UNC OB-GYN and N.C. Women's Hospital

Stem Cells in Mother’s Milk

2012-01-12T09:57:00.000-08:00

By Dr. Alison Stuebe

For the past 2 months, I’ve been learning about a fascinating study in Chapel Hill. Foteini Hassiotou, a researcher from the University of Western Australia, is working with Pilar Blancafort, a UNC faculty member, to study the cells in mother’s milk.

I’ve known for a long time that human milk contains infection-fighting immune cells. Indeed, one of my favorite images (right) compares the view under the microscope of mother’s milk, rich in infection-fighting cells and neatly packaged nutrients, with a bland splotch of infant formula.

It wasn’t until I met Dr. Hassiotou, however, that I learned that mother’s milk also contains cells from the milk-secreting structures in the breast. She has also isolated cells from milk that appear to have the potential to turn into many different structures, including bone, liver, pancreas and brain cells, much like embryonic stem cells. She’s now collecting milk samples from mothers in Chapel Hill to study the properties of these stem cells and try to determine their role in the health and development of breastfed babies.

Mothers wishing to participate come to the UNC Medical School campus to express 1-2 ounces of milk for the study and complete a brief questionnaire.

For more details, see the study flyer below, or contact Dr. Hassiotou at foteini.hassiotou@uwa.edu.au.

Enabling Mothers to Meet Breastfeeding Goals

2011-11-14T08:35:00.001-08:00

By Dr. Alison Stuebe

N.C. Women’s Hospital earns 5 stars for enabling mothers to meet their breastfeeding goals

Starting to breastfeed is a bit like learning to ride a bike. In the beginning there is a fair amount of wobbling, and even some crashing and burning, as mother and baby figure out to keep their balance in a completely new environment. And then one day, you start peddling, and you wonder why this was ever a struggle.

Just like learning to ride a bike, learning to breastfeed is easier if you start out on a soft surface, with training wheels, and with someone running along behind you to keep you upright. For most new moms, that learning process starts in the hospital, and multiple studies have shown that routine maternity care practices make a tremendous impact on whether mothers and babies build confidence and succeed, or crash and burn.

This week, North Carolina Women’s Hospital was one of just two maternity centers in North Carolina to earn 5 stars for protecting, supporting and promoting breastfeeding. N.C. Women’s earned this award for implementing all ten of the Ten Steps to Successful Breastfeeding, a World Health Organization initiative that is designed to ensure mothers and babies have the best chance of breastfeeding successfully. Think of it as the learning-to-breastfeed equivalent of taking off the training wheels on a very gentle, grassy incline with a well-rested and patient parent running along behind.

Multiple studies have shown that the Ten Steps play a crucial role in enabling mothers to achieve their own breastfeeding goals. A recent study followed breastfeeding outcomes among women who had planned to breastfeed for at least 2 months, and asked women about six of the Ten Steps.

Among those who received six out of six Steps, 97% were still breastfeeding at 6 weeks.
Among mothers who did not experience any of the Steps, 30% had weaned by 6 weeks. Put another way, almost a third of mothers who delivered in no-Steps hospitals failed to achieve their own breastfeeding goals.

For families giving birth at UNC, the 5 star designation means they will receive state-of-the-art care to enable them to achieve their infant feeding goals. For example, Step Four makes it routine practice to place babies skin-to-skin after birth. This practice keeps babies warm and calm, helping them transition to life in the outside world. Studies have shown that skin-to-skin care also markedly increases breastfeeding duration – in randomized trials, mothers and babies that cuddle skin-to-skin in the first hour after birth breastfeed 6 weeks longer than babies who are swaddled in a blanket.

As part of Ten Steps care, babies also stay in the room with their mothers, so that moms can pick up on early feeding cues, such as baby’s rooting or sucking on fingers, rather than waiting until a frantically hungry infant is brought in from the nursery. To support new families, all UNC staff completed comprehensive breastfeeding training.

After moms and babies leave the hospital, UNC provides outpatient lactation support through the UNC Pediatrics Clinic, where experienced lactation consultants touch base during well-baby checks and see mother and babies who are struggling with pain, low milk supply, and other difficulties. I also see patients in my Maternal Fetal Medicine Clinic, working with a lactation consultant to help mothers and babies achieve their feeding goals.

Over the past 3 years, we have worked with an interdisciplinary team of physicians, nurses, and researchers to develop a set of treatment algorithms for mothers with breastfeeding-associated pain. The mission of UNC’s Lactation Program is to provide integrated, evidence-based lactation care for the mom-baby dyad, thereby empowering all mothers to meet their breastfeeding goals. With data analysis underway for several pilot studies, we are hopeful that we’ll be able to find new approaches to help mothers who encounter obstacles to have a positive breastfeeding experience.

The Thin Red Line of Motherhood in Malawi

2011-11-07T05:31:00.000-08:00

By Dr. Jeffrey Wilkinson

Two women stood across this red line outside the operating room at Bwaila hospital Freedom from Fistula Foundation clinic in Lilongwe, Malawi last week. Each was asked if we could take her photo to share with people from different countries in order for others to understand her condition. Both readily agreed.

One woman is pictured here with her 13-month baby. She delivered at home for the third time at age 19. With the delivery, she experienced a tear of the vagina in to the rectum that remained unrepaired because there was no skilled birth attendant present. She was left with incontinence of stool for the last year and presented for care at the fistula center a couple weeks ago. The other patient, pictured alone here, also delivered at home, but ten years ago and experienced obstructed labor, delivery of a stillborn baby and was left with a fistula and unrelenting urinary incontinence since the delivery. Her injuries were so severe that she will never be capable of having a child. Her reproductive tract was irreparably scarred. Both women were fortunate to survive delivery far from a health center or hospital. Both women experienced relief of incontinence from their surgery, but go home to lead vastly different lives: One with a family and three healthy children. One left forever barren and divorced.

Straddling the thin red line of motherhood in Malawi are the nearly 1% of mothers who die in childbirth, the 6% of babies that are stillborn or die shortly after birth and the countless families that are left without wife, daughter, mother or child; Communities irreparably injured by lost persons or lost potential. The line separating the happy outcomes from the tragedies can be something as simple as 50 cent medication, a few hours worth of training, $2.00 for a ride to the hospital or an operating room with electricity and functioning lights. The line can be as thin as a few cell layers in the bladder that make the difference between total incontinence with isolation and shame or a life fully lived.

The balance across this line can be fundamentally altered in a positive direction with education of girls and boys, capacity building, access to family planning services and cost-conscious improvements in health delivery systems across the developing world. Poor countries such as Sri Lanka, Honduras and Bangladesh have proven the skeptics wrong by improving maternal health care outcomes despite persistent poverty. The balance can be shifted in Malawi as well.

Message from Malawi: Meet Agogo

2011-10-04T07:14:00.000-07:00

Dr. Jeffrey Wilkinson

By Dr. Jeffrey Wilkinson
Beginning in September, UNC's Dr. Jeffrey Wilkinson relocated to Southern Africa. Read more..

Below is the first in a series of blogs from Dr. Wilkinson about his experiences there.

Monday, September 26, 2011

I'm slowly settling in to life in Lilongwe.

We have seen 18 women in the fistula unit and have done 12 surgeries. Our two hospital rooms dedicated to the fistula patients are full with a third of the women sleeping on mattresses on the floor. This is still better than the average occupancy of the maternity wing in general at Bwaila Hospital which is 300% full at times. I occasionally will get messages from Dr. Clarke-Pearson about bed shortages at UNC and wonder if some people there would mind sharing a bed with their neighbor or sleeping on the floor. I suspect it would not pass JCAHO muster.

Meet Grandma or "Agogo"

This patient is 60 years old and has had a fistula for 32 years. She had been pregnant 10 times and had only one living child. About 70% of fistula patients never have a living child so she is still the exception. We have been calling her Grandma, or Agogo, in Chichewa. She waited for 32 years to get care for the fistula because she was unaware of any place she could go for care.

Her surgery was Thursday and we have high hopes for her full recovery.

Should Cystic Fibrosis Carrier Screening Be Offered?

2011-08-02T08:01:00.000-07:00

Patricia Devers, MS, CGC

Should we offer cystic fibrosis carrier screening to preconception or pregnant women now that cystic fibrosis has been added to the North Carolina newborn screen?

YES.

In 2001, the American College of Obstetricians and Gynecologists (ACOG) and the American College of Medical Genetics (ACMG) introduced guidelines for prenatal and preconception carrier screening for cystic fibrosis (CF). These guidelines were updated in 2005. In these guidelines, it was recommended that CF carrier screening be made available to all women who were considering pregnancy or were pregnant. In addition, it was recommended that CF carrier screening be verbally offered to women in the ‘high-risk’ group who were considering pregnancy or were pregnant. The ‘high-risk’ group was defined as non-Jewish Caucasians and Ashkenazi Jews or individuals of any ethnicity with a family history of CF. An emphasis on preconception testing was encouraged. These guidelines remain the current standard of care in the obstetrical field.

As of April 13, 2009, the North Carolina State Laboratory of Public Health (NCSLPH) began testing all newborn screening specimens for CF. Testing is performed with a two-tier screening process. First, the specimen is tested to determine the concentration of immunoreactive trypsinogen (IRT). The specimens with the highest 5% IRT values then undergo DNA testing using a panel of over 40 common CF mutations. Specimens with an IRT value less than or equal to 175 ng/mL and no identified mutations are reported as normal. Specimens with one or two identified mutations, or with an IRT value greater than 175 ng/mL and no identified mutations are reported as abnormal. All abnormal results are reported to the child’s health care provider to arrange for sweat testing at an accredited CF center.

So, if children with CF will be identified through newborn screening, what are the benefits of parental carrier screening?

PROS of carrier screening:

Identifies couples who may have an increased risk for CF in subsequent pregnancies, while a normal result on newborn screening does not provide information regarding future pregnancies.
Identifies families in whom a CF mutation is carried, allowing for preconception/prenatal testing for other family members – and for the children of the couple who have a much higher carrier risk
Allows prenatal diagnosis of CF and the option of pregnancy termination, adoption, or parental preparation
Allows other reproductive options to carrier couples, including donor egg or sperm, adoption, and pre-implantation genetic diagnosis

CONS of carrier screening:

May create anxiety when one member of the couple is found to be a carrier and the other is unavailable for testing or has a negative carrier screen
May increase anxiety for couples in which both partners are found to be carriers, but who are not interested in pursuing prenatal diagnosis
Cost of carrier screening is carried either by the patient or her insurance provider

So, while the guidelines state that preconception and prenatal carrier screening for CF should be made available to all women and offered to women who are considered ‘high-risk,’ the incorporation of CF in newborn screening is another factor for women to consider when electing or declining carrier screening. Couples should be informed of the inclusion of CF on newborn screening in order to make the most appropriate decision for their family.
________________________________________
References:

American College of Obstetricians and Gynecologists, American College of Medical Genetics. Preconception and prenatal carrier screening for cystic fibrosis: clinical and laboratory guidelines. Washington, DC: ACOG; Bethesda (MD): ACMG; 2001.

American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 325: Update on carrier screening for cystic fibrosis. Obstet Gynecol 2005; 106: 1465-8.

http://slph.state.nc.us/newborn/

What is Genetic Counseling?

2011-07-08T10:02:00.000-07:00

By Emily Hardisty, MS, CGC

I’m referring a patient for ultrasound and genetic counseling because she will be over 35 at delivery. She asked me what to expect from genetic counseling. While I know what genetic counseling is, I’m not sure how to explain it to her.

A formal definition of genetic counseling is a good starting point. According to the National Society of Genetic Counselors:

“Genetic counseling is the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease. This process integrates the interpretation of family and medical histories to assess the chance of disease occurrence or recurrence, education about inheritance, testing, management, prevention, resources and research, and counseling to promote informed choices and adaptation to the risk or condition” (NSGC, 2005).

So, genetic counseling is a process that includes information gathering, emotional support, and education. At our center, genetic counseling is provided by specially trained genetic counselors. All of the genetic counselors at the UNC Prenatal Diagnosis Center have a Master of Science in Genetic Counseling or a related field and are either board certified genetic counselors (CGC) or board eligible (BE) genetic counselors. These genetic counselors work closely with the maternal fetal medicine physicians and sonographers to help provide patients with comprehensive and clear information about their pregnancy.

When coming to our center for genetic counseling, patients can expect the following:

A review of their family and medical history. This information is used to determine if the family is at increased risk for any birth defects or genetic conditions. If warranted, additional testing may be discussed based on this family history.
An assessment of their risk in the current pregnancy. All pregnancies have some risk for birth defects. These risks may be increased as a result of increased maternal age, abnormal screening results, or abnormal ultrasound findings.
A discussion of testing options available in the current pregnancy. These testing options may include screening tests (such as first trimester screening or second trimester maternal serum screens), ultrasound, CVS, amniocentesis, or additional genetic tests.
A discussion of how the patient’s beliefs, values, and desires for the pregnancy may impact their decisions and attitudes regarding the risks in the pregnancy and their testing options.

Patient’s often come to us with misconceptions about genetic counseling based on word-of-mouth or internet research. We find that patient’s who are informed by their physician or nurse that they are being referred for genetic counseling and who are provided with some information about what to expect from genetic counseling are often the most receptive to and benefit the most from the genetic counseling process.

For more information about the UNC Prenatal Diagnosis Center, visit us on the web at www.mombaby.org or www.UNCmfm.org.

More Information for You - Birth Control Pills and Blood Clots

2011-06-02T12:26:00.000-07:00

Recently, the FDA released their review of some popular birth control pills for blood clot risk. Read article from Time Magazine's website...

We wanted to find out More Information for You so we asked our specialist at UNC OB/GYN about these latest findings.

David Grimes, MD

The best available study (EURAS), a large (140,000 woman-years study) with 98% follow-up and blinded adjudication of every suspected clot found that all oral contraceptives used in Europe have the same risk of venous thromboembolism (blood clot). The successor study (INAS), which is ongoing in the U.S. as well as in Europe, is finding the same results.

In contrast, methodologically weaker case-control studies and registry studies from Denmark have reported a higher risk of clots with drospirenone. This makes no biological sense, since drospirenone is pharmacologically similar to spironolactone, which does not cause clots.

In summary, the best available evidence suggests that all contemporary birth control pills carry the same small risk of clots, much less than that associated with pregnancy.

High-quality prospective cohort studies trump weaker retrospective registry and case-control studies, which are more prone to bias.

Disclaimer: Dr. Grimes serves as a member of the Data Safety Monitoring Board for Bayer’s INAS study,

More Information for You - Fibulin-5 and Pelvic Organ Prolapse

2011-05-25T05:40:00.000-07:00

A gynecologist and a molecular biologist at UT Southwestern Medical Center have collaborated to show for the first time that pelvic organ prolapse – a condition in which the uterus, bladder or vagina protrude from the body – is caused by a combination of a loss of elasticity and a breakdown of proteins in the vaginal wall. Read more about the research results....

We wanted to find out More Information for You so we asked our specialist at UNC OB/GYN about this latest research.

Dr. Elizabeth Geller

Researchers have shown that specific changes in a protein that helps with elastic fiber assembly, called fibulin-5, controls the activity of enzymes that break down collagen and elastic fibers, leading to a loss of the structural support of the vaginal wall.

We have known that there is a genetic component to the development of loss of vaginal wall support, also known as pelvic organ prolapse; but this study will help to further our understanding of that genetic relationship. Pelvic organ prolapse is due to many causes including genetics as well as pregnancy and childbirth and lifestyle factors such as obesity, chronic coughing, chronic constipation with straining, and repetitive heavy lifting.

For now we can advocate changes in lifestyle to avoid developing prolapse. With this new information we may be one step closer to understanding how prolapse develops in order to both prevent it and to treat it more effectively.

More Information for You - HPV and Pap Tests

2011-05-23T10:18:00.000-07:00

According to recently published recommendations by the American Congress of Obstetricians and Gynecologists, most women aged 30 and older with normal Pap and human paillomavirus (HPV) test results can safely wait three years until their next set of cervical cancer screening tests. Read more on Web MD about the guidelines ....

We wanted to find out More Information for You so we asked our specialist at UNC OB/GYN about these latest screening recommendations.

General Thoughts on the Recommendation
Alice Chuang, MD

The presence of HPV is necessary for the development of cervical cancer so the detection of it certainly is valuable in evaluating a patient’s cervical cancer risk. Remembering that these guidelines are for low risk patients and that a subset of the population is high risk. These guidelines do not necessarily apply to this subset.

Incorporating These Guidelines Into Practice
Lisa Rahandale, MD, MPH

It is hard for us as clinicians to change our practice. But some clinicians may not have an understanding of the natural history of cervical dysplasia and HPV, and follow the philosophy where more testing is better. This philosophy is how things were done for such a long time when it came to cervical cancer screening.

Additionally, clinicians may worry that patients will not return if they do not need a pap smear. I always encourage my patients that they need to come in for health care maintenance, STD screening, contraception or whatever applies to them. There is also medico legal side of things where clinicians are afraid of missing a cervical cancer. Clinicians aren't the only ones to resist this change, it's hard for patients to change their health care patterns.

How I Will Conduct My Screenings
D. Michael Armstrong, MD

I follow the ACOG recommended cervical screening strategy. ACOG updated the cervical screening practice bulletin in 12/2009. Since that time, for low risk patients I initiate screening at age 21 and screen every 2 years.

For patients 30 years old or older, I add HPV testing to the PAP test, and extend the screening interval to every 3 years for low risk patients. I adhere to these guidelines because several studies have confirmed the sensitivity of HPV testing and its accurary in detecting high grade cervical lesions.

New VBAC Guidelines

2011-05-11T09:31:00.000-07:00

Vaginal Birth after Previous Cesarean Delivery:
New Guidelines Increase the Number of Appropriate Candidates

Meg Berreth, CNM, MSN

The cesarean delivery rate in the United States has increased from 4.5% in 1965 to 32.3% in 2008 (Guise JM, 2010). Meanwhile, the rate of Vaginal Birth after Cesarean (VBAC) has decreased from its peak of 28.3% of all women with a prior cesarean delivery in 1996 to the most recent rate of just 8% in 2006 (National Institutes of Health, 2010). The reasons for this decrease are numerous and complex involving fear of potential dangers of VBAC, lack of access to facilities that offer VBAC and fear of litigation among providers. In March 2010 the National Institutes of Health (NIH) held a consensus conference to examine the safety of VBAC and repeat cesarean for women with prior cesarean deliveries. Following the NIH consensus statement, the American College of Obstetricians and Gynecologists (ACOG) released a new practice bulletin outlining their guidelines regarding the mode of delivery for women with a prior cesarean delivery (American College of Obstetricians and Gynecologists, 2010).

New Recommendations regarding VBAC
The best current evidence available supports that women with one prior cesarean delivery with a low-transverse uterine incision (the most common kind performed) are candidates for VBAC and should be counseled about VBAC and offered a trial of labor. In addition, there is good evidence to support that epidural anesthesia is a safe option for women attempting a VBAC (American College of Obstetricians and Gynecologists, 2010).

Based on limited or inconsistent evidence, ACOG supports offering the following women a VBAC: those with two prior low transverse uterine incisions, those with a current twin pregnancy who are otherwise good candidates for vaginal delivery, and those requiring an induction of labor for maternal or fetal indications (as long as prostaglandin preparations are not utilized). ACOG supports offering VBAC to women with an unknown uterine scar unless there is a high suspicion of previous classical (up and down) incision on the uterus. Women with a prior cesarean delivery and a current pregnancy complicated by a breech presentation can be offered external cephalic versions (a procedure of trying to turn a breech baby).

Who should offer VBACs
ACOG also outlines that VBACs should be attempted only in facilities capable of emergency deliveries. Surveys of hospital administrators found that 30% of hospitals do not offer VBACs due to the lack of emergency delivery services (National Institutes of Health, 2010). Providing care for women who desire a VBAC is within the scope of care for Certified Nurse Midwives who practice in facilities that have the ability to perform an emergency delivery (American College of Nurse-Midwives, 2000). The Certified Nurse Midwives at UNC work closely with our obstetricians and anesthesiologists and have a VBAC success great of greater than 80%.

Based on the best available data, the newest guidelines from ACOG increase the number of women that should be offered a VBAC. The benefits and risks of VBAC should be discussed with each woman based on her individual history and desires. Because the greatest risks of VBAC occur when they are not successful and a repeat cesarean delivery is required following labor, attempts have been made to predict a woman’s likelihood of success at VBAC. Caution should be used when trying to predict the likelihood of individual success at VBAC based on programs that calculate likelihood of success: “VBAC calculators” have only been studied at the population, not the individual, level (National Institutes of Health, 2010).

The decision about whether to attempt a VBAC or schedule a repeat cesarean is complex and multi-faceted. It can only be made by the woman and her family with appropriate, thorough counseling by her health care provider. More research is needed into the risks and benefits of VBAC and repeat cesarean and what factors influence these harms and benefits.

References:
American College of Nurse-Midwives. (2000, December). Position Statement: Vaginal Birth After Cesarean Delivery. Retrieved May 5, 2011, from American College of Nurse-Midwives: http://www.midwife.org
American College of Obtstricians and Gynecologists. (2010). Vaginal Birth After Previous Cesarean Delivery. Obstetrics and Gynecology , 450-463.
Guise JM, D. M. (2010). Vaginal Birth After Cesarean: New Insights on Maternal and Neonatal Outcomes. Obstetrics and Gynecology , 1267-1278.
National Institutes of Health. (2010). NIH Consensus Development Conference Statement on Vaginal Birth After Cesarean: New Insights. Vaginal Birth After Cesarean: New Insights (p. 4). Washington, DC: NIH.

UNC OB/GYN Special Visitor

2011-04-08T11:10:00.000-07:00


Lameck Chinula and Dr. John Thorp

This week we had a special visitor to our campus.

Lameck Chinula is a Malawian medical school graduate who has been sponsored by the UNC Project-Malawi in a South African obstetrics and gynecology residency.

He plans to return to Lilongwe upon graduation to serve his countrywomen and children.

He visited here this week to meet with UNC OB/GYN and Infection Disease faculty, shadow in clinic and participate in fellow activities.

He was welcomed by our Department and we look forward to working with him in the future.

North Carolina 17-P Update for Prevention of Recurrent Preterm Birth

2011-03-25T11:44:00.000-07:00

Dr. Bill Goodnight, Dr. Kate Menard, Dr. Nancy Chescheir, Dr. Tom Ivester, Dr. Bob Strauss and Dr. Honor Wolfe

Following the revelations that the FDA approved 17-P will be sold at 100-150 times the cost for compounded 17 P, many are scrambling at a national level to reverse this. Community providers are also confused as to the current status and availability of cost effective 17-P. The UNC MFM division would like to take this opportunity to keep you informed of the current details on how to prescribe progesterone to your patients.

We (UNC MFM) are highly concerned about the cost of Makena and feel the cost has potential to result in reduction in access to medication in a high risk population and result in an very high cost to the health care system
We are working with SMFM/ACOG who is in dialog with Ther-X/KV Pharma to develop more appropriate costs for the medication. The current status of this process can be found on www.mombaby.org and the SMFM Facebook page.
Information to obtain the FDA approved 17-P (Makena) is available on the website www.makena.com, including information for the financial assistance application. To order Makena, the form can be downloaded from this site, completed and faxed to the company. Currently, NC Medicaid IS covering Makena. Delivery of the medication may take 1-2 weeks, so advanced planning is recommended. If 17-P is needed on a more urgent basis, it can be obtained from a local compounding pharmacy or please contact our office at Rex and we can help arrange 17-P in the interval. Details can be found on www.mombaby.org.
Alere is continuing to provide home based 17-P services using a compounded preservative free medication. Medicaid does not currently cover home health visit through Alere, but is considering this option.
Based on smaller trials* an alternative is vaginal micronized progesterone obtained from compounding pharmacies. Recommended dosing based on these studies is 100-200 mg vaginal progesterone daily starting at a similar gestational age as 17-P. We feel that, while the data for vaginal progesterone in cases of ultrasound identified asymptomatic short cervix is good (Fonseca), the scientific rigor and sample size of studies for vaginal progesterone for prevention of recurrent preterm birth is not as compelling as the IM 17-P data (Meis trial) and prefer the 17-P form for this indication. There is too little data on 17-P compounded in other varieties of oils for us to comment on its use for preterm birth prevention at this time.

We are always happy to see the patient and discuss pros and cons of 17-P and alternatives as well as provide consultation and assist in care of patients at high risk for preterm birth. To refer a patient, call (919) 843-3051 or (919) 784-6425

*(Cetingoz, Arch Gynecol Obstet (2011) 283;423-429; O’Brien, Ultrasound Obstet Gynecol (2007) 30: 687-696; da Fonseca, Am J Obstet Gynecol 2003; 188:419-24, Fonseca, NEJM 357;5 2007, )

For more a practitioner algorithm click here.

Drug to Prevent Preemies About to Spike in Price

2011-03-23T09:32:00.000-07:00

Terbutaline and Preterm Labor

2011-03-11T08:25:00.000-08:00

William Goodnight, MD, MSCR

FDA has concluded that the risk of serious adverse events outweighs any potential benefit to pregnant women receiving prolonged treatment with terbutaline injection (beyond 48-72 hours), or acute or prolonged treatment with oral terbutaline

Potential appropriate uses of sc terbutaline:

Acute (greater than 72 hours) intermittent dose of sc terbutaline for cessation of preterm contractions to allow corticosteroid administration/maternal transfer
Acute sc dose during evaluation for preterm labor
Acute cessation of intrapartum uterine hyperstimulation
Acute sc dose prior to attempted external cephalic version

Avoid terbutaline:

Oral (always avoid) use after acute tocolysis – FDA states oral use is contraindicated in pregnancy
Oral maintenance use for symptomatic contractions or following arrested acute preterm labor
Prolonged sc pump terbutaline infusion

Maternal risks of terbutaline

Tachycardia, transient hyperglycemia, hypokalemia, cardiac arrhythmias, pulmonary edema, and myocardial ischemia
FDA bases these recommendations on 16 reported maternal deaths on terbutaline and 12 serious CV complications from 1998-2009.

Lack of benefits
As examples of the unproven benefits for prolonged therapy with sc or oral terbutaline, several Cochrane reviews of clinical studies have been done.

These include:

Oral maintenance of terbutaline (betamimetics) vs placebo following acute preterm labor: no difference in NICU admission, rates of preterm birth < 37 weeks, or perinatal morbidity or mortality (2)
Betamimetics for acute preterm labor: 30-40% reduction in delivery in 48 hours, no change in delivery at 7 days, no difference in RDS, perinatal death, CP, NEC. Association with withdraw from treatment due to CV complications (3)
Terbutaline pump vs placebo maintenance therapy: no difference in gestational age at delivery or delivery outcomes (4)

Thus given the lack of evidence improvement in fetal or neonatal outcomes and lack of evidence for prolongation of pregnancy or prevention of preterm birth, as well as the maternal risks of terbutaline, oral and prolonged sc use, including infusion, should be avoided. These recommendations are supported by ACOG.

Consultation is available with a UNC MFM specialist to discuss other management options.

___________________________________
Reference:

http://www.fda.gov/Drugs/DrugSafety/ucm243539.htm
Oral betamimetics for maintenance therapy after threatened preterm labour. Dodd JM, Crowther CA, Dare MR, Middleton P. Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003927
Betamimetics for inhibiting preterm labour. Anotayanonth S, Subhedar NV, Garner P, Neilson JP, Harigopal S. Cochrane Database Syst Rev. 2004 Oct 18;(4):CD004352
Terbutaline pump maintenance therapy after threatened preterm labor for preventing preterm birth. Nanda K, Cook LA, Gallo MF, Grimes DA. Cochrane Database Syst Rev. 2002;(4):CD003933

Did They Change How We Screen for Syphilis?

2011-03-10T06:48:00.000-08:00

Kim Boggess, MD and William Goodnight, MD, MSCR

Providers may have noticed that certain labs in the US have started testing for syphilis using treponemal tests (EIA or TP-PA) as first line tests. This has created confusion in how to interpret the results.

Here is an update.

In the United States, testing for syphilis traditionally has consisted of initial screening with an inexpensive nontreponemal test, then retesting reactive specimens with a more specific, and more expensive treponemal test.

To reduce the time and labor required for syphilis screening, some laboratories have adopted reverse sequence screening in which sera are tested first by a treponemal specific enzyme linked immunosorbant (EIA) or chemoluminescence (CIA) assay, followed by nontreponemal testing of reactive specimens. Under the reverse sequence testing strategy, discordant sera (EIA or CIA positive/nontreponemal test negative) should be tested by an treponemal-specific antibody test (Treponema pallidum particle agglutination, TP-PA). The reverse sequence testing strategy may have a false positive ranging between 17 and 30%.

Confusion exists regarding testing and treatment decisions and partner notification when using the reverse sequence testing. In a February 11, 2011 CDC Morbidity and Mortality Weekly Report, the CDC recommended that nontreponemal tests be used to screen for syphilis, and that treponemal testing be used to confirm syphilis as the cause of nontreponemal reactivity. The CDC asserted that this strategy performs well in identifying persons with active infection while minimizing false-positive results in low prevalence populations.

However, if reverse screening is used, the CDC recommends that a specimen with a reactive EIA/CIA result be tested reflexively with a quantitative nontreponemal (RPR or VDRL) test. If test results are discordant, the specimen should be reflexively tested using the TP-PA test. If the TP-PA is positive, the patient should be considered to have past or present syphilis; if negative, syphilis is unlikely. See flow charts below for how to use both testing strategies. Finally, consider discussion with your lab to deterime which strategy they use and if the follow up TP-PA is reflexively done.

Consultation is available with a UNC MFM specialist to discuss treatment strategies for suspected or confirmed syphilis. Visit www.UNCmfm.org for contact information.

Reverse Sequence Syphilis Screening
(Click to Enlarge)

Traditional Syphilis Testing
(Click to Enlarge)

My UNC Midwife Story: Nora Dennis

2011-02-16T08:28:00.000-08:00

Nora Dennis with her son

I switched from another, more traditional OB/GYN practice to UNC Midwives late in my pregnancy.

I had spent the first four months of my pregnancy living and working in West Africa and really loved how midwives ran the show there.   I knew that I wanted a natural childbirth and when I tried to raise this with my first OB/GYN and asked if I could go through my birth plan with them, they had minimal interest. I began to feel nervous about pursuing the childbirth in a setting that wouldn't be supportive of what I thought was best for me and my family. At the same time, I was in my fourth year of medical school and had a master's degree in maternal and child health, and didn't want to be without the best in medical technology should the unthinkable happen during my labor.

I initially went to NC Women's Hospital and attended one of the information sessions about the midwives just to check it out, and I was immediately charmed by the wisdom, experience and friendliness of the midwives.   I also chose UNC knowing that it was a baby-friendly hospital where breastfeeding is actively encouraged as it is known to be best for babies and mothers. I made the switch!

Right away I knew that it was the right choice. I was asked about my birth plan and got to work with the midwives on making smart decisions for my baby.

When I went past 40 weeks, I worked with Meg Berreth to make a reasonable plan for proceeding. We planned to induce me at 42 weeks and then, at 41 weeks and 5 days, I went into labor on my own.

By the time we arrived at the hospital and I was already 5 centimeters. Meg did an amazing job of empowering me to fulfill my own hopes for my birth and at the same time I would not have felt bad about myself had I needed an epidural. I was able to labor in a tub of warm water as well, and it made a huge difference.   My son was born just five hours after my labor started and he was allowed to nurse immediately.   When I had questions about nursing as a first time mother, the lactation consultants were extremely prompt in helping me and astute in addressing my concerns.

I could not have asked for a more supportive, medically sound, environment!

- Nora Dennis, MD, MSPH

How to talk to your doctor about hot flashes

2011-02-07T07:10:00.000-08:00

Gretchen Stuart, MD, MPH

Are hot flashes driving you crazy during the day by interrupting your activities?

Are hot flashes waking you up at night?

Do these hot flashes mean you are in menopause?

What should you think about before you go to your doctor’s appointment to discuss hot flashes?

Let’s review some definitions to help you get the most out of your doctor’s visit. Sometimes your doctor talks fast or may use words you don’t understand, knowing some definitions of words will help you and your doctor understand each other:

Menopause: A woman is in menopause when she has not had any periods for one year because ovulation has stopped. In America the most common age that women reach menopause is 51.
The Menopausal Transition: Some people call the menopausal transition perimenopause. A woman is in the menopausal transition during the time her body is getting ready to reach menopause. This is usually the time when women have annoying hot flashes. In America the menopausal transition usually lasts about 4 years, but the menopause transition can last for as short as one year, and as long as 8 years. The usual age at onset of the menopausal transition is in the mid- to late forties. But don’t worry, you are not alone! In America at least 30 million women are estimated to be in the menopause transition at any one time.
Hot flashes: Health care providers often call hot flashes vasomotor symptoms because hot flashes are a result of a complicated interaction between hormones and nerves in your blood, your nerves, and your brain. Hot flashes are probably the reason that so many other symptoms of menopause occur.
Other symptoms: Many women report many other discomforts and mood changes during the menopause transition. Women often report trouble sleeping, lack of enjoyment of sex, depression, anxiety, feeling like their mood is up and down, memory loss, fatigue, headache, joint pains, and weight gain.

Hot flashes can cause all those symptoms because hot flashes interrupt other important activities. For instance if hot flashes are always waking you up at night then you are probably not getting a good night’s sleep – for many nights in a row! Lack of sleep can cause things such as mood swings, fatigue, headaches, and even make you feel like you are depressed.

What information about your hot flashes should you think about before your doctor’s appointment?

These questions and answers can help you and your doctor decide what might be the best way to manage your hot flashes.

Are your hot flashes annoying?

Do they occur at inconvenient times during the day which make it hard to do your usual activities?
Are hot flashes waking you up at night a lot? Do you sometimes have to change your clothes or sheets in the middle of the night?

Are you having hot flashes but you don’t think they are a problem?

Some women have hot flashes but they are not bothersome. Please report this to your doctor anyway. Sometimes hot flashes can become worse and if you talk to your doctor about your current hot flashes at the appointment then if they become worse in the future it will be easier for your doctor to work with you to find a solution.

Recommendations for information on the Internet.

Contrary to popular belief, most doctors don’t hate the Internet.

The American College of Obstetricians and Gynecologists has excellent pamphlets on various Ob-Gyn problems and surgeries, available at http://www.acog.org/publications/patient_education/.
Also, the federal government has been putting patient information on the web for many years. A great deal of information is gathered at the portal www.womanshealth.gov , where there are links to a large number of understandable fact sheets.

By reviewing information from reputable sources, you will answer some of your questions, and perhaps come up with more questions about your own case that you may discuss with your doctor.

We look forward to seeing you at UNC so you can have all your questions answered and we can help you manage the hard symptoms of the menopausal transition.

Weight Loss & Fertility Support Group

2011-02-01T08:18:00.000-08:00

Are you feeling alone in the fertility and weight management process?

Do you have questions about the relationship between fertility, nutrition and exercise?

Do you feel overwhelmed, stressed, and frustrated by the fertility process?

Join Dr. Kathryn Calhoun
Fellow, UNC Reproductive Endocrinology & Infertility

Monthly meetings beginning March 2011:
* Nutrition
* Exercise
* Stress Management
* Fertility

For more information, email Dr. Calhoun at kathryn_calhoun@med.unc.edu.

Research Study Seeking Patients for Fertility Treatments

2011-01-27T11:06:00.000-08:00

Are you having trouble getting pregnant and considering IVF (in vitro fertilization)?

UNC Fertility Center is conducting a research study for infertile couples who are considering IVF to help them conceive. Qualifying couples will receive an IVF cycle at a discounted rate.

Study Details:

You and your partner will have a consultation appointment with a physician in our UNC Fertility Clinic to determine if you are a good candidate for IVF and for this study. Note that this visit is considered part of routine medical care.
Female partner must be <41 years old to participate in this study.
If you (your partner) are a good candidate for the study, you will undergo an IVF cycle with ovarian stimulation and egg retrieval, with the same methods that we routinely use for IVF.
For the study, we will divide the eggs into two groups - half will be fertilized immediately, and the other half will be frozen and immediately thawed, and then fertilized. We will perform an embryo transfer using embryos derived from the freeze/thaw cycle.
Note that couples planning IVF with an egg donor may qualify for the study as well. Female partner must be <48 years old in IVF cycles with an egg donor.

Benefits of participation:

Enrolled couples will receive an IVF cycle at a discounted cost.

To learn if you (your partner) would qualify for this study, call us for a consultation appointment at (919) 966-1150 or send an email to IVFstudy@unc.edu with your name, phone number and times that you can be reached. We will not share your email address with anyone outside of the study.

The principal investigator for this study, "Clinical evaluation of egg cryopreservation", is Jennifer Mersereau, MD, Department of Obstetrics and Gynecology, University of North Carolina. This study has received approval from the UNC Biomedical Institutional Review Board on 12/16/2010, study # 10-1911.

What Women Need to Know About Heart Disease

2011-01-20T07:38:00.000-08:00

Guest Blogger - Dr. Paula Miller, UNC Women's Heart Program

What Women Need to Know about Heart Disease

Many women are unaware that heart disease is a bigger health threat to them than breast cancer. Educating women on their risk factors and how to make life style modifications will help reduce the risk of developing cardiovascular disease. There are some risk factors that cannot be modified. These risk factors are:

Age:

The chance of developing cardiovascular disease increases as women get older. This increased risk with can be related to menopause as well as modifiable risks such as hypertension. Hypertension can cause structural changes in the heart increasing cardiac risk. Appropriate treatment of blood pressure can lessen this risk.

Family History of Premature Cardiac Disease:

Family history defined as a parent or sibling having a heart attack before the age of 50 years in a male and before the age of 60 in a female is an important predictor in women. A woman cannot change her genetics but should be aggressive in addressing all other risk factors.

Making Changes

Risk factors for heart disease that can be changed:

Smoking. Women who smoke have a higher death risk from cardiovascular disease.A woman who smokes can experience her first heart attack as much as 19 years earlier than a non-smoker..

High blood pressure. Blood pressure in women increase after age 50 and as a woman goes through menopause. If a woman has one parent with a history of hypertension, her risk for developing significant hypertension is 50% greater than a woman with no family history of hypertension. Lifestyle modifications such as eating a low salt diet and getting exercise will help keep blood pressure in a more normal range. If a woman smokes, quitting will also help.

High cholesterol and triglycerides. Women should be sure to get regular cholesterol screenings and maintain a low-fat, low-cholesterol diet.

Lack of exercise. Studies have found that a sedentary lifestyle is a major risk factor for coronary heart disease. The Physical Guidelines for Americans state 2 hours and 30 minutes, or 150 minutes, regular moderate-intensity aerobic exercise, such as brisk walking, tennis, dancing, and house and yard work each week, can reduce the risk for heart disease.

Excess pounds and/or a poor diet. You should consume plenty of fruits and vegetables, fiber-rich foods and cereals low in saturated and trans fats. The risk for heart disease is particularly high in women who have excess abdominal fat.

Diabetes. About 68 percent of people who have diabetes die from some form of heart disease or stroke. Compared with women of the same age without diabetes, diabetic women have a risk 5-7 times higher than a non-diabetic person for cardiovascualr disease..

Stress. Adopt healthy ways of dealing with stress. For example, take breaks from work and home duties, read books, take daily walks and avoid negative people in your life.

In addition to the traditional risk factors, depression and isolation are also risk factors in women. Ask your doctor about the risks specific to women and to you so that you can take lifesaving preventive measures.

For more information visit www.uncheartandvascular.org.

Making the Most of Your Annual Exam

2011-01-03T11:28:00.000-08:00

Mary Schlegel, MD

There have been several changes in the past couple of years regarding frequency of screening for various tests such as pap smears and mammograms. There are situations when a pap smear isn’t recommended, for example, in women less than 21 years of age, or after a hysterectomy done for benign disease. Most women equate having a pelvic examination with having a pap smear, but this is not always necessary or required.

It is helpful when you come in for your visit if you know:

- The first day of your last menstrual period,

- What medications or supplements you are taking (and the dosages), and

- Any allergies or side effects from medications.

Write down a list of your questions or concerns. It is also helpful to review any major personal or family health updates since your last visit.

Birth Control:

This is the time to talk about: a birth control method, a desire to plan a pregnancy, a change in your menstrual cycle, pain with intercourse, screening for a sexually transmitted infection, starting or stopping hormone replacement, or a significant life stressor.

Screenings:

For pap smears, the American Congress of Obstetrics and Gynecology and the American Society for Colposcopy and Cervical Pathology have changed the recommendations on when to begin screening for cervical cancer . It was changed to age 21, which previously had been 18, or three years after initiation of sexual intercourse. The recommendation is for pap smears every two years until age 30, provided all are normal. At age 30, a woman may opt for a pap smear PLUS a DNA test for the panel of high risk HPV (Human Papilloma Virus) subtypes. If the pap is normal and the HPV test is negative, then the woman may go three years until her next screening.

NOTE: exam frequency was not changed to every three years. The use of HPV testing is not recommended as up-front testing in women under 30 as there is a greater chance that it will be positive and lead to additional (and perhaps unnecessary) testing.

Mammogram screening is another hot topic which Dr. Howell discussed in the August 2010 blog post. The controversy swirls around when to start screening---either at age 40 or 50 (or sooner if you have a first-degree relative with a history of breast cancer). To help guide your decision-making on this check out the Gail model risk calculator www.cancer.gov/bcrisktool or www.cdc.gov/cancer.

Screening for colon cancer should begin at age 50 unless there is a family history in a first-degree relative (parent, sibling or child). www.uspreventiveservicestaskforce.org

It is recommended that all sexually active women under age 25 be screened annually for sexually transmitted infections, most specifically Chlamydia. It may be important to test at other ages if you are in a new sexual relationship, or if you ended a relationship in the previous year. www.ashastd.org Clinicians are also encouraged to screen for risk behaviors. This may include asking questions about: sexual behavior, domestic violence, substance use/abuse, seat belt use, wearing sunscreen , or symptoms of depression.

Doing a little homework before your visit can go a long way toward maximizing the time with your provider. Teamwork can help make 2011 a safe and healthy year for you.

Additional web sites for further information

Alcohol www.niaaa.nih.gov www.aa.org
Contraception www.arhp.org look at Method Match
Depression www.nimh.nih.gov
Domestic violence www.nccadv.org www.womenshealth.gov
Drug use www.nida.nih.gov
Infertility www.asrm.org www.resolve.org
Menopause www.nams.org
Sexual assault www.rainn.org
Sexual health www.siecus.org

Greetings from Malawi

2010-12-16T12:14:00.000-08:00

This is a blog from Dr. John Thorp on his trip with UNC's Chancellor Holden Thorp in Malawi.

I traveled with Chancellor Holden Thorp and his wife Patty, Vice Chancellor for Global Health Myron Cohen, Professor of Medicine Charles Vanderhorst, and my wife Joe Carol to South Africa and Malawi. In South Africa we met with officials from the University of Witwaterstrand in Johannesburg including the Vice-Chancellor and Principal, Loyisa Nongxa. In these meetings with deans and leaders from the business school, medical school, and school of public health at Wits we explored ways UNC could strengthen it's interactions and ties with it's South African partner in improving global health and education. Given Chancellor Thorp's focus on entrepreneurship these discussions looked at novel approaches to the creation and transfer of knowledge between universities and cultures.

Chancellor Thorp and Dr. Thorp listening to
Esmie Kamanga at sensitization session
We then traveled to Lilongwe, Malawi where we were the guests of the UNC Project that over the past 20 years has done groundbreaking research in HIV prevention and treatment. About 12% of the country has acquired the AIDs virus and malaria is endemic. We saw their numerous buildings and projects and were able to visit both the district and referral hospitals in the capital city. These institutions provide care to the millions of women who live in Lilongwe and are woefully understaffed. The highlight of our visit was to a school built by the UNC project in a remote village where the inhabitants subsisted on the hand cultivation of tobacco and corn (most impressive to a native Eastern Carolinian) The students were AIDs orphans and we were able to participate with them in their morning recitation and singing (see Chancellor Thorp's blog and tweets).

UNC OB/GYN has been doing work in Malawi for the past four years since we recruited Dr. Gretchen Stuart from UTSW as one of our WRHR scholars. We were able to meet her colleagues from Emory who are busy recruiting women in a postpartum IUD study. UNC surgeons were also on site working diligently to provide clinical care and establish a surgery residency program.

Lunch with Holden Thorp, VC Loyiso Nongxa,
Ian Sanne, J Thorp CVDH,
Prof Yosuf Veriava chair emeritus Med Wits
It was impressive to witness all the UNC Project had accomplished to improve the health of citizens in one of the world's poorest countries. Their efforts and progress in infectious diseases could be duplicated in women's health with a modest commitment of resources from the UNC Health Care System. We identified emergent obstetric care and the surgical management of fistulas as health problems with the greatest immediate need and highest probability of success. It was evident from the UNC Project's history and discussion with clinicians on the ground, that having a full-time OB/GYN physician stationed in the country would catalyze our clinical, educational,and research efforts. In the long run training African clinicians is the best hope to improving the difficult situations mothers face in Malawi.

Both Chancellor Thorp and Vice Chancellor Cohen were in agreement and pledged to work with the UNC HS and Departmental leadership to accomplish these goals.

- John Thorp, Jr, MD

What you should know before your trip…to the OR

2010-12-08T11:15:00.000-08:00

Cristina Munoz, MD

If you were taking the vacation of a lifetime, you would probably do a lot of tasks to get ready.

What about going for scheduled surgery?

Is there anything you should do to get ready for this important journey?

Getting a Map

When you plan an operation, you need a road map. Before you and your doctor make a final decision for surgery, you need to know what route you are taking (for example, you could have an open incision, laparoscopy, or a robotically assisted procedure, or there may be options about how extensive the surgery will be). Even if surgery is clearly the best option, it is good to know what other treatments are available, and what pitfalls or risks you might encounter along the way.

Contrary to popular belief, most doctors don’t hate the Internet. The American College of Obstetricians and Gynecologists has excellent pamphlets on various Ob-Gyn problems and surgeries, available at http://www.acog.org/publications/patient_education/. Also, the federal government has been putting patient information on the web for many years. A great deal of information is gathered at the portal www.womanshealth.gov, where there are links to a large number of understandable fact sheets. By reviewing information from reputable sources, you will answer some of your questions, and perhaps come up with more questions about your own case that you may discuss with your doctor.

During your surgery, your doctor may encounter some variations from the average anatomy, adhesions (scar tissue), or diseases that were different than the original diagnosis. Before you go to sleep in the operating room, it’s helpful to know whether you might wake up with an unexpected incision, or if you might need to have more or less extensive surgery than was planned.

Getting in Shape

Before a big ski trip or a hiking vacation, it would be useful for a vacationer to get fit, to avoid injury. While surgical patients don’t travel far during surgery, general anesthesia, surgery, and blood loss are all stresses on the body. Women with good cardiovascular function may tolerate surgical stresses well. Women with good flexibility and strength have a much easier time getting out of bed and resuming normal function after surgery. If your surgery is scheduled several weeks in advance, you may be able to improve your fitness by walking briskly for 1 or 2 miles a day. If you are anemic, you may take iron supplements or eat iron-rich foods, or take medications that stop heavy menstrual bleeding for weeks to months, so anemia can be corrected. Chronic medical conditions, such as diabetes and hypertension, are often in mediocre control. Your doctors can work with you to optimize your condition.

Bring Good Friends

Across North Carolina, it is common to see ten family members and the pastor waiting for a loved one in surgery. This is a good thing, even if the waiting room is a little crowded! Time and time again, we see that people with family and friends recover faster and do better than those who don’t have anyone with them. Trusted relatives are necessary on the day of surgery or the day after, because the hospital will not discharge a patient without a responsible adult to take them home. Your family member can be very helpful during hospitalization for tiny things like adjusting your pillow or running to the gift shop to get a magazine. They can also do critically important things, like writing down your questions and making sure they are addressed during the doctors’ work rounds. When you go home it is best if a family member stays with you, at least for a night or two, to help with household tasks. It is usually fine to get up and go to the kitchen or bathroom or even to walk up a flight of stairs, the day you are discharged from the hospital. Heavy cleaning, vacuuming, gardening, or other strenuous activities should wait till you are well on your way to recovery.

If you know what to expect, and you get yourself ready, your trip to the OR may go better than you expected. We hope you return to enjoying your usual life at home, and have fond memories of the new people you met at UNC.

Pap smears: Who, when and how often?

2010-12-06T05:26:00.000-08:00

Lisa Rahangdale, MD,MPH

Performing a pap smear every year has become a part of the practice of medicine based on little evidence. Based on a better understanding of how cervical dysplasia progresses to cancer and the role of HPV (Human Papillomavirus Infection), the American Congress of Obstetricians and Gynecologists (ACOG) updated its guidelines last year. Here is a quick summary.

However, it is important to remind our patients that just because a pap smear is not needed, annual examinations are still recommended for contraception management, STD screening, health care maintenance and all of the other things we do to provide care for women.

When should screening begin?
Age 21.

How often should screening occur?
Every 2 years in women aged 21-29.

Every 3 years in women age 30 and older IF they have had 3 negative pap smears in a row OR a negative HPV test at the time of their pap smear.

If women have any of the following risk factors:

HIV infection, immunosuppression, exposure to diethylstilbestrol in utero.
Prior treatment for CIN 2, 3 or cervical cancer, they may be considered for more frequent screening.
Women with a new HIV diagnosis should be screened twice in the first year and yearly thereafter.
Women who have had previous treatment for CIN 2, 3 or cancer should be screening yearly for 20 years.

When can you stop screening?

Screening can be stopped in low risk women with 3 consecutive negative pap smears in the last decade between at 65-70 years age. The American Cancer Society recommends discontinuation at age 70 and the U.S. Preventative Services Task Force recommends age 65.

Women who have had a hysterectomy may stop pap smear screening. If they have a history of CIN 2 or 3, then screening may continue for some time interval. However, the guidelines don’t tell us how long and say that there is no “good data to support or refute discontinuation of screening in this population.”

Women who have been vaccinated against Human Papilloma Virus (HPV) should still get routine pap smear screening.

What about HPV testing?

Use to decide whether colposcopy is needed after an ASCUS result in women over the age of 21.
Helpful to assess risk in postmenopausal women with LGSIL pap results.
(Is the result likely related to vaginal atrophy or actual dysplasia?)
Can be used to decide if a woman over 30 can be screened in 3 years.
An option in follow up after an abnormal pap smear workup.
(See www.asccp.org for management of abnormal cytology guidelines)

Reference:
ACOG Practice Bulletin 109: Cervical Cytology Screening. ObstetGynecol. 2009. 114;1409-12.

Are We Forgetting Mothers in the Fight Against Childhood Obesity?

2010-12-02T08:44:00.000-08:00

Wanda Nicholson, MD, MPH, MBA

In January, 2010, First Lady Michelle Obama announced the Let’s Move campaign to bring together community leaders, doctors, moms, dads, and teachers in an effort to tackle childhood obesity. While the effort is to be applauded, broader initiatives that target childbearing women as they prepare to start or extend their families might go further in addressing the epidemic of obesity in the current and future generations. It is clear that childhood obesity (95th percentile or above by growth charts) has increased at an alarming rate over the last 30 years. One out of three kids is currently considered overweight or obese.

Childbearing Women

Similar rates of overweight and obesity exist for childbearing women. About one-third (29%) of childbearing women aged 20–39 years are obese and 8% are extremely obese. The World Health Organization and the National Heart Lung and Blood Institute (NHLBI) classify overweight and obesity based on body mass index (BMI), defined as weight in kilograms divided by the square of height in meters (kg/m2) (8,9). A healthy or desirable BMI is between 18.9 and 24.9. A person is considered overweight if the BMI is between 25.0 and 29.9 and obese if the BMI is greater than or equal to 30.

With the increase in sedentary lifestyles and caloric intake in the United States, the number of childbearing women who are overweight and obese is projected to rise even further over the coming decades. As such, the downstream consequences of overweight and obesity on childbearing women, their offspring, and future generations is destined to become one of the biggest challenges for clinicians in the twenty-first century. Minority women, women in lower income strata and women living in urban areas are particularly at risk. Overweight and obesity in urban women may be worsened by additional barriers to physical activity and healthy eating, collectively referred to by social scientists and urban and public health planners as the built environment.

Impact on Pregnancy

Much of the discussion on obesity among obstetricians and gynecologists centers on the complications of pregnancy and delivery. A potential problem with this focus is that it addresses obesity after the woman conceives. One might argue for a paradigm shift to an “upstream approach,” in which maternal obesity is targeted in the peri-partum period. In this fashion, women have the opportunity to ask their providers about what important lifestyle changes should be made before considering their first or subsequent pregnancy. Women who have completed childbearing can benefit from these lifestyle modifications individually, but also have the opportunity to integrate these modifications into the daily lives of their children. There are studies that suggest that overweight and obesity among expectant mother can alter the metabolism of the fetus. These changes that occur during development inside the uterus can increase the risk of obesity once the baby is born.

What can childbearing women do with the help of their providers to achieve a healthy lifestyle?

Ask your physician to calculate and discuss your body mass index. Clinicians can access an on-line BMI calculator at the National Heart Lung Blood Institute (NHLBI) website (http://www.nhlbisupport.com/bmi/).
Ask your physician how much weight you should gain during pregnancy. The Institute of Medicine recently published guidelines for how much weight women should gain during pregnancy based on their body mass index just prior to pregnancy. Guidelines can be accessed at http://www.iom.edu/Reports/2009/Weight-Gain-During-Pregnancy-Reexamining-the-Guidelines.aspx
Advocate for expanding childbirth classes at your local hospital to include nutritional and physical activity information that can be used by participants after delivery to promote a healthy lifestyle.
Assess all of your current leisure activities. Make a plan for how you will continue these activities after delivery. Be sure to include activities where you can easily bring your newborn.
Ask about farmer’s markets in your community. They can provide a large array of choices for healthy eating at an economical price.
Assess your built environment. Use an easily accessible computer at home, work, or your local library to identify low cost venues for physical activity that can be used throughout the year. For example, you may find a church near your neighborhood that has an indoor track or sponsors exercise classes.

The strategies outlined above represent a series of simple first steps that women can take to make a positive difference in their lives and the lives of their offspring.
Are We Forgetting Mothers in the Fight Against Childhood Obesity?

Is CA-125 a good screening method for ovarian cancer?

2010-11-30T08:36:00.000-08:00

Victoria Bae-Jump, MD, PhD

Measurement of the concentration of the glycoprotein CA-125 antigen in blood is the most widely studied biochemical method of screening for ovarian cancer.

Although CA-125 is elevated in over 90% of late stage ovarian cancers, the problem remains that it is increased in only 50% of early stage ovarian cancers. In addition, CA-125 levels can be elevated for a variety of reasons unrelated to ovarian cancer. For example, CA-125 is increased in a variety of benign gynecologic conditions such as endometriosis, pelvic inflammatory disease and fibroids. CA-125 levels are also elevated in about 1% of healthy women, and these levels may fluctuate during the menstrual cycle. CA-125 may also be elevated in a number of other malignancies, including breast, colon and lung cancer.

Lastly, CA-125 levels can be increased in women with such diverse diseases as cirrhosis, renal failure and pancreatitis. Thus, the problem with CA-125 is that the specificity and positive predictive value (PPV) of this test are poor. The PPV is estimated at 3%, meaning that there will be 30 false positive tests for every ovarian cancer diagnosed. This will obviously lead to much anxiety and potentially unnecessary surgery for women. CA-125 may be better in combination with transvaginal ultrasound or if temporal changes were evaluated.

Best Strategies

In conclusion, the best screening strategy for ovarian cancer available is to pay attention to symptoms such as:

Bloating
Pelvic or abdominal pain
Difficulty eating or feeling full quickly
Urinary symptoms (urgency or frequency)

This strategy has been endorsed by the Gynecologic Cancer Foundation, the Society for Gynecologic Oncologists and the American Cancer Society. The NIH Health Consensus Conference on Ovarian Cancer recommends careful family history and annual pelvic exam for ovarian cancer screening. Other screening procedures such as CA-125 and transvaginal ultrasound are only recommended for women with a presumed hereditary ovarian cancer syndrome.

To see two ovarian patient survivor stories, click here.

Protecting the Perineum: What Can Be Done?

2010-10-27T08:07:00.000-07:00

Meg Berreth, CNM, MSN

A very common concern among women as they approach delivery is preventing lacerations during vaginal delivery. Several options are available that may reduce the occurrence and severity of perineal (vaginal opening) lacerations.

Episiotomy

A frequent statement that I hear is that women prefer to avoid an episiotomy. This preference is supported by numerous research studies that have found that when an episiotomy is performed, there is an increased risk of significant perineal lacerations that involve the rectum, with no improved outcomes for the neonate (1,2). Elective or routine episiotomy to ‘prevent’ bad tears is no longer recommended, and I am always happy to reassure women in our practice at UNC that the rate of episiotomy, while occasionally still necessary, is less than1%.

Perineal Massage

Many have heard about perineal massage before and during pushing, as well as variations in maternal position for delivery, and wonder what effects these might have on lacerations during delivery.

Prior to Labor

There is conflicting evidence regarding the use of perineal massage during pregnancy. In a 2006 Cochrane Database review, Beckmann and Garrett found that the available research supported that digital perineal massage (using the fingers to massage the vaginal opening) during pregnancy significantly reduced the risk of perineal injury in first-time mothers (3). The protective benefit of perineal massage was mostly seen in reducing the risk of episiotomy; there was not a significant reduction in spontaneous lacerations. Similarly, in a blinded prospective controlled trial of 234 first-time mothers, Elad et al. found that perineal massage during the last weeks of pregnancy was neither harmful nor protective to the perineum (4). In much of this research, the episiotomy rate is significantly higher than at UNC and in current obstetric practice. What is lacking is research into perineal massage prior to delivery in a setting where episiotomy use is restricted.

During pushing

The effects of perineal massage and maternal position during pushing on perinatal lacerations have been investigated as well. In a randomized study of 1211 healthy women, Albers et al. compared three management techniques for the pushing stage of labor. (5) Women were randomized to receive either warm compresses to the perineal area, massage with lubricant, or a “hands off” approach with no touching of the perineum until crowning of the fetal head. These authors found no difference in spontaneous lacerations among the three groups The measures in this study that were most protective were a sitting position for delivery and pushing to delivery of the fetal head between contractions. Of note, the overall laceration rate in the study was very low, so it is possible that these techniques would be more beneficial in a setting with a higher laceration rate. The two most significant risk factors for a perineal laceration were being a first-time mother and having a large baby. The other position for delivery that has been shown to be protective of the perineum is side-lying. Tolsma et al. found in a retrospective study of 510 women delivered by Certified Nurse Midwives that side-lying position at delivery, having received intravenous narcotics and warm compresses were most protective of the perineum (6). This research provides some guidance in delivering our patients with epidurals, as a side-lying position is often more feasible than a seated position for a patient with an epidural.

Summary

Clearly more research is needed about the many factors that influenceperineal lacerations. I encourage women to continue asking these questions, to consider birthing in an upright, side-lying or all-fours position when feasible, and to consider perineal massage in the last few months before delivery if they are interested. Finally, continued emphasis on obstetrical provider avoidance of ‘routine’ or ‘elective’ episiotomy may help reduce the severity of lacerations during delivery.

___________________________________

Raisanen S, Vehvilainen-Julkunen K, Heinonen S. “Need for and consequences of episiotomy in vaginal birth: a critical approach.” Midwifery (2010) 26, 348-356.
Hartman K, Viswanathan M, Palmieri R, Garlehner, G, Thorp J, Lohr KN. Outcomes of routine episiotomy: A systematic review. JAMA. 2005; 293:2141-2148.
Beckmann MM, Garrett AJ. “Antenatal perineal massage for reducing perineal trauma (Review). Cochrane Database Syst Rev 2006, Issue 1. Art. No. CD005123.
Mei-dan E, Walfisch A, Raz I, Levy A, Hallak M. Perineal massage during pregnancy: A prospective controlled trial. IMAJ 2008; 10: 499-502.
Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P. “Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: A randomized trial.” J Midwifery Women’s Health. 200; 50(5): 365-372.
Hastings-Tolsma M, Vincent D, Emeis C, Francisco T. Getting through birth in one piece: Protecting the perineum.” Journal of Maternal Child Nursing (2007); 32: 158-164.

Robotic Hysterectomy

2010-09-30T13:02:00.000-07:00

Click to view video

Listen and watch as Dr. Catherine Matthews performs a supracervical hysterectomy and cervicosacropexy with the DaVinci Surgical System.

This blog is for informational purposes only and not designed to describe a 'standard of care' as there may be many other appropriate clinical management options. For individual questions, please consult your provider or contact our office for a consultation.

Menopause Naturally

2010-09-13T12:29:00.000-07:00

Susan Nickel, CNM, MSN

Today, women approaching or in menopause are looking to maintain health and wellness without hormones or unnecessary medications. Hormone replacement therapy is no longer recommended for most women going through the “change of life.” The question becomes, what lifestyle changes can a menopausal woman adopt that will promote long term health and help with some of the physical changes associated with menopause.

Simple lifestyle changes can start in your kitchen. Eating at least 5 servings of fresh fruits and vegetables each day will add fiber to your diet that can promote colon health and also supply natural vitamins and minerals. To help with hot flashes, add soy products, yams, parsley, peas, potatoes, garlic, beans, seeds and nuts to your diet. Flax seeds are a wonderful way to get rich nutritional benefits from a small seed. Some nutritionists, researchers, and scientists believe that it could be the most important health-promoting supplement next to a multi-vitamin. Nearly every system in the body can benefit from flax seed oil's natural properties, including the cardiovascular system, immune system, circulatory system, reproductive system, nervous system, as well as joints. Although flaxseed contains all sorts of healthy components, it owes its healthy reputation primarily to three ingredients:

Omega-3 essential fatty acids, "good" fats that have been shown to have heart-healthy effects. Each tablespoon of ground flaxseed contains about 1.8 grams of plant omega-3s.
Lignans, which have both plant estrogen and antioxidant qualities. Flaxseed contains 75- 800 times more lignans than other plant foods
Fiber. Flaxseed contains both the soluble and insoluble types.

Flax seeds can be ground in a coffee grinder and sprinkled over cereal and salads. You can also purchase flax seed oil and use it over your freshly cooked vegetables. Or you can take 2-6 capsules by mouth per day. Just remember to keep flax seeds and oil refrigerated.

By reducing sugar, fat, alcohol, salt and caffeine you can lower your incidence and intensity of hot flashes. Drink 1 to 2 quarts of water a day to help your body stay well hydrated. To help with insomnia, eat a diet that is high in complex carbohydrates and fiber. This can prevent erratic blood-sugar levels that can disrupt your sleep.

After hot flashes, the most annoying symptoms of menopause come from changes in the vaginal tissues. The loss of our natural estrogens can lead to vaginal dryness, urinary incontinence and painful intercourse. I have had perimenopausal and menopausal women with vaginal dryness tell me that they feel like their bodies — and their lives — are drying up. I recommend rehydration with 1-2 quarts of water drunk every day and the use of personal lubricants. My favorites are Astroglide and Replens. You can also use flax seed oil or a Vitamin E capsule squirted on the vulva and in the vagina.

Many women find certain yoga postures helpful in reducing hot flashes and assisting with vaginal and bladder changes. My favorites are the Locust, the Wide Angle and the Pump . You may need to start with the half locust before doing the full locust. Check out this website for the description of these and other yoga posses for menopausal women. Another good yoga website is www.yogajournal.com.

The sobering truth is that heart disease is still the leading cause of death for older women. Much of a women’s risk of heart disease is directly related to lifestyle. According to the heart health researcher, Dean Ornish, M.D., most of the risk of cardiovascular disease can be reduced by following a program of a very low fat diet, regular exercise, stress management and psychosocial support. His studies have found that women can reverse heart disease more easily than men. His recommendations of these comprehensive changes in diet and lifestyle can reduce the risks of heart disease, cancer and osteoporosis.

Quoting Dr. Ornish:

"You have a full spectrum of nutrition and lifestyle choices. It's not all or nothing. To the degree that you move in a healthful direction along this spectrum, you're likely to look better, feel better, lose weight and gain health.”

Vulvar Dysplasias – Avoiding Over Treating and Under Treating

2010-09-08T06:03:00.000-07:00

John Soper, MD

The incidence of vulvar dysplasias and carcinoma in situ has increased dramatically over the past 50 years, as clinicians have become attuned to this entity. All too often we assume that the natural history of vulvar dysplasia (VIN) is similar to that of cervical dysplasia (CIN). Similarities to CIN exist, including identification of HPV in vulvar dysplasias and cancers, however, there are important differences that may influence behavior of the lesions and treatment.

Severe vulvar dysplasia and carcinoma in situ (VIN 3) lesions may have a slightly higher rate of co-existant invasive cancer than high-grade cervical (CIN 3) lesions. When adequately sampled, approximately 5-10% VIN 3 have co-existant invasion, compared to 1-2% of CIN 3 lesions treated with cervical conization. Therefore, adequate sampling of VIN 3 lesions is mandatory before treating with a destructive technique, such as laser vaporization.

On the other end of the spectrum, low-grade vulvar dysplasias, in particular VIN 1, have a less clearly defined natural history than low-grade CIN lesions. Furthermore, minor irritative changes or condylomatous changes that are not true dysplasias may be diagnosed as VIN 1 lesions. Because the treatment of VIN may cause considerable discomfort and alteration of sexual function, it is usually better to treat these patients with local measures designed to decrease inflammation and observe their lesions serially, rather than using surgery or laser vaporization of lesions that are low-grade (VIN 1-2) lesions but are not gross condylomas.

Reducing the risk of infection at the time of cesarean

2010-08-25T05:06:00.000-07:00

Bill Goodnight, MD

Reducing the risk of infection at the time of cesarean: Administer antibiotics prior to the skin incision.

In 2007, 32% of all deliveries in the US were by cesarean – an all time high. While most cesarean deliveries are safe, they are at increased risk of post-operative infection, most commonly infections of the uterus (endometritis) and the skin (wound infection). The rates of surgical site infection following cesarean range from 3-10%, 3-4 times higher than following vaginal delivery.

Antibiotics given to the mother at the time of cesarean have been used to reduce the risk of infection. In the past, antibiotics were not given to the mother until after delivery of the baby (cord clamp), as antibiotic exposure to the baby was thought to increase the risk of newborn infection, especially antibiotic resistant infections, and potentially delay the diagnosis of these infections.

As a culmination of several studies, the American College of Obstetricians and Gynecologists published updated recommendations for administration of antibiotics at the time of cesarean.

These recommendations reflect the findings from several studies and one meta-analysis that administering the antibiotics to the mother prior to the skin incision results in a 50% reduction in endometritis and total infectious morbidity, and a trend towards a 40% reduction in wound infection. In this same meta-analysis, there was no difference in neonatal infections, admission of the newborn to the neonatal ICU, or need for evaluation for newborn infections.

Thus the current recommendations for antimicrobial prophylaxis at cesarean delivery include: Administration of a broad spectrum IV antibiotic (cephalosporin) prior to the skin incision, ideally less than 60 minutes prior to the surgery.

____________________________________________
References:

www.CDC.gov
Costantine MM, Rahman M, Ghulmiyah L, et al. Timing of perioperative antibiotics for cesarean delivery: a metaanalysis. Am J Obstet Gynecol 2008;199:301.e1-301.
Sullivan SA, Smith T, Chang E, Hulsey T,Vandorsten JP, Soper D. Administration of cefazolin prior to skin incision is superior to cefazolin at cord clamping in preventing postcesarean infectious morbidity: a randomized, controlled trial. Am J Obstet Gynecol 2007;196:455.e1-5.
Thigpen BD, Hood WA, Chauhan S, et al. Timing of prophylactic antibiotic administration in the uninfected laboring gravida: a randomized clinical trial. Am J Obstet Gynecol 2005;192:1864-71.
Wax JR, Hersey K, Philput C, et al. Single dose cefazolin prophylaxis for postcesarean infections: before vs after cord clamping. J Matern Fetal Med 1997;6:61-5.

Breast Cancer Risk and Prevention: Top Five Myths

2010-08-20T06:03:00.000-07:00

Jennifer Howell, MD

As women’s healthcare providers and/or women ourselves we are often bombarded with questions, assertions, news flashes about breast cancer. There is so much information out there that it is not surprising when misconceptions get passed along . . .

1. I am too young for breast cancer, so why would I bother doing self-breast exams?

Although most women with breast cancer are older, there are ~250,000 women with breast cancer diagnosed less than age 40 in the U.S. and breast cancer is the leading cause of cancer death in women ages 15-54. There are no routine screening tests for women under 40, so self-breast exams are important. Twenty-five percent of breast cancers are picked up only on exam.

2. No one in my family has breast cancer, so I am safe.

This is simply not true! 80% of women with breast cancer have no family history. In fact, the Breast Cancer genes (BrCA1 and BrCA2) are linked to only 10% of breast cancers. It is also untrue that breast cancer risk is only from your mother’s side of the family; your father’s family is equally important.

3. Using birth control pills can cause breast cancer; so can having an abortion.

Abortions are not linked to breast cancer. Most studies show no increased risk with modern day lower dose birth control pills. There is one study that showed a slight increased risk in current users. This risk diminished over time and at the 10 year mark there were no differences in pill users vs. non-users.

4. New guidelines suggest mammograms are not necessary every year.

A government task force did recently recommend that mammograms aren’t necessary under age 50. But many experts in the field believe these recommendations are based on faulty analysis – for instance, the data analyzed did not take into account the use of digital mammography which is now not only widely used, but is more sensitive, particularly in women under 50.

5. Breast cancer can be prevented by living a healthy lifestyle.

While it is true that avoiding obesity and excess alcohol use can decrease your risk – in general, preventing breast cancer by eating a certain diet or taking supplements has not been proven in large studies. Despite recent news flashes re: multivitamins, fish oil, vitamin D – the jury is still out. We once thought Vitamin E was the supplement to prevent BrCA; further research disproved this.

Pregnancy in Women Over 40

2010-08-11T08:48:00.000-07:00

Bill Goodnight, MD

Third Trimester Complications

As delayed childbirth becomes more common, more women over 40 are becoming pregnant. In the US in 2003, more than 100,000 births were to women over 40 years old (Odibo, 2006). It is well established that there is an association with increasing maternal age and chromosome abnormalities. Recent evidence has also suggested that there is an increase in complications in the last trimester of pregnancy in women over 40, even when accounting for risk factors such as maternal medical disorders (for example, diabetes and hypertension) and fetal anomalies.

Women over 40 have a 3.2-3.9 times increased risk of poor fetal growth (intrauterine growth restriction – IUGR) (Obido, 2006). This rate of IUGR is similar to pregnancies complicated by hypertension or preexisting diabetes. Low birth weight/IUGR is associated with perinatal complications such as stillbirth, jaundice, infection, and poor beast feeding.

In women over 40, even with normal fetal growth, there is a 2-3 times increased risk of stillbirth compared to women in their 20’s (Saliu, 2008). The risk of stillbirth increases after 37 weeks gestational age, with the most significant increase at 40 weeks EGA (Bahtiyar, 2008). The overall rate of stillbirth in women over 40 is 10.5/1000, compared to 3-4/1000 in women between 20-35 years old (Salihu, 2008).

What can we do to do to prevent this risk of still birth?

Fretts, at al, suggest that weekly NST (Fetal Non-Stress Test) testing starting at 37 weeks will result in prevention of 3.9/1000 unexplained stillbirths in women over 35 (a decrease from a baseline of 5.2/1000 to 1.3/1000 stillbirths). Limiting testing to women over 40 will reduce the total number of testing needed, while providing similar protection from stillbirth. In addition, close evaluation for fetal growth is also recommended during pregnancy in women over 40.

Thus at UNC we now consider the following evaluation for uncomplicated pregnancies in women over 40 years old:

Ultrasound or clinical estimate at 32-34 weeks gestational age for fetal growth
Weekly NST testing starting at 36 weeks EGA
Delivery in the 40th week EGA (no indication for delivery prior to 39 weeks EGA)
If there are other maternal or fetal complications, then antenatal testing and delivery should be based on these conditions

More information can be found on www.mombaby.org
______________________________________________
References:
Salihu, HM, Wilson RE, Alio A, Kirby R. Advanced maternal age and risk of antepartum and intrapartum stillbirth. J Obstet Gynaecol Res 2008; 34 (5): 843-850.
Fretts, RC, et al. Should older women have antepartum testing to prevent unexplained stillbirth? Obstet Gynecol 2004; 104: 56-64.
Obido, AO, et al. Advanced maternal age is an independent risk factor for intrauterine growth restriction. A J Perinatol 2006; 23:325-328.
Bahtiyar MO, et al. Stillbirth at term in women of advanced maternal age in the United States: When could the antenatal testing be initiated? A J Perinatol 2008; 25:301-304.

Forgettable Contraception

2010-08-04T06:06:00.000-07:00

David Grimes, MD

About half of the six million pregnancies that occur each year in the U.S. are unplanned. This high proportion is unique among industrialized nations. The underlying reason is not the fallibility of contraceptive methods but, rather, the fallibility of human nature. The principal reason for accidental pregnancy is inconsistent use or non-use of contraception. For example, over 10 million women in the U.S. are currently using oral contraceptives (the birth control pill), and about 1 million of them get pregnant annually, due to missed pills or premature stopping of the method.

Men and women, both sick and well, find it difficult to take medicines on a regular basis, whether the medicine be a blood pressure pill, a diabetes pill, or a contraceptive pill. That's just human nature. Hence, one pragmatic solution to this problem is use of "forgettable" contraception.

"Forgettable" contraception is defined as a method that requires attention no more often than every three years. With forgettable contraception, one can start the method and then simply forget about it…for a long time.

These methods include three types: Sterilization (vasectomy for men or fallopian tube occlusion [tubal ligation] for women), the contraceptive implant, and intrauterine devices (IUDs). Sterilization, both male and female, has been a popular, permanent method in the U.S. for decades. A contraceptive implant about the size of a wooden match stick can be placed just under the skin of the arm; it releases a hormone (like in birth control pills) into the blood stream for three years. Two T-shaped IUDs are available in the US. The copper T is approved by the Food and Drug Administration for up to 10 years of use, although studies have shown that it can be used for up to 20 years. The hormonal IUD is approved for five years of use, but studies support its use for up to seven years. While the copper IUD tends to increase menstrual bleeding, the hormonal IUD has the opposite effect: bleeding is greatly reduced and may disappear altogether in many women.

A benefit common to all these "forgettable" methods is superior protection against pregnancy. All "forgettable" methods are in the top tier of contraceptive effectiveness. Women who use these methods have less than a 1% chance of accidental pregnancy per year. Indeed, the reversible "forgettable" methods (implant and IUDs) have efficacy that is equivalent to that of surgical sterilization, without its risks and expense.

OVA1: Should We Use It?

2010-08-02T05:34:00.000-07:00

Ovarian cancer is a rare disease occurring in mostly postmenopausal women. Unfortunately it is often lethal.

Developing an ovarian cyst or mass is a scary event for a patient: thoughts of cancer create havoc and anxiety. In the search for a test to determine whether an ovarian mass is benign or malignant, the OVA1 assay has recently been developed to aid physicians in their workup of an ovarian mass. In the presence of an ovarian mass or cyst, it is suggested that measuring OVA1 at that point will help determine if the cyst is malignant or benign so that appropriate surgical decisions can be made such as referral to a gynecologic oncologist.

What do we know about OVA1?

OVA1 is an index assay of a collection of five different levels of blood proteins including: CA-125, transthyretin, apolipoprotein A1, beta 2 microglobulin, and transferrin.
It is reported as a single numerical result.
For premenopausal women, when OVA1 is greater than 5 there is a higher probability that the ovarian mass may be malignant.
For postmenopausal women, similar to above, when OVA1 is greater than 4 there is a higher probability that the mass in question may be malignant.
OVA1 is not a screening test for the general population but should only be used when an ovarian cyst or mass has been found.
Results may be inaccurate if patients have elevated serum rheumatoid factor or triglycerides.
The cost of the test is $650.

In an abstract reporting a primary study of 516 patients presented recently at the 41st annual Society of Gynecologic Oncologists meeting, adding OVA1 testing to clinical assessment improved the negative predictive value, reassuring those with negative tests that there was an extremely low chance of ovarian cancer.

Should we use OVA1 yet?

It would be important to see all of the details of this study before incorporating OVA1 into practice, and it is NOT recommend for use in all women as a screen for ovarian cancer.

There is an excellent summary of the case for and against use of the OVA1 in the recent August publication of Obstetrics and Gynecology. Results from the primary trial and other studies should give us more insight as to the applicability of this test.

OVA1 is a trademark of Vermillion, Inc. Vermillion is the developer of OVA1 and has a strategic partnership with Quest Diagnostics.

What’s the deal with vitamin D and pregnancy?

2010-07-19T06:08:00.000-07:00

Arthur Baker, MD, FACOG

The impact of vitamin D deficiency in pregnancy has recently drawn a great deal of attention from both a clinical and research standpoint. In this blog, Dr Arthur Baker, Senior MFM Fellow at UNC, who has research interest in vitamin D, reviews some of the common questions around vitamin D’s importance in pregnancy.

Question: Is vitamin D deficiency in pregnancy common and who is at risk?

Dr Baker: Recent studies have demonstrated that vitamin d deficiency is common, ranging from 10-50%. A significant racial disparity has also been noted, with African American women at the highest risk for deficiency.

Question: What are the suspected risks of vitamin D deficiency and pregnancy?

Dr Baker: Several recent studies have linked vitamin D deficiency to adverse pregnancy outcomes, such as preeclampsia and gestational diabetes. There is also some evidence that fetal growth is dependent on adequate maternal intake of vitamin D. However, all of these studies are small, and randomized trials are needed to show that supplementing vitamin D in vitamin D deficient women improves pregnancy outcomes.

Question: Who should I screen for vitamin D deficiency, what test do I order, and what is too low?

Dr Baker: Consideration for vitamin D screening should be given to high risk groups including African American and Hispanic populations, obese women, those living in northern latitudes or with limited sun exposure, and women with malabsorptive disorders such as cystic fibrosis or inflammatory bowel disease. The best marker for vitamin D nutritional status is 25-hydroxyvitamin D [25(OH)D]. The optimal 25(OH)D level for promoting health is currently being debated but is thought to be approximately 75 nmol/L (30 ng/mL). Those patients with levels <50 nmol/L (20 ng/mL) are considered vitamin D deficient, while levels between 51-75 nmol/L (20-30 ng/mL) are considered insufficient. If a patient is truly vitamin D deficient, consultation with an endocrinologist is recommended to assess the underlying etiology of the deficiency and to start high dose replacement.

Question: If someone is deficient in vitamin D, what foods or amount of sun exposure can I recommend to increase their vitamin D levels?

Dr Baker: Wild caught fatty fishes such as salmon, shiitake mushrooms, and vitamin D fortified milk and cereals are excellent sources of vitamin D. However, if someone is truly deficient, they should also being using a vitamin D supplement.

Question: How much and what supplement should they take if they are deficient, and what is the usual recommend dietary intake of vitamin D in pregnancy?

Dr Baker: The Food and Nutrition Board’s current recommendation for vitamin D supplementation in both pregnant and nonpregnant individuals is 200 IU/day. However, recent studies have shown that this is too low to maintain adequate vitamin D stores in pregnant women. Studies are currently underway to determine the recommended dietary intake of vitamin D in pregnancy. Most experts believe that at least 2000-4000 IU/day is needed.

Emergency Contraception

2010-07-15T11:12:00.000-07:00

Mike Evers, MD

In the US, half of the 6.4 million pregnancies reported in 2001 were unintended, and of these, 42% resulted in induced abortions. Access to contraception has been emphasized as a method to reduce the numbers of pregnancy terminations. Another option for women if sexual intercourse has happened and they do not desire to become pregnant, is emergency contraception.

Emergency contraception (EC) is defined as a drug or device used to prevent pregnancy after unprotected sexual intercourse, including sexual assault, or after a recognized contraceptive failure.

Types of Emergency Contraception

There are three main forms of EC approved for use in the United States:

Oral Progesterone (levonorgestrel - LNG)
Brand names: Plan B, Next Choice
Over the counter – no prescription needed
Method – one pill and repeat in 12 hours or 2 pills at one time
Most effective within 72 hours of intercourse, may be effective up to 120 hours
‘Yupze Method’
Oral combination of ethinyl estradiol (EE) and LNG (Birth Control Pill)
Method - multiple pills from combination oral contraceptives in two doses taken 12 hours apart
19 brands of pills: dose and brand of pills available here: http://ec.princeton.edu/questions/dose.html
Most effective within 72 hours of intercourse, may be effective to 120 hours
A copper-bearing intrauterine device (IUD).
Copper T 380A IUD (marketed in the US as ParaGard)
Insert up to 5-7 days after ovulation/intercourse

How Emergency Contraception Works

Progesterone and estrogen/progesterone EC work by postponing ovulation, thickening cervical mucus, and immobilizing sperm, thus preventing conception. There is no evidence to suggest that LNG-only pills impair the implantation of a fertilized egg or prevent its normal development. LNG-only pills will not interrupt an established pregnancy.

The copper IUD creates temporary inflammation in uterus. This inflammation may impair the ability of the sperm to survive, prevent fertilization, or may hinder the embryo’s ability to implant. The placement of the IUD does not disrupt a pregnancy that is already established in the uterine lining.

How to obtain EC

LNG-only hormones are available over the counter to men and women aged 17 and older. Not all pharmacies stock EC and those who do keep it in an area without direct patient access (behind the counter). Organizations such as Planned Parenthood may stock EC. The IUD and combination oral contraceptives require a prescription.

More information can be found here:
http://www.cdc.gov/reproductivehealth/unintendedpregnancy/index.htm
www.NOT-2-LATE.com
http://ec.princeton.edu/
www.ec-help.org

Does induction of labor increase the risk of cesarean delivery?

2010-07-06T07:22:00.000-07:00

Bill Goodnight, MD

For many reasons, induction of labor has become more common in the US. At the same time, the rate of cesarean delivery has increased with all-time high rates of 31.8% in 2007. This increase is in cesarean delivery is seen across all ethnic, age, and racial groups. Cesarean delivery rates have been attributed to avoidance of breech vaginal deliveries, lower interest in VBAC, liability pressures, and increased maternal chronic health issues. Similarly, induction rates may be tied to the increased prevalence of maternal chronic health disorders as well as increased pressure from the parents for elective induction of labor.

The effect of induction rates on cesarean delivery has been unproved to date. In this month’s journal Obstetrics and Gynecology, Ehrenthal, et al describe the association of induction of labor on cesarean deliveries among a group of nulliparous, term, singleton, vertex women. In this retrospective review of 7800 deliveries between 2003 and 2006 at a large eastern US regional obstetrical center, cesarean delivery rates were compared between induction and spontaneous onset of labor. Induction indications included elective (25.6%), post 41 weeks (18%), maternal indications (25%), and fetal indications (14%). This sample included patients cared for by both residents and private attendings. In this study 43% of all pregnancies underwent IOL (39% of which were elective).

In this data, factors associated with increased cesarean delivery included, induction of labor, black race, maternal age greater than 35, BMI greater than/equal to 25, gestational weight gain greater than 40 lbs, EGA greater than 41 weeks, GDM, and birth weight > 4000grams. Induction of labor demonstrated a 2 x increased risk of cesarean compared to spontaneous labor (adjusted OR 1.93, 95% CI 1.71-2.17), and only BMI greater than 30 (OR 3.24) and birth weight greater than 4000 grams (aOR 2.28) had as much affect on cesarean rates as induction of labor. The same trend held when the analysis was limited to low risk patients, 29% of whom underwent IOL. Based on this data, 20% of the cesarean deliveries were attributable only to induction of labor.

What does this mean? Clearly, induction has indications and benefits, but can come at a cost. In an effort to reduce the first cesarean for a patient, careful consideration of risk and benefits of IOL should be reviewed and patients requesting an elective IOL should be counseled about the risk of cesarean associated with IOL. Overall reducing the number of inductions safely may have an impact on overall rates of cesarean.

Ehrenthal DB, Jiang X, Strobino DM. Labor induction and the risk of cesarean delivery among nulliparous women at term. Obstet Gynecol 2010;116:35-42.

Bio-identical Hormone Therapy for Menopause: Fact & Fiction

2010-05-24T06:02:00.000-07:00

Steven L. Young, MD, PhD

Are you a woman in the second half of your life who is troubled by weight gain, fatigue, hot flushes, and decreased libido?

Has your doctor been trying to hand you an unnatural, one-size fits all solution?

Aren’t you a unique individual with unique needs who wants a customized, natural solution to your menopausal symptoms?

Well, you've found the answer to your needs: an inspiring, medically validated approach to reverse the aging process and maintain a healthy, vibrant, mentally sharp, sexually active life! The answer is bio-identical hormone therapy!

Actually the answer is most definitely not bio-identical therapy, at least as it is usually practiced. The previous paragraph is my attempt to capture the marketing message from different proponents of bio-identical hormone therapy. In this blog, I will try to separate data-supported fact from marketer's fancy to give you some perspective on the nature of therapies marketed under the name, "bio-identical".

To begin with, there is no standard medical definition for "bio-identical". The FDA does not recognize the term and it is used by different people to mean different things. Most use the term to identify use of hormones highly similar or identical to ones made in the body. The mixture of hormones administered is often custom-compounded, based on testing claiming to identify specific hormonal deficiencies. The hormones given may include estradiol, estriol, progesterone, testosterone, cortisol, and many others. The hormones are often given via the skin, rather than by mouth to reduce the impact of metabolic breakdown in the liver. Finally, repeated testing is used to insure that “normal” hormone levels are restored.

In theory, the approach outlined above is rational and attractive. Unfortunately, the approach is invalidated by a number of critical limitations and an almost complete lack of research data. The foundation of therapy for many bio-identical practitioners is frequent salivary hormonal testing to identify specific hormonal deficiencies. The accuracy of salivary testing for most hormones has been examined and found to be highly inaccurate. All mainstream professional societies have issued statements condemning its use because of dramatic inaccuracies. For example the Endocrine Society states that salivary hormone tests are “inaccurate and should not be considered reliable measures of hormones in the body” and the American College of Obstetrics and Gynecology states that, “There is no biologically meaningful relationship between salivary sex steroid concentrations and free serum hormone concentrations."

Next is the issue of custom compounding of hormones. Studies have suggested that compounded hormonal products often contain inaccurate doses and furthermore have highly variable absorption rates, leading to unpredictable dosing. Estriol, a naturally occurring estrogen in women, has also been touted as safer than estradiol or other estrogens - a careful review of the data demonstrates that this is not true and the benefits (or harms) of estriol are unknown.

The term "natural" is often used to promote bio-identical, but all compounds used are made in a chemist's lab. The compounds used are inactive chemicals isolated from plants which are then chemically altered to produce hormones nearly identical to those in humans. In fact the same estrogen and progesterone found in bio-identical preparations can be found in commonly marketed estrogen patches, and oral micronized progesterone, whose absorption and effects have been well-studied. The only truly natural products with proven benefits in menopause are Premarin(c) pills and cream, whose active estrogenic ingredients are purified from pregnant horse urine! While, it may be unappealing, horse urine is natural.

Finally, the whole issue of guiding dosing completely by monitoring hormone levels is a problem. Women use hormone therapy to feel better (e.g. relief from hot flushes) with the added benefit of bone protection. We need to use the lowest levels of hormone that achieve these results rather than blindly trying to mimic the average levels seen in young women. Even if we had accurate ways to easily follow hormone levels, too high a dose of estrogen would likely increase the unwanted side-effects of cardiovascular disease.

In conclusion, the typical approach to bio-identical hormone therapy is an attractive idea, which unfortunately does not hold up to careful examination. Those who wish to most closely mimic naturally occurring hormones are best guided to commercially available estradiol and progesterone preparations, whose dosing, absorption, and biological effects have been best studied.

Growing Obesity

2010-05-19T09:25:00.000-07:00

Alice Chuang, MD

Obesity is defined as a body mass index (BMI) greater than or equal to 30 kg/m2; overweight is defined medically as a BMI of 25-29.9 kg/m2. In the United States, we have a 25% lifetime risk of being obese and a 50% risk of becoming overweight. Obesity will soon surpass tobacco as the number one preventable cause of death. Obesity is particularly important to obstetricians and gynecologists because it affects more women than men and has a negative impact on both pregnancy and fertility. These effects include increased ovulatory dysfunction, miscarriage, gestational and pregestational diabetes, pregnancy associated hypertension, need for induction of labor, increased chance of Cesarean section, macrosomia (fetus weighing greater than 4 kilograms or 8 pounds 15 ounces), postpartum infection and stillbirth to name a mere few.

Despite all of these detrimental effects, obesity is on the rise. We live in an obesogenic environment in which technology has decreased the need for activity or movement, urban development has decreased practicality and safety of walking or biking, and the industrialization of food has made food, often unhealthy food, more accessible. The good news is that a very modest weight loss of 10% of body weight improves blood pressure, cholesterol and psychological well being and decreases risk of diabetes.

But it is hard to lose weight. To lose one pound, you have to create an energy deficit of 3500 calories, by increasing your activity with exercise or decreasing your caloric intake by eating more healthful foods and eating less overall. Those who are most successful engage in a combination of both and commit to a positive change in their activity level and food intake for life. Diets are temporary. To be successful, you need to get rid of bad habits forever.

For example, if you are used to drinking one 12 ounce can of regular soda a day and you switch to diet soda, you will lose 14.6 pounds in a year. Similarly if you could just skip the 3 Oreo cookies from the cookie jar daily, then you could lose 16.8 pounds in a year. If you can’t skip the Oreos every day, maybe you could skip them every other day which would still cause you to lose 8 pounds a year. If you are a 140-pound female (calories expended depend on your weight) and spend 12 minutes during your lunch break walking up the stairs on workdays instead of checking Facebook, you can lose 10 pounds after a year. Some experts think if you do something 21 days in a row, it will be a habit and you won’t have to think about it anymore.

Brian Wansink studies human behavior and food and discovered that on average we make 221 food-related decisions a day. That is 221 opportunities to make a more healthy choice! Think about what happens when you walk into Starbucks in the morning....
What size coffee am I going to have?
Will I have nonfat?
Will I add sugar or an artificial sweetener with no calories?
Will I have a bagel too?
Will I put cream cheese on it?
What about butter?
Or should I use margarine?

That is seven decisions and the day hasn’t even started yet!

Think about the small changes you can make in your daily routine. Think about the large impact it can have on your weight and your health!

References:
Bray, GA. Screening for and clinical evaluation of obesity. UpToDate Online 18.1. Updated Jan 2010. Accessed at http://www.uptodate.com/online/content/topic.do?topicKey=obesity/4467&selectedTitle=2%7E150&source=search_result#
Nuthalapaty, FS, Rouse DJ. The impact of obesity on fertility and pregnancy. UpToDate Online 18.1. Updated Jan 2010. Accessed at http://www.uptodate.com/online/content/topic.do?topicKey=antenatl/19564&selectedTitle=13%7E150&source=search_result
Calories Burned Estimator. Accessed at: http://www.healthstatus.com/calculate/cbc
Wansink B, Sobal J. Mindless Eating. Environment and Behavior. Vol. 39, No. 1, 106-123 (2007)

Tamoxifen & Bleeding

2010-05-12T07:56:00.000-07:00

A 58 year-old G3P3 who was diagnosed with Stage I breast cancer 4 years ago is referred to you by her medical oncologist after she complained of some vaginal spotting. She is in remission from her breast cancer and has been on tamoxifen for the past 4 years. What should her work-up include? What are her risks for endometrial pathology?

Women taking tamoxifen who still have a uterus were at a higher risk of developing endometrial hyperplasia and endometrial carcinoma (risk ratio of 2.53) for compared to patients who took placebo in a randomized trial. Other case controlled studies have also shown an increased risk of developing endometrial hyperplasia while on tamoxifen, especially for postmenopausal women. Despite this, the absolute risk of endometrial cancer in a woman on tamoxifen is less than 1/1000. Therefore, women on tamoxifen should be counseled about the increased risk of both endometrial hyperplasia and carcinoma. Women taking tamoxifen should be instructed to report any abnormal vaginal bleeding, especially if she is post-menopausal. Premenopausal women appear to have no difference in the rates of endometrial hyperplasia or carcinoma while on tamoxifen and therefore do not need any care other than routine gynecologic care. Women who present to a gynecologist complaining of abnormal uterine bleeding while taking tamoxifen should have prompt histologic evaluation with either an endometrial biopsy or dilatation and curettage. Some advocate hysteroscopy with D&C for these women as these hyperplastic endometrial lesions can often be focal as opposed to diffuse. Based on the current literature and recommendations, there is no reason to routinely do ultrasounds or endometrial biopsies on women who are taking tamoxifen and are asymptomatic. Only women who have abnormal bleeding patterns while taking tamoxifen are shown to have significant endometrial hyperplasia or carcinoma.

References:
ACOG committee opinion. No. 336: Tamoxifen and uterine cancer. Obstet Gynecol 2006 Jun;107(6):1475-8.
Cohen I. Endometrial pathologies associated with postmenopausal tamoxifen treatment. Gynecol Oncol 2004 Aug;94(2):256-66.

Pap in Pregnancy

2010-05-06T05:04:00.000-07:00

At the new obstetrical exam, a woman who is 18 weeks pregnant is found to have an abnormal pap smear. How should this patient be evaluated during pregnancy? Is the management different than in the non-pregnant patient?

Women of childbearing age are most at risk for cervical neoplasia. Of the 4 million women who become pregnant each year in the United States, it is estimated that between 2 and 7% will have abnormal cervical cytology on a Papanicolaou smear. Cervical cancer screening guidelines are no different for pregnant women. Likewise, an abnormal Pap smear in pregnancy should be evaluated with colposcopy under the same circumstances as in a non-pregnant patient. The only exception is that colposcopy can be postponed until postpartum for LSIL or less, although it is preferred at the time of diagnosis in a non-adolescent.

Multiple factors make colposcopy during pregnancy more difficult, including increased pelvic congestion, vaginal wall laxity, and an enlarged cervix. Just as in a non-pregnant state, an adequate colposcopy with visualization of the transformation zone is ideal. Providers may be wary to perform the necessary evaluation of cervical neoplasia during pregnancy because of the concern of bleeding and complications. However, there is good evidence that cervical biopsy is safe during pregnancy. A biopsy should be performed in any patient for whom CIN 2, CIN 3, or invasive cancer is suspected. Endocervical curettage should be avoided as the risk to pregnancy is unknown. In the face of atypical glandular cells, colposcopy with cervical biopsy can be performed, but endocervical curettage and endometrial biopsy are contraindicated.

Similar to a non-pregnant patient, CIN1 can be followed by observation with cytology at the 6-week postpartum visit. Progression of CIN 2 or CIN 3 to invasive cancer is unlikely during pregnancy. Repeat colposcopy later in pregnancy can be performed to exclude this possibility, with biopsy only if the lesion appears worse. Otherwise, treatment of high-grade dysplasia should be postponed until postpartum.

References
Hunter MI, Monk BJ, Tewari KS. Cervical neoplasia in pregnancy. Part 1: screening and management of preinvasive disease. Am J Obstet Gynecol. 2008 Jul; 199(1): 3-9.

What are Uterine Fibroids?

2010-04-30T05:42:00.000-07:00

Michael Armstrong, MD

What are Uterine Fibroids?

Uterine fibroids (UF) are benign tumors or lumps of muscle cells and other tissue that grow within the wall of the uterus. Fibroids may grow as a single tumor or in clusters. A single fibroid can be less than one inch in size or can grow to eight inches across or more. Sometimes fibroids grow large enough to completely fill the pelvis or abdomen. A bunch or cluster of fibroids can also vary in size. As they grow, they can distort the inside as well as the outside of the uterus.

UF are one of the most common conditions affecting women of reproductive age. Fibroids also represent the most common indication for hysterectomy. According to the NIH, by age 50, the cumulative incidence of UF is over 80 percent for African-American women and about 70 percent for Caucasian women. These percentages demonstrate that many women do not know they have fibroids, and that UF are usually undetected until symptoms develop

Healthcare providers classify fibroids into three different groups:

Subserosal: fibroids that grow on the outside of the uterus. Some can grow on stalks and are called pedunculated.
Intramural: fibroids that grow in between the muscles of the uterus.
Submucosal: fibroids that grow just underneath the uterine lining.

What are the Signs and Symptoms of UF?

The majority of UF do not cause significant problems. When symptoms do occur, they usually fall into one of three categories:

Abnormal uterine bleeding: also known as menorrhagia is the most common initial symptom associated with UF. It is usually the indication for surgical intervention. Symptoms usually correlate with the location of the fibroids, their size, or the extent of degenerative changes.
Pelvic pressure and pain: this pain is mostly a chronic condition and may consist of very painful periods (dysmenorrhea), pain with sexual intercourse (dyspareunia), or discomfort from pelvic pressure. Pressure and increased abdominal girth are more commonly encountered than pain. As UF grow, pressure is exerted on adjacent organs with manifestations such as urinary frequency, urinary outflow obstruction, and even compression of the ureter. Gastrointestinal symptoms such as constipation or tenesmus (painful and ineffectual straining associated with defecation) may be the result of a posterior wall UF that is exerting pressure on the recto-sigmoid colon.

Acute pelvic pain: is rare, but usually associated with:

torsion of the pedicle of a pedunculated UF, or
cervical dilatation by a submucosal UF protruding through the lower portion of the uterus, or
degeneration of UF (more commonly seen during pregnancy).

Reproduction dysfunction: UF are the sole cause of infertility in only a small percentage of patients. However, history of infertility was found in 27% of women in which UF were surgically removed. UF that will impact reproduction are mostly submucosal and often distort the inner uterine cavity.

What are Risk Factors for UF?

An increased UF risk is seen with increasing adult BMI, as well as an increased risk that is seen with weight gain since age 18. About 51% of patients who have UF confirmed on pathology after hysterectomy- or myomectomy are overweight, and 16% are severely obese. Probably the link between obesity and the risk of UF is related to hormonal factors associated with obesity. Several relevant hormonal associations with obesity are known.

Not only is obesity an important risk factor, but exercise is also important. Studies have shown that non-athletes are 1.4X more likely to develop UF, when compared to athletes.

Likewise the impact of diet is also important. A moderate association was found between the risk of UF and the consumption of beef, other red meat, and ham, whereas a high intake of green vegetables seemed to have a protective effect. High fiber diets and low fat diets affect estrogen metabolism, while risky diets and its association to fibroid growth has been supported.

Other risk factors include early onset of menses in childhood, never having any children, and entering the fourth decade of life. Also it has been reported that African American women have a 2-3X higher risk for UF in comparison to Caucasians. This can be explained by a difference in estrogen metabolism.

How are UF Diagnosed?

Pelvic examination to feel for the presence of UF.
Hysteroscopy, a visual inspection of the interior of the uterus using a small, slender device.
Transvaginal ultrasound is uses sound waves from a probe inserted in the vagina to determine the size of the uterus and the size and location of any fibroid tumors.

Because the pelvic ultrasounds are performed at the UNC Ambulatory Care Center, where several gynecologists work, patients have access to a gynecologist to follow up with in the event that an abnormality is found on an ultrasound. If necessary, your family doctor or internist can refer you for a pelvic ultrasound at the UNC Ambulatory Care Center, and if you need to see a gynecologist, we can arrange this appointment for you. Drs. Alice Chuang, Mike Evers, and Michael Armstrong can be contacted regarding pelvic ultrasounds at UNC. For an appointment please call (919) 843-3051.

What are treatment options for UF?

Each year in the United States, 600,000 women undergo hysterectomy, and it is the most common non-pregnancy related procedure performed. By the age of 60, nearly one in three women will have undergone hysterectomy. International hysterectomy rates vary, with the highest rates being in the United States.

Not all UF require definitive surgery, though. If your main symptoms are pain and heavy bleeding, try an over the counter medicine like ibuprofen, and ask your doctor about birth control pills. These can help you feel better and make your periods lighter. If you have anemia, take iron pills and eat foods that are high in iron.

If your doctor recommends surgery, be sure to ask questions about alternatives to hysterectomy. For patients who are young, desire childbearing, or wish to retain their uterus there are other options.

Surgical treatment options include:

Myomectomy: solely, removing the UF. This is the only fibroid treatment that may improve your chances of having a baby.
Endometrial ablation: destroys the lining of the uterus (the endometrium) and is usually performed to stop heavy menstrual bleeding. It is not helpful for large fibroids or for fibroids that have grown outside of the interior uterine lining. For most women, this procedure stops the monthly menstrual flow.
Laparoscopic myomectomy or hysterectomy: can be done through one or more small incisions using laparoscopy, and through the vagina. The method depends on your condition: including where, how big, and what type of UF are growing in the uterus. Whether or not you desire to become pregnant also impacts the surgery choice.

If you choose a surgical option be sure to discuss with your doctor which type of procedure is best for you and ask questions so you will know how the procedure is done. Expert consultation is available with the UNC Women’s Primary Healthcare Division and the UNC Advanced Laparoscopy and Pelvic Pain Division.

References
Hart R (2003). Unexplained infertility, endometriosis, and fibroids. BMJ, 327(7417): 721–724.
Practice Committee of the American Society for Reproductive Medicine (2006). Myomas and reproductive function. Fertility and Sterility, 86(4): S194–S199.
Day Baird D, et al. (2003). Highly cumulative incidence of uterine leiomyoma in black and white women: Ultrasound evidence. American Journal of Obstetrics and Gynecology, 188(1): 100–107.
Wallach E, Vlahos NF (2004). Uterine myomas: An overview of development, clinical features, and management. Obstetrics and Gynecology, 104(2): 393–406.
Stewart EA (2001). Uterine fibroids. Lancet, 357(9252): 293–298.
Kjerulff KH, et al. (2000). Effectiveness of hysterectomy. Obstetrics and Gynecology, 95(3): 319–326.
Parker WH, et al. (2005). Ovarian conservation at the time of hysterectomy for benign disease. Obstetrics and Gynecology, 106(2): 219–226. American College of Obstetricians and Gynecologists (2000). Surgical alternatives to hysterectomy in the management of leiomyomas. ACOG Technical Bulletin No. 16. Obstetrics and Gynecology, 95(5): 1–9.

VAIN lesions

2010-04-29T05:23:00.000-07:00

A 38 year old woman presented for evaluation of LGSIL. She had 15-20 colposcopically identified lesions measuring 5-10 mm that had the colposcopic appearance of flat condylomata, distributed from the upper fornices to the lower one-third of the vagina. She had a renal transplant 4 years ago and is maintained on cyclosporine and prednisone. She underwent a vaginal hysterectomy 10 years ago for benign disease, but the pathology report from hysterectomy was not available. Multiple biopsies returned VAIN I-II.

What treatment modalities might be considered in this patient?

Surgical options would be limited in this patient. Given chronic immunosuppression, her likelihood of spontaneous regression would be less than expected in immunocompetent patients, and she would likely be at an increased risk for progression to invasive disease. Total vaginectomy with reconstruction using spit-thickness skin grafts would be a potentially morbid procedure. Laser vaporization of the entire vagina would have a high risk of recurrence and would be quite morbid.

Topical therapies would be the first consideration for this patient. Topical 5-fluorouracil (5-FU) and imiquimod have been studied in the treatment of VAIN. Topical treatments are relatively inexpensive compared to surgical modalities. They hypothetically permeate vaginal mucosa and recesses well which is beneficial in multifocal disease. Topical therapy is often the choice for poor surgical candidates, and may be ideal for women with larger low-grade lesions or multifocal disease. Remission of VAIN lesions occurs in about 60% of patients, though up to 40% of patients may recur.

Learn more about vaginal cancer.

____________________________________________
References:
Krebs HB, Helmkamp BF. Chronic ulcerations following topical therapy with 5-fluorouracil for vaginal human papillomavirus-associated lesions. Obstet Gynecol. 1991 Aug;78(2):205-8.

Murta EF, Neves MA, Sempionato LR, Costa MC, Maluf PJ. Vaginal intraepithelial neoplasia: Clinical-therapeutic analysis of 33 cases. Arch Gynecol Obstet 2005: 272: 261-4.

Buck HW, Guth KJ. Treatment of vaginal intraepithelial neoplasia (primarily low grade) with imiquimod 5% cream. J Low Genit Tract Dis. 2003 Oct;7(4):290-3.

Diakomanolis E, Haidopoulos D, Stefanidis K. Treatment of high-grade vaginal intraepithelial neoplasia with imiquimod cream.NEJM. 2002; 347(5); 374.

Endometrial Hyperplasia

2010-04-12T09:39:00.000-07:00

Case Scenario
A 46 year-old woman is referred to you by her primary care doctor for abnormal bleeding. The patient says that she has never stopped having periods but that over the past few months they have become more irregular and she occasionally has “two periods a month.” How should this patient be evaluated?

As stated earlier, the most common presenting symptom of endometrial hyperplasia and endometrial carcinoma is abnormal uterine bleeding. In this perimenopausal patient, non-hyperplastic causes such as anovulatory bleeding, uterine fibroids, or endometrial polyps are likely reasons for her abnormal bleeding. Endometrial hyperplasia should always be on the differential and 5% to 15% of patients will have some form of hyperplasia. Therefore, all peri- and postmenopausal woman with uterine bleeding should be evaluated with an endometrial biopsy or D and C.

Her endometrial biopsy is done in the office and returns complex hyperplasia with atypia. What are the treatment options?

Approximately 40% of peri- or postmenopausal woman with hyperplasia of any type with atypia will have endometrial carcinoma at the time of hysterectomy, and patients should be strongly encouraged to undergo TAH/BSO if medically suitable. We believe that all methods to perform a hysterectomy are equally effective. (Abdominal, vaginal, or laparoscopic). Except in very young women, we recommend removal of tubes and ovaries. The cervix should be removed in all circumstances and we advise against morcellation of the uterus. It is also recommended that peritoneal washings be obtained at the time of hysterectomy, because peritoneal cytology is an important component for staging endometrial carcinoma.

A decision to perform surgical staging (pelvic and paraaortic lymphadenectomy) would then await return of final pathology. Alternatively, frozen section could be performed at the time of hysterectomy and if there were evidence of carcinoma with myometrial invasion, immediate formal staging with pelvic and para-aortic lymphadenectomy could be performed. The strategy chosen may be dictated by the availability of a Gynecologic Oncologist, but patients should be counseled about the possible need for staging with lymphadenectomy if significant myometrial invasion or a high-grade lesion is identified.

__________________________
Montgomery BE, Daum GS, Dunton CJ. Endometrial hyperplasia: a review. Obstet Gynecol Surv 2004 May;59(5):368-78.

Boruban MC, Altundag K, Kilic GS, Blankstein J. From endometrial hyperplasia to endometrial cancer: insight into the biology and possible medical preventive measures. Eur J Cancer Prev 2008 Apr;17(2):133-8.

Espindola D, Kennedy KA, Fischer EG. Management of abnormal uterine bleeding and the pathology of endometrial hyperplasia. Obstet Gynecol Clin North Am 2007 Dec;34(4):717-37, ix.

Low Sexual Desire – Health Burdens & Novel Treatment

2010-04-06T09:22:00.000-07:00

John M. Thorp, Jr., MD

PART I: Loss of sexual desire affect health in women

Women with low levels of sexual desire, often as a result of menopause, are more likely to be depressed and to suffer physical symptoms – including back pain, fatigue and memory problems – than women who report higher levels of desire, according to a study published in November of 2009 by researchers at the University of North Carolina at Chapel Hill and Procter and Gamble Pharmaceuticals.

The study, published in Value in Health, the official journal of the International Society of Pharmacoeconomics and Outcomes Research, was based on telephone interviews with 1,189 postmenopausal women, using well-validated quality of life survey questionnaires. Our group found that postmenopausal women with hypoactive sexual desire disorder (HSDD) reported poorer health status and health-related quality of life than women without HSDD. In fact, results of the study show that women with HSDD have a degree of physical and mental impairment comparable to chronic conditions such as hypertension, diabetes, osteoarthritis and asthma.

Hypoactive sexual desire disorder is defined as the persistent lack of sexual desire causing marked stress or interpersonal difficulties. Studies have shown that the prevalence of HSDD among women in the United States ranges from 9 percent to 26 percent, depending on the woman’s current age and menopausal status.

UNC researchers conducted a total of 2,207 telephone interviews, with women aged 30 to 70, (from which the 1,189 interviews with postmenopausal women were selected). All women reported information about level of sexual desire and pleasure and feelings of physical and emotional well-being or distress. Results showed that women with HSDD were more likely to be depressed and to express dissatisfaction with their home lives and their sexual partners. Surgically menopausal women (i.e. women who underwent menopause by having their ovaries removed) were slightly more likely to report HSDD than women who underwent menopause naturally, and women with HSDD were more than twice as likely to report health issues including back pain, fatigue and memory problems.

PART II: Novel approach to treatment

The drug flibanserin, which was originally created as an antidepressant, is very effective in treating women with low libido, pooled results from four separate clinical trials have found.

When Flibanserin was given to women in our study who took it for hypoactive sexual desire disorder, they reported significant improvements in sexual desire and satisfactory sexual experiences.

Our group pooled data from four clinical trials of flibanserin conducted in the U.S., Canada and Europe. A total of 1,946 pre-menopausal women ages 18 and older were randomized to receive either flibanserin or placebo for 24 weeks, with 4 weeks of pre-treatment baseline measurement and 4 weeks of post-treatment follow-up.

The study concluded that treatment with 100 milligrams of flibanserin once a day was associated with significant improvements versus placebo in the number of satisfactory sexual encounters (SSE) reported, sexual desire, a reduction in distress associated with sexual dysfunction, and sexual functioning.

While this product has yet to be approved by the U.S. FDA, these results point to a promising new approach to treatment. Clinical trials are ongoing at UNC and for more information call Susan Wally, Clinial Trials Nurse at (919) 966-9846.

_____________________________________
The study was funded by Boehringer Ingelheim Pharmaceuticals, the manufacturer of flibanserin.

Endometrial Hyperplasia

2010-04-01T11:46:00.000-07:00

A 46 year-old woman is referred to you by her primary care doctor for abnormal bleeding. The patient says that she has never stopped having periods but that over the past few months they have become more irregular and she occasionally has “two periods a month.” How should this patient be evaluated?

Her endometrial biopsy is done in the office and returns complex hyperplasia with atypia. What are the treatment options?

_________________________
Montgomery BE, Daum GS, Dunton CJ. Endometrial hyperplasia: a review. Obstet Gynecol Surv 2004 May;59(5):368-78.
Boruban MC, Altundag K, Kilic GS, Blankstein J. From endometrial hyperplasia to endometrial cancer: insight into the biology and possible medical preventive measures. Eur J Cancer Prev 2008 Apr;17(2):133-8.
Espindola D, Kennedy KA, Fischer EG. Management of abnormal uterine bleeding and the pathology of endometrial hyperplasia. Obstet Gynecol Clin North Am 2007 Dec;34(4):717-37, ix.

Familial Breast and Ovarian Cancer

2010-03-25T08:09:00.000-07:00

Gynecologic Oncologists are often consulted to give counseling to women with a family history of breast or ovarian cancer regarding their risk for inheriting these malignancies, strategies for protecting against development of cancer, or screening for cancer in these individuals. The major genetic mutations responsible for familial breast and ovarian cancer are high-risk mutations of the BRCA1 and BRCA2 genes, and these are identified in 5-10% of women with ovarian cancer. BRCA1 and 2 mutations are inherited by an autosomal dominant pattern, though there are varying degrees of penetrance. The genetic mutation may be inherited from either the maternal or paternal side of the family tree. In the general population, BRCA mutations are carried by less than 0.1%. This rate varies greatly depending on ethnic background, with the highest carrier rate of 2% seen in women of Ashkenazi Jewish descent.

Women with BRCA1 or 2 mutations have a 50-85% lifetime risk of breast cancer, with some breast cancers diagnosed before the age of 30. BRCA1 is associated with a 30-40% ovarian cancer risk and BRCA2 with a 15-25% risk. In contrast, the baseline risk for sporadic breast cancer is 11% and for sporadic ovarian cancer is 1.6%. BRCA1 carriers diagnosed with ovarian cancer are usually younger than BRCA2 carriers. After age 35, the risk of contracting ovarian cancer for BRCA1 carriers is 1% per year, compared with BRCA2 carriers, who are rarely diagnosed prior to age 50. Conflicting data exist regarding whether BRCA mutations increase the risk of endometrial cancer, but to date there is not an established association. BRCA mutations also increase the risk of fallopian tube and primary peritoneal cancer.

The NCCN and other organizations have developed criteria to identify women at risk for harboring a genetic pre-disposition for breast or ovarian cancer, and for whom referral to a geneticist is recommended. The criteria include family history of early-onset or multifocal breast cancer, breast cancer clustered with other primary cancers, a family member with a known mutation, any male relative with breast cancer, breast cancer associated with any first-degree relative with ovarian, fallopian tube, or primary peritoneal cancer, and high-risk groups such as women of Ashekenazi Jewish descent. Recent recommendations include offering testing for all patients who develop primary breast or ovarian cancer at any age; because of the expense involved in identifying whether a BRCA mutation is present in a family, the best strategies revolve around testing individuals who have a malignancy. Once a high-risk BRCA mutation is identified, it is much easier to test other family members for that specific mutation.

Women who meet these criteria should be evaluated by a genetic counselor in order to decide whether BRCA testing should be undertaken and who should be tested. The benefit of testing would primarily be for cancer risk assessment and to allow the patient to make decisions regarding surveillance and prophylactic surgery if she were to test positive. A negative test would provide reassurance and allow her to receive routine screening. On the other hand, negative genetic testing does not completely exclude the possibility that the patient might develop breast or ovarian cancer. Unfortunately, misunderstanding by patients and some physicians has let to a false sense of reassurance in women who test negative for BRCA1 and 2. A possible negative consequence of testing is the potential for discrimination by medical insurers in the event of a positive test. However, there is currently little evidence of any widespread discriminatory practices based on genetic testing results. “Survivor’s guilt” is sometimes experienced by women who are negative for the mutation but have affected relatives. This may require counseling and support of the unaffected woman. Further discussions regarding surveillance or prophylactic surgery would be held depending on whether the individual agrees to testing and the results of the test.

_____________________________________

Maxwell GL, Berchuck A. Biology and genetics. In: Berek JS, Hacker NF, editors. Practical Gynecologic Oncology. 4th Ed. Philadelphia (PA): Lippencott, Williams, and Wilkins; 2005. p. 3-42.
Narod SA. Clinical genetics of gynecologic cancer. In: Hoskins WJ, Perez CA, Young RC, Barakat RR, Markman M, Randall ME, editors. Principles and Practice of Gynecologic Oncology. 4th Ed. Philadelphia (PA): Lippencott, Williams, and Wilkins; 2005. p. 33-8.
Lancaster JM, Powell CB, Kauff ND, et al. Society of Gynecologic Oncologists Education Committee Statement on Risk Assessment for Inherited Gynecologic Cancer Predispositions. Gynecologic Oncology 107 (2007) 159-162.
ACOG Committee Opinion: Ethical Issues in Genetic Testing, Number 410, June 2008.
Daly MB, et al. The NCCN Genetic/Familial High-Risk Assessment Clinical Practice Guidelines in Oncology, version 1, 2008. Available at: http://www.nccn.org.

Is it Time to Re-evaluate Cutoffs for the Diagnosis of Gestational Diabetes?

2010-03-22T06:38:00.000-07:00

Ashley Hickman, MD and Bill Goodnight, MD, MSCR

Adverse pregnancy outcomes from hyperglycemia isolated to pregnancy have been known since the 1800’s, but it wasn’t until the 1960s that the term “gestational diabetes (GDM)” was established. The 1-hour screening test used today was first done in Boston in the 1950s, to identify risks of diabetes following pregnancy. Landmark work by Dr. O’Sullivan in the 1950s and 1960s confirmed that gestational diabetes was associated with macrosomia and perinatal mortality and developed the current diagnostic criteria for GDM. This criteria was later adopted by the NDDG. Drs. Carpenter and Coustan later proposed more stringent diagnostic criteria, and the optimal diagnostic criteria remains controversial. ACOG currently has not endorsed a particular threshold.

Recent studies in gestational diabetes again raise the question of the optimal criteria for screening and diagnosis of GDM. In 2008, the results of the Hyperglycemia and Adverse Pregnancy Outcome (HAPO) trial were reported (1). This international study evaluated over 20,000 women and demonstrated a continuous association between increased maternal glucose and adverse outcome without a clear lower threshold at which the risk was eliminated. In 2009, Cheng and her colleagues reviewed the outcomes of over 14,000 pregnancies and noted an increased risk of fetal macrosomia, cesarean delivery, and shoulder dystocia among those who would only have been diagnosed by the Carpenter-Coustan criteria compared to women who were negative by both criteria (2). Finally, two recent randomized clinical trials of treatment compared to no treatment for mild GDM both demonstrate a reduction in adverse pregnancy outcomes with treatment (3,4).

So what are we doing at UNC? Until recently, we have used a screening threshold of 140 mg/dl on the 1 hour 50 gram OGTT to warrant a 3-hour diagnostic test, and we diagnosed gestational diabetes in women who had 2 or more abnormal values using the NDDG criteria. While changes may result in more patients needing a three hour test, we have adopted the one hour cut off of equal to or greater than 135 gm/dl and are using the Carpenter-Coustan criteria (2 abnormal values) for the diagnosis of GDM (Table 1).

Other pearls suggested for prevention of adverse effects of maternal hyperglycemia associated with pregnancy include:

First trimester screening for prior pregnancy with macrosomia, maternal BMI greater than 29
Nutrition and diet consultation for single abnormal value on 3 hour GTT
As the lifetime risk of DM following GDM is greater than 25%, screen for GDM at the 6 week post partum visit with either a FBS or 75 gram 2 hour GTT
Encourage avoidance of excessive weight gain in pregnancy and assist in weight loss post partum to achieve future pregnancy at ideal BMI – nutrition consultation as necessary

_____________________________________

Hyperglycemia and Adverse Pregnancy Outcome (HAPO); HAPO Study Cooperative-Metzger BE, Lowe LP, Dyer AR, et al.; NEJM. 2008
Carpenter-Coustan criteria compared with the National Diabetes Data Group thresholds for gestational diabetes; Cheng Y, Block-Kurbisch I; Obstet Gynecol. 2009.
Effect of treatment of gestational diabetes mellitus on pregnancy outcomes. Crowther CA, Hiller JE, Moss JR, McPhee AJ, Jeffries WS, Robinson JS; Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS) Trial Group.N Engl J Med. 2005 Jun 16;352(24):2477-86. Epub 2005 Jun 12.
A multicenter, randomized trial of treatment for mild gestational diabetes.
Landon MB, Spong CY, Thom E, Carpenter MW, Ramin SM, Casey B, Wapner RJ, Varner MW, Rouse DJ, Thorp JM Jr, Sciscione A, Catalano P, Harper M, Saade G, Lain KY, Sorokin Y, Peaceman AM, Tolosa JE, Anderson GB; Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. N Engl J Med. 2009 Oct 1;361(14):1339-48.

Photo credits:
http://emedicine.medscape.com/article/262865-overview
http://www.daisy-online.net/blog/archives/146

Ovarian Cysts and Adnexal Masses in Pregnancy

2010-03-18T12:16:00.000-07:00

John Soper, MD

With the routine use of ultrasound in prenatal care, the finding of an “incidental” ovarian mass in pregnancy has become more common. In the first trimester, up to 8.8% of patients will have ovarian cysts or masses diagnosed by ultrasound, but only 1-2% will persist into the second trimester. Most first trimester masses are corpus luteal cysts that regress by the 16th week of pregnancy. Because pregnant women are in the younger reproductive ages, types of tumors found are often different from tumors found in the later reproductive age group and during menopause. These more often are functional cysts, endometriosis, benign ovarian neoplasms, borderline (low malignant potential) tumors, and germ cell tumors, rather than malignant invasive epithelial ovarian cancers. The relative frequency of these tumors is related to the age group of the pregnant patient population rather than effects of pregnancy itself.

Ultrasound is the most important diagnostic tool used in the evaluation and management of the adnexal mass in the pregnant patient because of its overall safety for the fetus and accuracy. The same ultrasound parameters for evaluation of nonpregnant patients are used. Ultrasound is more able to make an accurate diagnosis of benign tumors rather than malignant tumors. Because of its known safety in pregnancy, magnetic resonance imaging (MRI) has also been used to provide additional diagnostic information including the ability to develop 3-dimensional images, delineate tissue planes, and characterize tissue composition. In general, however, the additional information that MRI provides is limited by cost and availability.

Management of adnexal masses in pregnancy revolves around expectant versus surgical management. Similar to the nonpregnant state, there is risk for torsion, hemorrhage, and rupture. The incidence of torsion in pregnancy has been reported to be from 3% to as high as 43%, with the incidence of cyst rupture between 9% and 17%. In some studies, patients who underwent emergency surgery for management of complications of an adnexal mass during pregnancy had an increased incidence of spontaneous abortion and preterm delivery compared with patients who underwent non-emergent, elective surgical management, but others have shown no difference in outcome between the elective and emergent laparotomy groups. Another potential benefit for removal of the mass includes preventing obstruction of labor at the time of delivery.

Timing of surgery is important. Because most masses during early pregnancy are corpus lutea or other functional cysts that usually resolve, elective removal of an adnexal mass is generally recommended if it persists into the second trimester. Delaying surgery until 16-18 weeks’ gestation prevents unnecessary surgery by allowing resolution of functional cysts. Delaying surgery may also decrease the rate of miscarriage from potential disruption of the corpus luteum and prevents exposure of the fetus to anesthesia during organogenesis, which is typically complete by the end of the first trimester. Additionally, surgery past the early second trimester may require a larger incision to obtain adequate exposure and increases the risk for premature labor.

Adnexal masses in pregnancy have traditionally been removed by laparotomy rather than laparoscopy. Concerns for laparoscopy during pregnancy include possible penetrating injury to the uterus from trocar placement. Recent case series indicate that laparoscopic removal of adnexal masses in pregnancy is safe and is associated with decreased blood loss, shorter hospital stays, and reduced postoperative pain. When performing laparoscopy during pregnancy an open technique or left upper quadrant entry is used to decrease potential uterine injury. No cervical or uterine instrumentation is performed. Excessive manipulation of the uterus during the procedure is also avoided to decrease uterine irritability.

Depending on the characteristics of the mass a cystectomy, oophorectomy (removal of the ovary), or salpingo-oophorectomy (removal of the tube and ovary) is performed. The Da Vinci robotic platform may facilitate cystectomy and reduce potential uterine manipulation compared to “straight-stick” laparoscopy, but prospective studies are needed to validate these impressions. Finally, when an ovarian malignancy is encountered, staging and debulking should be performed with a minimum of uterine manipulation, while preserving the uterus. Chemotherapy may be administered during the second and third trimesters of pregnancy in carefully selected patients.

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References
1.    Lavery JP, Koontz WL, Layman L, et al. Sonographic evaluation of the adnexa during early pregnancy. Surg Gynecol Obstet 1986;163:319-23.
2.    Leiserowitz G. Managing ovarian masses during pregnancy. Obstet Gynecol Surv 2006;61:463-470.
3.    Giuntoli RL, Vang RS, Bristow RE. Evaluation and management of adnexal masses during pregnancy. Clin Obstet Gynecol 2006:49(3): 492-505.
4.    Marino T, Craigo SD. Managing adnexal masses in pregnancy. Contemp Rev Obstet Gynecol 2000;45:130-143.
5.    Kumari I, Kaur S, Mohan H, Huria A. Adnexal masses in pregnancy: A 5-year review. Aust N Z J Obstet Gynecol 2006;46: 52-54.
6.    Leiserowitz GD, Xing G, Cress R, et al. Adnexal mass in pregnancy: How often are they malignant? Gynecol Oncol 2006;101:315-321.
7.    Kier R, McCarthy SM, Scoutt LM, et al. Pelvic masses in pregnant patients: MR imaging. Radiology 1990;176:709-713.
8.    Whitecar P, Turner S, Higby KA. Adnexal masses in pregnancy: a review of 130 cases undergoing surgical management. Am J Obstet Gynecol 1999;181: 19-24.
9.    Hess CU, Peaceman A, O’Brier WF, et al. Adnexal masses occurring with intrauterine pregnancy: report of 54 patients requiring laparotomy for mature management. Am J Obstet Gynecol 1988; 93: 585-589.
10.    Ribic-Pucelj M, Kobal B et al. Surgical treatment of adnexal masses in pregnancy. J Reprod Med 2007; 52:273-279.
11.    Yuen PM, Ng PS, Leung PL, Rogers MS. Outcome in laparoscopic management of persistent adnexal masses during the second trimester of pregnancy. Surg Endosc 2004;18: 1354-1357.
12.    Mathevet P, Nessah K, Dargent D, Mellier G. Laparoscopic management of adnexal masses in pregnancy: a case series. Eur J Obstet Gynecol Reprod Biol 2003;108: 217-222.

How can my OB help me breastfeed successfully?

2010-03-09T09:49:00.000-08:00

Dr. Alison Stuebe

My friend wanted to breastfeed, but she didn’t make enough milk.

What can I do to make sure this doesn’t happen to me?

All major medical organizations recommend that mothers feed their infants only breastmilk for the first six months of life. In North Carolina, 67% of mothers start out breastfeeding, but only 13% meet the six-month recommendation. Most mothers who wean early say they did not breastfeed as long as they had wanted to.

Obstetric providers can make a huge difference in helping mothers meet their breastfeeding goals. Several office practices affect breastfeeding success. For example, when providers ask open-ended questions during prenatal care, such as “What have you heard about breastfeeding?” and follow-up with targeted education, patients are more likely to initiate and continue breastfeeding. By contrast, when practices distributed formula promotional materials and gift packs, mothers who were uncertain about their breastfeeding plans were more likely to wean in a randomized clinical trial.

During labor and birth, OBs can play a key role. The American Academy of Pediatrics recommends placing the healthy newborn directly on the mother’s chest, skin-to-skin, until the first feeding has occurred. In a Cochrane meta-analysis, randomized trials of early skin-to-skin increased breastfeeding duration by 43 days. Providers can also support mothers by encouraging feeding on demand, avoiding pacifiers or supplemental feeds, and recommending that mothers keep babies with them in their rooms during the postpartum stay.

These recommendations are part of the evidence-based WHO Ten Steps for successful breastfeeding. In a recent study, just 14 percent of nulliparous mothers achieved their breastfeeding goals when they delivered at hospitals that did not implement any of the Ten Steps, compared with 86% of mothers who delivered at hospitals that implemented six or seven of the Ten Steps.

Postpartum, obstetric providers are a major resource for information on medication safety during lactation. Many of the drug databases used in pharmacies may inaccurately identify drugs as unsafe in lactation, leading mothers to wean or not take prescribed medications. LactMed provides free, up-to-date evidence-based monographs on medication safety from the National Library of Medicine.

OB providers can also advocate for mothers who are returning to work. A letter to the mother’s employer asking for accommodations to express milk can empower a mother to continue breastfeeding. Sample letters are available online from the Massachusetts Breastfeeding Coalition.

For patient handouts and additional information, visit the North Carolina Breastfeeding Coalition web site.

Weight Gain During Pregnancy

2010-03-05T10:19:00.000-08:00

Bill Goodnight, MD

Doctor, how much weight should I gain during pregnancy?

Among obstetrical providers, ideal weight gain in pregnancy remains a controversial subject. Women want to achieve appropriate weight gain for fetal growth without excess weight post partum.

Well established data suggests that low maternal weight gain, especially in women who are underweight at the start of the pregnancy increases the risk for a low birth weight baby. In addition, excessive weight gain in pregnancy is associated with increase post partum weight retention, potentially contributing to lifelong risks of diabetes and cardiovascular disease, as well as increased risk of gestational diabetes, large for gestational age neonates, and increased cesarean risks in future pregnancies.

In an effort to determine the balance between optimal fetal growth and maternal weight retention following pregnancy, the Institute of Medicine recently reviewed the available literature and revised the 1990 guidelines for weight gain in pregnancy. The ideal weight gain for singleton pregnancy is based on the mother’s prepregnancy BMI (see table).

IOM recommendations for weight gain for singleton pregnancy*

BMI	Total weight gain (lbs)	2^nd and 3^rd trimester rate of weight gain (lbs per week) Assumes 1.1-4.4 lbs wt gain in first trimester
Underweight ( < 18.5 kg/m2)	28-40	1
Normal ( 18.5-24.9 kg/m2)	25-35	1
Overweight (25.0 -29.9 kg/m2)	15-25	0.6
Obese (> 30 kg/m2)	11-20	0.5

IOM recommendations for maternal weight gain for multiple pregnancy*

BMI	Total weight gain (lbs)
Underweight (< 18.5 kg/m2)	Insufficient data I recommend 45-55 lbs
Normal ( 18.5-24.9 kg/m2)	37-54
Overweight (25.0 -29.9 kg/m2)	31-50
Obese (> 30 kg/m2)	25-42

The twin data is constructed from maternal weight gains with twin pregnancies that delivered after 37 weeks EGA with birth weight > 2500grams (‘ideal twin pregnancy’).

To help achieve these goals, providers should calculate the BMI at the first visit and evaluate weight gain during the pregnancy. Nutritional consultation for slow or excessive weight gain should be considered. Determination of the individual’s weight gain goal in early pregnancy and intervention for poor or excessive weight gain may reduce post partum weight retention and help to reduce the chance of low birth weight or macrosomic neonates.

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* IOM (Institute of Medicine) and NRC (National Research Council). 2009. Weight Gain during Pregnancy: Reexamining the Guidelines. Washington, DC: The National Academies Press.

Refractory Overactive Bladder and InterStim®

2010-03-05T05:47:00.000-08:00

Brent Parnell, MD

In 1998 the Food and Drug Administration approved a device known as the InterStim® Sacral Nerve Stimulation System for the treatment of refractory overactive bladder with symptoms of either urinary urge incontinence, urinary urgency-frequency or also those with non-obstructive urinary retention. The mechanism of action of the InterStim® device is still not completely understood, but it is thought to work through inhibition of the somatic afferent pathways in the spinal roots which in turn modulate voiding and continence reflex pathways in the central nervous system¹.

This type of neuromodulation has begun a new era in the treatment of both refractory overactive bladder and urinary retention in men and women. Overactive bladder (OAB) is a chronic debilitating condition that costs millions each year² and impacts 16% of men and 16.9% of women in the United States³ to the point that it impacts work productivity⁴. Unfortunately, conservative and medical management of OAB is not effective at relieving the symptoms of many people. This permanently implantable system has been show to provide benefit to those suffering from refractory overactive bladder and retention⁵. Refractory overactive bladder typically describes those women who have failed two anticholinergic medications.

InterStim® neuromodulation has been validated as a treatment modality for both overactive bladder with and without leakage as well as non-obstructive urinary retention.

The implantable device is comprised of a neurostimulator called the generator, an extension cable and a lead wire with quadripolar electrodes. The lead wire is implanted into a sacral foramen on either the right or left side of the body. Exact foramen location and right or left side is chosen based on the motor and sensory response of the patient at the time of placement – choosing the location with the best responses. Usually the S3 foramen provides the best response but sometimes S2 or S4 is chosen. Finally, the generator is placed in a subcutaneous pocket in the patient’s buttock. The device is programmed at the time of implantation but subsequent adjustments can be made by the patient or physician using an electronic programming device.

The lead wire and generator may be placed during a single visit to the operating room, if they have had a successful response to PNE (Percutaneous Nerve Evaluation) or as a staged procedure: Stage I for lead wire placement, followed by Stage II for generator placement following a successful Stage I trial of stimulation. Both the full and the staged implants are performed in the operating room under conscious sedation. The InterStim® generator battery life ranges from 5-10 years depending on battery use and can be replaced with a short outpatient procedure.

The InterStim® device and the placement procedures are covered by Medicare and most major insurance carriers.

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Leng WW, Chancellor MB. How sacral nerve stimulation neuromodulation works. Urol Clin North Am 2005;32:11-8.

Hashim H, Abrams P. Overactive bladder: an update. Curr Opin Urol 2007;17:231-6.

Stewart WF, Van Rooyen JB, Cundiff GW, et al. Prevalence and burden of overactive bladder in the United States. World J Urol 2003;20:327-36.

Sexton CC, Coyne KS, Vats V, Kopp ZS, Irwin DE, Wagner TH. Impact of overactive bladder on work productivity in the United States: results from EpiLUTS. Am J Manag Care 2009;15:S98-S107.

Herbison GP, Arnold EP. Sacral neuromodulation with implanted devices for urinary storage and voiding dysfunction in adults. Cochrane Database Syst Rev 2009:CD004202.

Awake For Surgery?

2010-03-04T16:11:00.001-08:00

Matthew Siedhoff, MD

Certainly every patient having an operation hopes her surgeons, anesthesiologists, and nurses are alert and well-rested, but I imagine most haven’t considered being awake during her own laparoscopic surgery.

My colleagues, Dr. Steege and Dr. Yunker, recently published an invited review regarding conscious “pain mapping” surgery in the Journal of Minimally Invasive Gynecology (Jan / Feb 2010, Vol 17 No 1). First described in the mid-1990s, the procedure involves placing tiny “ports” through anesthetized skin while the anesthesiologist provides controlled sedation. After the instruments are in place, the patient is awakened to a state where she can respond to questions. Various regions are gently probed and she is asked if the area hurts, to rate her pain on a 1-10 scale if it does, and if that pain recreates the pain that led to surgery in the first place. The uterus, ovaries, appendix, adhesions (scar tissue), and muscles are examples of areas tested during this procedure. Once the “mapping” is complete, usually full general anesthesia is induced and procedures indicated by the findings take place (e.g. excision of endometriosis, removal of a tender ovary).

Not everyone is a good candidate for conscious pain mapping surgery. For example, those with high levels of anxiety or claustrophobia don’t tolerate the procedure well. Or when the abdominal wall is deep, more pressure is needed on the instruments to manipulate them, creating distracting pain at the level of the skin. The surgeon should have a good therapeutic relationship with his or her patient as well as prior experience with the procedure. Dr. Steege was one of the first gynecologists to utilize this approach, and with over a decade’s experience at UNC, has refined the technique and learned which patients are likely to benefit from it.

The surgery is particularly helpful when the physical exam doesn’t point to an obvious source for someone’s pain, and having the additional information from a mapping will help guide how to intervene. The possibilities are discussed preoperatively. For example, a woman may have had an ovary removed already and would only want the other removed if it was clearly identified as the source of her pain. Sometimes, nearly every area examined is tender, suggesting a more generalized dysfunction of pain signaling.

The real question: does it help? If you count negative findings as helpful information (which I would in most cases), then in about 70% of cases, clinically useful information is obtained.

Clearly not every patient with pain needs this surgery, but, in the right circumstances, it can be very helpful both diagnostically and therapeutically.

Progesterone and Prevention of Recurrent Preterm Birth

2010-02-17T05:49:00.000-08:00

Bill Goodnight, MD

The obstetric literature has seen an explosion in research into the use of progesterone in the prevention of preterm birth (PTB). As PTB affects 12% of the US births, methods to reduce this rate will contribute to overall reductions in perinatal morbidity. This series of blogs will help to condense the use of progesterone in management of PTB risk.

RECURRENT PRETERM BIRTH

The most well accepted use of progesterone is the use of 17 alpha-hydroxyprogesterone acetate for the prevention of recurrent PTB. Meis, et al conducted the most well known of several clinical trials to date. In this trial, women with prior preterm birth at 20-36 weeks (including PPROM, spontaneous preterm birth - SPTB, and abruption) were treated with weekly 17-OHP 250mg IM starting at 16 weeks to 36^th week (compared to placebo). The risk of PTB < 35 weeks EGA was reduced by 33%, compared to placebo (see table).

Gestational age at delivery	17-P	Placebo
Less than 37 weeks	36%	55%
Less than 35 weeks	21%	31%
Less than 32 weeks	11%	20%

The neonatal outcomes were also improved among those in the 17-P groups demonstrating less perinatal morbidity, lower rates of necrotizing enterocolitis, IVH, and need for supplemental oxygen.

At this time17-P is available through compounding pharmacies and is reimbursed by most insurance providers and North Carolina Medicaid. Information on how to obtain 17-P can be found here.

Other trials have demonstrated similar results, with a few trials of differing progesterone formulations, study populations, and routes of administration not demonstrating improvements in preterm birth.

Thus the current ACOG/SMFM recommendations for the role of progesterone in preterm birth prevention include:

17-P weekly IM for singleton pregnancy with prior PTB (20-36 weeks) due to SPTB or PPROM
200mg micronized vaginal progesterone for asymptomatic women with cervical length <15mm between 18-26 weeks EGA (routine screening in routine risk patients is NOT recommended)
No studies are available and/or studies demonstrate no benefit, and thus progesterone not recommended in multiple gestations, adjunct to cerclage, as tocolytic or following tocolytic therapy, or following a positive FFN test.

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Meis PJ, Klebanoff M, Thom E, Dombrowski MP, Sibai B, Moawad AH, et al. Prevention of recurrent preterm delivery by 17 alpha-hydroxyprogesterone Caproate. N Engl J Med 2003;348:2379-85.

Use of Progesterone to Reduce Preterm Birth. ACOG Committee Opinion No. 419. American College of Obstetricians and Gynecologists. Obstet Gynecol 2008;112:963-5.

Does a Birth Plan Affect Perinatal Outcome?

2010-02-17T05:46:00.000-08:00

Bill Goodnight, MD

I came across this abstract at the recent SMFM annual meeting in Chicago. A group at the University of California, San Francisco posed the question, does having a birth plan influence perinatal morbidity? In this prospective, observational trial, 1285 women, 90 of whom (7%) had birth plans were followed through their deliveries.

The women with birth plans were more likely to be nulliparous (83 vs 55%) and older (43 vs 26% were over 35 years old). In this study, women with birth plans were more likely to have higher rates of slow active phase, less use of epidural anesthesia in labor, and higher rates of prolonged ROM. Overall the operative vaginal delivery rates (vacuum or forceps) were less in the birth plan groups (5.3 vs 17.7%) with no difference in cesarean delivery (20% vs 19.1%). In addition there was no difference in 3rd or 4th degree lacerations, post partum hemorrhage, or chorioamnionitis.

This study is limited in that the content of the birth plan was not reviewed, the presence of high risk factors in the women was not reported (including spontaneous vs induced labor, gestational age at delivery, and birth weight), and we will await the final published data to evaluate confounding variables.

Overall, this study shows no difference in perinatal morbidity between women with and without birth plans, as well as no difference in vaginal delivery rates.

This was interesting to me as I had not seen a trial of outcomes with birth plans.
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Jones J, Isaacs J, Cheng Y, Caughey A. What is the association between a birth plan characteristics and pregnancy outcomes? Poster. Presented at the SMFM 30th Annual Scientific Meeting, Chicago, Il, 2010.