [email protected] Regular mail: 10445 Victoria Ave. Riverside, CA 92503 Multiple submissions are permitted. Dr. Flamm will select what he considers to be the nine most clinically useful and concisely presented pearls. All decisions are final. The prize-winning pearls will be published in Dr. Flamm’s Clinical Pearls column beginning in the July 15, 2005, issue of OB.GYN. NEWS. Other submissions may be published in subsequent columns. All entries must be received by May 15, 2005. Visit Dr. Flamm at our booth at the ACOG annual meeting in San Francisco. Where: Exhibit Hall, OB.GYN. NEWS Booth #529 When: Monday, May 9, 11 a.m. to 12 p.m. Tuesday, May 10, 11 a.m. to 12 p.m.

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Early West Nile Case May Bode Ill for Western U.S. B Y B E T S Y B AT E S

Los Angeles Bureau

L O S A N G E L E S — The first human case of West Nile virus infection this year was diagnosed in Los Angeles in early February, perhaps setting the stage for an early and virulent season for the far western United States. “Since West Nile virus was [first] detected in 1999, we’ve seen a lengthening period of transmission,” said Ned Hayes, M.D, of the Centers for Disease Control and Prevention’s Division of Vector-Borne Infectious Diseases in Fort Collins, Colo. As the virus has spread south and west across the United States, new “ecological dynamics” have influenced transmission patterns, he explained. A wetter than normal winter in California and the Southwest may suit mosquitoes well, meaning physicians will need to be especially alert to possible cases of the now reportable disease. The Los Angeles County Department of Health Services announced an infection in an older man in east Los Angeles County on Feb. 8. As of mid-February, state and federal health officials had not completed confirmatory tests on the case. Symptoms of the infection include fever, headache, fatigue, body aches, skin rash, and swollen lymph nodes. More serious manifestations of West Nile encephalitis or meningitis also include neck stiffness, stupor, disorientation, coma, tremors, convulsions, and muscle weakness, as well as

a paralysis that can resemble polio. “It doesn’t matter whether we’ve had one case or five; if you see encephalitis or meningitis, you look for West Nile virus,” said Laurene Mascola, M.D., chief of the acute communicable disease control unit of Los Angeles County. The first bird carrying the virus was found in mid-January, whereas no bird evidence was confirmed in California until the end of March in 2004. Twelve birds in eight counties had been found to have the virus by mid-February. Birds are a key player in the transmission cycle of West Nile virus and are carefully tracked, although mosquitoes are the direct vectors infecting humans. California and the Southwest, where the disease struck hardest in 2004, have warmer climates than the northeastern states, where the virus first took hold in the United States. Mosquito vectors also differ, with Culex pipiens most common in the Northeast and C. tarsalis and C. quinquefasciatus more often the culprits in the West. C. tarsalis was a common vector in Colorado, where West Nile virus infected 3,000 people in 2003, killing 63. “It’s a very efficient vector. It avidly bites humans and also bites birds, and it seems to transmit the virus very well.” Dr. Hayes urged physicians to test for West Nile virus and report any cases to their state health departments, which, in turn, notify the CDC. West Nile virus infected 2,470 people in 40 states in 2004, resulting in 88 deaths.

Progesterone Prolongs Gestation 17P from page 1

involving 463 women who were pregnant Dr. Spong commented during the meetwith singletons and had a documented pri- ing. Similarly, 4.6 women whose earliest prior preterm birth. On the basis of several studies, the or preterm birth was between 28 and 33.9 American College of Obstetricians and weeks would require treatment to prevent Gynecologists in 2003 issued a committee one preterm birth. Although the study was not sufficientopinion stating that 17P appears to prevent ly powered to detect a sigpreterm birth in a select nificant improvement in group of high-risk women Unfortunately, preterm births among with prior spontaneous many pharmacies women whose earliest prior preterm births (Obstet. Gypreterm birth was between necol. 2003;102:1115-6). do not routinely 34 and 36.9 weeks’ gestation, Unfortunately, many stock this form of Dr. Spong calculated that pharmacies do not rouone would need to treat 7.2 tinely stock this form of progesterone. As women in this group to preprogesterone. As a result, a result, it can be vent one preterm birth. it can be very difficult to These number-needed-toobtain. very difficult treat values compare favorDr. Spong’s logistic reto obtain. ably with other common gression model adjusted for risk-avoidance recommenrace, gestational age at randomization, and having at least two prior dations. For example, one needs to treat 102 people with low-dose aspirin to prespontaneous preterm births. A physician would have to treat 4.7 vent a single cardiovascular incident, and women whose earliest prior preterm 42 patients with prior MI with  -blockers birth was between 20 and 27.9 weeks’ to prevent a single cardiac death, Dr. gestation to prevent one preterm birth, Spong said. ■